VOLUME 94, NUMBER 2, 2008
Michele Harms PhD MSc GradDipPhys MCSP Editor The Chartered Society of Physiotherapy London, UK

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Physiotherapy Editorial Office Elsevier Ltd, The Boulevard Langford Lane Kidlington Oxford OX5 1GB, UK Tel.: +44 (0)1865 843753 Fax: +44 (0)1865 843992 E-mail: Sheila Payne PhD BA(Hons) RN DipN C. Physchol Lancaster University Lancaster, UK Valerie Pomeroy PhD BA GradDipPhys FCSP University of East Anglia Norwich, UK Gabrielle Rankin PhD MSc GradDipPhys MCSP Chartered Society of Physiotherapy London, UK Patricia Roche PhD MSc BSc(Hons) MCSP Queen Margaret University College Edinburgh, Scotland Sally Singh PhD BSc MCSP Glenfield Hospital Leicester, UK Paul Watson PhD MSc GradDipPhys MCSP BSc(Hons) CertHSM PGCE DipPT University of Leicester Leicester, UK

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Claire Ballinger PhD MSc DipCOT Glasgow Caledonian University Glasgow, UK Richard Bohannon EdD, PT, NCS, FAHA, FAPTA University of Connecticut Connecticut, USA Tracy Bury MSc GradDipPhys MCSP WCPT Secretariat London, UK Vinette Cross PhD MMedEd MCSP DipTP CertEd University of Birmingham Birmingham, UK Mike Hurley PhD GradDipPhys MCSP King’s College London London, UK Sallie Lamb DPhil MSc GradDipPhys MCSP University of Warwick Warwick, UK Gareth Noble PhD BSc(Hons) University of Wales Swansea, Wales

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D. Bader (London, UK) K. Bo (Oslo, Norway) M. O’Brien (Ontario, Canada) C. Cott (Toronto, Canada) R. de Bie (Maastricht, The Netherlands) W. de Weerdt (Heverlee, Belgium) C. Eales (Johannesburg, South Africa) J. Hay Smith (Dunedin, New Zealand) S. Jenkins (Perth, Australia) G. Jensen (Nebraska, USA) R. Ladyshewsky (Perth, Australia) I. Nara (Kobe, Japan) A. Nieuwboer (Heverlee, Belgium) P. Pothongsunun (Chiang Mai, Thailand) G. Wulf (Nevada, USA)

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Physiotherapy 94 (2008) 89–90


Client-centred rehabilitation: what is it and how do we measure it?

Client centredness has emerged in recent years as an important underlying principle for the delivery of health and rehabilitation services [1]. Increasingly, hospitals are implementing programmes to enhance client centredness of care, but there are few measures to evaluate hospital performance in these areas. In Ontario, the largest province in Canada, indicators of client centredness have been developed at both client and organisational level in order to facilitate the evaluation of programmes in the ‘Hospital report: rehabilitation’, a province-wide quality improvement and research initiative that uses a balanced scorecard approach to evaluate the performance of all hospitals with designated rehabilitation beds. A balanced scorecard approach [2] recognises that hospital care is a complicated activity requiring a multitude of skills, experiences and technologies [3]. Performance measurement must therefore include a balanced scorecard of indicators that, when taken together, provide insights into the overall performance of a hospital. The balanced scorecard approach describes performance across four quadrants that are critical to the success of any healthcare organisation: system integration and change (SIC) (the changes and investments that facilities need to make in order to move ahead in the next 3–5 years); clinical utilisation and outcomes (elements of clinical success); client perspectives (dimensions of care that are most relevant to clients); and financial performance and condition. The first step in developing client-centredness indicators for the SIC and client perspectives quadrants required definition of the concept of interest, i.e. client-centred rehabilitation. A review of the literature revealed that there was no commonly used definition of client-centred rehabilitation [4], and that most available definitions focused on acute care, usually from the perspective of various health professionals rather than clients. In order to address these shortcomings, focus groups were conducted with adult rehabilitation clients with chronic physically disabling conditions and rehabilitation professionals in order to identify the important domains of client-centred rehabilitation [5,6]. From these studies, it was concluded that client-centred rehabilitation is a philosophy or approach to the delivery of rehabilitation services that reflects the needs

of individuals and groups of clients. Further, client-centred rehabilitation can be thought of at two levels: client (clients are actively involved in managing their care and their rehabilitation in partnership with service providers); and organisation (an approach to care that strives to incorporate client perspectives into the provision of services). Table 1 shows the seven domains of client-centred rehabilitation at client level and the seven domains of client-centred rehabilitation at organisational level identified in the research. These domains formed the basis for the development of indicators at two levels: client and organisation. Creation of a tool to measure client centredness at client level consisted of the development of five to six questionnaire items for each of the seven domains of client-centred rehabilitation, cognitive interviews with rehabilitation clients to evaluate the clarity and relevance of the items, and testing of the psychometric properties of the tool via a self-administered survey mailed to over 1000 patients discharged from two rehabilitation facilities. The product of this pilot work was a 30-item questionnaire – the Client Centred Rehabilitation Questionnaire (CCRQ) – which has demonstrated inter-item and test–retest reliability and concurrent validity [7]. Subsequently, the CCRQ was embedded within the client perspectives of rehabilitation survey for the ‘Hospital report: rehabilitation’. For the 2005 report, it was sent to all clients (n = 11 464) discharged from designated rehabilitation beds within the province of Ontario in 2004. There was a 46% response rate (n = 5274). Further construct validity testing was undertaken by correlating each individual question and each domain score in the CCRQ with a general measure of satisfaction (i.e. ‘Please rate the overall quality of care and services you received’) that functioned as a ‘gold standard’ of client satisfaction [8]. Clients perceived their quality of care to be higher when they felt that: they were involved in determining their progress in rehabilitation; their physical comfort needs were being recognised and handled by staff; they were being treated with respect and dignity; and they had been given the information that they needed to manage their condition in the community. Most important was feeling that they had been treated with respect and dignity, and that they were seen as a person and not just another case.

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Editorial / Physiotherapy 94 (2008) 89–90

Table 1 Domains of client-centred rehabilitation at client and organisational level Domains at client level Client participation in decision-making and goal-setting Client-centred education (information is timely and appropriate) Evaluation of outcomes from the client’s perspective, not just from the perspective of the rehabilitation professionals Family involvement and support Coordination and continuity of care (clients often feel isolated and abandoned after discharge from rehabilitation) Emotional support (clients feel they are being listened to and treated with respect and dignity) Physical comfort (recognition and management of pain) Domains at organisational level Client involvement in service planning Evaluation of the programmes and services from the clients’ perspective Organisational response to client feedback Accessibility Interdisciplinary approach Coordination and continuity with community services Organisational support for client-centred care

Two indicators were used to measure client centredness at organisational level. The first, evidence of client-centred care, measures the extent to which systems and processes are in place to ensure that the individual care that clients receive during their rehabilitation is client centred. It is derived from seven questions in the SIC questionnaire that parallel the following four components of client-centred rehabilitation: client involvement in decision-making and goal-setting; client-centred and family-centred education; family involvement; and emotional support mechanisms for clients/families and staff. The second organisational level indicator, evidence of organisational client centredness, measures the extent to which hospitals implement a client-centred approach to service delivery at organisational level. The indicator is constructed from four questions in the SIC questionnaire that address: the extent to which hospitals are collecting client/family feedback, including evidence that client perspectives are incorporated into service planning; strategies that hospitals utilise to disseminate client and family feedback results; and the existence of specific staff roles that facilitate client-centred care (e.g. patient advocate/ombudsman, designated contact person assigned to each client and family, or designated staff who addresses equity issues). More detailed definitions of the two indicators, including weighting of each question, are available in the rehabilitation technical summary at Preliminary examination of the inter-relationships between the client perspectives indicators and the two client-centredness SIC indicators found that hospitals which actively involve clients and families within the organisation are perceived by clients to provide care of higher quality, to recognise and manage physical comfort needs, and to actively involve clients in evaluating their rehabilitation outcomes. These results represent trends that could provide direction for hospitals with respect to quality improvement efforts. In conclusion, client centredness is an important component of any rehabilitation programme. It is important for

organisations to utilise measures of client centredness that can be used for discriminative and evaluative purposes so that quality of care can be monitored within and between programmes. In Ontario, measures of client centredness at both client and organisational level have been developed and are being used as part of a province-wide quality improvement initiative. Although developed in Canada, these measures are in the public domain and have the potential to be utilised in other rehabilitation service delivery systems. Conflict of interest: None. References
[1] Picker Institute. Eye on patient: a report by Picker Institute for the American Hospital Association. Boston, MA: Picker Institute Inc.; 2000. p. 1–14. [2] Kaplan RB, Norton DP. The balanced scorecard – measures that drive performance. Harvard Bus Rev 1992;70:71–9. [3] Baker GR, Pink GH. A balanced scorecard for Canadian hospitals. Healthcare Manage Forum 1995;8:7–13. [4] Cott CA, Boyle J, Fay J, Sutton D, Bowring J, Lineker S. Client-centred rehabilitation. Working Report 1–57. Toronto: Arthritis Community Research and Evaluation Unit; 2001. [5] Cott CA. Client-centred rehabilitation: client perspectives. Dis Rehabil 2004;26:1411–22. [6] Soever L, Cott CA, Boyle J. Client centred rehabilitation II: health care professional’s perspectives. Working Report 1–60. Toronto: Arthritis Community Research and Evaluation Unit; 2003. [7] Cott CA, Teare G, McGilton KS, Lineker S. Development and pilot testing of the client-centred rehabilitation questionnaire. Dis Rehabil 2006;28:1387–97. [8] Tyas J, Soever L, MacKay C, Cott CA. Client perspectives technical summary. Hospital report 2005: rehabilitation. Toronto: Hospital Report Research Collaborative, University of Toronto; 2005.

Cheryl A. Cott ∗ Department of Physical Therapy, Faculty of Medicine, University of Toronto, 160–500 University Avenue, Toronto, Ontario M5G 1V7, Canada Tel.: +1 416 978 0301; fax: +1 416 946 8562. E-mail address:

Available online at

Physiotherapy 94 (2008) 91–96

Incidence and effect of leg length discrepancy following total hip arthroplasty
D.J. Beard a,∗ , J. Palan a , J.G. Andrew b , J. Nolan c , D.W. Murray a , EPOS Study Group

Nuffield Department of Orthopaedic Surgery, University of Oxford, Nuffield Orthopaedic Centre, Oxford OX3 7LD, UK b Ysbyty Gwynedd District Hospital, Penrhosgarnedd, Bangor, UK c Norfolk and Norwich University Hospital, Norwich, UK

Abstract Objectives The clinical importance of a leg length discrepancy (LLD) following total hip arthroplasty (THA) remains controversial. This study was undertaken to determine the effects of LLD on clinical outcomes at up to 3 years follow-up. Design and setting Prospective, multicentre study. Participants Nine hundred and eighty-seven cases of primary THA, categorised into two main groups: the NoLLD group (LLD of less than 10 mm) and the LLD group (LLD of 10 mm or more). Main outcome measures The primary outcome measure was the change in Oxford Hip Score ( OHS) at up to 3 years follow-up. Secondary outcome measures were length of operating time and hospital stay, and revision and dislocation rates. Potential predisposing factors for LLD, including body mass index, age and type of anaesthesia employed, were examined. Results At 3 years, the LLD group had a significantly worse OHS [22.0; 95% confidence interval (CI) 20.5 to 23.5] compared with the NoLLD group (23.8; 95% CI 23.1 to 24.5) (P = 0.034). There were no significant differences in revision (P = 0.389) or dislocation (P = 0.220) rates between the two groups. Use of an epidural was associated with a decreased incidence of developing an LLD of 10 mm (P = 0.004). Conclusion A postoperative LLD of 10 mm or more leads to poorer functional outcomes. Further studies are needed to assess the impact of an LLD on clinical outcomes in the longer term. © 2008 Chartered Society of Physiotherapy. Published by Elsevier Ltd. All rights reserved.
Keywords: Leg length discrepancy; Arthroplasty, hip; Dislocation; Revision; Oxford Hip Score

Introduction Leg length discrepancy (LLD) has been well described as a common complication following total hip arthroplasty (THA) [1,2]. The presence of LLD has been associated with back pain [3,4], increased risk of nerve injury [5] and dislocation [6], poor patient satisfaction [7] and the need for revision surgery [8]. It has been cited as a major cause of litigation following THA [9]. In the literature, there is continuing debate about the importance of LLD and its clinical effect.
Corresponding author. Tel.: +44 1865 227454; fax: +44 1865 227671. E-mail address: (D.J. Beard).

A recent paper by Konyves and Bannister [10] concluded that patients with an LLD (longer leg length on operated side) had a worse functional outcome compared with patients who did not have an LLD. However, a study by White and Dougall [11] showed no statistical association between LLD and patient satisfaction and outcome. However, in both of these studies, the cohort size was small and single centred.

Objectives The aim of this study was to determine the clinical effects of LLD following THA using the change in the Oxford Hip Score ( OHS) as a primary outcome measure.

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spinal anaesthesia or an epidural. In the subgroup of patients with an LLD of 20 mm or more. The Charnley categories for each group of patients were not significantly different (P = 0. Category B describes bilateral hip disease and Category C describes multiple joint involvement which limits walking ability [15] (Table 1). of which 49 patients (45%) had a shortening of the operated leg and 61 patients (56%) had a lengthening of the operated leg.014).4) in the NoLLD group and the LLD group.6 mm. Chi-squared test). 1 year and 3 years. Pre. This was either a general anaesthetic. and the -level of significance was defined as less than 5% (P ≤ 0.135).014 0.05). Statistics For the outcome measures. The diagnosis in every case was that of primary osteoarthritis and all were unilateral hips. analysis of variance and Tukey’s Post Hoc test were used to compare differences in data between the groups. The OHS was also analysed as separate question components to identify if there were particular functional activities or symptoms which affected those patients with an LLD. 417 patients had equal leg lengths.803 985 936 939 792 752 754 69. There was no significant difference in the mean body mass index of the two groups (P = 0.9 mm and the mean length of leg lengthening was +15.5 27. Within the LLD Table 1 Demographics and preoperative data for the two study groups Total no. The type of anaesthetic used for each patient was recorded to assess if there was an association between the type of anaesthetic used and LLD. and revision and dislocation rates for each of the LLD groups.17] of assessing clinical outcomes on a patient-centred basis. and the LLD group. / Physiotherapy 94 (2008) 91–96 Design and setting This was a prospective non-randomised multicentre study involving seven centres. The true leg length was measured in millimetres (mm) using a direct tape measure method.7 mm [standard deviation (SD) ± 1.and postoperative OHSs were collected and the change in OHS ( OHS) was calculated at 3 months. The LLD was calculated as the difference between the two measurements.0 ± 4.1). Patients in the NoLLD group were younger than those in the LLD group (P = 0. Main outcome measures The OHS was used as a well-validated method [16. a cemented Exeter femoral stem (Stryker Howmedica Osteonics. 987 THAs were examined in this study. The mean LLD was 0.7 mm (SD ± 2. NoLLD group (LLD of less than 10 mm) 293 498 n 192 LLD group (LLD of 10 mm or more) 69 123 P-value 0.3 122 33 30 0. 75 cases of LLD of 10 mm or more (39%) were shorter and 118 cases (61%) were longer (P < 0. of total hip arthroplasties Gender (total) Men Women Mean age at operation (years) ± +1 SD Mean body mass index (kg/m2 ) ± +1 SD Charnley category A B C 983 n 791 group.0 502 141 111 193 184 185 71. with the patient in a supine position. . Mahwah. In all cases. Participants In total. The patients were categorised into two main groups: the NoLLD group.92 D. Beard et al. the mean length of leg shortening was −13. there were 110 patients with a minor LLD of less than 10 mm. USA) was used with various acetabular components. None of the patients had undergone previous surgery to the hip. In the NoLLD group. Category A describes unilateral hip disease. Categorical and frequency data were analysed using Chi-squared and Fisher’s Exact tests. The overall mean LLD in the series was 3. SD. with an LLD of less than 10 mm (n = 794). involving consultant and non-consultant surgeons and utilising two different surgical approaches (anterolateral and posterior). and 69 men and 123 women in the LLD group.4 ± 8.865). the mean LLD was 24. from the anterior superior iliac spine to the medial malleolus of the operated side and non-operated side [12–14].5 mm. each marked from one (best) to five (worst). Within this group.J. The LLD was assessed to determine whether the effect of the discrepancy was to lengthen or shorten the affected leg. In the LLD group.5 27. New Jersey. standard deviation.9 mm (SD ± 7. Patient demographics are shown in Table 1. leg length discrepancy.1 ± 8.001.135 0. A subgroup analysis was also performed on a small number of patients (n = 55) who had a severe LLD of 20 mm of more. Secondary outcome measures included the mean length of operating time and hospital stay. respectively.865 LLD. There were 293 men and 498 women in the NoLLD group. with an LLD of 10 mm or more (n = 193).8] and 14.6 ± 5. The OHS is scored from 12 (best) to 60 (worst) and consists of 12 questions.

1 (SPSS Inc.423 0. including the subgroup of patients with an LLD of 20 mm or more (P = 0.8 23. The absolute OHS (Table 2) at 3 years was also significantly different between the groups: 19.7 to 19. USA) was employed for statistical analysis of the data.0. indicating that patients who had a severe postoperative LLD had significantly more pain associated with their arthritic hip prior to their operation.03).022 0.5 16. IL.3 in the LLD group (LLD of 10 mm or more).6 to 21.7 to 19. leg length discrepancy. Patients with an LLD of 20 mm or more scored highest (worst) preoperatively for Question 1 compared with the other patients (P = 0.591) or 3 years (P = 0.034) (Fig. The mean preoperative OHS was 43. Error bars represent standard deviation (+1SD).2 18.9 17.8 to 43. with the NoLLD group showing the greater improvement in OHS (P = 0. However.9 20.5 LLD group (LLD of 10 mm or more) n 193 170 188 153 170 188 153 Mean 43.D.1 to 24. However. 1 year Fig.0 18.041 0. 12 and 36 months follow-up in the two study groups.537) or 1 year (P = 0. b OHS: 0 (worst) to 48 (best). With regards to limping. confidence intervals.5 23. .4 in the NoLLD group (LLD of less than 10 mm) and 43.5 0.3 25. At 3 years.4 19. Chicago. a statistically significant difference in the OHS between the groups was seen.6) compared with patients in the LLD group with an LLD of 10 to <20 mm (OHS = 42.584).6.3 for the NoLLD group and 21. / Physiotherapy 94 (2008) 91–96 93 Data from Questions 1 and 9 of the OHS were analysed using the non-parametric Kruskal–Wallis test.0 95% CI 42. A subgroup analysis of the LLD group was performed whereby patients with an LLD of 20 mm or more were also assessed in terms of their OHS and OHS.3) (P = 0.654).8 95% CI 42. 1). Questions 1 and 9 were scored from one to five points (one point being the best score. a Absolute OHS: 12 (best) to 60 (worst).086) after surgery (Table 2).5 to 23.2 to 24.3 24.1 18.2 to 23. The individual components of the OHS questionnaire were analysed. After surgery.086 0. Change in Oxford Hip Score (OHS) at 3.034 P-valuec LLD. differences emerged after surgery.and postoperative Oxford Hip Scores (OHSs) and change in OHS ( OHS) in the two study groups at up to 3 years follow-up Total no.498) when comparing a shorter LLD with a longer LLD (Table 3). this group of patients achieved a considerable benefit from surgery as evidenced by their OHS of 24. there were no significant differences in the scoring for Question 9 preoperatively between the NoLLD group and the LLD group.537 0.7 19. Results Primary outcome measure There was no difference in the preoperative OHS between the NoLLD group and the LLD group (P = 0.3 18. In particular.6 23.4 24.J. especially the patients with an LLD Table 2 Mean absolute pre. (P = 0.1 to 25. The clinical benefit of surgery as determined by the OHS was not significantly different between the groups at 3 months (P = 0. of total hip arthroplasties Preoperative OHS Mean absolute OHSa 3 months 1 year 3 years Mean OHSb 3 months 1 year 3 years 987 861 946 814 861 946 814 NoLLD group (LLD of less than 10 mm) n 794 691 758 661 691 758 661 Mean 43.9 to 20.9 24.9 to 19. respectively. this difference in pain was no longer significant (P = 0.6 to 22. Beard et al.885 0. CI.1 to 26. There was no difference in OHS at 3 months (P = 0. The effect of shortening and lengthening of the operated leg side was evaluated within the LLD group.4 23.2 to 44. emphasis was placed on Questions 1 and 9 which dealt specifically with pain and limping. indicating worse pain and functional symptoms prior to surgery.1 22.022). Statistical Package for the Social Sciences Version 12.9 19. with the LLD group.568).2 19. c P-value calculated using analysis of variance. The outcomes did not differ between the two groups until 3 years. five points being the worst score).5 21.1 for the LLD group (P = 0. at 3 years following THA.5 22.8 21. 1.017).885).2 20. This minority group of patients had a significantly higher preoperative OHS (45.

4 16.4 16.5 mm. with a mean LLD of 1 mm [19]. although there is a lack of consensus about what constitutes a clinically significant postoperative inequality [18]. In another study.9 to 24. As such.8 mm. In the present series. at up to 3 years follow-up. have described a two-point change in OHS as being the minimum clinical change perceived by patients as meaningful and which may lead to changes in clinical practice [22]. and therefore the benefit of surgery is especially pronounced in terms of improved OHS outcomes and the reduction of pain. Murray et al. Such a pronounced discrepancy has been described in the literature as being poorly tolerated by patients [21]. as was the length of hospital stay (P = 0. [14] found that LLD varied from −20 (shortened leg) to +15 mm (lengthened leg) with a mean of 2. yet achieved a comparable score to the other groups at 3 years follow-up.001). Ranawat and Rodriguez [20] demonstrated that the mean LLD was 3.307) or spinal (P = 0. of total hip arthroplasties Mean 3 months 1 year 3 years OHSa 170 188 153 68 73 57 18.220).6 22. Secondary outcome measures The percentage of patients in each of the three groups needing revision surgery was analysed.9 minutes.9 minutes) and a shorter length of hospital stay (9.3 to 20. Turula et al. b P-value calculated using analysis of variance.8 22. the analgesic effect of surgery was such as to offset the symptoms of significant LLD.3 0.006). however. Beard et al. The incidence of an LLD of 20 mm or more was 6% (55/987 cases). comparing a shorter and longer LLD Total no.568 0.9 102 115 96 17.3 18. 97% of patients undergoing THA had an LLD of less than 10 mm.9 to 23.004). P = 0. In a consecutive series of 100 patients. six of 794 cases [relative frequency (RF) = 1%] needed revision. P = 0.4 mm (range −10 to 18 mm).225) anaesthetic and an LLD of 10 mm or more. Clearly.591 0. length of hospital stay 10.8 22.5 20.6 21. The NoLLD group had a longer mean operating time (89. A higher percentage of patients in the NoLLD group (29%.498 Shorter LLD n Mean 95% CI n Longer LLD Mean 95% CI P-valueb CI. It may be because such patients had particularly severe pain symptoms from their diseased hip. 229/793 cases) received an epidural and had an LLD of less than 10 mm. patients with an LLD of 10 mm or more had twice the incidence of limping compared with patients with an LLD of less than 10 mm. three of 193 cases were revised (RF = 2%. It is surprising to note that those patients in the LLD group who had an LLD of 20 mm or more still gained a considerable benefit from having a THA and had a greater OHS at 3 years compared with patients who had an LLD of 10 to <20 mm. LLD group: RF = 1%.0 to 19.389). Patients with an LLD of 20 mm or more had a significantly higher score preoperatively for Question 1 of the OHS questionnaire (indicating worse pain symptoms) compared with the other groups. This suggests that surgery alleviated their pain to such an extent that even with an LLD of 20 mm or more. of 20 mm or more.J. some caution is advised when interpreting the significance of the results in this select group of patients. There was no difference in OHS at 3 years when a shorter LLD was compared with a longer LLD. / Physiotherapy 94 (2008) 91–96 Table 3 Mean change in Oxford Hip Score ( OHS) in the leg length discrepancy (LLD) group. No significant differences were associated with a general (P = 0. whereas in the LLD group. There was no significant difference in dislocation rate between the groups (NoLLD group: RF = 2%. Discussion LLD has been reported in the literature as being a common finding following primary THA. the relative frequency of patients with an LLD of less than 10 mm was 80%. This study has demonstrated that having an LLD of 10 mm or more is associated with having a significantly poorer outcome in terms of the clinical benefit of surgery ( OHS) compared with patients who either have equal leg lengths or an LLD of less than 10 mm. In the NoLLD group. The reason for this is unclear. Use of an epidural was associated with a decreased incidence of having an LLD greater than 10 mm (P = 0. scoring worse for Question 9 compared with the NoLLD group (P = 0.1 21. a OHS: 0 (worst) to 48 (best). the presence of an LLD . 3 years after surgery.5 to 24. The mean length of operating time for the two groups was significantly different (P = 0. 16/794 cases. and in the LLD group. Preoperatively.94 D.9 19. A power analysis was performed in this subgroup of patients and the sample size was insufficient to detect a two-point difference in OHS. The vast majority of these patients have an LLD of less than 10 mm. It should also be remembered that the sample size in this group was small and that this may affect the meaning of statistical tests of significance [23]. 1/193 cases. patients in all three groups had a similar incidence of limping. the percentage was 19% (36/193 cases).3 to 24. Whether such a difference in OHS is clinically important is more difficult to assess. with an overall mean LLD of 3. confidence intervals.6 days). Limping appeared to be more of a problem in patients with an LLD of 10 mm or more. in one series.038).0 days) compared with the LLD group (mean operating time 84.

Newbury. failure of non-operative therapy or if there is gross instability of the hip replacement. and clinical methods involving the tape measure method of determining LLD have been shown to be valid in the clinical setting [12. contractures of periarticular hip muscles including tensor fascia lata. Spine 1981. Tuson. / Physiotherapy 94 (2008) 91–96 95 of 10 mm of more is. It is important to differentiate between an apparent and a true LLD as the success of various treatment options will be different. In conclusion. Reeves BC. although this is a large and prospective study by design. Further studies are needed into the longer-term effects of an LLD following hip arthroplasty. An epidural provides a less potent muscle relaxant effect compared with a spinal or general anaesthetic [24]. The following are study co-ordinators for the EPOS group: A. UK) for their help in collating the EPOS data. Low-back pain associated with leg length inequality. time consumption and patient exposure to radiation [32].8:643–51. from a patient’s perspective. Nolan. this may lead to greater accuracy in assessing intra-operative leg lengths and hence minimise the risk of developing a substantial LLD [25]. In such cases. Mortality. perhaps not surprisingly. as the muscles are fully relaxed [6]. By and large.28]. A. Kate Honeybill and Dr.25]. Gibson. Darrah. Cawton. Clinical symptoms and biomechanics of lumbar spine and hip joint in leg length inequality.D. Acknowledgements The authors wish to thank Ms. Newbury. heel lift or. Taylor JR. L. because of persistent pain and impaired function. on the effects of an LLD on the forces at the hip joint. Reckling FW. [2] Williamson JA. Conflict of interest: This study was supported by Stryker Howmedica Osteonics. Reilly. [5] Pritchett JW. Shoe lifts have been used in patients with an LLD of less than 10 mm. A. gluteus minimus and medius. the measurement of leg length was performed by clinical measurement and not radiological measurements. Limb length discrepancy and related problems following total hip joint replacement. demographic data suggest that such patients had no particular differences and the number was small. An apparent LLD can be treated with aggressive physiotherapy in the form of stretching exercises. An apparent or functional LLD can occur as a result of a fixed spinal deformity (lumbosacral scoliosis). Inaparthy and C. this finding is supported by experimental evidence examining the potential dislocating forces around the hip joint. Beard et al. References [1] Williams O. Care should therefore be taken to minimise LLD intra-operatively in order to maximise the clinical benefits of THA for the patient. Mr. an LLD of more than 10 mm does appear to diminish the benefits of THA significantly in terms of OHS.J. Either the acetabular cup is implanted too distally (shifting the centre of the hip joint and causing the leg to migrate distally) or too long a femoral component is used [13]. Hamer. inexpensive and can be prepared and adjusted by trained physiotherapists [31]. In turn. it did have some incomplete data and there is always the potential that those patients lost to follow-up may have different characteristics. are limited by their costs.17:165–71. concluded that there are no substantial changes in hip forces for most types of LLD seen after THA. J Arthroplasty 2002. remains less clear. Most cases of an apparent LLD following THA resolve with time and physiotherapy. Jenkins. P. UK. manual massage and soft tissue mobilisation techniques occasionally supplemented with steroid or Botox injections [30]. Polly Winter (Clinical Research Associates. Cooper. under a general anaesthetic. and the patient’s muscles are in a more ‘physiologically’ normal state. the majority of treatments remain non-operative and involve the use of shoe or heel lifts to the shorter leg. Clin Orthop Relat Res 1978:135–8.6:510–21. Ethical approval: Salford and Trafford Research Ethics Committee. [4] Giles LG. . morbidity. which may be difficult to assess during surgery. K. and the presence of pelvic obliquity [20]. physiotherapy has a much more limited role as no amount of rehabilitation will correct the discrepancy. although considered the gold standard in measuring LLD accurately. Pitchfork. Whether this difference in OHS is clinically important. Stryker Howmedica Osteonics. surgical soft tissue releases or revision arthroplasty [20]. Occasionally. although a small subset of patients may require a shoe lift. associated with the presence of a limp. However. P. There are some potential limitations to this study. Morris RW. and are noninvasive. [3] Friberg O. In terms of dislocation. McGovern. Mr. C. The use of an epidural was associated with a decreased risk of having an LLD of 10 mm or more. revision surgery is required [13]. Fordyce and Mr. A. and 1-year outcomes of primary elective total hip arthroplasty. Clin Orthop Relat Res 2004:168– 71. Mr. Spine 1983. M. Potter. This study did not demonstrate any significant differences in revision or dislocation rates between the groups. Such imaging techniques. Fitzpatrick R. J. et al. Secondly. as a last resort. A true LLD is an anatomical deficit and occurs as a result of component malpositioning following THA. LLD is thought to be related to myofascial tension. C. The following are principal investigators of the EPOS group: Mr. Stimpson A. Project Number 98105 – MREC 98/8/20 UK Multi-centre Exeter Primary Outcome Study (EPOS). It is postulated that the reasoning for this relates to the degree of motor blockade achieved using an epidural compared with the other anaesthetic techniques. K. Hajat S. The present results contradict those of other studies which have demonstrated an association between LLD and dislocation rates [27. which is thought to be due to changes in the myofascial tension affecting the stability of the hip prosthesis [29]. Firstly. Gait analysis work by Brand and Yack [26]. Nerve injury and limb lengthening after hip replacement: treatment by shortening.

2):9– . Rodriguez JA. / Physiotherapy 94 (2008) 91–96 [19] Woolson ST. J Bone Joint Surg Br 1998. A comparison between the Harris hip score and the Nottingham Health Profile.420:72–9. 1):108–10. [26] Brand RA. Rothstein JM. Specific or general health outcome measures in the evaluation of total hip replacement. Bissett GA. Rogers K.J. Sawyer A. [32] Gurney B. Rawal N. J Arthroplasty 2003. Carr A. [17] Dawson J. Warashina H. Vankka E. Comparison of measures to assess outcomes in total hip replacement surgery. Malchau H.67:832–41.86:2075– 80. Bannister GC. The importance of leg length discrepancy after total hip arthroplasty. Clin Orthop Relat Res 2001. et al. J Bone Joint Surg Br 2002. [29] Padgett DE. Sharkey PF. Vail TP. Hallberg S. J Arthroplasty 2004. Beard DJ. [30] Bhave A. Starr R. Mont M. Surgical treatment of limb-length discrepancy following total hip arthroplasty. Clin Orthop Relat Res 2004. Leg length discrepancy in total hip arthroplasty. Functional problems and treatment solutions after total hip and knee joint arthroplasty. Clin Orthop Relat Res 1986:163–8. Fitzpatrick R. Pandit H. J Bone Joint Surg Br 1996.15:195–206. Qual Health Care 1996. Leg length discrepancy. Beard et al. Can J Anaesth 1993. Yack HJ. Laugaland K. J Arthroplasty 1997.85-A:2310–7.23:201–9. Morrey BF.18(Suppl.333:165–71. J Bone Joint Surg Br 2007. Combined spinal epidural block versus spinal and epidural block for orthopaedic surgery. Rothman RH. [13] Parvizi J.87:155–7. Late dislocations in patients with Charnley total hip arthroplasty. The use of the Oxford hip and knee scores. Conservative correction of leg-length discrepancies of 10 mm or less for the relief of chronic low back pain. Keeney JA. Arthroplasty of the hip. [6] Woo RY.96 D. Carr AJ. Carr A. [16] Dawson J. Management of limb length inequality during total hip replacement. Leg length is not important. J Bone Joint Surg Am 1985. Gait Posture 2002.40:601–6. Leg length inequality after total hip arthroplasty. [25] Jasty M. [24] Holmstrom B. Friberg O. Functional leg-length inequality following total hip arthroplasty. Am Statist 1986. Rothman RH. Pick CG. 1):88–90. The unstable total hip replacement. [12] Beattie P. Validity of derived measurements of leg-length differences obtained by use of a tape measure. Clin Orthop Relat Res 1996.393:157–62. Dislocations after total hip arthroplasty. [21] Gross RH. [10] Konyves A. Orthop Clin North Am 1992. Effects of leg length discrepancies on the forces at the hip joint. Hartford JM. Murray D. [9] Attarian DE. Sullivan PM.78:185–90. [27] Callaghan JJ. Available online at www.40:313–5. Webster W. Johnston RC. The effect of sample size on the meaning of significance tests. [8] Austin MS. [20] Ranawat CS. Sharkey PF. Clin Orthop Relat Res 2005:72–6.89:1010–4.12:359–64.84:335–8. J Bone Joint Surg Br 2005. Isaacson K. [22] Murray DW. Leg length discrepancy: how much is too much? Orthopedics 1978. Tallroth K. Heithoff BE. Phys Ther 1990. Hozack WJ.5:81–8.19(Suppl. Herberts P. Medicolegal aspects of hip and knee arthroplasty. Prevention of dislocation after hip arthroplasty: lessons from long-term followup. J Bone Joint Surg Am 1982. Leg length discrepancy after total hip arthroplasty. Harris W.1:307–10. [23] Royall RM. Ben Benyamin S.14:159–64. Aldubi RD. Dougall TW. Tennis S. [7] Maloney WJ. [11] White TO.80:600–6.333:172–80. [28] Coventry MB. J Bone Joint Surg Am 2003.64:1295–306. [14] Turula KB. Riddle DL. J Bone Joint Surg Am 2005. [18] Abraham WD. Hozack WJ. Goetz DD. Pedersen DR. [31] Defrin R. Fitzpatrick R. J Arthroplasty 1999. Murray D. Nickey M. [15] Garellick G. Clin Orthop Relat Res 1996. Dimon III JH. Results of a method of leg-length equalization for patients undergoing primary total hip replacement.70:150–7. Lindholm TS. Arch Phys Med Rehabil 2005. Questionnaire on the perceptions of patients about total hip replacement. Stability and leg length equality in total hip arthroplasty. Fitzpatrick R.87(Suppl. Etienne G.sciencedirect.

is commonly used by physiotherapists to treat patients with low back pain (LBP) [1. Results from smaller trials and lower quality RCTs showed more variation in differences between the intervention and control groups than larger or higher quality trials. thereby limiting their value in academic and clinical practice. a mobilisation/manipulation package is an effective intervention [compared with general practitioner (GP) care]. within manual therapy. manipulation. Ireland c Faculty for Health and Wellbeing. Chartered Society of Physiotherapy. Published by Elsevier Ltd. doi:10. Worthing and Southlands Hospitals NHS Trust.2]. methodological quality and statistical rigour on outcomes of randomised controlled trials on mobilisation. Sheffield S10 2BP. 0031-9406/$ – see front matter © 2007 Chartered Society of Physiotherapy. Conclusions Many RCTs in the area of manual therapy for LBP have shortcomings in sample size. Moreover. UK b a Abstract Objectives To assess the effect of sample size. Consequently.e. PEDro and the library collection of the Chartered Society of Physiotherapy. results of randomised controlled trials (RCTs) in this area are often difficult to interpret. AMED. Shoreham-by-Sea BN43 6TQ. London WC1R 4ED. © 2007 Chartered Society of Physiotherapy. Highfield. Anne Jackson a.1016/j. The sample size. Hettinga a . and to report results from RCTs with adequate sample size. Chris Mercer d . methodological quality and/or statistical rigour. manipulation and massage for low back pain of at least 6 weeks duration Dries M. for improvement in pain and function. Hurley b . University of Southampton. methodological quality and statistical rigour. Manipulation.5]. defined as massage. Results Ten RCTs were included in the review but only two qualified as higher quality RCTs. whilst manipulation used in isolation showed no real benefits over sham manipulation or an alternative intervention. UK d Physiotherapy Department. treatment exist. Tel. Upper Shoreham.2007. and (c) reporting statistical tests that compared the change in the intervention group with the change in the control group. Dublin 4. which means that their findings should be interpreted with caution. Evidence from Stephen May c . Belfield. Jackson). Massage. Review methods RCTs were identified that compared manual therapy with a control or alternative intervention in adults with non-specific LBP of at least 6 weeks duration. RCTs were regarded as higher quality if they fulfilled the following three criteria: (a) >40 subjects in the manual therapy group.: +44 1903 212116.Physiotherapy 94 (2008) 97–104 Systematic review Assessing the effect of sample size. for non-specific LBP of at least 6 weeks duration. Sheffield Hallam University. E-mail address: jacksona@csp.10. RCTs in the area of back pain often score low on methodological quality scales and include small sample sizes [4. CINAHL. Southampton SO17 1BJ. Unfortunately. UK School of Physiotherapy and Performance Science. All rights reserved. methodological quality and statistical rigour on outcomes of randomised controlled trials (RCTs) on manual therapy (i. No higher quality evidence considering massage was identified. different approaches to ∗ Corresponding author. Manual therapy. Cochrane. mobilisation and/or massage) for non-specific low back pain (LBP) of at least 6 weeks duration. Data sources MedLine.008 . high-quality RCTs with adequate statistical analyses showed that. Keywords: Low back pain. UK e School of Health Professions and Rehabilitation Sciences. methodological quality (adapted 10-point van Tulder scale) and statistical rigour were then assessed. mobilisation and/or manipulation in this review. University College Dublin. ranging from massage and mobilisation to manipulation.∗ . fax: +44 208 306 6653. However. Systematic review Introduction Manual therapy. Deirdre (A. All rights reserved. 14 Bedford Row. the literature does not always distinguish between mobilisation and manipulation [3]. (b) scoring >5/10 on the Van Tulder scale. Lisa Roberts e Research and Development. but there remains evidence from higher quality RCTs to support the use of a manual therapy package. compared with GP care. Published by Elsevier Ltd.

