A multivariate prognostic model for pain and activity limitation in people undergoing lumbar discectomy.

Purpose: The purpose of this study was to identify a multivariate predictive model for 6-month outcomes on overall pain, leg pain and activity limitation in patients undergoing lumbar discectomy. Identification of predictors of outcome for lumbar discectomy has the potential to assist identifying treatment targets, clinical decision making and disease understanding.Materials and methods: Prospective cohort design. Ninety-seven patients deemed by study surgeons to be suitable for lumbar discectomy completed a comprehensive clinical and radiological baseline assessment. At 6-months post surgery outcome measures of overall and leg pain (visual analogue scale) as well as activity limitation (Oswestry Disability Index) were completed. Univariate and multivariate analyses were conducted to determine the best multivariate predictive model of outcome.Results: In the multivariate model, presence of a compensation claim, longer duration of injury and presence of below knee pain and/or parasthesia were negative prognostic indicators for at least two of the outcomes. Peripheralization in response to mechanical loading strategies was a positive prognostic indicator for overall pain and leg pain. A range of other prognostic indicators for one outcome were also identified. The prognostic model explained up to 32% of the variance in outcome.Conclusions: An 11-factor prognostic model was identified from a range of clinically and radiologically assessed variables in accordance with a biopsychosocial model. The multivariate model has potential implications for researchers and practitioners in the field. Further high quality research is required to externally validate the prognostic model, evaluate effect of the identified prognostic factors on treatment effectiveness and explore potential mechanisms of effect.

The effectiveness of physiotherapy functional restoration for post-acute low back pain: a systematic review.

BACKGROUND: The effectiveness of multidisciplinary treatment for post-acute (>6 weeks) low back pain (LBP) has been established. Physiotherapists have sufficient training to conduct less intensive functional restoration. The effectiveness of physiotherapy functional restoration (PFR) has not been evaluated using current systematic review methodology. OBJECTIVES: To determine the effects of PFR for post-acute LBP. DATA SOURCES: Electronic databases searched include: MEDLINE, EMBASE, CINAHL, PsycINFO, PEDro and Cochrane CENTRAL. TRIAL ELIGIBILITY CRITERIA: Randomised controlled trials of physiotherapy treatment for post-acute LBP combining exercise and cognitive-behavioural intervention compared with other intervention, no intervention or placebo. TRIAL APPRAISAL AND SYNTHESIS METHODS: Two authors independently extracted data. Risk of bias was assessed using the PEDro scale and overall quality of the body of evidence was assessed using GRADE (Grading of Recommendations, Assessment, Development and Evaluation). Treatment effect sizes and 95% confidence intervals were calculated for pain, function and sick leave. RESULTS: Sixteen trials were included. Heterogeneity prevented meta-analysis for most comparisons. Meta-analyses showed moderate to high quality evidence of significant but small effects favouring PFR compared with advice for intermediate term function and intermediate and long term pain. There was however low to moderate quality evidence that PFR was no more effective than a range of other treatment types. Heterogeneous trials frequently contributed to very low quality evidence. CONCLUSIONS: Moderate to high quality evidence was found of small effects favouring PFR compared with advice. Preliminary evidence suggested PFR is not different to other treatment types. Further high quality research is required replicating existing trial protocols.

Simulation can contribute a part of cardiorespiratory physiotherapy clinical education: two randomized trials.

INTRODUCTION: Simulated learning environments (SLEs) are used worldwide in health professional education, including physiotherapy, to train certain attributes and skills. To date, no randomized controlled trial (RCT) has evaluated whether education in SLEs can partly replace time in the clinical environment for physiotherapy cardiorespiratory practice. METHODS: Two independent single-blind multi-institutional RCTs were conducted in parallel using a noninferiority design. Participants were volunteer physiotherapy students (RCT 1, n = 176; RCT 2, n = 173) entering acute care cardiorespiratory physiotherapy clinical placements. Two SLE models were investigated as follows: RCT 1, 1 week in SLE before 3 weeks of clinical immersion; RCT 2, 2 weeks of interspersed SLE/clinical immersion (equivalent to 1 SLE week) within the 4-week clinical placement. Students in each RCT were stratified on academic grade and randomly allocated to an SLE plus clinical immersion or clinical immersion control group. The primary outcome was competency to practice measured in 2 clinical examinations using the Assessment of Physiotherapy Practice. Secondary outcomes were student perception of experience and clinical educator and patient rating of student performance. RESULTS: There were no significant differences in student competency between the SLE and control groups in either RCT, although students in the interspersed group (RCT 2) achieved a higher score in 5 of 7 Assessment of Physiotherapy Practice standards (all P < 0.05). Students rated the SLE experience positively. Clinical educators and patients reported comparability between groups. CONCLUSIONS: An SLE can replace clinical time in cardiorespiratory physiotherapy practice. Part education in the SLE satisfied clinical competency requirements, and all stakeholders were satisfied.

