No previous randomised controlled trials had been undertaken investigating the effect of school seating on back pain in 14 to 16 year olds. This study was designed to test the effect of the use of a high-density foam wedge on normal school seating on the intensity of back pain.
Randomised controlled trial.
Suffolk, a predominantly rural county in eastern England.
One hundred and eighty-five students with back pain were recruited from 12 schools. Randomisation was stratified by school. The control and intervention groups included 92 and 83 students, respectively.
Following a 1-week baseline observation period, each student in the intervention group was given a wedge to use on their school chairs.
The primary outcome measure was pain intensity (numerical rating scale, 0 to 10) recorded in pain diaries over 4 weeks. Random effects models were used to analyse the pain intensity data.
Ninety-seven students (46 control group, 51 intervention group) completed the trial. For the intervention group, pain intensity was reduced significantly over the 3 weeks of wedge use. The average reduction in pain intensity was estimated to be 0.709 points (95% confidence interval 0.341 to 1.077), representing a 58% reduction in back pain for those in the intervention group.
Use of a wedge reduced the intensity of back pain significantly, especially in the evenings. The results suggest that further research into the longer-term effect of seating on pain intensity in adolescents should be considered.
I should like to begin by thanking you for asking me to give this address. The occasion is an auspicious one–all congresses are–and you do me a great honour by asking me to add my observations to the discussions you are to hold in the atmosphere of noble strife which circulates through the halls of professional conferences. Annual meetings of professional bodies or learned societies provide the occasion for the critical discussion of specialized experience and for the broadening of knowledge, as well as the opportunity for reflection on professional objectives and on education as a means of promoting legitimate aspirations. I could contribute little to your store of specialized physiotherapeutic knowledge, so I hope that you will permit me to offer a few discursive remarks on objectives and education in relation to physiotherapy in its current clinical and social setting.
To evaluate the long-term effect of high-dose, high-repetition medical exercise therapy (MET) in patients with patellofemoral pain syndrome (PFPS).
Follow-up study one year after completion of a randomized, controlled trial.
Follow-up testing in the primary healthcare physiotherapy clinics, where intervention was undertaken.
Twenty-eight patients with PFPS completed follow-up testing, fourteen in each group.
The groups received three treatments per week for 12 weeks: high-dose, high-repetition MET for the experimental group, and low-dose, low-repetition exercise therapy for the control group.
Main outcome measures:
Pain measured using a visual analogue scale (VAS: 0-10cm), and function measured using a step-down test (numbers of completed step-downs in 30 seconds) and the modified Functional Index Questionnaire (FIQ: 0 points indicates maximal disability, 16 points no disability).
At baseline there were no differences between groups. After intervention, there were statistically significant (p<0.05) and clinically important differences between groups for all outcome parameters, also when adjusting for gender and duration of symptoms: -1.6 for mean pain [95% confidence interval (CI) -2.4 to -0.8], 6.5 for step-down test (95% CI 3.8 to 9.2), and 3.1 for FIQ (95% CI 1.2 to 5.0). At follow-up the differences between groups were maintained and even increased for mean pain and step-down with significant differences (p<0.05) between groups; -1.8 for mean pain (95% CI: -2.7 to -1.0) and 4.5 for step-down test (95%CI: 2.4 to 6.5). The difference between groups for FIQ at follow-up: 1.1 (95% CI: -1.1 to 3.3).
There appear to be long-term effects of high-dose, high-repetition MET in patients with PFPS with respect to pain and functional outcomes. One year after completed intervention the experimental group has continued to improve, while the control group has relapsed. Registered on http://www.clinicaltrials.gov (identifier: NCT01290705).
A new randomised controlled trial of intervention in low back pain has been described recently. In this trial, a screening and targeted approach was found to be more effective and cost-effective than current best practice. Nested within the intervention arm were three different interventions targeting patients identified as 'low', 'medium' or 'high' risk dependent on the presence of (mainly) psychosocial risk factors. In this paper, the development and content of the STarT Back trial's 'high-risk' intervention is described. It offers a systematic approach, termed 'psychologically informed practice', to the integration of physical and psychological approaches to treatment for the management of people with low back pain by physiotherapists. The term 'disability' is used to refer to self-reported pain-associated functional limitations, and 'psychological' is used to refer to the beliefs/expectations, emotional responses and behavioural responses associated with low back pain.
