Physiotherapy Practice and Research

Background: The therapeutic effect of neuromuscular electrical stimulation (NMES) on muscle strengthening and hypertrophy depends on its dose. Patients must tolerate high doses of NMES to maximize gains in muscle function. It is unknown why some patients are able to achieve high NMES dose while others are not. Disability and psychological attributes may play a role in a patient's tolerance of NMES dose. Purpose: To explore if disability and psychological attributes associate with the ability to achieve high doses of NMES in patients with rheumatoid arthritis (RA). Methods: Cross-sectional study. Forty subjects with RA participated in 2 sessions of NMES intervention to the quadriceps muscles. The highest NMES dose achieved by each subject was recorded. Dose was defined as the torque produced by the NMES as a percentage of the torque produced during a maximum voluntary isometric contraction. Subjects were then grouped in high or low NMES dose. Variables investigated in this study included disability, pain coping strategies, pain acceptance, sense of mastery or control, anxiety, and depression. Correlations were sought between these factors and NMES dose. Main results: In unadjusted models, disability, coping self-statements, catastrophizing, and anxiety were predictors of NMES dose. In adjusted models only disability (OR = 0.17 [95% CI: 0.04, 0.77]) and catastrophizing (OR = 0.85 [95% CI: 0.72, 0.99]) predicted NMES dose. Conclusion: Patients with RA with lower disability and lower catastrophising achieve higher doses of NMES. Identifying factors associated with achieving high NMES dose may guide strategies to improve effectiveness of this intervention.

Background and purpose: The Stroke Impact Scale 16 (SIS-16) total score (TotSIS-16) as a self report of physical function has previously been associated with falls, but the relationship of individual SIS-16 items to fall history has not been examined. The purpose of this study was to examine the accuracy of individual SIS-16 items compared with TotSIS-16 in identifying falls history in people with chronic stroke. Methods: Forty-three people were categorized according to prior 6 month fall history as having either No falls (NF; n = 23) versus any fall (AF; one or more fall; n = 20). Group comparisons (AF versus NF) were made for individual SIS-16 item scores and the TotSIS-16 to identify items significantly related to fall history. Significant items were further analyzed for sensitivity (Sn) and specificity (Sp) of specific cutoff scores for identifying individuals with fall history. Results: TotSIS-16 and items related to balance, mobility and urinary continence had high Sp (0.70-0.96) useful for ruling in a history of falls while only the item 'Balance while Walking' had Sn (0.89) useful for ruling out falls. Discussion and conclusions: Individual SIS-16 items may be useful for ruling falls in (high Sp) or out (high Sn), depending on the clinical need. One or two items used together may be more accurate than the TotSIS-16 score. Study of a larger sample is needed to confirm these results.

OBJECTIVE: The satisfaction and acceptance of telehealth by the Irish physiotherapy service user is currently unclear. This study aims to evaluate the Irish service users’ experience of physiotherapy delivered totally or partially via telehealth, using a cross-sectional self-reported anonymous postal survey. METHODS: Service users (n = 250) of the Cavan Monaghan physiotherapy department, Health Service Executive (HSE), Republic of Ireland were surveyed. Data was collected on demographics, experience with technology, experience and satisfaction with physiotherapy delivered via telehealth. Qualitative thematic analysis of the free-text responses was completed. RESULTS: A response rate of 40% was achieved. Participants attended physiotherapy for an average of 2.65 months. Upper limb complaints comprised 29% of participants, 27% had a back complaint, 21% had a lower limb complaint and 14% attended for a women’s health issue. Those who received their physiotherapy consultation over the phone comprised 78%, while 15% received it virtually and 85% were highly or somewhat satisfied with the telehealth physiotherapy they received. However, 49% prefer blended care (combination of telehealth and face-to-face), 41% prefer face-to-face consultations only and 10% are satisfied with telehealth solely. The recipients of virtual calls were all satisfied. In the future, 60% of these participants would prefer blended care, 20% would prefer face-to-face care only and 20% would be satisfied with telehealth solely. CONCLUSION: The physiotherapy telehealth services were well received. There was a greater acceptance of future telehealth usage by video call recipients compared to those who received a phone call only. Engagement with appropriate service users and their needs will be required to ensure the longevity and success of telehealth.