Can simulation replace part of clinical time? Two parallel randomised controlled trials.

CONTEXT: Education in simulated learning environments (SLEs) has grown rapidly across health care professions, yet no substantive randomised controlled trial (RCT) has investigated whether SLEs can, in part, substitute for traditional clinical education. METHODS: Participants were physiotherapy students (RCT 1, n = 192; RCT 2, n = 178) from six Australian universities undertaking clinical education in an ambulatory care setting with patients with musculoskeletal disorders. A simulated learning programme was developed as a replica for clinical education in musculoskeletal practice to replace 1 week of a 4-week clinical education placement. Two SLE models were designed. Model 1 provided 1 week in the SLE, followed by 3 weeks in clinical immersion; Model 2 offered training in the SLE in parallel with clinical immersion during the first 2 weeks of the 4-week placement. Two single-blind, multicentre RCTs (RCT 1, Model 1; RCT 2, Model 2) were conducted using a non-inferiority design to determine if the clinical competencies of students part-educated in SLEs would be any worse than those of students educated fully in traditional clinical immersion. The RCTs were conducted simultaneously, but independently. Within each RCT, students were stratified on academic score and randomised to either the SLE group or the control ('Traditional') group, which undertook 4 weeks of traditional clinical immersion. The primary outcome measure was a blinded assessment of student competency conducted over two clinical examinations at week 4 using the Assessment of Physiotherapy Practice (APP) tool. RESULTS: Students' achievement of clinical competencies was no worse in the SLE groups than in the Traditional groups in either RCT (Margin [Δ] ≥ 0.4 difference on APP score; RCT 1: 95% CI - 0.07 to 0.17; RCT 2: 95% CI - 0.11 to 0.16). CONCLUSIONS: These RCTs provide evidence that clinical education in an SLE can in part (25%) replace clinical time with real patients without compromising students' attainment of the professional competencies required to practise.

Efficacy of directional preference management for low back pain: a systematic review.

BACKGROUND: Providing specific treatment based on symptom response for people with low back pain (LBP) and a directional preference (DP) is a widely used treatment approach. The efficacy of treatment using the principles of directional preference management (DPM) for LBP is unclear. OBJECTIVE: The purpose of this study was to determine the efficacy of treatment using the principles of DPM for people with LBP and a DP. METHODS: Computer databases were searched for randomized controlled trials (RCTs) published in English up to January 2010. Only RCTs investigating DPM for people with LBP and a DP were included. Outcomes for pain, back specific function, and work participation were extracted. RESULTS: Six RCTs were included in this review. Five were considered high quality. Clinical heterogeneity of the included trials prevented meta-analysis. GRADE quality assessment revealed mixed results; however, moderate evidence was identified that DPM was significantly more effective than a number of comparison treatments for pain, function, and work participation at short-term, intermediate-term, and long-term follow-ups. No trials found that DPM was significantly less effective than comparison treatments. CONCLUSIONS: Although this systematic review showed mixed results, some evidence was found supporting the effectiveness of DPM when applied to participants with a DP, particularly at short-term and intermediate-term follow-ups. Further high-quality RCTs are warranted to evaluate the effect of DPM applied to people with LBP and a DP.

The effect of dividing attention between walking and auxiliary tasks in people with Parkinson's disease.

