Physical Therapy- Journal of the APTA- January 2009, Volume 89, Issue 1

January 2009  Volume 89  Number 1

Research Reports 9

Motor Control Exercise for Persistent, Nonspecific Low Back Pain

26

Posterior Tibial Tendon Dysfunction

38

Continuing Education and Treatment of Neck Pain

51

Early Progressive Eccentric Exercise After Anterior Cruciate Ligament Reconstruction

60

Stepping Responses in Myelomeningocele

73

Predicting Activity Limitations in Chronic Stroke

Case Report 82

Low Back Pain and the World Health Organization’s International Classification of Functioning, Disability and Health Model

Perspective 91

Use of Mixed Methods Designs

N

O

R

T

H

C

O

A

S

T

M

E

D

I

C

A

Put the Pain on Ice.

PhysioIce. i

Enhance modality treatments with PhysioICEi analgesic gel. Cool, soothing PhysioICEipenetrates deeply to help relax muscles and increase blood flow for long-lasting relief from aches and pain associated with arthritis, tendinitis, strains and sprains. Non-greasy and fast-drying, PhysioICEi will not stain skin or clothes, and can be applied before, during and after treatment. For quick, effective relief that lasts, Put the Pain on Ice. PhysioICEi. TM

For a free sample of Physio ICEi, call toll-free, 800-821-9319 and ask for NC70080.

North Coast

North Coast Medical • 18305 Sutter Boulevard • Morgan Hill, CA 95037 • Toll-Free: 800-821-9319 Toll-Free Fax: 877-213-9300 • Local/Int’l: 408-776-5000 • www.ncmedical.com See Reader Service No 1 at www.apta.org/adinfo

L

Strengthen your expertise. Achieve Board certification through the Specialist Certification Program for physical therapists. Gain recognition for advanced proficiency in one of four clinical areas through Recognition of Advanced Proficiency for the PTA.

!DVANCED 0ROFICIENCY

Participate in one or more of APTA’s 18 special-interest sections tions and get connected with those who share your professional interests.

Experience the Benefits of APTA Membership! For more details about any of APTA’s exclusive member benefits, visit www.apta.org.

Find the Things That You Need. Virtually Any Time. Virtually Any Place! www.apta.org/store See what’s new from APTA! APTA’s online store features almost all the things that PTs, PTAs, and students of physical therapy need: practice essentials, guidelines and resources, home-study materials, patient education information, clinicians’ kits, self-assessment tools, community outreach materials, labcoats, personalized logowear, great gifts, and so much more! Bookmark this very important address right now. Then pay a quick visit whenever you need to make a purchase for yourself, your staff, your colleagues, or your students.

www.apta.org/opendoor

New In Open Door: Joanna Briggs Institute (JBI) JBI Evidence Summaries include 1,600+ standardized summaries of existing evidence on health care interventions and activities. Each summary covers one intervention and includes: the question, the clinical bottom line, evidence characteristics, best practice recommendations, and references. Access: 2006 to date. JBI Best Practice Information Sheets provide access to key issues and recommendations culled from systematic reviews and presented in 4-page information sheets. Access: 1997 to date. JBI Systematic Reviews focus on the feasibility and effectiveness of health care interventions. Published in the Journal of Evidence-Based Healthcare (JBI Reports), each peer-reviewed entry is regularly updated. Access: 1998 to date.

How do you access JBI? Go to Open Door, access ProQuest, click on the Publications tab, and type in “Briggs” for a list of these JBI databases, OR run your search as usual and look for the JBI resources in your results. Bookmark www.apta.org/opendoor for online access to vital clinical research, whenever and wherever you need it. Visit often for full-text access to research and articles from more than a thousand leading clinical and academic publications on topics critical to clinical practice.

Questions? E-mail [email protected] or call 800/999-2782 (ext 8534). Open Door is an APTA members–only benefit.

The Bottom Line The Bottom Line is a translation of study findings for application to clinical practice. It is not intended to substitute for a critical reading of the research article. Bottom Lines are written by invitation only. Macedo LG, Maher CG, Latimer J, McAuley JH. Motor Control Exercise for Persistent, Nonspecific Low Back Pain: A Systematic Review. Phys Ther. 2009;89:9–25. What problems did the researchers set out to study, and why? The authors of the study sought to investigate the current literature examining the effectiveness of motor control exercises on pain, disability, and quality of life at short term, intermediate, and long-term follow-up periods for patients with persistent, nonspecific low back pain (LBP). Despite widespread use clinically, the effectiveness of motor control exercises for persistent LBP remains unclear. Previous systematic reviews exhibited weaknesses in their method of analysis, limiting the ability to draw conclusions about this topic. Who participated in this study? The researchers performed an extensive literature search that ultimately resulted in the inclusion of 14 randomized or quasi-randomized clinical trials investigating the use of motor control exercises for the management of patients with persistent LBP, which was defined as subacute, chronic, or recurrent LBP lasting longer than 6 weeks.

Eric K Robertson EK Robertson, PT, DPT, OCS, is Assistant Professor, Department of Physical Therapy, Medical College of Georgia.

For more Bottom Lines on articles in this and other issues, visit www. ptjournal.org.

What new information does this study offer? The results of this analysis provide evidence that motor control exercises, alone or in conjunction with other interventions, are effective in reducing pain and disability for patients with persistent, nonspecific LBP. Motor control exercises were not found to be superior to manual therapy, other forms of exercise, or lumbar surgery. How did the researchers go about the study? The 14 studies were grouped into 4 treatment contrasts: (1) motor control versus minimal intervention, (2) motor control versus manual therapy, (3) motor control versus other forms of exercise, and (4) motor control versus lumbar fusion surgery. Data were pooled whenever possible, and analysis was performed according to the Cochrane Group guidelines for systematic reviews. How might these results be applied to physical therapist practice? Physical therapists often use motor control exercises in the management of patients with persistent nonspecific LBP. This study provides evidence to support this intervention, and physical therapists can feel confident that this intervention will offer a benefit to their patients. What are the limitations of the study, and what further research is needed? There was wide variation among trials included in this study, due in part to the lack of a standard definition of motor control exercises among clinicians. It is possible that studies were not included in the analysis that might have altered the conclusions. Future research is needed to determine the optimal method to administer motor control exercises. Additional research is also needed to better determine whether there is a subgroup of patients with decreased motor control who might experience greater benefit from this form of exercise than the general population of patients with persistent LBP.

January 2009

Volume 89 Number 1 Physical Therapy ■ 7

The Bottom Line Cleland JA, Fritz JM, Brennan GP, Magel J. Does Continuing Education Improve Physical Therapists’ Effectiveness in Treating Neck Pain? A Randomized Clinical Trial. Phys Ther. 2009;89:38–47. Eric K Robertson EK Robertson, PT, DPT, OCS, is Assistant Professor, Department of Physical Therapy, Medical College of Georgia.

What problems did the researchers set out to study, and why? Physical therapists often attend continuing education (CE) courses, but traditional CE programs might not improve clinical outcomes for patients with neck pain. These researchers wanted to examine whether an enhanced CE program—which included smallgroup teaching and an educational outreach visit in addition to a traditional 2-day course—improved clinical outcomes more than the traditional 2-day course alone. Who participated in this study? The study group consisted of 19 physical therapists with an average age of about 39 years and about 12 years’ experience. The group ranked their overall confidence in treating patients with neck pain as 2.6 on a 5-point Likert scale ranging from “not confident” (0) to “very confident” (5). Two therapists in each group had obtained orthopedic clinical specialization. What new information does this study offer? This study demonstrates the value of supplementing a traditional 2-day course with follow-up small-group teaching and an educational outreach visit. The physical therapists who attended the enhanced program achieved greater improvements in patient disability but not in pain. How did the researchers go about the study? Physical therapists working in 11 different clinics from one health system were invited to attend a 2-day CE course. The course consisted of lab and lecture instruction of an evidence-based, classification approach to the treatment of patients with neck pain. After the course, therapists were randomized to 2 groups. The experimental group received ongoing education in the form of two 1.5-hour meetings and an outreach visit that enabled each therapist to co-treat a patient with the lead instructor. Clinical data were obtained for patients treated by the study participants for a time period prior to training (245 patients) and a time period after training (511 patients). How might these results be applied to physical therapist practice? These findings are consistent with other research that suggests that traditional CE formats emphasizing short-term, intensive courses do not improve patient outcomes. Physical therapists might achieve improved patient outcomes if they seek out CE opportunities that include follow-up small-group teaching and educational outreach visits. What are the limitations of the study, and what further research is needed? Possible contamination bias existed where therapists in different groups but working at the same clinic might have communicated with each other. This bias means that the study potentially understimates the effect of the enhanced CE program. More research is needed to determine the cost-effectiveness of this approach and to investigate whether it can be adapted for other health problems that physical therapists manage.

8 ■

Physical Therapy Volume 89 Number 1

January 2009

Physical Therapy Journal of the American Physical Therapy Association

Editorial Office

Editor in Chief

Managing Editor / Associate Director of Publications: Jan P Reynolds, [email protected]

Rebecca L Craik, PT, PhD, FAPTA, Philadelphia, PA [email protected]

PTJ Online Editor / Assistant Managing Editor: Steven Glaros

Deputy Editor in Chief

Associate Editor: Stephen Brooks, ELS Production Manager: Liz Haberkorn Manuscripts Coordinator: Karen Darley Permissions / Reprint Coordinator: Michele Tillson Advertising Manager: Julie Hilgenberg Director of Publications: Lois Douthitt

APTA Executive Staff Senior Vice President for Communications: Felicity Feather Clancy Chief Operating Officer: Rob Batarla Chief Executive Officer: John D Barnes

Advertising Sales Ad Marketing Group, Inc 2200 Wilson Blvd, Suite 102-333 Arlington, VA 22201 703/243-9046, ext 102 President / Advertising Account Manager: Jane Dees Richardson

Board of Directors President: R Scott Ward, PT, PhD Vice President: Randy Roesch, PT, MBA, DPT Secretary: Babette S Sanders, PT, MS Treasurer: Connie D Hauser, PT, DPT, ATC Speaker of the House: Shawne E Soper, PT, DPT, MBA Vice Speaker of the House: Laurita M Hack, PT, DPT, MBA, PhD, FAPTA Directors: William D Bandy, PT, PhD, SCS, ATC; Sharon L Dunn, PT, PhD, OCS; Kevin L Hulsey, PT, DPT, MA; Dianne V Jewell, PT, DPT, PhD, CCS, FAACVPR; Aimee B Klein, PT, DPT, MS, OCS; Stephen CF McDavitt, PT, DPT, MS, FAAOMPT; Paul A Rockar Jr, PT, DPT, MS; Lisa K Saladin, PT, PhD; John G Wallace Jr, PT, MS, OCS

4 ■ Physical Therapy Volume 89 Number 1

Daniel L Riddle, PT, PhD, FAPTA, Richmond, VA

Editor in Chief Emeritus Jules M Rothstein, PT, PhD, FAPTA (1947–2005)

Steering Committee Anthony Delitto, PT, PhD, FAPTA (Chair), Pittsburgh, PA; J Haxby Abbott, PhD, MScPT, DipGrad, FNZCP, Dunedin, New Zealand; Joanell Bohmert, PT, MS, Mahtomedi, MN; Alan M Jette, PT, PhD, FAPTA, Boston, MA; Charles Magistro, PT, FAPTA, Claremont, CA; Ruth B Purtilo, PT, PhD, FAPTA, Boston, MA; Julie Whitman, PT, DSc, OCS, Westminster, CO

