Paula Regina Beckenkamp

Communication that values patient autonomy is associated with satisfaction with care: a systematic review

QUESTION Which communication factors used by clinicians during patient-clinician interactions are associated with satisfaction with care? DESIGN Systematic review with meta-analysis of studies investigating the association of verbal or nonverbal factors or interaction styles used by clinicians with patient satisfaction during an encounter between clinician and patient. PARTICIPANTS : Clinicians interacting with patients in primary care or rehabilitation settings. RESULTS Twenty seven studies investigated 129 verbal, nonverbal, and interaction style factors. Of these, 38 factors were consistently associated with satisfaction. Verbal factors concerning clinicians involving, facilitating, and supporting patients were associated with satisfaction with care. Most communication factors presented a fair correlation (r≥0.21 but <0.41) with satisfaction with care. Nonverbal factors such as time spent discussing prevention and time spent reading patient charts had a fair association with satisfaction with care (correlations range from 0.21 to 0.40). A moderate association was found between interaction styles such as caring (pooled r=0.51, 95% CI 0.42 to 0.60) and satisfaction with care. Over half (58%) of the 129 identified factors never associated with satisfaction with care and the remainder associated inconsistently. CONCLUSION The number of potential modifiable communication factors associated with satisfaction with care and the magnitude of their association partially support interventions to train clinicians in communication skills that value patient autonomy.

Prognosis of physical function following ankle fracture: a systematic review with meta-analysis

STUDY DESIGN Systematic review and meta-analysis of longitudinal studies. OBJECTIVES To quantify the prognosis of physical function following ankle fracture. BACKGROUND Information about the course of recovery of physical function after ankle fracture is essential for patient care and health care policy. The existing data have not previously been included in a meta-analysis. METHODS Studies were identified using searches of electronic databases (Cochrane Central Register of Controlled Trials, MEDLINE, Embase, CINAHL, PEDro, AMED, SPORTDiscus) and gray literature to September 2012. Studies of people with traumatic ankle fracture were included. Two reviewers independently screened references for inclusion, then extracted data and evaluated risk of bias. The outcome of interest was physical function (physical activity and activity limitation). Outcomes were converted to a common 100-point scale, on which higher scores indicated better outcomes. Meta-regression was conducted using generalized estimating equations. RESULTS Thirty-one studies (37 articles) were included. Adults with ankle fracture, present with significant activity limitation in the short term (mean at 1 month, 31.9; 95% confidence interval [CI]: 18.8, 45.1), recovered markedly but incompletely in the short to medium term (mean at 6 months, 78.3; 95% CI: 70.1, 85.1), and showed little further improvement in the long term (mean at 24 months, 86.6; 95% CI: 78.2, 95.0). Studies with older participants and predominantly male participants tended to report worse functional outcomes. CONCLUSION Adults typically experience a rapid initial recovery of physical function after ankle fracture (approximately 80% function at 6 months), but, on average, recovery remains incomplete 24 months after injury. PROSPERO registration number: 42012002979. LEVEL OF EVIDENCE Prognosis, level 2a.

Rehabilitation After Immobilization for Ankle Fracture: The EXACT Randomized Clinical Trial