This controlled study examined the effects of dividing attention between walking and the performance of a secondary cognitive task in people with mild to moderate Parkinson's disease (Hoehn and Yahr stages 2-3.5). Participants in the training group (n=6) received 30 min divided attention training in taking big steps while simultaneously performing serial three subtractions. Participants in the control group (n=6) received no training. Stride length, gait velocity and accurate enumeration rate were measured at baseline, immediate after training and 30 min after training under single-task (walk only or subtract only) and dual-task (walk and subtract) conditions. Data were also collected at training in the training group. Immediate improvement in stride length and gait velocity was found when instruction was given to participants to pay equal attention to gait and subtractions (p=0.001, p=0.05) compared to baseline. Short-term improvement in the gait variables was also found after training when compared to the controls (p=0.001, p=0.001). Nevertheless, there was no significant difference in the accurate enumeration rate. Based on the findings, we conclude that divided attention can be used as a strategy to improve slow and short-stepped gait under dual-task conditions. Divided attention can also be used in gait training for short term stride length and gait velocity improvement.

The effects of verbal instructions on gait in people with Parkinson's disease: a systematic review of randomized and non-randomized trials.

OBJECTIVE: To collate and appraise empirical evidence relating to the effects of verbal instructions (verbal commands given by another person) on stride length, gait velocity and stride variability in people with Parkinson's disease. DATA SOURCES: Cinahl, Cochrane, Embase, Medline, PEDro, PsycINFO and Web of Science. REVIEW METHODS: Independent reviewers extracted data from eligible studies and assessed methodological quality. The level of evidence was determined by best evidence synthesis based upon the experimental design, methodological quality and statistical findings of individual studies. RESULTS: One randomized controlled study and 12 non-controlled studies fulfilled the selection criteria and involved 149 participants. Five types of verbal instructions were examined which included 'take big steps', 'walk fast', 'swing arms when walking', 'count rhythm when walking' and 'walk fast with big steps'. Best evidence synthesis found indicative evidence in support of the use of the instruction to take big steps in walking training for stride length improvement in people with mild to moderate Parkinson's disease who are without cognitive impairment. There was insufficient evidence in support of effects on gait velocity and stride variability. There was also insufficient evidence in support of effects of other instructions on any of the gait variables. CONCLUSION: The empirical evidence in support of the benefits from verbal instructions is weak. The evidence is limited to short-term stride length improvement from the use of the instruction to take big steps in walking training.

Outcomes and adverse events from physiotherapy functional restoration for lumbar disc herniation with associated radiculopathy.

PURPOSE: To report the outcomes and adverse events of people diagnosed with lumbar disc herniation with associated radiculopathy (LDHR) who were treated with a physiotherapy functional restoration programme. METHOD: Data on functional outcome (Oswestry score), work status, global rating of change, and adverse events were extracted from the files of all people with LDHR treated by three physiotherapists using functional restoration principles from 2001 to 2009. RESULTS: Ninety-five participants were included. The Oswestry score reduced by a mean of 15.9 (95% CI, 11.8-20.1) points between baseline and discharge following a mean (SD) of 8.7 (9.4) months of treatment. The proportion of participants working full-time increased from 37% to 67% between baseline and discharge (p < 0.001). Eighty per cent of participants reported overall improvement between baseline and discharge on the global rating of change scale (p < 0.001). Minor adverse events were reported by eight (8%) participants, while one (1%) participant developed adhesive capsulitis. CONCLUSION: People with LDHR who undertook a physiotherapy functional restoration programme achieved significant improvements in Oswestry disability scores, work status, and global rating of change, with few adverse events reported. A randomised controlled trial is warranted to determine the efficacy of functional restoration for people with this condition.

Prioritizing gait in dual-task conditions in people with Parkinson's.

This controlled study examined the effects of a gait prioritization strategy on walking in people with Parkinson's disease (PD). Participants in the training group (n=6) received 30-min therapy to prioritize their attention to take big steps while performing serial three subtractions. Participants in the control group (n=6) received no therapy. Stride length, gait velocity, and accurate enumeration rate were measured at baseline, immediately after training and 30 min after training under both single-task (walk only or subtract only) and dual-task (walk and subtract) conditions. Performance was also assessed during therapy for the training group. Stride length and gait velocity increased immediately when participants followed instructions to prioritize their attention to take big steps (p=.005, p=.04). Further, the gait variables increased for both single and dual-task conditions for at least 30 min after training when compared to the controls; with a simultaneous reduction in the magnitude of dual-task interference (p=.03, p=.03). No difference in the accurate enumeration rate was found at any of the assessment time points. Therefore, prioritizing attention to take big steps can be an effective strategy to increase the stride length and walking speed in some people with PD.

