Physiotherapy Practice and Research - Volume 40, issue 2
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Physiotherapy Practice and Research is the Official Journal of
The Irish Society of Chartered Physiotherapists. It is an international, peer-reviewed journal which aims to advance physiotherapy practice and research through scholarly publication. The journal has a clinical focus and publishes material that will improve the evidence base for physiotherapy and assist physiotherapists in the management of their patients. Contemporary physiotherapy practice incorporates a diverse range of activity and the journal aims to support physiotherapists, and publish material, fromall areas of practice, be that the clinical setting, education, research or management.
Physiotherapy Practice and Research welcomes submissions in the form of original research papers, critical reviews (systematic or state-of-the-art papers), case studies, editorials, expert commentaries and book reviews. Letters to the editor are also welcome. The journal will commission focussed or clinical reviews in areas of interest; those planning such reviews should contact the editor in the first instance. Physiotherapy Practice and Research also aims to foster research capacity within the Profession and as such supports and encourages submission from new researchers.
Physiotherapy Practice and Research is a member of and subscribes to the principles of COPE, the Committee on Publication Ethics.
Abstract: BACKGROUND: Disorders associated with the rotator cuff are regarded as the most common shoulder pain presentation. The range of diagnostic terms used to explain this problem reflect uncertainty in relation to causative mechanisms, diagnosis, prognosis, and the most effective treatments. The aim of this consensus exercise was to facilitate a shared understanding as a means of reducing mixed messages, informing clinical practice and providing a foundation for future research. METHODS: Nine physiotherapists with clinical and academic expertise in shoulder pain participated in an online and face-to-face consensus exercise. RESULTS: This consensus exercise suggests specific factors in…the history and physical examination that might raise the index of suspicion of Rotator Cuff Related Shoulder Pain. The suggestions for non-surgical management include a minimal number of exercises prescribed to challenge the functional deficit of the patient over a minimum 12-week period. Apart from aiding exclusion of red flag pathology, imaging is not regarded as useful unless the patient does not respond as expected. Steroid injections wouldn’t be considered a first-line intervention unless pain was severe and preventing engagement with exercise. CONCLUSION: This consensus exercise provides a benchmark for clinical reflection while highlighting areas of uncertainty that still exist and require further research.
Abstract: BACKGROUND: Median nerve neurodynamic testing is described in the literature with the scapula blocked and depressed and there are numerous descriptions of structural differentiation performed during testing. A better understanding of how these variables impact median nerve neurodynamic testing is warranted. PURPOSE: To compare the Upper Limb Tension Test A (ULTT A) with the scapula blocked and depressed to determine: the reliability of ULTT A with the scapula blocked and depressed; if there is a statistically significant difference between the left and right arms; and if there is a statistically significant difference for ULTT A with the scapula…blocked or depressed. METHODS: This was a intertester and test-retest reliability and accuracy study. Elbow extension was measured with a standard goniometer. Sensory responses were captured with the Numeric Pain Rating Scale (NPRS). Subjects were randomly tested by Rater, side, and by test condition. RESULTS: The NPRS and end range elbow extension had moderate to good intertester reliability. There were poor to moderate findings for reliability of structural differentiation. There was no statistically significant difference (p > 0.05) between the left and right arms except for structural differentiation. There was a statistically significant difference between the scapula blocked vs scapula depressed test conditions except for the NPRS on the left arm (p = 0.08). CONCLUSIONS: ULTT A under the depressed scapula test condition is less reliable and more variable than the blocked scapula condition in the normal healthy population. Structural differentiation may not be a reliable or valid aspect of ULTT A.
