Margot Skinner

Early morning impairment in cerebral autoregulation and cerebrovascular CO2 reactivity in healthy humans: relation to endothelial function

The reduction in cerebrovascular reactivity to CO2 and/or endothelial function that occurs in the early hours after waking are potential causes for the increased risk for cardiovascular events at this time point. It is unknown whether cerebral autoregulation is reduced in the morning. We tested the hypothesis that early morning reduction in endothelium‐dependent vascular reactivity would be linked to changes in cerebrovascular reactivity to CO2 and cerebral autoregulation (CA). Overnight changes in a dynamic cerebral autoregulation index (ARI) were determined from continuous recordings of blood flow velocity in the middle cerebral artery (MCAv) and arterial blood pressure (BP) during transiently induced hypotension in 20 individuals. Frontal cortical oxygenation (near infrared spectroscopy) and cerebral haemodynamics were also monitored during hypercapnia and before and during 3 min of active standing. Brachial artery flow‐mediated endothelium‐dependent vasodilatation (FMD) and endothelium‐independent dilatation (NFMD) were also monitored. From evening to morning, there was a significant lowering in ARI (5.3 ± 0.5 versus 4.7 ± 0.6 a.u.; P < 0.05), cerebrovascular reactivity to CO2 (5.3 ± 0.6 versus 4.6 ± 1.1% mmHg−1; P < 0.05) and FMD (7.6 ± 0.9 versus 6.0 ± 1.4%; P < 0.05). The lowered FMD was related to the decrease in cerebrovascular reactivity to CO2 (r= 0.76; P < 0.05). Transient reductions in morning MCAv and cortical oxyhaemoglobin concentrations were observed upon resuming a supine‐to‐upright position (P < 0.05 versus evening). The early morning reduction in cerebral autoregulation may facilitate the onset of cerebrovascular accidents; this may be of particular relevance to at‐risk groups, especially upon resuming the upright position.

The effect of adiposity measured by dual-energy X-ray absorptiometry on lung function

Respiratory function is impaired in obesity but there are limitations with body mass index and skin-fold thickness in assessing this effect. The present authors hypothesised that the regional distribution of body fat and lean mass, as measured by dual-energy X-ray absorptiometry (DXA), might be more informative than conventional measurements of total body fat. In total, 107 subjects (55 female, 51.4%) aged 20–50 yrs with no respiratory disease were recruited. Respiratory function tests, anthropometric measurements and a DXA scan were performed. Partial correlation and linear regression analyses were used to explore the effect of adiposity and lean body mass on respiratory function. The majority of respiratory function parameters were significantly correlated with DXA and non-DXA measurements of body fat. Neither thoracic nor abdominal fat had a greater effect. There were some differences in the effect of adiposity between the sexes. Respiratory function was negatively associated with lean body mass in females but positively associated in males. This disappeared after adjustment in females but remained in males. The effects of thoracic and abdominal body fat on respiratory function are comparable but cannot be separated from one another.

Efficacy of the ‘tennis ball technique’ versus nCPAP in the management of position‐dependent obstructive sleep apnoea syndrome

Background and objective:  Avoidance of sleep in the supine position is recommended in the management of position‐dependent OSA hypopnoea syndrome (OSAHS). Our aim was to evaluate the efficacy of a thoracic anti‐supine band (TASB), designed to mimic the so‐called ‘tennis ball technique’, compared with nasal CPAP (nCPAP).

Elevated posture for the management of obstructive sleep apnea

This study aimed to evaluate the effectiveness of elevated posture in the management of obstructive sleep apnea (OSA). Fourteen subjects presenting with mild-moderate OSA, (apnea-hypopnea index [AHI] 10 to 60/h), were included in a randomized crossover investigation. A shoulder-head elevation pillow (SHEP) was compared with nasal continuous positive airway pressure (nCPAP) therapy. Treatment success was defined as AHI ≤ 10/h and partial success as AHI > 10 < 16/h. Four subjects achieved treatment success with the SHEP and three achieved partial success. The remaining seven subjects were treatment failures. In contrast, success was achieved with nCPAP in 12 subjects. One subject achieved partial success and one was a treatment failure. With the SHEP, the mean AHI decreased from 27 ± 12/h to 21 ± 17/h. With nCPAP, the mean AHI was 5 ± 3/h; (p= 0.008 for the difference between treatments). Although somewhat variable, these data provide evidence that elevated posture during sleep is helpful in the management of OSA in some individuals. Results support the use of elevated posture as second-line therapy in the management of OSA. However, no relationships could be identified between baseline data, including the identification of positional OSA, and objective outcomes that might predict patients who are likely to benefit from treatment in an elevated position.