PURPOSE: The aim of our study is to evaluate effects of early rehabilitation treatment in hospitalized patients with severe COVID-19, in order to improve patients’ autonomy and quality of life. METHODS: This observational study has been performed in hospitalized patients with severe COVID-19. All patients were evaluated at T0 using specific scales: Modified Barthel Index (MBI) for autonomy in ADL, Mini Mental State Examination (MMSE) for cognitive status, Borg scale for dyspnoea, EQ5D scale for quality of life. In absence of contraindications for the rehabilitation treatment, patients start early a rehabilitation protocol consisting of one session (30 minutes) per day, for 2 to 3 weeks; these scales have been repeated at patient’s demission (T1). RESULTS: 70 patients (37 women and 33 men, with average age of 71 years) with severe COVID-19 were included in the study. After rehabilitation treatment, MBI increases statistically significantly from T0 to T1 (39.8±35.0 with 95% CI 31.6–48, vs 69.8±38.1 with 95% CI 60.8–78.7, p < 0.001); besides MBI at T0 correlates inversely and statistically significantly with all EQ-5D variables at T0, similarly at T1 (p < 0.001), indicating the improvement of autonomy and therefore of the quality of life. The MMSE correlates statistically significantly with MBI at T0 and T1 (r = 0.569, r = 0.747 respectively, p < 0.001), indicating that an adequate cognitive status is connected with a greater increase in autonomy in ADL after rehabilitation treatment. MBI correlates directly and significantly with the PaO2/FiO2 value both at T0 and T1 (r = 0.263 with p = 0.039, r = 0.389 with p = 0.023 respectively), indicating that improving the oxygen exchanges also improves the patient’s autonomy. CONCLUSIONS: An early rehabilitation treatment should promote autonomy and a better quality of life in patients with COVID-19.

On April 25, 2015, a 7.8 magnitude earthquake occurred in Nepal; then on the afternoon of May 12, 2015, the small Himalayan nation experienced a second 7.3 magnitude earthquake. As of the writing of this commentary, the estimate of casualties has surpassed 8,500 making it the deadliest natural disaster in Nepal over the past 80 years. Technological advancesin emergency medicine and emergency preparedness have increased the likelihood of surviving a disaster. The result, however, is that populations often survive with complex disabilities that the health infrastructure struggles to accommodate in the early post-disaster period. Nepal had a relatively poor infrastructure for people with disabilities before the earthquake, and the health system will now will be challenged to meet their needs into the future. In this commentary, we argue that there were at least three main lessons learned for the rehabilitation sector following the 2015 earthquake. First, rehabilitation can facilitate earlier discharge from hospitals thereby improving the overall institutional capacity to treat a higher number of patients; second, rehabilitation can prevent secondary musculoskeletal, integumentary and pulmonary complications; and third, rehabilitation improves function so that individuals can have better access to other essential post-disaster services. While rehabilitation may not directly save 'lives' following a natural disaster such as an earthquake, it does save 'life' among the survivors. In our opinion, and given what we have learned regarding the role of rehabilitation in Nepal and other disasters, we argue that it is unethical and immoral not to integrate rehabilitation into disaster response.

BACKGROUND: Shoulder pain is a common musculoskeletal complaint and disorders of the rotator cuff (RC) are widely regarded as the most common cause. Where clinical care is required, physiotherapists play an integral role. Previous studies have reported physiotherapy practice across other countries as a means of determining current practice and understanding whether practice changes over time in response to emerging research evidence. AIM: To investigate the practice of Italian physiotherapists, in order to determine current practice for the assessment and management of RC disorders. METHODS: A cross sectional online survey. A 20-item questionnaire based on one clinical vignette was developed using Survey Monkey Software. Data were analyzed descriptively and difference in proportions between those with no specific education compared to those with a specific education (i.e. 'Master's Degree,' '1-2 days Training Course' or 'Other) were analysed using the chi-squared test. RESULTS: A total of 805 participants accessed the survey with a total of 436 completed responses (54%). Fifty-five percent of respondents were male (239/436). Seventy-one percent of respondents (309/436) reported having specific education with regards to RC disorders. The methods of diagnosing RC disorders were variable across the respondents as well as the requests for imaging (184/436, 42%), the adoption of manual therapy techniques (251/436, 58%), the duration of treatment (231/436, 53% visit the patient six times at least) and the administration of physical examination tests (175/436, 40%). Advice (279/436, 64%) and some form of exercise therapy (268/436, 62%) were the most popular choices of treatment. DISCUSSION AND CONCLUSION: This current study is the first to describe Italian physiotherapy practice for RC disorders. Italian physiotherapy practice is in line with other European countries. Italian physiotherapy practice also aligns with current recommendations with regards to minimal use of imaging and prescription of therapeutic exercise. However, there is heterogeneity across the responses particularly with regards the use of manual therapy, physical examination tests, and duration of treatment. Furthermore this study is a platform for future research to explore whether Italian physiotherapy practice changes over time.