15]. (1995) showed that although the quality of most reviews on spinal manipulation for LBP was low. published since the start of each database until June 2003. RCTs were included if they met the following criteria: • Patients aged >18 years with non-specific LBP of at least 6 weeks duration. A description of subacute or chronic patients was not sufficient. however. within-group analysis will not distinguish the natural course of LBP from the interventionspecific effect. those with the highest quality scores generally supported the use of spinal manipulation [13]. it is desirable to focus on high-quality research. In contrast. Adequate statistical power (i. Literature search An extensive literature search was conducted to identify systematic reviews and RCTs on physiotherapy interventions for the treatment of LBP. including the latest Cochrane review. Assendelft et al. an updated search was conducted using the same databases to identify any new systematic reviews or RCTs published between 2003 and 1 June 2005. Moreover. the actual duration of pain was needed. A good understanding of how the quality. whilst acknowledging the low quality of most RCTs. . Inadequate sample sizes in RCTs can result in unreliable results. Only appropriately powered RCTs will detect statistically significant differences [5]. Methods This review was part of a project aimed at developing physiotherapy-specific guidelines for the treatment of persistent LBP. Systematic reviews were used to identify relevant RCTs. Moreover. and 10 were identified as the most relevant for this review. This search in MedLine. research in other areas has shown that conclusions from reviews on multiple smaller RCTs can conflict with the results from one larger RCT [14. EMBASE. Again. Best available evidence in this context was defined as evidence from RCTs that fulfil the following three criteria: (a) high methodological quality. while the search on RCTs aimed to find RCTs that were not included in the systematic reviews or which were published after the last search date of the systematic reviews. including sample size. RCTs were not excluded if these manual therapies were combined with other non-physiotherapy interventions. while a short course of manipulation/mobilisation is recommended [6]. Cochrane. methodological quality and statistical rigour.e. published by the Chartered Society of Physiotherapy (CSP). Furthermore. this is of particular importance to LBP trials as their methodological quality is often impaired [4]. Some systematic reviews. conclude that there is insufficient evidence to recommend manipulation [11. • Either massage. Therefore. • The effectiveness of manual therapies was tested in at least one of the following areas: pain. conclude that massage might be beneficial for patients with LBP [7–10]. psychological status. A similar approach may be possible at RCT level. Some systematic reviews on massage for LBP. mobilisation and/or manipulation was used as the single intervention for at least one group in the trial. and (c) used adequate statistical analyses to directly compare the change achieved using manual therapy with the change in the control or alternative intervention group. the best available evidence can be used to inform clinical practice. (b) a large sample size (as an estimate for statistical power). This gives some insight into how methodological quality may impact upon outcome. The aim of this systematic review was to assess the effect of sample size. such as general practitioner (GP) care or medication. CINAHL. This shows that the evidence for manual therapy is still hotly debated. In June 2005.98 D. Thirdly. AMED. The original scale consists of 24 criteria. of RCTs may affect the reported outcome is essential if research is to inform clinical practice. sample size) is especially difficult to achieve in studies on LBP due to its natural history of resolution. Once this effect is known. the heterogeneity of the LBP population may hinder the clinician when applying the research findings to clinical practice. methodological quality and statistical rigour on outcomes of RCTs on manual therapy for LBP of at least 6 weeks duration. which illustrates the need for large RCTs. visualise this by using forest plots [8].5].17]. Secondly. some reviews on spinal manipulation. in this review. Systematic reviews attempt to control for this using various quality checklists or scales to assess the quality of the individual RCTs. PEDro and the library collection of the CSP resulted in 5065 articles. the effectiveness of an intervention for LBP should be tested by analysing differences in changes between two or more intervention groups. This search resulted in an additional 2660 articles. Definitions of these criteria are given below. persistent LBP was defined as pain persisting for 6 weeks or more. low methodological quality can impair the validity of the results from RCTs. The methodological quality of the included trials was assessed by two reviewers using an adapted version of the van Tulder criteria [18]. or return to work/sick leave. although not eliminate entirely. / Physiotherapy 94 (2008) 97–104 These shortcomings in the evidence for manual therapy for LBP are problematic when developing guidance for clinical practice. The European clinical guidelines for the treatment of chronic LBP do not recommend the use of massage. in particular those from the Cochrane Collaboration. the group of patients who recover spontaneously from acute LBP. excluding those with acute LBP (<6 weeks) will reduce. Hettinga et al. and a definitive statement on its effectiveness is not yet available. function. especially since the quality of RCTs in back pain is often reported to be impaired [4. In order to facilitate this debate.M. Since a large proportion of patients with LBP are reported to recover spontaneously [16.12].

Interventions have been described as massage (n = 2). age. G. E. G. B. I. Hettinga et al. Half of each group received additional physical modalities. H.M. J) 5 (A. G. E.22:2323–30 [18]. I) 4 (D. / Physiotherapy 94 (2008) 97–104 Pain: modified Von Korff pain scale Hernandez-Reif 2001 [24] Postachini 1988 [25] 3 (B. duration of complaints. methodological quality and statistical rigour. J) 353 (1334) Yes Waagen 1986 [28] Manual therapy (‘chiropractic manipulation’) vs sham manipulation 4 (B.e. E.g. D. H. these descriptions were inadequate. 99 . H. which has not been included in this review Pain: VAS Function: Oswestry Low Back Pain Disability Questionnaire Psychological status: modified Zung Depression Index Pain: Von Korff Pain Scale UK BEAM 2004 [27] Mobilisation + manipulation + GP care vs exercise + GP care vs mobilisation + manipulation + exercise + GP care vs GP care 6 (A. in many cases. VAS This trial presented a combined pain and function score. G. however. I) 1 (I) 12 (24) 52 (398) Yes Yes Triano 1995 [26] 7 (A. consequently. I) n in manual therapy group (total n) 78 (262) 15/15 (30) Statistical test to compare changes? No No Outcome measures included in this review Pain: 1–10 scale for bothersomeness Function: modified Roland Disability Scale Pain: VAS Evans 1978 [22] Gibson 1985 [23] Haas 2004 [30] 5 (B. H. these interventions are called ‘manual therapy’ (n = 5) in this table. B. I.Table 1 Characteristics of randomised controlled trials (RCTs) RCT Cherkin 2001 [21] Descarreux 2004 [29] Interventions Massage vs Chinese medical acupuncture vs self-care Manual therapy (‘intensive chiropractic care’ 12 treatments in 1 month) vs manual therapy (‘intensive chiropractic care’ same as above) + follow-up sessions (once every 3 weeks for 9 months) Manual therapy (‘manipulation’) vs untreated controls Manual therapy (‘osteopathic manipulation’) vs short-wave diathermy vs placebo (detuned short-wave diathermy) One manipulation per week vs two manipulations per week vs three manipulations per week vs four manipulations per week. D. D. E. I) 47 (209) Yes Function: modified Von Korff disability scale Pain: short-form McGill Pain Questionnaire. therefore eight treatment arms in total Massage vs relaxation therapy Manual therapy (‘chiropractic manipulation’) vs medication vs back school vs placebo (anti-oedema gel) Manipulation vs sham manipulation vs education programme Methodological quality score (criteria)a 7 (B. J) 32 (32) cross-over design 41 (109) 6 (72) No No Yes Function: modified Oswestry Questionnaire Pain: four-point scale Pain: VAS D. H. H. I. visual analogue scale. H. I) 11 (29) No Function: Roland-Morris Disability Questionnaire Psychological status: Fear-avoidance Behaviour Questionnaire Pain: VAS VAS. i. Spine 1997. B. G. value of main outcome measures) (C) Was the care provider blinded to the intervention? (D) Were co-interventions avoided or comparable? (E) Was the compliance rate in each group unlikely to cause bias? (F) Was the patient blinded to the intervention? (G) Was the outcome assessor blinded to the intervention? (H) Was the withdrawal/drop-out rate unlikely to cause bias? (I) Was the timing of the outcome assessments in both groups comparable? (J) Did the analysis include an intention-to-treat analysis? These criteria are derived from van Tulder et al. The RCTs in bold have been regarded as best evidence. manipulation (n = 2) and mobilisation + manipulation (n = 1) based on the description in the original articles. D. general practitioner. I) 4 (A. E. a Methodological quality criteria: (A) Treatment allocation: was the treatment allocation concealed? (B) Were the groups similar at baseline regarding the most important prognostic indicators? (e. GP. fulfilled the three criteria on sample size.

Open points represent results from smaller and/or lower quality trials. Instead of using the total number of subjects in the RCTs. Quantitative analysis Most of the RCTs monitored pain and function before and after intervention. 4). / Physiotherapy 94 (2008) 97–104 Nine of the criteria addressed internal validity of the RCT. while points towards the top-left corner favour the control interventions. All points are taken from larger randomised controlled trials (≥40 subjects in manual therapy group) with a quality score of 5 or more. description of interventions) or qualitatively assessed (e. The change in pain as a percentage of the baseline value for the intervention group compared with the same parameter of the comparator group. the number of subjects in the manual therapy group was used as an indication of sample size. and the control or alternative intervention group was displayed on the y-axis (Figs. To assess the effect of sample size and methodological quality. Black points represent results from larger randomised controlled trials (≥40 subjects in manual therapy group) with a quality score of 5 or more. Hettinga et al. statistical criteria). These percentage changes were plotted so that the change in the manual therapy group was displayed on the x-axis. 3) and the number of subjects in the manual therapy group (Fig.g. Points towards the bottom-right corner of the plots indicate that the manual therapy intervention was better. Fig. Sample size was considered separately as this is not included in the van Tulder criteria. This controls for RCTs with a relatively large sample size but multiple subgroups. significance of this value was unknown in other cases. The line y = x represents the line of no difference between the change in the manual therapy group and the control group. while any worsening in symptoms was expressed as a negative value. The difference in change (percentage change in manual therapy group minus percentage change in the control group) presented in the randomised controlled trials and the methodological quality score of the corresponding trial. These L’Abbe plots give a clear picture of all the data in the RCTs and facilitate identification of possible outliers [19]. The line y = x represents the line of no difference between the change in the manual therapy group and the control group. while the statistical Fig. The change in function as a percentage of the baseline value for the intervention group compared with the same parameter of the comparator group. The other criteria from the original 24-item van Tulder list that were not used to calculate the score in this review were either included in the scope of this review (e. eligibility criteria. 2. and one criterion addressed similarities of main baseline characteristics/predictors (see Table 1 for a list of all criteria).g. For every RCT.M. The smallest RCTs (≤15 subjects in the manual therapy group) that also scored very low on the methodological quality scale (≤2 out of 10) were excluded from this review. the change in pain and function after any follow-up period was calculated as a percentage of the baseline score of that group [(post-score − baseline score)/baseline score × 100%]. 1. An improvement in outcome was expressed as a positive value. the difference in change (percentage change in the manual therapy group minus percentage change in the control/alternative intervention) was plotted against the quality score of the trial (Fig. . 3. Some RCTs reported P-values for this difference in change. 1 and 2). and therefore these two outcomes were analysed quantitatively. Fig. Points along the line y = x indicate that the effectiveness of the manual therapy intervention was similar to that of the control intervention.100 D. Any outcome measure for pain and function was included in this analysis.

4).M. Qualitative analysis Since small sample size.26–28]. eight RCTs were considered since two trials compared different manual therapy interventions with one another.26. only two of these three trials reported sufficient statistical analyses to meet the inclusion criteria for the qualitative analysis [26. there is evidence from higher quality RCTs that states: • manipulation in combination with mobilisation is more effective than GP care for pain relief and function improvement [27]. The sample size of the RCTs ranged widely from 24 to 1334. 1 and 2).30].23.27]. and two of these points were statistically significant. eight of these compared manual therapy with a control or alternative intervention [21–28]. comparing pre.25–27]. This review only considered the difference in change between the manual therapy group and the comparator group. low methodological quality and inadequate statistical testing can distort the results of RCTs. 3 and 4. The third criterion for best available evidence in this review was adequate statistical testing to determine the level of statistical significance for the difference in change between the manual therapy group and the control/alternative intervention group. only RCTs that were large.23. and the level of statistical significance for that difference in change. only results from large. Five of the 10 RCTs were classified as larger (≥40 subjects in manual therapy group) [21.24. the difference in change between manual therapy and control/alternative intervention was calculated.and post-scores within one group is not sufficient to test the effectiveness of an intervention. RCTs scoring the median score or higher were considered to be of higher methodological quality.26. The methodological quality of the RCTs ranged from 1/10 to 7/10 and the median score was 5/10. Fig. high-quality RCTs with adequate statistical tests comparing the difference in change between intervention groups were considered for the qualitative analysis. 3) and the number of subjects in the manual therapy group (Fig. Qualitative analysis Based on the criteria of sample size. a pragmatic approach was used in this review due to limitations in the available data. Given that LBP is reported to improve in many patients over time [16. on the effect of chance on variability in patients’ response to pain relief interventions [20]. 16 of the 27 points came from larger. / Physiotherapy 94 (2008) 97–104 101 statistical tests were used to recommend specific manual therapy interventions for chronic non-specific LBP. This cut-off point was adapted from work by Moore et al.17]. high-quality and employed adequate . except the very small RCTs that also scored low on the quality scale. To distinguish larger from smaller trials and low quality from higher quality trials. Although a power analysis should determine adequate sample size. Fig. Fig. and two compared various forms of manual therapy [29. Although all RCTs that fulfilled the three inclusion criteria were included in the quantitative analysis. and the number of subjects in the manual therapy group ranged from nine to 353. An RCT with ≥40 subjects in the manual therapy group was defined as large.D. 1 gives the percentage change in pain for the manual therapy group and the corresponding control group. higher quality RCTs. Methodological quality was assessed on a 10-point scale and RCTs were considered to be of lower methodological quality if they scored less than the median score on the 10-point quality score. Results Ten RCTs fulfilled all inclusion criteria for this review (Table 1). all these points came from larger higher quality trials and three points were statistically significant at the 5% level. Quantitative analysis For the quantitative analysis. The difference in change (percentage change in the manual therapy group minus the percentage change in the control group) presented in the randomised controlled trials and the number of subjects in the manual therapy group of the corresponding trial. six trials reported pain values that could be used to calculate a percentage change score [21. 4. This difference in change was plotted against the methodological quality score of the RCT (Fig. Consequently. methodological quality and statistical rigour. 2 gives the same information for function. From the limited number of observations shown in Figs. Of these eight RCTs. Based on the percentage change in the manual therapy group and the control/alternative intervention group (shown in Figs. it can be seen that the smaller RCTs and those of lower quality tend to show more variation in the difference in change than the larger and higher quality RCTs.27]. However.27]. arbitrary cut-off points were agreed by expert panel consensus. and three trials reported function scores that could be used to calculate a percentage change score [21. Hettinga et al. Only three RCTs were both large and of higher methodological quality [21.

in Fig. but conducting a power analysis for all RCTs retrospectively was beyond the capacity of this study. Nevertheless. Finally. this is a restriction of all methodological quality scores. Whilst the use of the cut-off point in methodological quality score (i. Discussion The aim of this review was to assess the extent to which methodological quality. although some evidence has been identified to support this cut-off point [20]. the strict inclusion criteria used to identify relevant RCTs facilitated comparison. / Physiotherapy 94 (2008) 97–104 • manipulation in combination with mobilisation is as effective as GP care for reduction in fear-avoidance behaviour [27]. The results showed that the smaller and lower quality studies displayed more variation in outcome.e. The use of percentages in the current review also has some limitations. Analysing change scores within one group or comparing post-scores of two groups seems inadequate to detect the true effectiveness of an intervention. grouping changes in pain or . Firstly. in combination with manipulation. Secondly. Moreover.5]. However. It does not take into consideration any variance present in the subject groups.M. manipulation and/or massage for persistent LBP.102 D. especially towards their patients. and this requires comparison with a second group that either receives a control or alternative intervention. although most RCTs used standard outcome measures such as visual analogue scales for pain and the Roland-Morris Disability Questionnaire for function. and statistical analyses testing the difference in change between interventions. Furthermore. sample size and statistical rigour suggested that mobilisation. No clear evidence statement could be made for massage interventions as no large. It should be noted that this conclusion is based on a limited number of observations (see Table 1). and also resulted in the inclusion of only 10 RCTs. whereas a percentage is a more intuitive parameter. The use of a total score implies that shortcomings in certain methodological aspects can be compensated for by fulfilling other criteria. it is of interest to analyse original data in various ways. such scores. A similar tendency was evident for the smaller RCTs (Fig. Differences in subject characteristics could also have played a role since larger trials have to recruit from a larger pool of subjects. and therefore the results of these studies should be interpreted with caution. The justification for only considering RCTs that fulfilled all three criteria came from the quantitative analyses. especially in manual therapy where the same terms have been used to describe different interventions [3]. which may be more generalisable than more selective recruitment from smaller trials. Most other systematic reviews on manual therapy for LBP report effect sizes when comparing and summarising RCTs. (b) an effect size may be more difficult for clinicians to interpret. i. more points are located above the line y = 0. this review also raises some methodological issues. and this is evident from Figs. 4. the study definition of higher quality trials. was a useful and effective additional therapy to standard GP care for pain and function [27]. since there was high-quality evidence that such an intervention was of equal benefit to sham manipulation or an education programme [26]. It therefore seems reasonable to expect additional improvement from effective treatments. although the findings on impaired sample size and methodological quality in LBP trials have been reported previously [4. Nevertheless. Fig. Manipulation used in isolation appeared to be less effective. ≥5 out of 10 on the adapted van Tulder scale. are now commonly used in reviews. However.17]. it does distinguish the higher from the lower quality studies. and this value has been used in a similar review on exercise [31]. 1 and 2. Ideally. the smaller RCTs tended to result more often in positive results for the manual therapy group. 3 shows that there is a tendency for more variance in difference in change in the lower quality RCTs. nor does it indicate a clinically and statistically important difference. All scores from the RCTs included in this review are displayed in Table 1. is based on consensus from the authors and the wider Guideline Development Group involved in this project (see Acknowledgements). high-quality RCT with adequate statistical analysis was identified. 4). and • manipulation is as effective as sham manipulation or an education programme for pain relief and improvement in function and psychological status (relief of depression) [26]. the median value) was arbitrary. An arbitrary cut-off point was therefore agreed. due to their simplicity. Moreover. It is widely reported that LBP improves over time for many [16. the validity and reliability of the outcome measures for pain and function were not formally assessed. This may have been caused by publication bias as smaller trials with negative results are less likely to be published. this was not done in the present review because: (a) a measure of variation and the mean are needed to calculate effect size and it has been reported previously that this is not always reported in RCTs on manual therapy for LBP [12]. and the methodology used here may reveal new insights or strengthen existing views on trials in the area of manual therapy for LBP. Thirdly. ≥40 subjects in the manual therapy group. The authors proposed that only evidence from RCTs that scored high on these three criteria should be used to guide clinical practice.e. a power calculation should reveal the appropriate sample size. and (c) pooling effect sizes in systematic reviews can be useful but does not reflect the diversity in the treatments studied. systematic reviews are only as good as the component studies and this was reflected in the quantitative analysis. Evidence from RCTs that fulfilled the study criteria on methodological quality. In addition to the statistical limitations. sample size and statistical rigour affected the conclusions from RCTs on mobilisation. similar analyses on exercise interventions for LBP suggest that sample size and methodological quality can indeed result in misinterpretation of RCTs [31]. Hettinga et al.

Cedraschi C. Irvin E. Acknowledgements The authors would like to thank the people who assisted with conducting this review (Dr. Dr. There is a need for more thorough research into the effectiveness of various physiotherapy interventions to ensure that physiotherapists can continue to play a key role in evidence-based medicine and practice. Dr. Linda Griffiths.23:2014– 20. and • identification of the characteristics of subgroups for whom specific treatments. other staff at the CSP (Alex Warne. • relevant and valid outcome measures should be used. Deyo RA. Panos Barlos. the following points should be kept in mind in the design and analysis of RCTs: • description of the interventions and precise use of terms for the various elements of the intervention should be explicit and consistent. Prof. clinical prediction rules have been suggested [32]. massage therapy.M. et al.8:53–7. sensory. Eur Spine J 2006. Imamura M. Villumsen J. Massage for low back pain. UK. a reliable set of criteria for subclassification of LBP has yet to be established. Koes BW. Malmivaara A. Nevertheless. • an adequate sample size must be determined in advance to ensure detection of statistically significant and clinically relevant effects. Katherine Deane. Shekelle PG. Denis Martin. the library staff at the CSP (Samantha Molloy. Moreover. In conclusion.274:1942–8. Shekelle PG. Baxter GD. Reported methodologic quality and discrepancies between large and small randomized trials in metaanalyses. Physiother Can 2002. Gluud C. Cochrane Database Syst Rev 2002. Klaber-Moffett J. • the change achieved with the primary intervention should be compared with the change achieved with a control or alternative intervention. Ann Intern Med 2003. Spinal manipulation for low back pain. van Tulder MW. Thompson KA. Spine 1998. safety. van der Heijden GJ. Brosseau L. To ensure that future RCTs can be used to inform clinical practice. Suttorp MJ. A descriptive questionnaire of current clinical practice. Kovacs F. and all members of the Guideline Development Group (in addition to the authors. [3] Kotoulas M. The use. This does not.19:529–39. The relationship between methodological quality and conclusions in reviews of spinal manipulation. such as manual therapy. may be most effective. JAMA 1995. and a power calculation is essential. since such an analysis can reveal the true value of an intervention.138:898–906. Koes BW. Allen JM.D. Sarah Ferguson. no recommendations can be made for massage interventions due to the lack of RCTs fulfilling all criteria for best available evidence. Bouter LM. [5] Bouter LM. [14] Kjaergard LL. Spine 1996. Sherman KJ. van Tulder MW. [2] Gracey JH. At this point in time. References [1] Foster NE. Nia Taylor and Dr. [11] Koes BW. efficacy and costs of complimentary/alternative therapies for low back pain. [13] Assendelft WJ.2:CD001929. • highest methodological quality must be aimed for in the design and reporting of the trial. Brox JI. There is a need for further high-quality research into the use of manual therapy in the management of persistent LBP. McDonough SM. Massage therapy for low back pain: a systematic review. Management of nonspecific low back pain by physiotherapists in Britain and Ireland. this systematic review shows that limitations in sample size. and spinal manipulation for back pain. Helen Whittaker and Susan Williams). however. Jennifer Klaber-Moffett. European guidelines for the management of chronic nonspecific low back pain. the findings from the most robust RCTs supported the use of a comprehensive manual therapy package consisting of mobilisation and manipulation over GP care. Jude Monteath. Conflict of interest: None. manipulation used in isolation cannot be recommended. / Physiotherapy 94 (2008) 97–104 103 function at any follow-up time was justified by the fact that no correlation was found between follow-up time and difference in change (not displayed in figures). Best Pract Res Clin Rheumatol 2005. Yu EI.135:982–9. Baxter GD. [9] Ernst E. J Pain Symptom Manage 1999.17:65–9. it would be beneficial to identify the characteristics of subgroups in non-specific LBP who would benefit most from manual therapy. [6] Airaksinen O. function. and cost of acupuncture. For manipulation. [10] Ernst E.27:406–11. Bouter LM. global measure of improvement and return to work [18].15(Suppl. Physiotherapy management of low back pain: a survey of current practice in Northern Ireland. [8] Furlan AD. [4] Koes BW.54:53– 61.21:2860–71. for example the suggestions made by the Cochrane Collaboration to use at least outcome measures for pain. Vicki Harding. Ann Intern Med 2001. Spine 2002. Chapter 4. Anna Sewarniak and Alison Jinks). Jenni Hall and Sharlene Ting). Spine 1999. [7] Cherkin DC. [12] Assendelft WJ. The use and misuse of the terms ‘manipulation’ and ‘mobilization’ in the literature establishing their efficacy in the treatment of lumbar spine disorders. A review of the evidence for the effectiveness. Assendelft WJ. suggest that there were no differences in effectiveness between follow-up points within trials. Trends in methodological quality of randomised clinical trials in low back pain. Andrea Peace. it merely justifies pooling all follow-up points in the figures presented in this review. Similar results were found in a review on exercise for LBP [31]. Methodologic issues in low back pain research in primary care. However. Cochrane Database Syst Rev 2004.1:CD000447. Hettinga et al. Susan Greenhalgh. Jo Jordan. Morton SC. Funding: CSP and the CSP’s Charitable Trust. Hildebrandt J. Steve Woby). 2):s192–300. . Spinal manipulative therapy for low back pain. Dr. movement pattern. Eur J Phys Med Rehabil 1998.24:1332–42. neuromuscular and/or psychological parameters have all been suggested [33]. An updated systematic review of randomized clinical trials. methodological quality and statistical rigour could have impaired the validity of the results from RCTs in the field of manual therapy for LBP of at least 6 weeks duration. Likewise. Knipschild PG.

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environment. CIMT is a complex intervention and the optimum intensity and length of treatment remains unknown. shaping dosage. Transferring CIMT into the clinical environment has been hampered by the lack of standardisation in many aspects of the intervention. and compliance. Ten components were identified as being relevant to the actual delivery of CIMT: type of CIMT. Belper. Derby Road. and communication. CINHAL (1982–January 2007). Modified CIMT had to include both constraint and training components. specified side of hemiplegia.07. and CIMT or modified CIMT was compared with either no intervention. Clinical application Introduction Constraint-induced movement therapy (CIMT). cognitive impairment. a new treatment for the upper limb following stroke. Stroke. The technique consists of two components: constraint of the non-paretic upper limb. spasticity. UK Abstract Objectives To identify factors relevant to implementing constraint-induced movement therapy (CIMT) within the clinical setting. pain. All rights reserved. shaping. UK. Thirteen different patient selection criteria were identified: age. 0031-9406/$ – see front matter © 2007 Chartered Society of Physiotherapy. termed ‘learned non-use’. and shaping incremental repetitive task practise [3]. excluded activities. repeated unsuc∗ Present address: Inpatient Physiotherapy Department. Fax: +44 1773 525086. group versus individual treatment. Babington Hospital (Derbyshire County Primary Care Trust).2007. perception. sensation. This phenomenon. Data sources AMED (1995–January 2007). continued after the diaschisis had passed and the limb was potentially functional. Medline (1996–January 2007) and EMBASE (1996–January 2007) were searched to identify relevant studies. balance and mobility. hand dominance. has emerged from the concept of learnt misuse and has been cited as one of the few neurorehabilitation techniques developed from a scientific and theoretical foundation [1]. However.007 . Early investigations on the effect of somatosensory deafferentation in monkeys suggested that during a period of diaschisis. All rights reserved. constraint wear time. and that the application of appropriate training regimes could reduce learned non-use and increase spontaneous use of the paretic limb [2]. Published by Elsevier Ltd. Significant variability was identified in many aspects of CIMT. The quality of the studies varied. although there was evidence that this improved with more recent studies achieving higher PEDro scores. modified CIMT or alternative treatment. © 2007 Chartered Society of Physiotherapy. cessful attempts to use the paretic upper limb resulted in the monkey learning not to use that limb. Published by Elsevier Ltd. University of Nottingham. potential harms of CIMT. It was later hypothesised that learned non-use could occur in humans after stroke. length of time post stroke. resulting in significant improvements in speed of task performance. Conclusion The development of CIMT for stroke patients has provided clinicians with a treatment technique for a defined patient group that is now supported by a considerable evidence base. Keywords: Constraint-induced movement therapy. E-mail address: anna tuke@yahoo. range of active and passive movement. However. A third relevant consideration was the selection of outcome measures. had had a stroke. Implementation and evaluation in the clinical environment would strengthen the evidence base. Nottingham NG7 2RD. Derbyshire DE56 1WX. Results Twelve eligible studies were identified.Physiotherapy 94 (2008) 105–114 Narrative review Constraint-induced movement therapy: a narrative review Anna Tuke ∗ School of Psychology. Trials had to be published in English and score 4 or more on the PEDro scale. The combination of these is thought to cause extinction of the learned non-use. although there was evidence of greater standardisation in more recent studies. there is evidence that this is improving. hand function. doi:10. type of constraint. the application of training techniques and/or constraint increased the spontaneous use of the paretic limb. The study design was either a quasi-randomised controlled trial or a randomised controlled trial. Review methods Criteria for inclusion of trials in this study were that trial participants were over 18 years of age. Patient selection criteria and the components related to the delivery of CIMT were identified as relevant factors.1016/

Trials scoring 3 or less were not included. .19. more than 6 months [17]. but not clinically relevant. three reported using the Modified Ashworth Scale [10.20].13.4. constraint-induced movement therapy.106 Table 1 Criteria for inclusion of trials in this study A.16–19]. subacute and acute stroke patients. between 3 and 9 months [8. Twelve studies scored 4 or more on the PEDro scale (Table 3). Another study reported that there was a small. One study reported that age did not influence the results and therefore should not be used to exclude participants [8].16]. modified CIMT or alternative treatment • Modified CIMT had to comprise both constraint and training components • Randomised controlled trial or a quasi-randomised controlled trial • Published in the English language in a journal CIMT. 23 and 69 participants [4. who are more than 1 year post stroke and who can walk independently without an aid [9]. and found that the principal concerns were patient adherence and safety [10]. The most frequently used criteria were the requirement to have more than 20 degrees of active extension at the wrist and a defined level of cognitive impairment. Table 2 Search history Database AMED CINHAL Medline Medline EMBASE Years 1985–January 2007 1982–January 2007 1996–January 2007 1996–January 2007 1996–January 2007 Search terms No. Eight of the studies were small scale. there is no reference to the practical application of CIMT within any of the published literature. of hits No.12–18]. Therefore. the upper age limit ranged from 75 to 95 years (Table 4). difference in treatment gains between participants with paresis of their pre-stroke dominant side compared with those with paresis of their pre-stroke non-dominant side [8]. with less than 20 participants [3. As blinding of therapists and subjects is not possible with CIMT.19]. There is some evidence that therapists are sceptical about the use of CIMT within a clinical environment. selected Constraint Constraint Constraint CIMT Constraint 159 328 2108 108 106 8 3 0 5 0 CIMT.15]. Length of time post stroke CIMT has been applied to chronic. In the remaining six studies.13. The reference lists of all included trials were searched manually. Specified side of hemiplegia and hand dominance Two studies excluded participants on the basis of hand dominance and its relationship to side of stroke [3. The number included for each study ranged from 2 [18] to 15 [8. The completion of a large randomised controlled trial confirmed that CIMT produces statistically significant changes in upper limb function. less than 4 months [15].20].15] and one reported using the Motor Assessment Scale [19].4]. The largest trial recruited 222 stroke patients [8]. One study listed excessive spasticity as an exclusion criterion but did not report how it was Method A computerised search of relevant bibliographic databases was undertaken to identify all randomised control trials. The National Clinical Guidelines for Stroke recommended the use of CIMT in patients with at least 10 degrees of active wrist and finger extension. these have been condensed into 13 categories relevant to clinicians. 16 studies were identified. 24 selection criteria were identified (Table 4). between 1 and 6 months [10]. At present. Tuke / Physiotherapy 94 (2008) 105–114 Results In total. functional ability and increased use of the paretic upper limb [3–5]. the maximum score was 8/10. and three studies recruited 66.14. Page et al. This conclusion was subsequently supported following a meta-analysis of the effectiveness of CIMT [7]. The inclusion criteria are listed in Table 1 and the search history is given in Table 2.14. • Trial participants were over 18 years of age and had had a stroke • CIMT or modified CIMT was compared with either no intervention. which were maintained at 1 year [8]. Spasticity Of the five studies that reported excessive spasticity as an exclusion criterion. The former reported that this was for ease of test administration and the latter did not specify a reason. Age Six out of the 12 studies did not specify an upper age limit [8. and less than 14 days [18. Hand dominance and its relationship to the hemiplegic side was the least used criterion. (2002) investigated therapist opinions about CIMT through a self-reported questionnaire. The methodological quality of the studies was assessed using the PEDro scale [11]. The studies recruited participants at the following times post stroke: more than 12 months [3. constraint-induced movement therapy. Selection criteria In total. A systematic review of randomised controlled trials of CIMT in stroke concluded that ‘CIMT may improve upper limb function following stroke for some patients when compared to alternative or no treatment’ [6]. the aim of this paper is to identify and review the issues relevant to clinicians considering the development of a CIMT programme.

