Carrie Ritchie

Reliability and validity of physical fitness field tests for adults aged 55 to 70 years

The aim of this study was to examine the reliability and validity of field tests for assessing physical function in mid-aged and young-old people (55-70 y). Tests were selected that required minimal space and equipment and could be implemented in multiple field settings such as a general practitioners office. Nineteen participants completed 2 field and 1 laboratory testing sessions. Intra-class correlations showed good reliability for the tests of upper body strength (lift and reach, R= .66), lower body strength (sit to stand, R = .80) and functional capacity (Canadian Step Test, R= .92), but not for leg power (single timed chair rise. R = .28). There was also good reliability for the balance test during 3 stances: parallel (94.7% agreement), semi-tandem (73.7%), and tandem (52.6%). Comparison of field test results with objective laboratory measures found good validity for the sit to stand (cf 1RM leg press, Pearson r= .68, p < .05), and for the step test (cf PWC140, r = -.60, p < .001), but not for the lift and reach (cf 1RM bench press, r = .43, p > .05), balance (r = -.13, -.18, .23) and rate of force development tests (r = -.28). It was concluded that the lower body strength and cardiovascular function tests were appropriate for use in field settings with mid-aged and young-old adults.

Derivation of a clinical prediction rule to identify both chronic moderate/severe disability and full recovery following whiplash injury

Summary A clinical prediction rule comprising relevant biopsychosocial factors was derived to predict both chronic moderate/severe disability and full recovery following whiplash injury. Abstract Recovery following a whiplash injury is varied: approximately 50% of individuals fully recover, 25% develop persistent moderate/severe pain and disability, and 25% experience milder levels of disability. Identification of individuals likely to develop moderate/severe disability or to fully recover may help direct therapeutic resources and optimise treatment. A clinical prediction rule (CPR) is a research‐generated tool used to predict outcomes such as likelihood of developing moderate/severe disability or experiencing full recovery from whiplash injury. The purpose of this study was to assess the plausibility of developing a CPR. Participants from 2 prospective, longitudinal studies that examined prognostic factors for poor functional recovery following whiplash injury were used to derive this tool. Eight factors, previously identified as predictor variables of poor recovery, were included in the analyses: initial neck disability index (NDI), initial neck pain (visual analogue scale), cold pain threshold, range of neck movement, age, gender, presence of headache, and posttraumatic stress symptoms (Posttraumatic Diagnostic Scale [PDS]). An increased probability of developing chronic moderate/severe disability was predicted in the presence of older age and initially higher levels of NDI and hyperarousal symptoms (PDS) (positive predictive value [PPV] = 71%). The probability of full recovery was increased in younger individuals with initially lower levels of neck disability (PPV = 71%). This study provides initial evidence for a CPR to predict both chronic moderate/severe disability and full recovery following a whiplash injury. Further research is needed to validate the tool, determine the acceptability of the proposed CPR by practitioners, and assess the impact of inclusion in practice.

External validation of a clinical prediction rule to predict full recovery and ongoing moderate/severe disability following acute whiplash injury

STUDY DESIGN Retrospective secondary analysis of data. OBJECTIVES To investigate the external validity of the whiplash clinical prediction rule (CPR). BACKGROUND We recently derived a whiplash CPR to consolidate previously established prognostic factors for poor recovery from a whiplash injury and predicted 2 recovery pathways. Prognostic factors for full recovery were being less than 35 years of age and having an initial Neck Disability Index (NDI) score of 32% or less. Prognostic factors for ongoing moderate/severe pain and disability were being 35 years of age or older, having an initial NDI score of 40% or more, and the presence of hyperarousal symptoms. Validation is required to confirm the reproducibility and accuracy of this CPR. Clinician feedback on the usefulness of the CPR is also important to gauge acceptability. METHODS A secondary analysis of data from 101 individuals with acute whiplash-associated disorder who had previously participated in either a randomized controlled clinical trial or prospective cohort study was performed using accuracy statistics. Full recovery was defined as NDI score at 6 months of 10% or less, and ongoing moderate/severe pain and disability were defined as an NDI score at 6 months of 30% or greater. In addition, a small sample of physical therapists completed an anonymous survey on the clinical acceptability and usability of the tool. Results The positive predictive value of ongoing moderate/severe pain and disability was 90.9% in the validation cohort, and the positive predictive value of full recovery was 80.0%. Surveyed physical therapists reported that the whiplash CPR was simple, understandable, would be easy to use, and was an acceptable prognostic tool. CONCLUSION External validation of the whiplash CPR confirmed the reproducibility and accuracy of this dual-pathway tool for individuals with acute whiplash-associated disorder. Further research is needed to assess prospective validation, the impact of inclusion on practice, and to examine the efficacy of linking treatment strategies with predicted prognosis. LEVEL OF EVIDENCE Prognosis, level 1b.

Promoting physical activity to older adults: a preliminary evaluation of three general practice-based strategies.

