Meredith Newman

The Effects of Stretching in Spasticity: A Systematic Review

OBJECTIVES To investigate the general effect of stretching on spasticity and to explore the complexity of stretching in patients with spasticity. DATA SOURCES Two researchers independently performed a systematic literature search using the databases: Medline, PEDro, Cochrane library, Web of Science, CINAHL, and Allied and Complementary Medicine. STUDY SELECTION Studies on adults receiving a stretching technique to reduce spasticity were included. DATA EXTRACTION Randomized controlled trials (RCTs) were assessed on the PEDro scale for methodologic quality. Thirteen items from the CONSORT list and the Critical Appraisal Skills Program guideline were used to assess the methodologic quality of the other studies. DATA SYNTHESIS RCTs (n=10) and other clinical trials (n=11) were included. The methodologic quality of the RCTs was low, varying between 4 and 8 on the PEDro scale. All studies show great diversity at the levels of methodology, population, intervention, and outcome measures making a meta-analysis not feasible. Both manual and mechanical stretching methods were studied. Stretching protocols were generally inadequately described and poorly standardized. The outcome measures used often assessed impairments such as available range of motion but were unable to distinguish between neural and nonneural components of spasticity. Associated functional benefits were not usually investigated. Although there is some positive evidence supporting the immediate effects of 1 stretching session, it remains unclear how long these effects abide and its long-term consequences. CONCLUSIONS There is a wide diversity in studies investigating the effects of stretching on spasticity, and the available evidence on its clinical benefit is overall inconclusive. We recognize the need for consensus on a paradigm for stretching and for good-quality studies. Future research should address this issue and should investigate the clinical importance of the short- and long-term effects.

The role of foot and ankle assessment of patients with lower limb osteoarthritis

OBJECTIVES Physiotherapists do not routinely examine the feet of patients with lower limb osteoarthritis, and there is no widely used tool for measuring foot posture. However, differences in foot posture have been demonstrated between patients with medial compartment osteoarthritis of the knee and osteoarthritis of the hip, and guidelines for managing these patients include interventions such as orthotics which presume foot assessment. This study considers a new clinical tool, the Foot Posture Index (FPI). It examines its utility in a physiotherapy outpatient setting with a cohort of patients with medial compartment osteoarthritis of the knee and osteoarthritis of the hip, and investigates the relationship of FPI scores with the range of dorsiflexion of the ankle. DESIGN Cross-sectional observational study. SETTING A specialist orthopaedic hospital. PARTICIPANTS In total, there were 60 participants: 20 patients with medial compartment osteoarthritis of the knee, 20 patients with osteoarthritis of the hip, and a control group of 20 age-matched healthy volunteers. OUTCOME MEASURES A single measurement of the FPI and range of dorsiflexion. RESULTS Significant differences in FPI scores and range of dorsiflexion were seen between groups. On average, patients with osteoarthritis of the hip had more supinated, plantarflexed feet, and patients with medial compartment osteoarthritis of the knee had pronated feet. Healthy controls fell within the normal range. Patients with osteoarthritis of the hip had a median FPI score of -4.5, patients with medial compartment osteoarthritis of the knee had a median FPI score of 7.0, and the healthy controls had a median FPI score of 1.0. The median difference in FPI scores between patients with osteoarthritis of the hip and medial compartment osteoarthritis of the knee was 12 [95% confidence interval (CI) 10 to 13]; between patients with osteoarthritis of the hip and the healthy group was 6 (95% CI 3 to 9); and between patients with medial compartment osteoarthritis of the knee and the healthy group was 5 (95% CI 3 to 8). The median difference in dorsiflexion scores between patients with osteoarthritis of the hip and medial compartment osteoarthritis of the knee was 10 degrees (95% CI 8 to 15); between patients with osteoarthritis of the hip and the healthy group was 10 degrees (95% CI 7 to 15); and between patients with medial compartment osteoarthritis of the knee and the healthy group was 0 degrees (95% CI -3 to 5). Foot posture and range of dorsiflexion were moderately positively correlated (rho 0.57), with pronated feet having a greater range of dorsiflexion. CONCLUSION The FPI is sufficiently sensitive to measure differences in foot posture of patients with medial compartment osteoarthritis of the knee and osteoarthritis of the hip, and is easy to use. Accurate foot assessment is useful as foot postures may be influenced by specific physiotherapy treatment modalities and orthotic interventions.

Outcomes after metal-on-metal hip resurfacing: could we achieve better function?

