Physical Therapy Reviews

Published by Maney Publishing
Print ISSN: 1083-3196
Publications
Musculoskeletal injuries account for the largest proportion of workplace injuries. In an attempt to predict, and subsequently manage, the risk of sprains and strains in the workplace, employers are turning to pre-employment screening. Functional capacity evaluations (FCEs) are increasing in popularity as a tool for pre-employment screening despite limited published evidence for their validity in healthy working populations. This narrative review will present an overview of the state of the evidence for pre-employment functional testing, propose a framework for decision-making to determine the suitability of assessment tools, and discuss the role and potential ethical challenges for physiotherapists conducting pre-employment functional testing. Much of the evidence surrounding the validity of functional testing is in the context of the injured worker and prediction of return to work. In healthy populations, FCE components, such as aerobic fitness and manual handling activities, have demonstrated predictability of workplace injury in a small number of studies. This predictability improves when workers' performance is compared with the job demands. This job-specific approach is also required to meet anti-discrimination requirements. There are a number of practical limitations to functional testing, although these are not limited to the pre-employment domain. Physiotherapists need to have a clear understanding of the legal requirements and potential ethical challenges that they may face when conducting pre-employment functional assessments (PEFAs). Further research is needed into the efficacy of pre-employment testing for workplace injury prevention. Physiotherapists and PEFAs are just one part of a holistic approach to workplace injury prevention.
 
BACKGROUND: Because physical activity (PA) provides multiple medical and psychosocial benefits after a cancer diagnosis, greater integration of objective activity monitoring into research and clinical practice is warranted. OBJECTIVES: To review randomized PA trials in cancer survivors after diagnosis using an accelerometer or pedometer and make recommendations for integrating objective monitoring into research and practice. MAJOR FINDINGS: Ten published PA and post-cancer diagnosis randomized trials have used pedometers (n=3), accelerometers (n=3), or both (n=4). Pedometers were primarily used to motivate PA adherence with several studies also using unblinded pedometers to assess the intervention effect on PA adherence. Accelerometers were primarily used to assess PA adherence after a PA intervention with one study using accelerometers to assess PA increase as a benefit of a non-PA intervention. One study used accelerometers to document sufficient ground forces for improving bone density in cancer survivors. Across studies, the reported objective monitoring outcome varied and was not always consistent with the stated intervention goal. CONCLUSIONS: PA and post-cancer diagnosis randomized trials have used objective monitoring primarily for motivation and/or adherence assessment. Investigators and practitioners are encouraged to expand the use of objective monitoring to also include understanding mechanisms of PA benefits and assess non-PA treatment modality effects. Future clinical and research protocols should consider the 1) outcome to be measured and reported, 2) need (or not) for blinding of the instrument outputs to participants, 3) appropriateness of activity intensity cutpoints for interpreting accelerometer data, and 4) logistical issues relevant to cancer survivors after diagnosis.
 
Process flow chart for the participatory risk management model.  
Municipal home care workers provide high-quality services to an increasing proportion of elderly people living in private homes. The work environments and working conditions of these workers vary to a great extent, implying rapid priority-making among both employers and employees to ensure that the work can be performed in a safe way. This study aims to examine home care workers' perceptions of health, risks, working conditions, and risk management within their organization. The study was based on cross-sectional data collected from home care service staff in a municipality in the north of Sweden. Nursing assistants and care aides (n = 133) replied to a self-administered questionnaire. Descriptive statistics and between-group differences were analysed. Home care work was perceived to require high levels of professional skill and ingenuity, a good psychosocial work situation, but required a high physical workload. The general health, the capacity and self-efficacy of the staff in relation to work were good. Difficulty in performing risk assessments and following safety regulations due to lack of time, equipment, and information were identified. There is a need to increase participation in risk assessments among the staff, improve management support, structures, and cooperation with other divisions of the social services and the medical care organizations.
 
Flow-chart displaying selection of studies.
The aim of this article is to review systematically and appraise critically the literature surrounding the research, comparing inertial sensors with any kind of gold standard; this gold standard has to be a tool for measuring human movement (e.g. electrogoniometry, optoelectronic systems, electromagnetic systems, etc.). A MEDLINE, EMBASE, CINAHL, PEDRo and SCOPUS search of published English language articles was conducted, which focused on articles that compared inertial sensors to any kind of gold standard (e.g. electrogoniometry, optoelectronic systems, electromagnetic systems, etc.), from 2000 to 2010. Two independent reviewers completed the study selection, quality appraisal and data extraction. The Critical Appraisal Skills Programme Español tool was used to assess study quality, and a reliability comparison between the systems was made. Fourteen out of 242 articles were reviewed, which displayed a similar threat to validity, relating to sample selection and operator blinding. Other study limitations are discussed. A comparison between the different systems showed good agreement across a range of tasks and anatomical regions. This review concludes that inertial sensors can offer an accurate and reliable method to study human motion, but the degree of accuracy and reliability is site and task specific.
 
Evidence-based practice is critical to our professional survival in times of reduced and competing healthcare funding. The purpose of this review paper is to describe physiotherapy research activities in the universities and in clinical practice in Canada, and to elaborate upon the evidence-based practice initiatives facilitated by the Canadian Physiotherapy Association (CPA). First the undergraduate curriculum recommendations to encourage reflective practitioners are described, an overview of graduate education and academic research programmes is presented, and the status of clinical research is discussed. Finally, the role of CPA and its initiatives to facilitate and support evidence-based physiotherapy practice are summarized. Two of the significant challenges for continued development of physiotherapy research in Canada are to firmly establish evidence-based practice and to foster a highly regarded physiotherapy scientific commmuity.
 