Tuke / Physiotherapy 94 (2008) 105–114 Table 4 Inclusion criteria Taub 1993 [3] Time post stroke Age limit (years) Specified side of hemiplegia Serious medical condition Not participating in any trials Not in active rehabilitation No haemorrhagic lesions Hand dominance Extension at the wrist (degrees) Extension at the fingers (degrees) Extension at the metacarpophalangeal joints (degrees) Extension at the interphalangeal joints (degrees) Passive range of movement Movement at the thumb (degrees) Minimum/maximum hand function Balance Mobility Cognition Perception Sensation Communication Spasticity Pain >12 months <75 + + − − − + >20 >10 >10 − − + + + + + + + − − Van der Lee 1999 [4] >12 months 18–80 + − − − − − >20 >10 − − − − + + + + + + + − − Dromerick 2000 [19] <14 days − − + − − − − − − − − − − + − − + + − + + − Page 2002 [12] 1–6 months 95 − − + + + − >20 >10 >10 − − − − − + − − − + + Wittenberg 2003 [13] >12 months − − − − − − >20 >10 − − − − + − − − − − − − − Page 2004 [14] >12 months 18–95 − − + + + − >20 >10 >10 − − − − − + − − − + + Alberts 2004 [16] 3–9 months − − + + + − − >20 >10 >10 + >10 + + + + − − − − + Suputtitada 2004 [20] >12 months 18–80 − − − − − − >20 >10 − − − − + + + + − + + − − Page 2005 [15] <4 months 18–95 − + + − − >20 >10 >10 − − + − − + − − − + + Brogardh 2006 Ro 2006 [17] [18] >6 months − − + − − − >20 >10 − − − >10 + + + + − − + − − <14 days − − − − − − − − >10 − − − − − − − − − − + − − Wolf 2006 [8] 3–9 months − − + + + − − >10/20 >10 >10 + >10 + + + + − − − − + 107 −. listed as a criterion.Table 3 PEDro scores Author Taub 1993 [3] Van der Lee 1999 [4] Dromerick 2000 [19] Page 2002 [12] Wittenberg 2003 [13] Page 2004 [14] Page 2005 [15] Alberts 2004 [16] Suputtitada 2004 [20] Brogardh 2006 [17] Ro 2006 [18] Wolf 2006 [8] Random allocation Y N Y Y Y Y Y Y Y Y Y Y Concealed allocation N Y N N N Y N N N Y N Y Baseline comparability Y N Y N Y Y Y Y Y N Y Y Blind subjects N N N N N N N N N N N N Blind therapist N N N N N N N N N N N N Blind assessors Y Y Y Y Y Y Y N Y Y Y Y One key outcome from 85% of subjects Y Y Y Y Y Y Y Y Y N Y Y Intention-to-treat analysis N Y N N N N Y Y N Y Y Y Between-group comparisons Y Y Y Y Y Y Y Y Y Y Y Y Point estimates and variability N Y Y N N Y Y Y N Y Y Y Total score (out of 10) 5 6 6 4 5 7 7 6 5 6 7 8 A. not listed as a criterion. +. .

5 [8.16]. its measurement was not defined.20]. Another study reported that patients with a level of aphasia that prevented the completion of the outcome measures were excluded [18]. between 3 and 9 months [8. Out of the six studies that did not stipulate balance and mobility as criteria. able to walk inside without a stick [4]. Three studies stipulated that participants had to score more than 70 on the modified MMSE [12. although the exclusion scores were different [18. The MiniMental State Examination (MMSE) was reported in four studies [3. Stichting Afasie Netherlands [3].14].19] using the following range of tests: test of visual neglect [3]. line bisection test [4]. the operational details of testing these movements were only reported by two studies.20]. None of these studies documented which joints were assessed.14–16] or 2. requiring participants to score 0 or 1 on the consciousness.. This exceeded the minimal clinically important difference and was maintained at 1-year follow-up. and more than 6 months [17]. independent toilet transfers. Tuke / Physiotherapy 94 (2008) 105–114 assessed [3]. Two studies reported using the National Institute of Health Stroke Scale (NIHSS). between 1 and 6 months [15]. Two studies did not report a maximum score.10. independent 2-minute stand and independent sit–stand [8. Two studies specified the passive range of movement at the shoulder (90 degrees of abduction and flexion.8.14. Another study recruited participants scoring less than 65 on the Sollermans Hand Function Test (maximum score 80) [17].18].7 [13]. Of the 11 studies that did specify hand function as an inclusion criterion. less than 4 months [10]. Range of active and passive movement of extension in two additional digits [8]. Pain Five studies reported using excessive pain as an exclusion criterion [8. There is evidence that these lower function patients also benefited from CIMT [8]. and able to mobilise 20 metres in 40 seconds [17]. Two studies rated sensation using the Abbreviated SensoryPerceptual Examination [3] and a dichotomous scale [4]. (2002). letter cancellation test [3.16]. wrist (extension to neutral) and metacarpophalangeal joint (no contracture greater than 30 degrees) [8. Communication Most studies specified 20 degrees of active wrist extension and 10 degrees of active finger extension (Table 4). Perception Three studies assessed perception [3.10. six used the Motor Activity Log (MAL). One of these studies included lower functioning participants who had only 10 degrees of wrist extension. One study stated cognitive impairment as an exclusion criterion but did not report how it was measured [20]. communication and neglect items [19]. Balance and mobility In the six studies that stipulated balance and mobility as criteria. Hand function Only one study did not specify hand function as an inclusion criterion [3]. . participants were at the following times post stroke: more than 12 months [3.16]. Sensation One study reported impaired sensation as an exclusion criterion [20]. and the NIHSS [19]. 45 degrees of forearm supination and pronation from neutral). although neither specified impaired sensation as an exclusion criterion. and the NIHSS [19]. The inclusion criteria for the six studies were: able to mobilise without an assistive device at all times [3. 22. 45 degrees of external rotation).4]. Of these. (2004) and (2005) excluded participants scoring 4 or more on a 10 point visual analog pain scale.20]. Page et al. excluding participants if they scored more than 2. both of which specified the range of movement and the number of repetitions required at each joint [8. 10 degrees of thumb extension/abduction and at least 10 degrees Six studies reported impaired communication as an inclusion criterion. 24 and 24 respectively out of a total score of 30.16]. Cognitive impairment A minimum level of cognitive function was reported as an exclusion criterion in all papers except two [13.4. The effect of CIMT on perceptual impairments is currently unknown. All of these studies reported using a visual analogue scale.14–16]. The latter reported that patients with sensory disorders receiving CIMT exceeded the mean improvement in the ARA Test compared with patients with sensory disorders who received bimanual training [4]. However.4. participants were at the following times post stroke: more than 12 months [13. and less than 14 days [18. elbow (no less than −30 degrees of elbow extension.15]. one study did not mention the measure used [20].19]. The minimum scores used were 26.4. None of these studies reported using a standardised measure of balance and/or mobility. One study used the NIHSS to assess cognitive function. however. but excluded patients if they had ‘excessive pain in any joint of the paretic extremity’ [8. Two studies excluded participants if they scored more than 51 on the Action Research Arm (ARA) Test (maximum score 57) [4.19].17].16]. The remaining four studies used the following outcome measures: Token test [3.16].108 A.

20].17].13.15. between 1 and 4 months [10].13]. Activities excluded Intervention Ten relevant factors were identified in the delivery of CIMT: type of CIMT. Tuke / Physiotherapy 94 (2008) 105–114 109 Outcome measures Table 5 illustrates the outcome measures used to assess change in upper limb function following CIMT. Five studies reported issuing participants with a log book [4.8. sleeping. tional CIMT programme did not enhance the treatment effect [17]. Type of CIMT CIMT can be classified into the traditional format and a modified format.20]. Studies investigating the traditional format recruited participants who were 3 months [16].15.15. Type of constraint The type of constraint varied between studies (Table 6).18] to travelling. One study requested that participants should aim to wear the mitt for 90% of waking hours [18]. The remaining studies reported using either a mitt [8. between 3 and 9 months [8].17]. Three studies reported using a resting splint and sling [3.10.14. the total number of days and the length of time over which it is administered.A. type of constraint. None of the 12 studies reviewed compared one type of constraint with another. or less than 4 months [15] post stroke. or more than 12 months post stroke [3. Extending the mitt-wearing regime following a tradi- Four studies reported activities for which the constraint should not be worn (Table 6). group versus individual treatment. Four studies provided comments about the level of compliance [3. Shaping dosage Shaping dosage is defined as the number of hours spent shaping per day. The modified format was applied to participants who were less than 14 days [18. 6 months [17]. environment. Significant variation exists in interpretation of the therapy component of CIMT (Table 7). or for 5 hours on week days that were identified as a period of frequent hand use [10. a caregivers contract. Shaping Shaping is the therapy component of CIMT and is reported as being crucial to its success [3]. One study included a behavioural contract.10.17.14. There does not appear to be a relationship between the type of constraint.4.19]. The other studies did not report any activities for which the constraint should not be worn. Another study provided oral and written instructions to carers for those discharged prior to the end of treatment [18]. dressing [4] and toileting [3.8. four studies requested participants to wear the constraint for 90% of their waking hours [3. In total. and compliance. more than 12 months [14].4. mitt compliance device and daily schedule to increase levels of compliance [8]. although a number of different variations exist. these were predominantly positive. Six studies did not mention the term ‘shaping’ [3. These ranged from activities where balance or safety would have been compromised [3.10.16. Wear time In the studies investigating traditional CIMT. The studies investigating modified CIMT reported that the mitt should be worn for more than 6 hours per day [19]. One study reported a wear time of 6 hours during week days and 4 hours at weekends [13]. potential harms of CIMT.13. One study reported that the mitt compliance device consisted of a physical sensor and timer [8]. One study described the intervention as ‘forced use treatment’ [20].15]. participants were informed of the discrepancy and accurate reports occurred thereafter.15]. All seven studies reported 6 hours of shaping over . None of the studies provided the detailed information required to replicate the treatment.15–18]. excluded activities.15].14.20] Five studies reported using a modified format [10.19]. but the term was used in five studies [8.4.17]. and two studies did not report the length of time that participants were requested to wear the constraint [4. There was little variation in the shaping dosage in studies investigating traditional CIMT.16. referring to shaping or adaptive task practise and repetitive task practise [8. A number of different versions of the MAL exist and a clear description of the scoring system is not reported.14. and two studies reported using informal patient/therapist interviews [12.17]. Wolf Motor Function Test (WMFT).4.16–19] or a glove [20]. Compliance Six studies assessed compliance with the constraintwearing regime (Table 6). 12 different measures were identified.17]. and the MAL. Seven studies reported using the traditional format [3.18. Three other studies reported using mesh.14. the type of CIMT or the length of time post stroke. Fugl Meyer Test and ARA Test were used most commonly. length of time the constraint was worn (wear time). None of the 12 studies reviewed demonstrated that any one of these formats was superior. Three studies provided a more detailed account.16.19]. polystyrene-filled mitts and a sling [12. shaping dosage. On the few occasions that the self-reports did not match the output from the device.13. shaping.

listed as an outcome measure. .5/<2. the Motor Arm Scores correspond to normal (0).7 on the Motor Activity Log (maximum score not reported). maximum scores <2.5 <2. Tuke / Physiotherapy 94 (2008) 105–114 Page Brogardh 2005 [15] 2006 [17] Ro 2006 [18] Wolf 2006 [8] • • • Participants had to achieve a minimum score >51 on the Action Research Arm Test (maximum score 58). and a maximum score of 65 on the Sollermans Hand Function Test (maximum score 80) to be eligible for the study.5 Dromerick 2000 [19] Page Wittenberg 2003 Page Alberts 2004 Suputtitada 2002 [12] [13] 2004 [14] [16] 2004 [20] <51 <2.5 A. National Institutes of Health Stroke Scale. inability to hold arm up against gravity (2–3) and no movement (4).7 <2. drift of the outstretched upper extremity (1).110 Table 5 Hand function measures Taub Van der Lee 1993 [3] 1999 [4] Hand function (inclusion criteria) Action Research Arm Test Motor Activity Log Sollermans Hand Function Test National Institutes of Health Stroke Scale Hand function (outcome measure) Emory Motor Function Test Arm Motor Ability Test Motor Assessment Scale Motor Activity Log Wolf Motor Function Test Fuyl Meyer Assessment Action Research Arm Test Grip strength Pinch strength Two-point Discrimination Test Sollermans Hand Function Test Peg Board Test • • • • • • • • • • • • • • • • • • • • • • • • • • • • <51 <2.5 65 1–3 <2. •.5 1–2 <2.

toileting None None reported Log book Nil Log book Nil None reported A. 1/16 reported achieving 50% wear time None reported Adherence to mitt use while participants were in the research laboratory was usually very high 111 . patient diary. Tuke / Physiotherapy 94 (2008) 105–114 10 continuous inpatient days Week days for 10 weeks None reported None reported None reported Log book None reported None reported 12 None reported None None Glove Mesh. All participants reported that they enjoyed wearing the constraint. and one of them wanted to keep it after the study Nil Van der Lee 1999 [4] Dromerick 2000 [19] Page 2002 [12] Wittenberg 2003 [13] Page 2004 [14] Alberts 2004 [16] Suputtitada 2004 [20] Page 2005 [15] Brogardh 2006 [17] Outpatient/chronic (>12 months) Inpatient/acute (<14 days) Outpatient/subacute Mesh. 8/16 reported achieving 90% wear time. polystyrene-filled mitts and sling Mitt Resting splint at home and enclosed sling during treatment Padded mitten Not listed 12 6 hours per day 5 hours on week days identified as a period of frequent hand use 6 hours on week days/4 hours on weekends 5 hours on week days identified as a period of frequent hand use 90% of waking hours during intervention Not listed 5 hour of. 7/16 reported achieving 80–85% wear time. = 12 + 21 days Toileting Ro 2006 [18] Inpatient/subacute (<14 days) Mitten Target of 90% of waking hours 14 Wolf 2006 [8] Outpatient/3–9 months Mitten with monitoring device Target of 90% of waking hours 14 Activities in which safety would have been jeopardised None reported Oral/written instructions to those discharged before 14 days Monitoring device in mitten.Table 6 Constraint wear time and assessment of compliance Author Taub 1993 [3] Environment/patient Type of constraint type Outpatient/chronic (>12 months) Resting splint and enclosed sling Wear time 90% of waking hours Number of days 14 Activities excluded Activities where balance would be compromised (toileting) Assessment of compliance Nil Comments on compliance 3 participants worn it all the time and 1 participant worn it for 70% of the time. caregiver contract and daily schedule Participants reported that the mitt was good at increasing awareness of the hand. polystyrene-filled mitts and sling Mitt 10 Week days for 10 weeks None reported None reported None reported Log books. sleeping. behavioural contract. week days identified as a period of frequent hand use 90% of waking hours 14 Week days for 10 weeks Travelling. dressing. patient/therapist interviews Log book None reported High satisfaction 12 days and every other day for 2 weeks over a 3-month period. polystyrene-filled mitts (1–4 months) and sling Inpatient/chronic (>12 months) Outpatient/chronic (>12 months) Subacute and chronic/outpatient (3–9 months) Outpatient/chronic (>12 months) Inpatient/acute (<4 months) Chronic/outpatient (>6 months) Hand splint and sling Mesh.


Table 7 Description of therapy intervention Author Taub 1993 [3] Van der Lee 1999 [4] Form of CIMT Traditional Traditional Patient type/environment Chronic/outpatient (>12 months) Chronic/outpatient (>12 months) Description of therapy for the experimental group Practicing eating with a fork and spoon, throwing ball, dominoes, writing, pushing a broom Practice aimed at functional goals selected on the basis of patient’s residual sensorimotor capacity Individual/ group Not specified Group Duration 10 days 10 days Intensity 6 hours per day on week days 6 hours per day on week days Additional therapy None reported Group activities, exercises and therapist attention Routine interdisciplinary stroke rehabilitation None reported

Dromerick 2000 [19]


Acute/inpatient (<14 days)

Intervention that directed subject attention and effort towards hemiparetic arm. Circuit training encouraged use of the paretic arm with a variety of functional tasks Occupational therapy concentrated on functional tasks with same wrist/arm strengthening. Participants identified two to three tasks and practiced using shaping techniques. Physiotherapy concentrated on postural control activities Therapy involved progressively improving motor task performance by a successive approximation procedure combining physical/occupational and recreational therapy 25 minutes of occupational therapy concentrated on affected upper limb usage in functional tasks chosen by the patient. 5 minutes spent on strengthening and compensatory techniques using the unaffected limb. Shaping techniques were used for two to three upper limb activities chosen by the patients. Physiotherapy concentrated on postural control activities Shaping or adaptive task practice and repetitive task practice were used during the training sessions. Typical activities—stacking checkers, flipping cards, picking up marbles Forced use treatment Shaping techniques for three tasks such as brushing hair, writing, typing, picking up a cup and drinking from it. 5 minutes completing range of movement for paretic arm Shaping, task practice such as moving objects from one shelf to another, throwing balls in buckets. Fine motor practice such as fastening nuts on bolts, putting pegs in a board. Muscle strength training through lifting weights. Activity training such as laying the table, cleaning a window Shaping of the desired movements using the techniques of successive approximations Shaping (adaptive task practice) and standard task practice

Not specified

10 days

2 hours per day on week days

Page 2002 [12]


Subacute/outpatient (1–4 months)


10 weeks

30 minutes occupational therapy and physiotherapy three times per week 6 hours on week days and 4 hours on weekends 30 minutes three times per week of occupational therapy and physiotherapy

A. Tuke / Physiotherapy 94 (2008) 105–114

Wittenberg 2003 [13] Page 2004 [14]



Chronic/location unclear (>12 months) Chronic/outpatient (>12 months)

Not specified Individual

10 days

None reported

10 weeks

None reported

Alberts 2004 [16]


Subacute/outpatient (3–9 months post stroke) Chronic/outpatient (>12 months) Acute/inpatient and outpatient (<4 months) Chronic/outpatient (>6 months)


2 weeks

Up to 6 hours per day


Suputtitada 2004 [20] Page 2005 [15]

Traditional Modified

Groups of 3–4 Individual

10 days 10 weeks

6 hours per day 30 minutes three times per week

None reported None reported

Brogardh 2006 [17]

Modified and traditional

Groups of 2–3

2 weeks

6 hours per day

None reported

Ro 2006 [18] Wolf 2006 [8]

Modified Traditional

Subacute (<14 days) 3–9 months post stroke

Individual Not specified

12 days 10 days

3 hours per day 6 hours per day

None reported None specified

CIMT, constraint-induced movement therapy.

A. Tuke / Physiotherapy 94 (2008) 105–114


a 10-day period [3,4,8,13,16,17,20]. However, there was greater variation in studies using the modified format. One study reported 2 hours of shaping each day for 10 days [19]. Three studies reported 30 minutes of physiotherapy and occupational therapy three times a week for 10 weeks [12,14,15]. Another study reported 3 hours of shaping each day for 12 days (Table 7) [18]. Group versus individual treatment The delivery of the shaping component of CIMT also varied (Table 7), being delivered in a group session [4,17,20] or through individual sessions [10,14–16,18,19]. Other studies did not specify the format [3,8,13]. One study evaluated the effect of delivering the 6 hours of training within a group setting and reported a significant difference on the Motor Assessment Score, Sollermans Hand Function Test and the MAL [17]. The absence of a control group, in which shaping was delivered on an individual basis, makes it difficult to draw firm conclusions regarding which approach is superior. The lack of standardised outcome measures makes comparisons with studies using an individual approach difficult. However, there is some indication that participants value the opportunity to interact within a group environment [4,17]. At present, it is unknown whether or not this interaction has an impact on patient compliance with the CIMT programme. Environment Eight studies conducted CIMT within an outpatient environment [3,4,8,10,14,16,17,20]. All of these patients were at least 3 months post stroke. One study delivered CIMT to inpatients who were less than 14 days post stroke [19], and two studies delivered CIMT to inpatients and outpatients who were less than 4 months [15] or 14 days [18] post stroke. Another study did not state the environment in which the treatment was delivered [13]. None of the studies compared inpatient treatment with outpatient treatment. Potential harms of CIMT and adverse events One study reported that three out of four patients in the constraint group experienced muscle soreness half way through the CIMT protocol [3]. Another study reported three adverse events that affected three different participants [4]. Two of these were second-degree burns, one of which occurred in the constraint group and one in the control group. In the first case, the burns happened when the affected hand was used to operate the throttle of a scooter. The second case occurred whilst ironing. The third event was a minor skin lesion that occurred when one of the participants in the control group was shaving with the affected hand. The authors reported that these ‘adverse effects were the result of imprudent actions of the patients or overestimation of their own capabilities’ [4]. There were no reports of an increase in lesion size in any of the studies investigating CIMT. Another study

investigated serious adverse events in both a control group and an intervention group, and found no statistical difference between the groups [8].

Discussion This review has identified a number of factors that require consideration in the development of CIMT. Many aspects of CIMT are varied, although there is some evidence that a standardised approach is emerging [8,16,21]. One study standardised the inclusion/exclusion criteria, and clearly described the measures or procedures used to assess range of movement, cognition, balance and mobility [21]. This study also provided a clear description of the contracts used to encourage compliance, identify constraint wear time and involve carers in CIMT. A variety of different outcome measures have been used to assess change following CIMT. The WMFT and the MAL were reported as primary outcome measures in one study [21]. The WMFT has a high level of reliability and validity [23]. A number of different versions of the MAL exist and it is currently unclear which is the agreed format. A clear description of the 14-item version has been published [22], although uncertainty remains about whether it is appropriate for clinical use [24]. The use of acclerometry and the Actual Amount of Use Test as secondary measures [21] may be appropriate within the research community, but are likely to be too time/resource consuming for use within the clinical environment. An agreed set of outcome measures, which are accessible and usable by clinicians, would facilitate the transfer of CIMT into the clinical environment. Studies were selected to include those that had both constraint and shaping components. The variation in constraint wear time and shaping dosage means that, unlike the traditional format, there was little standardisation in the modified CIMT protocol. The optimum level of CIMT input, its distribution and application post stroke is unknown. There is some evidence that the length of time post stroke (between 3 and 9 months compared with more than 12 months) is not a predictor of motor improvement following CIMT. However, chronicity appears to be associated with greater pain and fatigue [25]. Therefore, a standardised modified CIMT protocol for patients, in both the acute and subacute phases, may be particularly important, strengthening the potential for the clinical use of CIMT. The interpretation of ‘shaping’ varied substantially, although the similarity in the descriptions increased in more recent studies. A clearer description of shaping is available [22], although publication of the battery of tasks would further clarify the content. The optimal training frequency and duration is not known. Safety and adherence have been highlighted as major issues in the application of CIMT [10]. However, in the studies reviewed, no significant problems were found. In the 12 studies reviewed, adverse events were not more likely to


A. Tuke / Physiotherapy 94 (2008) 105–114 [6] Hakkennes S, Keating J. Constraint-induced movement therapy following stroke: a systematic review of randomised controlled trials. Aust J Physiother 2005;51:221–31. [7] Bjorklund A, Fecht A. The effectiveness of constraint induced therapy as a stroke intervention. Occup Ther Health Care 2006;20:31–49. [8] Wolf S, Winstein C, Miller P, Taub E, Uswatte G, Morris D, et al. Effect of constraint-induced movement therapy on upper extremity function 3–9 months after stroke. JAMA 2006;296:2095–104. [9] Intercollegiate Stroke Working Party. The national clinical guidelines for stroke. 2nd ed. London: RCP; 2004. [10] Page S, Levine P, Sisto S, Bond Q, Johnston MV. Stroke patient’s and therapist opinion of constraint induced movement therapy. Clin Rehabil 2002;16:55–60. [11] Maher C, Sherrington C, Herbert R, Moseley A, Elkins M. Reliability of the PEDro scale for rating quality of randomised controlled trials. Phys Ther 2003;83:713–21. [12] Page S, Sisto S, Johnston MV, Levine P. Modified constraint-induced therapy after subacute stroke: a preliminary study. Am Soc Neurorehabil 2002;16:290–5. [13] Wittenberg GF, Chen R, Ishii K, Bushara KO, Taub E, Gerber LH. Constraint induced movement therapy in stroke: magneticstimulation motor maps and cerebral activation. Neurorehabil Repair 2003;17:48–57. [14] Page SJ, Sisto S, Levine P, McGrath RE. Efficacy of modified constraint induced movement therapy in chronic stroke: a single blinded randomized controlled trial. Arch Phys Med Rehabil 2004;85:14–8. [15] Page SJ, Levine P, Leonard AC. Modified constraint-induced therapy in acute stroke: a randomised controlled pilot study. Neurorehabil Neural Repair 2005;19:27–32. [16] Alberts JL, Bulter AJ, Wolf SL. The effects of constraint induced therapy on precision grip: a preliminary study. Neurorehabil Neural Repair 2004;18:250–8. [17] Brogardh C, Sjolund B. Constraint induced movement therapy patients with stroke; a pilot study on effects of small groups training and of extended mitt use. Clin Rehabil 2006;20:218–27. [18] Ro T, Noser E, Boake C, Johnson R, Gaber M, Speroni A, et al. Functional reorganization and recovery after constraint induced movement therapy in subacute stroke: case reports. Neurocase 2006;12:50–60. [19] Dromerick A, Edwards D, Hahm M. Does the application of constraintinduced movement therapy during acute rehabilitation reduce arm impairment after ischemic stroke? Stroke 2000;31:2984–8. [20] Suputtitada A, Suwanwela NC, Tumvitee PT. Effectiveness of constraint induced movement therapy in chronic stroke patients. J Med Assoc Thailand 2004;87:1482–90. [21] Winstein CJ, Miller P, Blanton S, Taub E, Uswatte G, Morris D, et al. Methods for a multisite randomized trial to investigate the effect of constraint induced movement therapy in improving upper extremity function among adults recovering from a cerebrovascular stroke. Neurorehabil Neural Repair 2003;17:137–52. [22] Taub E, Uswatte G, King DK, Morris D, Crago J, Chatterjee A. A placebo controlled trial of constraint induced movement therapy for upper extremity after stroke. cgi/content/full/37/4/1045. [23] Wolf SL, Catlin PA, Ellis M, Archer AL, Morgan B, Piacentino A. Assessing Wolf motor function test as outcome measure for research in patients after stroke. Stroke 2001;32:1635–9. [24] Van der Lee JH, Beckerman H, Knol DL, de Vet HCW, Bouter LM. Clinimetric properties of the motor activity log for the assessment of arm use in hemiparetic patients. Stroke 2004;35:1410–4. [25] Underwood J, Clark P, Blanton S, Aycock DM, Wolf SL. Pain, fatigue, and intensity of practise in people with stroke who are receiving constraint induced movement therapy. Phys Ther 2006;86:1241–50.

occur in the experimental group compared with the control group [4,8]. Compliance with CIMT is reported to be predominantly positive (Table 6). Recent studies have emphasised the use of techniques such as behavioural contracts, caregiver contracts and daily schedules to increase compliance and safety. This approach should be applied rigorously within the clinical environment, and the occurrence of adverse events should be monitored and disseminated. This review has attempted to identify the issues relevant to clinicians considering the development of CIMT. However, errors or bias may have occurred due to the following factors. Firstly, a significant number of studies identified were not randomised controlled trials and their inclusion may have affected the results. Secondly, only studies published in English were included and the majority of these were conducted within the American healthcare environment. Finally, the lack of a second reviewer could have increased the likelihood of errors and bias; however, the systematic approach to the review aimed to reduce this possibility.

Conclusion The development of CIMT for stroke patients has provided clinicians with a treatment technique for a defined patient group. However, transferring CIMT into the clinical environment has been hampered by its complexity and lack of standardisation. There is increasing evidence to support the use of CIMT, and recent publications have attempted to standardise the intervention. This should facilitate the implementation of CIMT within the clinical environment and ensure its continued evaluation. Conflicts of interest: None.

[1] Wolf S, Blanton S, Baer H, Breshears J, Bulter A. Repetitive task practise: a critical review of constraint induced movement therapy in stroke. Neurologist 2002;8:325–38. [2] Sunderland A, Tuke A. Neuroplasticity, learning and recovery after stroke: a critical evaluation of constraint-induced therapy. Neuropsychol Rehabil 2005;15(2):81–96. [3] Taub EMN, Novack T, Cook E, Flemming WC, Nepomuceno MD, et al. Technique to improve chronic motor deficit after stroke. Arch Phys Med Rehabil 1993;74:347–54. [4] Van der Lee JWR, Lankhorst GF, Vogelaar TW, Deville WL, Bouter LM. Forced use of the upper extremity in chronic stroke patients. Results from a single-blind randomised clinical trial. Stroke 1999;30:2369–75. [5] Kundel A, Kopp B, Muller G, Villringer K, Villringer A, Taub E, Herta Flor. Constraint induced movement therapy for motor recovery in chronic stroke patients. Arch Phys Med Rehabil 1999;80: 624–9.

Available online at

Physiotherapy 94 (2008) 115–124

Outcome following a physiotherapist-led intervention for chronic low back pain: the important role of cognitive processes
Steve R. Woby a,b,∗ , Neil K. Roach c , Martin Urmston a,b , Paul J. Watson d

Department of Physiotherapy, North Manchester General Hospital, Delaunays Road, Crumpsall, Manchester M8 5RB, UK b Centre for Rehabilitation Science, Division of Epidemiology and Health Sciences, University of Manchester, Manchester, UK c Department of Exercise and Sport Science, Manchester Metropolitan University (MMU Cheshire), Alsager, UK d Department of Health Sciences, University of Leicester, Leicester, UK

Abstract Objectives To examine whether patients with chronic low back pain exhibit changes in cognitive factors following Interactive Behavioural Modification Therapy (IBMT), delivered by physiotherapists; and to examine the association between pre- to post-treatment changes in cognitive factors (cognitive processes) and pre- to post-treatment changes in pain, disability and depression. Design Observational before–after study. Setting Outpatient physiotherapy department. Participants One hundred and thirty-seven patients with chronic low back pain. Interventions IBMT: ‘Work Back to Life’ rehabilitation programme. Main outcome measures Pre- to post-treatment changes in pain, disability and a range of cognitive factors. Results Patients demonstrated significant favourable changes for a range of cognitive factors. Furthermore, pre- to post-treatment changes in these cognitive factors explained an additional 22%, 17% and 15% of the variance in changes in pain, disability and depression, respectively, after controlling for other important factors. Conclusions Changes that emerge in cognitive factors are strongly related to treatment outcome within a physiotherapy treatment context. Specifically, reductions in fear of movement and catastrophising, and increases in functional self-efficacy appear to be particularly important. Modifying these cognitive factors should be seen as a priority when treating patients with chronic low back pain. © 2007 Chartered Society of Physiotherapy. Published by Elsevier Ltd. All rights reserved.
Keywords: Low back pain; Fear; Psychology; Self-efficacy; Treatment outcome; Physiotherapy

Introduction A cognitive process refers to a pre- to post-treatment change that occurs in a cognitive factor. In chronic low back pain (CLBP), it has been shown that treatment outcome is strongly influenced by cognitive processes [1–3] and these processes may be of greater importance than physical and/or behavioural processes [4,5]. Consequently, the successful modification of certain cognitive factors during physiotherapy treatment would appear to be a priority. Significant changes in certain cognitive factors have been shown

Corresponding author. Tel.: +44 161 720 2423; fax: +44 161 720 2490. E-mail address: (S.R. Woby).

to occur following cognitive-behavioural therapy and multidisciplinary treatment [6,7]. However, these interventions are unlikely to be the panacea to the huge social and economic problems associated with back pain, because they are typically expensive to deliver [8] and are inaccessible for many patients. On this basis, it would seem useful to determine the extent to which a physiotherapist-led intervention for CLBP can bring about changes in important cognitive factors. This form of intervention is less expensive and potentially far more accessible for patients than cognitive-behavioural therapy or multidisciplinary treatment. It has been reported that a physiotherapist-led exercise programme (‘Back to Fitness’ programme) that employed cognitive-behavioural principles was more effective than

0031-9406/$ – see front matter © 2007 Chartered Society of Physiotherapy. Published by Elsevier Ltd. All rights reserved. doi:10.1016/

However. Indeed.g. Both interventions were delivered by physiotherapists and the primary outcome was reduction in disability at 12 months post treatment. In contrast. Alternatively. * P < 0. disability and depression in the aforementioned treatment context. These two studies provide some support for the clinical effectiveness of a cognitive-behavioural-based intervention delivered by physiotherapists. This study aimed to examine whether CLBP patients exhibit changes in cognitive factors following Interactive Behavioural Modification Therapy (IBMT). sphincter impairment from neurological cause. A study conducted in primary care compared the effectiveness of a brief pain management programme with manual therapy for patients with subacute low back pain [11]. usually by two physiotherapists. catastrophising. In a subsequent study. a spinal manipulation intervention brought about significant reductions in disability at both 3 and 12 months post intervention [10]. although previous physiotherapist-led interventions have attempted to influence cognitive factors. The pain management programme attempted to influence a number of cognitive factors such as coping style use. and to determine the association between cognitive processes and changes in pain. in respect of clinical outcome. Patient characteristics are presented in Tables 1 and 2. recent urinary tract infection. The fact that the pain management programme did not bring about notable changes in important cognitive factors could potentially explain why this intervention was no more effective than the manual therapy intervention.8) 57* 65* 70* 33 14 22 13** 8 2 4 4 37 17 4 0 43 11 46 4 Values expressed as mean + standard deviation or percentage. it is unclear whether this mode of intervention provides any additional clinical benefits beyond those afforded by other forms of physiotherapy treatment. history of intravenous drug use).4 (11. which is a physiotherapist-led intervention underpinned by cognitivebehavioural principles. such as fear of movement/(re)injury. ** P < 0. this may be because current physiotherapistled interventions fail to bring about notable changes in cognitive factors. Based on the available evidence. In order to be referred to this intervention. and fear of movement/(re)injury [Tampa Scale for Kinesiophobia (TSK)] seemed to increase.116 S. and presence of ‘red flags’ (e. it is possible that cognitive processes exert less influence on treatment outcome in those patients who present to physiotherapy. It should be noted that although the pain management programme attempted to influence cognitive factors. progressive motor deficit. than an intervention that does not target cognitive factors explicitly. the aforementioned intervention brought about significant reductions in disability at 3 but not 12 months post intervention. / Physiotherapy 94 (2008) 115–124 routine management from a general practitioner in terms of reducing disability and improving clinical status [9].8) 40 49 56 37 21 19 2 4 3 3 11 37 15 3 3 39 17 44 5 Dropped out (n = 29) 42. avoidance behaviour etc. patients had to exhibit psychosocial risk factors (yellow flags). The study found no significant differences between the two interventions at 12 months post treatment.05. Woby et al. A total of six physiotherTable 1 Demographics and background information of patients who completed the intervention compared with patients who dropped out Variable Age (years) Male Nature of onset (gradual/sudden) Gradual Duration of back pain >1 year Employment status Employed and currently working Employed but currently on sick leave Unemployed because of back pain Unemployed but not due to health Housewife/househusband Student Retired Other Receiving wage compensation Pursuing medicolegal compensation Disabled/retired because of back pain Disabled but not because of back pain Previous history of back pain First episode One previous episode Two or more previous episodes Previous surgery for back pain Completed (n = 137) 44. levels of depression did not appear to change as a result of the programme. Methods Study population Data were collected from 166 CLBP patients who had been referred to the ‘Work Back to Life’ rehabilitation programme. [12]. Exclusion criteria were nerve root compression. it appears that physiotherapist-led interventions that target cognitive factors may be no more effective than routine physiotherapy. However. The intervention is highly interactive and is delivered to groups of approximately seven patients.01. The ‘Work Back to Life’ rehabilitation programme is a condition-specific form of IBMT developed for patients with CLBP. central nervous system impairment. . which suggests that a physiotherapist-led back pain intervention that targets cognitive factors may be no more effective.R. the extent to which changes in these factors underpin treatment outcome in a physiotherapy treatment context is unclear.5 (11. unexplained weight loss. IBMT: ‘Work Back to Life’ rehabilitation programme IBMT is a type of intervention that was developed by the chronic pain physiotherapy team based at North Manchester General Hospital. psychological distress and fear of movement/(re)injury.