OBJECTIVE To report functional outcomes after metal-on-metal (MOM) hip resurfacing. DESIGN A cohort of 126 MOM hip resurfacing operations were reviewed 1 year after surgery. SETTING Hospital trust specializing in orthopedic surgery. PARTICIPANTS Sixty-seven right and 59 left hips were reviewed in patients (N=120; 71 men, 49 women; mean age, 56+/-9y; range, 24-76y). INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES Administered once at follow-up. Function was measured using the Oxford Hip Score (OHS), Hip disability and Osteoarthritis Outcome Score, and UCLA Activity Score. Complications, pain, range of motion, Trendelenburg test, strength, walking, single-leg stand, stair climbing, and 10-m walk time were assessed. RESULTS Overall examination was satisfactory with few complications. High functional levels were reported. The median OHS was 15 and median UCLA Activity Score 7 (active). For 25%, outcome was poor with persistent pain, reduced hip flexion (mean, 94.46 degrees +/-12.7 degrees ), decreased strength (P<.001), restricted walking, and functional limitations. CONCLUSIONS Information about outcomes is important for patients undergoing surgery. Hip resurfacing remains an emergent technology, with further follow-up and investigation warranted. One explanation for suboptimal recovery may be current rehabilitation, originally developed after total hip arthroplasty. Rehabilitation tailored to hip resurfacing, paced for this active population and progressed to higher demand activities, may improve outcomes.

Patients' views of a multimedia resource featuring experiences of rheumatoid arthritis: pilot evaluation of www.healthtalkonline.org

The Internet is used increasingly for health information and patient support. Online health information users gravitate to websites that feature patient experiences. However, experiential accounts may mislead if they are unrepresentative. The quality of experiential websites remains unexplored. Obtaining user feedback online can be problematic. This study explored views of www.dipex.org/arthritis, a website based on, and featuring, clips from interviews about experiences of rheumatoid arthritis (RA). Thirty-seven rheumatology outpatients viewed the site and completed a questionnaire. Overall the website appeared relevant and understandable and could be recommended. Comments highlighted the need to update the site regularly with experiences of new treatments; to ensure positive and negative experiences are balanced; and to ensure information is easy to find. The site has since been updated with new experiences and rewritten summaries that present a better balance of experiences. Changes were incorporated in an entire site redesign launched in autumn 2008 as www.healthtalkonline.org.

The effect of supported standing in adults with upper motor neurone disorders: a systematic review

Objectives: To evaluate whether supported standing can affect lower limb muscle length, spasticity, bone mineral density or the function of adults with upper motor neurone disorders. Data sources: A search was conducted of MEDLINE, EMBASE, AMED, CINAHL and Cochrane library electronic databases; clinical trial registers via www.controlled-trials.com and complemented with citation tracking. Review methods: Two reviewers independently evaluated eligibility and methodological quality. Class I and II studies of assisted standing for adults with stroke, multiple sclerosis, traumatic brain injury or spinal cord injury were eligible. A domain-based risk of bias approach was used to assess quality. Results: Seventeen studies were included: 11 class I and 6 class II studies involving 540 participants, of whom 73% were non-ambulant. Quality was generally low, with only two high quality trials identified. High-quality evidence suggested tilt-table standing has a small effect on preventing loss of ankle dorsiflexion. One high-quality study found a low-dose standing programme did not alter bone loss early after spinal injury. Class II low-quality evidence suggested long-term, higher dose programmes may slow bone loss. Limited evidence for the effectiveness of standing on spasticity and function was inconclusive. Conclusion: Supported standing can prevent small losses of ankle mobility but the clinical importance of these effects is uncertain. Low-dose standing is unlikely to protect bone health.

Recovery of function following hip resurfacing arthroplasty: a randomized controlled trial comparing an accelerated versus standard physiotherapy rehabilitation programme

Objective: To identify if a tailored rehabilitation programme is more effective than standard practice at improving function in patients undergoing metal-on-metal hip resurfacing arthroplasty. Design: Randomized controlled trial. Setting: Specialist orthopaedic hospital. Subjects: 80 men with a median age of 56 years. Interventions: Tailored post-operative physiotherapy programme compared with standard physiotherapy. Main Outcomes: Primary outcome – Oxford Hip Score (OHS), Secondary outcomes: Hip disability and Osteoarthritis Outcome Score (HOOS), EuroQol (EQ-5D-3L) and UCLA activity score. Hip range of motion, hip muscle strength and patient selected goals were also assessed. Results: At one year the mean (SD) Oxford Hip Score of the intervention group was higher, 45.1 (5.3), than the control group, 39.6 (8.8). This was supported by a linear regression model, which detected a 5.8 unit change in Oxford Hip Score (p < 0.001), effect size 0.76. There was a statistically significant increase in Hip disability and Osteoarthritis Outcome Score of 12.4% (p < 0.0005), effect size 0.76; UCLA activity score differed by 0.66 points (p < 0.019), effect size 0.43; EQ 5D showed an improvement of 0.85 (p < 0.0005), effect size 0.76. A total of 80% (32 of 40) of the intervention group fully met their self-selected goal compared with 55% (22 of 40) of the control group. Hip range of motion increased significantly; hip flexion by a mean difference 17.9 degrees (p < 0.0005), hip extension by 5.7 degrees (p < 0.004) and abduction by 4 degrees (p < 0.05). Muscle strength improved more in the intervention group but was not statistically significant. Conclusions: A tailored physiotherapy programme improved self-reported functional outcomes and hip range of motion in patients undergoing hip resurfacing.

