Nicola R Heneghan

Barefoot vs common footwear: A systematic review of the kinematic, kinetic and muscle activity differences during walking.

Habitual footwear use has been reported to influence foot structure with an acute exposure being shown to alter foot position and mechanics. The foot is highly specialised thus these changes in structure/position could influence functionality. This review aims to investigate the effect of footwear on gait, specifically focussing on studies that have assessed kinematics, kinetics and muscle activity between walking barefoot and in common footwear. In line with PRISMA and published guidelines, a literature search was completed across six databases comprising Medline, EMBASE, Scopus, AMED, Cochrane Library and Web of Science. Fifteen of 466 articles met the predetermined inclusion criteria and were included in the review. All articles were assessed for methodological quality using a modified assessment tool based on the STROBE statement for reporting observational studies and the CASP appraisal tool. Walking barefoot enables increased forefoot spreading under load and habitual barefoot walkers have anatomically wider feet. Spatial-temporal differences including, reduced step/stride length and increased cadence, are observed when barefoot. Flatter foot placement, increased knee flexion and a reduced peak vertical ground reaction force at initial contact are also reported. Habitual barefoot walkers exhibit lower peak plantar pressures and pressure impulses, whereas peak plantar pressures are increased in the habitually shod wearer walking barefoot. Footwear particularly affects the kinematics and kinetics of gait acutely and chronically. Little research has been completed in older age populations (50+ years) and thus further research is required to better understand the effect of footwear on walking across the lifespan.

Recognising neuroplasticity in musculoskeletal rehabilitation: A basis for greater collaboration between musculoskeletal and neurological physiotherapists

Evidence is emerging for central nervous system (CNS) changes in the presence of musculoskeletal dysfunction and pain. Motor control exercises, and potentially manual therapy, can induce changes in the CNS, yet the focus in musculoskeletal physiotherapy practice is conventionally on movement impairments with less consideration of intervention-induced neuroplastic changes. Studies in healthy individuals and those with neurological dysfunction provide examples of strategies that may also be used to enhance neuroplasticity during the rehabilitation of individuals with musculoskeletal dysfunction, improving the effectiveness of interventions. In this paper, the evidence for neuroplastic changes in patients with musculoskeletal conditions is discussed. The authors compare and contrast neurological and musculoskeletal physiotherapy clinical paradigms in the context of the motor learning principles of experience-dependent plasticity: part and whole practice, repetition, task-specificity and feedback that induces an external focus of attention in the learner. It is proposed that increased collaboration between neurological and musculoskeletal physiotherapists and researchers will facilitate new discoveries on the neurophysiological mechanisms underpinning sensorimotor changes in patients with musculoskeletal dysfunction. This may lead to greater integration of strategies to enhance neuroplasticity in patients treated in musculoskeletal physiotherapy practice.

Supported self-management for patients with moderate to severe chronic obstructive pulmonary disease (COPD): an evidence synthesis and economic analysis