Editorial Board Andrea Behrman, PT, PhD, Melrose, FL; Rachelle Buchbinder, MBBS(Hons), MSc, PhD, FRACP, Malvern, Victoria, Australia; W Todd Cade, PT, PhD, St Louis, MO; John Childs, PT, PhD, Schertz, TX; Charles Ciccone, PT, PhD, FAPTA (Continuing Education), Ithaca, NY; Joshua Cleland, PT, DPT, PhD, OCS, FAAOMPT (The Bottom Line), Concord, NH; Janice J Eng, PT/OT, PhD, Vancouver, BC, Canada; G Kelley Fitzgerald, PT, PhD, OCS, Pittsburgh, PA; James C (Cole) Galloway, PT, PhD, Newark, DE; Kathleen Gill-Body, PT, DPT, NCS, Boston, MA; Paul JM Helders, PT, PhD, PCS, Utrecht, The Netherlands; Maura D Iversen, PT, MPH, ScD, Boston, MA; Diane U Jette, PT, DSc, Burlington, VT; Gregory Karst, PT, PhD, Omaha, NE; Christopher Maher, PT, PhD, Lidcombe, NSW, Australia; Christopher J Main, PhD, FBPsS, Keele, United Kingdom; Kathleen Kline Mangione, PT, PhD, GCS, Philadelphia, PA; Patricia Ohtake, PT, PhD, Buffalo, NY; Carolynn Patten, PT, PhD, Gainesville, FL; Christopher Powers, PT, PhD, Los Angeles, CA; Linda Resnik, PT, PhD, Providence, RI; Val Robertson, PT, PhD, Copacabana, NSW, Australia; Patty Solomon, PT, PhD, Hamilton, Ont, Canada

Statistical Consultants Steven E Hanna, PhD, Hamilton, Ont, Canada; John E Hewett, PhD, Columbia, MO; Hang Lee, PhD, Boston, MA; Samuel Wu, PhD, Gainesville, FL

The Bottom Line Committee Joanell Bohmert, PT, MS; Lara Boyd, PT, PhD; James Cavanaugh IV, PT, PhD, NCS; Todd Davenport, PT, DPT, OCS; Ann Dennison, PT, DPT, OCS; William Egan, PT, DPT, OCS; Helen Host, PT, PhD; Evan Johnson, PT, DPT, MS, OCS, MTC; M Kathleen Kelly, PT, PhD; Catherine Lang, PT, PhD; Tara Jo Manal, PT, MPT, OCS, SCS; Kristin Parlman, PT, DPT, NCS; Susan Perry, PT, DPT, NCS; Maj Nicole H Raney, PT, DSc, OCS, FAAOMPT; Rick Ritter, PT; Eric Robertson, PT, DPT; Kathleen Rockefeller, PT, MPH, ScD; Michael Ross, PT, DHS, OCS; Patty Scheets, PT, DPT, NCS; Katherine Sullivan, PT, PhD; Mary Thigpen, PT, PhD; Jamie Tomlinson, PT, MS; Brian Tovin, DPT, MMSc, SCS, ATC, FAAOMPT; Nancy White, PT, MS, OCS; Julie Whitman, PT, DSc, OCS

January 2009

Subscriptions

Physical Therapy (PTJ) (ISSN 00319023) is published monthly by the American Physical Therapy Association (APTA), 1111 North Fairfax Street, Alexandria, VA 22314-1488, at an annual subscription rate of $15 for members, included in dues. Nonmember rates are as follows: Individual (inside USA)— $99; individual (outside USA)—$119 surface mail, $179 air mail. Institutional (inside USA)—$129; institutional (outside USA)—$149 surface mail, $209 air mail. Periodical postage is paid at Alexandria, VA, and at additional mailing offices. Postmaster: Send address changes to Physical Therapy, 1111 North Fairfax Street, Alexandria, VA 22314-1488. Single copies: $15 USA, $15 outside USA; with the exception of January 2001: $50 USA, $70 outside USA. All orders payable in US currency. No replacements for nonreceipt after a 3-month period has elapsed. Canada Post International Publications Mail Product Sales Agreement No. 0055832.

Members and Subscribers Send changes of address to: APTA, Attn: Membership Dept, 1111 North Fairfax St, Alexandria, VA 22314-1488. Subscription inquiries: 703/684-2782, ext 3124. PTJ is available in a special format for readers who are visually impaired. For information, contact APTA’s Membership Department at 703/684-2782, ext 3124.

Mission Statement

Founded in 1921, Physical Therapy (PTJ) is the official publication of the American Physical Therapy Association (APTA) and is an international, scholarly, peer-reviewed journal. PTJ serves APTA members, other health care professionals, and patients/clients by (1) documenting basic and applied knowledge related to physical therapy, (2) providing evidence to guide clinical decision making, and (3) publishing a variety of research that is relevant to the field and diverse opinions that are based in scholarly arguments. PTJ, like the profession it serves, strives to enhance the health and well-being of all members of society.

January 2009

Readers are invited to submit manuscripts to PTJ. PTJ’s content—including editorials, commentaries, letters, and book reviews—represents the opinions of the authors and should not be attributed to PTJ or its Editorial Board. Content does not reflect the official policy of APTA or the institution with which the author is affiliated, unless expressly stated.

Technologies. Ingenta provides online document delivery for articles published since September 1988. Full-text articles are available for free at www.ptjournal.org 12 months after the publication date. Full text also is provided through DataStar, Dialog, EBSCOHost Academic Search, Factiva, InfoTrac, ProFound, and ProQuest.

Reprints

PTJ Online at www.ptjournal.org

Readers should direct requests for reprints to the corresponding author of the article. Students and other academic customers may receive permission to reprint copyrighted material from this publication by contacting the Copyright Clearance Center Inc, 222 Rosewood Dr, Danvers, MA 01923. Authors who want reprints should contact Nancy Boyles, Cadmus Reprints, at 800/4079190, or [email protected]. Nonacademic institutions needing reprint permission information should go to www.ptjournal.org/misc/terms.dtl.

PTJ’s Web site posts articles ahead of print and rapid reader responses to articles. Articles, letters to the editor, and editorials are available in full text starting with Volume 79 (1999) and in searchable PDF format starting with Volume 60 (1980). Entire issues are available online beginning with Volume 86 (2006) and include additional data, video clips, and podcasts.

Indexing and Document Delivery

Advertising

PTJ is indexed and/or abstracted by Abridged Index Medicus, Abstracts of Health Care Management Studies, AgeLine, AMED (Allied and Complementary Medicine Database), Bibliography of Developmental Medicine and Child Neurology, Current Contents, Cumulative Index to Nursing and Allied Health Literature (CINAHL), EMBASE/Exerpta Medica, Exceptional Child Education Resources, Focus on: Sports Science and Medicine, General Science Index (GSI), Health Index, Hospital and Health Administration Index, Index Medicus, Inpharma Weekly, International Nursing Index, ISR, Medical & Surgical Dermatology, MEDLINE, Neuroscience Citation Index, Personal Alert: Automatic Subject Citation Alert (ASCA), Pharmacoeconomics and Outcomes News, Physical Education Index, Reactions Weekly, RECAL Bibliographic Database, Science Citation Index (SCI), Social Sciences Citation Index (SSCI), and SportsS. Article abstracts are available online at www.ptjournal.org (1980 through present) and via DataStar, Dialog, FirstSearch, Information Access, Ovid

Advertisements are accepted by PTJ when they conform to the ethical standards of the American Physical Therapy Association. PTJ does not verify the accuracy of claims made in advertisements, and acceptance does not imply endorsement by PTJ or the Association. Acceptance of advertisements for professional development courses addressing advanced-level competencies in clinical specialty areas does not imply review or endorsement by the American Board of Physical Therapy Specialties.

Statement of Nondiscrimination APTA prohibits preferential or adverse discrimination on the basis of race, creed, color, gender, age, national or ethnic origin, sexual orientation, disability, or health status in all areas including, but not limited to, its qualifications for membership, rights of members, policies, programs, activities, and employment practices. APTA is committed to promoting cultural diversity throughout the profession.

Volume 89 Number 1 Physical Therapy ■ 5

Research Report

Motor Control Exercise for Persistent, Nonspecific Low Back Pain: A Systematic Review Luciana G Macedo, Christopher G Maher, Jane Latimer, James H McAuley

Background. Previous systematic reviews have concluded that the effectiveness of motor control exercise for persistent low back pain has not been clearly established.

Objective. The objective of this study was to systematically review randomized controlled trials evaluating the effectiveness of motor control exercises for persistent low back pain.

Methods. Electronic databases were searched to June 2008. Pain, disability, and quality-of-life outcomes were extracted and converted to a common 0 to 100 scale. Where possible, trials were pooled using Revman 4.2.

Results. Fourteen trials were included. Seven trials compared motor control exercise with minimal intervention or evaluated it as a supplement to another treatment. Four trials compared motor control exercise with manual therapy. Five trials compared motor control exercise with another form of exercise. One trial compared motor control exercise with lumbar fusion surgery. The pooling revealed that motor control exercise was better than minimal intervention in reducing pain at short-term follow-up (weighted mean difference⫽⫺14.3 points, 95% confidence interval [CI]⫽⫺20.4 to ⫺8.1), at intermediate follow-up (weighted mean difference⫽⫺13.6 points, 95% CI⫽⫺22.4 to ⫺4.1), and at long-term follow-up (weighted mean difference⫽⫺14.4 points, 95% CI⫽⫺23.1 to ⫺5.7) and in reducing disability at long-term follow-up (weighted mean difference⫽⫺10.8 points, 95% CI⫽⫺18.7 to ⫺2.8). Motor control exercise was better than manual therapy for pain (weighted mean difference⫽⫺5.7 points, 95% CI⫽⫺10.7 to ⫺0.8), disability (weighted mean difference⫽⫺4.0 points, 95% CI⫽⫺7.6 to ⫺0.4), and quality-of-life outcomes (weighted mean difference⫽⫺6.0 points, 95% CI⫽⫺11.2 to ⫺0.8) at intermediate follow-up and better than other forms of exercise in reducing disability at short-term follow-up (weighted mean difference⫽⫺5.1 points, 95% CI⫽⫺8.7 to ⫺1.4).

LG Macedo, PT, MSc, is a PhD student at The George Institute for International Health, The University of Sydney, PO Box M201, Missenden Rd, Camperdown, Sydney, New South Wales, 2050 Australia. Address all correspondence to Ms Macedo at: [email protected]. CG Maher, PT, PhD, is Director, Musculoskeletal Division, The George Institute for International Health, The University of Sydney. J Latimer, PT, PhD, is Associate Professor, The George Institute for International Health, The University of Sydney. JH McAuley, PhD, is Research Manager, The George Institute for International Health. [Macedo LG, Maher CG, Latimer J, McAuley JH. Motor control exercise for persistent, nonspecific low back pain: a systematic review. Phys Ther. 2009;89:9 –25.] © 2009 American Physical Therapy Association

Conclusions. Motor control exercise is superior to minimal intervention and confers benefit when added to another therapy for pain at all time points and for disability at long-term follow-up. Motor control exercise is not more effective than manual therapy or other forms of exercise.