Objective: The purpose of this narrative review is to assess current physical therapy ethics knowledge by synthesizing literature published since 2000. Method: This review builds on an earlier analysis.6 A rigorous search of major databases (including Medline, CINAHL, and PubMed) was conducted using specific keywords and explicit inclusion and exclusion criteria. The final review included 27 peer-reviewed articles and three editorials/lectures. Results: Four themes of papers were identified that focused on (1) development of physical therapy ethics knowledge, (2) ethical issues related to conducting research, (3) how ethical issues are identified and managed and how ethical practice is taught, and (4) development of theoretical ethical decision-making models. Discussion: The literature reflects a steady growth in interest in physical therapy ethics. Some 'gaps' in knowledge have been addressed but others have not, such as the impact of the institutional environment and cultural dimensions of practice on ethical reasoning. Research studies, using mostly qualitative approaches, identify similar issues but a synthesis of the findings is made difficult by lack of consistency in purpose and study design. While inclusion of ethics content in physical therapy curricula is recommended, little is known about how this is currently being achieved. Ethical theories are poorly integrated into the discussion of ethics in practice. Conclusion: This review reveals the continuing need to ensure the development of physical therapy ethical knowledge by consistently incorporating both ethical theories and practice knowledge in education curricula and establishing a rigorous research agenda that accurately reflects the unique and multidimensional nature of clinical practice.
 
Summary of research into the technique of manual hyperinflation presented chronologically 
Physiotherapy is reported to be an integral part of patient management in the intensive care unit (ICU) of hospitals in industrialised countries. There is substantial literature which supports the role of respiratory management and rehabilitation of critically ill patients, although there is a paucity of randomised controlled trials in this area and trials examining patient outcomes. The aims of this review are to present the current evidence for the role of physiotherapists in the adult ICU. The efficacy of 'chest physiotherapy' on short-term patient physiological outcomes has been studied extensively and there is moderate-to-strong evidence in support of its role. The safety of physiotherapy treatment in ICU has also recently been established. In addition, there is growing evidence for the role of exercise rehabilitation beginning in ICU and extending to beyond ICU discharge. Urgent research is required by physiotherapists to establish the effectiveness of such treatments.
 
This systematic review was undertaken to assess the effectiveness of 904nm low level laser therapy (LT) in musculoskeletal disorders. In order to retrieve randomized trials, computer-aided searches of databases and of bibliographic indexes were performed. Furthermore, congress reports, reviews and handbooks were all checked for relevant citations. Subsequently, all retrieved studies were scored on methodological quality. This review found 25 studies that investigated the effects of 904nm LT versus placebo or any other intervention, in subjects with a condition for which LT was thought a feasible intervention. Of these, 21 fulfilled the entry criteria for this review, and were assessed in a blinded manner on methodological criteria. Overall, study quality ranged from ‘poor’ to ‘reasonable’. In a classification of the material into diseases studied, no clear evidence was found for the effectiveness of LT, except perhaps for knee problems and myofascial pain. It is concluded that 904nm LTdoes not seem to be effective in the treatment of musculoskeletal disorders, but that further and improved research is needed to shed more light on its effectiveness.
 
Chest physiotherapy has undergone considerable changes during the last two decades. The purpose of this paper was to review studies on the effects of chest physiotherapy in open and laparoscopic abdominal surgery. Forty-four papers were reviewed, comparing different chest physiotherapeutic interventions in open abdominal surgery; 15 of these trials had an untreated control group. The results were difficult to interpret, as the study designs were not comparable with different treatment criteria for post-operative pulmonary complications, surgery performed and categories of patients. However, the results showed the beneficial effects of breathing exercises in preventing post-operative pulmonary complications, especially in high-risk patients. It was found that laparoscopic procedures impair post-operative respiratory function considerably less than open surgery. One trial published on the effects of physiotherapy in laparoscopic surgery found that routine treatment is not necessary after upper gastro-intestinal procedures such as fundoplication and vertical banded gastroplasty.
 
Background: Pedometers and accelerometers are often used in clinical research studies, and have the potential to provide valid and objective information on physical activity. Objectives: The purposes of this review are to introduce clinicians to various activity monitors that are commercially available, and to discuss their strengths and limitations. Scientific articles over the past 20 years were reviewed, and the most common types of physical activity monitors were identified. Emphasis was placed on devices with established validity and reliability, which were acceptable to participants and did not interfere with their activities. Ease-of-use from the investigator's standpoint was also considered. Major findings: A number of activity monitors were identified, including four pedometers (Yamax SW digiwalker, New Lifestyles NL-2000, Omron HJ-720 ITC, and StepWatch), three accelerometer-based activity monitors (ActiGraph, Actical, and RT3), and a multisensor device (Sensewear Armband). Validity and reliability of these devices is discussed. Conclusions: Pedometers and accelerometers are useful for tracking ambulatory physical activity in clinical populations, and those that display steps and/or calories are useful in motivating patients to increase their activity levels.
 
Slips and falls are major causes of accidents and injuries at work, in public areas and at home. Studies have shown that the more risk factors an individual is exposed to, the higher risk for slips and falls. The aim of this paper is to describe risk factors for slips and falls, methods that can be used in prevention, and ideas on how physiotherapists can work with prevention of slip and fall accidents. A review of the literature has been done, searching for relevant literature published in English between 1985 and 2000, from the Medline catalogue. The result showed many different risk factors for slip and fall accidents: (a) transfer situations; (b) reduced postural control, i.e. disturbed balance together with reduced muscle strength in the lower extremity; (c) reduced mobility in the hips and feet; (d) dizziness and vestibular asymmetries; and (e) medication. The following diseases may increase the risk for slip and fall accidents: stroke, cardiovascular diseases, musculoskeletal disorders, depression, Parkinson's disease, diabetes and dementia. Preventive interventions have been described but more are needed. A standardized fall anamnesis has been described including patients' earlier fall accidents and relevant risk factors present. Walking ability, balance, medicine consumption can be registered. Preventive programmes concerning risk factors for slips and falls, physical activities for daily use, and preventive aids have been developed and can be recommended for use by patients visiting primary health care and occupational health care. Studies have shown that physical training can increase the number of activities in daily life, reduce the use of technical aids, increase balance and walking ability, which all reduce the risk for slip and fall accidents.
 