BACKGROUND Self-management (SM) support for patients with chronic obstructive pulmonary disease (COPD) is variable in its coverage, content, method and timing of delivery. There is insufficient evidence for which SM interventions are the most effective and cost-effective. OBJECTIVES To undertake (1) a systematic review of the evidence for the effectiveness of SM interventions commencing within 6 weeks of hospital discharge for an exacerbation for COPD (review 1); (2) a systematic review of the qualitative evidence about patient satisfaction, acceptance and barriers to SM interventions (review 2); (3) a systematic review of the cost-effectiveness of SM support interventions within 6 weeks of hospital discharge for an exacerbation of COPD (review 3); (4) a cost-effectiveness analysis and economic model of post-exacerbation SM support compared with usual care (UC) (economic model); and (5) a wider systematic review of the evidence of the effectiveness of SM support, including interventions (such as pulmonary rehabilitation) in which there are significant components of SM, to identify which components are the most important in reducing exacerbations, hospital admissions/readmissions and improving quality of life (review 4). METHODS The following electronic databases were searched from inception to May 2012: MEDLINE, MEDLINE In-Process and Other Non-Indexed Citations, EMBASE, Cochrane Central Register of Controlled Trials (CENTRAL), and Science Citation Index [Institute of Scientific Information (ISI)]. Subject-specific databases were also searched: PEDro physiotherapy evidence database, PsycINFO and the Cochrane Airways Group Register of Trials. Ongoing studies were sourced through the metaRegister of Current Controlled Trials, International Standard Randomised Controlled Trial Number database, World Health Organization International Clinical Trials Registry Platform Portal and ClinicalTrials.gov. Specialist abstract and conference proceedings were sourced through ISIs Conference Proceedings Citation Index and British Librarys Electronic Table of Contents (Zetoc). Hand-searching through European Respiratory Society, the American Thoracic Society and British Thoracic Society conference proceedings from 2010 to 2012 was also undertaken, and selected websites were also examined. Title, abstracts and full texts of potentially relevant studies were scanned by two independent reviewers. Primary studies were included if ≈90% of the population had COPD, the majority were of at least moderate severity and reported on any intervention that included a SM component or package. Accepted study designs and outcomes differed between the reviews. Risk of bias for randomised controlled trials (RCTs) was assessed using the Cochrane tool. Random-effects meta-analysis was used to combine studies where appropriate. A Markov model, taking a 30-year time horizon, compared a SM intervention immediately following a hospital admission for an acute exacerbation with UC. Incremental costs and quality-adjusted life-years were calculated, with sensitivity analyses. RESULTS From 13,355 abstracts, 10 RCTs were included for review 1, one study each for reviews 2 and 3, and 174 RCTs for review 4. Available studies were heterogeneous and many were of poor quality. Meta-analysis identified no evidence of benefit of post-discharge SM support on admissions [hazard ratio (HR) 0.78, 95% confidence interval (CI) 0.52 to 1.17], mortality (HR 1.07, 95% CI 0.74 to 1.54) and most other health outcomes. A modest improvement in health-related quality of life (HRQoL) was identified but this was possibly biased due to high loss to follow-up. The economic model was speculative due to uncertainty in impact on readmissions. Compared with UC, post-discharge SM support (delivered within 6 weeks of discharge) was more costly and resulted in better outcomes (£683 cost difference and 0.0831 QALY gain). Studies assessing the effect of individual components were few but only exercise significantly improved HRQoL (3-month St Georges Respiratory Questionnaire 4.87, 95% CI 3.96 to 5.79). Multicomponent interventions produced an improved HRQoL compared with UC (mean difference 6.50, 95% CI 3.62 to 9.39, at 3 months). Results were consistent with a potential reduction in admissions. Interventions with more enhanced care from health-care professionals improved HRQoL and reduced admissions at 1-year follow-up. Interventions that included supervised or unsupervised structured exercise resulted in significant and clinically important improvements in HRQoL up to 6 months. LIMITATIONS This review was based on a comprehensive search strategy that should have identified most of the relevant studies. The main limitations result from the heterogeneity of studies available and widespread problems with their design and reporting. CONCLUSIONS There was little evidence of benefit of providing SM support to patients shortly after discharge from hospital, although effects observed were consistent with possible improvement in HRQoL and reduction in hospital admissions. It was not easy to tease out the most effective components of SM support packages, although interventions containing exercise seemed the most effective. Future work should include qualitative studies to explore barriers and facilitators to SM post exacerbation and novel approaches to affect behaviour change, tailored to the individual and their circumstances. Any new trials should be properly designed and conducted, with special attention to reducing loss to follow-up. Individual participant data meta-analysis may help to identify the most effective components of SM interventions. STUDY REGISTRATION This study is registered as PROSPERO CRD42011001588. FUNDING The National Institute for Health Research Health Technology Assessment programme.

Physiotherapy rehabilitation for whiplash associated disorder II: a systematic review and meta-analysis of randomised controlled trials

Objective To evaluate effectiveness of physiotherapy management in patients experiencing whiplash associated disorder II, on clinically relevant outcomes in the short and longer term. Design Systematic review and meta-analysis. Two reviewers independently searched information sources, assessed studies for inclusion, evaluated risk of bias and extracted data. A third reviewer mediated disagreement. Assessment of risk of bias was tabulated across included trials. Quantitative synthesis was conducted on comparable outcomes across trials with similar interventions. Meta-analyses compared effect sizes, with random effects as primary analyses. Data sources Predefined terms were employed to search electronic databases. Additional studies were identified from key journals, reference lists, authors and experts. Eligibility criteria for selecting studies Randomised controlled trials (RCTs) published in English before 31 December 2010 evaluating physiotherapy management of patients (>16 years), experiencing whiplash associated disorder II. Any physiotherapy intervention was included, when compared with other types of management, placebo/sham, or no intervention. Measurements reported on ≥1 outcome from the domains within the international classification of function, disability and health, were included. Results 21 RCTs (2126 participants, 9 countries) were included. Interventions were categorised as active physiotherapy or a specific physiotherapy intervention. 20/21 trials were evaluated as high risk of bias and one as unclear. 1395 participants were incorporated in the meta-analyses on 12 trials. In evaluating short term outcome in the acute/sub-acute stage, there was some evidence that active physiotherapy intervention reduces pain and improves range of movement, and that a specific physiotherapy intervention may reduce pain. However, moderate/considerable heterogeneity suggested that treatments may differ in nature or effect in different trial patients. Differences between participants, interventions and trial designs limited potential meta-analyses. Conclusions Inconclusive evidence exists for the effectiveness of physiotherapy management for whiplash associated disorder II. There is potential benefit for improving range of movement and pain short term through active physiotherapy, and for improving pain through a specific physiotherapy intervention.