Two key factors will determine the demand on the physiotherapy profession in contemporary Ireland in the future. Firstly, the shift towards primary care, with a focus on prevention and health promotion and secondly, the chronic conditions that will dominate illness care for the foreseeable future are incontestable given lifestyle profiles and changing life expectancies. For physiotherapists to become effective first contact primary care providers, their role must change from one exclusively geared towards illness, disease and disability to one that provides greater emphasis on the health and wellness, and prevention of 21st century health concerns, specifically, lifestyle related diseases. Modifying lifestyle practices (risk factors) such as tobacco use, excessive alcohol consumption, poor nutrition, weight gain and physical inactivity is listed as a major priority by the Health Services Executive (HSE), given that an escalating number of children, as well as over half Irish adults have one or more manifestations of lifestyle related conditions. Research has shown that a successful assault on lifestyle conditions is more likely achieved by addressing lifestyle rather than primarily focusing on symptom reduction, indicating that health assessment and risk factor modification, undoubtedly, warrant being 21st century physiotherapy competencies. Based on historical precedent and evidence, this article highlights how physiotherapists, by exploiting interventions such as health education, physical activity and exercise, can play a major role in prevention and in some cases, reversing the tide of lifestyle related conditions. Furthermore, the current transition to primary care, with a focus on prevention and health promotion, will facilitate Irish physiotherapists to affect public health practice in every person and patient. Physiotherapy in Ireland could lead the way globally by serving as a model of change.

BACKGROUND: The relationship between physical function and the development of complications in people after abdominal surgery is not well known. The objective of this study was to prospectively examine the relationship between simple physical functioning tests and complications following abdominal surgery. METHODS: Participants were recruited from an elective surgery waiting list. The following variables were measured pre-surgery; functional capacity (Six Minute Walk Test, 30 Second Sit to Stand Test), grip strength (hand dynamometer), self-report physical activity [International Physical Activity Questionnaire, (IPAQ)]. At 30 and 60 days post-operatively IPAQ and self-reported recovery were collected by telephone. Data related to complications and length of stay was extracted from the medical chart. RESULTS: Forty-nine participants (25M/18F) were recruited with a mean (SD) age of 59.5 (14.7) years. The complication rate was 41.9% (n = 18). Factors which differed between the complications and no complications groups were; longer operating time (p = 0.05),>2 co-morbidities (p = 0.033), body mass index >30 (p = 0.005), lower activity levels (p = 0.02), VO2 Peak (p = 0.017) and 6-minute walk distance (p = 0.019). There was an increased length of stay (p < 0.001) and sedentary time (p = 0.007) in the complications group. Activity levels reduced in the whole group (p < 0.001) even though self-report physical activity and recovery were high. CONCLUSION: A number of potentially modifiable physical functioning factors differed in the complication versus no complication groups. Future studies should evaluate whether optimizing physical functioning pre-operatively could alter complication rates and recovery in patients undergoing abdominal surgery.

INTRODUCTION: Poor cardiopulmonary fitness is associated with an increased risk of morbidity and mortality following major surgery. Targeted prehabilitation interventions with adequate intensity improve cardiopulmonary function. Several systematic reviews have noted the variation in outcomes for prehabilitation, providing poor evidence due to inadequate patient numbers and poor compliance. Our aim was to assess the outcomes of the Preoperative Education and Prehabilitation Program (PrEPP) for patients undergoing major abdominal or thoracic surgery. METHODS: PrEPP is a supervised education and exercise training program twice a week and an at-home exercise program three times a week for up to four weeks. A comparison of outcomes was made using the data collected on each patient in PrEPP with a historical control group. RESULTS: There were 370 patients, 185 in each group. They were matched for age (+/- 10 years), gender, and surgery type. There were significant reductions in prolonged ventilation (>48 hours) from 5.4% to 1.1% (p = 0.03) and mean length of stay (LOS) from 10.2 days to 8.5 days (p = 0.04) in the PrEPP group. The incidence of superficial surgical site infection was also found to be less in the PrEPP group (p = 0.02). There were no significant differences in the incidence of pneumonia (3.8% to 2.7% ), unplanned re-intubation (3.8% to 1.6% ), readmission rate (12.4% to 9.7% ), cardiac events or other post-surgical infections. CONCLUSION: The PrEPP was associated with reduced ventilation days and LOS. Further studies are required to confirm these results.

