Catherine Doody

Clinical Reasoning of Expert and Novice Physiotherapists in an Outpatient Orthopaedic Setting

Summary The purpose of this qualitative study was to investigate the clinical reasoning of expert and novice physiotherapists in an outpatient orthopaedic setting. Ten experienced clinicians and ten students were observed and audiotaped as they examined and treated a real, previously unseen, patient. The audiotape was reviewed immediately afterwards with the therapists by means of a semi-structured interview. The subsequent analysis showed that all used a hypothetico-deductive reasoning process. However, the experts and novices went beyond this essentially diagnostic process to include reasoning focused on treatment. In particular, manual therapy treatment was used as a method of further hypothesis testing. In addition to hypothetico-deductive reasoning the experts also made use of pattern recognition. The clinical reasoning of the physiotherapists in this study was found to be a dynamic, cyclical process. The results of the study support the model of clinical reasoning proposed by Jones (1992) .

Reliability of thermal quantitative sensory testing: a systematic review.

The use of quantitative sensory testing (QST) has become more widespread, with increasing focus on describing somatosensory profiles and pain mechanisms. However, the reliability of thermal QST has yet to be established. We systematically searched the literature using key medical databases. Independent reviewers evaluated reliability data using the Quality Appraisal for Reliability Studies checklist. Of the 21 studies we included in this review, we deemed 5 to have high methodological quality. Narrative analysis revealed that estimates of reliability varied considerably, but overall, the reliability of cold and warm detection thresholds ranged from poor to excellent, while heat and cold pain thresholds ranged from fair to excellent. The methodological quality of research investigating the reliability of thermal QST warrants improvement, particularly in terms of appropriate blinding. The results from this review showed considerable variability in the reliability of each thermal QST parameter.

Doctors' attitudes and beliefs regarding acute low back pain management: A systematic review

&NA; The aim of this systematic review was to determine the attitudes and beliefs of doctors to acute low back pain, and the factors that influence these. The review comprised three phases: a methodological assessment of databases (Medline, EMBASE, Psychinfo, BIOSIS, CINAHL, and the Cochrane Central Register of Controlled Trials) identified potential papers; these were screened for inclusion criteria by two independent reviewers, the extraction of data and the rating of internal validity and strength of the evidence, using valid and reliable scales from accepted papers. Themes were then identified from the accepted literature. The search generated a total of 15 papers of both qualitative (n = 3) and quantitative (n = 12) methodologies. Themes that emerged included doctors’ attitudes and beliefs, and four factors that influenced attitudes and beliefs: doctors’ specialty, demographic factors, personal beliefs and education. There was consistent evidence that doctors’ specialty impacted their attitudes and beliefs: lack of consensus regarding the natural history of LBP, around treatment options, and issues regarding work. There was inconsistent evidence that demographic factors (age) and level of education impacted doctors’ attitudes and beliefs. Strategies to address/ modify these attitudes and beliefs are required, as in some cases they are at odds with guideline recommendations. Long term, these changes in these areas have the potential to maximise patient‐care, and reduce costs to health services.

Self-Management Skills in Chronic Disease Management: What Role Does Health Literacy Have?

Background. Self-management–based interventions can lead to improved health outcomes in people with chronic diseases, and multiple patient characteristics are associated with the development of self-management behaviors. Low health literacy (HL) has been implicated in poorer self-management behaviors and increased costs to health services. However, the mechanisms behind this relationship remain unclear. Therefore, the aim of the current review is to assess the association between HL and patient characteristics related to self-management behaviors (i.e., disease-related knowledge, beliefs, and self-efficacy). Methods. The review comprised 3 phases: 1) database searches, 2) eligibility screening, and 3) study quality assessment and strength of evidence. Inclusion criteria specified that a valid HL screening tool was used, that at least one self-management behavior was assessed, and that patients had a chronic condition. Results. An initial search generated a total of 712 articles, of which 31 studies fulfilled the eligibility criteria. A consistent association was found between low HL and poorer disease-related knowledge in respiratory diseases, diabetes, and multiple disease categories. A significant association between low HL and poorer self-efficacy was reported in cardiovascular diseases, diabetes, human immunodeficiency virus, and multiple disease categories. HL was significantly associated with poorer beliefs in respiratory, musculoskeletal, and cardiovascular diseases. Discussion. The findings from the current review suggest that low HL may affect behaviors necessary for the development of self-management skills. Given that self-management strategies are core components for effective treatment of a range of chronic diseases, low HL poses a considerable health concern. Further research is needed to understand the mediating influence of HL on disease-related knowledge, self-efficacy, and beliefs. From this, HL-sensitive, self-management interventions ought to be devised and implemented.

