Tara Cusack

Manual therapy for osteoarthritis of the hip or knee – A systematic review

The aim of this systematic review was to determine if manual therapy improves pain and/or physical function in people with hip or knee OA. Eight databases were searched for randomised controlled trials (RCTs). Data were extracted and risk of bias assessed by independent reviewers. Four RCTs were eligible for inclusion (280 subjects), three of which studied people with knee OA and one studied those with hip OA. One study compared manual therapy to no treatment, one compared to placebo intervention, whilst two compared to alternative interventions. Meta-analysis was not possible due to clinical heterogeneity of the studies. One study had a low risk of bias and three had high risk of bias. All studies reported short-term effects, and long-term effects were measured in one study. There is silver level evidence that manual therapy is more effective than exercise for those with hip OA in the short and long-term. Due to the small number of RCTs and patients, this evidence could be considered to be inconclusive regarding the benefit of manual therapy on pain and function for knee or hip OA.

Family-Mediated Exercise Intervention (FAME) Evaluation of a Novel Form of Exercise Delivery After Stroke

Background and Purpose— Additional exercise therapy has been shown to have a positive impact on function after acute stroke and research is now focusing on methods to increase the amount of therapy that is delivered. This randomized controlled trial examined the impact of additional family-mediated exercise (FAME) therapy on outcome after acute stroke. Methods— Forty participants with acute stroke were randomly assigned to either a control group who received routine therapy with no formal input from their family members or a FAME group, who received routine therapy and additional lower limb FAME therapy for 8 weeks. The primary outcome measure used was the lower limb section of the Fugl-Meyer Assessment modified by Lindmark. Other measures of impairment, activity, and participation were completed at baseline, postintervention, and at a 3-month follow-up. Results— Statistically significant differences in favor of the FAME group were noted on all measures of impairment and activity postintervention (P<0.05). These improvements persisted at the 3-month follow-up but only walking was statistically significant (P<0.05). Participants in the FAME group were also significantly more integrated into their community at follow-up (P<0.05). Family members in the FAME group reported a significant decrease in their levels of caregiver strain at the follow-up when compared with those in the control group (P<0.01). Conclusions— This evidence-based FAME intervention can serve to optimize patient recovery and family involvement after acute stroke at the same time as being mindful of available resources.

Exercise and manual physiotherapy arthritis research trial (EMPART) for osteoarthritis of the hip: a multicenter randomized controlled trial.

OBJECTIVES To determine the effectiveness of exercise therapy (ET) compared with ET with adjunctive manual therapy (MT) for people with hip osteoarthritis (OA); and to identify if immediate commencement of treatment (ET or ET+MT) was more beneficial than a 9-week waiting period for either intervention. DESIGN Assessor-blind randomized controlled trial with a 9-week and 18-week follow-up. SETTING Four academic teaching hospitals in Dublin, Ireland. PARTICIPANTS Patients (N=131) with hip OA recruited from general practitioners, rheumatologists, orthopedic surgeons, and other hospital consultants were randomized to 1 of 3 groups: ET (n=45), ET+MT (n=43), and waitlist controls (n=43). INTERVENTIONS Participants in both the ET and ET+MT groups received up to 8 treatments over 8 weeks. Control group participants were rerandomized into either ET or ET+MT groups after 9 week follow-up. Their data were pooled with original treatment group data: ET (n=66) and ET+MT (n=65). MAIN OUTCOME MEASURES The primary outcome was the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) physical function (PF) subscale. Secondary outcomes included physical performance, pain severity, hip range of motion (ROM), anxiety/depression, quality of life, medication usage, patient-perceived change, and patient satisfaction. RESULTS There was no significant difference in WOMAC PF between the ET (n=66) and ET+MT (n=65) groups at 9 weeks (mean difference, .09; 95% confidence interval [CI] -2.93 to 3.11) or 18 weeks (mean difference, .42; 95% CI, -4.41 to 5.25), or between other outcomes, except patient satisfaction with outcomes, which was higher in the ET+MT group (P=.02). Improvements in WOMAC, hip ROM, and patient-perceived change occurred in both treatment groups compared with the control group. CONCLUSIONS Self-reported function, hip ROM, and patient-perceived improvement occurred after an 8-week program of ET for patients with OA of the hip. MT as an adjunct to exercise provided no further benefit, except for higher patient satisfaction with outcome.

