Physiotherapy - Research Publications

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    A survey of Australian chiropractors' attitudes and beliefs about evidence-based practice and their use of research literature and clinical practice guidelines.
    Walker, BF ; Stomski, NJ ; Hebert, JJ ; French, SD (Springer Science and Business Media LLC, 2013-12-17)
    BACKGROUND: Research into chiropractors' use of evidence in clinical practice appears limited to a single small qualitative study. The paucity of research in this area suggests that it is timely to undertake a more extensive study to build a more detailed understanding of the factors that influence chiropractors' adoption of evidence-based practice (EBP) principles. This study aimed to identify Australian chiropractors' attitudes and beliefs towards EBP in clinical practice, and also examine their use of research literature and clinical practice guidelines. METHODS: We used an online questionnaire about attitudes, beliefs and behaviours towards the use of EBP in clinical practice that had been developed to survey physiotherapists and modified it to ensure that it was relevant to chiropractic practice. We endeavoured to survey all registered Australian chiropractors (n = 4378) via email invitation distributed by Australian chiropractic professional organisations and the Chiropractic Board of Australia. Logistic regression analyses were conducted to examine univariate associations between responses to items measuring attitudes and beliefs with items measuring: age; years since registration; attention to literature; and use of clinical practice guidelines. RESULTS: Questionnaires were returned by 584 respondents (response rate approximately 13%). The respondents' perceptions of EBP were generally positive: most agreed that the application of EBP is necessary (77.9%), literature and research findings are useful (80.2%), EBP helps them make decisions about patient care (66.5%), and expressed an interest in learning or improving EBP skills (74.9%). Almost half of the respondents (45.1%) read between two to five articles a month. Close to half of the respondents (44.7%) used literature in the process of clinical decision making two to five times each month. About half of the respondents (52.4%) agreed that they used clinical practice guidelines, and around half (54.4%) agreed that they were able to incorporate patient preferences with clinical practice guidelines. The most common factor associated with increased research uptake was the perception that EBP helps make decisions about patient care. CONCLUSIONS: Most Australian chiropractors hold positive attitudes towards EBP, thought EBP was useful, and were interested in improving EBP skills. However, despite the favourable inclination towards EBP, many Australian chiropractors did not use clinical practice guidelines. Our findings should be interpreted cautiously due to the low response rate.
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    Economic Evaluation of Active Implementation versus Guideline Dissemination for Evidence-Based Care of Acute Low-Back Pain in a General Practice Setting
    Mortimer, D ; French, SD ; McKenzie, JE ; OConnor, DA ; Green, SE ; Manchikanti, L (PUBLIC LIBRARY SCIENCE, 2013-10-11)
    INTRODUCTION: The development and publication of clinical practice guidelines for acute low-back pain has resulted in evidence-based recommendations that have the potential to improve the quality and safety of care for acute low-back pain. Development and dissemination of guidelines may not, however, be sufficient to produce improvements in clinical practice; further investment in active implementation of guideline recommendations may be required. Further research is required to quantify the trade-off between the additional upfront cost of active implementation of guideline recommendations for low-back pain and any resulting improvements in clinical practice. METHODS: Cost-effectiveness analysis alongside the IMPLEMENT trial from a health sector perspective to compare active implementation of guideline recommendations via the IMPLEMENT intervention (plus standard dissemination) against standard dissemination alone. RESULTS: The base-case analysis suggests that delivery of the IMPLEMENT intervention dominates standard dissemination (less costly and more effective), yielding savings of $135 per x-ray referral avoided (-$462.93/3.43). However, confidence intervals around point estimates for the primary outcome suggest that--irrespective of willingness to pay (WTP)--we cannot be at least 95% confident that the IMPLEMENT intervention differs in value from standard dissemination. CONCLUSIONS: Our findings demonstrate that moving beyond development and dissemination to active implementation entails a significant additional upfront investment that may not be offset by health gains and/or reductions in health service utilization of sufficient magnitude to render active implementation cost-effective.