The movement towards accreditation and quality audits in higher education seems to have been generated by the political mood towards public accountability of the professions. There is a complex interplay between accreditation, authoritative demands of governments and professions, as well as integration of quality and access issues. Standards may provide a benchmark for training providers, industry and training bodies, educators, state and federal authorities. They may also be applied in considering individuals for registration, certification, and other forms of recognition of skills, for setting curricula and in assessment of various kinds. Thus, they may be linked to accreditation and quality audits. Although accreditation and quality audits serve multiple customers, they should be responsive to the expressed interests of the real consumers, not interests that are interpreted by accreditors and auditors. This paper reviews accreditation and quality audits and explores their relevance to the health professions, particularly to the practice of physical therapy.
 
Background: The basic premise of cryotherapy is to cool injured tissue; however, there is much confusion around how much cooling is adequate, and how this can be achieved clinically. Objectives: Our objective was to review recent literature to determine the rate and magnitude of tissue temperature reduction with cryotherapy. Values were compared with current recommended threshold temperatures deemed necessary for optimal cold induced analgesia (skin temperature
 
Children with brain injuries typically present with walking and balance difficulties, and successful rehabilitation depends on the therapist's ability to measure and understand the different components of gait accurately. Professional guidelines stress the need for adequate outcome measurement. Despite this, there is no standardised assessment of walking balance in children for use in clinical assessment. Measurement tools range from observational to three-dimensional gait analysis. Observational analysis lacks reliability and accuracy whilst clinical gait analysis is time-consuming and costly, requires complex nterpretation and is not routinely available to clinicians. Portable sensors and pressure sensitive devices have recently emerged as alternatives. In situations where it is preferable to avoid attachments to the child, the measurement of the forces or pressures generated by the body to control its movement and balance offers a practical solution. This review will discuss the advantages and limitations of these tools.
 
This review is based upon two papers delivered at the third post-basic education conference of the Standing Liaison Committee of Physiotherapists in the European Union held in Estoril, Portugal in April 1998. It considers trends and the desirability of specialization in physiotherapy practice, opportunities for individual practitioners to gain recognition as specialists, and the Scope for achieving greater harmonization of specialist practice and recognition across the EU. The special interest groups, the profession's developing understanding of what constitutes specialist practice, and an increasing commitment to lifelong learning, are key to achieving these ends.While acknowledging that a range of factors potentially work against a common approach to specialization and specialist recognition in the EU, the paper suggests that an outcomes-based framework could offer a promising route to articulating and recognizing specialist practice in a way that promotes harmonization while respecting national difference.
 
Interferential therapy is a therapeutic modality that has been used for the past several decades, with little empirical evidence to support its continued use within the clinical setting. The purpose of this review paper is to discuss the current clinical application of interferential therapy with reference to its analgesic potential and possible mechanism(s) of action. There is not a large base of literature for interferential therapy (especially compared with transcutaneous electrical nerve stimulation; a modality with similar methods of application), thus it is not possible to provide a systematic review owing to inconsistencies in reported clinical protocols.
 
Flow chart of literature search for foot orthoses and lower limb muscle activation
Summary of papers reviewed
Summary of papers investigating semi-rigid foot orthoses
Summary of papers investigating rigid foot orthoses
Summary of papers investigating therapeutic footwear
Foot orthoses can be a valuable component of musculoskeletal rehabilitation, improving lower limb alignment, controlling motion and providing shock absorbency. Recent evidence suggests foot orthoses may also have a significant effect on lower limb muscle activation in young, healthy adults. This review examines the evidence for changes in muscle activation patterns when wearing orthoses, and explores the proposed mechanisms by which foot orthoses may bring about changes in lower limb muscle activity. Based on the current results it is proposed that different mechanisms may occur by which orthoses affect muscle activity, due to their differing construction and design.
 
Specific categories along with the illustrative diagnoses, numbers in each group, mean age, gender and functional scores represented by the Rivermead Mobility Index (RMI) for each category 
Equations used to calculate co-activation co-efficient 
Co-activation of agonist and antagonist muscles in healthy people is considered a normal strategy that aids movement efficiency during the performance of functional activities. In some cases, however, it is an abnormal strategy that aids stability and/or precision but not efficiency of movement. Co-activation varies not only between agonist and antagonist pairs, but within a pair from time to time, and depending on a range of factors. Muscle co-activation strategies are used when uncertainty in relation to execution of a specific task occurs, during the learning of a new skill or as compensation. Movement dysfunction in neurological conditions may coincide with abnormal levels of co-activation. It is unclear at what level co-activation assists or impedes functional ability, and to what extent reduced agonist excitation and antagonist co-activation combine to cause significant weakness. A major limitation in understanding the mechanisms of co-activation in neurologically impaired individuals is the wide range of methods that are used to determine levels of antagonist activation and hence co-activation levels. The muscle action, joint position, contraction type and testing conditions may influence the antagonist EMG recorded. This review investigates the methods routinely used to quantify co-activation, and relevant findings, particularly with respect to neurologically impaired individuals. Inconsistencies in methods used limit comparison between studies, but it is clear that whilst co-activation may occur alongside clinical features in neurological conditions, it is often viewed as a task-related strategy used to cope with the complexity of a task. This review highlights whether the use of co-activation strategies should be considered useful contributions to successful rehabilitation.
 