Keywords: Median nerve, radiculopathy, reproducibility of results, diagnostic
tests, upper extremity
Abstract: BACKGROUND AND PURPOSE: Shoulder injury is common in cricketers, with disorders of the upper-limb accounting for up to one fifth of the total number of injuries in modern-day cricket. Pain and cross-season loss of range of motion of the dominant side have been demonstrated in over-head throwing athletes, but only limited data exists concerning cricketers. We aimed to inform injury prevention and management strategies by determining whether elite cricketers demonstrated altered shoulder range or strength, and whether this related to pain presentation, across a competitive period. METHODS: Eighteen male professional county cricket players (mean±SD) aged 24.0±4.3 years, 1.8±0.1m…height, and 83.6±7.7kg body mass underwent shoulder range-of-movement (ROM), strength, and pain assessment using the Kerlan-Jobe Orthopaedic Clinic (KJOC) Shoulder and Elbow score on two separate occasions at least 12 weeks apart (13.2±1.0), over the course of a competitive season. RESULTS: One third of all players tested reported playing with shoulder pain at some stage during season. Both dominant (20°±11.8°) and non-dominant (14°±14.7°) throwing arm Total Arc ROM increased between testing intervals (p ≤0.01), with significant concomitant increases in player external rotation (ER) ROM of both dominant (11.6°±8.4°) and non-dominant (8.8°±6.4°) throwing arms (p ≤0.01). The dominant shoulders of prospectively injured players demonstrated a reduction in ROM (mean Total Arc ROM difference of -17.3°±6.2° vs -0.6°±11.8°), and lower dominant ER:IR strength ratios mean ER 0.71±0.13 vs IR 0.93±0.21) at baseline testing compared to non-injured players. ER strength decreased in both arms (p ≤0.01), while ER:IR DOM strength ratios were significantly lower than at pre-season (mean loss of 16–18±21N/0.2±0.25 ER MVIC NBW per side, p ≤0.05). CONCLUSION: Professional county cricket players exhibit increases in shoulder ROM and decreases in dominant throwing arm strength ratios across a competitive Cricket season. Pre-season differences in dominant vs non-dominant shoulder ROM and dominant throwing arm shoulder strength ratios appear to be associated with prospective onset of in-season shoulder trouble in the professional cricketers studied.
Abstract: In Ireland, stroke is the leading cause of disability with 5000–6000 new stroke survivors each year requiring rehabilitation. While clinical rehabilitation programmes have been proven effective in motor re-learning, barriers exist in the sustainability of regular and repetitive behavioural activities. A common barrier to effective rehabilitation is patient motivation with repetitive training in itself often described by patients as boring and time consuming. Virtual reality is the use of “interactive simulations created with computer hardware and software to present users with opportunities to engage in environments that appear and feel similar to real world objects and events”. With recent advancements…in digital technology; gaming and virtual reality are attracting much attention as innovative solutions to the resourcing and motivational challenges facing conventional clinical stroke therapy. In this commentary, we highlight the potential of immersive and non-immersive virtual reality in the rehabilitation after stroke. The value of virtual reality may not lie in replacing conventional therapy but in providing an alternative method of therapy that increases rehabilitation activity time and motivates users into repetitive practice. Such a therapy would be even more advantageous in the sub-acute and chronic phases of recovery when patients have limited access to further rehabilitation.
Abstract: BACKGROUND: New and innovative approaches are needed to overcome the barriers to engaging people in physical and leisure activity after stroke. Outdoor cycling, including the use of adapted or electric bicycles, may be one approach. However, perceptions of stroke survivors on this topic have not yet been explored. PURPOSE: To explore a sample of stroke survivors’ perspectives, who expressed an interest in cycling, about cycling and the use of electric bicycles. METHODS: A convenience sample of stroke survivors were identified through focus groups at a ‘Cycling after Stroke’ event, local stroke support groups, and structured interviews…at a national conference for stroke survivors. Quantitative data were analysed descriptively, and qualitative data analysed thematically. RESULTS: Data were collected from 21 stroke survivors, seven of whom were current cyclists. All participants were independently mobile with, or without, the use of a walking aid. Themes oriented around the value of cycling (e.g. getting out of the house, doing something for yourself, and feeling part of a community); concerns and challenges (safety and negotiating adaptations); and how they could be overcome (starting slowly and identifying sources of assistance). CONCLUSION: Outdoor cycling may be a worthwhile approach to increasing physical and leisure activity after stroke. However, barriers still exist and need to be addressed to provide inclusive opportunities for adapted and electric cycling for stroke survivors. Due to the small sample size and bias population, further research is needed to explore stroke survivors’ perspectives on cycling to provide solutions to overcome the barriers identified.