Post a Rapid Response or find The Bottom Line: www.ptjournal.org January 2009

Volume 89

Number 1

Physical Therapy f

9

Motor Control Exercise for Persistent, Nonspecific LBP

L

ow back pain (LBP) is one of the main causes of disability, and, despite its high prevalence, the source of pain is not established in the majority of cases and the term “nonspecific low back pain” is used.1– 4 One factor that has been proposed as important in the genesis and persistence of nonspecific LBP is stability and control of the spine.4 Studies of individuals with LBP have identified impairments in the control of the deep trunk muscles (eg, transversus abdominis and multifidus) responsible for maintaining the stability of the spine.5– 8 For example, activity of the transversus abdominis muscles9 and the multifidus muscles7 is delayed during arm movements (that challenge the stability of the spine) in individuals with LBP. Furthermore, there is evidence of decreased cross-sectional area10 and increased fatiguability11 and a suggestion of increased intramuscular fat in the paraspinal muscles of individuals with LBP.12 Therefore, theoretically, an intervention that aims to correct the changes occurring in the deep trunk muscles and that targets the restoration of control and coordination of these muscles should be effective in the management of persistent LBP. Motor control exercise was developed based on the principle that individuals with LBP have a lack of control of the trunk muscles. The idea is to use a motor learning approach to retrain the optimal control and coordination of the spine. The intervention involves the training of preactivation of the deep trunk muscles, with progression toward more complex static, dynamic, and functional tasks integrating the activation of deep and global trunk muscles.13,14 Although a number of laboratory studies supporting the underlying mechanism of action of motor control exercises have been published in the last decades,5,9,15 the clinical ef10

f

Physical Therapy

Volume 89

fectiveness of motor control exercise for persistent LBP is still unclear.5,9,15 Three systematic reviews of motor control exercise have been published16 –18; however, the authors of these reviews searched the literature only up until October 2005. Hauggaard and Persson,17 the authors of the latest published review, included 10 trials testing the efficacy of motor control for acute, subacute, and chronic LBP. The review used a simple descriptive approach to summarize the results of each individual trial. Rackwitz et al18 summarized the results of 7 randomized controlled trials of acute, subacute, and chronic LBP, and although they used a better approach to summarize the available evidence, no metaanalytical analysis with pooling of the data was used. Ferreira et al16 summarized the results of 13 randomized controlled trials of recurrent, acute, subacute, and chronic LBP and cervical pain. This review was the only one that included a meta-analytical approach; however, only a few trials were pooled, limiting the generalization of the results. A meta-analytical approach is superior to the other forms of analysis for systematic reviews because it provides a treatment effect size with 95% confidence interval (CI). Consistent with the Cochrane Collaboration,19 we felt that an updated review incorporating new randomized controlled trials would make a useful contribution to the literature. In addition, a meta-analytical approach, which has not been widely used in the previous published systematic reviews, can potentially add useful information about the magnitude of the effect of motor control exercises. Because our main interest was to study persistent LBP and guidelines suggest that persistent and acute LBP should be considered separately,19 –21 we included only trials studying patients with LBP that persisted beyond the acute phase.

Number 1

The term “persistent low back pain” is used to describe subacute, chronic, and recurrent pain. Thus, the objective of this study was to systematically review randomized controlled trials testing the effect of motor control exercise in patients with persistent, nonspecific LBP.

Method Data Sources and Searches A computerized electronic search was performed to identify relevant articles. The search was conducted on MEDLINE (1950 to June 2008), CINAHL (1982 to June 2008), AMED (1985 to June 2008), PEDro (to June 2008), and EMBASE (1988 to June 2008). Key words relating to the domains of randomized controlled trials and back pain were used, as recommended by the Cochrane Back Review Group.19 Terms for motor control and specific stabilization exercises were extracted from the review by Ferreira et al.16 Subject subheadings and word truncations, according to each database, were used. There was no language restriction. One reviewer (LGM) screened search results for potentially eligible studies, and 2 reviewers (LGM, CGM) independently reviewed articles for eligibility. A third independent reviewer (JL) resolved any disagreement about inclusion of trials. Authors were contacted if more information about the trial was needed to allow inclusion of the study. Researchers who published in the area were contacted to help identify gray literature and articles in press. Citation tracking was performed using ISI Web of Science, and a manual search of the reference lists of previous reviews and the eligible trials was performed. Study Selection The reviewers followed a research protocol, developed prior to the beginning of the review, that included January 2009

Motor Control Exercise for Persistent, Nonspecific LBP a checklist for inclusion criteria. Articles were eligible for inclusion if they were randomized or quasirandomized controlled trials comparing motor control exercise with a placebo treatment, no treatment, or another active treatment or when motor control exercise was added as a supplement to other interventions. When motor control exercise was used in addition to other treatments, motor control exercises had to represent at least 40% of the total treatment program. This criterion was judged by reading the description of the treatment with the reviewer making a global yes/no judgment. Trials were considered to have evaluated motor control exercise if the exercise treatment was described as motor control or specific spinal stabilization or core stability exercise and where the protocol described exercise targeting specific trunk muscles in order to improve control and coordination of the spine and pelvis. Randomized or quasi-randomized controlled trials were included if they explicitly reported that a criterion for entry was nonspecific LBP (with or without leg pain) of at least 6 weeks’ duration (nonacute LBP) or recurrent LBP. Studies evaluating individuals of all age groups of either sex were included. Trials were included if one of the following outcome measures had been reported: pain, disability, quality of life, return to work, or recurrence. Data Extraction and Quality Assessment The methodological quality of the trials was assessed using the PEDro scale,22 with scores extracted from the PEDro database. Assessment of quality of trials in the PEDro database was performed by 2 trained independent raters, and disagreements were resolved by a third rater.23 One study24 was extracted from a conferJanuary 2009

ence proceeding, and, therefore, the PEDro score was not available in the database. However, 2 PEDro raters evaluated the information available in the abstract and in an initial version of a manuscript, and a PEDro score was given. Methodological quality was not an inclusion criterion. Three independent reviewers (LGM, CGM, JL) extracted data from each included study using a standardized extraction form. Mean scores, standard deviations, and sample sizes were extracted from the studies. When this information was not provided in the trial, the values were calculated or estimated using methods recommended in the Cochrane Handbook for Systematic Reviews of Interventions.25 When there was insufficient information about outcomes to allow data analysis, the authors of the study were contacted, and all authors replied to our inquiries.24,26 –28 Outcomes were extracted for pain and disability for short-term follow-up (less than 3 months after randomization), intermediate follow-up (at least 3 months but less than 12 months after randomization), and long-term follow-up (12 months or more after randomization). When there were multiple time points that fell within the same category, the one that was closer to the end of the treatment for the short-term follow-up, closer to 6 months for the intermediate followup, and closer to 12 months for the long-term follow-up was used. These references for time points were based on guidelines from the Cochrane Back Review Group. Scores for pain and disability were converted to a 0 to 100 scale.29 Data Synthesis and Analysis The studies were grouped into 4 treatment contrasts: (1) motor control versus minimal intervention (no

intervention, general practitioner care, education) or motor control as a supplement, (2) motor control versus spinal manipulative therapy, (3) motor control versus exercise, and (4) motor control versus surgery (lumbar fusion). Results were pooled when trials were considered sufficiently homogenous with respect to participant characteristics, interventions, and outcomes. I2 was calculated using RevMan 4.2* to analyze statistical heterogeneity. I2 describes the percentage of the variability in effect estimates that is due to heterogeneity rather than sampling error (chance). A value greater than 50% may be considered substantial heterogeneity.25 When trials were statistically homogeneous (I2⬍50%), pooled effects (weighted mean difference) were calculated using a fixed-effect model. When trials were statistically heterogeneous (I2⬎50%) pooled estimates of effect (weighted mean difference) were obtained using a random-effects model.25 When there was a single trial for the comparison, results were expressed as mean differences and 95% CI.

Results Study Selection The initial electronic database search resulted in a total of 1,052 articles. Of these, 42 were selected as potentially eligible based on their title and abstract. Through a Web of Science search of these articles, 3 other potentially eligible articles were identified. A total of 45 potentially eligible articles were considered for inclusion, with only 14 eligible for inclusion in this review (Fig. 1). Reasons for exclusion are shown in Figure 1 for those articles2,3,15,30 –57 that were excluded from this review. Only 1 of the 26 experts contacted sent information to us on a new trial for inclusion. * Copenhagen, Denmark: The Nordic Cochrane Centre, The Cochrane Collaboration, 2003.

Volume 89

Number 1

Physical Therapy f

11

Motor Control Exercise for Persistent, Nonspecific LBP

Figure 1. Flow chart of systematic review inclusion and exclusion. RCT⫽randomized controlled trial.

A number of randomized controlled trials that were included in previous systematic reviews of motor control exercises were not included in this review. Reasons for exclusion included: patients had acute but not persistent back pain,15,51,53 patients had neck pain and headache but not back pain,58 the trial did not use a motor control intervention according to our review definition,56 and 12

f

Physical Therapy

Volume 89

the trial did not have the outcomes of interest.59,60 Four new trials13,24,26,61 that were not included in any of the previously published reviews were included in this review, accounting for the addition of 560 patients. Methodological Quality The methodological quality assessment using the PEDro scale revealed

Number 1

a mean score of 6 (range⫽2– 8). Blinding of the therapist and blinding of the subject were not used in any of the trials, as would be expected for an exercise therapy study. An intention-to-treat analysis was used in 36% of the trials, and allocation concealment was present in 58% of the trials. One of the articles24 included in the review was from a conference proceeding, and, thereJanuary 2009

Motor Control Exercise for Persistent, Nonspecific LBP fore, not much information on the conduct of the trial was available. With the limited information available, this trial received a score of 2 on the PEDro scale and was the only trial that was a quasi-randomized controlled trial.24 Study Characteristics The 14 randomized controlled trials included in this review compared motor control exercise against another treatment or against no treatment (Tabs. 1 and 2). No placebocontrolled trials were identified. Trials were grouped into 4 treatment contrasts: (1) motor control exercise versus minimal intervention or motor control exercise as a supplement, (2) motor control exercise versus manual therapy, (3) motor control exercise versus other forms of exercise, and (4) motor control exercise versus surgery. Seven trials (603 patients) were included in the first treatment contrast: 4 trials (343 patients) that compared motor control exercise with minimal intervention (no intervention, general practitioner care, or education)14,27,62,63 and 3 trials (260 patients) that used motor control exercise as a supplement to other treatment (general exercise or usual physical therapy.28,64,65 Four trials (523 patients) compared motor control exercise with manual therapy (high- or low-velocity trust).13,26,64,66 Five trials (508 patients) compared motor control exercise with another form of exercise therapy (pain management, general exercises, or the McKenzie approach).13,24,26,61,67 One trial (61 patients) compared motor control exercise with lumbar fusion surgery.68 The characteristics of the motor control exercise programs that were evaluated in each trial are provided in Table 2.

