Transgender, Gender-Diverse, and Nonbinary Experiences in Physical Therapy: A Descriptive Qualitative Study.

OBJECTIVE: The objective was to explore experiences with and identify barriers and facilitators of utilizing physical therapy for people who identify as transgender, gender diverse, and nonbinary (TGNB). METHODS: A qualitative descriptive design was employed using semistructured interviews conducted in New Zealand. Eligible participants were individuals who were 12 years old or older, who self-identified as TGNB, and who had accessed physical therapy at a community-based clinic that also provides a gender-affirming service. Participants were recruited via email invitation to the clinic database. Interview data were analyzed using reflexive thematic analysis. Demographics are reported descriptively. RESULTS: Seventeen individuals (15-64 years old and identifying as 11 different genders) participated. All participants reported physical therapist experiences relating to 1 or more of the following 4 themes: challenging cisnormativity at policy, environmental, clinic, and therapist levels; safety and trust throughout the clinical experience, including clinic credibility for being a safe provider, clinic displays of TGNB inclusivity, implementation of safe clinic processes, and respectful therapist interactions; inclusive experiences in a clinic that provided affordable care and took active steps to understand and affirm TGNB identities and with physical therapists who had a high level of knowledge of TGNB-specific health issues and took a biopsychosocial approach to care; and sensitivity to body discomfort or dysphoria triggers. Barriers to and facilitators of care were identified at policy, environmental, clinic, and therapist levels. CONCLUSION: People who identify as TGNB face challenges to accessing safe and culturally sensitive physical therapy. However, there are achievable areas for improvement at policy, environmental, clinic, and physical therapist levels to gain trust and engagement in care for the TGNB community. IMPACT: This study provides a detailed exploration of TGNB physical therapist experiences and identifies specific areas of improvement for TGNB physical therapy care to provide clinicians and physical therapy clinics insights into the provision of safe and culturally sensitive physical therapy.

Reliability of lower limb strength assessment in female team sport athletes.

BACKGROUND: Lower limb injury rates have increased dramatically in line with increased female sport participation levels. Muscle strength is a modifiable lower limb injury risk factor, guiding performance monitoring and rehabilitation. OBJECTIVES: The aim of this study was to investigate the test-retest reliability of isokinetic and isometric lower limb peak torque to body mass of muscles acting on the hip, knee, and ankle in female team sport athletes. It was hypothesised the test-retest reliability would be good (intraclass correlation coefficients (ICC) ≥ 0.75). METHODS: Thirty-eight female athletes (Australian Rules Football = 18, netball = 12, soccer = 8) aged 16-35 years participated in this study. Participants performed isokinetic (60°/s and 120°/s) and isometric testing on a Biodex Isokinetic Dynamometer on three separate days. RESULTS: Poor to good reliability was demonstrated for all joint movements (ICC = 0.38-0.88) with small to moderate effect sizes (0.00-0.43) and typical errors (5.65-24.49). CONCLUSION: Differences in peak torque to body mass were observed between sessions one and two and/or one and three, demonstrating a learning effect. Therefore, three testing sessions, and/or the inclusion of a familiarisation session, is recommended for future assessments in populations unfamiliar with dynamometry.

Reliability of the running vertical jump test in female team sport athletes.

Injury rates to the lower limb have increased over the past 40 years, coinciding with increases in female sport participation rates. Sport specific tests such as the running vertical jump (RVJ) are utilised for injury risk profiling, however the test-retest reliability is unknown. OBJECTIVES: The aim of this study was to investigate the test-retest reliability of the thorax, pelvis and lower limb joint angular kinematics and kinetics for the RVJ test in female team sport athletes. DESIGN: Three-dimensional motion capture with force plate integration was utilised as participants performed five trials on each limb on three separate days. SETTING: Testing occurred in a biomechanics laboratory. PARTICIPANTS: Thirty-four females (Australian Rules Football = 15, Netball = 12, Soccer = 7) participated in this study. MAIN OUTCOME MEASURES: Intraclass correlation coefficients (ICC), effect sizes and typical errors (TE) of segment and joint angular kinematics and kinetics were calculated. RESULTS: Poor to excellent reliability (ICC = -0.12 - 0.92), small to large effect sizes (0.00-0.90) and TE (0.02-289.24) were observed across segment and joint angular kinematics and kinetics. CONCLUSIONS: The RVJ test is recommended when analysing ground reaction forces and joint angular kinematics in female team sport athletes.