Physiotherapy is an important management option in hip osteoarthritis. Its effectiveness can be evaluated with the use of valid and reliable outcome measures in research and clinical practice. Numerous outcome measures for use in hip osteoarthritis are available and the ICF classification can be used to guide decision making to ensure that all aspects of human functioning are represented. The activity and participation components of ICF are a vital part of assessment, but are traditionally under-utilised in physiotherapy. A number of questionnaire-based outcomes that measure activity and participation can be used in clinical or research practice with hip osteoarthritis patients such as The Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), Lequense Index of Severity, Harris Hip Score (HHS), Arthritis Impact Measurement Scale (AIMS), Short Form-36 (SF-36) and European Quality of Life scale (Euroqol). These are discussed with particular reference to their psychometric properties of reliability, validity and responsiveness. To date, the WOMAC has undergone the most psychometric testing of the disease-specific measures, whilst the SF-36 is the most widely tested generic measure. Both of these measures are recommended for use in hip osteoarthritis. Further psychometric testing is required of the other measures which will enable clinicians and researchers to decide which is the most appropriate measure for use in hip osteoarthritis.
 
Aims: This paper discusses the evidence for the analgesic efficacy of Acu-TENS, the application of transcutaneous electrical nerve stimulation to acupuncture points, and its possible mechanisms of action. Method: A brief review of recent clinical studies of Acu-TENS in isolation, in combination with other treatment and in comparison with electro-acupuncture, and laboratory studies using pain models is followed by a wider discussion of the evidence. This discussion is structured around questions relating to whether the site of TENS application influences analgesic response; the influence of parameters of Acu-TENS; whether Acu-TENS and acupuncture induce analgesia via similar mechanisms; and possible placebo effects. Results: While Acu-TENS does appear to induce analgesia, evidence for the use of particular TENS parameters and specific stimulation points is limited. The analgesic effects of Acu-TENS appear to be modulated at multiple levels within the central nervous system including recognised physiological, neuropharmacological and placebo mechanisms. Conclusion: Much future research is needed but it should be coordinated through collaboration between researchers and practitioners if the essential evidence base is to be systematically built. In addition to establishing the most effective Acu-TENS parameters and points of application, influences including psychological and cultural factors and beliefs, which may be pivotal to response, merit investigation.
 
The use of acupuncture by chartered physiotherapists has expanded in recent years. It is now readily available in many private and National Health Service (NHS) physiotherapy departments. In spite of acupuncture's increasing popularity, few physiotherapy or medical undergraduate syllabuses in the UK include acupuncture. This paper reviews the attitudes and knowledge of undergraduate physiotherapy and medical students towards acupuncture. Findings from studies on students' attitudes, their knowledge of acupuncture and its evidence base and correlations between knowledge and attitudes are discussed. Whilst students' attitudes towards acupuncture were generally very positive, students have been found to have very little actual knowledge of acupuncture. The willingness of future practitioners to accept (with very little prior knowledge) this treatment approach, raises a number of pertinent issues for the profession.
 
Physical therapists from many countries are including acupuncture in their treatment programmes. With their knowledge of anatomy and manual skills, physiotherapists are particularly suited to use acupuncture. This paper gives an international overview on the use of acupuncture by physiotherapists and traces its development in the UK. While the scientific basis for acupuncture is gradually being demonstrated, much further research is needed. The design of acupuncture trials is difficult. This is illustrated in the recent paper on acupuncture pain relief by Jackson in this journal (Jackson, Phys Ther Rev 1997; 2: 13–18) and the response to this by Barlas (Phys Ther Rev 1997; 2: 239–40). Many physiotherapists, as well as using acupuncture for pain relief, are also using acupuncture for other effects such as relief of stress or reduction of bronchospasm in asthma. Some examples of the cost benefits of acupuncture as part of treatment programmes are given. The paper provides an overview of the status and some of the potential benefits of acupuncture in physiotherapy.
 
The aim of this systematic review was to assess the efficacy of biofeedback, acupuncture and transcutaneous electric nerve stimulation in the management of temporomandibular disorders. Articles evaluating the efficacy of biofeedback, acupuncture and transcutaneous electric nerve stimulation in temporomandibular disorders were obtained from the databases Medline, Cinahl, Embase, PsycINFO and Cochrane Controlled Trials register up to May 2002. Seven controlled clinical trials met the criteria for inclusion. The patients included in the studies ranged from 19–100. Three studies assessed the efficacy of biofeedback, three studies assessed the efficacy of acupuncture and one study assessed the efficacy of transcutaneous electric nerve stimulation. A criteria list was used to assess the internal validity of these studies. The studies were considered to be of high quality if at least five of the ten criteria were fulfilled and otherwise were considered to be low quality. The results of the studies were considered positive, negative or indifferent based on the statistical significance of between-group differences. None of the seven studies were of high quality. An analysis of the degree of evidence of the results revealed no evidence for the efficacy of biofeedback, acupuncture or transcutaneous electric nerve stimulation in the management of temporomandibular disorders.
 
The use of acupuncture treatment as a technique for pain relief in the clinical situation has increased dramatically over the past few years. It has attracted much attention in this area of practice because of its putative effectiveness and practical convenience of use. This paper attempts to briefly review the efficacy of acupuncture as a clinical tool by examining available evidence to ascertain whether these claims are justified. Evidence relating to the physical, histological and biophysical properties of acupuncture points is considered with what is known about the effects of stimulating these sites. Findings from studies on the biochemical, pharmacological and physiological effects of acupuncture are overviewed. While there is some evidence to support the use of acupuncture as a pain relieving treatment modality, additional well structured randomized controlled trials need to be conducted together with high quality systematic reviews of the existing literature before this modality can be fully accepted as an effective therapeutic modality.
 