The aim of this study was to explore the feasibility of an exercise scientist (ES) working in general practice to promote physical activity (PA) to 55 to 70 year old adults. Participants were randomised into one of three groups: either brief verbal and written advice from a general practitioner (GP) (G1, N=9): or individualised counselling and follow-up telephone calls from an ES, either with (G3, N=8) or without a pedometer (G2, N=11). PA levels were assessed at week 1, after the 12-wk intervention and again at 24 weeks. After the 12-wk intervention, the average increase in PA was 116 (SD=237) min/wk: N=28, p<0.001. Although there were no statistically significant between-group differences, the average increases in PA among G2 and G3 participants were 195 (SD=207) and 138 (SD=315) min/wk respectively, compared with no change (0.36, SD=157) in G1. After 24 weeks, average PA levels remained 56 (SD=129) min/wk higher than in week 1. The small numbers of participants in this feasibility study limit the power to detect significant differences between groups, but it would appear that individualised counselling and follow-up contact from an ES, with or without a pedometer, can result in substantial changes in PA levels. A larger study is now planned to confirm these findings.

Exercise induced hypoalgesia is elicited by isometric, but not aerobic exercise in individuals with chronic whiplash associated disorders

Abstract Background and aims Reduced pain sensitivity following exercise is termed exercise induced hypoalgesia (EIH). Preliminary evidence suggests that impairment of EIH is evident in individuals with whiplash associated disorders (WAD) following submaximal aerobic exercise. This study aimed to compare EIH responses to isometric and aerobic exercise in patients with chronic WAD and healthy controls and investigate relationships between EIH, conditioned pain modulation (CPM) and psychological factors in patients with chronic WAD. Methods A cross sectional pre-post study investigated the effect of a single session of submaximal aerobic cycling exercise and a single session of isometric timed wall squat exercise on EIH in a group of participants with chronic WAD (n = 21) and a group of asymptomatic control participants (n = 19). Bivariate analyses between EIH and baseline measures of CPM and psychological features (fear of movement, pain catastrophization and posttraumatic stress symptoms) were also investigated. Results The isometric wall squat exercise but not the aerobic cycling exercise resulted in EIH in both groups (P < .023) with no between-group differences (P > .55) demonstrated for either exercise. There were no significant associations measured between EIH (for either exercise performed), and CPM, or any of the psychological variables. Conclusions This study showed that individuals with chronic WAD and mild to moderate pain and disability, and no evidence of dysfunctional CPM, demonstrated reduced pain sensitivity, both in the cervical spine and over the tibialis anterior following an isometric, timed wall squat exercise. Cycling exercise did not increase pain sensitivity. Implications Individuals with chronic WAD and mild to moderate levels of neck pain and disability may experience less pain sensitivity both locally and remotely following an exercise program directed at nonpainful muscles performing isometric exercises. Individuals cycling for 30 min at 75% of age-predicted heart rate maximum do not experience increased pain sensitivity.

Rating of Perceived Exertion (RPE)

CORRELATION BETWEEN RPE AND HEART RATE The number on the RPE Scale relates to a 6-second heart rate count, especially in the aerobic phase. Practice by estimating your RPE first and then count your heart rate for each phase of your workout. R P E HR 6 SEC. COUNT MAX HR Warm up 6 11 61 111 30 55% Aerobic 12 17 121 173 60 85% Cool Down 6 11 61 111 30 55% 6 20 BORG / RPE SCALE 6 No Exertion No movement, very relaxed & comfortable 7 Extremely Light Able to maintain this pace all day 8 9 Very Light Still comfortable, but breathing a little harder 10 11 Light Feel good, sweating a little, can talk easily 12 13 Somewhat Hard Slightly breathless, but can still talk 14 Sweating, still able to talk, but don’t want to 15 Hard / Heavy Able to push & still maintain form, sweating 16 17 Very Hard Can keep fast pace only for a short time 18 19 Extremely Hard Near muscle exhaustion, hard to breathe 20 Maximally Hard Totally exhausted, need to stop

StressModEx--Physiotherapist-led Stress Inoculation Training integrated with exercise for acute whiplash injury: study protocol for a randomised controlled trial.

