Suzanne J. Snodgrass

Factors related to thumb pain in physiotherapists

The aim of this study was to determine whether differences exist between physiotherapists with work-related thumb pain and physiotherapists without thumb pain. Twenty-four physiotherapists with work-related thumb pain (Pain Group) and 20 physiotherapists without thumb or wrist pain (Non-pain Group), who were working at least 20 hours per week in an outpatient musculoskeletal setting, were compared on a number of attributes: generalised joint laxity, hand and thumb strength, height, weight, working environment, hand position and force applied during mobilisation, mobility at individual thumb joints, extent of osteoarthritis at the thumb and radial-sided wrist joints, and demographic data including age, gender and years of experience. All physiotherapists in the Pain Group reported their thumb pain was related to and initially caused by the performance of manual techniques, and 88% had altered their manual techniques because of pain in the thumb. There was extreme variability in hand position and force applied during mobilisation, and a slightly high prevalence of osteoarthritis (22.7%) considering the mean age of the total sample (38.6 years). Statistically significant differences between groups included increased right carpometacarpal joint laxity (6.4%, 95% CI 0.19 to 12.6), decreased right tip pinch strength (0.84 kg, 95% CI 0.01 to 1.68), and lower body mass index (2.0, 95% CI 0.11 to 3.9) for the Pain Group. Other factors were not statistically different between groups. These results indicate that work-related thumb pain affects physiotherapists ability to administer manual treatments, and suggest that decreased stability and strength of the thumb may be associated with work-related thumb pain.

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.

Perceptions of older people about falls injury prevention and physical activity

Objectives:  The purpose of this study was to explore the beliefs and perceptions of older people about falls injury prevention services, and to identify incentives and barriers to attending falls prevention services, including programs targeting physical activity.

The Effects of Thoracic Manipulation on Posteroanterior Spinal Stiffness

STUDY DESIGN Controlled laboratory study, with measurements taken before and after a standardized clinical intervention. OBJECTIVES To determine if thoracic manipulation alters the posteroanterior (PA) spinal stiffness of the thoracic spine, and the factors associated with any potential changes in stiffness. BACKGROUND Spinal manipulation is commonly used to treat thoracic pain and dysfunction. Therapists use manual assessment of PA spinal stiffness to determine the appropriateness and effectiveness of treatment, with potential changes in spinal stiffness possibly contributing to symptomatic improvement following manipulation. METHODS Thoracic PA spinal stiffness was measured at 5 vertebral levels (manipulated level and 2 levels above and below), in 24 asymptomatic subjects, before and after manipulation. Five cycles of standardized mechanical PA force were applied to the spinous process while recording resistance to movement and concurrent displacement, with stiffness defined as the slope of the linear portion of the force-displacement curve. A 2-way repeated-measures analysis of variance determined differences between premanipulation and postmanipulation among multiple spinal levels. Linear regression determined the relationship between stiffness magnitude and its change following manipulation. Generalized linear mixed models were used to determine if subject age, gender, spinal level, premanipulation stiffness, or manipulative thrust parameters were associated with postmanipulation stiffness. RESULTS Thoracic spine PA stiffness differed between spinal levels (F4,92=21.1, P<.001) but was not significantly different following manipulation. The mean change in spinal stiffness correlated with stiffness magnitude at the manipulated spinal level only but not other levels (Pearson r, –0.65; P<.001). Greater postmanipulation stiffness was associated with being male (regression coefficient, 1.16; 95% CI: 0.52, 1.79; P<.001) and with higher premanipulation stiffness (regression coefficient, 0.63; 95% CI: 0.49, 0.77; P<.001). Manipulation force parameters were not associated with postmanipulation stiffness. CONCLUSION In asymptomatic individuals, thoracic PA spinal stiffness is not significantly different when measured before and after thrust manipulation, but any potential mechanical effects appear associated with the manipulated spinal level rather than other levels.