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    Low-cost evaluation and real-time feedback of static and dynamic weight bearing asymmetry in patients undergoing in-patient physiotherapy rehabilitation for neurological conditions
    Foo, J ; Paterson, K ; Williams, G ; Clark, R (BMC, 2013-07-12)
    BACKGROUND: Weight bearing asymmetry is common in patients with neurological conditions, and recent advances in gaming technology have produced force platforms that are suitable for use in a clinical setting. The aim of this research is to determine whether commercially-available Wii Balance Boards with customized software providing real-time feedback could be used in a clinical setting to evaluate and improve weight-bearing asymmetry in people with various neurological conditions. METHODS: Twenty participants (age = 43.25 ± 19.37 years) receiving physiotherapy as a result of a neurological condition performed three trials each of two tasks (static standing and sit-to-stand) with and without visual feedback. Vertical forces were measured using available Wii Balance Boards coupled with customized software that displayed visual feedback in real-time. Primary outcome measures included weight-bearing asymmetry as a percentage of body mass, peak force symmetry index, and a visual analogue scale score rating self-perceived level of asymmetry. RESULTS: Weight-bearing asymmetry during the static balance task was significantly reduced (Z = -2.912, p = 0.004, ES = 0.65) with visual feedback. There was no significant difference (Z = -0.336, p = 0.737) with visual feedback for the dynamic task, however subgroup analysis indicated that those with higher weight-bearing asymmetry responded the most to feedback. Correlation analysis revealed little or no relationship between participant perception of weight-bearing asymmetry and the results for the static or dynamic balance task (Spearman's rho: ρ = 0.138, p = 0.561 and ρ = 0.018, ρ =0.940 respectively). CONCLUSIONS: These findings suggest that weight-bearing asymmetry can be reduced during static tasks in patients with neurological conditions using inexpensive commercially-available Wii Balance Boards coupled with customized visual feedback software. Further research is needed to determine whether real-time visual feedback is appropriate for reducing dynamic weight-bearing asymmetry, whether improvements result in improved physical function, and how cognitive and physical impairments influence the patient's ability to respond to treatment.
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    Strength Training for Arthritis Trial (START): design and rationale
    Messier, SP ; Mihalko, SL ; Beavers, DP ; Nicklas, BJ ; DeVita, P ; Carr, JJ ; Hunter, DJ ; Williamson, JD ; Bennell, KL ; Guermazi, A ; Lyles, M ; Loeser, RF (BMC, 2013-07-15)
    BACKGROUND: Muscle loss and fat gain contribute to the disability, pain, and morbidity associated with knee osteoarthritis (OA), and thigh muscle weakness is an independent and modifiable risk factor for it. However, while all published treatment guidelines recommend muscle strengthening exercise to combat loss of muscle mass and strength in knee OA patients, previous strength training studies either used intensities or loads below recommended levels for healthy adults or were generally short, lasting only 6 to 24 weeks. The efficacy of high-intensity strength training in improving OA symptoms, slowing progression, and affecting the underlying mechanisms has not been examined due to the unsubstantiated belief that it might exacerbate symptoms. We hypothesize that in addition to short-term clinical benefits, combining greater duration with high-intensity strength training will alter thigh composition sufficiently to attain long-term reductions in knee-joint forces, lower pain levels, decrease inflammatory cytokines, and slow OA progression. METHODS/DESIGN: This is an assessor-blind, randomized controlled trial. The study population consists of 372 older (age ≥ 55 yrs) ambulatory, community-dwelling persons with: (1) mild-to-moderate medial tibiofemoral OA (Kellgren-Lawrence (KL) = 2 or 3); (2) knee neutral or varus aligned knee ( -2° valgus ≤ angle ≤ 10° varus); (3) 20 kg.m-2 ≥ BMI ≤ 45 kg.m-2; and (3) no participation in a formal strength-training program for more than 30 minutes per week within the past 6 months. Participants are randomized to one of 3 groups: high-intensity strength training (75-90% 1Repetition Maximum (1RM)); low-intensity strength training (30-40%1RM); or healthy living education. The primary clinical aim is to compare the interventions' effects on knee pain, and the primary mechanistic aim is to compare their effects on knee-joint compressive forces during walking, a mechanism that affects the OA disease pathway. Secondary aims will compare the interventions' effects on additional clinical measures of disease severity (e.g., function, mobility); disease progression measured by x-ray; thigh muscle and fat volume, measured by computed tomography (CT); components of thigh muscle function, including hip abductor strength and quadriceps strength, and power; additional measures of knee-joint loading; inflammatory and OA biomarkers; and health-related quality of life. DISCUSSION: Test-retest reliability for the thigh CT scan was: total thigh volume, intra-class correlation coefficients (ICC) = 0.99; total fat volume, ICC = 0.99, and total muscle volume, ICC = 0.99. ICC for both isokinetic concentric knee flexion and extension strength was 0.93, and for hip-abductor concentric strength was 0.99. The reliability of our 1RM testing was: leg press, ICC = 0.95; leg curl, ICC = 0.99; and leg extension, ICC = 0.98. Results of this trial will provide critically needed guidance for clinicians in a variety of health professions who prescribe and oversee treatment and prevention of OA-related complications. Given the prevalence and impact of OA and the widespread availability of this intervention, assessing the efficacy of optimal strength training has the potential for immediate and vital clinical impact. TRIAL REGISTRATION: ClinicalTrials.gov, NCT01489462.