IMPORTANCE The benefits of rehabilitation after immobilization for ankle fracture are unclear. OBJECTIVES To determine the effectiveness of a supervised exercise program and advice (rehabilitation) compared with advice alone and to determine if effects are moderated by fracture severity or age and sex. DESIGN, SETTING, AND PARTICIPANTS The EXACT trial was a pragmatic, randomized clinical trial conducted from December 2010 to June 2014. Patients with isolated ankle fracture presenting to fracture clinics in 7 Australian hospitals were randomized on the day of removal of immobilization. Of 571 eligible patients, 357 chose not to participate and 214 were allocated to rehabilitation (n = 106) or advice alone (n = 108), with 194 (91%) followed up at 1 month, 173 (81%) at 3 months, and 170 (79%) at 6 months. There were no withdrawals attributed to adverse effects. Recruitment terminated early on December 31, 2013 (planned enrollment, 342; actual, 214), because funding was exhausted. INTERVENTIONS Supervised exercise program and advice about self-management (rehabilitation) (individually tailored, prescribed, monitored, and progressed) or advice alone, both delivered by a physical therapist. MAIN OUTCOMES AND MEASURES Primary outcomes were activity limitation assessed using the Lower Extremity Functional Scale (score range, 0-80; higher scores indicate better activity), and quality of life assessed using the Assessment of Quality of Life (score range, 0-1; higher scores indicate better quality of life), measured at baseline and at 1, 3 (primary time point), and 6 months. RESULTS Mean activity limitation and quality of life at baseline were 30.1 (SD, 12.5) and 0.51 (SD, 0.24), respectively, for advice and 30.2 (SD, 13.2) and 0.54 (SD, 0.24) for rehabilitation, increasing to 64.3 (SD, 13.5) and 0.85 (SD, 0.17) for advice vs 64.3 (SD, 15.1) and 0.85 (SD, 0.20) for rehabilitation at 3 months. Rehabilitation was not more effective than advice for activity limitation (mean effect at 3 months, 0.4 [95% CI, -3.3 to 4.1]) or quality of life (-0.01 [95% CI, -0.06 to 0.04]). Treatment effects were not moderated by fracture severity or age and sex. CONCLUSIONS AND RELEVANCE A supervised exercise program and advice did not confer additional benefits in activity limitation or quality of life compared with advice alone for patients with isolated and uncomplicated ankle fracture. These findings do not support the routine use of supervised exercise programs after removal of immobilization for patients with isolated and uncomplicated ankle fracture. TRIAL REGISTRATION anzctr.org.au Identifier: ACTRN12610000979055.

Usage evaluation of a resource to support evidence-based physiotherapy: the Physiotherapy Evidence Database (PEDro)

OBJECTIVES The Physiotherapy Evidence Database (PEDro) is a free, web-based database of reports of randomised controlled trials, systematic reviews and evidence-based clinical practice guidelines in physiotherapy. The objective of this study was to describe the usage of PEDro over a 2-year period, including the number of visits and searches performed, the number of countries and territories from which users accessed PEDro, and amount of usage from each country. DESIGN Survey of web-site and database log files. MAIN OUTCOME MEASURES Usage of the PEDro home-page (www.pedro.org.au) and the search function were logged for a 2-year period. Visit and search data were used to calculate the number of visits and searches each month. Domain data were used to calculate the total number of countries accessing PEDro and the amount of usage from each country and territory. RESULTS The PEDro home-page received 921,181 visits from 205 countries and territories in 2010 and 2011, with 3,350,740 new searches performed. On average, a new search was initiated every 19seconds. The highest usage was from the United States of America (15%), Australia (13%) and Brasil (8%). Highest normalised usage was from Peru (255 searches/physiotherapist), Chile (154) and Columbia (90), and from Australia (19,883 searches/million-population), New Zealand (13,267) and Switzerland (11,361). CONCLUSIONS There was substantial use of the PEDro resource by the global physiotherapy community during 2010 and 2011. The provision of the PEDro search function in languages other than English may enhance accessibility.

Activity level predicts 6-minute walk distance in healthy older females: an observational study

BACKGROUND The 6-minute walk test (6MWT) is widely used in clinical practice and research. Few studies have investigated activity level as a predictor of 6-minute walk distance (6MWD), and existing predictive models do not allow for activity level. OBJECTIVES To evaluate if knowledge of the level of physical activity enhanced the ability to predict 6MWD, and if the inclusion of activity level added to the predictive accuracy of existing models for the 6MWT in healthy older women; and to validate existent predictive models for 6MWD in a new sample. DESIGN Cross-sectional, observational study. SETTING Four elderly communities. PARTICIPANTS A convenience sample of healthy active and sedentary older non-smoking females with no musculoskeletal or lung disorders. MAIN OUTCOME MEASURES Age, height, weight, spirometric values and 6MWD. RESULTS Seventy-seven out of 154 females met the inclusion criteria [mean age 66 (standard deviation 6.5) years]: 46 were active and composed the active group and 31 were sedentary and composed the sedentary group. The active group had significantly greater 6MWD than the sedentary group (mean 44m; 95% confidence interval 14 to 73m; P<0.01). Previous published models that did not allow for activity level either over or underestimated the 6MWD in this sample. The activity level was shown to be an important independent predictor of 6MWD. CONCLUSION This study demonstrates the importance of considering the level of physical activity when predicting 6MWD in older women.