The Efficacy of a Mandibular Advancement Splint in Relation to Cephalometric Variables

The efficacy of a titratable mandibular advancement splint (MAS) for the management of obstructive sleep apnea (OSA) was investigated in relation to supine cephalometric variables. Fourteen adults with diagnosed OSA were recruited following an initial polysomnogram. Supine cephalographic radiographs were taken at baseline and subjects wore the MAS nightly for 6 to 8 weeks. The polysomnogram and cephalogram were repeated with the MAS at maximal titration. The MAS resulted in complete or partial treatment response in all subjects as measured by the improvement in mean apnea/hypopnea index (AHI) (baseline AHI 34 ± 22/hr, with MAS 10 ± 5/hr; p = 0.001). The perpendicular distance between the hyoid bone and the mandibular plane (HYML) measured in awake subjects decreased with the MAS (baseline HYML 25.3 ± 7.8 mm, with MAS 16.5 ± 9.6 mm; p = 0.002). Baseline HYML was the only cephalometric variable associated with a successful clinical outcome. It was strongly linked to improvements in AHI (adjusted R2 = 0.37, p = 0.012) and arousals (adjusted R2 = 0.455, p = 0.005). We conclude that the MAS is an effective therapy for OSA and baseline HYML is an important predictor of improvement. Improvements in AHI may be explained by the MAS maintaining the new or existing relationship of the hyoid and its surrounding structures, thus preventing obstruction in the upper airway during sleep.

The Second Physical Therapy Summit on Global Health: developing an action plan to promote health in daily practice and reduce the burden of non-communicable diseases

Abstract Based on indicators that emerged from The First Physical Therapy Summit on Global Health (2007), the Second Summit (2011) identified themes to inform a global physical therapy action plan to integrate health promotion into practice across the World Confederation for Physical Therapy (WCPT) regions. Working questions were: (1) how well is health promotion implemented within physical therapy practice; and (2) how might this be improved across five target audiences (i.e. physical therapist practitioners, educators, researchers, professional body representatives, and government liaisons/consultants). In structured facilitated sessions, Summit representatives (n = 32) discussed: (1) within WCPT regions, what is working and the challenges; and (2) across WCPT regions, what are potential directions using World CaféTM methodology. Commonalities outweighed differences with respect to strategies to advance health-focused physical therapy as a clinical competency across regions and within target audiences. Participants agreed that health-focused practice is a professional priority, and a strategic action plan was needed to develop it as a clinical competency. The action plan and recommendations largely paralleled the principles and objectives of the World Health Organization’s non-communicable diseases action plan. A third Summit planned for 2015 will provide a mechanism for follow-up to evaluate progress in integrating health-focused physical therapy within the profession.

Acupuncture for Low Back Pain: An Overview of Systematic Reviews

Objective. As evidence of the effectiveness of acupuncture for low back pain (LBP) is inconsistent, we aimed to critically appraise the evidence from relevant systematic reviews. Methods. Systematic reviews of randomized controlled trials (RCTs) concerning acupuncture and LBP were searched in seven databases. Internal validity and external validity of systematic reviews were assessed. Systematic reviews were categorized and high quality reviews assigned greater weightings. Conclusions were generated from a narrative synthesis of the outcomes of subgroup comparisons. Results. Sixteen systematic reviews were appraised. Overall, the methodological quality was low and external validity weak. For acute LBP, evidence that acupuncture has a more favorable effect than sham acupuncture in relieving pain was inconsistent; it had a similar effect on improving function. For chronic LBP, evidence consistently demonstrated that acupuncture provides short-term clinically relevant benefits for pain relief and functional improvement compared with no treatment or acupuncture plus another conventional intervention. Conclusion. Systematic reviews of variable quality showed that acupuncture, either used in isolation or as an adjunct to conventional therapy, provides short-term improvements in pain and function for chronic LBP. More efforts are needed to improve both internal and external validity of systematic reviews and RCTs in this area.

Changes in head and neck posture using an office chair with and without lumbar roll support.