Abstract: BACKGROUND: Many pregnant women develop pelvic pain during their pregnancy. Pregnancy can modify pelvic geometry while causing micro-mobility, leading to some instability, which will manifest itself through pain and an increase of tiredness when walking. Pelvic belts could restore stability and help reduce pain, thus facilitating motor activities such as walking. However, there are no guidelines on the use of pelvic belts. PURPOSE: The objective of this study was to compare the effects of two types of belts and several belt positions on gait parameters in pregnant women. METHODS: Forty-six pregnant women with pelvic girdle pain…and 23 non-pregnant women were recruited. The motor task consisted in several gait trials at three different speeds, with and without pelvic belt. Temporal and spatial parameters were analysed. Two pelvic belts (narrow and flexible or broad and rigid) and several positions (high or low) were used. An analysis of variance for repeated measures (ANOVA) assessed the effects of group (pregnant/not pregnant), gait speed and belt. RESULTS: Gait parameters did not show any significant difference according to belt type or position. For pregnant women, gait velocity was reduced. Gait cycle phases were modified by an increase of stance phase and double support. Gait pattern displayed alterations during pregnancy. These changes favour a more stable and safe gait. Conclusion: There was no difference between belt positions (high and low) or between belt types (narrow and flexible or broad and rigid) on gait parameters. This suggests that all belt types and positions could be advised to pregnant women.
Keywords: Pregnant women, gait, pelvic girdle pain, pelvic belt
Abstract: BACKGROUND: Pregnancy is the main risk factor for the development of Stress Urinary Incontinence (SUI) which is known to have detrimental effects on quality of life in approximately 54.3% of women. The recommended treatment for SUI is to increase pelvic floor muscle strength, however, it is not clear why long-term adherence to pelvic floor muscle exercise (PFME) is poor. OBJECTIVES: To understand multiparous women’s experience of incontinence and the prescription of pelvic floor muscle exercise (PFME) in the ante and post-natal period on their first pregnancy, and the differences, if any, that they experienced on subsequent pregnancies.…METHODS: Purposive sampling was used to recruit women who had two or more children. The 1 : 1 semi-structured interviews were recorded, transcribed verbatim and anonymised. Thematic analysis was undertaken by both researchers, independently, and the codes and themes were agreed by consensus. RESULTS: Women were not aware that PFME could prevent incontinence, and the education provided was not sufficient to enable adherence to a PFME program. PFME were prescribed by health professionals, but there was a lack of detail, and the importance of PFME was not emphasised on first or subsequent pregnancies. On subsequent pregnancies, women were more aware of PFME and incontinence, however, this education came from informal sources, not the health care professionals providing the ante or post-natal care. CONCLUSIONS: Health care professionals should include more information, and better guidance regarding PFMEs. Most of the information about PFMEs came from informal sources, especially on the second and subsequent pregnancies.
