Tracey Howe

Gait variability in older adults: A structured review of testing protocol and clinimetric properties

Gait variability (stride-to-stride fluctuations) is used increasingly as a marker for gait performance and future mobility status, cognitive status, and falls. This structured review explicitly examined literature that reported on the reliability, validity and responsiveness of gait variability in older adults. We searched Medline, Embase, Web of Science, Scopus, CINAHL, PEDRO, Biomechanics, SportDiscus and PsycInfo databases. Two independent reviewers undertook data extraction, with adjudication by a third reviewer in cases of disagreement. Twenty-two full papers were screened and 10 met the predefined inclusion criteria, involving 1036 participants who were mainly community dwelling older adults in their 8th decade. A wide range of gait variability parameters, testing protocols and calculations of gait variability were reported. Reliability estimates varied, but were mostly fair to moderate. Concurrent validity was established for stance time variability and change estimates were reported for stance time and swing time. Standard of reporting was generally poor, with insufficient detail provided for aspects of measurement and testing protocols. Further research is required to standardise testing procedures and establish reliability, responsiveness and validity for confident use of gait variability as a robust measure.

Lower-limb risk factors for falls in people with diabetes mellitus

Diabet. Med. 27, 162–168 (2010)

A systematic review of measures of self-reported adherence to unsupervised home-based rehabilitation exercise programmes, and their psychometric properties

Background Adherence is an important factor contributing to the effectiveness of exercise-based rehabilitation. However, there appears to be a lack of reliable, validated measures to assess self-reported adherence to prescribed but unsupervised home-based rehabilitation exercises. Objectives A systematic review was conducted to establish what measures were available and to evaluate their psychometric properties. Data sources MEDLINE, EMBASE, PsycINFO CINAHL (June 2013) and the Cochrane library were searched (September 2013). Reference lists from articles meeting the inclusion criteria were checked to ensure all relevant papers were included. Study selection To be included articles had to be available in English; use a self-report measure of adherence in relation to a prescribed but unsupervised home-based exercise or physical rehabilitation programme; involve participants over the age of 18. All health conditions and clinical populations were included. Data extraction Descriptive data reported were collated on a data extraction sheet. The measures were evaluated in terms of eight psychometric quality criteria. Results 58 studies were included, reporting 61 different measures including 29 questionnaires, 29 logs, two visual analogue scales and one tally counter. Only two measures scored positively for one psychometric property (content validity). The majority of measures had no reported validity or reliability testing. Conclusions The results expose a gap in the literature for well-developed measures that capture self-reported adherence to prescribed but unsupervised home-based rehabilitation exercises.

Vertical ground reaction forces in patients with unilateral plantar heel pain — a pilot study

Plantar heel pain (PHP) is a foot pathology commonly reported in both athletic and non-athletic populations. The etiology of PHP is complex and identification of risk factors associated with PHP is required to predict who is at increased risk of injury. Excessive plantar heel force and pressures are intrinsic risk factors that may play a contributing role in the development of PHP. Limited research, however, has been undertaken in terms of ground reaction forces associated with PHP. The aim of the study was to test the hypothesis that there were significant differences in the vertical ground reaction forces and loading rates at rearfoot contact between symptomatic and contra-lateral asymptomatic feet in 23 subjects diagnosed with unilateral PHP. The equipment consisted of a portable force plate using a 10-m modular walkway sampled at 200 Hz by an independent observer. Paired t-tests demonstrated no significant difference (P0.05) in the vertical ground reaction forces and loading rates between the symptomatic and contra-lateral asymptomatic feet. The results suggest that single risk factors such as vertical ground reaction force and loading rates do not contribute to PHP. The authors conclude that a model that incorporates a multi-factorial approach to risk factors may lead to a better understanding into the etiology and management of those individuals who suffer from heel pathologies.