A novel blinding protocol to test participant and therapist blinding during dry needling: a randomised controlled experiment.

OBJECTIVES: Dry needling is widely used in physiotherapy. Lack of blinding in clinical trials means that dry needling effects and mechanisms remain unclear, with blinding issues accepted as an unavoidable barrier to better evidence. The authors aimed to overcome this barrier by designing a protocol to double-blind dry needling trials. DESIGN: A prospectively registered randomised experiment tested a novel blinding protocol for blinding effectiveness. SETTING: University physiotherapy clinic. PARTICIPANTS: Therapists (n=15) and asymptomatic volunteers ('recipients') (n=45) were randomly allocated to real and/or sham interventions. INTERVENTIONS: The protocol involved custom-made needles and cognitive and multisensory blinding techniques. MAIN OUTCOME MEASURES: The primary outcome was guesses about allocation. The a priori criterion for successful blinding was ≤50% correct guesses (random chance). Secondary analyses explored blinding patterns using blinding indices. RESULTS: Correct guesses were not different from 50% for therapists [41% (95%CI 30 to 50), n=120 guesses] or recipients [49% (95%CI 38 to 60), n=90 guesses]. Blinding indices supported the primary result but revealed that recipients were better at detecting real dry needling than sham. CONCLUSION: Both therapists and recipients were successfully blinded, which contrasts with the widely held assumption that double-blinding is impossible for needling interventions. The authors recommend that any future trials can, and therefore should, blind therapists. However, secondary analyses revealed that recipients receiving real dry needling were less blinded than sham recipients, which may still create bias in clinical trials and suggests further work is needed to improve recipient blinding. Nonetheless, the current findings offer an opportunity to gain better evidence concerning the effects and mechanisms of dry needling. STUDY REGISTRATION: https://osf.io/rkzeb/.

A collaborative experiential problem-solving approach to develop shams for complex physical interventions: a case study of dry needling.

OBJECTIVE: Complex physical interventions are widely used in physiotherapy, despite doubts over the validity of clinical trial results due to lack of credible shams. Credible shams are critically needed, so too, therefore, is a process by which they can be developed. The authors used a novel methodology to develop and test blinding protocols for dry needling, a complex physical intervention for which blinding is particularly difficult. DESIGN: The research design was a practical three-day workshop influenced by Participatory Action Research, which uses iteration and reflection to solve a problem. PARTICIPANTS: Five multidisciplinary experts (researchers, clinicians, technician, magician) were invited. Healthy volunteers ('recipients', n=17) and accredited physiotherapists (n=6) were recruited to enable testing of blinding strategies. MAIN OUTCOME MEASURES: Primary outcomes were expert opinion on the potential to blind recipients/therapists for (1) individual blinding strategies, and (2) entire blinding protocols. Secondary outcomes included recipient/therapist blinding effectiveness and acceptability. RESULTS: Experts iteratively developed 11 blinding protocols involving 22 blinding strategies. Experts rated 18 of the blinding strategies to 'definitely have potential' and identified four categories: knowledge of the sham, clinical interaction, disinformation, and sensation. Recipient and therapist blinding became more successful as the protocols evolved. CONCLUSIONS: Credible shams capable of simultaneous recipient and therapist blinding have been regarded to be impossible in dry needling. The preliminary success of the devised protocols suggest that our novel approach may be a crucial step in sham development. Improvements in expert rankings and blinding effectiveness as the protocols progressed support the value of this workshop approach.

Towards more credible shams for physical interventions: A Delphi survey.