The aim of this systematic review was two-fold: to assess the efficacy of acupuncture in the management of tension-type headache, and to compare three criteria lists assessing the quality of studies. Searches to selected criteria lists were carried out with no time limit using the database for the Cochrane Central Register of Controlled Trials. Articles of controlled clinical trials evaluating the efficacy of acupuncture in the management of tension-type headache were obtained by searching through the databases MEDLINE, CINAHL, EMBASE, AMED and Cochrane Central Register of Controlled Trials up to February 2003. Six articles met the criteria for inclusion and three criteria lists were used to assess the internal validity of these studies. The studies were considered to be of high quality or low quality in accordance with the criteria lists utilised. The results of the trials were considered positive, negative or indifferent based on statistically significant between group differences. The three criteria lists utilised yielded the same results and indicate that two of six studies were of high quality. Results indicated limited evidence for the efficacy of acupuncture in the management of tension-type headache. This systematic review shows that qualitative assessments by three criteria lists focusing on internal validity, gave the same results, and that there is limited evidence for the efficacy of acupuncture in the management of tension-type headache.
 
Background: Pneumothorax is a very rare but serious complication associated with acupuncture and dry needling around the thoracic region. Physiotherapists and other health practitioners should be aware of the risks associated with needling in this region and should take care to minimize the possibility of an iatrogenic pneumothorax. Findings: An awareness of the signs and symptoms of a pneumothorax is necessary for practitioners using acupuncture and dry needling in the thoracic region. Understanding the normal anatomy and its variants can minimize risk associated with needling practices in this region. Various technique modifications are suggested so that the pleura or lungs are avoided while using acupuncture or dry needling in the thoracic region. Discussion/Conclusion: Acupuncture and dry needling in this region administered by well-trained physiotherapists and other health practitioners is very safe; however, to maximize safety therapists should consider the relevant anatomy and not practise using advanced acupuncture and dry needling techniques without adequate competency-based training.
 
Conventional transcutaneous electrical nerve stimulation (TENS) is a simple, non-invasive analgesic technique which is delivered using high frequency (10–250 Hz) currents to produce a ‘strong but comfortable’ paraesthesia within the site of pain. Acupuncture-like TENS (AL-TENS) is a variant of conventional TENS and is defined in this article as the induction of forceful but non-painful phasic muscle contractions using low frequency (1–10 Hz) electrical currents. The purpose of this paper is to discuss the analgesic effects and clinical effectiveness of AL-TENS. There is insufficient evidence to support or refute claims that there are differences in the analgesic profiles of conventional TENS and AL-TENS. Despite a large literature on TENS, it is not possible to perform an objective review of the clinical effectiveness of AL-TENS due to inconsistency in the method of application and insufficient detail on TENS treatment interventions in written reports. The use of banner terms, such as AL-TENS, to describe electrotherapeutic treatment modalities is seriously questioned.
 
The acute effects of exercise in water may differ from those on land because of the physical properties of the water. The increased hydrostatic pressure causes a hypervolaemia, which influences the haemodynamic effects of exercise in water. Water resistance and temperature affect the metabolic pathways utilized during exercise. As a result the use of land-based norms to prescribe and monitor water exercise may be unreliable. This review focuses on upright exercise in water, namely cycle ergometry and walking/running.Oxygen consumption (VO2) and heart rate are influenced by the depth and temperature of the water, exercise mode and speed. For example, cycle ergometry on land and in water yield similar maximal oxygen uptake (VO2max) responses. However, shallow water running elicits a VO2max which is approximately 10% lower than similar land activity. Deep water running yields a 26% lower VO2max than on land.Cycle ergometry and walking/running in water have been shown to provide cardiovascular benefits in line with the American College of Sports Medicine guidelines. However a complex interaction exists between the water, exercise and subject variables which will affect the exercise response. Future research should focus on the biomechanical and neuromuscular effects of exercise in water at various depths.
 
Opportunities for physiotherapists are greater than ever, both clinically and professionally, due to an increasing wealth of clinical arenas, which need to be developed and modernised, and span the whole spectrum of patient care from acute services to community-based care. There are also vital non-clinical roles, many in addition to full-time posts, to be undertaken. This article will use the national changes in the health-care system in the UK to exemplify some professional and clinical opportunities currently available to physiotherapists in respiratory care, including the role of the consultant physiotherapist.
 
The aim of the current systematic review was to investigate the effect of positioning on the severity of sleep apnea syndrome (SAS), in order to identify which subjects will show this effect and to establish the efficacy of positioning as a treatment. Databases searched were: Premedline and Medline, Psychinfo, Embase, CINAHL, PEDro, all EMB Reviews and the Scottish Intercollegiate Guidelines Network plus hand searching. All study types, except case studies, were included and the methodological quality was evaluated using a tool designed by Downes and Black. Twenty papers were included. Taken together they suggested that less obese SAS patients have fewer apneic attacks when sleeping on their side and very obese patients when sleeping sitting up. Treatments that avoid supine lying reduce the incidence of apneic attacks, and positioning may be useful in avoiding hypoxaemia in stroke. Generally the papers were of poor quality, thus highlighting the need for further studies.
 
Sport injury prevention is becoming an essential element in providing physiotherapy services to an active population, both at the recreational and elite levels of sport. Prior to developing prevention strategies for injury it is important to establish modifiable risk factors for injury. Acute muscle strain injury is one of the most common injuries seen in sport, however, there is relatively little known about prevention of this injury. These injuries often recur and can become chronic. The cause of acute muscle strain injury in sport has been attributed to: improper warm-up, poor flexibility, overuse, muscle weakness, muscle imbalance, and fatigue by many authors. Most of the evidence to support these potential causal factors, however, appears to be based on animal studies and anecdotal evidence. The purpose of this systematic review of the literature is to determine if decreased muscle strength is a cause of acute muscle strain injury in sport. This review is based on observational epidemiological evidence in which the exposure measure is an objective measurement of muscle strength or an intervention including a specific strengthening programme, the outcome measure is an acute muscle strain injury and an attempt has been made to create a comparison group. There were no clinical trials published addressing this issue. Most studies reported some association between decreased muscle strength and acute hamstring strain injury in sport. Most studies had limitations regarding internal validity. All studies had limitations precluding applicability to a wider athlete population. Despite an apparent association between decreased muscle strength and specific hamstring strain injury in elite male athletes in sport, the evidence for decreased muscle strength as a risk factor for or cause of muscle strain injury in sport is inconclusive. Further research is required to confirm this relationship.
 