Motor Control Exercise Versus Minimal Intervention or Motor Control Exercise as a Supplement Of the 7 studies included in this treatment contrast, 4 compared motor control exercise with a minimal intervention program (usual general practitioner care or no intervention)14,27,62,63 and 3 compared motor control exercise as a supplement to another intervention versus this other intervention alone.28,64,65 Methodological quality of the articles ranged from 4 to 8. Data for pain, disability, and quality of life were available for pooling at short-term, intermediate, and long-term followup. Data were pooled using a random-effects model for all comparisons except for quality of life at intermediate and long-term follow-ups, where a fixed-effects model was used because I2 was smaller than 50%. The pooled results favored motor control exercise for pain and disability outcomes at each follow-up, with 4 of the 6 estimates of treatment effect being statistically significant. The random-effects model showed a statistically significant decrease in pain favoring motor control exercise at short-term follow-up (weighted mean difference [on a 0 –100 scale]⫽⫺14.3 points, 95% CI⫽⫺20.4 to ⫺8.1), intermediate follow-up (weighted mean difference⫽13.6 points, 95% CI⫽⫺22.4 to ⫺4.1), and long-term follow-up (weighted mean difference⫽⫺14.4 points, 95% CI⫽⫺23.1 to ⫺5.7) and in reducing disability at long-term follow-up (weighted mean difference⫽⫺10.8 points, 95% CI⫽⫺18.7 to ⫺2.8) (Fig. 2). There was no evidence that motor control exercise was effective for improving quality of life. Motor Control Exercise Versus Manual Therapy Four trials13,26,64,66 compared motor control exercise with manual ther-

January 2009

apy, with pain and disability outcomes measured at short-term, intermediate, and long-term follow-ups and quality of life measured at intermediate and long-term follow-ups. The methodological quality of the articles ranged from 4 to 8. Because I2 was smaller than 50% for all time points, a fixed-effects model was used to pool the results. The pooled effects for pain and disability outcomes favored motor control exercise, but the effects were always small and reached statistical significance for only 2 of the 6 estimates. There was a significant difference between treatment groups favoring motor control exercise for pain and disability at intermediate follow-up (weighted mean difference⫽⫺5.7 points, 95% CI⫽⫺10.7 to ⫺0.8 for pain and weighted mean difference⫽⫺4.0 points, 95% CI⫽⫺7.6 to ⫺0.4 for disability) (Fig. 3). The pooled estimates of treatment effects on quality of life were small, favoring motor control exercise at short-term follow-up and favoring manual therapy at long-term follow-up. Motor Control Exercise Versus Other Forms of Exercise Five trials13,24,26,61,67 compared motor control exercise with another form of exercise therapy. The methodological quality of the trials ranged from 2 to 8. The trial with a methodological quality score of 2 had its PEDro score assessed from a conference proceeding and some information given by the authors.24 Results were pooled for pain and disability at short-term, intermediate, and longterm follow-ups. Because I2 was greater than 50% for pain at shortterm follow-up and for disability at long-term follow-up, pooled effects for these time points were calculated using a random-effects model. All other pooled effects were calculated using a fixed-effects model. All estimates of treatment effect were small. Five of the 6 estimates favored motor control exercise; however, only one

Volume 89

Number 1

Physical Therapy f

13

14

f

Patient Characteristics, Sample Size, and Duration of Complaint Interventions

Patients recruited from advertisement Aged 24–46 y Main exclusion criterion: neurological signs or prior back surgery N⫽204 Duration of LBP ⬎3 mo

Patients from an orthopedic clinic in a hospital and general practitioners Main exclusion criterion: prior back surgery or radiological signs of spinal instability N⫽55 Duration of LBP ⬎6 wk

Patients with spondylolysis or spondylolisthesis Aged 16–49 y Main exclusion criterion: neurological signs or inflammatory joint disease N⫽42 Duration of LBP ⬎3 months

Patients from health care practitioners Pelvic girdle pain lateral to L5–S1 Main exclusion criterion: neurological signs N⫽81 Duration of LBP ⬎6 wk

Patients from general practitioners and physical therapy clinics Main exclusion criterion: worsening neurological signs N⫽57 Duration of LBP ⬎2 mo

Patients from orthopedic clinics Aged 20–60 y Main exclusion criterion: neurological signs or inflammatory joint disease N⫽41 Duration of LBP ⬎3 mo

Patients from physical therapy department of a hospital Aged 18–65 y Main exclusion criterion: neurological signs or prior back surgery N⫽124 Duration of LBP ⬎3 wk

Niemisto et al,62 2003

Koumantakis et al,65 2005

O’Sullivan et al,14 1997

Physical Therapy

Volume 89

Number 1

Stuge et al,28 2004

Moseley,27 2002

Shaughnessy et al,63 2004

Goldby et al,64 200619

Pain (back pain NRS 0–100) Disability (ODI) Quality of life (Nothingham Health Profile)

Motor control exercises ⫹ education vs education only

Pain (back pain NRS 0–10) Disability (RM-18)

Motor control exercises ⫹ manual therapy ⫹ education vs usual general practitioner care

Pain (SF-36 bodily pain) Disability (RM-24) Quality of life (SF-36 general health)

Pain (VAS pain evening) Disability (ODI)

Motor control exercises ⫹ usual physical therapy vs usual physical therapy only

Motor control exercises vs no intervention

Pain (short-form McGill VAS) Disability (ODI)

Pain (VAS) Disability (RM-24)

Motor control exercises ⫹ general exercises vs general exercises only

Motor control exercises vs usual general practitioner care

Pain (VAS) Disability (ODI) Quality of life (health-related quality of life)

Outcomes (Measure)

Motor control exercises ⫹ muscle energy vs usual general practitioner care (education)

Motor control exercises versus minimal intervention or motor control exercises as a supplement

Article

Details of the Included Randomized Controlled Trialsa

Table 1.

4

5

6

7

7

7

8

PEDro Score

(Continued)

Included in Ferreira et al,16 2006; and Hauggaard et al,17 2007

Included in Hauggaard et al,17 2007

Included in Ferreira et al,16 2006; and Rackwitz et al,18 2006

Included in Ferreira et al,16 2006

Included in Ferreira et al,16 2006; Rackwitz et al,18 2006; and Hauggaard et al,17 2007

Included in Ferreira et al,16 2006; and Hauggaard et al,17 2007

Included in Ferreira et al,16 2006; Rackwitz et al,18 2006; and Hauggaard et al,17 2007

Article Included in Previous Reviews

Motor Control Exercise for Persistent, Nonspecific LBP

January 2009

January 2009

Patient Characteristics, Sample Size, and Duration of Complaint

Patients recruited from referrals by specialists or primary care practitioners to physical therapy departments of hospitals Aged 18 y or older With or without leg symptoms or neurologic signs Main exclusion criterion: prior spinal surgery, hematologic disease, or had physical therapy in the last 6 mo N⫽143 Duration of LBP ⬎12 wk

N⫽47 Duration of LBP ⬎6 wk

Patients from physical therapy department of a hospital Aged 18–65 y Main exclusion criterion: neurological signs or prior back surgery N⫽173 Duration of LBP ⬎3 wk

Critchley et al,26 2007

Rasmussen-Barr et al,66 2003

Goldby et al,64 2006

Patients seeking care from physical therapy departments of public hospitals Aged 18–80 y Main exclusion criterion: neurological signs or prior back surgery N⫽160 Duration of LBP ⬎3 mo

Patients recruited from referrals by specialists or primary care practitioners to physical therapy departments of hospitals Aged 18 y or older With or without leg symptoms or neurologic signs Main exclusion criterion: prior spinal surgery, hematological disease, or had physical therapy in the last 6 mo N⫽141 Duration of LBP ⬎12 wk

Ferreira et al,13 2007

Critchley et al,26 2007

Motor control exercises versus other forms of exercise

Patients seeking care from physical therapy departments of public hospitals Aged 18–80 y Main exclusion criterion: neurological signs or prior back surgery N⫽160 Duration of LBP ⬎3 mo

Ferreira et al,13 2007

Motor control exercises versus manual therapy

Article

Continued

Table 1.

Volume 89

Motor control exercises vs manual therapy ⫹ home exercises vs pain management program

Pain (VAS) Disability (RM-24) Quality of life (EQ-5D)

Pain (VAS) Disability (RM-24)

Pain (back pain NRS 0–100) Disability (ODI) Quality of life (Nothingham Health Profile)

Motor control exercises ⫹ education vs spinal manipulative therapy ⫹ education

Motor control exercises vs general exercises

Pain (VAS) Disability (ODI)

Pain (VAS) Disability (RM-24) Quality of life (EQ-5D)

Pain (VAS) Disability (RM-24)

Outcomes (Measure)

Motor control exercises vs spinal manipulative therapy

Motor control exercises vs manual therapy ⫹ home exercises vs pain management program

Motor control exercises vs spinal manipulative therapy

Interventions

7

8

4

5

7

8

PEDro Score

Number 1

(Continued)

Not included in previous reviews

Not included in previous reviews

Included in Ferreira et al,16 2006; and Hauggaard et al,17 2007

Included in Ferreira et al,16 2006; and Rackwitz et al,18 2006

Not included in previous reviews

Not included in previous reviews

Article Included in Previous Reviews

Motor Control Exercise for Persistent, Nonspecific LBP

Physical Therapy f

15

16

f

Physical Therapy

Volume 89

Number 1

Patients from an outpatient physical therapy clinic Aged above 18 y Main exclusion criterion: more than one back surgery or systemic inflammatory disease N⫽30 Duration of LBP ⬎7 wk

Patients with nonspecific LBP from the physical medicine and orthopedic surgery department of a hospital Aged 18–65 y Main exclusion criteria: specific LBP, radicular symptoms, back surgery, and neurologic or systemic condition N⫽78 Duration of LBP ⬎3 mo or recurrent

Miller et al,61 2005

Stevens et al,24 2007

Patients from departments of orthopedic surgery, neurosurgery, physical medicine, and rehabilitation Aged 25–60 y Spine degeneration or spondylosis had to be present Main exclusion criterion: neurological signs or prior back surgery N⫽61 Duration of LBP ⬎1 y

Pain (back pain 0–100 scale) Disability (ODI) Quality of life (life satisfaction scale)

Pain (VAS) Disability (QBPDS) Quality of life (SF-36 general health)

Motor control exercises ⫹ manual therapy (10%) vs general exercises of trunk muscle function and coordination

Motor control exercises ⫹ cognitive behavioral therapy vs surgery

Pain (VAS) Disability (functional status 0–100)

Pain (back pain NRS) Disability (ODI)

Outcomes (Measure)

Motor control exercises vs McKenzie approach

Motor control exercises ⫹ general exercises vs general exercises ⫹ manual therapy

Interventions

8

2

5

5

PEDro Score

Included in Ferreira et al,16 2006

Not included in previous reviews

Not included in previous reviews

Included in Ferreira et al,16 2006; Rackwitz et al,18 2006; and Hauggaard et al,17 2007

Article Included in Previous Reviews

a LBP⫽low back pain, ODI⫽Oswestry Disability Index, VAS⫽visual analog scale, RM-18⫽18-item Roland-Morris Disability Questionnaire, RM-24⫽24-item Roland-Morris Disability Questionnaire, NRS⫽numerical rating scale, SF-36⫽Medical Outcome Study 36-Item Short-Form Health Survey, QBPDS⫽Quebec Back Pain Disability Scale, EQ-5D⫽EuroQol questionnaire.

Brox et al,68 2003

Motor control exercises versus surgery

Patients sent to the outpatient rehabilitation department due to back pain Aged 18–55 y Patients with or without radiation or with or without disk hernia or protrusion Main exclusion criteria: prior spinal surgery, arthritis of the joints, injuries, or trauma N⫽99 Subacute and chronic

Patient Characteristics, Sample Size, and Duration of Complaint

Kladny et al,67 2003

Article

Continued

Table 1. Motor Control Exercise for Persistent, Nonspecific LBP

January 2009

January 2009

Not stated

2 sessions of 30 to 45 min per week for 8 wk

Kladny et al,67 2003

Koumantakis et al,65 2005

Volume 89

Number 1

2 sessions per week for 4 wk

1 session per week for 4 wk

Moseley,27 2002

Niemisto et al,62 2003

6 wk

1 session of 11⁄2 h per week for 10 wk

Goldby et al,64 2006

Miller et al,61 2005

12 sessions in 8 wk

Ferreira et al,13 2007

5-wk intervention (1 session in the first week, 2 wk of home program, and another 2 wk of treatment) Average duration was about 25 h per week

8 sessions of 90 min

2003

Duration of Motor Control Intervention

Critchley et al,26 2007

Brox et

al,68

Article

Details of the Motor Control Exercises

Table 2.