BACKGROUND/AIMS: In clinical trials of physical interventions, participant blinding is often poorly addressed and therapist blinding routinely omitted. This situation presents a substantial barrier to moving the field forward. Improving the success of blinding will be a vital step towards determining the true mechanisms of physical interventions. We used a Delphi approach to identify important elements of shams for physical interventions to maximise the likelihood of participant and therapist blinding in clinical trials. METHODS: Two expert groups were recruited: (1) experts in research methodology and (2) experts in deceptive and/or hypnotic techniques including magic. Magicians were included because they were considered a potentially rich source of innovation for developing credible shams due to their unique skills in altering perceptions and beliefs. Three rounds of survey were conducted, commencing with an open-ended question. Responses were converted to single 'items', which participants rated in the following two rounds using a 9-point Likert scale, categorised as 'Not important' (0-3), 'Depends' (4-6) and 'Essential' (7-9). Consensus was pre-defined as ≥80% agreement within a 3-point category. RESULTS: Thirty-eight experts agreed to participate (research methodology: n = 22; deceptive and/or hypnotic techniques: n = 16), and 30 experts responded to at least one round (research methodology: n = 19; deceptive and/or hypnotic techniques: n = 11). Of 79 items, five reached consensus in the 'Essential' category in both groups, which related to beliefs of participants (n = 3 items), interactions with researchers (n = 1 item) and standardisation of clinical assessments (n = 1 item). Thirteen additional items reached consensus in the 'Essential' category in one group. Experts in research methodology had one additional item reach consensus, related to authentic delivery of study information. The remaining 12 additional items that reached consensus in the deceptive and/or hypnotic techniques group related mainly to therapist attitude and behaviour and the clinical interaction. CONCLUSION: Experts agreed that, for shams to be believable, consideration of cognitive influences is essential. Contrary to the focus of previous shams for physical interventions, replicating the tactile sensation of the active treatment was not considered an essential part of sham development. Therefore, when designing sham-controlled clinical trials, researchers should carefully consider the cognitive credibility of the entire intervention experience, and not just the indistinguishability of the sham intervention itself. The findings provide new guidance to researchers on important contributors to blinding in physical intervention trials.

Towards more homogenous and rigorous methods in sham-controlled dry needling trials: two Delphi surveys.

OBJECTIVES: Sham-controlled trials of dry needling, a popular treatment for pain, use a range of methods and theoretical frameworks and most have high risk of bias. Critically, patient blinding is often unsuccessful and therapist blinding has not been attempted. The specific effects of dry needling on pain therefore remain unclear. Our objectives were to identify (1) important elements of active dry needling; (2) important elements of shams for dry needling. DESIGN AND PARTICIPANTS: Two Delphi surveys (to quantify levels of consensus) were undertaken with three expert groups: experts in (1) dry needling, (2) research methodology, and (3) deceptive/hypnotic techniques including magic. Experts in dry needling participated in Delphi 1 and all three groups participated in Delphi 2. Each survey commenced with an open-ended question. Responses were converted to single 'items' suitable for rating on 9-point Likert scales [categorised as 'Not important' (0-3), Depends (4-6), and Essential (7-9)], which participants rated in the following two rounds. Consensus was pre-defined as ≥80% agreement within a 3-point category. RESULTS: In Delphi 1 (n=20 experts), of 80 items, 35 reached consensus in the 'Essential' category, which related to explanations, therapist knowledge/skills, intervention rationale, the setting, and safety. In Delphi 2 (n=53 experts), of 97 items, 15 items reached consensus in the 'Essential' category in all three groups, which related to standardisation/indistinguishability, therapist attributes, expectations/beliefs, vision, protocol, and environment. CONCLUSIONS: Experts placed high importance on the entire intervention experience for active and sham protocols. Cognitive influences that extend beyond mimicking of tactile sensations should be used to create a believable simulation of active dry needling.

Blinding Strategies in Dry Needling Trials: Systematic Review and Meta-Analysis.