EXACT: EXercise or Advice after ankle fraCTure. Design of a randomised controlled trial

BackgroundAnkle fractures are common. Management of ankle fractures generally involves a period of immobilisation followed by rehabilitation to reduce pain, stiffness, weakness and swelling. The effects of a rehabilitation program are still unclear. However, it has been shown that important components of rehabilitation programs may not confer additional benefits over exercise alone. The primary aim of this trial is to determine the effectiveness and cost-effectiveness of an exercise-based rehabilitation program after ankle fracture, compared to advice alone.Methods/DesignA pragmatic randomised trial will be conducted. Participants will be 342 adults with stiff, painful ankles after ankle fracture treated with immobilisation. They will be randomly allocated using a concealed randomisation procedure to either an Advice or Rehabilitation group. Participants in the Advice group will receive verbal and written advice about exercise at the time of removal of immobilisation. Participants in the Rehabilitation group will be provided with a 4-week rehabilitation program that is designed, monitored and progressed by a physiotherapist, in addition to verbal and written advice. Outcomes will be measured by a blinded assessor at 1, 3 and 6 months. The primary outcomes will be activity limitation and quality-adjusted life years.DiscussionThis pragmatic trial will determine if a rehabilitation program reduces activity limitation and improves quality of life, compared to advice alone, after immobilisation for ankle fracture.

Reduced Physical Activity in People Following Ankle Fractures: A Longitudinal Study.

STUDY DESIGN Longitudinal observational cohort. BACKGROUND The impact of ankle fracture on physical activity and sitting time and the course of recovery of physical activity are unclear. OBJECTIVES To assess the course of recovery of physical activity after ankle fracture and the extent to which this population may be less physically active and more sedentary than the general population. METHODS A cohort of individuals with ankle fracture was derived from a randomized trial and assessed with the International Physical Activity Questionnaire-Short Form (IPAQ-SF) at immobilization removal and 1, 3, and 6 months later. Total metabolic equivalent (MET) minutes per week were calculated to evaluate the course of recovery of physical activity. Sitting time (minutes per day) and the percentage of those who met the World Health Organization physical activity guidelines were calculated. Normative data were derived from a population-based cohort study that assessed physical activity using the IPAQ-SF. RESULTS In people with ankle fracture (n = 214), physical activity increased in the first month (from a median of 99 at immobilization removal to 979 MET min/wk) and leveled off by 6 months (1386 MET min/wk). Only 22% of the ankle fracture cohort met World Health Organization guidelines at immobilization removal, compared to 80% of the cohort from the general population (P<.001). This difference diminished over time. Sitting time in the ankle fracture cohort was higher than population norms at all time points (P<.001). CONCLUSION People with ankle fracture are less physically active and more sedentary than the general population. Strategies to increase physical activity must be considered. LEVEL OF EVIDENCE Prognosis, level 4.

The effects of warm-up on physical performance are not clear

▶ 1. Fradkin AJ, 2. Tsharni RZ, 3. Smoliga JM . J Strength Cond Res 2010;24:140–8. [OpenUrl][1][CrossRef][2][PubMed][3][Web of Science][4] Warm-up is commonly used as part of an exercise programme. Previous reviews have cast doubts on the beneficial effects long thought to be associated with warm-up.1 2 However, recent evidence indicates that warm-up prevents sports-related injuries.3,–,5 Warm-up in the form of stretching has a small effect in reducing muscle soreness following exercise3 and leads to an increase in joint range of motion, but magnitude of the increase is small. Thus, it has an uncertain clinical importance.6 7 In addition to preventing muscle soreness and injury, another possible benefit of warm-up is enhanced physical performance. Only one previous review has examined the effects of warm-up on performance,2 but found limited evidence. Hence, the effects of warm-up on performance during sport … [1]: {openurl}?query=rft.jtitle%253DJournal%2Bof%2Bstrength%2Band%2Bconditioning%2Bresearch%2B%252F%2BNational%2BStrength%2B%2526%2BConditioning%2BAssociation%26rft.stitle%253DJ%2BStrength%2BCond%2BRes%26rft.aulast%253DFradkin%26rft.auinit1%253DA.%2BJ.%26rft.volume%253D24%26rft.issue%253D1%26rft.spage%253D140%26rft.epage%253D148%26rft.atitle%253DEffects%2Bof%2Bwarming-up%2Bon%2Bphysical%2Bperformance%253A%2Ba%2Bsystematic%2Breview%2Bwith%2Bmeta-analysis.%26rft_id%253Dinfo%253Adoi%252F10.1519%252FJSC.0b013e3181c643a0%26rft_id%253Dinfo%253Apmid%252F19996770%26rft.genre%253Darticle%26rft_val_fmt%253Dinfo%253Aofi%252Ffmt%253Akev%253Amtx%253Ajournal%26ctx_ver%253DZ39.88-2004%26url_ver%253DZ39.88-2004%26url_ctx_fmt%253Dinfo%253Aofi%252Ffmt%253Akev%253Amtx%253Actx [2]: /lookup/external-ref?access_num=10.1519/JSC.0b013e3181c643a0&link_type=DOI [3]: /lookup/external-ref?access_num=19996770&link_type=MED&atom=%2Fbjsports%2F45%2F6%2F525.atom [4]: /lookup/external-ref?access_num=000273558300021&link_type=ISI