The perception of pain is regarded as a phenomenon involving sensory, affective and cognitive components. Paper 1 in this series (of 2) reviewed the augmentation of nociceptive sensation in the central nervous system (CNS), concluding that a model of pain is required that unifies these components through the emerging concepts of neuroplasticity and system dynamics.This paper reviews the connectivity of the CNS, and builds upon part 1 to identify ways in which ‘experience’ modifies and ‘weights’ those connections, promoting emergent patterns of activities in neuronal networks. Pain experience is presented as a feature of a complex adaptive system, with pain states seen as state attractors in a self-organizing system. The implications for physiotherapists in understanding and treating the complex and paradoxical nature of pain are explored.
 
Objectives: To determine the effectiveness of continuous passive motion (CPM) following total knee arthroplasty when compared to a rehabilitation protocol that permits early knee mobilisation, and to determine if an optimal CPM dosage schedule exists. Methods: An electronic database search was conducted to find relevant investigations. Strict inclusion and exclusion criteria were applied. Outcomes were summarised using a rating system consisting of four levels of scientific evidence. Data were divided into short-term effects (seven days or less after surgery), and long-term effects (greater than seven days after surgery). Results: Eight investigations met inclusion criteria for this review. There was strong evidence that CPM exerts no influence on short and long-term knee extension, long-term knee flexion, long-term function, pain, complications, and length of hospital stay when compared to a rehabilitation protocol that permits early knee mobilisation. Data for short-term knee flexion, quadriceps strength, and short-term function were conflicting. Preliminary evidence suggests that CPM applied immediately postoperatively, at a high flexion arc of motion, and for a significant amount of time each day leads to better outcomes with regards to short-term knee flexion. Conclusions: With rehabilitation protocols now permitting early knee mobilisation, the use of CPM as an adjunct should be questioned as the current body of research generally does not support its use. However, before writing off CPM as unnecessary, further clinical trials utilising more aggressive CPM parameters need to be conducted as this may provide better outcomes.
 
Adolescent idiopathic scoliosis is a disorder which can exhibit considerable variation in both clinical presentation and rate of progression. Most severe scoliotic curves require surgical stabilization, however there is a group of patients with less severe presentations for whom conservative treatments are often considered as a first line of management. The most commonly utilized conservative therapies are bracing, electrical muscle stimulation and various forms of exercise. These treatments are time consuming and carry with them the potential for physical and psychological side effects. It is imperative therefore that such treatments, if they are to be utilized, should show a clear beneficial effect in limiting the progression and adverse effects of scoliosis. This paper reviews the available data from clinical trials investigating various forms of conservative therapy and discusses the outcomes of these trials in relation to the natural history of scoliosis. The author concludes that the benefits of conservative treatment are at best marginal and that there is little clear data to support the use of one treatment above any others. Published research in this area is fraught with methodological inadequacies which make it difficult to support or indeed, to categorically refute the value of any particular treatment for specific patient groups. Proposals relevant to improving the quality of future studies have therefore been included in the paper. While the present paper does not provide support for the use of conservative treatment modalities in the management of adolescent idiopathic scoliosis it is hoped that researchers will continue to address this topic and that new treatment approaches may be developed.
 
The commonest bedside tool for assessing spasticity is the Ashworth Scale. Recently, particularly in the paediatric literature, the Tardieu Scale has gained favour because it can quantify spasticity. Also, preliminary findings suggest that it is more reliable than the modified Ashworth Scale. Fundamental to the clinical examination of spasticity and hypertonia is a clear understanding of the terminology and the mechanical and neurophysiological changes that accompany upper motor neuron lesions. With these objectives in mind, the literature was reviewed in order to examine the clinical relevance of the Ashworth and Tardieu Scales.
 
Cardiorespiratory physiotherapy is no longer synonymous with airway clearance; however, in broadening skills and expertise, especially into rehabilitation, the pendulum has swung too far, and airway clearance is not always used when indicated. Clinical practice is influenced by clinical guidelines which are based on systematic reviews, and in the absence of systematic reviews, on single randomised controlled trials and even single quasi-experimental trials. Systematic reviews invariably conclude that there is little evidence to support a particular technique, which is no surprise as many early cardiorespiratory physiotherapy studies did not use the randomised controlled trial method. This paper looks at the evidence which is available for airway clearance, and emphasises the need for more randomised controlled trials in this field.
 
Older adults with dementia are at greater risk for falls and for significant injury than cognitively intact older adults. The cause of falls in older adults is multifactorial, and there appears to be additional contributing factors to falls in older adults with cognitive dysfunction. This paper presents a review of the literature on falls in older adults with cognitive dysfunction. The purpose of this paper is to identify changes in the postural control mechanisms of older adults with cognitive dysfunction that may contribute to the increased risk of falls noted with this population. By developing a better understanding of the particular physical, physiological and perceptual changes that occur in older adults with dementia, healthcare providers may be better able to address the special needs of this population, thus hopefully minimising injury and mortality that may occur as a result of falling.
 
Functional status, the degree to which an older person is able to perform socially allocated roles free of limitations and disability, is an important issue in gerontology. Functional status measures are increasingly being used to assess clinical progress, evaluate programs, and establish appropriate eligibility criteria for government and insurance programs. This review discusses and evaluates commonly used self-report and performance-orientated functional status measures employed in older populations. A description of the disablement pathway is provided, followed by a discussion of the components of functional measures. Finally, subjective and objective functional status measures used in clinical and research settings with older adults are discussed and evaluated.
 