BACKGROUND: Blinding of participants and therapists in trials of physical interventions is a significant and ongoing challenge. There is no widely accepted sham protocol for dry needling. PURPOSE: The purpose of this review was to summarize the effectiveness and limitations of blinding strategies and types of shams that have been used in dry needling trials. DATA SOURCES: Twelve databases were searched from inception to February 2016. STUDY SELECTION: Trials that compared active dry needling with a sham that simulated dry needling were included. DATA EXTRACTION: The main domains of data extraction were participant/therapist details, intervention details, blinding strategies, blinding assessment outcomes, and key conclusions of authors. Reported blinding strategies and sham types were synthesized descriptively, with available blinding effectiveness data synthesized using a chance-corrected measurement of blinding (blinding index). DATA SYNTHESIS: The search identified 4894 individual publications with 27 trials eligible for inclusion. In 22 trials, risk of methodological bias was high or unclear. Across trials, blinding strategies and sham types were heterogeneous. Notably, no trials attempted therapist blinding. Sham protocols have focused on participant blinding using strategies related to group standardization and simulation of tactile sensations. There has been little attention given to the other senses or cognitive strategies to enhance intervention credibility. Nonpenetrating sham types may provide effective participant blinding. LIMITATIONS: Trials were clinically and methodologically diverse, which limited the comparability of blinding effectiveness across trials. Reported blinding evaluations had a high risk of chance findings with power clearly achieved in only 1 trial. CONCLUSIONS: Evidence-based consensus on a sham protocol for dry needling is required. Recommendations provided in this review may be used to develop sham protocols so that future protocols are more consistent and potentially more effective.

Effectiveness and adequacy of blinding in the moderation of pain outcomes: Systematic review and meta-analyses of dry needling trials.

BACKGROUND: Blinding is critical to clinical trials because it allows for separation of specific intervention effects from bias, by equalising all factors between groups except for the proposed mechanism of action. Absent or inadequate blinding in clinical trials has consistently been shown in large meta-analyses to result in overestimation of intervention effects. Blinding in dry needling trials, particularly blinding of participants and therapists, is a practical challenge; therefore, specific effects of dry needling have yet to be determined. Despite this, dry needling is widely used by health practitioners internationally for the treatment of pain. This review presents the first empirical account of the influence of blinding on intervention effect estimates in dry needling trials. The aim of this systematic review was to determine whether participant beliefs about group allocation relative to actual allocation (blinding effectiveness), and/or adequacy of blinding procedures, moderated pain outcomes in dry needling trials. METHODS: Twelve databases (MEDLINE, EMBASE, AMED, Scopus, CINAHL, PEDro, The Cochrane Library, Trove, ProQuest, trial registries) were searched from inception to February 2016. Trials that compared active dry needling with a sham that simulated dry needling were included. Two independent reviewers performed screening, data extraction, and critical appraisal. Available blinding effectiveness data were converted to a blinding index, a quantitative measurement of blinding, and meta-regression was used to investigate the influence of the blinding index on pain. Adequacy of blinding procedures was based on critical appraisal, and subgroup meta-analyses were used to investigate the influence of blinding adequacy on pain. Meta-analytical techniques used inverse-variance random-effects models. RESULTS: The search identified 4,894 individual publications with 24 eligible for inclusion in the quantitative syntheses. In 19 trials risk of methodological bias was high or unclear. Five trials were adequately blinded, and blinding was assessed and sufficiently reported to compute the blinding index in 10 trials. There was no evidence of a moderating effect of blinding index on pain. For short-term and long-term pain assessments pooled effects for inadequately blinded trials were statistically significant in favour of active dry needling, whereas there was no evidence of a difference between active and sham groups for adequately blinded trials. DISCUSSION: The small number and size of included trials meant there was insufficient evidence to conclusively determine if a moderating effect of blinding effectiveness or adequacy existed. However, with the caveats of small sample size, generally unclear risk of bias, statistical heterogeneity, potential publication bias, and the limitations of subgroup analyses, the available evidence suggests that inadequate blinding procedures could lead to exaggerated intervention effects in dry needling trials.

Does Physical Activity Increase After Total Hip or Knee Arthroplasty for Osteoarthritis? A Systematic Review.