Dose Optimization for Spinal Treatment Effectiveness: A Randomized Controlled Trial Investigating the Effects of High and Low Mobilization Forces in Patients With Neck Pain

STUDY DESIGN Randomized controlled trial. Objective To determine if force magnitude during posterior-to-anterior mobilization affects immediate and short-term outcomes in patients with chronic, nonspecific neck pain. BACKGROUND The optimal dose of mobilization to effectively treat patients with neck pain is not known. METHODS Patients with neck pain of at least 3 months in duration (n = 64) were randomized to receive a single treatment of posterior-to-anterior mobilization applied with 30 N or 90 N of mean peak force (3 sets of 30 seconds) or a placebo (detuned laser) on the spinous process at the painful spinal level. Pressure pain threshold, pain measured with a visual analog scale (range, 0-100 mm), cervical range of motion, and spinal stiffness at the painful spinal level (measured with a custom device and normalized as a percentage of C7 stiffness) were assessed before, immediately after, and at a mean ± SD follow-up of 4.0 ± 1.8 days following treatment. Repeated-measures analysis of covariance and Bonferroni-adjusted post hoc tests determined group differences for each outcome measure after treatment and at follow-up. RESULTS At follow-up, the 90-N group had less pain than the 30-N group (mean difference, 11.3 mm; 95% confidence interval: 0.1, 22.6 mm; P = .048) and lower stiffness than the placebo group (mean difference, 17.5%; 95% confidence interval: 4.2%, 30.9%; P = .006). These differences were not present immediately after treatment. There were no significant between-group differences in pressure pain threshold or range of motion after treatment or at follow-up. CONCLUSION A specific dose of mobilization, in terms of applied force, appears necessary for reducing stiffness and potentially pain in patients with chronic neck pain. Changes were not observed immediately after mobilization, suggesting that its effects are not directly mechanical. TRIAL REGISTRATION Australian and New Zealand Clinical Trials Registry ( http://www.anzctr.org.au/): ACTRN12611000374965. LEVEL OF EVIDENCE Therapy, level 1b-.

HOBOE (Head-of-Bed Optimization of Elevation) Study: Association of Higher Angle With Reduced Cerebral Blood Flow Velocity in Acute Ischemic Stroke

Background Cerebral autoregulation can be impaired after ischemic stroke, with potential adverse effects on cerebral blood flow during early rehabilitation. Objective The objective of this study was to assess changes in cerebral blood flow velocity with orthostatic variation at 24 hours after stroke. Design This investigation was an observational study comparing mean flow velocities (MFVs) at 30, 15, and 0 degrees of elevation of the head of the bed (HOB). Methods Eight participants underwent bilateral middle cerebral artery (MCA) transcranial Doppler monitoring during orthostatic variation at 24 hours after ischemic stroke. Computed tomography angiography separated participants into recanalized (artery completely reopened) and incompletely recanalized groups. Friedman tests were used to determine MFVs at the various HOB angles. Mann-Whitney U tests were used to compare the change in MFV (from 30° to 0°) between groups and between hemispheres within groups. Results For stroke-affected MCAs in the incompletely recanalized group, MFVs differed at the various HOB angles (30°: median MFV=51.5 cm/s, interquartile range [IQR]=33.0 to 103.8; 15°: median MFV=55.5 cm/s, IQR=34.0 to 117.5; 0°: median MFV=85.0 cm/s, IQR=58.8 to 127.0); there were no significant differences for other MCAs. For stroke-affected MCAs in the incompletely recanalized group, MFVs increased with a change in the HOB angle from 30 degrees to 0 degrees by a median of 26.0 cm/s (IQR=21.3 to 35.3); there were no significant changes in the recanalized group (−3.5 cm/s, IQR=−12.3 to 0.8). The changes in MFV with a change in the HOB angle from 30 degrees to 0 degrees differed between hemispheres in the incompletely recanalized group but not in the recanalized group. Limitations Generalizability was limited by sample size. Conclusions The incompletely recanalized group showed changes in MFVs at various HOB angles, suggesting that cerebral blood flow in this group may be sensitive to orthostatic variation, whereas the recanalized group maintained stable blood flow velocities.

Cervical spine mobilisation forces applied by physiotherapy students

OBJECTIVES Postero-anterior (PA) mobilisation is commonly used in cervical spine treatment and included in physiotherapy curricula. The manual forces that students apply while learning cervical mobilisation are not known. Quantifying these forces informs the development of strategies for learning to apply cervical mobilisation effectively and safely. This study describes the mechanical properties of cervical PA mobilisation techniques applied by students, and investigates factors associated with force application. PARTICIPANTS Physiotherapy students (n=120) mobilised one of 32 asymptomatic subjects. METHODS Students applied Grades I to IV central and unilateral PA mobilisation to C2 and C7 of one asymptomatic subject. Manual forces were measured in three directions using an instrumented treatment table. Spinal stiffness of mobilised subjects was measured at C2 and C7 using a device that applied a standard oscillating force while measuring this force and its concurrent displacement. Analysis of variance was used to determine differences between techniques and grades, intraclass correlation coefficients (ICC) were used to calculate the inter- and intrastudent repeatability of forces, and linear regression was used to determine the associations between applied forces and characteristics of students and mobilised subjects. RESULTS Mobilisation forces increased from Grades I to IV (highest mean peak force, Grade IV C7 central PA technique: 63.7N). Interstudent reliability was poor [ICC(2,1)=0.23, 95% confidence interval (CI) 0.14 to 0.43], but intrastudent repeatability of forces was somewhat better (0.83, 95% CI 0.81 to 0.86). Higher applied force was associated with greater C7 stiffness, increased frequency of thumb pain, male gender of the student or mobilised subject, and a student being earlier in their learning process. Lower forces were associated with greater C2 stiffness. CONCLUSION This study describes the cervical mobilisation forces applied by students, and the characteristics of the student and mobilised subject associated with these forces. These results form a basis for the development of strategies to provide objective feedback to students learning to apply cervical mobilisation.