Progression was performed by instructing the patients to perform exercises in a morefunctional manner and further integrate them in daily activities.

Not stated

Treatment was divided into 3 phases. Phase 1 goal was to perform 10 repetitions of 10-s holds in different positions. Phase 2 goal was contraction of the transversus abdominis and multifidus muscles with loading of the limbs in different positions. Phase 3 goal was more complex loading exercises.

Progression toward the goal of 10 contractions of 10 s duration (1–2 wk). Progression to functional activities when patients were able to: (1) contract muscle in a specific pattern and (2) perform 10 contractions of 10 s holds (3–5 wk). Heavier-load functional tasks were progressively introduced in the last 3 wk of the program.

Not stated

Not stated

Progression by incorporating more functional positions and training the coordination of all trunk muscles during those functional tasks

Progression was based on the ability of the patients to maintain a stable and minimally painful spine. The exercises aimed to improve muscle motor control to provide dynamic segmental stability for the lumbar spine.

Not stated

Progression Rule

Standard home exercises

Patients were asked to perform approximately 10–15 min of home exercises

Home exercises included

Not stated

Not stated

Not stated

Not stated

2 wk of home program

Home Program

Not stated

Not stated

Adherence was 12.12 (2.69) sessions per patient, and home exercises had median of 23.5 sessions

Stated only that patients did 16.4 (4.8) d of motor control ⫹ 9.5 (3.4) d of general exercises

Not stated

Adherence was 9.2 (3.4) sessions per patient

Not stated

Adherence was 3 (7) sessions per patient

Adherence Mean (SD)

Physical Therapy f

(Continued)

Verbal, visual, tactile, and pressure gauge

Not stated

Verbal, tactile, and pressure gauge

Tactile and pressure cues

Real-time ultrasound

Not stated

Real-time ultrasound

Not stated

Not stated

Feedback

Motor Control Exercise for Persistent, Nonspecific LBP

17

18

f

Physical Therapy

Volume 89

1 session of 45 min per week for 6 wk

10 sessions in 10 wk This consisted of two 1-h sessions during week 1, two 30-min sessions during week 2, one 30-min session during each of weeks 3–6, and one 30-min session during weeks 8 and 10.

18 individual sessions of 45 min in 12 wk (2 times per week in the first 6 wk and 1 time per week in the next 6 wk)

Sessions of 30 to 60 min, 3 days per week, for 18 to 20 wk

Shaughnessy et al,63 2004

Stevens et al,24 2007

Stuge et al,28 2004

1 session per week for 10 wk

Duration of Motor Control Intervention

Rasmussen-Barr et al,66 2003

O’Sullivan et al,14 1997

Article

Continued

Table 2.

Progression Rule

Number 1 First, the focus was on the specific contraction of the transversely oriented abdominal muscle. After approximately 4 wk, loading was progressively increased.

Exercises were practiced in different environments and contexts to maximize transfers to daily situations. The physical therapist was free to choose the type of exercise and the progression he felt most suitable for individual patient. Based on continuous clinical examination, the treatment process contained a clear line of progression achieved by changing parameters such as postural load, reduction of attention demands, reduction of speed, or additional strategies to augment performance, with the final goal to obtain functional improvement.

Contractions were first performed with the goal to achieve 10 contractions of 10-s holds. Once patients were able to perform sustained contractions in low-load postures, the regimen was progressed by adding leverage through limb movements.

Exercises were progressed by applying low load to the muscle through the limbs in different positions. Patients were instructed in how to use contraction of the muscles during activities of daily living and in situations that set off pain.

Holding time of exercises was increased gradually, as well as the pressure on biofeedback monitor. Goal was 10 contractions of 10-s holds. Further low loads were applied by adding leverage through limbs. When accurate activation of the cocontraction pattern was achieved, exercises were progressed to functional holding of postures and activities known to previously aggravate patients’ symptoms.

Home Program

Exercises were mainly performed at home. Patients were encouraged to activate the transversus abdominis muscles regularly during daily activities.

Daily home exercises were encouraged; however, adherence was not assessed

Patients performed daily maintenance exercises at home

Patients were asked to do daily exercises of approximately 10–15 min

Patients were asked to do daily exercises of approximately 10–15 min

Adherence Mean (SD)

Adherence was 11 sessions per patient. 80% of patients did their exercise program 3 times per week, either at the clinic or at home.

Not stated

Not stated

Not stated

Patients completed a daily exercises sheet to monitor adherence, but results were not presented

Feedback

Not stated

Not stated

Verbal, visual, tactile, and pressure gauge

Tactile and pressure gauge

Pressure gauge

Motor Control Exercise for Persistent, Nonspecific LBP

January 2009

Motor Control Exercise for Persistent, Nonspecific LBP

Figure 2. Forest plot of the results of randomized controlled trials comparing motor control exercises with minimal intervention or motor control exercises as a supplement. Values presented are effect size (weighted mean difference) and 95% confidence interval. The pooled effect sizes were calculated using a random-effects model except for quality of life at intermediate and long-term follow-ups.

January 2009

Volume 89

Number 1

Physical Therapy f

19

Motor Control Exercise for Persistent, Nonspecific LBP

Figure 3. Forest plot of the results of randomized controlled trials comparing motor control exercises with spinal manipulative therapy. Values represent effect size (weighted mean difference) and 95% confidence interval. The pooled effect size was calculated using a fixed-effect model.

20

f

Physical Therapy

Volume 89

Number 1

January 2009

Motor Control Exercise for Persistent, Nonspecific LBP

Figure 4. Forest plot of the results of randomized controlled trials comparing motor control exercises with other forms of exercise. Values represent effect size (weighted mean difference) and 95% confidence interval. The pooled effect size was calculated using a random-effects model for pain at short-term follow-up and for disability at long-term follow-up and using a fixed-effect model for all other comparisons.

effect was statistically significant. The results showed that motor control exercise was better than other forms of exercises only for reducing disability at short-term follow-up (weighted mean difference⫽⫺5.1 points, 95% CI⫽⫺8.7 to 1.4) (Fig. 4). The results of a single trial26 showed no difference between treatment groups for quality of life at shortterm follow-up.

January 2009

Motor Control Exercise Versus Surgery Only one study68 compared motor control exercise with surgery, with a methodological quality score of 8. Surgery consisted of lumbar fusion with transpedicular screws of the L4 –L5 segments or the L5–S1 segments. Brox et al68 found no statistically significant differences for pain (mean difference [on a 0 –100 scale]⫽⫺9 points, 95% CI⫽⫺22.1 to 3.5), disability (mean difference⫽

⫺3.3 points, 95% CI⫽⫺12.8 to 6.2), and quality of life (mean difference⫽ 0.4 points, 95% CI⫽⫺1.6 to 0.8) at the long-term follow-up (Fig. 5).

Discussion This systematic review provides evidence that motor control exercise, alone or as a supplement to another therapy, is effective in reducing pain and disability in patients with persistent, nonspecific LBP. We did not find convincing evidence that motor

Volume 89

Number 1

Physical Therapy f

21

Motor Control Exercise for Persistent, Nonspecific LBP

Figure 5. Forest plot of the results of a randomized controlled trials comparing motor control exercises with surgery. Values represent mean difference and 95% confidence interval.

control exercise was superior to manual therapy, other forms of exercise, or surgery. Figure 2 shows that there was some variation among studies in the effect sizes for motor control exercise. Features that could influence the treatment effect sizes are characteristics of the patients (eg, symptom duration), characteristics of treatment implementation (eg, program duration, experience of the therapist), and the methodological quality of the trial. Unfortunately, there are too few trials to systematically evaluate the effects of these features using techniques such as meta-regression. An intriguing finding of this review was that motor control exercise was as effective in reducing pain and increasing quality of life as a lesscomplex form of exercise therapy that did not incorporate the retraining of specific muscles that often is time consuming to therapists and patients. When taking in consideration the results for disability, motor control exercise was more effective than other forms of exercise only at shortterm follow-up, but the point estimate was small (5.1 out of 100), showing differences between interventions that may not be clinically important. The results of a single trial68 showed that motor control exercise was not more effective than surgery. This finding is interesting because both interventions target the restoration 22

f

Physical Therapy

Volume 89

of spinal stability, and although spinal stability was not directly measured, the findings suggest that the motor control approach is as effective in maintaining stability as an invasive intervention that creates stability by fusing the spine. However, this was the finding of a single trial, and more research is needed to confirm the results. Although a motor control intervention has been shown to reduce pain, it is still unknown whether these changes are accompanied by improvements in measures of motor control. Tsao and Hodges69 have shown improvements in motor control (anticipatory contraction of the transversus abdominis muscle during arm movement) after a single treatment session where the isolation of the transversus abdominis muscle was trained. In a different trial, Hall and colleagues70 did not find that motor control (anticipatory contraction of the transversus abdominis muscle during arm movement and a walking task) changed after training the trunk muscles in a nonisolated manner. Therefore, the results of these 2 studies support the principles of a motor control intervention where the isolated training of the deep trunk muscles is emphasized. However, there has not been a published randomized controlled trial that used clinical and physiological measures to detect improvements in motor control that can be associated with improvements in pain and dis-

Number 1

ability and the maintenance of these changes. One question that is still to be answered is whether individuals with reduced motor control respond best to this intervention or whether there are other clinical features that can be used to define a subgroup of patients who will respond best to this type of intervention. A standard protocol and definitions for motor control exercise are yet to be established, and this is reflected in the wide variation among trials in how the exercise was named and implemented (Tab. 2). Although in most cases O’Sullivan et al14 and Richardson et al71 were cited as references, it is apparent from inspection of the articles that the interventions in the trials were quite heterogeneous. There was variation in the duration of the exercise program, progression rule, use of home exercise programs, and type of feedback used with the motor control intervention. As an illustration, the program lasted 10 weeks in the trial by O’Sullivan et al, whereas the program lasted 18 to 20 weeks in the trial by Stuge et al.28 In the trial by Ferreira et al,13 ultrasound was used for feedback, and Stuge et al28 used Terapi Master exercise equipment†: 2 elements missing from the trial by O’Sullivan and colleagues.

†

Nordisk Terapi A/S, Kilsund 4290, Staubo, Norway.