Lateral weight transference exercises following acute stroke: a preliminary study of clinical effectiveness

Objectives: To evaluate a training programme aimed at improving lateral weight transference in patients following acute stroke to determine main treatment effects, if any, to inform the design of future studies. Design: A single-blind randomized controlled trial. Setting: The Stroke Unit at The James Cook University Hospital, Middlesbrough, UK. Subjects: Thirty-five patients with an acute stroke. Interventions: All subjects received their usual care, including physiotherapy. The treatment group (n / 17) received 12 additional therapy sessions (over four weeks) comprising exercises aimed at improving lateral weight transference in sitting delivered by trained physiotherapy assistants. Main outcome measures: Measures of dynamic reaching, sitting and standing, and static standing balance were undertaken by a blind independent observer. Results: Specific measures of weight displacement in standing and reaching, and timed standing up and sitting down did not detect any differences over time regardless of group. Neither were there any significant changes over time, except for sway during static standing (p B=0.01) and time to return to their original position during dynamic reaching (p / 0.01). Conclusions: A training programme aimed at improving lateral weight transference did not appear to enhance the rehabilitation of acute stroke patients. Improvements observed in postural control in standing and sitting may be attributable to usual care or natural recovery.

Recommendations for a core outcome set for measuring standing balance in adult populations: a consensus-based approach.

Background Standing balance is imperative for mobility and avoiding falls. Use of an excessive number of standing balance measures has limited the synthesis of balance intervention data and hampered consistent clinical practice. Objective To develop recommendations for a core outcome set (COS) of standing balance measures for research and practice among adults. Methodology A combination of scoping reviews, literature appraisal, anonymous voting and face-to-face meetings with fourteen invited experts from a range of disciplines with international recognition in balance measurement and falls prevention. Consensus was sought over three rounds using pre-established criteria. Data sources The scoping review identified 56 existing standing balance measures validated in adult populations with evidence of use in the past five years, and these were considered for inclusion in the COS. Results Fifteen measures were excluded after the first round of scoring and a further 36 after round two. Five measures were considered in round three. Two measures reached consensus for recommendation, and the expert panel recommended that at a minimum, either the Berg Balance Scale or Mini Balance Evaluation Systems Test be used when measuring standing balance in adult populations. Limitations Inclusion of two measures in the COS may increase the feasibility of potential uptake, but poses challenges for data synthesis. Adoption of the standing balance COS does not constitute a comprehensive balance assessment for any population, and users should include additional validated measures as appropriate. Conclusions The absence of a gold standard for measuring standing balance has contributed to the proliferation of outcome measures. These recommendations represent an important first step towards greater standardization in the assessment and measurement of this critical skill and will inform clinical research and practice internationally.

A systematic review of instruments for the assessment of work-related psychosocial factors (blue flags) in individuals with non-specific low back pain

In individuals with low back pain (LBP) psychosocial factors can act as obstacles to return to work. A coloured Flags Framework has been conceptualised, in which Blue Flags represent work-related psychosocial issues. This systematic review was conducted to appraise available instruments for the assessment of Blue Flags in working age adults with non-specific LBP. The Ovid versions of MEDLINE, EMBASE, PsycINFO, AMED and CINAHL databases were searched from inception until the first week of March 2010; additionally, experts and study authors were contacted. Two authors independently selected studies, extracted data and assessed methodological quality. Eight studies (recruiting 5630 participants) met the review inclusion criteria, reporting six instruments: the Back Disability Risk Questionnaire (BDRQ); Occupational Role Questionnaire (ORQ); Obstacles to Return to Work Questionnaire (ORTWQ); Psychosocial Aspects of Work Questionnaire (PAWQ); Vermont Disability Prediction Questionnaire (VDPQ); and Modified Work Adaptation, Partnership, Growth, Affection and Resolve. Limited psychometric testing had been performed on the instruments, and solely by the original developers. None of the instruments, in their current stage of development, can be recommended as Blue Flags assessment instruments. The ORTWQ was the only instrument that showed adequate psychometric properties but was not considered clinically feasible in its present format. Future research should focus on further psychometric development of the ORTWQ.

Quadriceps force generation in patients with osteoarthritis of the knee and asymptomatic participants during patellar tendon reflex reactions: an exploratory cross-sectional study