Stability and intra-tester reliability of an in vivo measurement of thoracic axial rotation using an innovative methodology

The aim of this study was to evaluate the stability and intra-tester reliability of an innovative approach to measure active thoracic spine axial rotation. Ultrasound imaging of a thoracic vertebra in conjunction with Polhemus motion analysis of the transducer was used to measure axial thoracic spine rotation in a functional position. The range of motion in a convenience sample of asymptomatic subjects (n=24) was calculated across ten repetitions of a single trial to evaluate stability. The protocol was repeated the same day and 7-10 days later to provide data for within and between day intra-tester reliability. Mean total range of axial rotation was 85.15 degrees across a single trial with SD=14.8, CV=17.4, SEM=3.04. SEM ranged 0.63-3.37 for individual subjects and 2.60-3.64 across repetitions. Stability of performance occurred at repetitions 2-4. Intra-tester reliability (ICC(2,1)) was excellent within day (0.89-0.98) and good/excellent between days (0.720.94). Bland-Altman plots however suggest that agreement may range from 0 to 10% for within day measures and from 0 to 15% for between day measures. Whether this combined approach has sufficient precision and accuracy as a clinical research tool has yet to be fully evaluated.

Physiotherapy rehabilitation following lumbar spinal fusion: a systematic review and meta-analysis of randomised controlled trials

Objective To evaluate the effectiveness of physiotherapy intervention following lumbar spinal fusion. Design Systematic review and meta-analysis. 2 independent reviewers searched information sources, assessed studies for inclusion and evaluated risk of bias. Quantitative synthesis using standardised mean differences was conducted on comparable outcomes across trials with similar interventions. Information sources Predefined terms were employed to search electronic databases. Additional studies were identified from key journals, reference lists, authors and experts. Eligibility criteria for included studies Randomised control trials published in English prior to 30 September 2011 investigating physiotherapy outpatient management of patients (>16 years), following lumbar spinal fusion, with measurements reported on one or more outcome of disability, function and health were included. Results 2 Randomised control trials (188 participants) from two countries were included. Both trials included a behavioural and an exercise intervention. 1 trial was evaluated as high risk of bias and one as unclear. 159 participants were incorporated in the meta-analysis. Although evidence from both trials suggested that intervention might reduce back pain short term (6 months) and long term (12 months and 2 years), and a behavioural intervention might be more beneficial than an exercise intervention, the pooled effects (0.72, 95% CI −0.25 to 1.69 at 6 months; 0.52, 95% CI −0.45 to 1.49 at 12 months and 0.75, 95% CI −0.46 to 1.96 at 2 years) did not demonstrate statistically significant effects. There was no evidence that intervention changes pain in the short (6 months) or long term (12 months and 2 years). The wide CI for pooled effects indicated that intervention could be potentially beneficial or harmful. Considerable heterogeneity was evident. Conclusions Inconclusive, very low-quality evidence exists for the effectiveness of physiotherapy management following lumbar spinal fusion. Best practice remains unclear. Limited comparability of outcomes and retrieval of only two trials reflect a lack of research in this area that requires urgent consideration.

Soft tissue artefact in the thoracic spine during axial rotation and arm elevation using ultrasound imaging: A descriptive study

Much of the current understanding of thoracic motion analysis is based on the use of skin sensors or markers. Skin tissue artefact, movement occurring between the skin and underlying bone, is readily acknowledged by researchers as a source or measurement error, yet to date has not been quantified. The aim of this study was therefore to evaluate skin tissue artefact, during thoracic axial rotation and single arm elevation. Using an ultrasound imaging technique this study describes soft tissue artefact in the thoracic spine during axial rotation and single arm elevation in sitting using 30 asymptomatic individuals. The findings from this study indicate that soft tissue artefact (STA) in the mid thoracic region ranges between 14 and 16 mm for 35-degrees of rotation. During single arm elevation 0.8-1.5 mm STA was measured at the levels of T1-T6-T12. The results of this study suggests that STA is a considerable and variable source of error in all regions of the thoracic spine, but most notably for the mid thoracic region during axial rotation.