education. Total scores range from 17 to 68.4) 40. with higher scores reflecting greater levels of depression. CSQ. spanning a period of 6 weeks. This does not assess severe psychopathology and is therefore considered to be more acceptable to chronic pain patients [19]. The goals are negotiated between practitioners and patients. All items are scored on a four-point scale from 0 to 3. visual analogue scale. with higher scores indicating greater pain intensity.21]. Twisting.R. HADS. Hospital Anxiety and Depression Scale. with higher scores reflecting greater fear of movement/(re)injury. each of 3. activity pacing. / Physiotherapy 94 (2008) 115–124 Table 2 Baseline characteristics of patients who completed the intervention compared with patients who dropped out Variable Disability (RDQ) Pain intensity (VAS) Depression (HADS) Fear of movement/(re)injury (TSK) Functional self-efficacy (CPSS-PF) Catastrophising (CSQ) Control over pain (CSQ) Ability to decrease pain (CSQ) Completed (n = 137) 11. the chronic pain cycle. Scores can range from 0 to 21.5 hours duration. and the final session takes place 2 weeks after the fourth session. Total scores range from 0 to 24. star jumps) are included in the exercise programme. VAS. The measure has excellent reliability. These include: common medical terms used to describe back pain. Specifically.5) 38. TSK. methods of pain control. In addition to long-term goals. Scores range from 0 to 100.26]. thus ensuring that the goals are acceptable to patients.9) 3 (1. Total scores range from 0 to 36. These goals have to involve re-engaging in activities that patients have stopped doing because of their back pain. it was felt that exposing patients to these types of activities gradually would help to reduce pain-related fear and enhance functional self-efficacy. postural advice. The exercise programme consists of specific stretching and strengthening exercises that aim to improve patients’ range of motion.5 (6.g. Pain intensity A 100-mm horizontal pain visual analogue scale (VAS) with endpoints labelled ‘no pain’ and ‘worst possible pain’ was employed to assess current pain intensity. and to enhance self-efficacy by gradually exposing patients (via exercise and goal setting) to activities that they perceive as harmful and/or threatening. The catastrophising subscale of the Coping Strategies Questionnaire (CSQ) [27] requires patients to rate the frequency with which they engage in catastrophic thoughts about their pain. patients also agree short-term behavioural goals that are reviewed on a weekly basis.2 (6. Woby et al.7 (16.5) 7. apists (each trained in IBMT) were involved in delivering the intervention throughout the duration of this study. thoughts and beliefs. The intervention comprises an exercise programme. the intervention involves five treatment sessions.3) 3. The TSK [23] requires patients to rate 17-items on a four-point Likert scale with scoring alternatives ranging from ‘strongly disagree’ to ‘strongly agree’. 8.7) 39 (22. Specific topics are covered during the interactive educational sessions. 12 and 16 are inversely scored. Physical Functioning Subscale of the Chronic Pain Self-efficacy Scale. the multifactorial nature of chronic pain with specific emphasis on the influential role of emotions. and relapse prevention. RDQ. The depression subscale has established validity and reliability [20. with higher scores reflecting greater disability. Items 4. The intervention is underpinned by cognitive-behavioural principles but is not cognitive-behaviour therapy.5 (7. muscular endurance.2) 7. These exercises are included because it is believed that back pain patients are often fearful of activities of this nature. Roland Disability Questionnaire. general strength and cardiorespiratory fitness.2) Dropped out (n = 29) 12. Depression The depression subscale of the Hospital Anxiety and Depression Scale [18] was used to assess depression. Values expressed as mean ± standard deviation.3) 2. Therefore. Change scores (post-treatment score minus pre-treatment score) were calculated for each of the measures.1 (1. management of a flareup. The initial four sessions are held on consecutive weeks. validity and responsiveness [16.4 (17.8 (1. Outcome measures (in regression analyses) Disability The Roland Disability Questionnaire [13] is a 24-item selfreport measure that assesses disability due to back pain.1) 13. Catastrophising Catastrophising has been operationalised as ‘an exaggerated negative orientation toward pain stimuli and pain experience’ [25.4 (4.8) 41 (7.6 (7.S. returning to personally valued activities. problem solving and progressive goal setting. Patients also agree long-term behavioural goals that can realistically be achieved by the end of the programme. validity and responsiveness [13–15].1) 2.6 (5. The VAS has been widely used in pain research and demonstrates good reliability. The primary aims of the intervention are to reduce fear of movement and catastrophising.8 (1. Coping Strategies Questionnaire. CPSS-PF.1) 39.7 (3.17]. bending and light impact exercises (e. Cognitive processes (predictors in regression analyses) Fear of movement/(re)injury Fear of movement/(re)injury (also known as kinesiophobia) has been defined as ‘an irritational and debilitating fear of physical movement resulting from a feeling of vulnerability to painful injury or reinjury’ [22].4) 44 (22. The English version of the TSK possesses good psychometric properties [24].2) 117 Measures Patients completed a series of self-report measures before and after the intervention.4) 12. Tampa Scale for Kinesiophobia. .

g. social activities. Firstly. Woby et al. Functional self-efficacy Functional self-efficacy refers to the confidence that a person has in their ability to accomplish certain functional activities successfully (e.28] and high test–retest reliability [28]. demographics were entered in Step 1. 56% had reported back pain symptoms for >1 year and the mean age was approximately 44 years. respectively. However.R. and therefore parametric analysis could not be performed. household activities.and post-treatment data were available from all 137 patients.88. 25% attended four sessions and 69% attended all five sessions. which enabled determination of the extent to which the cognitive processes contributed to the outcome of interest after controlling for other potentially important variables. 4 (moderately confident) and 8 (totally confident). hierarchical multiple regression analyses were performed to determine whether change scores on the cognitive factors were associated with changes in pain intensity.20.93).15]. Of those patients who completed the intervention. and is anchored with endpoints of 10 (very uncertain) and 100 (very certain). Wilcoxon signed ranks tests were used because KolmogorovSmirnov tests indicated that baseline scores on a number of the self-report measures were not normally distributed. confidence interval 0. The majority of patients were not currently working. Physiotherapists checked the self-report measures after they had been completed. family activities). Control over and ability to decrease pain The two single-item scales from the CSQ [28] were employed. Pearson’s product-moment correlation coefficients were computed to show the inter-relations that existed between the changes that emerged in the cognitive factors. The scale possessed excellent internal consistency (α = 0. The two scales possess acceptable test–retest reliability over a 14-day period [1]. Finally. The catastrophising subscale possesses good internal consistency [27. 0. Scores range from 0 to 72. age and sex (demographics) were entered in Step 1 of the analysis. there were no other significant baseline differences between those patients who completed the programme and those who dropped out.80– 0. parametric analyses could be used when analysing change scores.50 and 0. The written descriptors used were 0 (totally unconfident). 6% attended three sessions. disability and depression. Tables 1 and 2 show that patients who dropped out of the intervention were more likely to have been male. Sixty percent of the sample was female. to have had back pain for >1 year.80 or more as small. Aside from these differences. Effect sizes were also calculated to provide an indication of the size of any change that emerged on a variable of interest. Patients have to rate the extent to which they can control. Wilcoxon signed ranks tests were computed to determine whether pre. Chi-square and Fisher’s exact tests were used to explore differences in categorical measures. Statistical analyses Data were analysed in four stages. When change in depression was the outcome. and decrease.118 S. a nine-point Likert scale was employed in this study because it provided patients with a mid-point option. Kolmogorov-Smirnov tests indicated that the change scores that emerged on each of the self-report measures were normally distributed.33]. The psychometric properties of this scale were assessed in a group of CLBP patients (n = 111). Secondly. disability and depression beyond those variables entered in earlier steps of the analysis. This ensured that complete pre. to have experienced a gradual onset of back pain. demographics were entered in Step 1. Consequently. The functional subscale of the Chronic Pain Self-efficacy Scale (CPSS-PF) [29] was used to measure functional self-efficacy. with higher scores indicating greater functional self-efficacy. and to be unemployed but not for health reasons. . and patients were required to answer any questions that they had missed. moderate or large. The original CPSSPF is scored on a 10-point Likert scale. and changes in the cognitive factors were entered in Step 3. The sample reported moderate levels of pain [31] and disability [13. Thirty-seven percent were receiving wage compensation and 15% were pursuing medicolegal compensation. changes in pain and disability were entered in Step 2. and Mann Whitney U-tests were calculated to explore differences in continuous variables. When change in disability was the outcome. / Physiotherapy 94 (2008) 115–124 with higher scores denoting greater catastrophic thinking. Using a hierarchical approach enabled predictor variables to be entered in a specific order. change scores in pain intensity were entered in Step post-treatment changes occurred in the cognitive measures. followed by the change scores in the cognitive factors in Step 2. Change scores in the cognitive factors were entered in the final step to determine the extent to which they contributed to changes in pain intensity. a series of tests were performed to explore whether the baseline characteristics of patients who completed the intervention differed from those who dropped out. Cohen [30] defined effect sizes (ES) of 0. Therefore. Results Patient characteristics Seventy-five percent of patients (n = 137) completed the intervention. and relatively high levels of fear of movement [32.88) and test–retest reliability over a 3-day period (intraclass correlation coefficient 0. their pain on seven-point scales. When change in pain intensity was the outcome. and 19% perceived that they were not working because of their back pain. and change scores in the cognitive factors were entered in Step 3. Multiple regression analysis determines the extent to which a series of predictor variables are related to an outcome of interest.

29*** − post-treatment changes in the self-report measures The pre.05.54*** 0.49*** – −0.3)*** 3.15 −0.5) Post-treatment 8.04 −0.31* 1. Multiple regression analyses Pain intensity as the outcome As shown in Table 5. age and sex were not significantly associated with changes in pain intensity. Physical Functioning Subscale of the Chronic Pain Self-efficacy Scale.31*** −0.33 Values expressed as mean ± standard deviation. – 0.14 −1.R.38*** (two-tailed).12 −2. HADS.9 (8. which means that the change scores that emerged for the cognitive factors could be entered as separate predictor variables in the regression analyses [34].2)*** 10 (8. 3 4 5 6 7 8 Pain intensity Disability Depression Fear of movement Self-efficacy Catastrophising Decrease pain Control over pain (two-tailed).23 0.32*** 0.10 −0.56 0.1) 39.55*** – *** P < 0.13 1.4)** 0. Hospital Anxiety and Depression Scale. P < 0. RDQ.6 (5.7) 39 (22.00 R2 change 0.01 −1. VAS.82 βa t R2 0.47 −0.90. TSK.49*** −0.2 (1.01.32*** (two-tailed). CSQ. After controlling for these two variables.5 (6. Woby et al.7)* 34.43*** −0. which 38. Significant reductions were observed in disability.53 −0.4)*** 3.5)*** (6.59*** 0. and ability to decrease pain.66*** −0.54*** −0. perceptions of control over pain.36*** – −0. Changes in pain intensity explained an additional 22% of the variance in changes in disability beyond that accounted for by age and sex. Significant increases emerged in functional self-efficacy.8 (1.45 0. the changes that occurred in the cognitive factors accounted for an additional 22% of the variance in changes in pain intensity.4 (4.22 − post-treatment changes that occurred in each of the measures (n = 137) Variable Disability (RDQ) Pain intensity (VAS) Depression (HADS) Fear of movement/(re)injury (TSK) Functional self-efficacy (CPSS-PF) Catastrophising (CSQ) Control over pain (CSQ) Ability to decrease pain (CSQ) Pre-treatment 11.001 Table 5 Hierarchical regression analysis with change ( ) in pain intensity as the outcome and Step 1 Variable Demographics Age Sex Cognitive factors Fear of movement/(re)injury Functional self-efficacy Catastrophising Ability to decrease pain Control over pain a * *** in cognitive factors as predictor variables (n = 137) F change 0.22 0.39*** – 0.57 −1.3 (18. fear of movement/(re)injury.5 (4.37*** −0.29*** −0.001.49*** 0.05 2 – 0.00 2 0.01 −0.5) 7.5 (1. No signifiTable 4 Correlations between the changes ( ) that occurred in the measures (n = 137) 1 1 2 3 4 5 6 7 8 * P < 0.6) 6. Correlations Table 4 shows that significant associations were evident between the change scores that emerged for each of the measures.44 0. * P < 0.1) 13.1) 2.40*** – −0.2) 47.71 119 cant change occurred in pain intensity.50*** −0.21* −0. and functional self-efficacy.23. Examination of the β weights revealed that an increase in functional self-efficacy was the cognitive process most strongly related to a reduction in pain intensity (β = −0.22 6. CPSS-PF.5 (7.41*** 0.46*** 0. catastrophising and depression. Coping Strategies Questionnaire.50*** 0.9) 3 (1.28*** −0. Disability as the outcome Table 6 shows the results of the regression analysis when change in disability was the outcome.39*** −0.S.37*** 0.0001. P < 0.1)*** Effect size −0. / Physiotherapy 94 (2008) 115–124 Table 3 Pre.7 (16. Tampa Scale for Kinesiophobia. .19 Standardised regression coefficient. *** P < 0.31*** 0. P < 0.9 (27. Roland Disability Questionnaire. ** P < 0.94 −0. fear of movement/(re)injury.44*** −0. Pre.01 – 0.00 0. Moderate effect sizes were evident on the measures for disability. None of the correlation coefficients exceeded 0. visual analogue scale. ** P < 0.4 37.05).to post-treatment changes that occurred for each of the measures are shown in Table 3.001.

01.02 F change 1.36 −0. Examination of the β weights revealed that sex.01).05) and increases in functional self-efficacy (β = −0. Table 7 Hierarchical regression analysis with change ( ) in depression as the outcome and Step 1 Variable Demographics Age Sex Pain and disability Pain intensity Disability Cognitive factors Fear of movement/(re)injury Functional self-efficacy Catastrophising Ability to decrease pain Control over pain a * ** *** in cognitive factors as predictor variables (n = 137) F change 7. Together.001.08** 0. whereas changes in pain intensity were not (β = 0.01 −0.95*** 0.24 0.20 −0.15 0.33* −3.22.27 0.91 1. P < 0. Woby et al. Changes that occurred in the cognitive factors accounted for an additional 15% of the variance in outcome. The final model was able to explain 54% of the variance in outcome.79** −1. the cognitive processes explained a further 17% of the variance in outcome. P < 0.05).35 3.02 2 3 0.05.54 0.68 3.01). Discussion This study aimed to determine whether CLBP patients exhibited changes in cognitive factors following IBMT.001.74 −3.15 7.6*** 2. P < 0.08** 0.25 3 0.29 −1. P < 0. P < 0. P < 0.10 −0. P < 0. P > 0.02 0. P < 0. but not age.03. According to the β weights.20. After adjusting for age.25.22 0. / Physiotherapy 94 (2008) 115–124 Table 6 Hierarchical regression analysis with change ( ) in disability as the outcome and Step 1 Variable Demographics Age Sex Pain intensity Cognitive factors Fear of movement/(re)injury Functional self-efficacy Catastrophising Ability to decrease pain Control over pain a * ** *** in cognitive factors as predictor variables (n = 137) R2 change 0.27.53 βa t R2 0.29 0.97 0. Increases in functional self-efficacy (β = −0.R.15.05. Demographics contributed significantly to the prediction of outcome. P < 0.03 0. sex and changes in pain intensity. Examination of the β weights revealed that reductions in disability were strongly related to reductions in depression (β = 0.01.10 Standardised regression coefficient. the cognitive processes most strongly related to outcome were reductions in fear of movement (β = 0.11 2 0. accounted for a non-significant 2% of the variance.24*** 0.01) were both predictive of reductions in depression. P < 0.42 0.03 −0.18* 0.32*** 0. the changes that emerged in pain intensity and disability accounted for an extra 28% of the variance in outcome beyond demographics.05). accounting for 11% of the variance. females were more likely to exhibit a reduction in depression (β = 0.47*** 0. was related to outcome.39 0.24 0. P < 0.14 Standardised regression coefficient. P < 0.11 R2 change 0. beyond demographics and changes in pain intensity and disability.39 −0. and . The final model explained 42% of the total variance in changes in disability. Depression as the outcome The results of the regression analysis when change in depression was the outcome are shown in Table 7.17 36.01) and reductions in catastrophising (β = 0.22 −0.08 0.54*** 6.28 28. Specifically.25 βa t R2 0.23 2.04** 2.24.120 S.05 −0.08 0.

This suggests that IBMT may only be able to bring about modest changes in important cognitive factors.S. as evidenced by the significant reduction in post-treatment changes in cognitive factors (cognitive processes) and pre. in the present study and in the study by Woby et al. The finding that such a large proportion of additional variance was explained highlights the important role that cognitive processes play in bringing about reductions in disability within a physiotherapy context. It is feasible that a physiotherapist-led intervention may be capable of bringing about short-term. a brief pain management programme delivered by physiotherapists on a one-to-one basis did not appear to bring about notable changes in cognitive factors. Relationship between cognitive processes and changes in disability After controlling for age. [4]. In further support of this. In their study. whereas the intervention employed in this study. [4] attempted to influence cognitive factors directly. which found that a physiotherapistled exercise programme that employed cognitive-behavioural principles brought about changes in fear-avoidance beliefs and general back pain beliefs (3 months post intervention). Hay et al. Whilst in partial agreement with findings from the UK BEAM trial [10]. [4] may explain why these factors only explained a relatively small proportion of the variance. perceptions of control over pain. catastrophising and depression. However.38]. the lack of ‘disconfirmatory’ experiences could potentially lead to a gradual increase in pain perception.R. disability and depression. individuals in the study by Mannion et al. / Physiotherapy 94 (2008) 115–124 121 to examine the association between pre. the effect sizes were only small to moderate. which failed to explain a significant proportion of the variance. sex and changes in pain intensity. thus limiting their exposure to painful experiences [37. [11]. A number of reasons could potentially explain the difference between these studies. None of the interventions employed in the study by Mannion et al. It is therefore possible that the increases in self-efficacy that emerged in this study led patients to engage in previously avoided post-treatment changes in cognitive factors Patients who completed the intervention demonstrated significant reductions in fear of movement/(re)injury. such as IBMT. the majority of patients (94%) in the present study received between 14 and 17. With prolonged avoidance of activity. the cognitive processes explained a further 17% of the variance in reductions in disability. Increases in functional self-efficacy were strongly related to reductions in pain intensity. changes in cognitive factors. Further work is required to determine the extent to which IBMT brings about long-term changes in cognitive factors.5. why a much larger proportion of the variance was explained. respectively.8% of the variance in disability. attempted to modify certain cognitive factors explicitly. This would have provided patients with an increased number of ‘disconfirmatory’ experiences that may have led to an overall decrease in pain perception. Firstly. Individuals who volunteer to participate in an exercise-based intervention may not be representative of .36]. In addition. in the study by Hay et al. Patients with lower functional self-efficacy are less likely to engage in certain activities.5 hours of treatment. the present findings were in direct contrast to those reported by Hay et al. This means that patients have less opportunity to compare the pain they expect to experience during a particular activity with the pain they actually experience during that activity [39]. after adjusting for age and sex. but not long-term. sex and changes in pain intensity. and significant increases in functional self-efficacy.4]. It is noteworthy that previous studies have only explored a relatively small number of cognitive processes within the same study. in part. The fact that cognitive factors were not targeted in the study by Mannion et al. and factors such as fear of movement actually appeared to increase as a result of the intervention. It should be noted that although highly significant favourable changes occurred in the cognitive factors. cognitive processes explained only 7. [11]. These findings partly support those of the UK BEAM trial [10]. [1]. Relationship between cognitive processes and changes in pain intensity Cognitive processes explained an additional 22% of the variance in pain intensity. Interestingly. patients randomised to the pain management programme received a median of three. and the study by Woby et al.35. and perceptions of their ability to decrease pain. the UK BEAM trial [10] found that a physiotherapistled exercise programme that employed cognitive-behavioural principles did not bring about long-term changes in cognitive factors.5% of the variance in pain intensity [1. Previous studies have also shown that cognitive processes are strongly related to changes in disability after controlling for changes in pain intensity [1. [11] also examined long-term (12 months post intervention) changes in cognitive factors. Woby et al. The fact that the present study explored a larger number of cognitive processes could explain. This suggests that physiotherapists may need to deliver fairly comprehensive interventions. in the study conducted by Mannion et al. Pre. 20-minute sessions of treatment. This is considerably more than the variance explained in previous back pain studies. which demonstrated that cognitive processes typically explain between 0 and 16. These findings intimate that IBMT may be an effective way of bringing about changes in cognitive factors in CLBP patients. However. after controlling for age. [4] were recruited via advertisements in the local media and not directly from clinical practice. whereas the present study only explored short-term post-treatment changes in pain. in order to bring about changes in cognitive factors. cognitive processes explained an additional 17% and 22% of the variance. [1].

when the consequences of having back pain are the primary cause of a patient’s depression. which potentially threatens the generalisability of the findings. individuals seen in clinical practice often exhibit an elevated fear of movement and low self-efficacy. After adjusting for changes in pain and disability. This indicates that data for this study were derived from patients who were representative of the original sample. For instance.R. This demonstrates the important role that cognitive processes play in bringing about reductions in depression. However. to have had back pain for >1 year. avoidance behaviour etc. can bring about long-term changes in cognitive factors.43]. data were only obtained from 75% of patients who were originally referred to the intervention. Importantly. It is therefore imperative to target these cognitive factors when treating CLBP patients. to have experienced a gradual onset of back pain. suggesting that the results have good generalisability. this was not the case for changes in pain intensity. A further limitation relates to the fact that the study only investigated the relationship between short-term changes in cognitive factors and short-term changes in clinical outcomes.122 S. Future studies should explore the extent to which long-term changes in cognitive factors correspond to long-term changes in pain. given the protracted duration of symptoms experienced by the patients in this study (>50% had reported symptoms >1 year).40]. the findings of this study clearly demonstrate that many of the factors that lead to a reduction in depression (reduced disability. such as IBMT. such as pain-related fear. the cognitive processes explained an additional 15% of the variance in changes in depression. The present findings also provide partial support for a recently proposed modified version of the fear-avoidance model. the authors believe that physiotherapists are ideally placed to tackle this problem. In order to establish whether cognitive processes were related to treatment outcome. Finally. no other significant baseline differences were evident between those patients who completed the programme and those who dropped out. Indeed. although changes in disability were strongly related to changes in depression. and to be unemployed but not for health reasons. future randomised controlled trials are required to determine the extent to which IBMT brings about changes in cognitive factors relative to other interventions. Relationship between cognitive processes and changes in depression Together. / Physiotherapy 94 (2008) 115–124 those individuals typically seen within clinical practice. Nevertheless. It is also important to establish whether a physiotherapist-led intervention. it is possible that the changes that emerged in the cognitive factors may have occurred as a result of natural history or regression to the mean. and increases in functional self-efficacy emerged as strong predictors of treatment outcome. require onward referral to an appropriately trained specialist. In determining the extent to which IBMT brought about changes in cognitive factors. The authors agree that severe cases of depression. Specifically. changes in pain and disability explained a large proportion of the variance in changes in depression. This potentially means that the importance of cognitive processes may have been more pronounced within the sample. even after controlling for factors such as changes in pain and disability. However. This appears to support the notion that pain intensity is not directly related to depressive symptoms. it is unlikely that the changes in cognitive factors were solely the result of natural history or regression to the mean. disability and depression. Therefore. Those patients who dropped out from the intervention were more likely to have been male. Both reductions in fear of movement and increases in functional self-efficacy were strongly related to reductions in disability. these findings suggest that these cognitive factors can be modified following IBMT. This supports fear-avoidance models which postulate that reducing fear of movement will lead to a reduction in disability [39. . However. An interesting area for future research would be to examine the degree to which cognitive processes are related to treatment outcome in different cohorts of CLBP patients who manifest contrasting psychosocial profiles. Anecdotally. Increases in functional selfefficacy and reductions in catastrophising were both strongly related to reductions in depression. whereas individuals who volunteer to participate in an exercise programme are probably less likely to exhibit an elevated fear of movement and/or low self-efficacy. physiotherapists often suggest that tackling the depression exhibited by CLBP patients falls outside their clinical remit. thus limiting the generalisability of the findings. aside from the aforementioned differences. but is indirectly related to depression via the mediating role of interference with activities [42. rather than as a result of the intervention per se. it should be noted that data for this study were derived from patients who exhibited psychosocial risk factors. Conclusions This study showed that cognitive processes were strongly related to treatment outcome within a physiotherapy treatment context. the study employed a correlational design. Interestingly. Limitations Due to dropout. [12]. which precludes any causal inferences from being made. Woby et al. it should be noted that no control or comparison group was used. which implies that the interaction between fear of movement and functional self-efficacy is a key factor underpinning levels of disability in CLBP patients [41]. reductions in fear of movement and catastrophising. or depression that is not the direct consequence of loss of function or loss of valued activities. catastrophising. reduced catastrophising and increased self-efficacy) are amenable to a physiotherapistbased intervention.

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and the majority of respondents reported measuring balance. The four outcome measures used most commonly for balance.2007. Chris Boyes Faculty of Health and Life Sciences. outcome measurement does not always take place. more than half of studies were using locally developed measures as opposed to published and standardised measures [5].: +44 1904 until the most appropriate outcome indicators have been identified. and the Functional Reach Test. Therapists are not the only group failing to measure the outcome of interventions.S. Results Questionnaires were sent to 347 members of the ACPIN. Participants Members of a random sample of regions of the Association of Chartered Physiotherapists Interested in Neurology (ACPIN). A project aimed to increase awareness amongst members of the Association of Chartered Physiotherapists Interested in Neurology (ACPIN) of the need to measure motor performance revealed that few therapists were routinely using standardised measures [2]. Respondents reported spending a median of 80% (IQR 70–90) of their working time clinically. When these departments were resurveyed. All rights reserved. walking and gait. Design Survey by postal questionnaire. It has been suggested that clinicians should not develop their own measures locally but should focus on the evaluation of existing standardised measures [6].yoward@yorksj. fax: +44 1904 716801. data on who uses what and when is lacking. walking and gait were: the 10-metre (or other distance) walk test. Physiotherapy Introduction The measurement of outcome of intervention is a requirement of all physiotherapists working in the UK according to the core standards of practice [1]. UK Abstract Objective To explore the current practice of measurement of balance. walking and gait: 84% (227/269). only 10 were found to use standardised measures exclusively. All respondents were working at a senior level and the median number of years qualified was 10 [interquartile range (IQR) 6–18].005 . and 269 completed questionnaires were returned (response rate 78%). Many different methods are used clinically to measure balance. Keywords: Outcome measure. All rights reserved. and seven departments were using a combination of standardised and non-standardised measures. Balance.08. 76% (204/269) and 61% (165/269). Patrick Doherty. York YO31 7EX. the Get Up and Go/Timed Up and Go Test. A survey of rehabilitation centres in the UK found that 23% of the centres did not collect standardised measures as part of routine clinical practice [4]. Johnson [7] contradicts this and recommends that. Conclusion The majority of ACPIN members reported that they measure the outcome of intervention. respectively. © 2007 Chartered Society of Physiotherapy.1016/j. Published by Elsevier Ltd. Samantha Yoward ∗ . Published by Elsevier Ltd. Lord Mayor’s Walk. of the initial sample of departments that were using standardised measures [3]. Neurology. walking and gait amongst UK physiotherapists who work in neurology. The UK Clearing House for Information on the Assessment of Health Services Outcomes found that. walking and gait amongst physiotherapists working in neurology in the UK L. York St John University.Physiotherapy 94 (2008) 125–132 A survey of outcome measurement of following a request for information about planned outcome measures projects. Although it is likely that the use of outcome measurement is increasing over time. but only four methods were used by at least 50% of the study respondents. A survey of 247 therapists in Scotland revealed that 39% of therapy departments reported using outcome measures [3].uk (L. service 0031-9406/$ – see front matter © 2007 Chartered Society of Physiotherapy. Yoward). Ninety-one percent of respondents (245/269) reported that they measure the outcome of their interventions with a standardised measure. the Berg Balance Scale. Tel. these represented 9% ∗ Corresponding author. Together. However. doi:10. E-mail address: l.

walking and gait by physiotherapists. and the reasons for nonmeasurement if appropriate. These steps in the questionnaire design enhanced the content validity. It was presented in three parts: the first part established demographic details and whether or not respondents measured outcome using standardised tools. including gait and balance [12]. Combinations of the keywords ‘outcome’. rehabilitation and elderly care caseloads [10. . where the asterisk indicates alternatives for the word. Members of the ACPIN were chosen as the study population for convenience. and surveying all available members in the nine regions selected. a literature search was conducted using Medline (1965–2005). judged to be important areas for measurement in the field of neurorehabilitation. In view of the benefits and the professional requirement to measure. and two further physiotherapists with a special interest in neurology. walking and gait amongst UK physiotherapists who work in neurology. therefore. leading the authors to conclude that there is no published survey to determine the current practice of physiotherapists for the outcome measurement of balance. to enhance the validity of the measure. it may also be important to establish the measurement tools that are currently being used to contribute to knowledge of minimum data set requirements.S. Copies of the questionnaire are available. that are beyond the scope of this paper). suggesting that the largest employer of physiotherapists in the UK employed a significant number of ACPIN members [15].126 L. for example. designed to support research in the National Health Service (NHS). In addition. on request. and some questions were therefore adapted for use in this questionnaire to enhance overall validity. a lay member for comments on language use. if possible. that they would be willing to participate in research. when joining the Association. A study examining the main areas for evaluation and treatment in physiotherapy for patients with Parkinson’s disease found that there were four core areas. ‘measuring’ and ‘measurement’.11]. In order to identify previous studies that have explored the measurement of balance. The themes from this discussion were used to construct a questionnaire that was piloted using a member of the original panel. when asking about the collection of standardised outcome measures in the course of routine clinical practice [4] and when asking about the frequency of use [16]. and the third part explored the tools used (as well as other items. ‘measur*’ and ‘physi*’ were used. a level of participant consent was inherent in the researcher receiving their details. gait and walking. The final questionnaire was sent to all members (whose details were provided by the ACPIN) of the nine selected regions. CINAHL (1982–2005) and AMED (1985–2005) databases. Yoward et al. a previous survey of ACPIN members revealed that 90% (234/261) of respondents worked in the NHS. The sample was obtained by selecting half of the 18 ACPIN regions at random. The initial stage of development of the questionnaire comprised a consultation with senior clinicians in neurophysiotherapy. the second part explored the specific measurement of certain items including gait. / Physiotherapy 94 (2008) 125–132 providers should be able to use local measures if they seem more appropriate than measures that are already available. for example. such as rating scales. with the implementation of the UK Comprehensive Research Network [9]. Balance and mobility were. These members had already indicated to the ACPIN. there are numerous practical reasons why physiotherapists should measure. It has been assumed that they are representative of all physiotherapists who work in neurology. The following questions have been formulated: • Do physiotherapists who work in neurology measure the outcome of their interventions with standardised measurement tools? • Which measurement tools are used by the majority of neurophysiotherapists for balance. In addition. from the corresponding author. for example. investigating the current practice of measurement amongst physiotherapists is worthwhile. People with balance difficulties constitute a large proportion of all neurological. ‘measures’. External pressures on clinicians to demonstrate the benefits of their interventions for the purposes of commissioning of services and benchmarking also suggest a need to engage more actively in outcome measurement. walking and balance. and have been described as ‘market-leaders’ and ‘opinion-leaders’ [14]. for baseline information. some studies [4. gait and walking? The overall aim of this study was to explore the current practice of measurement of balance. However. Survey The study intended to use a pre-existing survey tool. A pre-printed and stamped postcard was included with a Methods Participants The target population of this study was physiotherapists in the UK who work with patients who have a neurological impairment. and mobility has been highlighted as the most important activity of daily living amongst a patient group [13]. As well as being a professional standard to measure outcome [1]. Thus. and was designed to highlight the issues of concern or interest in the field of balance measurement [17]. The final questionnaire comprised eight sides of A4 paper and was estimated to take no more than 15 minutes to complete.16] had used questionnaires relating to the collection of outcome measurement data. This search revealed no published studies on the specific topic. to aid planning treatment and for feedback to patients [8].

Yorkshire (72%. 43/60). This ranged from 2 to 38 years with a mean of 12. Kent (69% 18/26). Response by ACPIN region The questionnaires returned by region were: Northern Ireland (86%. Ethical approval for the study was obtained from York St John University College. All data were analysed using Statistical Package for the Social Sciences software. Given that the responses did not form a normal distribution. The non-completions were due to: being on a career break (n = 2). 46% (125/269) with patients with multiple sclerosis. Again. Results At the time of the study. Seven percent (18/269) of returned questionnaires either reported a different region or failed to complete the question. Of these.L. the median number of years qualified was 10 with an interquartile range (IQR) of 6–18 years. retired (n = 1). the responses were not normally distributed. 48/60). no longer working clinically (n = 5). It can be seen that all respondents were working at a senior level. to trace those who had responded without losing anonymity of the questionnaires. Two questionnaires were undelivered and nine were returned uncompleted. Scotland (80%. the median percentage of working time spent clinically was 80% with an IQR of 70–90% and a range of 0–100%. Northampton (60%. The respondents worked with patients who had a wide variety of conditions. Table 1 shows the grade reported by the respondents. Yoward et al. i. . General outcome measurement collection Respondents were asked: Do you collect at least one standardised outcome measure in the course of routine clinical practice. In total. 26% (70/269) with patients with Parkinson’s disease. This alerted the research administrator to those members of the sample who had returned the questionnaire and those who had not. ensuring that reminder letters were only sent to the appropriate people [18]. Surrey (78%. The respondents spent an average of 79% (SD 18) of their working time clinically. 34/43). 13% (34/269) with patients with a spinal cord injury and 12% (32/269) with patients with a tumour of the central nervous system. so a negative response to this question was assumed. Two respondents did not complete this question. Taking into account the assumptions from the non-completed responses.e. The random sample of half of the regions contained 36% of this population. the total membership of the ACPIN who were willing to receive questionnaires was 957. 23/41).6 years [standard deviation (SD) 8]. The questionnaire was structured such that a negative response to this question indicated that a reason should be given for the non-collection of measures. and no longer working in neurology (n = 1). All postcards and completed questionnaires were returned to the research administrator. they were asked to report the percentage of time spent with each condition treated. All the respondents were included in the analysis of the questionnaires. A reminder letter and further questionnaire was sent to those who had not responded by the allotted time. 347 questionnaires were sent and 269 completed questionnaires were returned. Eighty-seven percent (237/269) worked with people who had had a stroke. so it was assumed that this person did collect outcome measures. 31/40). Only those who spent more than 5% of their time with patients with a specific condition were documented. A further 23 respondents reported that they do not collect outcome measures and 244 reported that they do collect outcome measures. a test or scale that has been shown to measure a particular attribute? Please circle as appropriate: Yes No Table 1 Grade of respondents Number (%) of respondents Senior I Senior II Superintendent III Clinical specialist Private practitioner Split role Team leader Superintendent II Superintendent IV Consultant Extended scope practitioner Lecturer Reader in rehabilitation Researcher Total 130 (48) 58 (22) 21 (8) 21 (8) 12 (5) 12 (5) 4 (2) 3 (1) 2 (<1) 2 (<1) 1 (<1) 1 (<1) 1 (<1) 1 (<1) 269 Percentages do not add up to 100% due to rounding.S. Merseyside (79%. / Physiotherapy 94 (2008) 125–132 127 request that respondents return the postcard at the same time as the questionnaire. a response rate of 78%. and that the rest of the questionnaire did not require completion. Consent was assumed from the return of the completed questionnaire [19]. Respondents were asked to indicate the number of years that they had been qualified. and Northern (56%. 9/15). The second provided a reason for non-collection. 21/34). Other conditions were seen by less than 10% of respondents. North Trent (62%. As this was expected. 91% (245/269) of respondents collected outcome measures. but separately. 29% (78/269) with patients with a traumatic brain injury. one went on to answer the rest of the questionnaire. 24/28).