Thumb Pain in Physiotherapists: Potential Risk Factors and Proposed Prevention Strategies

Abstract Work-related injury to the thumb has become a recognized problem for physiotherapists who perform manual techniques in the treatment of patients with orthopaedic musculoskeletal disorders. Pain in the thumb often causes physiotherapists to alter their methods of treatment, which may decrease the effectiveness of physiotherapy services and lead to increased financial costs for patients and their funding agencies. Substantial numbers of physiotherapists have changed their specialty area or left the profession because of work-related injury, which further burdens education and healthcare systems. The extent of the influence of individual risk factors and preventive strategies on the development of thumb pain in physiotherapists has not been conclusively determined. This paper discusses the potential causes and consequences of thumb pain in physiotherapists, and reviews the supporting evidence on the incidence, risk, prevention, and treatment of this common occupational injury in physiotherapists.

Manual therapy for cervicogenic dizziness: Long-term outcomes of a randomised trial

Manual therapy is effective for reducing cervicogenic dizziness, a disabling and persistent problem, in the short term. This study investigated the effects of sustained natural apophyseal glides (SNAGs) and passive joint mobilisations (PJMs) on cervicogenic dizziness compared to a placebo at 12 months post-treatment. Eighty-six participants (mean age 62 years, standard deviation (SD) 12.7) with chronic cervicogenic dizziness were randomised to receive SNAGs with self-SNAGs (n = 29), PJMs with range-of-motion (ROM) exercises (n = 29), or a placebo (n = 28) for 2-6 sessions over 6 weeks. Outcome measures were dizziness intensity, dizziness frequency (rated between 0 [none] and 5 [>once/day]), the Dizziness Handicap Inventory (DHI), pain intensity, head repositioning accuracy (HRA), cervical spine ROM, balance, and global perceived effect (GPE). At 12 months both manual therapy groups had less dizziness frequency (mean difference SNAGs vs placebo -0.7, 95% confidence interval (CI) -1.3, -0.2, p = 0.01; PJMs vs placebo -0.7, -1.2, -0.1, p = 0.02), lower DHI scores (mean difference SNAGs vs placebo -8.9, 95% CI -16.3, -1.6, p = 0.02; PJMs vs placebo -13.6, -20.8, -6.4, p < 0.001) and higher GPE compared to placebo, whereas there were no between-group differences in dizziness intensity, pain intensity or HRA. There was greater ROM in all six directions for the SNAG group and in four directions for the PJM group compared to placebo, and small improvements in balance for the SNAG group compared to placebo. There were no adverse effects. These results provide evidence that both forms of manual therapy have long-term beneficial effects in the treatment of chronic cervicogenic dizziness.

Survey of Australian practitioners' provision of healthy lifestyle advice to clients who are obese

Obesity is a global issue, with healthcare practitioners increasingly involved in clinical interactions with people who are overweight or obese. These interactions are opportunities to provide evidence-based healthy lifestyle advice, and impact on public health. This study used a cross-sectional survey of Australian healthcare practitioners to investigate what influenced the provision of healthy lifestyle advice to obese and overweight clients. A modified theory of planned behavior was used to explore knowledge translation processes. Knowledge translation was linked to three factors: (i) a healthcare practitioners education and confidence in the currency of their knowledge; (ii) personal characteristics - whether they accepted that providing this advice was within their domain of practice; and (iii) the existence of organizational support structures, such as access to education, and best practice guidelines. To fulfill the potential role healthcare practitioners can play in the provision of evidence-based health promotion advice requires organizations to provide access to practice guidelines and to instill a belief in their workforce that this is a shared professional domain.