The Impact of Increased Duration of Exercise Therapy on Functional Recovery Following Stroke — What Is the Evidence?

Abstract This article focuses on the impact of increased duration of exercise therapy on functional recovery after stroke. A comprehensive literature search using multiple databases was used to identify all relevant randomized controlled trials. Their quality was reviewed by two independent assessors, and a narrative systematic review and meta-analysis was completed. Methodological quality of all the 20 randomized controlled trials (RCTs) identified had a median of 6 points (range 5–8) on the 10-point PEDro scale. A meta-analysis was completed for studies that had a common outcome measure. For each outcome measure, the estimated effect size (ES) and the summary effect size (SES) were expressed as standardized mean differences (SMD). The results of the meta-analysis demonstrated that increased duration of exercise therapy time has a small but positive effect on activities of daily living as measured by the Barthel Index (SES 0.13; CI 0.01–0.25; Z = 2.15; p = .03) and that these improvements are maintained over a 6-month period (SES 0.15; CI 0.05–0.26; Z = 2.8; p = .00). Pooling reported differences in the various upper and lower extremity outcome measures demonstrated no significant SESs. However, the meta-analysis is supportive of the hypothesis that additional, focused exercise on the lower extremity has a favourable effect on lower extremity impairment and walking speed. The narrative review raises a number of issues that need to be considered in the development of future RCTs.

Addition of motivational interventions to exercise and traditional Physiotherapy: a review and meta-analysis

BACKGROUND Incontestable epidemiological trends indicate that, for the foreseeable future, mortality and morbidity will be dominated by an escalation in chronic lifestyle-related diseases. International guidelines recommend the implementation of evidence-based approaches to bring about health behaviour changes. Motivational interventions to increase adherence and physical activity are not part of traditional physiotherapy for any condition. OBJECTIVE To evaluate the evidence for the effectiveness of adding motivational interventions to traditional physiotherapy to increase physical activity and short- and long-term adherence to exercise prescriptions. DATA SOURCES A literature search of PubMed, EMBASE, Scopus, CINAHL, PsychINFO, AMED and Allied Health Evidence database using keywords and subject headings. STUDY SELECTION Only randomised controlled trials comparing two or more arms, with one arm focused on motivational interventions influencing exercise and one control arm, were included. The search identified 493 titles, of which 14 studies (comprising 1504 participants) were included. DATA EXTRACTION The principal investigator extracted data that were reviewed independently by another author. Methodological quality was assessed independently by two authors using the Cochrane Risk of Bias tool and the PEDro scale. Outcomes were measured at the level of impairment, activity limitation and participation restriction. The standardised mean difference between the control and intervention groups at follow-up time points was used as the mode of analysis. I2≤50% was used as the cut-off point for acceptable heterogeneity, above which a random effects model was applied. RESULTS Exercise attendance was measured in six studies (n=378), and the results indicate that there was no significant difference in exercise attendance between the groups (Random effects model, standardised mean difference 0.33, 95% confidence interval -0.03 to 0.68, I2 62%). Perceived self-efficacy results were pooled from six studies (n=722), and a significant difference was found between the groups in favour of the interventions (Fixed effects model, standardised mean difference 0.71, 95% confidence interval 0.55 to 0.87, I2 41%). The results for levels of activity limitation were pooled (n=550), and a significant difference was found between the groups in favour of the interventions (REM, standardised mean difference -0.37, 95% confidence interval -0.65 to -0.08, I(2) 61%). LIMITATIONS The majority of the included studies were of medium quality, and four studies were of low quality. Data were pooled from a wide variety of different populations and settings, increasing the assortment of study characteristics. CONCLUSIONS Motivational interventions can help adherence to exercise, have a positive effect on long-term exercise behaviour, improve self-efficacy and reduce levels of activity limitation. The optimal theory choice and the most beneficial length and type of intervention have not been defined, although all interventions showed benefits. There is a need to determine how practising physiotherapists currently optimise adherence, and their current levels of knowledge about motivational interventions. IMPLICATIONS OF KEY FINDINGS The results indicate that motivational interventions are successful for increasing healthy physical activity behaviour. Physiotherapists are ideally placed to take on this role, and motivational interventions must become part of physiotherapy practice.