BackgroundIt has been postulated that muscle contraction is slower in patients with osteoarthritis of the knee than asymptomatic individuals, a factor that could theoretically impair joint protection mechanisms. This study investigated whether patients with osteoarthritis of the knee took longer than asymptomatic participants to generate force during reflex quadriceps muscle contraction. This was an exploratory study to inform sample size for future studies.MethodsAn exploratory observational cross sectional study was carried out. Two subject groups were tested, asymptomatic participants (n = 17), mean (SD) 56.7 (8.6) years, and patients with osteoarthritis of the knee, diagnosed by an orthopaedic surgeon, (n = 16), age 65.9 (7.8) years. Patellar tendon reflex responses were elicited from participants and measured with a load cell. Force latency, contraction time, and force of the reflex response were determined from digitally stored data. The Mann-Whitney U test was used for the between group comparisons in these variables. Bland and Altman within-subject standard deviation values were calculated to evaluate the measurement error or precision of force latency and contraction time.ResultsNo significant differences were found between the groups for force latency (p = 0.47), contraction time (p = 0.91), or force (p = 0.72). The two standard deviation measurement error values for force latency were 27.9 ms for asymptomatic participants and 16.4 ms for OA knee patients. For contraction time, these values were 29.3 ms for asymptomatic participants and 28.1 ms for OA knee patients. Post hoc calculations revealed that the study was adequately powered (80%) to detect a difference between the groups of 30 ms in force latency. However it was inadequately powered (59%) to detect this same difference in contraction time, and 28 participants would be required in each group to reach 80% power.ConclusionPatients with osteoarthritis of the knee do not appear to have compromised temporal parameters or magnitude of force generation during patellar tendon reflex reactions when compared to a group of asymptomatic participants. However, these results suggest that larger studies are carried out to investigate this area further.

A grounded theory of taking control after fall-induced hip fracture

Purpose: We applied the grounded theory method to explore the post discharge concerns of older people after fall-induced hip fracture repair. It was anticipated that this understanding would increase awareness of issues that may impact on recovery and rehabilitation. Method: Semi-structured interviews were carried out with 19 older people after discharge home. Initially, purposive sampling guided data collection and thereafter theoretical sampling was employed. Interviews were analysed using the constant comparative method. Results: We generated a theory of how older people ‘take control’ after hip fracture. Conceptually, taking control was about ‘balancing’ and was both a process and a range of strategies. The three stages of the process that people moved through were: ‘going under’, ‘keeping afloat’ and ‘gaining ground’. Nautical metaphors conceptualise the precarious and unstable conditions that older people faced as they struggled to regain their independence. Older people struggled to balance help and risk, in their attempt to manage their concerns relating to losing control of their future independence. Conclusion: Older people are vulnerable to losing a sense of control after a health trauma. This theory adds a new dimension to our understanding of recovery from hip fracture and highlights that older people and their families need tailored information and support to enable them to take control safely and appropriately. Implications for Rehabilitation Older people are vulnerable to losing a sense of control after traumatic injury such as hip fracture. Our research suggests that older people engage in a precarious process of balancing as they strive to take control after fall induced hip fracture. Successful balancing entails the provision of tailored information and support. This theoretical explanation aims to help practitioners understand the older person’s perspective of recovery from traumatic injury in a new light.

Physiotherapists’ assessment and management of psychosocial factors (Yellow and Blue Flags) in individuals with back pain

Abstract Background: Personal and work-related psychosocial factors play an important role in persisting symptoms and delaying return to work in individuals with back pain. Therefore, it is essential that physiotherapists have the motivation and skills to assess and manage psychosocial factors as part of back pain management. Objectives: To systematically review and summarize the literature on physiotherapists’ perceptions of and skills in assessing and managing psychosocial factors (Yellow and Blue Flags) in individuals with back pain. Methods: Searches were conducted of the: Ovid versions of MEDLINE, PsycINFO and EMBASE; EBSCO CINAHL; Cochrane Database of Systematic Reviews; Cochrane Central Register of Controlled Trials (Clinical Trials); and Physiotherapy Evidence Database (PEDro) from inception until end October 2011. Results: There were 384 hits of which 17 papers describing 15 studies met the inclusion criteria; these were: two randomized controlled trials; two observational studies; six survey based studies; two qualitative studies; and three using Delphi consensus development. Studies found that although physiotherapists theoretically support a biospychosocial management approach to back pain, in practice few are doing so adequately, even following training in cognitive behavioral principles. Physiotherapists expressed reluctance to engage in the management of work-related psychosocial factors (Blue Flags), perceiving that tackling work issues was outside their professional role. Conclusions: Despite evidence of the barriers to doing so, we put out a call to action that physiotherapists embrace the importance of integrating psychosocial factors in their everyday professional practice. In particular, gaining confidence in tackling Blue Flags is critical to establish physiotherapists as essential players in combating the growing public health concern of worklessness.