January 2009

Motor Control Exercise for Persistent, Nonspecific LBP Detailed comparison among trials is difficult because in many trials the authors did not thoroughly describe the motor control intervention that was evaluated. Accordingly, although we can conclude from this review that motor control exercise is an effective treatment for persistent LBP, the optimal way to implement this intervention is not yet clear. When looking at the quality of the trials included in this review, a mean score of 6 can be considered a high score because these trials were exercise trials where it is impossible to blind the treatment provider and subjects, and, therefore, the maximum PEDro score that can be achieved is 8. However, because some trials were of lower methodological quality, they potentially present biased (and overly optimistic) estimates of treatment effects. To assess the impact of the lowerquality studies on the review conclusions, a sensitivity analysis with exclusion of trials with scores lower than 524,64 was performed. When the lower-quality studies were deleted, the effect size unexpectedly increased slightly for pain and disability outcomes (we did not conduct a sensitivity analysis for quality of life because the exclusion of these trials would leave only one trial in the treatment contrast). Therefore, we do not believe that our conclusion that motor control exercise is effective (compared with minimal intervention or when used as a supplement) is an artifact of the inclusion of low-quality trials. This review not only includes 4 new trials that were not included in previous reviews, accounting for the addition of 560 patients, but also allowed the use of a meta-analytical approach with the inclusion of a greater number of articles into each treatment contrast. The pooled results of this systematic review showed smaller and more-precise esJanuary 2009

timates of treatment effects when compared with the pooled results of Ferreira et al.13 This difference among studies can be seen when looking, for example, at the motor control exercise versus minimal intervention contrast. For this contrast, Ferreira et al13 included 2 trials and found an effect of ⫺21 on a 0 to 100 scale (95% CI⫽⫺32 to ⫺9) for pain, whereas we found, based on 5 trials, an effect of ⫺14.3 (95% CI⫽⫺20.4 to ⫺8.1). Although it has been only recently that reviews of motor control exercises have been published, this type of intervention is widely accepted and used in the clinical field around the world. Therefore, it is still crucial that further studies in the area be developed, such as a placebocontrolled trial and trials aiming to identify subgroups of patients who will benefit more from a motor control intervention. More fundamental studies in LBP to establish reliable and valid clinical assessment tools to identify deficits in motor control also are needed.

Conclusion The results of this systematic review suggest that motor control exercise is more effective than minimal intervention and adds benefit to another form of intervention in reducing pain and disability for people with persistent LBP. The optimal implementation of motor control exercise at present is unclear. Future trials evaluating issues such as dosage parameters, feedback approaches, and effects in defined subgroups are a high priority. Ms Macedo, Dr Maher, and Dr Latimer provided concept/idea/research design and data collection. Ms Macedo and Dr Maher provided writing and data analysis. Ms Macedo, Dr Maher, and Dr McAuley provided project management. Dr Latimer provided clerical support and consultation (including review of manuscript before submission).

Ms Macedo holds a PhD scholarship jointly funded by The University of Sydney and the Australian Government. Dr Maher’s research fellowship is funded by Australia’s National Health and Medical Research Council. This article was received April 3, 2008, and was accepted October 10, 2008. DOI: 10.2522/ptj.20080103

References 1 Hancock MJ, Maher CG, Latimer J, et al. Systematic review of tests to identify the disc, SIJ or facet joint as the source of low back pain. Eur Spine J. 2007;16: 1539 –1550. 2 Niemisto L, Rissanen P, Sarna S, et al. Costeffectiveness of combined manipulation, stabilizing exercises, and physician consultation compared to physician consultation alone for chronic low back pain: a prospective randomized trial with 2-year follow-up [with consumer summary]. Spine. 2005;30:1109 –1115. 3 Niemisto L, Sarna S, Lahtinen-Suopanki T, et al. Predictive factors for 1-year outcome of chronic low back pain following manipulation, stabilizing exercises, and physician consultation or physician consultation alone. J Rehabil Med. 2004;36:104 – 109. 4 Panjabi MM. Clinical spinal instability and low back pain. J Electromyogr Kinesiol. 2003;13:371–379. 5 Hodges PW, Richardson CA. Delayed postural contraction of transversus abdominis in low back pain associated with movement of the lower limb. J Spinal Disord. 1998;11:46 –56. 6 Hodges PW, Richardson CA. Relationship between limb movement speed and associated contraction of the trunk muscles. Ergonomics. 1997;40:1220 –1230. 7 MacDonald D, Moseley GL, Hodges PW. The function of the lumbar multifidus in unilateral low back pain. Presented at: World Congress of Low Back and Pelvic Pain; 2004; Melbourne, Australia. 8 Moseley GL, Hodges PW, Gandevia S. Deep and superficial fibers of the lumbar multifidus muscle are differentially active during voluntary arm movements. Spine. 2002;27:E29 –E36. 9 Hodges PW, Richardson CA. Inefficient muscular stabilisation of the lumbar spine associated with low back pain: a motor control evaluation of transversus abdominis. Spine. 1996;21:2640 –2650. 10 Hides JA, Stokes MJ, Saide M, et al. Evidence of lumbar multifidus muscle wasting ipsilateral to symptoms in patients with acute/subacute low back pain. Spine. 1994;19:165–177. 11 Roy SH, DeLuca CJ, Casavant DA. Lumbar muscle fatigue and chronic low back pain. Spine. 1989;14:992–1001. 12 Alaranta H, Tallroth K, Soukka A, et al. Fat content of lumbar extensor muscles in low back disability: a radiographic and clinical comparison. J Spinal Disord. 1993;6:137–140.

Volume 89

Number 1

Physical Therapy f

23

Motor Control Exercise for Persistent, Nonspecific LBP 13 Ferreira ML, Ferreira PH, Latimer J, et al. Comparison of general exercise, motor control exercise and spinal manipulative therapy for chronic low back pain: a randomized trial. Pain. 2007;131:31–37. 14 O’Sullivan PB, Phyty GD, Twomey LT, et al. Evaluation of specific stabilizing exercise in the treatment of chronic low back pain with radiologic diagnosis of spondylolysis or spondylolisthesis. Spine. 1997;22:2959 –2967. 15 Hides JA, Richardson CA, Jull GA. Multifidus muscle recovery is not automatic after resolution of acute, first-episode low back pain. Spine. 1996;21:2763–2769. 16 Ferreira PH, Ferreira ML, Maher CG, et al. Specific stabilisation exercise for spinal and pelvic pain: a systematic review. Aust J Physiother. 2006;52:79 – 88. 17 Hauggaard A, Persson A. Specific spinal stabilisation exercises in patients with low back pain: a systematic review. Phys Ther Rev. 2007;12:233–248. 18 Rackwitz B, de Bie R, Limm H, et al. Segmental stabilizing exercises and low back pain. What is the evidence? A systematic review of randomized controlled trials. Clin Rehabil. 2006;20:553–567. 19 Bombardier C, van Tulder MW, Pennick V, et al. Cochrane Back Group. About the Cochrane Collaboration (Cochrane Review Groups [CRGs]). 2006:4. 20 Airaksinen O, Brox JI, Cedraschi C, et al. Chapter 4: European guidelines for the management of chronic nonspecific low back pain. Eur Spine J. 2006;15(Suppl 2):S192–S300. 21 van Tulder MW, Becker A, Bekkering T, et al. Chapter 3: European guidelines for the management of acute nonspecific low back pain in primary care. Eur Spine J. 2006;15(Suppl 2):S169 –S191. 22 Maher CG, Sherrington C, Herbert RD, et al. Reliability of the PEDro scale for rating quality of randomized controlled trials. Phys Ther. 2003;83:713–721. 23 Sherrington C, Herbert RD, Maher C, et al. PEDro: a database of randomised controlled trials and systematic reviews in physiotherapy. Man Ther. 2000;5:223– 226. 24 Stevens V, Crombez G, Parlevliet T, et al. The effectiveness of specific exercise therapy versus device exercise therapy in the treatment of chronic low back pain patients. In: Proceedings of the 6th Interdisciplinary World Congress of Low Back and Pelvic Pain; 2007; Barcelona, Spain; 2007: 177. 25 Higgins J, Green S. Cochrane Handbook for Systematic Reviews of Interventions 4.2.6 [updated September 2006]. In: The Cochrane Library, issue 4, 2006. Chichester, United Kingdom: John Wiley & Sons Ltd; 2006. 26 Critchley DJ, Ratcliffe J, Noonan S, et al. Effectiveness and cost-effectiveness of three types of physiotherapy used to reduce chronic low back pain disability: a pragmatic randomized trial with economic evaluation [with consumer summary]. Spine. 2007;32:1474 –1481.

24

f

Physical Therapy

Volume 89

27 Moseley L. Combined physiotherapy and education is efficacious for chronic low back pain. Aust J Physiother. 2002;48: 297–302. 28 Stuge B, Laerum E, Kirkesola G, et al. The efficacy of a treatment program focusing on specific stabilizing exercises for pelvic girdle pain after pregnancy: a randomized controlled trial. Spine. 2004;29:351–359. 29 van Tulder MW, Furlan A, Bombardier C, et al. Updated method guidelines for systematic reviews in Cochrane Collaboration Back Review Group. Spine. 2003;28: 1290 –1299. 30 Bendix AF, Bendix T, Lund C, et al. Comparison of three intensive programs for chronic low back pain patients: a prospective, randomized, observer-blinded study with one-year follow-up. Scand J Rehabil Med. 1997;29:81– 89. 31 Bentsen H, Lindgarde F, Manthorpe R. The effect of dynamic strength back exercise and/or a home training program in 57year-old women with chronic low back pain: results of a prospective randomized study with a 3-year follow-up period. Spine. 1997;22:1494 –1500. 32 Cambron JA, Gudavalli MR, Hedeker D, et al. One-year follow-up of a randomized clinical trial comparing flexion distraction with an exercise program for chronic lowback pain. J Altern Complement Med. 2006;12:659 – 668. 33 Friedrich M, Gittler G, Halberstadt Y, et al. Combined exercise and motivation program: effect on the compliance and level of disability of patients with chronic low back pain—a randomized controlled trial. Arch Phys Med Rehabil. 1998;79: 475– 487. 34 Frost H, Lamb SE, Doll HA, et al. Randomised controlled trial of physiotherapy compared with advice for low back pain. BMJ. 2004;329:708 –713. 35 Gudavalli MR, Cambron JA, McGregor M, et al. A randomized clinical trial and subgroup analysis to compare flexiondistraction with active exercise for chronic low back pain. Eur Spine J. 2006;15:1070 – 82. 36 Helewa A, Goldsmith CH, Lee P, et al. Does strengthening the abdominal muscles prevent low back pain: a randomized controlled trial. J Rheumatol. 1999;26: 1808 –1815. 37 Koes BW, Bouter LM, van Mameren H, et al. The effectiveness of manual therapy, physiotherapy, and treatment by the general practitioner for nonspecific back and neck complaints: a randomized clinical trial. Spine. 1992;17:28 –35. 38 Lie H, Frey S, Lie H, et al. Mobilizing or stabilizing exercise in degenerative disk disease in the lumbar region? [in Norwegian]. Tidsskrift for Den Norske Laegeforening. 1999;119:2051–2053. 39 Mannion AF, Muntener M, Taimela S, et al. Comparison of three active therapies for chronic low back pain: results of a randomized clinical trial with one-year followup. Rheumatology. 2001;40:772–778.