S. walking or gait did not need to complete further items on the questionnaire. Only 4% (10/236) of respondents reported that they occasionally or hardly ever measure balance. a Reasons offered as ‘other’ by respondents. Measurement of gait in patients with a gait difficulty Sixty-five percent (151/231) of the respondents indicated that they always or almost always measure gait in patients with a gait difficulty. A number of respondents (13%. Yoward et al. Items measured Respondents were asked to underline the items that they measured. Seven percent (16/232) of the respondents reported that they hardly ever or occasionally measure walking. There was a wide variety in the measures used. Therefore. Measurement of walking in patients with a walking difficulty Seventy-five percent (174/232) of the respondents indicated that they always or almost always measure walking in patients with a walking difficulty. 89 measures were recorded. . Table 2 shows the reasons given by those respondents who did not measure the outcome of treatment with a standardised tool. walking and gait. walking and gait. Reasons for non-measurement of treatment using standardised tools Respondents were asked for their reasons for noncollection of standardised measures in the course of routine clinical practice. Measurement of balance in patients with a balance difficulty Eighty percent (188/236) of the respondents indicated that they always or almost always measure balance in patients with a balance difficulty. respectively. A table of possible responses was provided. including space for respondents to provide an alternative reason. These are presented as the wording/abbreviations chosen by respondents. Four respondents did not complete the question. whereas 17% (39/231) of respondents reported that they hardly ever or occasionally measure gait. Nine respondents did not complete the question. n = 89 and n = 99.128 L. Eight respondents did not complete the question. the questionnaire found that the majority of respondents measure balance. and gait was defined as ‘the style of walking’. In order to complete the question. and Table 3 shows the frequency of items reported Table 3 Items measured by respondents Item measured Balance Walking Range of movement Strength Gait Tone Co-ordination Sensory systems Alignment Sitting balance Other Number (%) of respondents 227 (84) 204 (76) 183 (68) 174 (65) 165 (61) 137 (51) 113 (42) 112 (42) 76 (28) 1 (<1) 1 (<1) A list of 14 measures was provided in alphabetical order for respondents to indicate which measures they use (the question and possible responses are shown in Appendix A). operational definitions of balance. in total. Some respondents provided more than one reason. / Physiotherapy 94 (2008) 125–132 Table 2 Reasons reported for non-measurement of outcome of treatment using a standardised tool Reason for non-measurement of treatment I do use a measure but it is not standardised There are no suitable tests available for my needs I know how to but I do not have the time The level of impairment of my patients is too severe Someone else does I would rather spend time on treatment itself I do not know how to A team measure is useda We have never got round to agreeing what we should measurea Preparing to implement outcome measuresa I do not always believe that very specific measures actually benefit patientsa Piloting MDT measuresa It is not important to measure I know how to but I do not have the equipment I am not allowed to The level of impairment of my patients is too mild Number of respondents 10 9 8 7 5 4 3 1 1 1 1 1 0 0 0 0 by the respondents. Those who did not measure balance. walking was defined as ‘mobility using both lower limbs for support and propulsion’. such as the Nine Hole Peg Test. The majority of respondents measured balance. Balance was defined as the ‘ability to maintain postural stability without falling’. a space was left for respondents to include other measures. walking and gait. As it was anticipated that the measures listed would not cover the entire range of those used by the sample. Outcome measures used by respondents MDT = Multidisciplinary Team. gait and walking were provided in the questionnaire. Some respondents completed the ‘other’ section with measures that were not directly relevant to the topic of balance. whereas others included measures that were partially relevant such as global disability measures. and always or almost always perform measures where the patient demonstrates difficulty.

It is unclear whether those who reported using Tinetti or modified Tinetti were referring to the POAM. This places more pressure on healthcare professionals to be able to demonstrate the positive outcomes of their work. Also. Percentages are of whole sample. . In addition. The respondents who use this have been added to those who reported using Tinetti or modified Tinetti. changes in healthcare provision have resulted in competition in the workplace with commissioning for services. who are potentially highly motivated to maintain professional standards in their field. This is mirrored by the UK Clearing House for Information on the Assessment of Health Services Outcomes. and a requirement from managers and commissioners to access these objective outcomes. In the last 10 years. the Chartered Society of Physiotherapy has a database of over 200 outcome measures on their website [22]. this is reassuring as it is a core standard of practice [1].L. for example. Only a very small number (1%. pressures from within the profession enforce the collection of outcome measures [1]. 34/369) reported using Tinetti or modified Tinetti. A previous study investigating the use of outcome measures amongst therapists in Scotland found that only 44% (38/86) of physiotherapy respondents reported that their departments were using outcome measures. a Performance Oriented Assessment of Mobility (POAM) was developed by Tinetti and was included as a possible response on the list provided. 3/269) of respondents reported not knowing how to measure. A sample of all grades of staff who work in neurology would be required to confirm this assumption. A further difference is the time lapse between the two studies. It is unclear from this survey why the respondents did not know how to measure. In addition. Whilst this sample represents the ACPIN. and a further survey of physiotherapists in Australia and New Zealand confirmed that reliability and validity of outcome measures influenced usage [23]. In addition. respectively) 129 To be included. A second survey of the same respondents who had reported using outcome measures revealed that the majority were using non-standardised measures. Given the very small number. it may not be representative of all physiotherapists who work in neurology. . / Physiotherapy 94 (2008) 125–132 Table 4 Measures used by respondents Measure used by respondents 10-metre (or other distance) walk test Berg Balance Scale Get Up and Go/Timed Up and Go Functional Reach Timed Standing (incorporating Timed Unsupported Standing/TUSS) Rivermead Mobility Index Rivermead Mobility Index incorporating modified Rivermead Mobility Index POAM/Tinetti/modified Tinettia 6-minute (or other time) walk test Postural Sway Motor Assessment Scale Elderly Mobility Scale Turn tests combined (180◦ and 360◦ ) Number (%) of respondents 201 (75) 191 (71) 143 (53) 140 (52) 129 (48) 76 (28) 88 (33) 46 (17) 39 (14) 23 (9) 23 (9) 17 (6) 15 (11 and 4. Measures used by more than 5% of all respondents are shown in Table 4. although there was a wide range of responses amongst therapists generally (17–65%).’ so the response of 91% is extremely high compared with previous reports. respectively) (4 and 2.S. the difference may be accounted for by the fact that the samples used in the studies were very different. It is possible that ‘social desirability bias’ resulted in over-reporting of use [21]. it can be assumed that the vast majority of physiotherapists who are ACPIN members do know how to measure using a standardised tool. A survey of Australian private physiotherapy practitioners revealed that more than 90% endorsed statements that health professionals should monitor patient progress using reliable and valid tools [21]. although the Performance Oriented Assessment of Mobility (POAM) was provided and was developed by Tinetti [20]. This option had not been provided on the list. the concept of outcome measurement is more frequently publicised. depending on the area of the country in which they worked [3]. This suggests that these individuals value research and are perhaps more comfortable with the idea of being questioned about their own ‘data collection’. the present study sample only contained senior physiotherapists and it is likely that junior physiotherapists also work in neurology. the sample from the present study had all given their consent to the special interest group administrators that they may be contacted for the purposes of research. Interviews with these respondents would have been beneficial to explore this further. For example. at least 5% of respondents had to report using the measure. . These external pressures have resulted in the need for more widespread gathering of clinical information [7]. The current questionnaire specifically asked respondents to state whether they use ‘at least one standardised outcome measure . for example. A survey of a general population of physiotherapists in the UK would be useful to confirm the current status. Also. and standardised outcome measures are more easily available. As a result of external and internal influences. it may be that respondents are unfamiliar with the concept of measurement per se or simply that they are not aware of an appropriate measure for their clinical need. but this has been assumed in the results table by summing the frequency for both. the sample from the current study only included individuals from a special interest group. but this was not possible because of the anonymity of the questionnaires. Yoward et al. who also found that the majority of studies reported were using locally developed measures [5]. it may be that more physiotherapists are genuinely collecting standardised outcome measures than was the case a decade ago. Discussion A very high number of physiotherapists from this sample reported that they measure the outcome of their interventions with standardised tests and scales.

range of motion. or whether the tools chosen for this measurement were standardised tools. This may be because they are a group of individuals sufficiently motivated to join a special interest group. Terms related to outcome measurement may be understood in different ways by different respondents [3. it seems likely that many patients who experience neurological impairment have the potential to develop problems with their balance. Likewise. It has been widely tested for reliability and validity for measurement of mobility amongst patients with neurological impairments [40–42]. Certainly balance impairment frequently presents in patients with neurological impairment [10. It has since been tested in older people [35] and in neurological conditions. in contrast to previous studies. may not be so. closely followed by walking (76%). proprioception and coordination. Yoward et al. Parkinson’s disease [31]. / Physiotherapy 94 (2008) 125–132 Balance.24]. As the majority of respondents indicated that they measure balance. almost 10% of members of the ACPIN do not measure the outcome of their interventions. Recommendations for further study The next series of studies from the authors’ research group will investigate the use of specific measures in particular patient populations in terms of validity and reliability. the Berg Balance Scale. Balance was measured by more respondents than the other items (84%). it can be assumed that these are considered important to measure. walking and gait are the 10-metre walk test. Limitations of the study The sample. However. the Get Up and Go/Timed Up and Go Test and the Functional Reach Test. and a version of it has been presented as a suggested standardisation for patients with neurological impairment [39]. attempts were made to clarify terms used by operationally defining key words and terms such as ‘balance’. walking and gait always or almost always when their patients present with difficulty. it has been suggested that any motor skill depends to an extent on the ability to control posture and balance [26]. amongst others.27]. it is possible that there may still have been misunderstandings or alternative interpretations over the meaning of these words. and reflects the issues of importance in patient groups. and specifically measure outcomes related to balance. vision. it is not known how frequently the measurements take place for each individual item.130 L. To alleviate the potential for this occurrence. However. including the concept of outcome measurement. It may be assumed that balance is a prerequisite for normal walking given that the body is unstable during walking. and therefore potentially motivated enough to ensure that they work to the professional standards set. As many factors contribute to the ability to balance. The Functional Reach Test was originally developed as a balance measure and specifically excluded those with neurological impairment during its development [34]. but has since been tested amongst other populations with neurological conditions such as stroke [30]. The Berg Balance Scale was initially developed for elderly individuals [28. in spite of this being core to the professional standards. ‘gait’ and ‘standardised outcome measure’. This could have been explored further by interview but was beyond the scope of this study.45]. are highly favoured for measurement. may be predisposed to problems with walking. The most widely used outcome measures for balance. ‘walking’. the Berg Balance Scale. Further study is required to find out why these items. so patients with any impairment of balance. . walking is an activity that also requires contribution from other systems for it to be efficient. strength. It is possible that the measures may be used clinically for a population of patients in which testing has not yet taken place. The 10-metre walk test is widely used clinically and in research. hence the importance attributed to its restoration in neurological physiotherapy [10. in particular. This suggests that these aspects of care are considered important by this group of professionals.S. This information could be used to inform minimum data set requirements for further research. This may reflect the value placed on these abilities or may be representative of the type of measures that are available. including Parkinson’s disease [36]. A systematic review of the literature for the psychometric properties of these tests in varying neurological conditions is warranted so that clinicians are able to choose an appropriate outcome measure for individual patients. These results suggest that. and was later modified to the Timed Up and Go Test that was used for testing mobility in the elderly [44]. walking and gait were all measured by at least half of the respondents.29]. The measures used by at least half of the respondents were: the 10-metre walk test. it cannot be stated that they have all been tested for reliability and validity in all populations of neurological conditions. walking and gait. the Timed Up and Go Test. vision and proprioception. such as strength. In addition. Although the top four measures have all been tested to some degree. and the Functional Reach Test. brain injury [32] and multiple sclerosis [33]. The Get Up and Go Test was originally developed for testing balance in elderly people [43]. with approximately 80% of the cycle spent in single limb support [25]. Conclusion This study found that the majority of physiotherapists who are members of the ACPIN do measure the outcome of their interventions. and conclusions drawn from the collection of that data are therefore limited. children with spasticity [37] and in a modified form for people who have a spinal cord injury [38]. What remains unclear is the extent to which the measures are being used appropriately. whilst argued to be representative of physiotherapists working in neurology in the UK. However. a high percentage of physiotherapists measure the outcome of intervention.

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All rights reserved.d a Department of Medical Rehabilitation.1016/j. doi:10. Nigeria d Department of Physiotherapy. Setting Three outpatient physiotherapy clinics in Nigeria. which may have influenced the reporting of the characteristics and history of their LBP. affective. Keywords: Back pain. Nigeria c Bodija Physiotherapy Clinic. cognitive and emotional components [1–4]. particularly those classified as being of low socio-economic status. on a 0–100 numerical rating scale. (M. Caucasian race. Vincent C. Bodija.4] and Caucasian (mean pain score 79. All rights reserved. mean 41 years). 95% CI 74. throbbing and pressure qualities. Low socio-economic status patients who had experienced a high number of life-stressing events were more likely to show emotional and psychological symptoms. Main outcome measures The Low Back Pain Questionnaire.2007. burning.∗ . Further research is required to determine how the outcome of treatment may be influenced by these factors. Socio-economic status and pain levels. Obafemi Awolowo University. Ile-Ife. Egwu). Ile-Ife. There is a need to assess these issues when managing LBP patients. with LBP of at least 6 weeks duration were recruited over a 9-year period. including 107 Black Nigerians (age range 26–65 years. 0031-9406/$ – see front matter © 2007 Chartered Society of Physiotherapy. Negroid race Introduction Pain is known to create immediate awareness of actual or threatening injury and has sensory. Ibadan. Social Re-adjustment Rating Scale. Faculty of Basic Medical Sciences. Subjects who recorded higher numbers of life-stressing events on the Social Re-adjustment Rating Scale also recorded higher scores on a number of LBP attributes including hot. Pain intensity and state anxiety correlated significantly with life-stressing event scores among Caucasian patients. Obafemi Awolowo University. This study examined the relationship between life-stressing events and sensory and psychological attributes among Nigerian and Caucasian patients with LBP. State-Trait Anxiety Inventory and Multiple Affect Adjective Check List. single cohort questionnaire study. State and trait anxiety and emotional discomfort scores correlated significantly with life-stressing event scores among Nigerian patients. Stressful events. Published by Elsevier Ltd. Nigeria Abstract Objectives Socio-economic status and life-stressing events have been shown to have ethnic and racial differences that exert a strong influence on care-seeking habits and recovery from low back pain (LBP). were also recorded. Obafemi Awolowo University. Egwu a. 95% confidence interval (CI) 73. College of Health Sciences. who were mainly of high socio-economic status. Published by Elsevier Ltd. Design Stratified. psychological ∗ Correspondence: Department of Medical Rehabilitation. © 2007 Chartered Society of Physiotherapy. Nigeria b EMO Physiotherapy Ile-Ife. Conclusion Most patients had experienced a number of life-stressing events. who were mainly of low to medium socio-economic status. Nwuga c. Socioeconomic status.b. Faculty of Basic Medical Sciences.8 to 84. mean 52 years) and 58 Caucasians (age range 25–62 years. Results Recorded pain intensity was similar in Nigerian [mean pain score 78. Due to recognition of the fact that painful conditions such as low back pain (LBP) result from the interaction between biological. Faculty of Basic Medical Sciences. College of Health Sciences.8) patients. Participants One hundred and sixty-five patients. E-mail address: egwumo@yahoo. Racial stocks.Physiotherapy 94 (2008) 133–140 Relationship between low back pain and life-stressing events among Nigerian and Caucasian patients Michael O. College of Health Sciences.08. Tel. Questionnaires were administered within 5 days of the patient reporting at the clinic. and the influence of socio-economic status on this relationship. Ile-Ife.4 to 83.O.009 . bright.: +2348033739499.

current reports suggest that the various responses to a painful experience within and between races are shaped by culture. However.16].9]. The nature of the study was explained and patients who gave their consent to take part received the questionnaire. facial type. previous pain history. [8] observed that Caucasians report their pain promptly while African Americans with chronic pain report later and have more pain. the State-Trait Anxiety Inventory [27]. literacy level and socioeconomic status. it is widely believed that the perception and response to pain vary with ethnicity and race [7–10]. Of these. socio-economic disparities and cultural norms about expressing pain may be important factors in the observed racial differences. Nwuga [30] used some of these tools to study the relationship between LBP and life-stressing events among Nigerian patients. which are largely environmental factors [7–9]. emotional and social health. Methods Subjects One hundred and sixty-five LBP patients (93 males. depression.B. cranial profile and amount. the delay in reporting pain observed among Australian aborigines and African Americans was associated with significant decreases in quality of life and psychological distress. The characteristics of LBP and life-stressing events have been measured for several decades using tools including: the Modified Somatic Perception Questionnaire [23]. The purpose of this investigation was to examine the relationship between sensory and psychological attributes of LBP and life-stressing events among Nigerian and Caucasian patients. and pain reproduced by at least one direction of trunk move- . On the basis of these criteria. The pain-coping response of LBP patients may be in the form of confrontation or avoidance [19–22]. the pain-coping strategy of individuals with similar psychosocial or mood states experiencing LBP may differ [5. the current trend is to view pain as a biopsychosocial experience [1. [21] highlighted that there is a contin- uum between extreme avoidance and extreme confrontation of pain. divorced. personality and social denials were predictors of who complained of LBP [17. mean 52 years) and 58 were Caucasians (age range 25–62 years. including care-seeking habits. texture and colour of hair [10–12]. This suggests that there is a relationship between LBP and life-stressing events that may have racial and socio-economic differences. personality traits and life-stressing events [6. However. Black Nigerians [7] and Senegalese [14] indicate that rural–urban variations also exist in the perception and reaction to pain.19. mean 41 years).6]. Patients who did not wish to participate in the study were treated normally. There is a need for physiotherapy managers to recognise the different emerging experiences and attitudes of people towards LBP. literacy level.5. widows and in people who change jobs frequently [6. Patients were diagnosed with LBP of mechanical origin and referred to the participating institutions (Bodija Physiotherapy Clinic.O.C. The avoidance approach normally leads to the maintenance and exacerbation of fear. the Multiple Affect Adjective Check List [25]. it has been noted that back pain is prevalent in the bereaved.6. the Affect Adjective Check List [24]. financial status etc.134 M. the Minnesota Multiphasic Personality Inventory [26]. religion. 107 were Black Nigerians (age range 26–65 years. Furthermore. Negroid and Caucosoid were identified. the exact nature of this relationship is not clearly understood.15. Green et al.) and cultural (beliefs. Nwuga / Physiotherapy 94 (2008) 133–140 and social factors. V. These rural–urban differences reflect discrepancies in social (access to healthcare personnel and facilities. and EMO Physiotherapy Clinic in Ibadan and Ile-Ife. and noted that an individual’s position along the continuum is determined by the psychosocial context in which the initial LBP occurs. in different human settlements. while the confrontation approach may lead to a reduction of fear and/or suppression of pain [21. attitudes towards pain itself. family size and nature of job) variables that shape the aetiology and response to LBP. Studies from industrial workplaces show that job satisfaction. over the years. and increased life stresses [8. the Social Re-adjustment Rating Scale [28]. Moreover. post-traumatic stress disorders and impairment in their physical. and the effect of socio-economic status on this relationship. South-West Nigeria) between February 1996 and September 2004. They concluded that perceptions of the health system. and found that life-stressing events related to some sensory and psychological attributes of LBP but not to emotional state. Egwu. Lethem et al. and poor marital. social and sexual adjustments have also been associated with LBP [15–17]. Over the years. Globalisation of workplaces and industries and increased movement/resettlement of people across the globe have created major changes in the mix of cultures in some countries and major cities of the world. Physiotherapy Department. races such as the Mongoloid.20]. Inclusion criteria Inclusion criteria were: LBP of at least 6 weeks duration.22]. level of awareness. The psychosocial context reflects components of anxiety (an uncomfortable feeling of nervousness or worry about something that is happening or may happen in the future) that may be measured by pain-coping strategies. The above findings suggest that mood and other psychosocial states may be crucial factors in determining which individuals complain of LBP. Obafemi Awolowo University Teaching Hospital Complex. However.18]. and to adopt appropriate strategies that are effective in meeting their needs. and the Low Back Pain Questionnaire [29]. people of different races (common descent) have been distinguished by skin colour. 72 females) participated in the study. Studies of Australian aborigines [9]. Nevertheless.19–22]. but efforts to establish a genetic base for these phenotypic differences remain equivocal [11–13].

The Social Re-adjustment Rating Scale containing 43 lifestressing items was used to assess life-stressing events. was presented to each subject to mark the relevant items. completion of a doctoral degree was rated ‘7’ and formal education below the level of first school leaving certificate was rated ‘1’. 74/165) were of high socio- . respectively. mild skin pressure sensation. 27 of them were excluded during data analysis due to incomplete responses (n = 15) and inability to give appropriate responses even after interpretation and explanation (n = 12). Questionnaires were translated into the local language for those who could not read English. scored and added together to obtain a life-stressing event score for the patient.B. dishwasher. Factor VI. the type of housing estate. medium and low socio-economic status were computed. [32]. the State-Trait Anxiety Inventory was used to measure anxiety. Sensory and psychological factors The Low Back Pain Questionnaire was administered and scored as described in the text manual [29] after taking a brief pain history. [31]. Factor IV. Specifically. washing machine etc. Classification of socio-economic status Criteria for classification into groups of socio-economic status were based on a questionnaire adapted from Olusi et al. the scores were summed to obtain a value representative of the total socio-economic status. For example. For each patient. This score shows the significant change in life events in the preceding year for the patient. USA) was used for data analysis. The Anderson-Darling test [33] was used to check the data for normality.. Household utensils and appliances were each assigned 0. Factor III. Crowding indices (defined as the ratio of the number of rooms to the number of people in the house) lower and greater than 0. Similarly.5 points. respectively. while Nigerian subjects were brown-black skinned with curly black hair. Egwu. Therefore. while pain intensity was measured using a 0–100 scale where 0 indicates no pain and 100 indicates maximum pain. The questionnaire. IL. and pain scores were subjected to analysis of variance to determine differences in group socio-economic status. Subsequently. life-stressing events and socio-economic status scores between Nigerian and Caucasian patients. Student’s t-tests were used to check for differences in reported pain. with a mean of 46. Ownership of a house and a car were each rated ‘1’. Chicago. however. Fisher’s Z transformation was used to check the distribution of differences in the size of the correlation coefficient between the two groups and three levels of socio-economic status [34]. as modified by Balogun et al. and those with scores above 17 were classified as being of high socio-economic status. listing the life-stressing items on a single sheet. severe emotional discomfort. moderate constant burning sensation. Results One hundred and ninety-two patients gave their consent to participate in this study.O. The minimum and maximum possible scores on the questionnaire were 0 and 26 points. In order to determine the relationship between life-stressing events and the sensory and psychological attributes of LBP. Scores were assigned to each item in the questionnaire based on their ‘status symbol’ in Nigerian society.5 were assigned 0. and the data were found to be normally distributed. Statistical Package for the Social Sciences Version 11 (SPSS Inc. information was collected on: the highest educational attainment of the subjects. moderate bright pressure sensation. gas cooker. This questionnaire has a cluster of seven patterns with the following factors: Factor I. refrigerator. Nwuga / Physiotherapy 94 (2008) 133–140 135 ment (mechanical activity). Mean pain scores and 95% confidence intervals for patients in the groups of high. However. patients rated the statements in the order of their accuracy in describing the patient at that moment. and household utensils and appliances such as stereo. Subjects with scores lower than 9 were classified as being of low socio-economic status. Fisher’s Z transformation demonstrated that the linear relationship between the Caucasian and Nigerian patients was similar and their correlation coefficients were equal.C. moderate intermittent hot sensation.M. Factor II. Caucasian subjects were white-skinned expatriates or their dependants with straight hair. life-stressing event scores were significantly higher and socio-economic status scores were significantly lower for Nigerian patients than their Caucasian counterparts (Table 2). Therefore. The items were then weighted. mild pressure sensation. 165 valid responses were analysed. severe throbbing pressure sensation.5 points and 1 point. The majority of the subjects (44%. Patients were also asked to score their average pain on this scale. those with scores between 9 and 17 were classified as being of medium socio-economic status. Factor V. Racial classifications were based on skin colour and type of hair because previous reports indicated that the Caucasoid race has white skin and straight hair while the Negroid race has brown to brown-black or dark brown skin and curly black hair [10–13]. The Multiple Affect Adjective Check List was used to measure depression and hostility. V. From the 40 self-evaluative inventories.5 years. and the subjects were tested with these instruments within 5 days of reporting at the clinic. Table 1 shows that the average pain scores of Nigerian and Caucasian patients were similar regardless of socio-economic status. their land and property. the number of rooms and people in the household. The age range for the subjects was 25 to 65 years. and Factor VII. the total score was used to classify the subjects into groups of different socio-economic status. Pearson’s product-moment correlation coefficient (r) was calculated.

2) Caucasians 21 (2.C.2. moderate constant burning sensation (P < 0.8) 78 (75.3) 78 (75. However. the authors considered that 6 weeks was an appropriate cut-off for the acute phase of LBP [37].36]. V.001).01). Other variables. others have considered LBP of more than 6 weeks duration as chronic [35. The linear relationships between moderate bright pressure sensation.1) 279 (6. although this will have been affected by small numbers.05).8) All n 74 59 32 165 Mean pain intensity (95% CI) 80 (77. trait anxiety (P < 0.001). Relationship between sensory and psychological attributes of LBP and life-stressing events Eight of the 12 sensory and psychological attributes of LBP correlated with life-stressing events in the entire sample (Table 3): severe throbbing pressure sensation (P < 0.01). Merskey and Bogduk [2] classified chronic pain as that which persists beyond the normal time of healing of 1 to 6 months. severe throbbing pressure sensation and life-stressing event scores were not affected by socio-economic status.136 M.001). low socio-economic status was related to higher severe emotional discomfort and state and trait anxiety. and recommended 3 months as a convenient point of demarcation between acute and chronic pain. mild pressure sensation (P < 0.01).8 to 80.4 to 83. moderate constant burning sensation (P < 0. including severe emotional discomfort.8 to 84. Table 2 Socio-economic status. moderate bright pressure sensation (P < 0.8) 79 (74. However. and trait anxiety (P < 0.05).6) economic status.9 to 84. confidence intervals. However. All of the subjects classified as being of low socio-economic status (19%. moderate intermittent hot sensation (P < 0. mild pressure sensation (P < 0. their individual contribution to the variability in the outcome variable may be relatively small.05). hostility and moderate skin pressure sensation demonstrated low coefficients. state anxiety (P < 0. However.6 to 84. The data did not suggest a relationship between depression and lifestressing events.3 to 82.4) Caucasians n 52 6 58 Mean pain intensity (95% CI) 80 (77.0) 0. the following attributes correlated with the number of life-stressing events: trait anxiety (P < 0. suggesting that.1) 79 (74.1) 78 (73. particularly the group of Caucasian patients of medium socio-economic status.8 to 86.05). Some of the coefficients will have been affected by the small numbers in the subgroups.001). Mean pain intensity (95% CI) 80 (73.6) 172 (3.01).001). of these. among the Nigerian patients.001 <0. Socio-economic status The effects of socio-economic status on the correlations between life-stressing events and the sensory and psychological attributes of LBP are presented in Table 4. socio-economic status appeared to have little effect on these relationships.001). Egwu. When the results of all the subjects were combined. pain intensity (P < 0. moderate intermittent hot sensation (P < 0.2 to 82. As most LBP patients who attend physiotherapy clinics are chronic episodic back pain sufferers experiencing a flare-up.1) P-value <0.2) 80 (77. low socio-economic status was related to higher severe emotional discomfort and signs of state and trait anxiety.9 to 84. Ninety percent (52/58) of the Caucasian patients were of high socio-economic status. the following attributes correlated with the number of life-stressing events: severe throbbing pressure sensation (P < 0. and most subjects of medium socio-economic status were also Nigerian (90%. severe emotional discomfort (P < 0.001). life-stressing events and pain scores in Nigerian and Caucasian patients [mean (standard deviation)] Nigerians Socio-economic status Life-stressing events (Social Re-adjustment Rating Scale) Pain intensity (numerical rating scale 0–100) 16 (4.7) 78 (70. In the Caucasian patients.35. despite their statistical significance.O. some trends are apparent: depression. 32/165) were Nigerian. Among the Caucasian patients. were not linearly related to life-stressing events in the Caucasian patients.001 and moderate constant burning sensation (P < 0. severe throbbing pressure sensation (P < 0. moderate bright pressure sensation (P < 0.01).001). In the Nigerian patients.8) 81 (77. 70% (52/74) were Caucasians. Subjects 78 (6. it should be noted that the r2 statistics for most of these variables are relatively small.2 to 85.B. and severe emotional discomfort (P < 0. moderate bright pressure sensation (P < 0. Discussion Classification of the duration of back pain into chronic and acute pain is controversial [1.37].01).01).4) 79 (4.001). state anxiety (P < 0.991 .2 to 80. 53/59). Nwuga / Physiotherapy 94 (2008) 133–140 Table 1 Low back pain intensity of Nigerian and Caucasian subjects grouped by socio-economic status Nigerians n Socio-economic status High 22 Medium 53 Low 32 All 107 CI.01).01). moderate intermittent hot sensation (P < 0.

B.13 0.15 0.17 0.62c 0.60c 0.55c 0.18 0. .51c Moderate skin pressure sensation 0. V.12 137 a P < 0.09 0.42b 0.62c 0.41b 0.44b 0.17 0.11 0.58c 0.51c 0.25a 0.45b 0.33b 0.09 – 0.64c 0.51c 0.19 M.09 0.12 – 0.61c – 0.08 0.34b – 0.62c – – 0.23a 0.C.38b 0.13 0.O.19 0.11 – 0.12 0.55c 0.20a 0.51c 0.35b 0.Table 3 Pearson’s product-moment correlation coefficient between life-stressing events and sensory and psychological attributes of low back pain patients Group Low back pain factors Severe emotional discomfort Life-stressing events Nigerians (n = 107) Caucasians (n = 58) All subjects (n = 165) Mild pressure sensation Moderate bright pressure sensation 0.54c 0.15 0.49c 0.50c 0.16 – 0.48c 0.41b 0.18 0.08 0.45b 0.52c 0.48c 0.54c 0.16 0.46b – 0.15 0.52c – 0.30b 0.001.27a 0.38b 0.15 0. c P < 0.13 0.10 0.21a 0.01.12 0.05.16 0.17 Moderate constant burning sensation 0.14 – 0.18 0.12 0.06 0.11 0.38b Severe throbbing pressure sensation 0.45b 0.32b 0.01.39b 0.12 0.34b 0. b P < 0.19 0.46b 0.49c 0.52c 0.17 0.12 0.39b Moderate intermittent hot sensation 0.001.32b 0.53c 0. Egwu.26a 0.15 0.11 0.42b 0.44b 0. Nwuga / Physiotherapy 94 (2008) 133–140 a P < 0.58c 0.14 0.14 0.46b 0.46b 0.19 0.37b 0.42b 0.08 – 0.45b 0.32b 0.16 0.11 0.26a – 0. c P < 0.33b 0.19 0.41 0.14 0.05.24a 0.09 0.22a 0.37b 0.18 0. Table 4 Effect of socio-economic status on Pearson’s product-moment correlation coefficient between life-stressing events and sensory and psychological attributes of low back pain patients Low back pain factors Severe emotional discomfort Life-stressing events Nigerians (n = 107) High (n = 22) Medium (n = 53) Low (n = 32) Caucasians (n = 58) High (n = 52) Medium (n = 6) Low (n = 6) All subjects (n = 165) High (n = 68) Medium (n = 65) Low (n = 32) Mild pressure sensation Moderate bright pressure sensation Moderate skin pressure sensation Moderate constant burning sensation Moderate intermittent hot sensation Severe throbbing pressure sensation Psychological factors Trait anxiety State anxiety Hostility Depression Pain intensity 0.29a 0.15 0.63c 0.44b 0.11 0.28a 0.39b 0.13 0.30b 0.36b 0.14 0.56c 0. b P < 0.19 0.58c 0.16 0.53c Psychological factors Trait anxiety State pressure Hostility Depression Pain intensity 0.

18. which then feedback to colour the perception of what is happening. Sensory attributes have been more closely associated with tissue damage and affective attributes with mood. even in the same geographical location. reflecting the psychosocial context in which the initial LBP occurred. These factors appear to respond to socio-economic dynamics influenced by the number and types of life-stressing events. On the other hand. compelling them to report more quickly for treatment [8. Therefore. while attention alters both pain sensation and unpleasantness. how the body responds physiologically and what actions are taken. heart rate. these findings can be interpreted to mean that life-stressing events exacerbate the sensory components of LBP in Caucasian patients whereas the affective emotional components of LBP are related to life-stressing events in Nigerian patients. the meanings assigned to it. and emotional states influence whether and how an aversive stimulus such as pain is perceived. The findings in the present study agree with these hypotheses to some extent.38]. Nwuga [30] suggested that life-stressing events have a selective effect on the sensory attributes of LBP. Nigerian patients of medium to low socio-economic status having experienced a high number of life-stressing events may have focused more attention on socio-economic. affective. [43]. pain intensity only correlated with the lifestressing event scores in Caucasian patients. where we have been. The results reveal that severe throbbing. Zola [40] suggested that people seeking help for a symptom for the first time do so because they are unable to tolerate it any longer. Emotional states also influence physiological processes (e. financial and emotional problems. The results of previous studies show that life-stressing events have an exacerbatory effect on physical illness [30. including care-seeking habits. However. Caucasian and Nigerian patients of high socio-economic status who have experienced fewer life-stressing events and pressures may have focused more attention on the possible harmful effects of the intensity and spread of the hot. [39] noted that life-stressing events exacerbate certain types of pain and that the types of pain exacerbated differ in people with and without organic disease. there is evidence that life-stressing events influence pain reporting and pain unpleasantness. are inextricably intertwined. . was not affected by mood. Also.O.B. Leavitt et al.41. The fact that sensory and affective attributes are often differentiated during the experience of pain has long been known [16. muscle tension etc. LBP is culturally interpreted by most Nigerian patients as a harmless experience that accompanies ageing. Thus an exacerbating symptom that becomes intolerable for a Nigerian patient may differ from that of a Caucasian patient. In addition. Based on the model which suggests that pain has sensory. and the actions taken in response.41.138 M. or where we are going and we can take no actions to close the gap’.g. One hundred and sixty-five patients were studied over a 9-year period. the consequences inferred to follow. which implies that emotional manipulations by intensity of life stresses alter pain unpleasantness more than pain sensation. the greater the number of life-stressing events and the greater the psychological symptoms for a given intensity of perceived pain. depression and mild pressure sensation were not linearly related to life-stressing event scores. This observation is supported by Budd [41] who characterised suffering as occurring ‘when we assess ourselves in a situation and don’t like where we are. It does appear that the latency periods for the sensory and affective-emotional components of pain differ. The reason for the differences in the relationship between life-stressing events and some sensory and psychological attributes of LBP between Caucasian and Nigerian patients reporting a similar intensity of pain (Table 2) is unclear. It is therefore important to ascertain the socio-economic status and number of life-stressing events that a LBP patient has experienced before and after the onset of pain. V. there may be racial and/or socio-economic differences in the variables that shape the aetiology and response to LBP. moderate bright and mild pressure sensations. however. whereas reading depressive statements worsened mood and reduced pain tolerance. This implies that apart from rural–urban variations. This may be due to discrepancies in the nature of the patient’s life events. influencing their care-seeking behaviour and potentially leading to delays in reporting for treatment [7. as well as anticipation of what the future holds. Hostility. reading elative statements improved mood and pain tolerance. In the study by Zelman et al.). and the two are products of information processing concerning sensory experiences. and expression of pain is seen as a sign of weakness [7]. blood pressure. Further analysis of data revealed that severe emotional discomfort and trait anxiety were related to life-stressing events in Nigerian patients but not in Caucasian patients.42]. as these may be crucial factors in a patient’s response to therapy. Pain intensity rating.42]. Conversely. pressure or throbbing qualities of LBP. burning. moderate constant burning.43]. cognitive and emotional components. It is even more difficult to ascertain whether these differences reflect socio-economic or racial variations in perception. which reflects the sensory aspect of pain.C. Egwu. Nwuga / Physiotherapy 94 (2008) 133–140 were accordingly defined as patients with chronic LBP of mechanical origin. level of education and information processing. individual tolerances vary. because the average time between onset of pain and time of reporting was shorter for the Caucasian patients (8 weeks) than the Nigerian patients (17 weeks). intermittent hot sensations and anxiety correlated significantly with life-stressing events in this group of patients. Fordyce [17] explained that perception of the nature and meaning of incoming sensory information. these data suggest that the lower the socio-economic status. Furthermore. The reason why life-stressing events relate to some but not all sensory and psychological attributes of LBP is open to speculation.