3D motion analysis represents a method of collecting objective, accurate and repeatable gait data, however the high cost of equipment inhibits its widespread use in routine clinical practice.
To determine the marker tracking accuracy of a new low-cost optical 3D motion analysis system.
Comparative between-system study.
Clinical motion analysis laboratories.
A rigid cluster of four reflective markers was used to compare a low-cost Optitrack 3D motion analysis system against two more expensive systems (Vicon 612 and Vicon MX). Accuracy was measured by comparing the mean vector magnitudes (between each combination of markers) for each system, and reliability was measured through the coefficients of variation (CV). Gaps in the marker trajectories, which are considered undesirable, were also counted.
In terms of accuracy, the largest disagreement between mean vector magnitudes for Optitrack and Vicon MX was 2.2%. The largest disagreement between Vicon 612 and Vicon MX was 2.1%. Regarding reliability, the mean CV was lowest in Vicon MX (0.3%) and similar in the Vicon 612 (2.5%) and Optitrack (2.3%) systems. The number of trajectory gaps for the Vicon MX, Vicon 612 and Optitrack systems were; zero, six and 11 respectively.
The Optitrack system provides a low-cost 3D motion analysis system that can offer marker tracking accuracy and reliability which is comparable with an older and still widely used system (Vicon 612). Further development work is required before Optitrack can be used for full 3D gait analysis by physiotherapists and other health professionals.
A multicentre randomised controlled trial has been commissioned to evaluate cognitive-behavioural (CB) approaches in the management of subacute and chronic low back pain in primary care. This paper describes the development of the CB intervention based on best-available evidence. Several methods were used to design the intervention. Risk factors for the development of chronic low back pain were identified from the literature to provide targets for treatment, essential components of a CB intervention were considered using the CB treatment model, and the optimal delivery method was used to balance clinical effectiveness and cost-effectiveness within primary care.
Rotator cuff tendinopathy is a common source of shoulder pain characterised by persistent and/or recurrent problems for a proportion of sufferers. The aim of this study was to pilot the methods proposed to conduct a substantive study to evaluate the effectiveness of a self-managed loaded exercise programme versus usual physiotherapy treatment for rotator cuff tendinopathy.
A single-centre pragmatic unblinded parallel group pilot randomised controlled trial.
One private physiotherapy clinic, northern England.
Twenty-four participants with rotator cuff tendinopathy.
The intervention was a programme of self-managed loaded exercise. The control group received usual physiotherapy treatment.
Baseline assessment comprised the Shoulder Pain and Disability Index (SPADI) and the Short-Form 36, repeated three months post randomisation.
The recruitment target was met and the majority of participants (98%) were willing to be randomised. 100% retention was attained with all participants completing the SPADI at three months. Exercise adherence rates were excellent (90%). The mean change in SPADI score was -23.7 (95% CI -14.4 to -33.3) points for the self-managed exercise group and -19.0 (95% CI -6.0 to -31.9) points for the usual physiotherapy treatment group. The difference in three month SPADI scores was 0.1 (95% CI -16.6 to 16.9) points in favour of the usual physiotherapy treatment group.
In keeping with previous research which indicates the need for further evaluation of self-managed loaded exercise for rotator cuff tendinopathy, these methods and the preliminary evaluation of outcome offer a foundation and stimulus to conduct a substantive study.
The authors conclude that ultrasonic therapy, properly administered and given to patients whose condition requires such effects as it can produce, is a most valuable adjunct to the treatments available in a physiotherapy department today. Experience has shown that it is justifiable to continue this method of treatment in the 1970s.
To compare the effect of the abdominal draw-in manoeuvre with the abdominal draw-in manoeuvre in combination with ankle dorsiflexion on changes in muscle thickness and associated muscle activity in abdominal muscles.
A preliminary, randomised, controlled study.