Conservative management of lumbar disc herniation with associated radiculopathy: a systematic review.

STUDY DESIGN: A systematic review of randomized controlled trials. OBJECTIVE: To determine the efficacy and adverse effects of conservative treatments for people who have lumbar disc herniation with associated radiculopathy (LDHR). SUMMARY OF BACKGROUND DATA: Although conservative management is commonly used for people who have LDHR, the efficacy and adverse effects of conservative treatments for this condition are unclear. METHODS: We searched 10 computer databases for trials published in English between 1971 and 2008. Trials focusing on people with referred leg symptoms and radiologic confirmation of a lumbar disc herniation were included if at least 1 group received a conservative and noninjection treatment. RESULTS: Eighteen trials involving 1671 participants were included. Seven (39%) trials were considered of high quality. Meta-analysis on 2 high-quality trials revealed that advice is less effective than microdiscectomy surgery at short-term follow-up, but equally effective at long-term follow-up. Individual high-quality trials provided moderate evidence that stabilization exercises are more effective than no treatment, that manipulation is more effective than sham manipulation for people with acute symptoms and an intact anulus, and that no difference exists among traction, laser, and ultrasound. One trial showed some additional benefit from adding mechanical traction to medication and electrotherapy methods. Adverse events were associated with traction (pain, anxiety, lower limb weakness, and fainting) and ibuprofen (gastrointestinal events). CONCLUSION: Advice is less effective than microdiscectomy in the short term but equally effective in the long term for people who have LDHR. Moderate evidence favors stabilization exercises over no treatment, manipulation over sham manipulation, and the addition of mechanical traction to medication and electrotherapy. There was no difference among traction, laser, and ultrasound. Adverse events were associated with traction and ibuprofen. Additional high-quality trials would allow firmer conclusions regarding adverse effects and efficacy.

The effect of local anaesthetic on age-related capsaicin-induced mechanical hyperalgesia--a randomised, controlled study.

Adults over 65 years exhibit a prolonged punctate hyperalgesia induced by topical application of capsaicin. The aim of this study was to investigate the role of peripheral afferent input in the slowed resolution of punctate hyperalgesia in older people. Twenty young (25.7+/-4.8 years) and 19 old (74.9+/-4.4 years) healthy adults were recruited, and subjects in each age group were randomly assigned to receive either EMLA cream (a local anaesthetic) (n=10 in each age group) or Sorbolene treatment (n=9 in the older group, n=10 in the young group) after the development of punctate hyperalgesia. EMLA cream blocked punctate sensation and greatly reduced touch and warmth sensation. In comparison to Sorbolene treatment, EMLA abolished stroking but not punctate hyperalgesia in both age groups. The area of punctate hyperalgesia was maintained in older adults over 4 h, while it declined in the young. Older adults also reported reduced ratings to capsaicin-induced sensation and to stroking stimulation, and had a smaller area of stroking hyperalgesia. Ratings to punctate stimulation did not, however, differ between the age groups. Stoicism and cautiousness measured with Pain Attitude Questionnaire were negatively correlated with highest pain rating in the young, but not in the older groups. We suggest that the prolonged punctate hyperalgesia in older adults is possibly sustained by central mechanisms, indicating age differences in central plasticity following acute injury. The relationship between such age-related changes and the chronicity of pain in older adults should be further explored.

The test-retest reliability and concurrent validity of the Subjective Complaints Questionnaire for low back pain.

Physiotherapists commonly record detailed patient information regarding subjective complaints for low back pain (LBP), particularly to assist in the process of classifying patients into specific subgroups. A self-administered Subjective Complaints Questionnaire for LBP (SCQ-LBP) measuring such information was developed for the purposes of future clinical research, particularly in the area of LBP classification. The development comprised literature review, feedback from experienced physiotherapists and pilot questionnaire testing in a patient population. Test-retest reliability of the questionnaire in a self administered format as well as concurrent validity against a suitable reference standard was evaluated. The agreement between the self administered questionnaire compared to when administered by a physiotherapist was also tested as the latter method is the most common form of retrieving subjective complaints in clinical practice. Thirty participants with LBP were recruited and at least moderate test-retest reliability was demonstrated in 56 of the 57 self administered questionnaire items. Preliminary evidence was found supporting the concurrent validity of selected items. At least moderate agreement was demonstrated in 51 of the 57 items when comparing between the self administered and physiotherapist administered conditions. The questionnaire is a useful tool for collecting subjective complaints information, particularly for clinical research on the classification of LBP, however, further research regarding validity is required.