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    Evaluation of a Theory-Informed Implementation Intervention for the Management of Acute Low Back Pain in General Medical Practice: The IMPLEMENT Cluster Randomised Trial
    French, SD ; McKenzie, JE ; O'Connor, DA ; Grimshaw, JM ; Mortimer, D ; Francis, JJ ; Michie, S ; Spike, N ; Schattner, P ; Kent, P ; Buchbinder, R ; Page, MJ ; Green, SE ; Gagnier, JJ (PUBLIC LIBRARY SCIENCE, 2013-06-13)
    INTRODUCTION: This cluster randomised trial evaluated an intervention to decrease x-ray referrals and increase giving advice to stay active for people with acute low back pain (LBP) in general practice. METHODS: General practices were randomised to either access to a guideline for acute LBP (control) or facilitated interactive workshops (intervention). We measured behavioural predictors (e.g. knowledge, attitudes and intentions) and fear avoidance beliefs. We were unable to recruit sufficient patients to measure our original primary outcomes so we introduced other outcomes measured at the general practitioner (GP) level: behavioural simulation (clinical decision about vignettes) and rates of x-ray and CT-scan (medical administrative data). All those not involved in the delivery of the intervention were blinded to allocation. RESULTS: 47 practices (53 GPs) were randomised to the control and 45 practices (59 GPs) to the intervention. The number of GPs available for analysis at 12 months varied by outcome due to missing confounder information; a minimum of 38 GPs were available from the intervention group, and a minimum of 40 GPs from the control group. For the behavioural constructs, although effect estimates were small, the intervention group GPs had greater intention of practising consistent with the guideline for the clinical behaviour of x-ray referral. For behavioural simulation, intervention group GPs were more likely to adhere to guideline recommendations about x-ray (OR 1.76, 95%CI 1.01, 3.05) and more likely to give advice to stay active (OR 4.49, 95%CI 1.90 to 10.60). Imaging referral was not statistically significantly different between groups and the potential importance of effects was unclear; rate ratio 0.87 (95%CI 0.68, 1.10) for x-ray or CT-scan. CONCLUSIONS: The intervention led to small changes in GP intention to practice in a manner that is consistent with an evidence-based guideline, but it did not result in statistically significant changes in actual behaviour. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry ACTRN012606000098538.
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    The use of the international classification of functioning, disability and health (ICF) in indigenous healthcare: a systematic literature review
    Alford, VM ; Remedios, LJ ; Webb, GR ; Ewen, S (BMC, 2013-05-16)
    INTRODUCTION: The International Classification of Functioning, Disability and Health (ICF) was endorsed by the World Health Organisation (WHO) in 2001 to obtain a comprehensive perspective of health and functioning of individuals and groups. Health disparities exist between Indigenous and non-Indigenous Australians and there is a need to understand the health experiences of Indigenous communities from Indigenous Australian's perspectives in order to develop and implement culturally appropriate and effective intervention strategies to improve Indigenous health. This systematic review examines the literature to identify the extent and context of use of the ICF in Indigenous healthcare, to provide the foundation on which to consider its potential use for understanding the health experiences of Indigenous communities from their perspective. METHODS: The search was conducted between May and June 2012 of five scientific and medical electronic databases: MEDLINE, Web of Science, CINAHL, Academic Search Complete and PsychInfo and six Indigenous-specific databases: AIATSIS, APAIS-health, ATSI-health, health and society, MAIS-ATSIS and RURAL. Reference lists of included papers were also searched. Articles which applied the ICF within an Indigenous context were selected. Quantitative and qualitative data were extracted and analysed by two independent reviewers. Agreement was reached by consensus. RESULTS: Five articles met the inclusion criteria however two of the articles were not exclusively in an Indigenous context. One article applied the ICF in the context of understanding the health experience and priorities of Indigenous people and a second study had a similar focus but used the revised version of the International Classification of Impairments, Disability and Handicap (ICIDH-2), the predecessor to the ICF. Four of the five papers involved Indigenous Australians, and one of the paper’s participants were Indigenous (First Nation) Canadians. CONCLUSION: Literature referring to the use of the ICF with Indigenous populations is limited. The ICF has the potential to help understand the health and functioning experience of Indigenous persons from their perspective. Further research is required to determine if the ICF is a culturally appropriate tool and whether it is able to capture the Indigenous health experience or whether modification of the framework is necessary for use with this population.