Background: Recommendations on minimum exercise levels for the elderly have to date been based largely on extrapolation of epidemiological findings in middle-aged adults. Questionnaire assessments of physical activity in the latter age group have been correlated with health outcomes observed over 10 or more years. The reliability and construct validity of questionnaires have sometimes been reasonably high, but information on the volume of physical activity has been exaggerated as much as three- to five-fold, with corresponding uncertainties in health inferences. Objectives: To assess the contribution of inexpensive pedometer/accelerometers to objective determinations of physical activity needs in the elderly. Major findings: Pedometer/accelerometers work well in the elderly, whose main deliberate activity is walking. The steps taken on a treadmill or a walking course can be determined with considerable accuracy, but more tests are needed under free-living conditions. In elderly people, the relationship between step counts and health outcomes is progressive; even a small increase in daily activity yields some health benefit. For many outcomes, advantage is seen with a nominal count of 8000 steps/day, probably reflecting 4000 paces of deliberate walking, and the spending of at least 20 minutes per day at an exercise intensity >3 METs. This corresponds to a weekly energy expenditure of 1–2 MJ, substantially less than inferred from some questionnaire analyses. Conclusions: Cross-sectional analyses show that healthier old people reach a nominal count of 8000 steps/day, exercising >20 minutes per day at an intensity >3 METs. Longitudinal studies are needed to test the causality of these relationships.
 
Asthma is a chronic disease which already affects a large proportion of the population in the world, and whose prevalence is increasing. Asthmatics suffer from recurrent airway narrowing, giving rise to symptoms such as breathlessness, tightness of the chest, wheezing, and coughing. They often lack adequate knowledge about asthma in relation to exercise, and perceive their disease as a limiting factor to physical activity. Medical treatment is a cornerstone in asthma management, but needs to be supported by other tools if self-management is to be the goal. One such tool is physical exercise, another is education. Persons with mild to moderate asthma are able to exercise at a maximal intensity level without deleterious effects on their asthma. After a rehabilitation period, including physical training and theoretical and practical education, improvements in health status and fitness were observed as well as reductions in emergency department visits, and alleviation of exercise-induced asthma and asthma symptoms. The deleterious effects on daily life decrease when the patients learn how to manage the disease. Both increased knowledge and improvements in practical skills contribute to this improvement.
 
Manual hyperinflation is a technique that is commonly used by physiotherapists to provide a greater than baseline tidal volume to the lungs of mechanically ventilated patients. The use of this technique is based more on clinical experience than on scientific evidence as the physiological effects of manual hyperinflation are uncertain. This review uses evidence-based principles to investigate the effects of manual hyperinflation using rebreathing bags on lung compliance, oxygenation and haemodynamic variables in intubated adults. The lack of good quality randomised controlled trials makes it difficult to draw firm conclusions and so the strategic implications and recommendations for further research are discussed. There is also consideration of how best to traverse the 'grey zones' of clinical practice where evidence is inadequate or contradictory.
 
Medical advances are resulting in increasing longevity of persons with mental retardation. The greater numbers of mentally retarded individuals surviving into old age has resulted in the need for better understanding regarding their specific medical needs, and improved information about the aging processes in this group. It is still widely believed that there is a tendency for older adults with mental retardation to demonstrate premature signs of aging, characterized by physical changes in body composition, functional decline, and increased morbidity. Knowledge of specific age-related health risk factors associated with mental retardation can lead to enhanced prevention, early diagnosis of potentially damaging conditions, and appropriate treatment. Routine screening of physical characteristics and functional capabilities in elderly mentally retarded populations is important, in order to assess their specific medical status, and develop appropriate rehabilitative and psychotherapeutic programs.
 
Flow diagram of process for inclusion / exclusion for systematic review 
Flow diagram of process for inclusion/exclusion of outcome measures 
Background: The primary aim of this review was to identify existing instruments that have been used to assess the mobility status of community-dwelling older adults. The secondary aims were to identify instruments that have face validity for measuring across the full mobility spectrum and to summarise and compare their clinimetric properties. Methods: MEDLINE, CINAHL, PEDro, and EMBASE were searched until April 2007. The first stage included searching for papers that reported mobility outcome measures that had been applied to healthy community-dwelling older adults. The second stage identified these outcome measures and the third stage compared clinimetric properties of the instruments that had face validity for measuring across the full mobility spectrum (from bed-bound to high levels of independent mobility). Two independent reviewers extracted data from the included studies. Results: From the 128 included papers, 14 outcome measures were identified, two of which, the Lower Extremity Functional Scale (LEFS) and the Elderly Mobility Scale (EMS), measured across the full spectrum of mobility. No clinimetric evidence was found for the LEFS amongst a community-dwelling older population and only evidence of known groups validity was identified for the EMS. Discussion: An outcome measure that has face validity for measuring across the full mobility spectrum and has sufficient clinimetric evidence in a community dwelling population was not identified. Conclusion: This review supports the need for the development of such an instrument.
 
Purpose: This paper provides a descriptive review of research in the area of motor functioning in older adults with mild cognitive impairment (MCI) and early Alzheimer's disease (AD). The specific aims of this paper are to examine: (1) the correlation between clinical measures of motor function and cognitive change in older adults; (2) clinical measures of motor function as predictors of conversion to cognitive impairment in healthy older adults and progression of cognitive impairment in people with MCI; (3) clinical measures of motor function as predictors of rate of decline in cognitive function in healthy older adults, people with MCI, and those with early AD. An additional objective is to discuss the relevance of this information to the practice of physical therapy. Methods: A literature search was conducted using Psych Info, CINAHL, Medline and Pubmed databases. Mild cognitive impairment (MCI), AD and cog* were each combined with gait, balance, fine motor, gross motor and extrapyramidal signs. Studies were included if they met the inclusion and exclusion criteria for the current review. Results: Review of the literature revealed that various domains of physical function such as gait, balance, fine and gross motor skills, and extrapyramidal signs change in tandem with or as a predecessor to declines in cognitive impairment. Furthermore, measures in several of these domains have been found to be predictive of future cognitive and functional decline in nondemented adults as well as those with MCI. Conclusions: Identification of specific motor impairments may differentiate between cognitively unimpaired older adults and those with MCI or AD. These impairments may also predict future cognitive decline and increase diagnostic sensitivity when included in cognitive assessment batteries, thus providing increased opportunities for early intervention.
 