A targeted home- and center-based exercise program for people after total hip replacement: a randomized clinical trial.

OBJECTIVE: To examine the physical function, gait, and quality of life of patients after total hip replacement (THR) randomly assigned to either a targeted home- or center-based exercise program. DESIGN: Randomized controlled trial. SETTING: Rehabilitation research center in Australia. PARTICIPANTS: Twenty-three patients with unilateral THR were randomly assigned to a supervised center-based exercise group (n=11) or an unsupervised home-based exercise group (n=12). INTERVENTION: The center-based group completed an 8-week targeted exercise program while under the direct supervision of a physiotherapist. After initial instruction, the home-based group completed the 8-week targeted exercise program at home without further supervision. MAIN OUTCOME MEASURES: Quality of life, physical function, and spatiotemporal measures of gait. RESULTS: No significant interaction (group by time) or main effects of grouping were found. Within each group, quality of life, and stair climbing improved significantly (P<.05) as did Timed Up & Go test and 6-minute walk test performances (P<.05). Walking speed increased by 16 cm/s (P<.01), cadence by 8 steps/min (P<.05), step length by 4.7 cm (P<.05), and double-support time reduced by a factor of 16%. Step length symmetry showed significant improvement (P<.05) over time. Step length differential between the affected and unaffected limbs reduced from 4.0 to 2.7 cm. CONCLUSIONS: The targeted strengthening program was effective for both the home- and center-based groups. No group differences were found in the majority of the outcome measures. This finding is important because it shows that THR patients can achieve significant improvements through a targeted strengthening program delivered at a center or at home.

A clinical education and practice placements in the allied health professions: an international perspective.

This report describes the outcomes of extensive discussions surrounding clinical education and practice placement issues undertaken by an international group of allied health educators (in audiology, occupational therapy, physiotherapy, and speech pathology) who have met since 2001 as part of Universitas 21 Health Sciences annual meetings. The report outlines key issues associated with clinical education and practice placements from an international perspective and across these four allied health professions. The allied health practice context is described in terms of the range of allied health educational programs in Universitas 21 and recent changes in health and tertiary education sectors in represented countries. Some issues and benefits related to supervision during allied health students' practice placements are addressed. A new approach is proposed through partnership such that frameworks for the provision of practice placements can be created to facilitate student learning and educate and support clinical educators. A set of guidelines that can enhance partnerships and collaborative practice for the benefit of clinical education within complex and changing health/human service and educational environments is proposed.

Australian physiotherapy student intake is increasing and attrition remains lower than the university average: a demographic study.

QUESTIONS: Have student numbers (ie, intake and attrition) changed since the introduction of graduate entry-level physiotherapy courses in Australian universities? What is the impact of any changes in student numbers on university funding? What is the impact of any changes in student numbers on the workforce? Have student characteristics (ie, gender, country of origin, background) changed? DESIGN: Demographic study of 2003 graduates, 2004 student intake, and estimated 2007 student intake. PARTICIPANTS: Eleven Schools of Physiotherapy in Australia. RESULTS: In 2003, 836 new physiotherapists graduated, and in 2004, 1108 students commenced with the percentage of graduate-entry Masters and international students increasing. Compared to the overall average 25% attrition rate of students from university, the rate for physiotherapy students was less than 5%; the funding formula thus underestimates physiotherapy student numbers across the years of the courses. While it remains the case that in undergraduate and graduate-entry programs most physiotherapy students are female, a greater proportion of males are entering graduate-entry Masters programs than undergraduate courses. International student numbers are increasing in line with trends across the sector, but representation of Aboriginal and Torres Strait Islander students in physiotherapy courses was lower than within universities generally. CONCLUSIONS: The marked overall increase in student numbers and greater retention rate in the graduate entry-level courses puts physiotherapy at a disadvantage in relation to Department of Education, Science and Training student funding. While the substantial increase in new physiotherapists may serve to ease workforce demands in the short term, significant pressure on physiotherapy academics and clinical educators was evident.