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003 .S. Males. doi:10. attitude statements and free text for comments were sent to all consenting patients 4 weeks after discharge from physiotherapy. Glasgow Caledonian University.129). The Scottish Physiotherapy Self Referral Study Group a School of Health and Social Care. despite there being a distinct lack of knowledge about the profession. Participants Three thousand and ten patients over 16 years of age. National Trial. Published by Elsevier Ltd. for a patient-centred National Health Service with improved access to services [1–5]. with no significant association between level of knowledge and referral group (P = 0. access and physiotherapy: patients’ knowledge and attitudes—results of a national trial Valerie S. Keywords: Self-Referral. There is a clear need to raise awareness and knowledge of physiotherapy if autonomous health-seeking behaviours are to be encouraged and self-referral schemes progressed appropriately. Patents’ Views. UK b NHS Quality Improvement Scotland. E-mail address: v.∗ . evidence relating to their actual views and/or level of support for such systems is limited [6–8]. Conclusions Physiotherapy was regarded positively by all referral groups. Methods Postal questionnaires containing a mix of open and closed questions. Published by Elsevier Ltd. have consistently emphasised the need ∗ Corresponding author. This interest has +44 141 331 8118.2007. there has been growing interest in the concept of patient self-referral to a range of services provided by the National Health Service. since 1997. fax: +44 141 331 8112. Physiotherapy. 0031-9406/$ – see front matter © 2008 Chartered Society of Physiotherapy. particularly by self-referred patients. Holdsworth b . Questionnaire Introduction Throughout the UK.1016/j. Whilst healthcare practitioners. less than 23% reported being knowledgeable or very knowledgeable about physiotherapy. Glasgow G4 0BA. All rights reserved. Results A response rate of 72% (2177/3010) was achieved. Tel.webster@gcal. © 2008 Chartered Society of Physiotherapy. Webster). Helen Little a . and patients referred at the suggestion of their GP. G1 2NP Abstract Objectives To identify service users’ views and attitudes to access. including physiotherapy. physiotherapy and patient-autonomous health-seeking behaviours.Physiotherapy 94 (2008) 141–149 Self-referral. All rights reserved. The current ‘Patient Focused Public Involvement’ agenda of UK Government health policies makes clear the need to actively seek and respond to the views of service users when developing or redesigning services [9].physio.001). Glasgow. females and all age groups were (V. and more supportive of physiotherapists making decisions about their fitness for work or activities (59% vs 53% of GP-referred patients and 53% of patients referred at the suggestion of their GP). more supportive of being able to self-refer (83% vs 69% of GP-referred patients and 71% of patients referred at the suggestion of their GP). Despite more than 80% of respondents claiming that they were able to confidently predict when they needed physiotherapy. Self-referred patients were more satisfied (P < 0. professional bodies and policy makers consider the introduction of self-referral as facilitating the empowerment of service users. Angus K. Webster a. because of the significant drivers for change contained within Government policies which. Study design Mixed qualitative and quantitative questionnaire. patients referred by their general practitioner (GP). Responses were analysed by referral group: self-referred patients. not least. Lesley K. Strong support for the effectiveness of physiotherapy was reported by all groups (>90%). Setting Twenty-six locations representing a range of socio-economic and geographical settings throughout Scotland. McFadyen a .

and/or a reticence to adopt autonomous health-seeking behaviours. Very little is known about how knowledgeable the public and service users are about physiotherapy or their associated perceptions. Aim The aim of this study was to identify the views and perceptions of physiotherapy service users about access and their physiotherapy experience. All patients referred to physiotherapy were asked for their consent to participate in the follow-up study. and consistently recommended the need for wider marketing of the profession [18. which would involve completing and returning a postal questionnaire.142 V. Although important indicators. This method allowed patients to complete the questionnaire in the privacy of their own homes [26. a full explanation of the trial was provided to patients. / Physiotherapy 94 (2008) 141–149 Patient satisfaction Within the National Health Service. nor do they provide any indication of underlying influencing attitudes. Both reported high levels of satisfaction with self-referral but did not explore respondents’ views or attitudes further. Although self-referral to physiotherapy appears to be feasible. Additionally. . They were assured that there was no obligation to take part in the follow-up phase. Only by engaging with service users will some of these questions be answered. patients referred by their general practitioner (GP). This paper reports the results of a follow-up study to the recently reported Scottish national trial [11–13]. It has to be accepted.27]. patients have to have knowledge of physiotherapy. self-referred patients. Webster et al. even if they agreed to take part in the initial study.e. irrespec- tive of their level of knowledge. what is not known is whether they were expressing their support for the concept of patients being able to refer.21]. values or perceptions. Chicken or egg or both? In the only published large-scale UK study investigating the efficacy of self-referral to physiotherapy. a lack of confidence. or whether they actually had existing knowledge from which to make an informed decision. Autonomous behaviours If self-referral systems are to be accessed appropriately. Methods Participants The full methodology of the main study has been reported previously [11]. surveys of satisfaction are known to elicit positive ratings which may not be sensitive to specific problems [15]. the annual report of the American Physical Therapy Association emphasised a number of strategies being used to highlight physiotherapy to the American public [24]. In a study of patients’ experiences of an ‘open access’ (self-referral) system for the ongoing management of inflammatory bowel disease. may still prefer healthcare professionals to make decisions on their behalf. the only published UK evidence relating to service users’ views about systems of self-referral consisted of two small-scale satisfaction studies (n = 133. that a proportion of patients. being unaware of the self-referral facility. and patients referred at the suggestion of their GP.14]. the authors found that preference for self-referral was based on whether patients exhibited a desire to take control of their health and its management. Prior to their initial physiotherapy contact. n = 58) [8. It must also be recognised that studies undertaken within local settings by clinical delivery teams may result in a favourable bias. i. They were also free not to return the questionnaire if they wished to withdraw at a later time. including any differences reported by referral group. As recently as 2004. Each reported a lack of public awareness of physiotherapy.19. and aims to provide information to add to the emerging evidence base about the acceptability of patient self-referral to physiotherapy. a 22% (648/3010) self-referral rate was reported [8]. appropriate and cost-effective [11–13]. It also reported that some patients were not confident with this approach and still preferred the doctor to take control of their management options [25]. consumer satisfaction is often viewed as an indicator of quality. The reason for this relatively low figure is unknown but it may have been as a consequence of any or all of the following: a lack of knowledge of physiotherapy. Study design A postal questionnaire was designed to illicit the views and perceptions of patients about physiotherapy. due to respondents feeling constrained in their ability to respond honestly for fear of having to use the service again. However. and remains an important part of the consumer perspective on healthcare systems [10]. particularly from widespread geographical areas. Postal questionnaires are an appropriate and cost-effective way of engaging significant numbers of individuals to gather broad-based information. Existing knowledge of physiotherapy A recent poll in the UK revealed that 88% of respondents were supportive of being able to refer themselves to physiotherapy [16]. confidence in its potential effectiveness and adopt autonomous healthseeking behaviours. the only studies that have attempted to explore some of these issues were conducted overseas [17–23].S. therefore. at the time of conducting this study.

Awareness of self-referral facility Respondents were questioned about whether they were aware that they could refer themselves to physiotherapy Proportion of questionnaires returned by referral group 1271 (71%) 364 (67%) 542 (84%) 2177 (72%) . The questions included were designed to capture respondents’ views relating to the key themes outlined in Box 1 . a computer-based programme designed specifically to produce and analyse questionnaires. including ‘other. one open question. Chisquared test and extended Chi-squared test were used to examine the association between the groups of nominal data. No direct patient-identifiable information was collected. Freepost envelopes were used to minimise the associated financial costs and to encourage return rates. 1997). Further verification of their applicability was ascertained prior to finalisation of the questionnaire. please state’ to capture alternative views. explanatory letter and freepost envelope were sent to all consenting patients 4 weeks after discharge from physiotherapy. A questionnaire. The level of significance was set at 5% and confidence levels at 95%. Results A response rate of 72% (2177/3010) was achieved (Table 1).S. The item pool consisted of nine attitude statements. / Physiotherapy 94 (2008) 141–149 143 Box 1: Key question themes Demographics: gender. The questionnaire was developed and refined in line with the principles advocated by Oppenheim [26] and Chesson [27]. general practitioner. Respondents were asked to complete the questionnaire within 1 week and return it via a supplied freepost envelope to the study centre. Principles of questionnaire design The questionnaire was developed and processed using PinPoint Questionnaire Software (Longman. Information about gender. and respondents were asked to indicate the extent to which they agreed or disagreed with each statement using a five-point Likert scale. Return to the study centre rather than the local physiotherapy service was chosen to encourage open and honest responses. age group. Longtron.V. not constrained by a fear that any future involvement with the local service could be compromised. and each patient was only categorised by their referral group and location so that individual results could be returned to each location on an aggregated basis. a semantic differential section conTable 1 Questionnaire response rates Questionnaire returns GP referral GP-suggested referral Self-referral Number of questionnaires issued GP. and a box for comments. age group and primary condition for which they had attended physiotherapy was also collected. All comments were transcribed verbatim and listed under the appropriate referral mode. Questionnaires issued 1795 542 648 3010 Data analysis The data from all the questionnaires were analysed using PinPoint Questionnaire Software. Ordinal and continuous data were examined using the Mann Whitney test. The final version consisted of a series of closed questions with a choice of predetermined answers. Frequency distributions were reported in percentages with the differences between the groups studied by means of non-parametric tests. Webster et al. Demographics and condition breakdown by referral group are presented in Table 2. then reviewed to identify themes and subthemes. The multiple choice answers were predominantly those rigorously developed and subsequently used in a previously published study (n = 485) [28]. A statistician was consulted at all stages of development. The themes were then verified by two independent observers. post code Type of problem that physiotherapist was consulted about Awareness of ability to self-refer Source of awareness (if appropriate) Perceived level of knowledge of physiotherapy Satisfaction with physiotherapy intervention Current symptom status Other healthcare practitioners consulted Attitude statements in relation to aspects of: access to physiotherapy effectiveness of physiotherapy confidence with autonomous behaviours physiotherapy roles free comments sisting of an attitude item pool of individual statements. Data collection Questionnaires were ‘bar coded’ to ensure that the three referral groups were easily identifiable.

486 P = 0. The majority of self-referred patients stated that they had been made aware of the facility through the local press or word of mouth (63%. 2). over 70% (1536/2128) of respondents reported continued symptoms. . 342/542). Not surprisingly. (Fig. compared with 26% (330/1271) of patients referred by their GP and 34% (124/364) of patients referred at the suggestion of their GP. LBP. general practitioner.129). Awareness of ability to self-refer. Satisfaction Despite there being a significant association between satisfaction and referral group (P < 0. 3). Reported level of knowledge of physiotherapy Most respondents classified themselves as having limited knowledge of physiotherapy (Fig. low back pain. the majority of all respondents were either satisfied or very satisfied with their physiotherapy intervention: 79% of self-referred patients. followed by poster displays (31%. 1. Less than 3% of all respondents reported that they were not satisfied.210 Missing data 9 Condition category P = 0. and if so. / Physiotherapy 94 (2008) 141–149 Table 2 Summary of descriptive data relating to respondents GP referral Gender Missing data 47 Age (years) Male Female 16–20 21–30 31–40 41–50 51–64 65–74 >75 LBP Neck Lower limb Shoulder Knee Upper limb Multiple Other 463 (37%) 782 (63%) 26 (2%) 65 (5%) 169 (13%) 213 (17%) 438 (35%) 224 (18%) 130 (10%) 203 (16%) 89 (7%) 86 (7%) 171 (14%) 161 (13%) 123 (10%) 290 (23%) 138 (10%) GP-suggested referral 134 (37%) 224 (63%) 5 (1%) 19 (5%) 51 (14%) 60 (17%) 135 (37%) 67 (18%) 27 (8%) 64 (18%) 30 (8%) 32 (9%) 36 (10%) 36 (10%) 30 (9%) 106 (29%) 26 (7%) Self-referral 181 (34%) 346 (66%) 9 (2%) 44 (8%) 61 (11%) 105 (19%) 178 (33%) 100 (19%) 42 (8%) 104 (20%) 32 (6%) 59 (11%) 63 (12%) 70 (13%) 43 (8%) 111 (21%) 49 (9%) Significance P = 0. and 74% of patients referred by their GP) (Fig.006 Missing data 25 GP. Less than 5% of all respondents in all groups considered themselves to be very knowledgeable. 1).S. Approximately one-fifth of respondents reported that they had consulted a healthcare professional specifically about the problem for which they had attended physiotherapy since Fig. the source of this knowledge.144 V. Perceived knowledge of physiotherapy. 102/330). with no significant association between knowledge and referral group (P = 0. patients referred by their GP citied their GP as the most common source of information (37%.001). 2. although the majority stated that their symptoms were improving. All self-referred patients reported being aware. 122/330). Current symptoms One month after discharge. Fig. Webster et al. 73% of patients referred at the suggestion of their GP.

suggests that a person initiating access to health care is dependent on a number of factors such as enabling. the method of returning completed questionnaires to an independent study centre enhances the reliability of these findings. the method used to elicit their views and. the patients in this study reported high levels of satisfaction with physiotherapy. the Anderson model [33. One of the most established. Others highlighted the constraints of a system that only operated during ‘office’ hours. Suggestions for improvement included: increased level of physiotherapy provision.V. but on what is this support based? Whilst not decrying the use of patient satisfaction as an indicator. Attitudes The levels of agreement/disagreement with the nine attitude statements are detailed in Table 3. Self-referred patients were more likely to be strongly supportive of being able to self-refer.219). The majority of all respondents. Some patients reported that their physiotherapy intervention time was ‘rushed’. There were significant differences between the referral groups in views relating to access to physiotherapy. little evidence exists to provide any indication of what patients or the public actually know about physiotherapy. Respondents’ comments . These factors include not only age. 2). predisposing and a need for care. gender and race. in particular. with GPs being most frequently cited by all referral groups: 17% (93/534) of self-referred patients. the Chartered Society of Physiotherapy has been actively campaigning for self-referral to be a ‘real choice for primary care patients by 2007’ [4]. claimed to have limited knowledge of physiotherapy (Fig. / Physiotherapy 94 (2008) 141–149 145 apy could offer and to whom. knowledge. In line with the previously published satisfaction surveys [8. Government policy published in 2006 also included the intention to introduce and evaluate patient self-referral to physiotherapy in locations throughout England [1]. what physiotherSince the 1960s. irrespective of referral group. Webster et al. and providing a help desk/telephone advice line to provide and/or clarify information/advice. Discussion The emerging and growing evidence about the clinical effectiveness and cost-effectiveness of patient self-referral [8.S. and most supportive of physiotherapists making decisions about patients’ fitness for work or normal activities (Table 3). politicians. and 19% (236/1244) of patients referred by their GP (P = 0. 2008/2149). with many arguing for continuance of the schemes. being discharged. There were also issues highlighted where it was felt that improvements could be made to the service. healthcare managers.14]. Interest has been voiced increasingly by the physiotherapy profession. Knowledge of physiotherapy Forty-six percent (1002/2177) of respondents provided additional comments which were grouped into four themes (Box 2). Since 2003.11–13] assumes that this mode of access is also supported by patients who are comfortable. GPs. theoretical models have emerged that aim to demonstrate the concept of patient access to healthcare services. Patient satisfaction It has been stated that the concept of self-referral is well supported by the public [16]. Self-referred patients were least likely to lack confidence in their ability to determine when physiotherapy was appropriate. this emphasis is somewhat surprising considering that the only UK evidence about service users’ views on physiotherapy relates to a limited number of patient satisfaction studies [8. and individual attitudes and beliefs. In some respects. This finding is perhaps understandable as the respondents were seen within phys- Fig. Some were concerned that introducing self-referral without a parallel public education/awareness campaign would result in inappropriate presentations and longer waiting lists. The vast majority were very positive. greater collaboration between physiotherapists and GPs. 3. Perceived levels of satisfaction. agreeing that self-referral could save them time and they would use the service again in the future. autonomous behaviours and future use of physiotherapy. professional bodies. but also factors such as access.14]. The vast majority of all respondents agreed or strongly agreed that physiotherapy was effective (92%. able and willing to initiate access to physiotherapy themselves. 22% (79/358) of patients referred at the suggestion of their GP.34]. timing of service delivery. despite a recent experience. and even patients and the wider public [29–32].

023 P < 0.0001 Missing data 22 Physiotherapists offer effective treatment for conditions such as back and neck. Webster et al.S.545 13 (1%) 28 (2%) 57 (4%) 702 (56%) 461 (37%) 2 (1%) 7 (2%) 12 (3%) 175 (49%) 161 (45%) 3 (1%) 6 (1%) 15 (3%) 275 (52%) 234 (44%) P = 0.146 V. GP-suggested referrals and self-referrals Questions Only GPs should be able to refer patients to physiotherapy Responses Strongly disagree Disagree No opinion Agree Strongly agree GP referral 199 (16%) 665 (53%) 150 (12%) 190 (15%) 45 (4%) GP-suggested referral 53 (15%) 204 (56%) 35 (10%) 50 (14%) 18 (5%) Self-referral 135 (25%) 307(58%) 39 (7%) 44 (8%) 8 (2%) Significance P < 0. joint or soft tissue problems Strongly disagree Disagree No opinion Agree Strongly agree Missing data 26 I am not happy for physiotherapists to make decisions about whether I am fit for work or normal activities Strongly disagree Disagree No opinion Agree Strongly agree Missing data 84 I am confident I know myself when I need to consult a physiotherapist Strongly disagree Disagree No opinion Agree Strongly agree Missing data 32 Patients can learn a lot about how to help to manage their health problems themselves Strongly disagree Disagree No opinion Agree Strongly agree Missing data 35 I would feel happier consulting both my GP and the physiotherapist Strongly disagree Disagree No opinion Agree Strongly agree Missing data 52 I would use the service again Strongly disagree Disagree No opinion Agree Strongly agree 12 (1%) 12 (1%) 15 (1%) 665 (53%) 548 (44%) 3 (1%) 3 (1%) 2 (1%) 155 (42%) 199 (55%) 4 (1%) 4 (1%) 4 (1%) 223 (41%) 301 (56%) 25 (2%) 263 (21%) 233 (19%) 602 (49%) 117 (9%) 7 (2%) 59 (17%) 45 (13%) 186 (52%) 58 (16%) 18 (3%) 151 (28%) 133 (25%) 205 (39%) 23 (4%) P < 0.011 19 (1%) 154 (12%) 76 (6%) 774 (62%) 232 (19%) 3 (1%) 43 (12%) 9 (3%) 223 (62%) 80 (22%) 6 (1%) 38 (7%) 28 (5%) 344 (65%) 116 (22%) P < 0. / Physiotherapy 94 (2008) 141–149 Table 3 Summary of opinion data relating to general practitioner (GP) referrals.007 138 (11%) 511 (42%) 331 (27%) 191 (15%) 58 (5%) 39 (11%) 145 (42%) 88 (26%) 56 (16%) 17 (5%) 70 (14%) 234 (45%) 130 (25%) 67 (13%) 18 (3%) P = 0.001 Missing data 27 .001 10 (1%) 85 (7%) 86 (7%) 808 (64%) 263 (21%) 7 (2%) 20 (6%) 16 (4%) 223 (62%) 93 (26%) 12 (2%) 23 (4%) 29 (6%) 330 (62%) 1370 (26%) P < 0.0001 Missing data 35 Self-referral to physiotherapy could save a lot of time Strongly disagree Disagree No opinion Agree Strongly agree 25 (2%) 73 (6%) 43 (3%) 665 (53%) 455 (36%) 10 (3%) 20 (6%) 7 (2%) 176 (49%) 144 (40%) 6 (1%) 17 (3%) 11 (2%) 237 (44%) 266 (50%) P < 0.

34. cope much better now Gave me control over pain which previously was intolerable If you self-refer. shows desire to get better Reassurance that what you are doing is right. Webster et al. very good at explaining A physiotherapist might not have experience on your condition that your general practitioner does have Any opinion on ‘fitness for work’ would have to be in liaison with a doctor. If. These findings support the recommendation made by other authors that . I might still be talking to her which was no use Excellent. only during working hours difficult Want to be able to see my general practitioner General practitioner should refer Danger patients will refer with minor problems so waiting would increase Empowered patients Physiotherapy service More treatment sessions needed Treatment sessions too short (20 minutes) Found initial appointment difficult Physiotherapists only look at the problem you present with. and that would not be sufficient to inform an overall increased knowledge. thank you. she could not fully attend to my needs and I feel everything was a bit rushed Godsend for the ‘older’ patient Exercises/advice have improved intervals between attacks considerably Referred me to occupational therapist for specialist help. then a lack of knowledge will inhibit autonomous behaviours [33. priceless General practitioner time Saved general practitioner time. excellent idea please keep it Access easier. It should also be noted that respondents’ understanding of their own condition was at variance with that of the physiotherapists. / Physiotherapy 94 (2008) 141–149 147 Box 2: Examples of comments made by respondents Positive Access and location Pleased I was able to choose.V. a key factor influencing initiation of contact is knowledge. but these results suggest that physiotherapy has some way to go before this is a reality for all.S. not whole person Better if see same physiotherapist throughout In my experience. over 20% of patients referred by their GP (290/1271) and self-referred patients (83/542). good physiotherapists are rare and cannot be effective in health centres Assessment of priority patients based on those working or not is flawed System could be open to abuse with patients who genuinely need to see a physiotherapist having to wait longer due to non-genuine complaints Did not seem too interested As physiotherapist had other clients on the go at the same time. should be done for other clinics.g. better to see physiotherapist Doctors’ time not taken up by patients who they just refer on My general practitioner gave me no encouragement or support and without your schemes.36]. YOU are taking responsibility. saves a lot of time and pain Self-referral.35]. undervalued Would not hesitate to go back First time been able to access in 30 years and has transformed my life Courteous and knowledgeable. very positive Got exercises should have had 12 years ago iotherapy outpatient clinics. There might be other medical problems Negative Waiting times too long Not well publicised Appointment times could be improved. very happy with treatment Thank you for this way of getting physiotherapy Very pleased with self-referral and treatment Self-referral much more effective. less than 2% (39/3010) of subjects were identified as being referred with multiple problems. predominately requiring one physiotherapy episode of care for an average number of four contacts [11. It is not therefore unreasonable to surmise that respondents were only exposed to specific aspects of physiotherapy. and nearly 30% (107/364) of patients referred at the suggestion of their GP stated that they had attended with multiple problems. Joint understanding and decision making are key elements of current healthcare practice. hope it gets lots of support. In the main study. less hassle. excellent innovation I know what to do in the future if symptoms recur Able to get clear understanding of condition and what affects it I have quality of life now Gave confidence. e. but in this follow-up study. first class. speedier recovery Should encourage self-referral. warts Waste of time seeing general practitioner for painkillers/back pain. as proposed by other authors.

Webster et (last accessed 23 December 2004). although the lack of knowledge about the profession and how it can assist in managing health was rather concerning. [6] Chartered Society of Physiotherapy. [4] Scottish Executive.scotland. our say. Edinburgh: Scottish Executive. In line with other evidence.S.34. personal to Publications/2005/11/02102635/26356 (last accessed 8 January 2006). A number of specific issues were highlighted about the local arrangements for access. Members of the general public who rarely visit their local general practice or have contact with other healthcare providers may be unaware of the facility. one-quarter of all respondents. Limitations This study represents an attempt to quantify the views of physiotherapy patients in relation to self-referral as a viable mode of access. and to publicise how access to these services can be achieved. our care. [7] Chartered Society of Physiotherapy.21. provided through practice newsletters. a plan for reform. this method of marketing relies heavily on people having some contact with other healthcare services to gain information. As a responsible profession. Griffin E. Forth Valley NHS and participating sites. Delivering the NHS Plan.H. irrespective of referral group. There were high levels of support for the value of and wider access to physiotherapy. [8] Ferguson A. MREC/02/0/37. References [1] Department of Health. Health Serv Manag Res 2003. This does not necessarily indicate that respondents were ambivalent about these issues.S. Ref no. Attitudes and beliefs The stronger attitudes of self-referred patients about a number of issues support other published evidence [33. Mulcahy C. word of mouth and via healthcare professionals. although selfreferred respondents were more strongly supportive of using the service again (Table 3).24]. 2004.148 V.19.? Physiotherapy 1999. 2006. Perceived access in a managed care environment: determinants of satisfaction. even with limited knowledge. Conclusions The high response rate and large proportion of additional comments suggest that the public are keen to contribute to discussions about patient access in general and physiotherapy specifically. communication and information/knowledge. Although appropriate in this case. they only relate to Scottish physiotherapy patients and may not represent the views of the rest of the UK. As well as being more satisfied. Acknowledgements The authors would like to acknowledge the Scottish Physiotherapy Self Referral Study Group. a new direction for community services.85:13–20. [2] Department of Health. London: Department of Health. 16:85–95. self-referred patients had a greater overall confidence in the effectiveness of physiotherapy. Edinburgh: Scottish Executive. 2005. it is essential that the physiotherapy profession uses effective modern marketing strategies to enhance the public’s awareness and confidence in physiotherapy-led services. Rebuilding our National Health Service: a plan for action. [9] Scottish Executive. Available at: http://www. [5] Scottish Executive. If systems of self-referral .36] that attitudes and beliefs are also key predisposing factors to access. Perhaps they did not feel strongly about who actually made these decisions. The NHS Plan: a plan for investment. the methods used to advertise the self-referral facility were. Although these views are representative of a large physiotherapy population. it is imperative that physiotherapy regularly identifies and responds to feedback from service users and the public using these findings to meaningfully inform policy and service level development. it will be vital to ensure that the public are more aware of the potential role of professions. Making physiotherapy count. 2003. Briefing paper: self referral to physiotherapy services. This study also identified that self-referred patients appear to have more confidence in their own autonomous behaviours and more positive attitudes to physiotherapy than patients referred from other Funding: Glasgow Caledonian University. 2004. Patient self referral to physiotherapy in general practice – a model for the new N. for the most part. Fair to all. Our health. London: Chartered Society of Physiotherapy. London: Chartered Society of Physiotherapy. London: Department of Health.scotland. Ethical approval: Multi-centred Research Ethics Committee (Scotland). Possibly not so surprising was the fact that self-referred patients had stronger supportive attitudes about the advantages of adopting autonomous behaviours. [3] Department of Health. Conflict of interests: None declared. Over 90% (2008/2177) of all respondents reported strong support for the effectiveness of physiotherapy. 2000. Interestingly. Sinay T. a plan for change. London: Department of Health. are to be encouraged. Available at: http://www. and sets a challenge as to how this can be achieved [18. Edinburgh: Scottish Executive. / Physiotherapy 94 (2008) 141–149 there is a need to raise public awareness and knowledge of physiotherapy. and were accepting of the appropriateness of either physiotherapists or doctors undertaking these roles. [10] Kasper H cited in Akinci posters. the next steps for NHS Scotland. Delivering for Health Scotland. 2002. In this study. 2004. expressed no opinion about who should make decisions about their fitness for work or activities.

Public perception of physiotherapy: implications for marketing.30:8–16. illness and physiotherapy of Maori identifying with Ngatitoma. [16] Chartered Society of Physiotherapy. Public perception of physiotherapy in Singapore: a marketing research report. de Bakker D. Health Pol 1998. Physiotherapy 2005. Holt EAL. Direct access to physiotherapy in primary care: now?—and into the future? Physiotherapy 2004. Physiother Singapore 1998. Kennedy A.30:35–8. [13] Holdsworth L.40:265–71. Physiotherapy 1998.30:30–40. [32] Wigmore-Welsh J. Webster V.V.90:64–72. The physiotherapist: appreciated but not well known. editorial.S. Frontline Supplement.91:61– 2. [27] Chesson R. Perceived access in a managed care environment: determinants of satisfaction. New Zealand resident Tongan people’s perceptions of physiotherapy. Tango SM. Webster V.92:26–33. Revising the behavioural model and access to medical care: does it matter? J Health Soc Behav 1995. [30] Chartered Society Physiotherapy. Physiotherapy 1993. Hsu . Shamus E. [22] Bassett SF. [29] Chartered Society of Physiotherapy.90:64–72. [23] Bassett SF. Are patients who refer themselves to physiotherapy different from those referred by GPs? Results of a national trial.45:84–7. Patients’ experiences and satisfaction with health care: results of questionnaire study of specific aspects of care. Questionnaire design. Hill C. [26] Oppenheim AN. Annual report 2004. Frontline 2001. Quality Safe Health Care 2002. Patients’ experiences of an open access follow up arrangement in managing inflammatory bowel disease. Musculoskeletal physiotherapy in general practice fundholding practices. [33] Andersen RM. London: Chartered Society of Physiotherapy. Frontline 2003. Sinay T. [21] Snow L. Physiotherapy 2004. London: Continuum International Publishing Group. interviewing and attitude measurement. [19] Hus D. Robinson A. 149 [24] American Physical Therapy Association. [20] White N. Webster VS. McFadyen AK.36:1–10. Physiotherapy 2006.92:16–25. J Allied Health 2001. Webster et al.27:5–15. London: Chartered Society of Physiotherapy. NZ J Physiother 2002. McFadyen AK.11:335–9. Nelson E. Self-referral to physiotherapy: deprivation and geographical setting: is there a relationship? Results of a national trial. Chandola T. Direct access to physiotherapy in primary care: now and into the future. [12] Holdsworth L. Bithell C. [25] Rogers A. Delnoij D. Physiother Can 1993. Briefing paper: self referral to physiotherapy services. Aust J Physiother 1994. Referral system controls entry to NHS physiotherapy.May 29:3. [35] Minns C. Perceptions of health. Richards N. 2004. Direct access in Australia.13:374–8. [15] Jenkinson C.79:711–3. [36] Kula-Glasgow I. Maori people’s experiences of being physiotherapy patients: a phenomenological study.sciencedirect. 2004. [31] Boyce R. Self-referral in a gatekeeping system: patients’ reasons for skipping the general-practitioner. Physiotherapy 2006. Bassett SF. Quality Safety Health Care 2004. Coulter A.1:117–26. NZ J Physiother 2002. [34] Anderson RM 1968 cited in Akinci F. Physical therapy as primary health care: public perceptions. 16:85–95. How to design a questionnaire – a ten stage strategy. Annual report 2004/05. Webster V. 2005. Mavoa H.45:221–38. Available online at www.January 17:23.84:84–92. [28] Holdsworth LK. Bruster S. 1992. / Physiotherapy 94 (2008) 141–149 [11] Holdsworth L. McFadyen A. 2004. Health Serv Manag Res 2003. London: The Chartered Society of Physiotherapy. [14] Chadda D. [17] Sabourin J. [18] Sheppard L. NZ J Physiother 1999. Widening access: improving patient care. Alexandria: American Physical Therapy Association.

Munich. Disability and Health (ICF). course of acute medical care [1]. Ludwig Maximilians University Munich. IHRS. their evaluation and planning. An early onset of interventions and their appropriate management has been demonstrated to improve functional outcome and to prevent the need for long-term care [2–9]. This process involves the identification of problems and needs. Disability and Health Rene Mittrach a . The most frequent intervention goals for cardiopulmonary patients were: functions of the cardiovascular system. Germany d Swiss Paraplegic Research. Stucki).1016/j. doi:10. and respiration functions. Ludwig-Maximilians-University. Switzerland Abstract Objective To provide an example of how goals of physiotherapy interventions and their typical patterns can be described using the International Classification of Functioning.Physiotherapy 94 (2008) 150–157 Goals of physiotherapy interventions can be described using the International Classification of Functioning.5 years and 44% were female. Nottwil. fax: +49 89 7095 8836.08. intervention goals can serve as standardised documentation for physiotherapy interventions. Results The mean age of the subjects was 58.∗ a ICF Research Branch. The most frequent intervention goals in patients with neurological conditions were: muscle power functions.: +49 89 7095 4050. Germany b Department of Rheumatology and Institute for Physical Medicine.uni-muenchen. University Hospital Zurich. Germany. Main outcome measures The case record form consisted of two parts: a standardised questionnaire for functioning and health of the patient. control of voluntary movement functions.stucki@med. Keywords: Physical therapy (speciality). muscle tone functions. changing basic body position. Treatment outcome. © 2007 Chartered Society of Physiotherapy.9). E-mail address: gerold. musculoskeletal or cardiopulmonary conditions requiring physiotherapy interventions in University Hospital Zurich between January 2003 and October 2003. Design Cross-sectional study. All rights reserved. psychosocial factors. Switzerland c Department of Physical Medicine and Rehabilitation. ICF Introduction The outcome of an acute illness or injury depends not only on appropriate medical and surgical care. Monika Walchner-Bonjean a . maintaining a body position.d. Setting Acute hospital. rehabilitation relates mainly to interventions by nurses and physiotherapists that accompany the ∗ Correspondence: Department of Physical Medicine and Rehabilitation. Published by Elsevier (G.2 years (standard deviation 15. health condition and environmental factors. Goals. but also on the recognition of patients’ needs during rehabilitation. muscle power functions. Ludwig-Maximilians-University. Tel. 15. Erika Omega Huber b .2007. and transferring oneself. the relation of the problems to relevant factors of the person. and muscle endurance functions. Munich. the median age was 60. Published by Elsevier Ltd. Marchioninistr. Participants One hundred patients with neurological. 0031-9406/$ – see front matter © 2007 Chartered Society of Physiotherapy. definition of goals. WHO FIC Collaborating Center (DIMDI).c. 81377 Munich. Physiotherapy interventions are integrated into a continuous and cyclic process. Monika Scheuringer a . In the acute setting. Typical goals depend on individual patient characteristics such as age. muscle tone functions.006 . Eva Grill a . and a standardised record form for physiotherapy interventions. Both parts were based on the ICF. stability of joint functions. The goals of physiotherapy interventions in the acute setting are to maintain and restore functioning and to prevent functional decline. All rights reserved. Christine Boldt a . Documentation. The most frequent intervention goals in patients with musculoskeletal conditions were: sensation of pain. Conclusion By using the ICF as a framework and linguistic support. Gerold Stucki a.