Abstract: BACKGROUND: Thoracic spine pain and dysfunction (TSPD) has received less attention in the literature compared to the lumbar and cervical spine, which has created challenges for differential diagnosis in the region. AIMS: The study purpose was to describe the clinical activity and outcomes of TSPD patients attending a clinical specialist physiotherapist (CSP)-led orthopaedic and rheumatology triage service, known as the ‘Musculoskeletal Assessment Clinic’ (MAC). METHODS: The Clinical Audit department of St Vincent’s University Hospital, Dublin, approved this study. A retrospective service evaluation was carried out of patients who attended the MAC with TSPD between August 2012…and October 2015. Data were analysed using descriptive statistics with SPSS version 20. RESULTS: Of the n = 5,143 new patients referred to the MAC over a period of 37 months, 88 of these (2%) (mean age 36.66, years sd = 16.61), were referred primarily for TSPD. Sixty nine percent (n = 61) of patients were categorized as non-specific thoracic spine pain (NSTSP) and 18% (n = 16) structural. Seventy-six investigations were requested for 59% (n = 52) of patients and plain radiograph was the most frequently requested (40.8%, n = 31). Eighty percent (n = 70) of patients were independently managed by CSPs, with 16% (n = 14) of patients being referred for a surgical or medical consultant opinion. CONCLUSION: The majority (80%) of the patients were independently managed by the CSPs. Presentations of TSPD to a physiotherapy-led triage service in a secondary care setting attributable to underlying serious pathologies appears to be rare. Replication of this study in other healthcare institutions would be useful for corroborating our findings.
Keywords: Thoracic spine pain, physiotherapy triage, service evaluation, physiotherapy
Abstract: PURPOSE: Advanced Practice Physiotherapy (APP) in paediatric orthopaedics is an effective adjunct to traditional consultant-led clinics, improving patient access to outpatient services, and reducing both waiting lists and times. However there has been no published economic evaluation of a paediatric orthopaedic APP service. This study performs a cost analysis, utilising a cost minimisation approach, comparing an APP Clinic in Paediatric Orthopaedics with usual care, from a health care perspective. METHODS: Data on all patients managed by the APP clinic for one calendar year were collected and outcomes and associated costs were calculated, including follow-up care. These costs were…compared to the estimated costs of the usual care pathway, an Orthopaedic Consultant Elective Clinic (OCEC) and incremental savings per patient was calculated. RESULTS: A total of 534 patients attended the APP clinic for initial assessment during the calendar year 2017. The unit cost of a new appintment with the APP clinic is € 32.46 in comparison with € 56.98 for a new appointment in the OCEC. Our results demonstrate an incremental per patient saving of € 24.51 in favour of the APP clinic. Sensitivity analysis demonstrates that the cost savings obtained hold consistent in all cases, varying from € 23.13 to € 29.67 per patient in favour of the APP clinic pathway. This represents a cost saving of 43% for the APP Pathway over that of usual care. CONCLUSION(S): This is the first study to perform an economic analysis of the APP role in paediatric orthopaedics and demonstrates that an APP clinic for non-complex paediatric orthopaedic patients is substantially less costly than usual care.
Keywords: Advanced practice physiotherapy, cost minimisation, economic evaluation, paediatric orthopaedics
Abstract: BACKGROUND: Despite some progress in recent years, leadership in healthcare is still dominated by men. While women make up the majority of the health care workforce, the gender percentages of leadership positions remain skewed towards men and many health organisations neglect the issue of gender equality in their leadership. PURPOSE: To explore female healthcare students’ perceptions and experiences of leadership in healthcare. METHOD: A focus group was conducted with a purposive sample of 7 students from a range of health sciences courses (physiotherapy, occupational therapy, pharmacy and dentistry). The focus group data were analysed using inductive…thematic analysis. RESULTS: Four major themes were found in the analysis of the focus group data: leader attributes, gender differences, leadership barriers and leadership facilitators. The participants identified three main categories of barriers to women attaining leadership positions in the health system: intrinsic, societal and structural. Modelling, family experiences, leadership training and gender quotas were discussed as potential facilitators of female leadership. CONCLUSIONS: The participants in this study demonstrated awareness of potential issues and challenges that can face female healthcare professionals as they pursue leadership positions. However, to date, the participants had completed very little formal leadership training. Leadership development programmes that incorporate gender diversity issues should be introduced during entry-to-practice degree courses to address issues of implicit bias and try to increase the proportion of women in leadership positions in the healthcare sector.
Keywords: Healthcare leadership, female leadership, gender equality, healthcare students