Reliability of thermal quantitative sensory testing of the hand in a cohort of young, healthy adults

Introduction: The reliability of thermal quantitative sensory testing (QST) has yet to be fully established. In this study we investigated intra‐ and interrater reliability of thermal QST in a blinded manner. Methods: Two investigators recorded thermal detection and pain thresholds on the hand of 22 volunteers, twice on two occasions. Results were analyzed using descriptive statistics, intraclass correlation coefficients (ICCs), and coefficients of variation (CVs). Results: Mean intraindividual differences were small for all measures except cold pain thresholds. ICC values for intra‐ and interrater reliability were: cold detection, 0.27–0.55; warm detection, 0.33–0.69; and heat pain, 0.39–0.86. Cold pain yielded high ICC values (0.87–0.94), but also high CV (84.9–90.2%). Conclusions: In young, healthy adults, thermal detection and heat pain thresholds of the hand demonstrated good reliability for group comparisons and individual analyses. Cold pain threshold measures may be suitable for group comparisons, but a large variance in the data limits individual analyses. Muscle Nerve, 2011

Adverse events following trigger point dry needling: a prospective survey of chartered physiotherapists

Abstract Objectives: Trigger point dry needling (TrP-DN) is commonly used to treat persons with myofascial pain, but no studies currently exist investigating its safety. The aim of this study was to determine the incidence of Adverse Events (AEs) associated with the use of TrP-DN by a sample of physiotherapists in Ireland. Methods: A prospective survey was undertaken consisting of two forms recording mild and significant AEs. Physiotherapists who had completed TrP-DN training with the David G Simons Academy (DGSA) were eligible to take part in the study. Data were collected over a ten-month period. Results: In the study, 39 physiotherapists participated and 1463 (19·18%) mild AEs were reported in 7629 treatments with TrP-DN. No significant AEs were reported giving an estimated upper risk rate for significant AEs of less than or equal to (≤) 0·04%. Common AEs included bruising (7·55%), bleeding (4·65%), pain during treatment (3·01%), and pain after treatment (2·19%). Uncommon AEs were aggravation of symptoms (0·88%), drowsiness (0·26%), headache (0·14%), and nausea (0·13%). Rare AEs were fatigue (0·04%), altered emotions (0·04%), shaking, itching, claustrophobia, and numbness, all 0·01%. Discussion: While mild AEs were very commonly reported in this study of TrP-DN, no significant AEs occurred. For the physiotherapists surveyed, TrP-DN appeared to be a safe treatment.

Factors impacting on doctors' management of acute low back pain: a systematic review.

The aim of this review was to determine the factors that impact on doctors’ management of patients with acute low back pain. A methodological assessment of databases (Medline, EMBASE, Psychinfo, BIOSIS, CINAHL, and the Cochrane Central Register of Controlled Trials) identified papers which were screened for inclusion criteria by two independent reviewers. Data were extracted from accepted papers, and the internal validity and strength of the evidence were determined using valid and reliable scales.

Lifestyle interventions for secondary disease prevention in stroke and transient ischaemic attack: a systematic review:

Background and purpose Secondary prevention in ischaemic stroke and transient ischaemic attack (TIA) is dominated by pharmacological interventions with evidence for non-pharmacological interventions being less robust. This systematic review and meta-analysis examines the impact of lifestyle interventions on secondary prevention in stroke or TIA. Methods A systematic literature search was performed. Randomised controlled trials (RCTs) examining the effectiveness of intervention packages incorporating any key component of health education/promotion/counselling on lifestyle and/or aerobic exercise compared to usual care ± a sham intervention in participants with ischaemic stroke or TIA were included. Outcomes of interest were mortality, cardiovascular disease (CVD) event rates, cardiovascular risk factors including blood pressure, lipid profiles and physical activity participation. Methodological quality was assessed. Statistical analyses determining treatment effect were conducted using Cochrane Review Manager Software. Results Seventeen RCTs were included. Data pooled from eight studies with a total of 2478 patients, demonstrated no effect in favour of lifestyle interventions compared to routine or sham interventions on mortality (risk ratio (RR) = 1.13 (95% confidence interval (CI), 0.85–1.52), I2 = 0%). Data relating to CVD events were pooled from four studies (1013 patients), demonstrated non-significant findings (RR = 1.16 (95% CI, 0.80--1.71), I2 = 0%). Similar results were reported for total cholesterol. Physical activity participation demonstrated significant improvement [SMD 0.24 (95% CI, 0.08–0.41), l2 = 47%]. Blood pressure reductions were noted but were non-significant when corrected for multimodal packages including enhanced pharmacotherapy compliance. Conclusions There is currently insufficient high quality research to support lifestyle interventions post-stroke or TIA on mortality, CVD event rates and cardio-metabolic risk factor profiles. Promising blood pressure reductions were noted in multimodal interventions which addressed lifestyle.

Manual therapy for the cervical spine and reported adverse effects: a survey of Irish manipulative physiotherapists.

The purpose of this study was to determine the use of manipulation and mobilisation by the Chartered Physiotherapists (CMPT) in Manipulative Therapy Ireland and to describe adverse effects associated with the use of these techniques. A 44 item postal survey was sent to all 259 members of the CPMT (response rate 49%, n=127). All 127 respondents used non-High Velocity Thrust Techniques (HVTT) and 27% (n=34) used HVTT. Nine percent (n=12) used HVTT on the upper cervical spine. Twenty six percent (n=33) reported an adverse effect in the previous 2 years. The adverse effects were associated with the use of HVTT (4%, n=5), non-HVTT (20%, n=26) and cervical traction (2%, n=2). The most serious adverse effects were associated with non-HVTT and included 1 drop attack, 1 fainting episode and 1 Transient Ischemic Attack (TIA) 4 days post treatment. Fifty three percent (n=18) of HVTT users and 40% (n=44) of non-HVTT users reported carrying out a vertebrobasilar insufficiency (VBI) assessment. The study shows that VBI assessment may not detect every patient at risk of adverse effects. Large scale studies to investigate the risk of serious adverse reactions are needed. A system of reporting adverse effects on a routine basis could be considered.

Exercise-induced Hypoalgesia in People With Knee Osteoarthritis With Normal and Abnormal Conditioned Pain Modulation

Objectives: Normal efficiency of exercise-induced hypoalgesia (EIH) has been demonstrated in people with knee osteoarthritis (OA), while recent evidence suggests that EIH may be associated with features of pain sensitization such as abnormal conditioned pain modulation (CPM). The aim of this study was to investigate whether people with knee OA with abnormal CPM have dysfunctional EIH compared with those with normal CPM and pain-free controls. Methods: Forty peoples with knee OA were subdivided into groups with abnormal and normal CPM, as determined by a decrease/increase in pressure pain thresholds (PPTs) following the cold pressor test. Abnormal CPM (n=19), normal CPM (n=21), and control participants (n=20) underwent PPT testing before, during, and after aerobic and isometric exercise protocols. Between-group differences were analyzed using repeated-measures analysis of variance and within-group differences were analyzed using Wilcoxon signed-rank tests. Results: Significant differences were demonstrated between groups for changes in PPTs postaerobic (F2,55=4.860; P=0.011) and isometric (F2,57=4.727; P=0.013) exercise, with significant decreases in PPTs demonstrated during and postexercise in the abnormal CPM group (P<0.05), and significant increases in PPTs shown during and postexercise in the normal CPM and control groups (P<0.05). Conclusions: Results are suggestive of dysfunctional EIH in response to aerobic and isometric exercise in knee OA patients with abnormal CPM, and normal function of EIH in knee OA patients with an efficient CPM response. Identification of people with knee OA with inefficient endogenous pain modulation may allow for a more individualized and graded approach to exercises in these individuals.