The second component is about activity and participation. The objective of this study was to describe goals of physiotherapy interventions and their typical patterns using the ICF. (2) to describe their most frequent combinations. but is not yet classified. ‘Body structures’ (s) and ‘Activities and participation’ (d). are followed by a numeric code starting with the chapter number (one digit) followed by the second level (two digits). age or lifestyle. ICF categories are ‘nested’ [14] so that ICF chapters are defined to include the more detailed second-level ICF categories (Box 1 ). ‘Activities and participation’ and ‘Contextual factors’. The third component is about environmental factors and describes external influences on functioning. or flora and fauna.g. 1. expressed as ICF categories. Mittrach et al. food. Activity is the execution of a task. and the corresponding physiotherapy intervention goals. each containing two separate components. but also in the interaction with personal factors and the environment. By including all these factors. The ICF unifies these two models by looking at functioning not only in association with morbidity. The ICF has two parts. Part 2 covers contextual factors and includes the components ‘Environmental factors’ (e) and ‘Personal factors’ (Fig. d and e. and (3) to examine the association between limitations and impairment in functioning. gender. which refer to the components of the classification. It is likely that the ICF. and the third and fourth level (one digit each). particularly. Disability and Health model. personal factors. Specific objectives were: (1) to identify and quantify the goals of physiotherapy interventions in the acute setting using ICF categories. e. social and psychological environment. the study population consisted of all patients with neurological. in a standardised way. included in all three condition-specific acute ICF core sets. caused by injury or disease. The International Classification of Functioning. The ICF provides a model of functioning and a classification to describe and classify functioning. and which are the most relevant components of functioning for patients in the acute setting. In the ICF classification. and participation describes the involvement of individuals in real-life situations. the letters b. the ICF complements the International Classification of Disease-10 [16] which provides a classification system for diagnoses and causes of death. Simultaneously. devices. policies. Methods Study design and study population This cross-sectional study on physiotherapy interventions was part of a larger multicentre. musculoskeletal or cardiopulmonary conditions requiring physiotherapy interventions at University Hospital Zurich between January 2003 and October 2003 who gave informed consent. and refers to task execution by individuals. in the community. One approach to classify and standardise physiotherapy interventions is to relate them to their individual goals [13].g. using a telephone. Measures The case record form used in this study consisted of two parts: a standardised questionnaire for functioning and health of the patient. At present. cross-sectional study that has been described in detail elsewhere [15]. In brief. e. Both parts are based on the ICF and its notation. / Physiotherapy 94 (2008) 150–157 151 planning of interventions.12]. Interviewers were advised to record limitations or impairments as present or absent due to the condition that had been the reason for hospitalisation. e. Goal setting and re-evaluation allows measurement of the result of any intervention. and a standardised record form for physiother- apy intervention goals. While the medical model sees disability as a problem of the individual. Patients were recruited from predefined acute and intensive care wards. the social model defines disability as lack of integration of individuals into society. However. The ICF consists of four components. Fig. International Classification of Functioning.g. one major barrier to the appropriate evaluation of treatment effects is the challenge of describing interventions. The first component refers to body functions and body structures as physiological functions. one of the key objectives of the ICF is to provide a universal language for all health professionals. Twenty-six ICF second-level categories. and includes the components ‘Body functions’ (b). such as mobility of joints and anatomical parts such as tendons. . there is no commonly understood terminology that qualifies for the description of interventions [11. Part 1 covers functioning and disability. describes internal influences on functioning. e. were used to document functioning and health of the patients [17–19].R. The ICF describes the human within his/her physical. s. will become a universal framework in medicine and. with its components ‘Body functions and structures’. health and disability. 1). at home or at the workplace. and assessment of the effects [10].g. in rehabilitation. namely physiotherapy interventions. These core sets are selections of second-level ICF categories that have been developed in a comprehensive consensus process [20]. Disability and Health (ICF) [14] may provide a framework and classification for such a standardised documentation. The fourth component.

unspecified A standardised case record form based on the ICF categories was developed by four experienced therapists (physical therapist. For cardiopulmonary conditions. T07) Patients (%) 41 25 10 10 Cardiopulmonary (n = 20) 88 Musculoskeletal (n = 30) 70 26 . If information was not obtainable from the patient. and all were ICF categories of the components ‘Body functions’ and ‘Activities and participation’. Leading diagnoses are shown in Table 1. the most frequent and common interventions were identified. expressed as second-level ICF categories. and 44% were female. Only those intervention goals that had a relative frequency of 50% or more were taken into account to describe the most frequent combinations. e. the median age was 68.5 years. occupational therapist. the mean age was 57. All intervention goals could be found within the ICF framework. and relative frequency is the observed proportion of goals among all goals.5 years. The mean number of days since the event was 19. the absolute and relative frequencies of patients not reporting an impairment but receiving an intervention aimed at these categories were also calculated. other specified b7309 Muscle power functions.1 years (SD 13. and 35% were female.152 R. Likewise. the median age was 60. / Physiotherapy 94 (2008) 150–157 Box 1: Example for the International Classification of Functioning. Interviewers were trained during a structured 1-day meeting and provided with a manual.1 years (SD 14. For musculoskeletal conditions. In order to analyse the association between perceived impairments and limitations in functioning and the prevalence of intervention goals. I70–I99) Diseases of the musculoskeletal system and connective tissue (M00–M99) Injuries (exclusive injuries to the head) and unspecified multiple injuries (S10–S99. An ICF category was included as an intervention goal if there was a specific intervention aimed at prevention or therapy of this specific category. Physiotherapy interventions Ninety-seven percent of the patients received physiotherapy. The final questionnaire comprised 73 intervention goals. was calculated. the medical record sheet was checked. Mittrach et al.9).2). health professionals of the relevant wards or relatives were asked. the median age was 58. Absolute frequency is the observed number of goals for the sample. and receiving or not receiving an intervention aimed at these categories.0 years.2 years (standard deviation (SD) 15. respiratory therapy with its many therapeutic possibilities all aiming at respiration functions. For the neurological conditions. and 36% were female. Data analysis Absolute and relative frequencies were reported to quantify the goals of physiotherapy interventions.9). 50 with neurological conditions. The mean age was 58. Before each interview started.3 years (SD 16. All data forms were checked by a second person for completeness and plausibility. Each interviewer was asked to check the data-collection form immediately after the interview to correct unclear statements and to add comments. T07) Diseases of the circulatory system (I10–I59. the mean age was 55. the absolute and relative frequencies of patients reporting an impairment or a limitation in the 26 ICF categories. Results One hundred patients were included. speech therapist) from University Hospital Zurich to record the goals of physiotherapy interventions. Data collection and quality assurance The interviews were held and the patients were treated by health professionals trained in the application and principles of the ICF.9).5 years. the median age was 58. 20 with cardiopulmonary conditions and 30 with musculoskeletal conditions. the mean age was 65. and 63% were female.8 (SD 23. Patients with neurological conditions had a higher Table 1 Most frequent diagnoses responsible for inpatient stay (International Classification of Disease-10) (n = 100) Condition responsible Neurological (n = 50) Diagnosis Cerebrovascular disease (I60–I69) Malignant neoplasms (C00–C97) Cerebral palsy and other paralytic syndromes (G80–G83) Injuries to the head and unspecified multiple injuries (S00–S09.g. nutritionist. Based on the average number of prescribed physiotherapy interventions over the last 6 months. Disability and Health hierarchy: muscle power function b7 Neuromusculoskeletal and movement-related functions b730 Muscle power functions b7300 Power of isolated muscles and muscle groups b7301 Power of muscles of one limb b7302 Power of muscles of one side of the body b7303 Power of muscles in lower half of the body b7304 Power of muscles of all limbs b7305 Power of muscles of the trunk b7306 Power of all muscles of the body b7308 Muscle power functions.9).

. 36) 153 Musculoskeletal conditions (n = 30) 7 (3. 9) 12.5 (3. 17) 3 (0. 30) 3.) Total (min. max.) 11 (0..R. 28) 7 (0. 22) Table 3 Therapeutic intervention goals expressed as International Classification of Functioning..) Activities and participation (min.5 (4. 5) 10 (3. max. max. Mittrach et al. Disability and Health (ICF) categories (body functions): relative frequency of patients receiving physiotherapy interventions aimed at the corresponding ICF category ICF code b114 b130 b140 b144 b152 b156 b160 b167 b172 b176 b210–b229 b230–b249 b250–b279 b280 b310 b320 b330 b340 b410–b429 b440 b445 b450 b460 b510 b515 b525 b530 b535 b540 b620 b630 b710 b715 b720 b730 b735 b740 b750 b755 b760 b765 b770 b780 b810–b849 b850–b869 ICF code description Orientation functions Energy and drive functions Attention functions Memory functions Emotional functions Perceptual functions Thought functions Mental functions of language Calculation functions Mental function of sequencing complex movements Seeing and related functions Hearing functions Additional sensory functions Sensation of pain Voice functions Articulation functions Fluency and rhythm of speech functions Alternative vocalisation functions Functions of the cardiovascular system Respiration functions Respiratory muscle functions Additional respiratory functions Sensations associated with cardiovascular and respiratory functions Ingestion functions Digestive functions Defaecation functions Weight maintenance functions Sensations associated with the digestive system General metabolic functions Urinary functions Sensations associated with urinary functions Mobility of joint functions Stability of joint functions Mobility of bone functions Muscle power functions Muscle tone functions Muscle endurance functions Motor reflex functions Involuntary movement reaction functions Control of voluntary movement functions Involuntary movement functions Gait pattern functions Sensations related to muscles and movement functions Functions of the skin Functions of the hair and nails Neurological conditions n = 50 (%) 38 28 46 10 8 72 8 16 – 40 22 32 52 16 10 8 4 4 14 26 16 16 4 12 2 2 8 – 2 2 2 26 70 8 80 82 64 8 56 84 38 60 44 12 2 Cardiopulmonary conditions n = 20 (%) 30 10 15 – 5 20 10 – – 5 15 15 5 15 – – – – 85 80 65 60 65 5 5 5 10 5 15 – – 45 35 30 55 45 55 15 15 10 10 30 15 10 5 Musculoskeletal conditions n = 30 (%) – 7 – – 7 37 – – – 13 – – 17 80 – – – – 10 17 7 3 – – – – – – 10 – – 70 83 13 77 77 77 3 3 37 3 50 50 3 3 . 15) 18 (0. 43) Cardiopulmonary conditions (n = 20) 8. / Physiotherapy 94 (2008) 150–157 Table 2 Median of intervention goals per patient Neurological conditions (n = 50) Body functions (min.5 (0.

5) or musculoskeletal (n = 10) conditions (Table 2). 2. Disability and Health intervention goals and other frequent combinations. muscle tone functions. Mittrach et al. . maintaining a body position. and transferring oneself. changing basic body position. The most frequent intervention goals for Fig. control of voluntary movement functions. Thirteen of 73 intervention goals were prevalent in the three health conditions in more than 75% of the patients. / Physiotherapy 94 (2008) 150–157 Table 4 Therapeutic intervention goals expressed as International Classification of Functioning. Disability and Health (ICF) categories (activity and participation): relative frequency of patients receiving physiotherapy interventions aimed at the corresponding ICF category ICF code d310 d315 d320 d325 d330 d335 d340 d345 d350 d355 d360 d410 d415 d420 d430 d435 d440 d445 d450 d455 d460 d465 d510 d520 d530 d540 d550 d560 ICF code description Communicating with – receiving – spoken messages Communicating with – receiving – non-verbal messages Communicating with – receiving – formal sign language messages Communicating with – receiving – written messages Speaking Producing non-verbal messages Producing messages in formal sign language Writing messages Conversation Discussion Using communication devices and techniques Changing basic body position Maintaining a body position Transferring oneself Lifting and carrying objects Moving objects with lower extremities Fine hand use (picking up. The most frequent intervention goals in patients with neurological conditions were: muscle power functions. Two main combinations of International Classification of Functioning.154 R. grasping) Hand and arm use Walking Moving around Moving around in different locations Moving around using equipment Washing oneself Caring for body parts Toileting Dressing Eating Drinking Neurological conditions n = 50 (%) 36 22 – – 22 6 – 4 16 8 2 80 78 78 20 18 28 64 60 14 30 18 6 6 8 24 6 10 Cardiopulmonary conditions n = 20 (%) 25 20 – – 5 10 – – 15 10 – 35 30 20 15 – 10 20 55 – 30 5 5 – – 5 – – Musculoskeletal conditions n = 30 (%) – – – – – – – – – – – 60 63 47 10 7 – 17 43 10 7 – – – – 3 – – number of different intervention goals (n = 18) than patients with cardiopulmonary (n = 12.

grasping) Hand and arm use Walking Washing oneself Caring for body parts Toileting Dressing Eating Drinking 91 91 99 99 100 99 89 16 (56%) 31 (29%) 8 (100%) 7 (0%) 13 (77%) 8 (63%) 1 (100%) Cardiopulmonary 6 (33%) 2 (0%) 3 (100%) 17 (88%) 16 (75%) 13 (77%) 12 (92%) Musculoskeletal – 11 (0%) 24 (96%) 3 (67%) 5 (40%) 2 (100%) – n not impaired (% of not impaired receiving intervention for this category) Neurological 27 (19%) 12 (25%) 41 (39%) 42 (12%) 37 (8%) 41 (10%) 41 (17%) Cardiopulmonary 13 (8%) 16 (25%) 17 (65%) 3 (100%) 4 (50%) 7 (0%) 6 (100%) Musculoskeletal 29 (3%) 19 (21%) 6 (67%) 27 (4%) 25 (16%) 28 (14%) 29 (14%) R. / Physiotherapy 94 (2008) 150–157 b525 b710 b730 b735 b740 b780 d410 d415 d420 d430 d440 d445 d450 d510 d520 d530 d540 d550 d560 100 100 100 100 98 91 100 100 100 96 100 69 97 100 100 100 100 100 100 1 (0%) 23 (70%) 40 (98%) 41 (100%) 32 (94%) 17 (65%) 40 (78%) 39 (74%) 38 (82%) 10 (60%) 14 (86%) 23 (48%) 30 (83%) 3 (100%) 3 (33%) 4 (100%) 12 (100%) 3 (100%) 5 (80%) 1 (100%) 9 (44%) 11 (73%) 9 (56%) 10 (90%) 3 (33%) 7 (43%) 6 (0%) 4 (75%) 3 (67%) 2 (50%) – 10 (20%) 1 (100%) – – 1 (100%) – – – 21 (100%) 23 (100%) 23 (96%) 23 (87%) 15 (67%) 18 (100%) 19 (95%) 14 (86%) 3 (100%) – 4 (25%) 13 (92%) – – – 1 (100%) – – 49 (49%) 27 (19%) 10 (60%) 9 (56%) 18 (83%) 25 (36%) 10 (20%) 11 (27%) 12 (25%) 40 (72%) 36 (69%) 15 (53%) 20 (85%) 47 (70%) 47 (68%) 46 (70%) 38 (66%) 47 (51%) 45 (29%) 19 (32%) 11 (18%) 9 (67%) 11 (18%) 8 (100%) 16 (44%) 13 (38%) 14 (43%) 16 (37%) 16 (50%) 18 (28%) 4 (0%) 8 (75%) 19 (42%) 20 (30%) 20 (30%) 19 (37%) 20 (30%) 20 (25%) 30 (40%) 9 (100%) 7 (86%) 7 (86%) 7 (71%) 15 (80%) 12 (100%) 11 (91%) 16 (87%) 24 (92%) 30 (23%) 23 (9%) 16 (94%) 30 (53%) 30 (30%) 30 (33%) 29 (76%) 30 (20%) 30 (10%) This reads as follows: 16 neurological patients reported impairment in orientation functions. and of those. Mittrach et al. 56% received physiotherapeutic intervention aiming at this impairment. 19% received physiotherapeutic intervention aiming at this impairment. and of those. 155 .Table 5 Association between limitations and impairment in functioning and the corresponding physiotherapy intervention goals ICF category Content n n impaired (% of impaired receiving intervention for this category) Neurological b114 b156 b280 b410 b440 b445 b460 Orientation functions Perceptual functions Sensation of pain Heart functions Respiration functions Respiratory muscle functions Sensations associated with cardiovascular and respiratory functions Defaecation functions Mobility of joint functions Muscle power functions Muscle tone functions Muscle endurance functions Sensations related to muscles and movement functions Changing basic body position Maintaining a body position Transferring oneself Lifting and carrying objects Fine hand use (picking up. 27 neurological patients were not impaired in orientation functions.

this study demonstrated that goals of physiotherapy interventions can be documented plausibly with the help of ICF categories. transfer and mobility issues. Different therapists performing the same intervention. Additionally. These two combinations were also associated with several other intervention goals. In combination with further typical goals. however. However. Conclusion Focusing on intervention goals to classify physiotherapeutic interventions and using the ICF as a classification tool . Activities of daily living. Thus. 2 shows the combinations along with their frequencies and further associated intervention goals. expressed as ICF categories. however. may have different goals in mind [11]. and respiration functions. There were. Routine use. may not be sufficiently detailed for daily and profession-specific documentation. / Physiotherapy 94 (2008) 150–157 cardiopulmonary patients were: functions of the cardiovascular system. The second-level categories of the ICF. information about pain is added. Additionally.3 (mobility of a single joint – severe impairment) and s75011. sensation of pain. not interventions. physiotherapeutic records are vital to acknowledge not only the impairment but also the potential for loss of functioning. Interviewer bias may have been an issue. in more than 90% of the neurological patients. however. To give an example. so the authors are confident that this source of bias was minimised. It is of great importance to keep track of functions at risk and of preventive interventions. The association between limitations and impairment in functioning. This is in line with the complex effects of physiotherapy interventions described previously [21–23]. Patients reporting problems in multifaceted issues such as walking or lifting/carrying objects but not receiving the corresponding intervention may have been too frail or still in a very acute stage of disease. Most patients reporting a specific problem did receive the corresponding physiotherapy intervention.156 R. some patients who received interventions aimed at unimpaired categories such as muscle power.371 (structure of the knee joint – severe impairment – qualitative changes in structure – right side) can describe a severe mobility impairment of the right knee exactly. Appropriate training and supervision of interviewers. even without a prevalent problem [25–27]. of the deeper levels of the ICF is not possible in clinical settings and should be reserved for situations where the most detailed description is actually warranted. and changing basic body position/maintaining a body position with transferring oneself. Neuromusculoskeletal and movement-related functions and activities are the first goals of early interventions for all patients in the acute setting because these functions are the first to suffer from immobilisation. most patients with neurological conditions received interventions aimed at mental functions such as attention and perceptual functions. A moderate proportion of patients received interventions aimed at goals that were not reported as problems. muscle power functions. The most frequent intervention goals in patients with musculoskeletal conditions were: sensation of pain. such as muscle endurance or control of voluntary movement functions. At the same time. Mittrach et al.1 (pain in joints – mild impairment). muscle tone functions. dressing and eating. Muscle power and muscle endurance functions are most likely to be treated to prevent further damage or loss in functioning. however. To give an example. some intervention goals may be secondary effects inseparable from the main goal. Clinical stereotypes and routines in prescribing physiotherapy interventions can serve as another explanation for interventions. Several limitations of this study need to be considered. and the corresponding physiotherapy intervention goals is shown in Table 5. To give an example. were most frequently addressed by interventions when limited or impaired. With the code b28016. since evaluation of goals and functioning is subject to error. One dealt with power and stability of muscles and joints. however. Two major patterns of intervention goals could be detected. Fig. and muscle endurance functions (see Tables 3 and 4). muscle tone and the sensation of pain were reported intervention goals if these functions were a problem. muscle endurance. stability of joint functions. Interviewers reported intervention goals. A range of intervention goals plausible for patients in the acute setting was found. these functions are preconditions for self-care activities. Discussion This study provides an example of how physiotherapy intervention goals in the acute setting and their typical patterns can be identified. This study may have captured intervention goals without the necessary precision. the combination of the two ICF codes b7100. quantified and analysed using ICF categories. used throughout this study. toileting. and the body functions.25]. functions of muscle power. was provided before and during the study. such as washing oneself. A Delphi process among physiotherapists gave similar results [13]. a more detailed and specific documentation is possible. muscle power functions and muscle endurance functions. Both are sound descriptions of physiotherapy ‘packages’. an exercise such as improving hip and knee mobility with the help of the hands will also strengthen the arm muscles. The two most frequent combinations of intervention goals were: stability of joint functions/muscle power functions with muscle tone functions. they give a good impression of patterns and the purpose of physiotherapy in the acute setting [24. Pretests showed that reliability of ICF category coding is good. Translation of physiotherapy interventions into a common standardised language still remains a major challenge. and the other dealt with postural control and transfer. With the use of the third and fourth levels of the ICF categories.

/ Physiotherapy 94 (2008) 150–157 157 has several advantages. et al. Levine P. Total hip arthroplasty rehabilitation. By using the ICF as a framework and linguistic support. Stoll J. Disability and Health: a Delphi exercise. their evaluation and planning. 1998. Rheumatology. ICF core set for patients with cardiopulmonary conditions in the acute hospital. Kostanjsek N. Disabil Rehabil 2005. Portrait of the physiotherapy profession. Munneke M.27:353–60. [27] Higgs J. and overcoming them. [22] Page SJ. [26] Zimmerman JR. based on the International Classification of Functioning. 2001. Ellis E.34:211–4. Melvin J. Arch Neurol 1993. Levine P. Dieppe PA. editors. Huber EO. 2nd ed. Grill E. a commonly understood taxonomy of intervention goals can be a start for improved goal setting and communication between health professionals in the acute setting. Early intervention in severe head injury. intervention goals can serve as standardised documentation for interventions. 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11. Participants Fifty-two normal healthy individuals from hospital staff and family members.3 cmH2 O (limits of agreement −4. Fax: +44 1224 263000.1016/j. subjects with MND −20. and in Psn. Hussey b . McNally). Motor neurone disease Introduction Sniff nasal inspiratory pressure (SNIP) has become increasingly popular for the measurement of inspiratory muscle strength in both neuromuscular and skeletal disorders. Brennan a . Measurement of SNIP 0031-9406/$ – see front matter © 2007 Chartered Society of Physiotherapy. All rights reserved.6 to −45. © 2007 Chartered Society of Physiotherapy. Five patients were unable to produce acceptable and reproducible SNIP data. Goodman b . Psn yielded significantly higher values. each conducted by the same operator. SNIP has significantly increased the diagnostic abilities in this area of respiratory assessment. McNally b.9). Main outcome measures Inspiratory nasal pressure (cmH2 O).uk (S.3 cmH2 O (limits of agreement 9. All rights reserved. In SNIP. Six consecutive measurements of SNIP and Psn were carried out on each subject through both the right and left nostrils. Costello c b a Department of Neurology. In one of the earlier studies detailing SNIP measurement. Published by Elsevier Ltd. inates the use of orofacial muscles. The two methods of nasal inspiratory testing showed a relatively good level of agreement. Conclusion Psn may be used to complement SNIP in the evaluation of respiratory muscle testing of patients.1)].W. Sniff nasal inspiratory pressure. the contralateral nostril is occluded. Results Data were analysed from 52 control subjects and 25 subjects with MND. and one control subject was unable to perform Psn. R. Published by Elsevier Ltd. the lack of published reference values to date for Psn may limit its utility as a diagnostic or serial measurement tool in the short term. Bland and Altman plots were used to determine the level of agreement between the two sets of measurements. Ireland School of Physics. P. and is easily performed by most patients in a clinical setting.2007. Thus. a measuring nasal bung is placed in one nostril. Keywords: Respiratory muscle strength. Setting Multidisciplinary clinic in a regional hospital.2 to −32. Kevin Street. UK. Design A prospective.∗ . Sniffing through a nostril using a volitional manoeuvre elim∗ Corresponding author at: School of Health Sciences. E-mail address: 0609775@rgu. M.002 . The Robert Gordon University. Subjects then proceeded to exhale to functional residual capacity followed by a short sharp maximal sniff. correlational design using two different techniques in random order at the same session. thus producing a measurable peak Ireland c Department of Medicine.Physiotherapy 94 (2008) 158–162 Nasal inspiratory pressure as an indirect measurement of respiratory muscle strength measured during SNIP and Psn methods in healthy subjects and subjects with motor neurone disease S. and a group of 25 subjects with motor neurone disease (MND) recruited from a specialised MND clinic. doi:10. Dublin 9. These results suggest that both methods of application are useful in the detection of respiratory muscle strength. the contralateral nostril is However. particularly in those patients who have significant bulbar weakness throughout disease progression. Interventions In both SNIP and Psn. the authors used a method where a nasal bung was placed in one nostril and the contralateral nostril remained unoccluded [1]. However.c. Aberdeen AB10 7QG. Ireland Abstract Objective To investigate the difference in nasal inspiratory pressure as an indirect measurement of inspiratory muscle strength when the established sniff nasal inspiratory method (SNIP) is compared with a novel method of SNIP application known as Psn. the inspiratory pressure measured using SNIP was lower than that measured using Psn [mean difference: control subjects −12. P. Beaumont Hospital. as controls. Dublin 9. Dublin Institute of Technology. Psn may be more informative in advanced disease. Dublin 7. Beaumont Hospital.

but it is invasive. Data on gender. from a specialised multidisciplinary MND clinic. The primary aim of the present study was to determine the levels of agreement between both methods of testing SNIP in normal subjects. many important interventions such as the accurate timing of non-invasive ventilation may be delayed. to allow the passage of air’ [10].2. results seem to be more reproducible and less problematic in obtaining dependable measurements. a more sustained manoeuvre may achieve a greater pattern of inspiratory muscle activation [9]. especially in the latter stages of MND where subjects may have significant orofacial and bulbar weakness. subjects were provided with both visual and audible feedback [11].S. Phrenic nerve stimulation is an important measure of respiratory muscle strength. until a general age spread from 18 to 80 years was established. / Physiotherapy 94 (2008) 158–162 159 has gained importance due to its simplicity and utility in the laboratory and in clinical and bedside settings to assess the strength of the respiratory muscles [2–7]. The guidelines for respiratory muscle testing suggest that ‘sniffs can be achieved only when one or both nostrils are unoccluded. However. six using the SNIP method and six using the Psn method. For each measurement. Thus. subjects were familiarised with both techniques by performing four additional trials to eradicate a potential bias of testing. A learning effect of both testing methods had been observed previously.D. Subjects were at different stages of disease progression.) for all measurements conducted (i.0. Six efforts were performed to achieve replication of test results. It concluded that the results were similar [8]. The statistical test by Bland and Altman [12] was utilised for assessing agreement between the more established SNIP and the alternative method of Psn was performed. . in total. in clinical practice. six measurements for SNIP and six measurements for Psn).e. Statistical analysis Data were averaged and expressed as mean and standard deviation (S. In contrast. many patients tend to open their mouth during maximal SNIP. so prior to testing. depending on the results obtained during the familiarisation of trials. this method may have limitations with disease progression. However. where both nostrils are occluded. 12 tests were performed for the purposes of the study.0 (MedCalc Software. Materials and methods Population Fifty-two normal control subjects were included in the current study. In addition. All statistical analyses were performed using MedCalc for Windows. The problems encountered with disease progression. A more equal pattern of respiratory muscle activation may aid the overall prognostic information required for the appropriate clinical management of subjects with MND. Exclusion criteria for the normal control subjects included neuromuscular disease. may reduce the effectiveness of SNIP. During all manoeuvres. where SNIP consisted of a rapid generation of pressure (less than 1 second). in the method known as Psn. Belgium). None of these 25 subjects had performed either SNIP or Psn before the study commenced. The secondary aim was to determine any measurable difference between the two techniques in a group of subjects with motor neurone disease (MND). the guidelines suggest ‘an occluded sniff may be called a “gasp”. All tests were performed by the same experienced operator. Previous authors have documented that in severe disease. Seventeen of the 25 patients who participated in the study were diagnosed as bulbar MND and the remaining eight as limb MND. especially in patients with pronounced orofacial or bulbar muscle weakness where coordination of muscle activation may be reduced. All participants agreed to perform two sets of measurements in their dominant nostril. testing was conducted in one nostril (right or left) where the greatest pressure was obtained in conjunction with patient/subject preference to minimise the effects or influence of the nasal cycle on the results obtained. cardiopulmonary disease. A previous study highlighted the use of an occluded nasal sniff and compared this with phrenic nerve stimulation. Furthermore. using the mean of each measurement separately. Psn was more sustained and prolonged (more than 1 second and less than 2 seconds). Thus. When using the method with the contralateral nostril unoccluded. Acceptable and reproducible measurements consisted of performance from functional residual capacity where a rapid sharp SNIP was performed to total lung capacity for maximal values to be obtained. height and method of sniff nasal pressure measurement were recorded. less than 18 years of age or any chronic disease. and is more difficult for subjects to perform reproducibility’. Mariakerke. Version 9. the coordination of muscle activation required to achieve SNIP becomes more important. Testing of subjects with MND with variable disease progression was also performed in 25 subjects recruited Results Measurements were made on 52 normal control subjects and 25 subjects with MND (Table 1). connected to a Micromedical manometer. and the highest value of the six efforts with a maximum of 5% variability was documented. and tests were conducted in a random order. Sniff nasal inspiratory pressure Both SNIP and Psn were measured from functional residual capacity in subjects in a sitting position. six acceptable and reproducible manoeuvres were performed with a 1-minute rest between tests. In addition. This is increasingly evident in the bulbar population. Subjects were recruited over a 2-month period. with disease progression. McNally et al.

7 cmH2 O (95% CI: 106.D.9 MND.) age for men and women was 60. in control subjects.9 101.0).3) and mean Psn was 126.3 (10.9).3) and mean Psn was 101.4 7. n = 52). In males.4) years.4 15. the mean (S. although there was a positive correlation between SNIP and Psn in subjects with MND there was relatively poor agreement. McNally et al. and on 95% of occasions.7) and mean Psn was 70. . 1.9 cmH2 O higher than those taken using SNIP.7 176.5) and mean Psn was 84.160 S. respectively.9) cmH2 O higher than when taken using SNIP.2 16. Fig.2). standard deviation.9 cmH2 O (15.5 24.4 126.7] and mean Psn was 113. measurements using Psn will be. Comparison of SNIP and Psn in subjects with MND In subjects with MND patients. / Physiotherapy 94 (2008) 158–162 Table 1 Summary statistics of control subjects and patients with motor neurone disease Variables Control subjects Men (n = 24) Mean Age (years) Height (cm) SNIP (cmH2 O) Psn (cmH2 O) 45.3 (8. the variation coefficients for SNIP and Psn were similar. Bland–Altman plot: difference between sniff nasal inspiratory pressure (SNIP) and sniff nasal pressure (Psn) plotted against the mean of these two variables (subjects with motor neurone disease patients.5 cmH2 O (16.3 cmH2 O (28. Bland–Altman plot: difference between sniff nasal inspiratory pressure (SNIP) and sniff nasal pressure (Psn) plotted against the mean of these two variables (control subjects.2 to 61. mean SNIP was 66. mean SNIP was 112. in healthy subjects.9).4 25. These results suggest a poor level of agreement between the two methods in MND patients. the mean (S.6 S. 1 is a Bland and Altman plot which suggests that.6 66.0 to 107. sniff nasal inspiratory pressure. Fig.6 cmH2 O lower and 45. Mean SNIP was 51 cmH2 O (95% CI: 40. 15. S. The main findings can be summarised as follows: firstly.3 84. Comparison of SNIP and Psn in control subjects In the control subjects.D.2 35.2 cmH2 O lower and 32. 12. suggesting that Psn may be used for respiratory muscle strength assessment in patients free from neuromuscular disease. 2 is a Bland and Altman plot which shows that. on average. To accomplish this.6 cmH2 O (27. mean SNIP was 35. motor neurone disease. 8.7) cmH2 O higher than when taken using SNIP. This study represents the first assessment of an alternative method of application for its feasibility and usefulness in both a normal healthy group of subjects and a small group of subjects with MND. both the absolute values obtained in each method and the agreements of these values with consecutive measurements were com- Fig.6 cmH2 O (24.4 cmH2 O [95% confidence interval (CI): 95.1) years and 42.5 to 120.3 164. sniff nasal pressure.D.8) and mean Psn was 59. and results show a relatively good level of agreement.4) years.7 S. Psn.0 3.3 (12. In females.0 Women (n = 28) Mean 42.7 91. the measurements using Psn will lie between 4.1 cmH2 O higher than those taken using SNIP.5 160. respectively. 12.4 cmH2 O (25.4 5.7 (11. on average.3).0) years and 62.4 176.D. and on 95% of occasions.3 14.8 16.D. In males.3 Subjects with MND Men (n = 11) Mean 60.1 cmH2 O (16..52 cmH2 O (95% CI: 60.5 59.) age for men and women was 45. measurements using Psn will be. Mean SNIP was 101.6 to 80. In females. Limits of agreement between SNIP and Psn were measured using Bland and Altman plots. 11. n = 25). 20. mean SNIP was 91.6 S.4 (15. 2.2 Women (n = 14) Mean 62.3 27.3). SNIP.9 112.7 cmH2 O (14.D.D. and secondly. and the level of agreement between both tests was relatively good. in subjects with MND.2 28. the measurements using Psn will lie between 9. Fig.5 (12. Discussion This study was designed to establish the compatibility of two methods of measuring inspiratory muscle strength in both normal subjects and a group of subjects with MND with variable extents of disease progression.1 8.1 S.

a 12 cmH2 O mean difference in normal control subjects and 20 cmH2 O mean difference in subjects with MND is likely to occur. reduces the apparent overestimation shown previously while performing a occluded rapid sniff or ‘gasp’ over shorter periods. SNIP and Psn. with Psn achieving the higher values. without additional published reference values for Psn. aid the testing of patients with respiratory muscle weakness. the method of application while performing the Psn test departed from standard practice. This weakness in advanced disease has the potential to lead to air leaks through air being sucked through the mouth. it is . measurements of Psn will be between 9. Discoordination of orofacial musculature in particular while performing the SNIP test was observed in both bulbar and non-bulbar patients in this study. Psn is a static measurement and requires an intentional leak to prevent glottic closure. where the replications of tests performed were similar to SNIP. all measurements of Psn would need to be repeated six times in either nostril and averaged to achieve information similar to that presented. Negative pressure is more difficult to equalise and requires active dilation of the tube by muscular contraction. it is important to document any proposed changes from standard practice which may. However. on 95% of occasions. and makes assessment possible in a range of clinical circumstances’ [13]. it was noted that occlusion of the contralateral nostril permitted detection of nasal alae contraction. such as Psn. McNally et al. Comparing the present study with other published articles [1–7]. Using the limits of agreement. both of which would mainly affect the dynamic manoeuvres such as the sniff test’ [14]. which is probably a more sustained isometric task. this was not apparent in the present study. the use of Psn avoids all possibility of using the cheeks. which occurs while performing the occluded Psn method. A previous study reported ‘that many factors contributing to low values in bulbar patients include upper airway collapse and discoordinated/dyspractic contraction of the various respiratory muscles during the tests. However. The reasons for this lack of agreement are unknown. In comparison. the occluded method allows for a more controlled evaluation using a closed circuit. Thus. However. Since there is no airflow present using Psn compared with SNIP. In addition. when comparing measurements of SNIP and Psn. although a similar method to maximal inspiratory pressure. Conclusion Sniff nasal inspiratory testing remains one of the most widely used techniques to assess functional capacity and confirm a diagnosis of respiratory muscle weakness.2 cmH2 O lower and 32. ‘A more sustained manoeuvre may achieve a greater pattern of inspiratory muscle activation in severely affected patients’ [9]. As patients with advanced disease tend to make poor efforts using SNIP and often need encouragement. thus eliminating the air sucking that usually occurs with the standard SNIP method through orofacial muscle weakness and disease progression in MND.1 cmH2 O higher than SNIP in subjects with MND.6 cmH2 O lower and 45. Many subjects with MND produced spuriously low values while performing the SNIP method. in the future. the guidelines state that respiratory muscle strength performed through one nostril with the contralateral nostril occluded. SNIP performed through one nostril with the contralateral nostril unoccluded is generated during a ballistic manoeuvre where the inspiratory muscles shorten to a greater extent and at a higher speed than during the proposed alternative method. generate a pressure that is a reflection of complex interactions between several muscle groups. The authors believe that this explains why a large proportion of bulbar patients were able to perform the technique in a previous study [7]. is not a reproducible method of obtaining indirect measurements of respiratory muscle strength [10]. Comparison of the conventional method of testing which involves placing a nasal bung in one nostril with the contralateral nostril unoccluded showed positive correlation and relatively good agreement. It could be that the ability of the eustachian tube to equalise negative pressure. together with the intentional leak of the device during the more sustained method. this was not evident in the present study and thus requires further comparison studies to establish this effect [10]. What are acceptable limits of agreement when comparisons are made with a test to measure respiratory muscle function? Many researchers in this field have found this question difficult. These data suggest that Psn is as useful as SNIP in monitoring respiratory muscle strength in both normal subjects and subjects with MND. This study found that both techniques provide essential information in the assessment of respiratory muscle weakness in MND when administered and supervised by trained and qualified personnel. its suitability for testing subjects with MND remains unclear. However. / Physiotherapy 94 (2008) 158–162 161 pared from one visit. similar to the established Muller manoeuvre.9 cmH2 O higher than SNIP in healthy subjects. which results in poor performance and lower values. Thus. Firstly. since the efforts produce different mechanisms of activity. Pressure equalisation of positive pressure is usually done without much effort by either passive pressure opening or active muscular opening of the tube. To use the results obtained in this study clinically. and thus permitted encouragement of maximal inspiratory efforts without sucking air through the mouth. Both manoeuvres. a study concluded that ‘having multiple tests of respiratory muscle function available both increases diagnostic precision. it is important to raise some methodological considerations. In addition. and Psn will be between 4. the pressure measured in the upper airways often exceeds the simultaneous intrathoracic pressure and thereby overestimates inspiratory muscle strength. Recently. This study demonstrated that the Psn method of testing is a valid and easy method to measure respiratory muscle strength in normal healthy subjects. Although the guidelines state that in an occluded inspiratory effort.S. and results did not correlate well with patient symptoms.