INTRODUCTION Whiplash associated disorders are the most common non-hospitalised injuries following a road traffic crash. Up to 50% of individuals who experience a whiplash injury will not fully recover and report ongoing pain and disability. Most recovery, if it occurs, takes place in the first 2-3 months post injury, indicating that treatment provided in the early stages is critical to long-term outcome. However, early management approaches for people with acute whiplash associated disorders are modestly effective. One reason may be that the treatments have been non-specific and have not targeted the processes shown to be associated with poor recovery, such as post-traumatic stress symptoms. Targeting and modulating these early stress responses in the early management of acute whiplash associated disorders may improve health outcomes. Early aggressive psychological interventions in the form of psychological debriefing may be detrimental to recovery and are now not recommended for management of early post-traumatic stress symptoms. In contrast, Stress Inoculation Training (SIT) is a cognitive behavioural approach that teaches various general problem-solving and coping strategies to manage stress-related anxiety (ie, relaxation training, cognitive restructuring and positive self-statements) and provides important information to injured individuals about the impact of stress on their physical and psychological wellbeing. While referral to a psychologist may be necessary in some cases where acute stress disorder or other more significant psychological reactions to stress are evident, in the case of acute whiplash injuries, it is neither feasible nor necessary for a psychologist to deliver the early stress modulation intervention to all injured individuals. The feasibility of using other specially trained health professionals to deliver psychological interventions has been explored in conditions such as chronic low back pain, chronic whiplash and cancer, but few trials have studied this approach in acute musculoskeletal conditions with the aim of preventing the development of chronic pain. As physiotherapy is the most common intervention received by individuals with a whiplash injury, physiotherapists are ideally placed to provide SIT in conjunction with standard physical rehabilitation. This study (StressModEx) will target individuals in the acute stage of injury and address the stress responses associated with the accident or injury (event-related distress) with the aim of improving both physical and mental health outcomes. RESEARCH QUESTION Is SIT integrated with standard physiotherapy exercise and delivered by physiotherapists more effective than physiotherapy exercise alone in reducing neck pain and disability in individuals with acute whiplash associated disorders? DESIGN Parallel randomised controlled trial with blinded outcome assessment. PARTICIPANTS AND SETTING 100 individuals with grade II or III (no fracture/dislocation or neurological loss) acute whiplash associated disorder<4 weeks duration and at least moderate neck pain-related disability and hyper-arousal symptoms will be recruited for the study. Participants will be assessed via online surveys or in-person at a university research laboratory. Interventions will be provided at community physiotherapy practices in Brisbane, Gold Coast, Toowoomba and Mackay, Queensland, Australia. INTERVENTION Clinical-guideline-recommended supervised physiotherapy exercise sessions (10 sessions) integrated with six (once per week) SIT sessions. CONTROL Clinical-guideline-recommended supervised physiotherapy exercise sessions (10) only. MEASUREMENTS Primary (Neck Disability Index) and secondary (Acute Stress Disorder Scale; Post-traumatic Stress Diagnostic Scale; Depression, Anxiety and Stress Scale; Pain Catastrophisingo Scale; Pain Self-Efficacy Questionnaire; Coping Strategies Questionnaire; Global impression of recovery; pain intensity; SF36) outcomes will be measured at baseline, 6 weeks, 6 months and 12 months after randomisation. ANALYSIS Data analysis will be blinded and by intention to treat. Outcomes will be analysed using linear mixed and logistic regression models that will include baseline scores as covariates, participants as random effects and treatment conditions as fixed factors. DISCUSSION This study will be the first to address early stress responses following acute whiplash injury through a novel intervention that integrates SIT and physiotherapy exercise.

Living with ongoing whiplash associated disorders: a qualitative study of individual perceptions and experiences

BackgroundWhiplash associated disorders (WAD) are the most common non-hospitalised injury resulting from a motor vehicle crash. Approximately 50% of individuals with WAD experience on-going pain and disability. Results from intervention trials for individuals with chronic WAD are equivocal and optimal treatment continues to be a challenge. It may be that traditional quantitative measures included in treatment trials have not captured the full benefits patients experience through participation in an intervention. The aim of the present study was to explore participant subjective experiences and perceptions of living with on-going WAD.MethodsTwenty-seven individuals with chronic WAD participated in a one-on-one, semi-structured individual telephone interview. All interviews were audio-taped, transcribed verbatim and data were analysed using an inductive thematic analysis process.ResultsTwo themes emerged that described the experience of living with chronic WAD. First, all participants described navigating the healthcare system after their whiplash injury to help understand their injury and interpret therapeutic recommendations. Participants highlighted the need to ‘find the right healthcare practitioner (HCP)’ to help with this process. Many participants also described additional complexities in navigating and understanding healthcare incurred by interactions with compensation and funding systems. Second, participants described a journey of realisation, and the trial and error used to establish self-management strategies to both prevent and relieve pain. Participants described trying to understand the impact of their initial injury in relation to the gradual realisation that there may be on-going residual deficit. Seeking information from multiple sources, including personal experience gained through trial and error, was important in the search for acceptable management strategies.ConclusionRecovery from a whiplash injury is an adaptive process and more than elimination of pain or disability, therefore may be different from common clinical patient reported outcomes. Early identification of patient understandings of pain, expectations of recovery, symptoms and therapy may help merge patient and HCP understandings. Additionally, helping individuals to recognise symptom triggers and develop appropriate strategies to minimise triggers may actively engage patients in their recovery. Finally, acknowledgement and validation of the whiplash injury by HCPs is seen by many as a necessary step in the recovery process.