Self-management of health care behaviors for COPD: a systematic review and meta-analysis

Purpose This systematic review aimed to identify the most effective components of interventions to facilitate self-management of health care behaviors for patients with COPD. PROSPERO registration number CRD42011001588. Methods We used standard review methods with a systematic search to May 2012 for randomized controlled trials of self-management interventions reporting hospital admissions or health-related quality of life (HRQoL). Mean differences (MD), hazard ratios, and 95% confidence intervals (CIs) were calculated and pooled using random-effects meta-analyses. Effects among different subgroups of interventions were explored including single/multiple components and multicomponent interventions with/without exercise. Results One hundred and seventy-three randomized controlled trials were identified. Self-management interventions had a minimal effect on hospital admission rates. Multicomponent interventions improved HRQoL (studies with follow-up >6 months St George’s Respiratory Questionnaire (MD 2.40, 95% CI 0.75–4.04, I2 57.9). Exercise was an effective individual component (St George’s Respiratory Questionnaire at 3 months MD 4.87, 95% CI 3.96–5.79, I2 0%). Conclusion While many self-management interventions increased HRQoL, little effect was seen on hospital admissions. More trials should report admissions and follow-up participants beyond the end of the intervention.

Supported self-management for patients with COPD who have recently been discharged from hospital: a systematic review and meta-analysis

Purpose Although many hospitals promote self-management to chronic obstructive pulmonary disease (COPD) patients post discharge from hospital, the clinical effectiveness of this is unknown. We undertook a systematic review of the evidence as part of a Health Technology Assessment review. Methods A comprehensive search strategy with no language restrictions was conducted across relevant databases from inception to May 2012. Randomized controlled trials of patients with COPD, recently discharged from hospital after an acute exacerbation and comparing a self-management intervention with control, usual care or other intervention were included. Study selection, data extraction, and risk of bias assessment were undertaken by two reviewers independently. Results Of 13,559 citations, 836 full texts were reviewed with nine randomized controlled trials finally included in quantitative syntheses. Interventions were heterogeneous. Five trials assessed highly supported multi-component interventions and four trials were less supported with fewer contacts with health care professionals and mainly home-based interventions. Total sample size was 1,466 (range 33–464 per trial) with length of follow-up 2–12 months. Trials varied in quality; poor patient follow-up and poor reporting was common. No evidence of effect in favor of self-management support was observed for all-cause mortality (pooled hazard ratio =1.07; 95% confidence interval [0.74 to 1.55]; I2=0.0%, [n=5 trials]). No clear evidence of effect on all-cause hospital admissions was observed (hazard ratio 0.88 [0.61, 1.27] I2=66.0%). Improvements in St George’s Respiratory Questionnaire score were seen in favor of self-management interventions (mean difference =3.84 [1.29 to 6.40]; I2=14.6%), although patient follow-up rates were low. Conclusion There is insufficient evidence to support self-management interventions post-discharge. There is a need for good quality primary research to identify effective approaches.

Thoracic manual therapy in the management of non-specific shoulder pain: a systematic review

Abstract Objectives: Non-specific shoulder pain (NSSP) is often persistent and disabling leading to high socioeconomic costs. Cervical manipulation has demonstrated improvements in patients with NSSP, although risks associated with thrust techniques are documented. Thoracic manual therapy (TMT) may utilise similar neurophysiological effects with less risk. The current evidence for TMT in treating NSSP is limited to systematic reviews of manual therapy (MT) applied to the upper quadrant. These reviews included trials that used shoulder girdle manual therapy (SG-MT) in the TMT group. This limits the scope of their conclusions with regard to the exclusive effectiveness of TMT for NSSP. Methods: This review used a steering group for subject and methodological expertise and was reported in line with Preferred Reporting items for Systematic Reviews and Meta-analysis (PRISMA) guidelines. Key databases were searched (1990–2014) using relevant search terms and medical subject headings (MeSH); eligibility was evaluated independently by two reviewers based on pre-defined criteria. Study participants had NSSP including impingement syndrome and excluding cervical pain. Interventions included cervicothoracic junction and TMT with or without supplementary exercises. Studies that included MT applied to the shoulder girdle including the glenohumeral joint, acromioclavicular joint or sternoclavicular joint in the TMT group, without a control, were excluded. Included studies utilised outcome measures that monitored pain and disability scores. Randomized controlled trials (RCTs) and clinical studies were eligible. Using a standardised form, each reviewer independently extracted data. Risk of bias was assessed using GRADE and PEDro scale. Results were tabulated for semi-quantitative comparison. Results: Over 912 articles were retrieved: three RCTs, one single-arm trial and three pre–post test studies were eligible. Studies varied from poor to high quality. Three RCTs demonstrated that TMT reduced pain and disability at 6, 26 and 52 weeks compared with usual care. Two pre–post test studies found between 76% and 100% of patients experienced significant pain reduction immediately post-TMT. An additional pre–post test study and a single-arm trial showed reductions in pain and disability scores 48 hours post-TMT. Discussion: Thoracic manual therapy accelerated recovery and reduced pain and disability immediately and for up to 52 weeks compared with usual care for NSSP. Further, high-quality RCTs investigating the effect of TMT in isolation for the treatment of patients with NSSP are now required.