Physiotherapy Rehabilitation for Osteoporotic Vertebral Fracture (PROVE): study protocol for a randomised controlled trial.

BackgroundOsteoporosis and vertebral fracture can have a considerable impact on an individual’s quality of life. There is increasing evidence that physiotherapy including manual techniques and exercise interventions may have an important treatment role. This pragmatic randomised controlled trial will investigate the clinical and cost-effectiveness of two different physiotherapy approaches for people with osteoporosis and vertebral fracture, in comparison to usual care.Methods/DesignSix hundred people with osteoporosis and a clinically diagnosed vertebral fracture will be recruited and randomly allocated to one of three management strategies, usual care (control - A), an exercise-based physiotherapy intervention (B) or a manual therapy-based physiotherapy intervention (C). Those in the usual care arm will receive a single session of education and advice, those in the active treatment arms (B + C) will be offered seven individual physiotherapy sessions over 12 weeks. The trial is designed as a prospective, adaptive single-blinded randomised controlled trial. An interim analysis will be completed and if one intervention is clearly superior the trial will be adapted at this point to continue with just one intervention and the control. The primary outcomes are quality of life measured by the disease specific QUALLEFO 41 and the Timed Loaded Standing test measured at 1 year.DiscussionThere are a variety of different physiotherapy packages used to treat patients with osteoporotic vertebral fracture. At present, the indication for each different therapy is not well defined, and the effectiveness of different modalities is unknown.Trial registrationReference number ISRCTN49117867.

Effect of different angles of knee flexion on leg extensor power in healthy individuals

OBJECTIVES To investigate the effect of fixed flexion knee deformity on leg extensor power as measured by the Nottingham leg extensor power rig. DESIGN Cross-sectional observational study. SETTING Orthopaedic hospital. PARTICIPANTS A convenience sample of 135 adult participants. MAIN OUTCOME MEASURES leg extensor power normalised for body weight, UCLA activity scale. RESULTS Power values at 0° FF were found to be significantly less than power values at 15° FF [difference 0.21W/kg SD .36], and power values at 15° FF were significantly less than those at 30° FF [difference 0.31W/kg SD .43; P<0.001) in both right and left legs. Age and activity levels were moderately negatively correlated, with UCLA score decreasing with increasing age (-0.343, P<0.0005). No significant correlation was found between activity levels measured on the UCLA and power on the LEP. CONCLUSIONS Given the large range of pre-operative maximal extension, the validity of testing each patient at their own maximal range of pre-intervention extension and then at the same angle post-intervention is questionable. In studies assessing change in power following an intervention, the end point angle should be standardised between individuals. In future studies investigating leg extensor power on the LEP rig pre and post intervention, it could be more appropriate to standardise the angle of FF to 30°, with individuals who are unable to achieve this position excluded from the study.

The reliability and validity of the Figure of 8 Walk test in older people with knee replacement: does the setting have an impact?

OBJECTIVE To determine the reliability and validity of the Figure of 8 Walk test (F8W) for older people after knee replacement surgery in the home setting. DESIGN Observational repeated measures. SETTING A specialist orthopaedic hospital and participants homes. PARTICIPANTS Seventy-four older adults aged over 55 years one year following knee replacement surgery participated in two assessments more than one week apart. MAIN OUTCOME MEASURE The time to complete, steps, boundary limits and smoothness score from the Figure of 8 Walk test (F8W), the time to complete the Timed Up and Go (TUG) test and the time to complete the Timed Walk Test (TWT). RESULTS Overall, on 95% of occasions, the difference between the measurements for intra-rater reliability were within 1.8second of the two test times. The difference between the measurements for inter-rater reliability were found to be narrower than for intra-rater reliability with scores within 1.2second overall on 95% of occasions. The time to perform the F8W was highly correlated to the Timed Up and Go (overall sample r=0.921) and the variability spread within narrow limits (-0.8 to 0.8 z-scores). This was also true for the Timed Walk Test (overall sample r=0.834) with a narrow limit of variability on almost all of the observations (-1.16 to 1.16 z-scores). CONCLUSIONS The F8W test has good reliability and validity when used in either a clinical or home setting for patients around one year following knee replacement surgery.