Study Design Systematic review. Background Despite improvements in self-reported symptoms and perceived functional ability after total hip arthroplasty (THA) and total knee arthroplasty (TKA), it is unclear whether changes in objectively measured physical activity (PA) occur after surgery. Objective To determine if objectively measured PA increases after THA and TKA in adults with osteoarthritis. Methods Five electronic databases were searched from inception to March 3, 2015. All study designs objectively measuring PA before and after THA or TKA were eligible, including randomized controlled trials, cohort studies, and case-control studies. Two reviewers independently screened abstracts and full texts and extracted study demographic, PA, and clinical outcome data. Standardized mean differences (SMDs) and 95% confidence intervals were calculated for accelerometer- and pedometer-derived estimates of PA. Risk of methodological bias was assessed with Critical Appraisal Skills Programme checklists. Results Eight studies with a total of 373 participants (238 TKA, 135 THA) were included. Findings were mixed regarding improvement in objectively measured PA at 6 months after THA (SMDs, -0.20 to 1.80) and TKA (SMDs, -0.36 to 0.63). Larger improvements from 2 studies at 1 year postsurgery were generally observed after THA (SMDs, 0.39 to 0.79) and TKA (SMDs, 0.10 to 0.85). However, at 1 year, PA levels were still considerably lower than those of healthy controls (THA SMDs, -0.25 to -0.77; TKA SMDs, -1.46 to -1.80). Risk-of-bias scores ranged from 3 to 9 out of 11 (27%-82%) for cohort studies, and from 3 to 8 out of 10 (30%-80%) for case-control studies. Conclusion The best available evidence indicates negligible changes in PA at 6 months after THA or TKA, with limited evidence for larger changes at 1 year after surgery. In the 4 studies that reported control-group data, postoperative PA levels were still considerably less than those of healthy controls. Improved perioperative strategies to instill behavioral change are required to narrow the gap between patient-perceived functional improvement and the actual amount of PA undertaken after THA and TKA. Registered with PROSPERO (registration number CRD42014010155). Level of Evidence Therapy, level 2a. J Orthop Sports Phys Ther 2016;46(6):431-442. Epub 26 Apr 2016. doi:10.2519/jospt.2016.6449.

Does the method of component fixation influence clinical outcomes after total knee replacement? A systematic literature review.

A systematic literature review was conducted to identify the best available evidence describing the differences in clinical outcome associated with the different methods of total knee replacement (TKR) fixation. Randomized trials published between 1980 and January 2011 comparing differences in clinical outcome scores between groups allocated to either cemented or uncemented fixation for TKR were included. Nine of the 11 studies included in the review reported no significant differences in clinical outcomes between groups with either cemented or uncemented prosthesis components. Critical appraisal of methodological bias revealed consistent shortcomings in study design and execution. It is apparent that more rigorous studies with longer follow-up periods are required to verify which method of fixation may be preferable in enhancing clinical outcomes.

Snakes and ladders: the barriers and facilitators of elective hip- and knee-replacement surgery in Australian public hospitals.