Background: Transversus Abdominis (TrA) has an important role in spinal stability contributing to both intraabdominal pressure and the formation of a muscular corset around the spine. Transversus Abdominis has been shown to be dysfunctional in patients with low back pain (LBP) and ultrasound (US) imaging is seen to have an increasing role in the assessment and management of these patients. This study assessed the intrarater reliability of a novice operator to measure the thickness of transversus abdominis when using brightness (B) mode ultrasound imaging. Method: Twenty normal subjects participated in an operator blinded study to assess the intra-rater reliability of US in measuring the thickness of TrA when contracted using the abdominal hollowing exercise (AHE). Brightness (B) mode US was used to image the TrA at the end of expiration. Subjects were then re-imaged in the standardized position. Results: An intraclass correlation coefficient of 0.96 with 95% confidence intervals of 0.93- 0.98 were obtained indicating excellent reliability. However, limits of agreement were - 1.52 mm to +1.35mm (range 2.87mm) suggesting that clinically meaningful measurements may not reliably be measured by a novice operator. Conclusion: This study indicates that additional training is required to achieve clinically meaningful results. It also highlights the importance of using more than one method of establishing reliability.

BACKGROUND: The distortion of truth or “spin” has become a major concern in various fields as it can affect the accuracy of research dissemination. Recognizing the extent of this issue in physiotherapy research is essential for promoting good-quality research and raising awareness. OBJECTIVE: This study aimed to determine the prevalence of spin in randomized controlled trials (RCTs) published by Indian physiotherapists. METHODS: A Medline search was conducted to identify RCTs published by Indian physiotherapists from January 2000 to November 2018. We included studies with nonsignificant primary outcomes and reviewed them for spin in both abstracts and full texts using the Boutron checklist. Three reviewers were involved in the process. RESULTS: Of the 44 RCTs with nonsignificant outcomes, 40 (90%) showed spin in their ABSTRACTS AND 39 (88%) IN THEIR MAIN TEXT CONCLUSIONS. CONCLUSIONS: Our findings reveal a significant prevalence of spin in nonsignificant RCTs published by physiotherapy researchers. Improving research knowledge, enhancing scientific writing skills, and providing mentorship may help reduce spin in result reporting.

Background: There is growing evidence to support the benefits of Acceptance and Commitment Therapy for people with chronic pain. Despite this, there is limited qualitative research published in this field. Purpose: The aim of this qualitative study was to explore individuals’ perspectives related to ‘acceptance’, following participation in an eight-week multidisciplinary pain management programme (PMP) based on the psychological approach Acceptance and Commitment Therapy (ACT). Methods: Twenty-six participants attended one of five focus groups. Interviews were audio-recorded and transcribed verbatim. Transcripts were imported into NVivo 11 and were analysed using an interpretative phenomenological approach. Results: Three broad themes emerged, representing different stages of acceptance: (1) perception of acceptance as a step towards better living with chronic pain, (2) contemplation of acceptance and (3) non-acceptance. The participants in this study who appeared to have reached a point of acceptance, or were contemplating acceptance, reported positive behaviour changes that led to enhanced fulfilment and quality of life. However not all participants believed that acceptance of chronic pain was possible. Factors emerging as relevant to participants’ perceptions of acceptance included attitudes towards finding a cure, self-identity, self-efficacy, contact with personal values, feelings of loss and perceived injustice. Conclusion: This qualitative study highlights the complexity of acceptance and provides new and unique insights in relation to the views of people with chronic pain on the concept of acceptance, following participation in a multidisciplinary ACT-based PMP.

STUDY DESIGN: Retrospective diagnostic test study (N = 120). BACKGROUND: Due to reorganisation of healthcare provision to meet rising demands, traditional medical roles such as the diagnosis of meniscal tears is now being undertaken by Extended Scope Practitioners (ESP) with a background in physiotherapy. There are limited studies supporting the diagnostic expertise of these clinicians. OBJECTIVE: To compare diagnostic accuracy of Orthopaedic Extended Scope Practitioners (ESP, N = 7) with Consultant Orthopaedic Surgeons (COS, N = 3) in the diagnosis of meniscal tears of the knee. METHODS: The records of 120 patients seen by seven ESP and three COS between July 2006 and July 2007 were accessed. The initial diagnosis given was compared with the findings at MRI scan. Sensitivity (Sn), specificity (Sp), accuracy (Acc), positive predictive value (PPV) and negative predictive value (NPV) were calculated for each profession. A Pearson's chi squared test (χ) was undertaken to determine if there was a statistically significant difference between ESP and COS in the proportions of patients with the clinical diagnosis of a meniscal tear that was subsequently confirmed at MRI scan. RESULTS: ESP had higher Sensitivity, Accuracy and Positive Predictive Value (82.5%, 77.7%, and 82.9%) than COS (70%, 71.6%, and 77.4%) but lower Specificity and Negative Predictive Value (65%, 65%) than COS (75%, 66.5%). Pearson's χ analysis showed that there was no significant difference between these groups in the proportions of patients correctly diagnosed as having a meniscal tear (p = 0.19, χ = 1.726). CONCLUSION: In the diagnosis of meniscal tears in a single Orthopaedic clinic, ESP appeared to possess diagnostic capability comparable with COS.