Number 1

40 Nelson BW, O’Reilly E, Miller M, et al. The clinical effects of intensive, specific exercise on chronic low back pain: a controlled study of 895 consecutive patients with 1-year follow up. Orthopedics. 1995; 18:971–981. 41 Shaughnessy A. Can a specific exercise program combined with brief counseling by a physical therapist offer benefits over usual care? Evidence-Based Practice. 1999;2:1–2. 42 Suni J, Rinne M, Natri A, et al. Control of the lumbar neutral zone decreases low back pain and improves self-evaluated work ability: a 12-month randomized controlled study. Spine. 2006;31:E611–E620. 43 Timm KE. A randomized-control study of active and passive treatments for chronic low back pain following L5 laminectomy. J Orthop Sports Phys Ther. 1994;20:276 – 286. 44 Freburger JK, Carey TS, Holmes GM, et al. Effectiveness of physical therapy for the management of chronic spine disorders: a propensity score approach. Phys Ther. 2006;86:381–394. 45 Hicks GE, Fritz JM, Delitto A, et al. Preliminary development of a clinical prediction rule for determining which patients with low back pain will respond to a stabilization exercise program. Arch Phys Med Rehabil. 2005;86:1753–1762. 46 Kasai R. Current trends in exercise management for chronic low back pain: comparison between strengthening exercise and spinal segmental stabilization exercise. J Phys Med Sci. 2006;18:97–105. 47 Ljungkvist I, Ljungkvist I. Short- and longterm effects of a 12-week intensive functional restoration programme in individuals work-disabled by chronic spinal pain. Scand J Rehabil Med Suppl. 2000;40:1– 14. 48 Weinhardt C, Heller KD, Weh L, et al. Non-operative treatment of chronic low back pain: specific back muscular strength training versus improvement of physical fitness. Zeitschrift fur Orthopadie und Ihre Grenzgebiete. 2001;139:490 – 495. 49 Koumantakis GA, Watson PJ, Oldham JA, et al. Supplementation of general endurance exercise with stabilisation training versus general exercise only: physiological and functional outcomes of a randomised controlled trial of patients with recurrent low back pain. Clin Biomech. 2005;20: 474 – 482. 50 Stuge B, Veierod MB, Laerum E, et al. The efficacy of a treatment program focusing on specific stabilizing exercises for pelvic girdle pain after pregnancy: a two-year follow-up of a randomized clinical trial. Spine. 2004;29:E197–E203. 51 Cairns MC, Foster NE, Wright C, et al. Randomized controlled trial of specific spinal stabilization exercises and conventional physiotherapy for recurrent low back pain. Spine. 2006;31:E670 –E681. 52 Gagnon LH. Efficacy of Pilates Exercises as Therapeutic Intervention in Treating Patients With Low Back Pain [dissertation]. Knoxville, TN: University of Tennessee; 2005:119.

January 2009

Motor Control Exercise for Persistent, Nonspecific LBP 53 Hides JA, Jull GA, Richardson CA. Longterm effects of specific stabilizing exercises for first-episode low back pain. Spine. 2001;26:E243–E248. 54 Aure OF, Nilse JH, Vasseljen O. Manual therapy and exercise therapy in patients with chronic low back pain. Spine. 2003;28:525–532. 55 Monticone M, Barbarino A, Testi C, et al. Symptomatic efficacy of stabilizing treatment versus laser therapy for sub-acute low back pain with positive tests for sacroiliac dysfunction: a randomized clinical controlled trial with 1-year follow-up. Europa Medicophysica. 2004;40:263–268. 56 Lewis JS, Hewitt JS, Billington L, et al. A randomized clinical trial comparing two physiotherapy interventions for chronic low back pain. Spine. 2005;30:711–721. 57 Riipinen M, Niemisto L, Lindgren KA, et al. Psychosocial differences as predictors for recovery from chronic low back pain following manipulation, stabilizing exercises and physician consultation or physician consultation alone. J Rehabil Med. 2005; 37:152–158. 58 Jull GA, Trott P, Potter H, et al. A randomized controlled trial of exercises and manipulative therapy for cervicogenic headache. Spine. 2002;27:1835–1843; discussion 1843. 59 Danneels LA, Cools AM, Vanderstraeten GG, et al. The effects of three different training modalities on the cross-sectional area of the paravertebral muscles. Scand J Med Sci Sports. 2001;11:335–341.

January 2009

60 Danneels LA, Vanderstraeten GG, Cambier DC, et al. Effects of three different training modalities on the cross-sectional area of the lumbar multifidus muscle in patients with chronic low back pain. Br J Sports Med. 2001;35:186 –191; comment in 2001; 35:186 –191. 61 Miller ER, Schenk RJ, Karnes JL, et al. A comparison of the McKenzie approach to a specific spine stabilization program for chronic low back pain. Journal of Manual and Manipulative Therapy. 2005;13: 103–112. 62 Niemisto L, Lahtinen-Suopanki T, Rissanen P, et al. A randomized trial of combined manipulation, stabilizing exercises, and physician consultation compared to physician consultation alone for chronic low back pain. Spine. 2003;28:2185–2191. 63 Shaughnessy M, Caulfield B, Shaughnessy M, et al. A pilot study to investigate the effect of lumbar stabilisation exercise training on functional ability and quality of life in patients with chronic low back pain. Int J Rehabil Res. 2004;27:297–301. 64 Goldby LJ, Moore AP, Doust J, et al. A randomized controlled trial investigating the efficiency of musculoskeletal physiotherapy on chronic low back disorder. Spine. 2006;31:1083–1093. 65 Koumantakis GA, Watson PJ, Oldham JA. Trunk muscle stabilization training plus general exercise versus general exercise only: randomized controlled trial of patients with recurrent low back pain. Phys Ther. 2005;85:209 –225.

66 Rasmussen-Barr E, Nilsson-Wikmar L, Arvidsson I, et al. Stabilizing training compared with manual treatment in sub-acute and chronic low-back pain. Man Ther. 2003;8:233–241. 67 Kladny B, Fischer FC, Haase I, et al. Evaluation of specific stabilizing exercise in the treatment of low back pain and lumbar disk disease in outpatient rehabilitation. Zeitschrift fur Orthopadie und Ihre Grenzgebiete. 2003;141:401– 405. 68 Brox JI, Sørensen R, Friis A, et al. Randomized clinical trial of lumbar instrumented fusion and cognitive intervention and exercise in patients with chronic low back pain and disc degeneration. Spine. 2003; 28:1913–1921; comment in 2004;29: 1913–1921. 69 Tsao H, Hodges PW. Immediate changes in feedforward postural adjustment following voluntary motor training. Exp Brain Res. 2007;181:537–546. 70 Hall L, Tsao T, MacDonald D, et al. Immediate effects of co-contraction training on motor control of the trunk muscles in people with recurrent low back pain. J Electromyogr Kinesiol. 2007 Nov 21 [Epub ahead of print]. 71 Richardson CA, Jull GA, Hodges PW. Therapeutic Exercise for Spinal Segmental Stabilization in Low Back Pain. Edinburgh, Scotland: Churchill Livingstone; 1999.

Volume 89

Number 1

Physical Therapy f

25

Research Report

K Kulig, PT, PhD, is Associate Professor of Clinical Physical Therapy, Division of Biokinesiology and Physical Therapy, University of Southern California, 1540 E Alcazar St, CHP-155, Los Angeles, CA 90033 (USA). Address all correspondence to Dr Kulig at: [email protected]. SF Reischl, PT, DPT, OCS, is Adjunct Associate Professor of Clinical Physical Therapy, Division of Biokinesiology and Physical Therapy, University of Southern California. AB Pomrantz, PT, DPT, OCS, ATC, is Adjunct Instructor of Clinical Physical Therapy, Division of Biokinesiology and Physical Therapy, University of Southern California. JM Burnfield, PT, PhD, is Director, Movement Sciences Center, and Clifton Chair in Physical Therapy and Movement Science, Institute for Rehabilitation Science and Engineering, Madonna Rehabilitation Hospital, Lincoln, Nebraska.

Nonsurgical Management of Posterior Tibial Tendon Dysfunction With Orthoses and Resistive Exercise: A Randomized Controlled Trial Kornelia Kulig, Stephen F Reischl, Amy B Pomrantz, Judith M Burnfield, Susan Mais-Requejo, David B Thordarson, Ronald W Smith

Background and Purpose. Tibialis posterior tendinopathy can lead to debilitating dysfunction. This study examined the effectiveness of orthoses and resistance exercise in the early management of tibialis posterior tendinopathy. Subjects. Thirty-six adults with stage I or II tibialis posterior tendinopathy participated in this study.

Methods. Participants were randomly assigned to 1 of 3 groups to complete a 12-week program of: (1) orthoses wear and stretching (O group); (2) orthoses wear, stretching, and concentric progressive resistive exercise (OC group); or (3) orthoses wear, stretching, and eccentric progressive resistive exercise (OE group). Preintervention and post-intervention data (Foot Functional Index, distance traveled in the 5-Minute Walk Test, and pain immediately after the 5-Minute Walk Test) were collected.

S Mais-Requejo, PT, DPT, OCS, is Adjunct Assistant Professor of Clinical Physical Therapy, Division of Biokinesiology and Physical Therapy, University of Southern California.

Results. Foot Functional Index scores (total, pain, and disability) decreased in all groups after the intervention. The OE group demonstrated the most improvement in each subcategory, and the O group demonstrated the least improvement. Pain immediately after the 5-Minute Walk Test was significantly reduced across all groups after the intervention.

DB Thordarson, MD, is Professor of Orthopedic Surgery, Department of Orthopedic Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California.

Discussion and Conclusion. People with early stages of tibialis posterior tendinopathy benefited from a program of orthoses wear and stretching. Eccentric and concentric progressive resistive exercises further reduced pain and improved perceptions of function.

RW Smith, MD, is Orthopedic Foot and Ankle Surgeon, Long Beach Memorial Medical Center, Long Beach, California. [Kulig K, Reischl SF, Pomrantz AB, et al. Nonsurgical management of posterior tibial tendon dysfunction with orthoses and resistive exercise: a randomized controlled trial. Phys Ther. 2009;89:26 –37.] © 2009 American Physical Therapy Association Post a Rapid Response or find The Bottom Line: www.ptjournal.org 26

f

Physical Therapy

Volume 89

Number 1

January 2009

Posterior Tibial Tendon Dysfunction

P

osterior tibial tendon dysfunction (PTTD) is a well-recognized source of pain and walking dysfunction1,2 and is one of the leading causes of acquired flatfoot deformity in the adult population.3–9 Descriptively, the various presentations of this condition are divided into 3 stages.1 Stage I is characterized by mild swelling, medial ankle pain, normal but possibly painful heel rise, and no deformity. Stage II is characterized by progressive flattening of the arch, with an abducted midfoot indicating secondary midfoot deformity. The hindfoot is still flexible, but the tendon is functionally incompetent or ruptured, and patients are commonly unable to perform a heel rise. Stage III includes all of the signs of stage II, except that the hindfoot deformity has become fixed. In severe cases, pain may be present at the calcaneal-fibular articulation because of lateral abutment. Myerson and Corrigan10 added stage IV for patients who progressed to valgus tilt of the talus in the ankle mortise, leading to lateral tibiotalar degeneration. Despite the high prevalence of PTTD,4 there are no intervention guidelines for stage I or II, and surgical repair is the only definitive treatment for stage III or IV. Factors associated with PTTD include age-related degeneration, inflammatory arthritides,11,12 hypertension, diabetes mellitus, obesity, and, less frequently, acute traumatic rupture.10,12,13 Because the pathogenesis of this condition is theorized to be tendon degeneration (tendinosis),14,15 rehabilitation efforts in the early stages of the disorder frequently focus on mechanically supporting the flattened arch to prevent further tendon lengthening and foot deformity.2,16,17 It has been observed that a flattened arch may be accompanied by an everted calcaneus, promoting a shortened calf musculotendinous January 2009

complex. Exercises to strengthen the weakened tibialis posterior musculotendinous complex also have been strongly recommended to prevent further degeneration.16,18 Lacking in the literature, however, are guidelines specifying how to most effectively strengthen the muscle in the presence of painful tendon dysfunction. Although early reports suggested that the dysfunction arises from an inflammatory process in or around the tibialis posterior tendon (tendinitis or tenosynovitis),19 recent histological studies suggested that the changes associated with PTTD are more consistent with a degenerative process. In a comparison of gross and histological findings for specimens obtained from 15 people undergoing surgical intervention for stage II PTTD, Mosier and colleagues14,15 reported an absence of inflammatory infiltrates in the tendons despite the clinical appearance of tenosynovitis during surgery. Additionally, they identified disruption of the linear organization of the collagen bundles, which could reduce the tensile strength of the tendon and predispose it to further attenuation or rupture under a large load. The development of an exercise program that strengthens the weakened tibialis posterior musculotendinous complex is essential for effectively managing the early stages of PTTD and preventing further degeneration. The specificity and intensity of training are central concepts in designing an optimal treatment paradigm. Kulig and colleagues20 examined the activation of the tibialis posterior muscle during repeated movements and reported that a closed-chain resisted foot adduction exercise performed barefoot most effectively and selectively activated the tibialis posterior muscle in people with a normal arch index. In a subsequent study of people with pes