46:887–93. Psn is a well-tolerated and valuable procedure. ‘We want to know by how much the new method is likely to differ from the old: if this is not enough to cause problems in clinical interpretation we can replace the old method by the new or use the two interchangeably. References [1] Heritier F. de Muralt B. Available online at www. Benoist MR. [4] Fitting JW. Bye PT. it is important that the different application of pressures generated in this study be clearly understood and utilised in a similar fashion. Am J Respir Crit Care Med 2005. Thorax 2007. Hardiman O. Sniff nasal pressure: a sensitive respiratory test to assess progression of amyotrophic lateral sclerosis. if the SNIP and Psn method were unlikely to give readings that differed by more than. Use of sniff nasal-inspiratory force to predict survival in amyotrophic lateral sclerosis. [7] Morgan RK. Perret C. Psn would be unlikely to be satisfactory. In addition. Sharshar T. using the Bland and Altman analogy. The value of multiple tests of respiratory muscle strength.sciencedirect. [8] Esau SA. if the methods differed by 30 cmH2 O. Lancet 1986. [10] American Thoracic Society/European Respiratory Society.’ In addition.55:731–5. Paillex R. Polkey MI. [3] Stefanutti D. [2] Stefanutti D.166:518–624. Rafferty GF. Ethical approval: Dublin Institute of Technology Ethics Committee. According to Bland and Altman. Chaussain M.162 S.58:1469–76. ATS/ERS statement on respiratory muscle testing. Man WD. et al. although the results suggest that the two methods are not interchangeable. Scheinmann P. Hirt L. further studies are required to determine reference values to enable the use of Psn as a serial measurement in the overall assessment of subjects with MND. Sniff nasal inspiratory pressure. Alexander M. Falaize L. Am J Respir Crit Care Med 2002. say. [14] Uldry C. [12] Bland JM. Changes in rate of relaxation of sniffs with diaphragmatic fatigue in humans. et al. How far apart measurements can be without causing difficulties will be a question of judgment.74:1685–7.10:1292–6. Limitations of sniff nasal pressure in patients with severe neuromuscular weakness. 10 cmH2 O. J Appl Physiol 1983. Eur Respir J 1997. Funding: None. [5] Fitting JW.159:107–11. McNally et al. Raphael JC. Seymour . Am J Respir Crit Care Med 1999. J Neurol Neurosurg Psychiatry 2003.1:307–10. Esophageal and mouth pressure during sniffs with and without nasal occlusion. moreover.172:932–3 [author reply 933]. Reference values in Caucasian children.162:1507–11. Fitting JW. Am J Respir Crit Care Med 2000. J Appl Physiol 1985.27:881–3. Without reference values.171:269–74. [6] Fitting JW. Altman DG. Some methodological considerations pertaining to sniff nasal inspiratory pressure (SNIP).62:975–80. Janssens JP. Ann Neurol 1999. and should be included in the overall non-invasive evaluation of respiratory muscle weakness. Aebischer P. Grassino A. Conroy R. Costello RW. [9] Hart N. [11] Laporta D. Statistical methods for assessing agreement between two methods of clinical measurement. McNally S. Schluep M. On the other hand. Fauroux B. Fitting JW. Fitting JW. Respir Physiol 1991. Fitting JW. there is a reduction in the utility of the Psn measurement as a diagnostic or discriminatory tool. SNIP could be replaced by Psn because such a small difference would not affect decisions on patient management. / Physiotherapy 94 (2008) 158–162 a question that needs to be addressed if future publications on validating the use of respiratory tests are to be of true scientific worth. In conclusion. Pardy RL. Sniff nasal inspiratory pressure: simple or too simple? Eur Respir J 2006.86:305–13. Conflict of interest: None. Am J Respir Crit Care Med 2005. Assessment of transdiaphragmatic pressure in humans. Usefulness of sniff nasal pressure in patients with neuromuscular or skeletal disorders. Kaul S. Sniff nasal inspiratory pressure in patients with chronic obstructive pulmonary disease. Jolley C. [13] Steier J.

In contrast. © 2007 Chartered Society of Physiotherapy. The mean difference between the two conditions was 5 seconds (95%CI −21 to 31). Tel. Published by Elsevier Ltd. the choking approach [6] advocates that spectator pressure adds to self-consciousness. mance of difficult tasks will decline when spectators are present due to the distracting effect of spectators. treatments and exercises are performed in a variety of settings. Choking is more likely to occur during skilful activities. The term ‘spectators’ will be used predominantly in this article. A state of self-awareness emphasises the weaknesses between actual behaviour and an ideal or expected behaviour. fax: +353 1 4531915. which will disturb proficiency in executing a task. which will further improve performance. These may be other patients.686). On the other hand.07.e.008 . Dublin 8. Single leg stance Introduction Physiotherapy assessments. Conclusions Female performance of a straightforward exercise such as single leg stance was not affected by the presence of three spectators. The non-specific drive theory states that the mere presence of others will increase the drive and activation level of the performer in such a way that dominant reactions will be enhanced [2]. Finally. As there were only four males. the theory of objective self-awareness [4] assumes that people direct attention on themselves when they feel that they are being observed by others. if a performer believes a task is difficult and fears appearing especially those that demand accuracy and speed. All rights reserved. Main outcome measure Duration of single leg stance in seconds. This was not statistically significant using a paired t-test (P = 0. while that of the spectator condition was 168 seconds (95%CI 128 to 208). E-mail address: walshj2@tcd. relatives or staff members and are known as ‘spectators’.ie (J. All rights reserved. i. under the investigator condition was 173 seconds [95% confidence interval (CI) 131 to 214]. these were excluded from the analysis. stating that the perfor∗ Corresponding author. Walsh). Participants Forty adult volunteer subjects (36 females. Trinity Centre. the performer will ‘choke under pressure’. ‘observers’ or an ‘audience’ in the literature. Geraldine Gill Discipline of Physiotherapy. Ireland Abstract Objective To investigate the effect of spectators on the performance of a physiotherapy exercise. Results The mean duration of single leg stance.1016/j. Design Observational study. Keywords: Spectators. performance will be impaired. The effect of spectators on the performance of physiotherapy activities is unknown.Physiotherapy 94 (2008) 163–167 Effect of spectators on the performance of a physiotherapy exercise Jeremy Walsh ∗ . the performance of expert or skilled performers and the accomplishment of simple tasks will improve in the presence of spectators. Interventions Subjects were observed and timed while performing single leg stance in two conditions 48 hours apart. Trinity College Dublin. the performer tries to reduce these weaknesses. doi:10. Trinity College Dublin. In other words. James’s Hospital. while the performance of unskilled or novice performers and the execution of complex/difficult tasks will decline under this condition. Much of the research in the literature pertaining to the effect of spectators on performance 0031-9406/$ – see front matter © 2007 Chartered Society of Physiotherapy. as a result. Performance. Setting Research laboratory. A number of theories exist about why the presence of spectators may have an effect on performance [1]. The self-presentation theory [5] infers that if a task is deemed to be easy. Published by Elsevier Ltd. and other people are often present. four males).2007. once with the investigator present (investigator condition) and once with the investigator and three spectators present (spectator condition).: +353 86 1713077. St. The distraction-conflict hypothesis [3] concurs with the non-specific drive theory. for females. the performer will be able to demonstrate ability and appear competent to spectators.

a hospital ward). positive reactions from friends/family despite a poor performance) and damaging (high expectations from supporters. it is worth noting that a socalled supportive audience may actually be a hindrance to the patient. It was found that there is a greater tendency towards performance inadequacy under this condition. Overall. Gill / Physiotherapy 94 (2008) 163–167 has concentrated on sporting activities [7–11]. Also. there are conflicting findings in the literature concerning the effects of spectators on the performance of non-sporting activities. Research has also been conducted to determine the effect of spectators on the performance of non-sporting activities. a difficult mental arithmetic task was performed before a neutral stranger and again before a friend. Butler and Baumeister [17] devised different experiments to study the effects that can be created by a supportive audience. Furthermore. In a second experiment. there is conflicting evidence in relation to the effects of spectators on sporting performance. Forgas et al. causing all categories of motorist to drive more slowly. increased pressure to maintain appearance) effects of a supportive audience. Considering the conflicting findings. Chevrette [8] found that the presence of spectators had no effect on girls’ performance of a number of physical exercise activities. research is warranted to determine whether spectators affect the performance of physiotherapy activities positively. It must also be borne in mind that the presence of spectators may have different effects depending on the personality type of the performer. outlined above. their true capabilities may not be facilitated in such circumstances. [7]. who studied the consequences of spectator presence and competition on maximal weight-lifting performance. Baxter and Manstead [12] investigated the influence that a passenger may have on driver behaviour. two basketball teams played 11 games with spectators and 11 without spectators during one season. a player matches his competitor in order to provide a better spectacle for the audience. In the clinical setting (e. Although people generally prefer supportive attention. On analysis of official basketball score sheets incorporating details of offensive and defensive team performance and individual player information. Studies in relation to the effect of spectators on sports performance have produced conflicting findings.g. Due to a measles epidemic. Moore and Brylinsky [9] investigated the effect of spectators on basketball performance. Kimble and Rezabek [13] found that video-game performance deteriorated under an audience condition. It has been demonstrated that mere presence is enough to affect behaviour and performance [16]. In contrast. The type of audience may also influence performance. Fewer correct calculations were made with a friend watching. where the therapist will try to instil positive feelings in the patient while performing tasks that challenge their abilities. The authors provided a background into the beneficial (emotional boost. However. Walsh. Similarly. This may be particularly significant in a physiotherapy setting. Graydon and Murphy [15] found that extroverts performed better at table tennis before an audience. The authors speculated that instead of trying to outdo the opponent. the investigators found that both teams played better when there were no spectators present. Methods Physiotherapy exercise Single leg stance was chosen as the physiotherapy exercise as it is commonly used in assessment and rehabilitation. and as an outcome measure across a wide variety of disciplines . driver compliance with the speed limit increased with passenger presence. The aim of this study was to investigate whether the presence of spectators has any effect on the performance of a physiotherapy exercise.164 J. whereas introverts performed better without an audience. there may be people present who are not focusing on the sub- ject but who still have an effect on the subject. while Rhea et al. despite the fact that the performer perceived this condition to be less stressful and less distracting. In the first experiment. Thus. both speed and accuracy while completing a video game were found to worsen with a supportive audience. there is a lack of evidence regarding the effect that spectators may have on the performance of physiotherapy activities. These factors should be recognised and considered in the clinical setting so that the optimal environment for the performance of the task is tailored to each patient’s individual needs. although unskilled subjects showed reduced accuracy. This is known as the ‘mere presence effect’. playing video games [13] and learning [14]. Chevrette [8] found that the running performance of boys improved when they were observed by mixed or opposite sex spectators. such as driving [12]. However. Older female passengers had a significant influence. the one exception was that drivers with younger male passengers exceeded the speed limit. These findings reveal that a combination of factors and traits modify an individual’s performance in the presence of spectators. Bell and Yee [11] showed that the presence of spectators had no effect on the performance of karate kicks by skilled subjects. in relation to the effect of spectators on the performance of non-physiotherapy activities. [10] demonstrated that squash players’ performance deteriorated in the presence of two spectators. G. despite subjects reporting reduced feelings of pressure compared with the neutral condition. while Sawyer and Noel [14] studied the effects of spectators on the learning of a motor task and concluded that the presence of an audience has a negative effect on initial learning of a motor task but has no effect on further learning or retention of the exercise. concluded that competition and audience presence have a positive effect on power and strength performance. negatively or not at all. Such information could be used to determine the optimal environment (in relation to the presence or absence of spectators) for the performance of physiotherapy activities.

these were excluded from the analysis. The mean duration of single leg stance. under each condition. Walsh. the subjects returned to repeat the test under the other condition. Sample Forty-eight volunteers responded to the advertisement but eight of these failed to present for testing. Exclusion criteria were inability to perform the exercise for any reason. as illustrated in Fig. Forty-eight hours later. The mean difference between the two conditions. As the data were normally distributed. Mean and 95% confidence intervals for duration of single leg stance. have reported that spectators have no effect on performance [8. and the duration of each single leg stance was recorded in seconds. Subjects were timed until their dominant foot touched the surface again. Subjects were instructed to remove socks and shoes and to ensure that both feet were visible in order to accurately time when the suspended foot touched the surface again. others have demonstrated a negative effect on performance [9. these studies concentrated on sporting and nonsporting rather than physiotherapy activities. Version 14. Therefore. and others. Procedure Half of the subjects initially performed the task under the investigator condition. only the investigator was present. four males) participated in the study. Some studies have found that the presence of spectators has a positive effect on performance [7. An induction session was held for those who responded to the advertisements to explain and demonstrate the procedure.12–14]. They were instructed to try and maintain that position for as long as possible. the investigator and three spectators (unknown to the subject) were present. Discussion This study found that the presence of three spectators had no effect on the performance of a single leg stance physiotherapy exercise by females. As stated previously.12]. As only four males were recruited. . Inclusion and exclusion criteria Subjects who declared themselves able to perform a single leg stance. They were asked to stand on their non-dominant leg on a pillow.8. and were told that they would be timed.5) years with a range of 17–25 years.10. 1. 40 subjects (36 females. Therefore.11]. Under the investigator condition. However. was 5 seconds (95%CI −21 to 31). with the dominant leg off the surface (but not suspended against the non-dominant leg). Results The mean (standard deviation) age of the female subjects was 19. and so are not directly comparable. 1. The spectators were instructed to sit (approximately 3 metres away from the subject) and direct their attention on the subject. for females. while under the spectator condition. including the present study. but not to speak or offer any vocal encouragement to the subject while performing the task. under the investigator condition was 173 seconds [95% confidence interval (CI) 131 to 214]. Recruitment Healthy volunteers from staff and students at Trinity College Dublin were recruited via noticeboard advertisements in December 2005. for females.0. Data analysis Data were analysed using Microsoft Excel and Statistical Package for the Social Sciences. As the subjects in this study were healthy (and therefore more akin to the type of patient that would require a more challenging exercise). G.J. a paired t-test was used to compare times under the two conditions. but that they could stop whenever they wanted to or if they felt any pain or discomfort. there is conflicting evidence in the literature about the effects of spectators on performance. and the other half did so under the spectator condition to negate any learning effect between tests. a pillow was used to provide a less stable surface to render the single leg stance more challenging. for females. Fig. while that of the spectator condition was 168 seconds (95%CI 128 to 208). to comprehend English and who gave informed consent were included. and the presence or history of any condition that may impair balance.3 (1. Gill / Physiotherapy 94 (2008) 163–167 165 [18–20]. This can be made more challenging as a means of assessment or rehabilitation by providing a less stable surface [21] in appropriate cases. the presence or absence of spectators should not play a major role in influencing the location of the performance of such a physiotherapy exercise by a female. The investigator timed each subject with a stopwatch.

J Soc Psychol 1980. Soc Behav Pers 1992. Wicklund RA. A theory of objective self-awareness. [3] Sanders GS. [11] Bell PA. J Psychol 1968. G. Due to a lack of volunteers and time constraints. there may be a mixture of people present. However. the presence of three spectators had no effect on the performance of single leg stance in healthy females.32:956–63. for statistical advice. Social facilitation in motor tasks: a review of research and theory. Therefore. an assistant. a student and a relative). Due to the anxieties inherent with being a patient. there may be a different interaction between a patient and spectators compared with that of healthy volunteers. the majority of subjects tended to focus their attention on a point on the wall or on their own foot rather than look directly at the spectators. Choking under pressure: self-consciousness and paradoxical effects of incentives on skilful performance. Kane JF. Strauss [1] outlined the contrasting views in the literature relating to audience size and its effect. where a small number of people may be present (e. Alvar BA. it would be worthwhile investigating the effect of mere presence on the performance of physiotherapy activities. However. Ethical approval: Faculty of Health Sciences Ethics Committee. J Strength Cond Res 2003. decisions regarding the most appropriate environment or location for optimal performance of such exercises.129:191–200. In the clinical setting. It is conceivable that a larger number of spectators would have increased subject stimulation and perhaps affected performance. as in a typical physiotherapy scenario. [13] Kimble CE. As such. However. by females. Science 1965. Conflict of interest: None.16:77–84.166 J. This may have reduced the spectators’ influence on the subject. Manstead ASR. Social facilitation. In summary. while the spectators had no effect on the performance of single leg stance. so a study should be performed in a patient population. Walsh. patients at end-stage rehabilitation may be similar to healthy subjects. Brylinsky JA. Social facilitation: a self-presentational view.g. [7] Rhea MR. It is also worth noting that while the spectators had no effect on performance in this study of healthy volunteers. For the purposes of this study. Trinity College Dublin. Gill / Physiotherapy 94 (2008) 163–167 This study had a number of limitations. J Sport Behav 1993. further research is required to determine the effects of different numbers of spectators and spectators of different characteristics on the performance of a variety of physiotherapy activities by both males and females of differing personality types.3:237–56. it would be useful to investigate the effect of spectators on more complex physiotherapy activities. assessment and rehabilitation of healthy individuals (e. The effects of competition and the presence of an audience on weight lifting performance. Also.81:351–61. Brennan G. as this is a fairly straightforward exercise. although it may have replicated the clinical setting. References [1] Strauss B. Playing games before an audience: social facilitation or choking. Social facilitation and driver behaviour. should be based on individual patient and physiotherapist needs rather than the presence or absence of a few other people. New York: Academic Press. Howe S. Although the subject faced the spectators during the test. subjects are encouraged to focus attention on the exercise being performed rather than on other people present. J Pers Soc Psychol 1982. and physiotherapists may be involved in the screening. For the purposes of the current study. preventative medicine). an insufficient number of males was recruited for worthwhile statistical analysis. J Pers Soc Psychol 1984. these were not determined in this study. [8] Chevrette JM. although it has been shown that subject personality type [15] and spectator characteristics [16] can influence performance. The motivating effect of distraction on task performance. Rezabek JS. sports physiotherapy.46:610–20.149:269–74. In the clinical setting. Trinity College Dublin. it was decided to determine the effect of focused spectators rather than that of mere presence on performance. people other than the patient and physiotherapist are often present during the performance of physiotherapy activities. the findings of this study may be applicable to females of such populations. Landers DM. Br J Psychol 1990.70:113–9. it was felt that three spectators replicated many clinical scenarios. Spectator effect on team performance in college basketball. the effect of spectators known to the patient on performance also needs to be determined. 1972. Acknowledgements The authors would like to thank Dr. Arent SM. Psychol Sport Exerc 2002. research into the effect of various spectator types and numbers on different personality types and on the performance of more complex physiotherapy activities needs to be conducted on both males and females before definitive conclusions are drawn. [10] Forgas JP. positive effects. while this study showed that the presence of three spectators had no effect on the performance of single leg stance by females.g. The spectators were unknown to the subject. J Pers Soc Psychol 1975. occupational health. some known and some unknown to the patient. The effect of peer observation on selected tests of physical performance.42:1042–50. [6] Baumeister RF. Conclusion There is conflicting evidence in the literature in relation to the effects of spectators on performance.20:115–20. negative effects and no effects have been reported. Skill level and audience effects on performance of a karate drill. Audience effects on squash players’ performance. [5] Bond Jr CF. J Soc Psychol 1989. In this study. [2] Zajonc RB. [9] Moore JC. Yee LA. Therefore.111:41–7. Baron RS.17:303–6. [12] Baxter JS. . the effect of spectators on a patient population may differ. Kathleen Bennett. Sweet S. [4] Duval S. Finally.

167 [18] Berg K. Khan K. Available online at www. [19] Petty NJ. 2007.83(Suppl.J. Gayton D. Sydney: McGrawHill. Murphy T. Noel FJ. Measuring balance in the elderly: validation of an instrument. 3rd ed. G. 2006. The trouble with friendly faces: skilled performance with a supportive audience. Percept Motor Skills 2000. 3rd ed. [21] Brukner P. [17] Butler JL. 2):S7–11. Louis: Mosby. Neuromusculoskeletal examination and assessment. Baumeister RF. Clinical sports medicine.19(2):265–7. J Pers Soc Psychol 1998. 2002.75:1213–30. St.14:389–97. [16] Markus H.91:539–45. Personality Individual Differences . J Exp Soc Psychol 1978. The effect of personality on social facilitation whilst performing a sport related task. [20] Sahrmann SA. Gill / Physiotherapy 94 (2008) 163–167 [14] Sawyer DT. Walsh. Wood-Dauphine SL. Diagnosis and treatment of movement impairment syndromes. Edinburgh: Elsevier Churchill Livingstone. Williams JL. Effect of an audience on learning a novel motor skill.sciencedirect. Can J Public Health 1992. The effect of mere presence on social facilitation: an unobtrusive test. [15] Graydon J.

in part. Toby O.1016/j. John Dixon Norfolk and Norwich University Hospital. Design A cross-sectional observational study measuring EMG activity during stepping down from a step and during straight leg raise exercises. Furthermore.5 years. fax: +44 1642 342770. It is hypothesised that the higher prevalence of patellofemoral pain syndrome in females could be due. numerous studies have been undertaken to assess the electromyographic (EMG) activity of these muscles [11. these differences were not statistically significant (P = 0.26 to 0. The average intensity of the rectified and smoothed EMG activity from each activity was normalised to that elicited in a maximal quadriceps setting exercise. Pathology. These studies have been clinically important since either a delay in EMG onset timing or a reduced EMG intensity in VMO relative to VL may lead to a biomechanical imbalance at the patellofemoral joint [19].20) during straight leg raise. Colney Lane. E-mail address: John. one female (mean age 23. Female Introduction Patellofemoral pain syndrome is a common musculoskeletal condition that has a higher prevalence rate in females than males [1–3].Dixon@tees.5 years. UK Abstract Objectives To investigate whether there was a gender difference in the intensity of electromyographic (EMG) activity in vastus medialis oblique (VMO) relative to vastus lateralis (VL). Conclusions This study found no gender difference in the VMO:VL EMG intensity ratio in asymptomatic participants.08. Using Mann Whitney U-tests. Setting University campus laboratory. Middlesbrough.007 . Dixon).00] during step down and −0. It has been speculated that neuromuscular imbalances of the vastus medialis obliqus (VMO) relative to the vastus lateralis (VL) muscle may contribute to patellofemoral pain ∗ Corresponding author. Keywords: Electromyography. n = 15). However. to gender differences in muscle activity. Consequently. University of Teesside.2007.13–18].physio. Participants Two groups of healthy participants were (J. when participants are asymptomatic.∗ . Knee. syndrome [9–12]. Tel. n = 15) and one male (mean age 23. the issue 0031-9406/$ – see front matter © 2007 Chartered Society of Physiotherapy.: +44 1642 384125. Main outcome measures Surface EMG activity (sampling rate 1000 Hz) was recorded from VMO and VL of the dominant limb during five repetitions of a step down activity and five repetitions of a straight leg raise exercise.Physiotherapy 94 (2008) 168–173 The vastus medialis oblique:vastus lateralis electromyographic intensity ratio does not differ by gender in young participants without knee pathology Damien Bowyer a. All rights reserved.648 and 0. The ratio of normalised VMO:VL EMG intensity levels was calculated. doi:10. and which is typically managed conservatively through exercise and other physiotherapeutic modalities [4–8]. respectively). Quadriceps muscle. Physiotherapy Department. Smith b b a School of Health and Social Care. This suggests that the difference in incidence of patellofemoral pain syndrome between genders is not influenced by quadriceps intensity ratios. Results The median difference in the VMO:VL ratio between the groups was 0. Mikaela Armstrong a .b . UK Orthopaedic Physiotherapy Research Unit. Published by Elsevier Ltd.11 [approximate 95% confidence interval (CI) −0. Norwich. patellofemoral malalignment has been suggested to be one of the major causes of patellofemoral pain syndrome [6–8]. © 2007 Chartered Society of Physiotherapy. All rights reserved. The cause of such a gender difference is unclear. Published by Elsevier Ltd.619.62 to 1. Male.07 (approximate 95% CI −0.

and are presented in Table 1. Firstly. In a recent study. knee in extension and ankle plantar grade throughout the execution of the SLR.18. The independent variable was gender and the dependent variable was the VMO:VL ratio.18. if such a difference in VMO:VL ratios existed. and during a straight leg raise (SLR) exercise. The position of the electrode on the VL was 10 cm superior to and 7 cm lateral to the superior border of the patella [18]. and orientated 55◦ to the femur along the presumed line of muscle fibre orientation [39].7) Height (m) 1. Electromyography EMG recordings were collected and stored digitally using a physiological data acquisition system (Biopac Inc.. Table 1 Descriptive characteristics of participants: mean (standard deviation) Group Female Male Number of participants 15 15 Age (years) 23. mimicking a typical outpatient protocol.07) Weight (kg) 66. Placement and orientation of the electrode positions was performed using a retractable tape measure and a goniometer. height and weight of each participant were recorded prior to testing. Biopac Inc. each participant provided written informed consent.38]. Goleta. or any history of ongoing knee pain.5 cm. actual gender data were not presented.15. To be included. neuropathology.79 (0. This was measured during step down activity. ECG-TENS) was applied to each electrode to improve electrical conductance between the skin and the electrode. Herrington et al. The recording electrode was positioned on the VMO 4 cm superior to and 3 cm medial to the superomedial border of the patella [18].4 mm. any imbalance in the VMO:VL ratio may account for the difference in incidence of patellofemoral pain syndrome in males and females. but have not compared VMO and VL simultaneously [22. Straight leg raise Methods This was a cross-sectional observational study to investigate whether the VMO:VL ratio differed between male and female participants. [21] reported that in their cohort. Myer et al. participants had to be aged between 18 and 25 years.25.33–36]. Cerny [14] reported no gender difference in the VMO:VL ratios of male and female participants.11. interelectrode distance 20 mm. Hypoallergenic conductance gel (Lectron II.. as this comparison was not one of the main study aims. The height was con- . Prior to electrode application. [20] observed no gender difference in VMO:VL ratios during open and closed kinetic chain exercises with participants assessed using an isokinetic dynamometer. Unfortunately. Before taking part. a commonly prescribed quadriceps exercise [5. A reference electrode was positioned on the tibial tuberosity on the contralateral limb [18]. USA) comprising of a MP100 workstation with a high level transducer (HLT100) and dedicated software (AcqKnowledge 3.0) Ethics Committee. Goleta. Ethical approval was granted by the University of Teesside. It was hypothesised that there would be a statistically significant difference in the VMO:VL ratios between male and female participants. and orientated 15◦ to the femur along the line of muscle fibre orientation [39]. Secondly. In contrast.06) 1.5 (0. Verbal commands were given to commence the SLR.8 (12. measured from the plinth to the participant’s heel.28–32] and has been studied previously in mixed gender cohorts [9.5) 81. / Physiotherapy 94 (2008) 168–173 169 of whether the ratio of VMO:VL EMG intensity (VMO:VL ratio) differs between genders has not been resolved within the literature.5 (0. All electrodes were held firmly in position using hypoallergenic tape.68 (0.23]. A literature review identified three studies that have assessed this difference. The age. this may question the appropriateness of comparing male and female subjects in studies assessing the VMO:VL ratio that are not matched for gender [4. CA. Recordings were taken from the dominant limb of each participant. The EMG sampling rate was 1000 Hz. CA. EMG activity was recorded using bipolar surface electrodes (TSD150B.2 (13. USA) with diameter 11. Exclusion criteria included: subjects with any lower limb pathology.37. Other studies have investigated gender differences in muscle activity around the knee joint.D. Each participant was positioned in half lying on a plinth for EMG electrode placement. two groups were formed according to gender.24–27].24. determined by asking which leg they would use to kick a ball.6) 23. The aim of this study was to investigate whether there is a gender difference in the VMO:VL ratio in asymptomatic participants. Bowyer et al. which is cited as aggravating patellofemoral pain syndrome symptoms [5. The height of the SLR was 17. built-in pre-amplification (×350) and 3 dB band pass 12–500 Hz. This study also reported that male participants had a greater VMO:VL ratio than females. School of Health and Social Care The participants were positioned in half lying on the plinth and asked to maintain both lower limbs in the position of: hip neutral (no rotation). This area therefore needs to be addressed further as a gender difference in the VMO:VL ratio could be important for two reasons. Participants A convenience sample of 30 participants (15 males and 15 females) was recruited from physiotherapy degree courses at the University of Teesside. the skin area was shaved and cleaned with an alcohol wipe to improve conductivity. there was a gender difference in the VMO:VL ratio where subjects flexed and leaned on the examined knee.7) on a personal computer.

using the contraction ‘plateau’ of approximately 4 seconds in duration [41]. Fig.98 (95% CI 0. 0. For each of the five repetitions of each activity from each participant. the contraction was held for 3 seconds and then released. The participants were then instructed to step down from the step. The activity was repeated five times with 30-second rest periods between repetitions. Results The average intra-class correlation method (ICC 3. with their feet shoulder width apart.96 (95% CI 0. with the participant positioned in half lying on the plinth.5 cm long.91 to 0. As the EMG data breached the assumptions of normality.99) for male VMO. commonly described as a quadriceps setting exercise [42]. the area under the curve (V. Whilst the EMG data were being recorded. differences between the groups were tested for statistical significance using the Mann Whitney U-test. the normalising maximal voluntary isometric contraction was performed with the knee joint in full extension [17. To calculate the VMO:VL ratio during step down and SLR for each participant. / Physiotherapy 94 (2008) 168–173 trolled by a piece of card 17. Normalisation is the conversion of an EMG amplitude during a particular activity to a percentage of its maximal amplitude.95 (95% CI 0. the average EMG was calculated similarly. Participants were asked to stand on top of the step.34]. providing median and approximate 95% confidence interval values. these values were 0. The VMO:VL ratio data were compared as the main variable of interest. Bowyer et al.91 to 0.5) values for repeatability of the within-session EMG levels during step down were 0. and is necessary when comparing EMG levels between subjects [41] as nonnormalised amplitudes may differ because of factors such as body fat or muscle bulk. For the maximal voluntary isometric contraction recordings.98) for male VL.second) and time (seconds) were extracted.7). As in previous studies.92 to 0. Normalised vastus medialis oblique (VMO):vastus lateralis (VL) intensity ratios during step down activity.98) for female VMO and 0. 0.96 (95% CI 0.90 to 0. At this height.94 to 0. Differences between the groups in the normalised EMG amplitudes (percentage of maximal voluntary isometric contraction) of VMO and VL were also analysed separately. Maximal voluntary isometric contraction To enable normalisation of the EMG amplitudes during the activities. raw EMG data were rectified and smoothed using an infinite impulse response 6 Hz low pass filter.96 (95% CI 0. The mean of the five average EMG values was calculated for VMO and VL for each activity. For SLR. Alpha was set at 0. Statistical analysis was performed using Statistical Package for the Social Sciences Version 10 for Windows. . Step down The step down activity took place from a step measuring 19 cm in height. This was repeated five times.96 (95% CI 0.89 to 0. and the average EMG (V) was calculated by dividing area under the curve (V. their toes just behind the step edge and their arms relaxed by their sides.25. The onset and cessation of EMG activity were determined as the point at which the EMG exceeded three standard deviations (SD) above the baseline mean resting level. Normalisation was then achieved for each participant by converting the average value (V) during step down and SLR to a percentage of that during the maximal voluntary isometric contraction [40].5) [43]. defined as a 300-millisecond window prior to activity [18.41].99) for male VMO. the participant was instructed to perform a quadriceps maximal voluntary isometric contraction for 5 seconds and then to relax. and the participant was instructed to use the necessary muscular effort to hold the SLR when they judged their heel to be in line with the top edge of the card. leading with their non-dominant limb. For all activities. performing an eccentric quadriceps muscle contraction.40].170 D. All EMG recordings were stored digitally for later analysis.05. participants carried out practice attempts for familiarisation with the procedures.second) by time (seconds).98) for male VL. 1. 0. The relative repeatability of within-subject EMG activation levels was assessed by analysing the repeated measurements of the participants during the test session using the intra-class correlation method (ICC 3. A 3-second contraction was chosen as an arbitrary figure for this exercise. a maximal voluntary isometric contraction of the quadriceps was carried out [40. Data analysis Using dedicated analysis software (AcqKnowledge 3. The order of activities was always SLR. step down and maximal voluntary isometric contraction. All EMG traces were inspected visually to ensure that movement artefacts did not affect the results. the normalised VMO amplitude was divided by the normalised VL amplitude.98) for female VL.

7) VL 23. the median VMO:VL ratio was 0. [21] who reported that the VMO:VL ratio was significantly greater in males than females during a weightbearing activity. but no between-group statistical tests were performed. 1 and 2. In contrast. Due to the dearth of published research on this topic. Table 2 presents a comparison of the average normalised EMG activity for VMO and VL separately (i.3 to 28. the median difference between the groups in the level of activation was −3. During step down.852). during the step down activity. in non-ratio form) during the step down and SLR.92 (IQR 0.5% (approximate 95% CI −21. respectively.6 to 9.6% (approximate 95% CI −14. it is interesting to note that the present study found no significant difference between males and females in the levels of EMG activity elicited during SLR and step down. in the study by Myer et al.44]. SD 0.36) for males. The median difference between the groups in the VMO:VL ratio was 0. / Physiotherapy 94 (2008) 168–173 171 during step down for VMO (P = 0.648 and 0. analysis with Mann Whitney U-tests revealed that the differences between the groups were not significant Table 2 Median (interquartile range) normalised vastus medialis oblique (VMO) and vastus lateralis (VL) average electromyographic activity (percentages of maximal) during step down and straight leg raise Group Step down VMO Female Male 38. increased VL activity or both.9) Straight leg raise VMO 20.3 (14.27) for females and 0. During SLR. that could have produced differences. Bowyer et al. This concurs with studies by Cerny [14] and Herrington et al. Firstly.8) for VMO.32.3 to 8.79 (IQR 0.13) for males. as shown in Table 2.6 to 9.07 (approximate 95% CI −0.4) for VL.1) VL 24.e. SD 0. the median difference between the groups in the level of activation was 5. these differences were not statistically significant (P = 0. such as recording electrode type.619.D. but differs from the results of Cerny [14].20) during SLR.6. The results for the normalised VMO:VL ratios during step down and SLR are presented in Figs.9) 24. there may still be differences in patients with patellofemoral pain syndrome. Cerny [14] found that asymptomatic females required approximately twice the activity in VMO and VL to perform the step down activity compared with males. [21].520). Using Mann Whitney U-tests. Discussion The aim of this study was to determine whether a gender difference existed between VMO:VL ratios in asymptomatic participants.26 to 0.62 to 1.86 to 0.40 (IQR 1.4 (57.3) 27.99 (95% CI 0. EMG data for all participants were normalised to levels elicited during a seated knee extension with a 20-kg weight. and 0. however. 2. This is similar to the results of Myer et al. [21]. the participants were asymptomatic.1) for VL.55 [interquartile range (IQR) 1. it would be inappropriate to use these findings to make generalisations on patellofemoral pain syndrome populations.3). or during SLR for VMO (P = 0.494) or VL (P = 0.9. the present results differ from those of Myer et al. rather than to a maximal contraction which is more commonly recommended and adopted [9.3 (12.98) for female VL. This study exhibited a number of limitations. During SLR. patellofemoral pain syndrome mean 0. further research is recommended. This may indicate that the patellofemoral pain syndrome group had either decreased VMO activity.11 (approximate 95% CI −0. Further study should be undertaken to assess gender differences in VMO:VL activity in patients with patellofemoral pain syn- Fig. average VMO:VL ratios in the asymptomatic group were greater than those in the symptomatic patellofemoral pain syndrome group (asymptomatic mean 1.2. During step down. the median VMO:VL ratio was 1.7) 32. Again.00) during step down and −0.8% (approximate 95% CI −8.8 (22.9) . 0.7 (40.8% (approximate 95% CI −15.756) or VL (P = 0.94 (95% CI 0.97 to 0. respectively). Hence. as a percentage of maximal voluntary isometric contraction.10. although there were no differences in activity ratios between genders in asymptomatic participants in the present study. the latter method was adopted in the present study. Several methodological differences existed between the studies.3 (18.4) 41. These all indicated excellent repeatability [43].7 (16. Accordingly. who reported that the female group exhibited a trend for greater EMG activity than the male group in both VMO and VL during step down when normalised to maximal voluntary isometric contraction levels. [20].8) for VMO and −5. Normalised vastus medialis oblique (VMO):vastus lateralis (VL) intensity ratios during straight leg raise. In addition. It should be noted that in the study by Cerny [14]. Interestingly.44] for females and 1. sampling rate and normalisation procedures. The results of this study showed that the differences between males and females in the VMO:VL EMG ratio during step down and SLR were not statistically significant.7 (21.99) for female VMO and 0. electrode placement.

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