Forty healthy adults (18 males, 22 females) were allocated at random to the experimental group [mean age (SD) 24 (1.6) years, n=20] or the control group [mean age (SD) 24 (1.9) years, n=20]. The experimental group performed the abdominal draw-in manoeuvre in combination with ankle dorsiflexion, and the control group performed the abdominal draw-in manoeuvre alone, five times a day.
Ultrasonography and electromyography were used to determine the intervention-related changes in muscle activity and the thickness of abdominal muscles during the abdominal draw-in manoeuvre or the abdominal draw-in manoeuvre in combination with ankle dorsiflexion.
A significant difference was found in the thickness of the transverse abdominal muscle between the groups [mean difference 0.24 cm, 95% confidence interval (CI) 0.08 to 0.40, P=0.005. On electromyography, a significant difference was demonstrated in the amplitude of the transverse abdominal muscle contraction between the two techniques in the experimental group (mean difference 68.76 mV, 95% CI 53.16 to 84.36, P=0.000. The intra-class correlation coefficient (ICC(2,1)) showed excellent test-retest reliability of ultrasound measurement of the abdominal muscles: 0.96 (95% CI 0.85 to 0.99) for the transverse abdominal muscle, 0.87 (95% CI 0.62 to 0.98) for the internal oblique muscle and 0.77 (95% CI 0.44 to 0.96) for the external oblique muscle.
This is the first study to demonstrate the additive effect of ankle dorsiflexion on deep core muscle thickness and activity, thus contributing to existing knowledge about therapeutic exercise for the effective management of low back pain.
Previous Australian studies reported that postoperative pulmonary complications affect 13% of patients undergoing upper abdominal laparotomy. This study measured the incidence of postoperative pulmonary complications, risk factors for the diagnosis of postoperative pulmonary complications and barriers to physiotherapy mobilisation in a cohort of patients undergoing high-risk abdominal surgery.
Prospective, observational cohort study.
Two surgical wards in a tertiary Australian hospital.
Seventy-two patients undergoing high-risk abdominal surgery (participants in a larger trial evaluating a novel model of medical co-management).
Main outcome measures:
Incidence of, and risk factors for, postoperative pulmonary complications, barriers to mobilisation and length of stay.
The incidence of postoperative pulmonary complications was 39%. Incision type and time to mobilise away from the bed were independently associated with a diagnosis of postoperative pulmonary complications. Patients were 3.0 (95% confidence interval 1.2 to 8.0) times more likely to develop a postoperative pulmonary complication for each postoperative day they did not mobilise away from the bed. Fifty-two percent of patients had a barrier to mobilisation away from the bed on the first postoperative day, with the most common barrier being hypotension, although cessation criteria were not defined objectively by physiotherapists. Development of a postoperative pulmonary complication increased median hospital length of stay (16 vs 13 days; P=0.046).
This study demonstrated an association between delayed postoperative mobilisation and postoperative pulmonary complications. Randomised controlled trials are required to test the role of early mobilisation in preventing postoperative pulmonary complications in patients undergoing high-risk upper abdominal surgery.
There are indications that segmental stabilising exercises (SSEs) are effective in the treatment of low back pain. The evaluation of successful training in SSE performance in patients requires a reliable outcome measure. The PRONE test gives an indication of the activity of the transversus abdominis muscle. Performed in prone lying using a pressure biofeedback unit, it has been used as an aid to training and to assess the subject's ability to perform SSEs correctly.
To evaluate inter-observer and test-retest reliability of the PRONE test.
Repeated measures by three observers on 2 days.
Department of Physical Medicine and Rehabilitation, Ludwig-Maximilian University, Munich, Germany.
Forty nurses (39 females and one male), aged between 24 and 62 years, with at least one episode of low back pain.
During the test, movement of the abdominal wall was monitored by measuring a change in pressure during muscle contraction termed 'abdominal hollowing'. Defined observation and palpation criteria were verified by the observers to ensure correct execution of the test.
Participants were tested on two separate days. On the first day, Observer A performed two similar test sets, each with four exercises. On the second test day, Observers B and C conducted one test set each.