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    Reliability and validity of the Microsoft Kinect for evaluating static foot posture
    Mentiplay, BF ; Clark, RA ; Mullins, A ; Bryant, AL ; Bartold, S ; Paterson, K (BMC, 2013-04-08)
    BACKGROUND: The evaluation of foot posture in a clinical setting is useful to screen for potential injury, however disagreement remains as to which method has the greatest clinical utility. An inexpensive and widely available imaging system, the Microsoft Kinect™, may possess the characteristics to objectively evaluate static foot posture in a clinical setting with high accuracy. The aim of this study was to assess the intra-rater reliability and validity of this system for assessing static foot posture. METHODS: Three measures were used to assess static foot posture; traditional visual observation using the Foot Posture Index (FPI), a 3D motion analysis (3DMA) system and software designed to collect and analyse image and depth data from the Kinect. Spearman's rho was used to assess intra-rater reliability and concurrent validity of the Kinect to evaluate foot posture, and a linear regression was used to examine the ability of the Kinect to predict total visual FPI score. RESULTS: The Kinect demonstrated moderate to good intra-rater reliability for four FPI items of foot posture (ρ = 0.62 to 0.78) and moderate to good correlations with the 3DMA system for four items of foot posture (ρ = 0.51 to 0.85). In contrast, intra-rater reliability of visual FPI items was poor to moderate (ρ = 0.17 to 0.63), and correlations with the Kinect and 3DMA systems were poor (absolute ρ = 0.01 to 0.44). Kinect FPI items with moderate to good reliability predicted 61% of the variance in total visual FPI score. CONCLUSIONS: The majority of the foot posture items derived using the Kinect were more reliable than the traditional visual assessment of FPI, and were valid when compared to a 3DMA system. Individual foot posture items recorded using the Kinect were also shown to predict a moderate degree of variance in the total visual FPI score. Combined, these results support the future potential of the Kinect to accurately evaluate static foot posture in a clinical setting.
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    Relationship between health-related quality of life, and acute care re-admissions and survival in older adults with chronic illness
    Hutchinson, A ; Rasekaba, TM ; Graco, M ; Berlowitz, DJ ; Hawthorne, G ; Lim, WK (BMC, 2013-08-06)
    BACKGROUND: Australia's ageing population means that there is increasing emphasis on developing innovative models of health care delivery for older adults. The assessment of the most appropriate mix of services and measurement of their impact on patient outcomes is challenging. The aim of this evaluation was to describe the health related quality of life (HRQoL) of older adults with complex needs and to explore the relationship between HRQoL, readmission to acute care and survival. METHODS: The study was conducted in metropolitan Melbourne, Australia; participants were recruited from a cohort of older adults enrolled in a multidisciplinary case management service. HRQoL was measured at enrolment into the case-management service using The Assessment of Quality of Life (AQoL) instrument. In 2007-2009, participating service clinicians approached their patients and asked for consent to study participation. Administrative databases were used to obtain data on comorbidities (Charlson Comorbidity Index) at enrolment, and follow-up data on acute care readmissions over 12 months and five year mortality. HRQoL was compared to aged-matched norms using Welch's approximate t-tests. Univariate and multivariate logistic regression models were used to explore which patient factors were predictive of readmissions and mortality. RESULTS: There were 210 study participants, mean age 78 years, 67% were female. Participants reported significantly worse HRQoL than age-matched population norms with a mean AQOL of 0.30 (SD 0.27). Seventy-eight (38%) participants were readmitted over 12-months and 5-year mortality was 65 (31%). Multivariate regression found that an AQOL utility score <0.37 (OR 1.95, 95%CI, 1.03 - 3.70), and a Charlson Comorbidity Index ≥6 (OR 4.89, 95%CI 2.37 - 10.09) were predictive of readmission. Multivariate analysis demonstrated that age ≥80 years (OR 7.15, 95%CI, 1.83 - 28.02), and Charlson Comorbidity Index ≥6 (OR 6.00, 95%CI, 2.82 - 12.79) were predictive of death. CONCLUSION: This study confirms that the AQoL instrument is a robust measure of HRQoL in older community-dwelling adults with chronic illness. Lower self-reported HRQoL was associated with an increased risk of readmission independently of comorbidity and kind of service provided, but was not an independent predictor of five-year mortality.