Study Design. A repeated measures observational study. Objective. To investigate change in sagittal alignment of head and neck posture in response to adjustments of an office chair with and without a lumbar roll in situ. Summary of Background Data. Forward head posture has been identified as a risk factor for neck pain, and there is evidence to show that ergonomic correction in sitting may reduce the incidence of pain. The effect placement of a lumbar roll has on cervical spine posture has not been previously investigated experimentally but rather, is assumed to have a positive influence on head and neck posture. Methods. Thirty healthy male participants (18–30 years) were photographed while registered in the natural head resting position in each of 4 sitting positions with and without a lumbar roll in situ. Two positions incorporated adjustments to the back rest and 1 to the seat pan of the office chair. The craniovertebral (CV) angle, as a determinant of head and neck posture was measured from the set of digitized photographs obtained for each participant. Comparisons between the CV angle in all postural registrations were made using a mixed model analysis adjusted for multiple comparisons. Results. Of the positions examined, significant differences in the mean CV angles were found with the backrest of the chair at 100° and at 110° (P < 0.001). With the lumbar roll in situ and the backrest position at 110°, there was a significant increase in the mean CV compared with the angle without the lumbar roll in situ (2.32°, 95% confidence interval: 1.31–3.33; P < 0.001). Conclusion. The degree of angulation of the backrest support of an office chair plus the addition of lumbar roll support are the 2 most important factors to be taken into account when considering seating factors likely to favorably change head and neck postural alignment, at least in asymptomatic subjects.

Motor Control Test responses to balance perturbations in adults with an intellectual disability

Abstract Background The aims of this small exploratory study were to determine (1) whether adults with intellectual disability who had a recent history of falling had slower motor responses to postural perturbations than a sample of adults without disability when measured with the Motor Control Test (MCT) and (2) to identify any learning effects associated with the test. Methods A sample of 7 adults with intellectual disability (58 ± 12 years) and 13 adults without disability (49 ± 6 years) were tested three times over the period of one week. Results The mean response latency for participants with intellectual disability was 158 ± 18 ms and for the control participants was 140 ± 13 ms. No evidence was found for a learning effect with repeated testing. Conclusion Some adults with an intellectual disability, who have a history of falling, may have delayed responses to postural perturbations and this impairment could be targeted in physiotherapy interventions aimed at improving balance capabilities and preventing falls.

Toward core inter-professional health promotion competencies to address the non-communicable diseases and their risk factors through knowledge translation: Curriculum content assessment

BackgroundTo increase the global impact of health promotion related to non-communicable diseases, health professionals need evidence-based core competencies in health assessment and lifestyle behavior change. Assessment of health promotion curricula by health professional programs is a first step. Such program assessment is a means of 1. demonstrating collective commitment across health professionals to prevent non-communicable diseases; 2. addressing the knowledge translation gap between what is known about non-communicable diseases and their risk factors consistent with ‘best’ practice; and, 3. establishing core health-based competencies in the entry-level curricula of established health professions.DiscussionConsistent with the World Health Organization’s definition of health (i.e., physical, emotional and social wellbeing) and the Ottawa Charter, health promotion competencies are those that support health rather than reduce signs and symptoms primarily. A process algorithm to guide the implementation of health promotion competencies by health professionals is described. The algorithm outlines steps from the initial assessment of a patient’s/client’s health and the indications for health behavior change, to the determination of whether that health professional assumes primary responsibility for implementing health behavior change interventions or refers the patient/client to others.An evidence-based template for assessment of the health promotion curriculum content of health professional education programs is outlined. It includes clinically-relevant behavior change theory; health assessment/examination tools; and health behavior change strategies/interventions that can be readily integrated into health professionals’ practices.SummaryAssessment of the curricula in health professional education programs with respect to health promotion competencies is a compelling and potentially cost-effective initial means of preventing and reversing non-communicable diseases. Learning evidence-based health promotion competencies within an inter-professional context would help students maximize use of non-pharmacologic/non-surgical approaches and the contribution of each member of the health team. Such a unified approach would lead patients/clients to expect their health professionals to assess their health and lifestyle practices, and empower and support them in achieving lifelong health. Benefits of such curriculum assessment include a basis for reflection and discussion within and across health professional programs that could impact the epidemic of non-communicable diseases globally, through inter-professional education and evidence-based practice related to health promotion.