This study found an intra-class correlation coefficient (ICC) of 0.47 [95% confidence interval (CI) 0.20 to 0.67] for inter-observer reliability, and an ICC of 0.81 (95% CI 0.67 to 0.90) for test-retest reliability. Kappa values and the limits of agreement were also calculated with similar results.
For this subject group, the PRONE test had relatively low inter-observer reliability but, as may be expected, higher test-retest reliability. It is suggested that by providing visual feedback, the PRONE test may enhance patients' insight into their deep abdominal muscle recruitment and thereby increase their motivation to exercise.
Measurements from pressure biofeedback units (PBUs) can be used to evaluate the activity of the transversus abdominis (TrA) muscle indirectly. These measurements can classify patients or monitor the progress of treatment programmes for people with low back pain.
To systematically review studies on the measurement properties of PBUs for the assessment of TrA activity.
Eligible studies were identified through searches of PUBMED, CINAHL and BIREME (1990 to 2009). In addition, hand searches of journals and citation tracking were performed.
Full-text studies involving any type of clinimetric tests of PBU measurement for the assessment of TrA activity were selected.
Two independent reviewers selected the studies, extracted the data and assessed methodological quality.
Due to the heterogeneity of study designs and statistical analysis, it was not possible to pool the data for a meta-analysis.
Six studies met the inclusion criteria. These studies were typically of low quality and recruited healthy subjects rather than patients with low back pain. The studies found moderate to good reproducibility (intra-class correlation coefficients from 0.47 to 0.82) and acceptable construct validity (intra-class correlation coefficients from 0.48 to 0.90).
The current evidence about the measurement properties of PBUs for the assessment of TrA activity is mainly based on studies with suboptimal designs, and the findings from these studies are likely to be overly optimistic. The most important clinical questions about the measurement properties of PBUs for the assessment of TrA activity are yet to be answered.
To analyse the accuracy and reproducibility of photogrammetry in detecting thoracic abnormalities in infants born prematurely.
The Premature Clinic at the Federal University of São Paolo.
Fifty-eight infants born prematurely in their first year of life.
Measurement of the manubrium/acromion/trapezius angle (degrees) and the deepest thoracic retraction (cm). Digitised photographs were analysed by two blinded physiotherapists using a computer program (SAPO; http://SAPO.incubadora.fapesp.br) to detect shoulder elevation and thoracic retraction. Physical examinations performed independently by two physiotherapists were used to assess the accuracy of the new tool.
Thoracic alterations were detected in 39 (67%) and in 40 (69%) infants by Physiotherapists 1 and 2, respectively (kappa coefficient=0.80). Using a receiver operating characteristic curve, measurement of the manubrium/acromion/trapezius angle and the deepest thoracic retraction indicated accuracy of 0.79 and 0.91, respectively. For measurement of the manubrium/acromion/trapezius angle, the Bland and Altman limits of agreement were -6.22 to 7.22° [mean difference (d)=0.5] for repeated measures by one physiotherapist, and -5.29 to 5.79° (d=0.75) between two physiotherapists. For thoracic retraction, the intra-rater limits of agreement were -0.14 to 0.18cm (d=0.02) and the inter-rater limits of agreement were -0.20 to -0.17cm (d=0.02).
SAPO provided an accurate and reliable tool for the detection of thoracic abnormalities in preterm infants.
"Geography would be incomprehensible without maps. They've reduced a tremendous muddle of facts into something you can read at a glance. Now I suspect [passive movement] is fundamentally no more difficult than geography. Except that it's about things in motion. If only somebody would invent a dynamic map." C. P. Snow(2.)
Abscess formation following pneumococcal pneumonia is a rare occurrence nowadays with the widespread use of early, effective antibiotic treatment. Necrosis of lung tissue is thought to be caused by vascular thrombosis related to the reduction in bronchial arterial blood flow during the acute stage. Surgical intervention is sometimes indicated if the abscess persists. Fortuitously, in this case, the communication between the abscess and bronchi enabled complete drainage to be achieved with subsequent resolution.