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    Auto-titrating continuous positive airway pressure treatment for obstructive sleep apnoea after acute quadriplegia (COSAQ): study protocol for a randomized controlled trial
    Berlowitz, DJ ; Ayas, N ; Barnes, M ; Brown, DJ ; Cistulli, PA ; Geraghty, T ; Graham, A ; Lee, BB ; Morris, M ; O'Donoghue, F ; Rochford, PD ; Ross, J ; Singhal, B ; Spong, J ; Wadsworth, B ; Pierce, RJ (BMC, 2013-06-19)
    BACKGROUND: Quadriplegia is a severe, catastrophic injury that predominantly affects people early in life, resulting in lifelong physical disability. Obstructive sleep apnoea is a direct consequence of quadriplegia and is associated with neurocognitive deficits, sleepiness and reduced quality of life. The usual treatment for sleep apnoea is nasal continuous positive airway pressure (CPAP); however, this is poorly tolerated in quadriplegia. To encourage patients to use this therapy, we have to demonstrate that the benefits outweigh the inconvenience. We therefore propose a prospective, multinational randomized controlled trial of three months of CPAP for obstructive sleep apnoea after acute quadriplegia. METHODS/DESIGN: Specialist spinal cord injury centres across Australia, New Zealand, the UK and Canada will recruit medically stable individuals who have sustained a (new) traumatic quadriplegia (complete or incomplete second cervical to first thoracic level lesions). Participants will be screened for obstructive sleep apnoea using full, portable sleep studies. Those with an apnoea hypopnoea index greater than 10 per hour will proceed to an initial three-night trial of CPAP. Those who can tolerate CPAP for at least 4 hours on at least one night of the initial trial will be randomized to either usual care or a 3-month period of auto-titrating CPAP. The primary hypothesis is that nocturnal CPAP will improve neuropsychological functioning more than usual care alone. The secondary hypothesis is that the magnitude of improvement of neuropsychological function will be predicted by the severity of baseline sleepiness measures, sleep fragmentation and sleep apnoea. Neuropsychological tests and full polysomnography will be performed at baseline and 3 months with interim measures of sleepiness and symptoms of autonomic dysfunction measured weekly. Spirometry will be performed monthly. Neuropsychological tests will be administered by blinded assessors. Recruitment commenced in July 2009. DISCUSSION: The results of this trial will demonstrate the effect of nocturnal CPAP treatment of obstructive sleep apnoea in acute quadriplegia. If CPAP can improve neurocognitive function after injury, it is likely that rehabilitation and subsequent community participation will be substantially improved for this group of predominantly young and severely physically disabled people. TRIAL REGISTRATION: Australian New Zealand Clinical Trial Registry ACTRN12605000799651.
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    Who uses Australian chiropractic services?
    French, S ; Densley, K ; Charity, M ; Gunn, J (BIOMED CENTRAL LTD, 2013-09-26)
    BACKGROUND: The use of chiropractic services is widespread, however, little is known about the characteristics of people who seek chiropractic care in Australia. This study compared the characteristics of users and non-users of chiropractic services from a cohort of patients sourced from general medical practice in Victoria, Australia. METHODS: This is a secondary analysis of baseline screening data from a prospective adult cohort study beginning in 2005. Thirty randomly selected Australian general medical practices mailed out surveys to 17,780 of their patients. Differences were examined between chiropractic users and others, and between chiropractic users who reported a back problem to those who did not. RESULTS: Of 7,519 respondents, 15% indicated they had visited a chiropractor in the last 12 months. Chiropractic users were more likely to have their GP located in a rural location and to be born in Australia; they were less likely to be in the older age group (55-76), to be unemployed or to have a pension/benefit as their main source of income. Chiropractic users were more likely to: have a back problem; use complementary or alternative medication; visit another type of complementary health practitioner or a physiotherapist. They were less likely to take medication for certain health problems (e.g. for high blood pressure, high cholesterol or asthma). No important differences were seen between chiropractic users and non-users for other health problems. People who visited a chiropractor and reported a back problem were more likely to: be a current smoker; have a number of other chronic conditions, including arthritis, hypertension, chronic sinusitis, asthma, dermatitis, depression and anxiety; report taking medications, including antidepressants, analgesics (painkillers and arthritis medication) and complementary or alternative medications. CONCLUSIONS: This large cross-sectional study of general medical practice attendees suggests that chiropractors are the most commonly consulted complementary health profession. Chiropractors should ensure they are aware of their patients' health conditions other than musculoskeletal problems and should ensure they are appropriately managed.