Approximately 30% of elderly community dwellers fall each year. A large number of exercise-based interventions have been designed to reduce fall incidence, the movement therapy of Tai Chi being used increasingly. The aim of this systematic review was to examine the current literature surrounding the effectiveness of Tai Chi in reducing the incidence of and fear of falling in older people. A computerised literature search of Medline, AMED, CINAHL, the Cochrane Central Register of Controlled Trials, PubMed, PEDro and Scirus was performed. Only randomised controlled trials, with a study population aged over 60 years, investigating Tai Chi as an intervention to reduce incidence of falls and/or fear of falling were included. The methodological quality of the included trials was rated using the Delphi List. Owing to clinical heterogeneity, the data were qualitatively analysed using a 'best-evidence synthesis'. Seven randomised controlled trials involving a total of 1146 people met the inclusion criteria. The duration, frequency and intensity of the Tai Chi interventions showed great variation. The trials included were of high methodological quality. There is strong evidence to support the effectiveness of Tai Chi in reducing fear of falling, and weak evidence supporting its effectiveness in reducing the incidence of falls in older adults. Future research should focus on targeting defined clinical subpopulations with high-quality, well-designed randomised controlled trials of sufficient size and with long-term follow-up, to provide further evidence supporting the use of Tai Chi to reduce the incidence and fear of falling in older people.
 
Objectives: To review current and explore future applications of neuromuscular electrical stimulation (NMES) to restore or retrain upper limb (UL) recovery after stroke. Methods: Short summaries of NMES applications that have been investigated and a discussion of future research directions are presented. Results: Neuromuscular electrical stimulation applications that have been developed and investigated to restore or retrain UL recovery after stroke include: cyclic NMES; triggered NMES which includes electromyogram-triggered NMES (EMG-NMES), positional feedback NMES, contralateral-triggered NMES, outcome-triggered NMES and accelerometer-triggered NMES; iterative learning control mediated NMES; and neuroprostheses such as the Bioness H200. Overall, published studies of these applications indicate that NMES can improve UL function after stroke, with improvements at the impairment level more common than improvements at the activity level. While EMG-NMES has been researched most widely and has the highest level of evidence to support its use, newer applications (e.g. outcome-triggered NMES, accelerometer-triggered NMES) appear promising, on the basis that key requirements for motor learning are employed. Discussion: There are several areas for further research of NMES to achieve greater functional gains at the activity level than are currently achieved post-stroke. These include the use of NMES to retrain multijoint movements; and exploration of single- versus multichannel stimulation, cortical changes that occur after NMES, and NMES with other technologies. Use of NMES to restore or retrain UL function after stroke has come a long way and presents exciting challenges for research and clinicians in the future.
 
Lack of compliance with treatment represents a significant problem for physiotherapists in the treatment of chronic low back pain. A literature review was therefore performed in this area, with particular attention given to compliance with physiotherapy exercise and advice, given the generally positive evidence to support the effectiveness of these treatment modalities in the treatment of chronic low back pain. A variety of literature was reviewed in relation to the direct and indirect influences on compliance, including examination of the influence of exercise counselling, pain, patient attitudes and beliefs, self-efficacy, locus of control, stage of change and psychosocial issues. It was clear from this review that patient compliance with physiotherapy cannot simply be assumed. Very little literature was found on compliance with physiotherapy exercise and advice in the treatment of chronic low back pain, and further research is recommended in order to establish compliance within this patient group, and how best this can be improved.
 
Objective: Osteoarthritis (OA) affects a large proportion of the population. Aerobic exercise has long been a rehabilitation intervention for treating patients with OA in efforts to decrease pain and improve functional status. The purpose of this meta-analysis was to examine the efficacy of aerobic exercise among individuals with OA. Methods: A systematic review was conducted following a protocol of methods recommended by the Cochrane Collaboration. Eligible trials were identified by a literature search of Medline, Embase, and the Cochrane Controlled Trials Register. Twelve trials were included with 1363 patients undergoing various forms and combinations of aerobic physical activities including walking programmes, aquatic exercises, jogging in water, yoga and T'ai Chi. Results: The overall results of this analysis indicate that various forms of aerobic exercise, such as a walking programme, jogging in water, yoga and T'ai Chi can have statistically significant effects on pain, joint tenderness, functional status, and respiratory capacity for patients with OA. Conclusions: The most efficacious exercise regimen has yet to be determined but aerobic exercise in general is more beneficial for the OA patient than no exercise at all, and is superior or equivalent to strengthening exercises. The research indicates long-term effects need to be explored further, and combined behavioural strategies need to be studied to facilitate the sustainability of the beneficial effect of aerobic exercises.
 
This paper deals with the phenomenon of lateral epicondylalgia or tennis elbow. This is a relatively common disorder with a well defined clinical presentation. It has been used extensively as a clinical model in studies evaluating the nature of musculoskeletal pain and dysfunction, and the factors contributing to the development of such dysfunction. It might be anticipated that this body of research would have provided a sound understanding of the epidemiology, pathophysiology, aetiology and natural history of this disorder. This paper presents a critical review of the available research which suggests that many questions remain unaddressed or unanswered. Widespread preconceptions such as the widely accepted belief in the role of inflammation in the pathogenesis of lateral epicondylalgia may need to be reappraised. Existing research is critiqued and directions for future research including improvements in research methodology are proposed.
 
Top-cited authors
Joshua Cleland
  • Tufts University
Jonathan Mark Williams
  • Bournemouth University
David J Magee
  • University of Alberta
Susan Armijo-Olivo
  • University of Alberta
Antonio Cuesta-Vargas
  • University of Malaga