Preoperative exercise halves the postoperative complication rate in patients with lung cancer: a systematic review of the effect of exercise on complications, length of stay and quality of life in patients with cancer

Objective To investigate the effectiveness of preoperative exercises interventions in patients undergoing oncological surgery, on postoperative complications, length of hospital stay and quality of life. Design Intervention systematic review with meta-analysis. Data sources MEDLINE, Embase and PEDro. Eligibility criteria for selecting studies Trials investigating the effectiveness of preoperative exercise for any oncological patient undergoing surgery were included. The outcomes of interest were postoperative complications, length of hospital stay and quality of life. Relative risks (RRs), mean differences (MDs) and 95% CI were calculated using random-effects models. Results Seventeen articles (reporting on 13 different trials) involving 806 individual participants and 6 tumour types were included. There was moderate-quality evidence that preoperative exercise significantly reduced postoperative complication rates (RR 0.52, 95% CI 0.36 to 0.74) and length of hospital stay (MD −2.86 days, 95% CI −5.40 to −0.33) in patients undergoing lung resection, compared with control. For patients with oesophageal cancer, preoperative exercise was not effective in reducing length of hospital stay (MD 2.00 days, 95% CI −2.35 to 6.35). Although only assessed in individual studies, preoperative exercise improved postoperative quality of life in patients with oral or prostate cancer. No effect was found in patients with colon and colorectal liver metastases. Conclusions Preoperative exercise was effective in reducing postoperative complications and length of hospital stay in patients with lung cancer. Whether preoperative exercise reduces complications, length of hospital stay and improves quality of life in other groups of patients undergoing oncological surgery is uncertain as the quality of evidence is low. PROSPEROregistration number

Diagnostic accuracy of the Ottawa Ankle and Midfoot Rules: a systematic review with meta-analysis

Objective To review the diagnostic accuracy of the Ottawa Ankle and Midfoot Rules and explore if clinical features and/or methodological quality of the study influence diagnostic accuracy estimates. Design Systematic review with meta-analysis. Data sources MEDLINE, EMBASE, CINAHL, SPORTDiscus and Cochrane Library. Eligibility criteria for selecting studies Primary diagnostic studies reporting the accuracy of the Rules in people with ankle and/or midfoot injury were retrieved. Diagnostic accuracy estimates, overall and for subgroups (patient’s age, profession of the assessor and setting of application), were made. Sensitivity analyses included studies with a low risk of bias and studies where all patients received radiographs. Results 66 studies were included. Ankle and Midfoot Rules presented similar accuracies, which were homogeneous and high for sensitivity and negative likelihood ratios and poor and heterogeneous for specificity and positive likelihood ratios (mean, 95% CI pooled sensitivity of Ankle Rules: 99.4%, 97.9% to 99.8%; specificity: 35.3%, 28.8% to 42.3%). Sensitivity of the Ankle Rules was higher in adults than in children, but the profession of the assessor did not appear to influence accuracy. Specificity was higher for Midfoot than for Ankle Rules. There were not enough studies to allow comparison according to setting of application. Studies with a low risk of bias and where all patients received radiographs provided lower accuracy estimates. Specificity heterogeneity was not explained by assessor training, use of imaging in all patients and low risk of bias. Conclusions Study features and the methodological quality influence estimates of the diagnostic accuracy of the Ottawa Ankle and Midfoot Rules.