To what extent are family members and friends involved in physiotherapy and the delivery of exercises to people with stroke

Purpose. To examine the views of people with stroke, their ‘family members/friends’ and physiotherapists on the role of the family in physiotherapy and the delivery of exercises following stroke. Methods. A self-report questionnaire was administered to 100 ‘family members/friends’ and 75 people with stroke. Two focus groups were conducted with 10 expert physiotherapists working in the area of stroke rehabilitation. Results. Family members of people with stroke are willing to participate in the delivery of unsupervised exercises in the hospital and the home setting (n = 91). Furthermore, this is also acceptable to people with stroke (n = 65) as an adjunct to routine physiotherapy. Physiotherapists highlighted a number of factors that influenced participation in physiotherapy such as; level of interest and motivation of the family (n = 5), availability (n = 3) and importance of education (n = 2). ‘Family members/friends’ identified reasons that would also limit participation such as work commitments (n = 24), lack of confidence (n = 20) and unsuitable treatment times (n = 13). The expert practitioners outlined a number of areas that family involvement can have an impact, such as treatment carry-over, assisting the family unit to cope on discharge and improving handling skills. Conclusions. Our study identifies an under-utilised role for ‘family members/friends’ in the rehabilitation of people with stroke. Family mediated exercises can maximise the carry-over outside formal physiotherapy giving patients the opportunity for informal practice. This study highlights the need to examine the value of a structured programme of exercises that can be delivered to people with stroke by their ‘family members/friends’.

The effect of a dual task on gait speed in community dwelling older adults: A systematic review and meta-analysis

BACKGROUND AND PURPOSE Reduced walking speed in older adults is associated with adverse health outcomes. This review aims to examine the effect of a cognitive dual-task on the gait speed of community-dwelling older adults with no significant pathology affecting gait. DATA SOURCES AND STUDY SELECTION Electronic database searches were performed in, Web of Science, PubMed, SCOPUS, Embase and psychINFO. Eligibility and methodological quality was assessed by two independent reviewers. The effect size on gait speed was measured as the raw mean difference (95% confidence interval) between single and dual-task performance. Pooled estimates of the overall effect were computed using a random effects method and forest plots generated. DATA EXTRACTION AND DATA SYNTHESIS 22 studies (27 data sets) with a population of 3728 were reviewed and pooled for meta-analysis. The mean walking speed of participants included in all studies was >1.0m/s and all studies reported the effect of a cognitive dual-task on gait speed. Sub-analysis examined the effect of type of cognitive task (mental-tracking vs. verbal-fluency). Mean single-task gait speed was 1.21 (0.13)m/s, the addition of a dual-task reduced speed by 0.19 m/s to 1.02 (0.16)m/s (p<0.00001), both mental-tracking and verbal-fluency tasks resulted in significant reduction in gait speed. LIMITATIONS AND CONCLUSION The cross-sectional design of the studies made quality assessment difficult. Despite efforts, high heterogeneity remained, possibly due to participant characteristics and testing protocols. This meta-analysis shows that in community-dwelling older adults, the addition of a dual-task significantly reduces gait speed and may indicate the value of including dual-task walking as part of the standard clinical assessment of older people.

Exercise and manual physiotherapy arthritis research trial (EMPART): a multicentre randomised controlled trial