Physiotherapy in rural and regional Australia.

OBJECTIVE: To inform rural physiotherapy recruitment and retention strategies by describing physiotherapists in the Shepparton region: reasons for career choice, education and physiotherapy professional issues. DESIGN: Survey. SETTING: Health service providers. PARTICIPANTS: Practising and non-practising physiotherapists. MAIN OUTCOME MEASURE: Survey responses. RESULTS: Survey response rate 79%. Eighty four physiotherapists (79 practicing and 5 non-practicing; 80% female) clustered in main regional centres responded. Two-thirds worked part-time with most in the public sector (70%), with one third holding more than one position. One-third considered themselves generalists and one-third specialists. Physiotherapy was first career choice for 83% who made this decision between 14 and 19 years old (16.8-2.5 years) because of contact with a physiotherapist. Professional issues challenging physiotherapists in a rural location are compounded by lack of career path, professional support, access to professional development and postgraduate education. Additional issues are the costs and time to attend courses and conferences, travel/distance, and inadequate resources. Positive elements of rural practice were part-time employment opportunities, independence as primary health providers, practice variety and community recognition. CONCLUSION: Rural physiotherapy recruitment and retention strategies must address resource shortcomings by developing career paths, access to postgraduate education and support. Enhancing workforce capacity could enable more students to have meaningful rural experience to assist recruitment. Strategies highlighting existing positive features of rural practice, reinforced with tangible rewards and recognition of physiotherapists' contribution to the health care of Australians are recommended.

Indicators of lumbar zygapophyseal joint pain: survey of an expert panel with the Delphi technique.

BACKGROUND AND PURPOSE: The lumbar zygapophyseal joints (LZJs) are thought to be a source of low back pain (LBP); however, no valid or reliable indicators exist. The purpose of this study was to obtain a consensus from an expert panel on the indicators of LZJ pain. SUBJECTS: A multidisciplinary panel of 20 experts in the field of LBP participated in this study. METHODS: A 3-round Delphi survey designed to obtain a consensus on the indicators of LZJ pain was completed by use of accepted protocols. Subjects also were asked to justify their selection of each indicator. RESULTS: Following the 3 rounds, consensus was achieved, and 12 indicators were identified. Those that reached the highest levels of consensus were a positive response to facet joint injection, localized unilateral LBP, positive medial branch block, pain upon unilateral palpation of the LZJ or transverse process, lack of radicular features, pain eased by flexion, and pain, if referred, located above the knee. Justifications for the experts' selection of the indicators, predominantly based on pathoanatomical mechanisms, also were described. DISCUSSION AND CONCLUSION: This Delphi survey identified 12 indicators of LZJ pain, each with an associated pathoanatomical mechanism justifying selection. This survey provides preliminary validation for these indicators, which will be of value in further research into the classification and treatment of LZJ pain.

Exploring the contribution of patient-reported and clinician based variables for the prediction of low back work status.

BACKGROUND: Successful management of workers on sick leave due to low back pain by the general physician and physiotherapist depends on reliable prognostic information on the course of low back pain and work resumption. METHODS: Retrospective cohort study in 194 patients who were compensated because of chronic low back pain and who were treated by a physiotherapy functional restoration program. Patient-reported and clinician based prognostic indicators were assessed at baseline before patients entered the functional restoration program. We investigated the predictive value of these indicators on work status at 6 months. Relationships were studied using logistic regression analysis in a 2-step bootstrap modelling approach and a nomogram was developed. Discrimination and calibration of the nomogram was evaluated internally and the explained variation of the nomogram calculated. RESULTS: Seventy percent of workers were back to work at 6 months. We found that including duration of complaints, functional disability, disc herniation and fear avoidance beliefs resulted in the "best" prognostic model. All these factors delayed work resumption. This model was used to construct a nomogram. The explained variation of the nomogram was 23.7%. Discrimination was estimated by the area under the receiver operating characteristic curve and was 0.76 and for calibration we used the slope estimate that was 0.91. The positive predictive values of the nomogram at different cut-off levels of predicted probability were good. CONCLUSIONS: Knowledge of the predictive value of these indicators by physicians and physiotherapists will help to identify subgroups of patients and will thus enhance clinical decision-making.