OBJECTIVES: Waiting lists for elective surgery are a persistent problem faced by health systems. The progression through elective surgery waiting lists can be likened to a game of snakes and ladders where barriers (snakes) delay access to surgery and facilitators (ladders) expedite access. The aim of the present study was to describe the barriers and facilitators to delivery of total hip- and total knee-replacement surgery in South Australian public-funded hospitals. METHODS: Semistructured interviews with staff, direct observation of administrative processes and documentation analysis were combined under a systems theory framework. RESULTS: System barriers (snakes) were grouped into five categories: resources, workload, hospital engagement, community engagement and system processes. Inadequate resources was the most prominent barrier, patient cancellations resulted in one-third of administrative tasks being repeated and there was a perceived lack of engagement to maximising efficiency. Interestingly, despite a lack of resources being perceived to be the biggest problem, additional resources without system change was not considered an effective long-term strategy. CONCLUSIONS: Given the complexity of the elective surgery system, it is not surprising that single-item reforms have not created lasting reductions in waiting times. Multifaceted, whole-system reforms may be more successful. WHAT IS KNOWN ABOUT THE TOPIC? Waiting lists and waiting times for surgery are controversial, associated with frequent reforms and negative emotive headlines. We know from existing literature and anecdotal reports that individuals frequently experience lengthy delays before receiving elective surgery. Anecdotal reports also suggest that there are inefficiencies within elective surgery systems that contribute to these delays and result in cancellations, patient deterioration and poor overall satisfaction with the public health system in Australia. What isn't clear is whether this perception is accurate and what inefficiencies do exist that could be specifically targeted for reform. WHAT DOES THIS PAPER ADD? This paper adds weight to the argument that some inefficiencies exist within elective surgery systems, and identifies specific barriers to the delivery of total hip- and total knee-replacement surgery in South Australian public hospitals. It also identifies several strategies that could improve system function, some of which have already been implemented at a local level in response to stress on the system, and some of which require broad region- or state-wide change. In contrast to existing research, the level of detail provided in the present paper should allow for targeted reforms with the potential to improve system function and the efficiency with which joint-replacement surgery can be delivered. WHAT ARE THE IMPLICATIONS FOR PRACTITIONERS? All clinicians aim to provide the best intervention for their patients. Should the findings of this study be used to inform elective surgery system changes, patients and clinicians should experience a more streamlined approach to referral for and receipt of elective surgery in public hospitals. The consistency with which barriers and facilitators were identified across the four hospitals involved in this research supports the generalisability of the results. This further suggests that although specific to hip and knee replacement, many of the same barriers and facilitators could be in place across numerous surgical and non-surgical disciplines.

All the stereotypes confirmed: differences in how Australian boys and girls use their time.

BACKGROUND: To influence adolescent health, a greater understanding of time use and covariates such as gender is required. PURPOSE: To explore gender-specific time use patterns in Australian adolescents using high-resolution time use data. METHOD: This study analyzed 24-hour recall time use data collected as part of the 2007 Australian National Children's Nutrition and Physical Activity Survey (n = 2,200). Univariate analyses to determine gender differences in time use were conducted. RESULTS: Boys spent more (p < .0001) time participating in screen-based (17.7 % vs. 14.2% daily time) and physical activities (10.7% vs. 9.2%). Girls spent more (p < .0001) time being social (4.7% vs. 3.4% daily time), studying (2.0% vs. 1.7%), and doing household chores (4.7% vs. 3.4%). CONCLUSIONS: There are gender-specific differences in time use behavior among Australian adolescents. The results reinforce existing time use gender-based stereotypes. Implications. The gender-specific time use behaviors offer intervention design possibilities.

Effect of a low-Dye application of Scotchcast Soft Cast on peak and mean plantar pressures in subjects with a navicular drop greater than 10 mm.

BACKGROUND: We investigated whether a low-Dye application of Scotchcast Soft Cast significantly altered plantar pressure distribution during gait in patients with a navicular drop greater than 10 mm. METHODS: An experimental, same-subject, repeated-measures design was used. Thirty-two subjects aged 18 to 35 years were screened with the navicular drop test and were included if a navicular drop greater than 10 mm was established. The Emed-AT-2 platform system was used to measure the plantar pressure distribution under the right foot of each subject using the midgait method of data collection. Each subject performed six barefoot walks and six walks with Soft Cast applied to the right foot. Average peak and mean plantar pressure measurements were recorded for ten discrete areas (masks). The heel and midfoot were each divided into two masks, and the forefoot and toe regions were divided into three masks each. Paired t tests were used to detect differences in peak and mean plantar pressures for each mask. RESULTS: Soft Cast significantly affected peak and mean plantar pressures in seven and nine of the ten masks, respectively. No significant change in peak or mean plantar pressure was found beneath the medial midfoot. CONCLUSION: Plantar pressure may represent dynamic foot and ankle joint motion. With further research, Soft Cast may provide an alternative to current management techniques in controlling foot pronation and reducing symptoms of lower-limb abnormalities.