BackgroundOsteoarthritis (OA) of the hip is a major cause of functional disability and reduced quality of life. Management options aim to reduce pain and improve or maintain physical functioning. Current evidence indicates that therapeutic exercise has a beneficial but short-term effect on pain and disability, with poor long-term benefit. The optimal content, duration and type of exercise are yet to be ascertained. There has been little scientific investigation into the effectiveness of manual therapy in hip OA. Only one randomized controlled trial (RCT) found greater improvements in patient-perceived improvement and physical function with manual therapy, compared to exercise therapy.Methods and designAn assessor-blind multicentre RCT will be undertaken to compare the effect of a combination of manual therapy and exercise therapy, exercise therapy only, and a waiting-list control on physical function in hip OA. One hundred and fifty people with a diagnosis of hip OA will be recruited and randomly allocated to one of 3 groups: exercise therapy, exercise therapy with manual therapy and a waiting-list control. Subjects in the intervention groups will attend physiotherapy for 6–8 sessions over 8 weeks. Those in the control group will remain on the waiting list until after this time and will then be re-randomised to one of the two intervention groups. Outcome measures will include physical function (WOMAC), pain severity (numerical rating scale), patient perceived change (7-point Likert scale), quality of life (SF-36), mood (hospital anxiety and depression scale), patient satisfaction, physical activity (IPAQ) and physical measures of range of motion, 50-foot walk and repeated sit-to stand tests.DiscussionThis RCT will compare the effectiveness of the addition of manual therapy to exercise therapy to exercise therapy only and a waiting-list control in hip OA. A high quality methodology will be used in keeping with CONSORT guidelines. The results will contribute to the evidence base regarding the clinical efficacy for physiotherapy interventions in hip OA.Trial RegistrationNumber: NCT00709566

Functional exercise after total hip replacement (FEATHER) a randomised control trial

BackgroundProlonged physical impairments in range of movement, postural stability and walking speed are commonly reported following total hip replacement (THR). It is unclear from the current body of evidence what kind of exercises should be performed to maximize patient function and quality of life.Methods/designThis will be a single blind multi centre randomized control trial with two arms. Seventy subjects post primary total hip arthroplasty will be randomized into either an experimental group (n=35), or to a control group (n=35). The experimental group will attend a functional exercise class twice weekly for a six week period from week 12 to week 18 post surgery. The functional exercise group will follow a circuit based functional exercise class supervised by a chartered Physiotherapist. The control group will receive usual care. The principal investigator (BM) will perform blinded outcome assessments on all patients using validated measures for pain, stiffness, and function using the Western Ontario and Mc Master Universities Osteoarthritis index (WOMAC). This is the primary outcome measurement tool. Secondary outcome measurements include Quality of life (SF-36), 6 min walk test, Visual Analogue Scale, and the Berg Balance score. The WOMAC score will be collated on day five post surgery and repeated at week twelve and week eighteen. All other measurements will be taken at week 12 and repeated at week eighteen. In addition a blinded radiologist will measure gluteus medius cross sectional area using real time ultrasound for all subjects at week 12 and at week 18 to determine if the functional exercise programme has any effect on muscle size.DiscussionThis randomised controlled trial will add to the body of evidence on the relationship between muscle size, functional ability, balance, quality of life and time post surgery in patients following total hip arthroplasty. The CONSORT guidelines will be followed to throughout. Ethical approval has been gained from the Ethics committee Health Services Executive Dublin North East.Trial registrationThis trial is registered with ClinicalTrials.gov (a service of the United States National Institutes of Health) identifier NCT01683201

Activation levels of gluteus medius during therapeutic exercise as measured with electromyography: a structured review

Abstract Background: Strengthening exercise for gluteus medius (GMed) is an important management strategy for lower limb disorders such as osteoarthritis and patello-femoral syndrome, and exercises in functional positions are commonly prescribed. Electromyography (EMG) can be used to measure muscle activation to ascertain the extent of muscle recruitment during exercise. Objectives: To review the available evidence on the magnitude of GMed activation measured with EMG during therapeutic exercise. Methods: A structured review of studies which measured EMG magnitude of GMed during a range of therapeutic exercises was undertaken. Amplitude levels of GMed were reported as a percentage of maximum voluntary isometric contraction. Results: Fifteen studies were included. Most of these were conducted on asymptomatic volunteers, with three studies investigating individuals with knee or hip pathology. A wide range of exercises was investigated in both weightbearing (WB) and nonweightbearing (NWB) positions. In general, EMG activation was greater in WB positions but variation occurred across studies. Many exercises were below levels considered necessary for strength gains. Generally, methodological quality was good but there was variation in the reporting of technical aspects of the study. Many of the studies did not acknowledge the range of limitations of EMG in measuring muscle activation in therapeutic exercise. Conclusions: The results provide some information regarding GMed recruitment during exercise, although there were some discrepancies in results between studies which may be due to factors related to EMG measurement and recording as well as the execution of the exercise. Extrapolation of results to symptomatic populations in a clinical setting islimited.