planus who were asymptomatic, the authors determined that, although the tibialis posterior muscle was preferentially recruited during the same exercise, the most effective and selective activation occurred only when subjects wore archsupporting orthoses and shoes.21 The effectiveness of this exercise for people with painful PTTD was not studied. The intensity of a stimulus, such as exercise, requires sufficient load and frequency to trigger adaptation. The musculotendinous complex tolerates a larger load during eccentric exercise than during concentric exercise.22 However, the level of muscle activation is lower during eccentric exercise,23 suggesting that eccentric training may be optimal if the desired outcome is to load the tendon to promote adaptation. To test this assumption, we proposed a comparison of concentric and eccentric resistive exercises. Given the above data, it is feasible that within a 12-week period of twice-daily progressive resistive exercises, an eccentric program would allow for exercise at loads exceeding those in a concentric program and, therefore, would provide a larger load to the tendon. Furthermore, to address the everted calcaneus, which is associated with a shortened calf musculotendinous complex and flatfoot deformity, we added stretching of the calf musculature to the exercise protocol. Recent research focusing on people with painful Achilles tendinosis determined that participation in a heavy-load eccentric calf muscle training program improved function,24,25 reduced pain,25 and enhanced tendon structure.26 Influenced by those studies and our own positive clinical observations after the use of an adapted form of this protocol for people with PTTD, we designed a study to test the effects of

Volume 89

Number 1

Physical Therapy f

27

Posterior Tibial Tendon Dysfunction Table 1. Demographic and Anthropometric Characteristics of Participants Duration of Symptoms, moa

Body Weight, kga

Body Height, ma

Body Mass Indexa,b

Arch Indexa,c

Age, ya

Sex

Involved Side

Orthoses (n⫽12)

51.3 (17.2)

8 women, 4 men

5 right, 7 left

25.3 (50.3)

82.5 (18.8)

1.70 (0.07)

28.7 (6.26)

0.169 (0.035)

Orthoses and concentric exercise (n⫽12)

55.3 (16.4)

10 women, 2 men

9 right, 3 left

26.0 (36.2)

85.9 (22.7)

1.65 (0.14)

32.0 (9.24)

0.160 (0.027)

Orthoses and eccentric exercise (n⫽12)

49.4 (12.6)

10 women, 2 men

3 right, 9 left

40.5 (69.4)

80.4 (23.0)

1.67 (0.10)

28.5 (7.09)

0.169 (0.050)

Group

a

Reported as X (SD). Body mass index: ⬍18.5⫽underweight, 18.5–24.9⫽normal, 25.0 –29.9⫽overweight, ⬎30.0⫽obese.28 c Arch index: 0.193 (0.034)⫽normal.27 b

eccentric loading of the tibialis posterior tendon on pain and function in people with tibialis posterior tendinosis. We hypothesized that participation in an eccentric tibialis posterior tendon exercise program would lead to greater improvements in function and reductions in pain than would be achieved with a concentric exercise program or the use of archcorrecting orthoses alone.

Method Participants Thirty-six participants were recruited from the Department of Orthopedics at the University of Southern California and Long Beach Memorial Medical Center between 2002 and 2006. Recruitment included a referral by a physician who determined, by history and physical examination, that the participants met the inclusion criteria listed below. All participants were then interviewed by one of the study investigators via telephone or in person to further screen for eligibility. To be enrolled in the study, participants had to have a current complaint of foot and ankle pain that had lasted for 3 months or more. The inclusion criteria were based on the guidelines set forth by Johnson and Strom for stage I and stage II PTTD1 as discussed above: symptoms located at the medial ankle or foot, tenderness to palpation specific to the tibialis posterior tendon, foot flattening, ab28

f

Physical Therapy

Volume 89

ducted midfoot, and absence of rigid foot deformity. Foot flattening was determined with the arch index27; midfoot abduction was determined by observation of the “too-many-toes sign”1; and the presence or absence of rigid foot deformity was determined by observation of calcaneal valgus and midfoot abductus deformities, which were either rigid or flexible with passive mobilization. No participants reported pain at the lateral foot. Heel-rise performance varied among participants with regard to symptoms and ability. Because participants with both stage I and stage II PTTD were included in the study and the inability to perform a heel rise did not help with regard to classification as stage II, III, or IV, this information was used only to develop foot orthoses for each participant. Participants were excluded if they had any of the following conditions: fixed foot deformities; previous foot surgery; or cardiovascular, neurovascular, peripheral vascular, or musculoskeletal pathology that would have limited participation in the study. Participants agreed to discontinue athletic activities and to refrain from increasing activity once enrolled in the study. All participants signed an informed consent form before enrollment. Demographic and anthropometric28 information for the participants is provided in Table 1.

Number 1

Study Design This study was a randomized controlled trial designed to compare the effectiveness of foot orthoses in combination with eccentric or concentric resistive exercise with that of foot orthoses alone. Outcome Measures Foot Functional Index (FFI). The FFI consists of 23 self-reported items divided into 3 subcategories (pain, disability, and activity limitation). The pain subcategory consists of 9 items and measures foot pain in different situations, such as walking barefoot versus walking with shoes. The disability subcategory consists of 9 items and measures difficulty performing various functional activities because of foot problems, such as difficulty climbing stairs. The activity limitation subcategory consists of 5 items and measures limitations in activities because of foot problems, such as staying in bed all day. Recorded on a visual analog scale (VAS), scores range from 0 to 100 mm, with higher scores indicating worse pain. Both total and subcategory scores are calculated.29 The FFI has been validated and determined to yield reliable data for people with rheumatoid arthritis29 and nontraumatic foot or ankle problems.30 5-Minute Walk Test. The 5-Minute Walk Test measures the distance a participant can walk in a 5-minute January 2009

Posterior Tibial Tendon Dysfunction period as fast as tolerated. Good day-to-day test-retest reliability (the ability of a test to provide reliable results when testing is performed on 2 different days) of this test has been established for people with low back pain (intraclass correlation coefficient⫽.87), and moderate dayto-day test-retest reliability has been reported for people who are healthy (intraclass correlation coefficient⫽.60).31 VAS. The VAS assesses pain on a single-dimension scale with endpoints marked as “no pain” and “worst pain possible.” It has been established as a reliable and valid measure of self-reported pain intensity.32 In this study, the VAS was used to measure pain intensity after completion of the 5-Minute Walk Test. Timing of Evaluations All tests and questionnaires were administered before and after the intervention. In addition, at the first visit, a research investigator performed a standard orthopedic lower-quadrant assessment to document structural condition, mobility, and strength (force-generating capacity); the assessment included clinical observation (foot structure, posture, and gait), palpation, manual muscle testing, heel-rise testing, and determination of the arch index with methods described by Williams and McClay.27 This information was used only to determine whether participants met study inclusion or exclusion criteria and to develop foot orthoses for each participant. Types of Interventions Orthoses. All participants received custom-made orthoses.* The participants were asked to adhere to the protocol by wearing the orthoses during 90% of their waking hours. * Biomechanical Service, 1050 Central Ave, Suite D, Long Beach, CA 92832.

January 2009

Stretching. All participants were instructed in the performance of gastrocnemius and soleus muscle stretches to be performed 2 times per day. Each participant was issued a Slant by OPTP,† a lightweight, portable foam wedge to be used for calf muscle stretching. Participants were instructed to place the slant facing away from a wall, within a footlength distance, and to place the shod foot of the leg to be stretched on the slant with the toes pointing up. They were instructed to lean forward until a strong but tolerable stretch was perceived in the calf muscles. This maneuver was repeated 3 times with the knee extended to target the gastrocnemius muscle and 3 times with the knee slightly flexed to more selectively isolate the soleus muscle. Stretch positions were held for 30 seconds. The lumbar spine was placed in a “neutral” position to reduce the potential risk of strain to the low back region. In addition to practice trials and verbal explanations, pictorial and written descriptions of the stretching technique were provided to each participant (Appendix). Stretching was initiated on the day of the initial evaluations, after all clinical assessments were completed. Progressive resistive exercise. Previous work indicated that the tibialis posterior muscle was preferentially recruited during a resisted foot horizontal adduction exercise in people with pes planus20 and that this muscle was selectively activated when people with foot flattening performed the exercise while wearing arch-supporting orthoses and shoes.21 Therefore, the exercise intervention implemented in this study consisted of isolated loading of the tibialis posterior musculotendinous unit (horizontal adduction with

† OPTP, PO Box 47009, Minneapolis, MN 55447-0009.

plantar flexion) with participants wearing both orthoses and shoes. The exercise was performed with a specialized exercise unit (TibPost Loader‡) that could be adjusted to progressively load the tendon either concentrically or eccentrically, depending on group assignment (Fig. 1). The design of the TibPost Loader allowed participants in the concentric exercise group to first actively horizontally adduct the foot to an end-range position and then passively horizontally abduct back to a neutral position to eliminate an eccentric contraction. The hand lever allowed participants in the eccentric exercise group to first passively horizontally adduct the foot to an end-range position (to eliminate a concentric contraction) and then actively resist horizontal abduction back to a neutral position, providing for eccentric loading. Participants began the resistive exercise when the custom-made orthoses were delivered, approximately 1 to 2 weeks after evaluation. Resistance was provided by Conforce Constant Force springs,§ starting with 0.9 kg (2 lb) and increasing in at least 0.9-kg increments on the basis of each participant’s ability to perform 15 repetitions. Once the participant was able to perform 15 repetitions in 3 sets, with good technique (smooth path), a new 15-repetition maximum was established. In all cases, the addition of a 0.9-kg spring was sufficient. Interestingly, none of the participants reported pain in the tendon even when the load was at the level of the participant’s maximum ability to resist the movement of the loaded footplate. A unique feature of these springs is their ability to provide constant resistance throughout their range of elongation. ‡ Ron Kelderhaus, PT, DPT, PO Box 9006, Los Angeles, CA 90089. § Vulcan Spring & Mfg Co, 501 Schoolhouse Rd, Telford, PA 18969.

Volume 89

Number 1

Physical Therapy f

29

Posterior Tibial Tendon Dysfunction

Figure 1. Exercise device (TibPost Loader) designed to provide progressive, constant (throughout the range) resistance (0.9 –9 kg [2–20 lb]) in the transverse plane. The hand lever (3) allows for selective application of resistance in one direction only. When the footplate is moved by the foot against the resistance of the spring (2) into horizontal adduction, the tibialis posterior tendon is recruited concentrically. Conversely, when the foot resists the motion of the footplate toward horizontal abduction, the tibialis posterior tendon is recruited eccentrically. To minimize the activity of the anterior tibialis tendon with transverse-plane motion, secondary static resistance (0.9 kg) to plantar flexion is provided. Light-emitting diodes indicate whether the foot is pressing into plantar flexion (1).

Group Allocation Participants were randomly assigned to 1 of 3 groups: (1) orthoses wear and calf stretching (O group); (2) orthoses wear, calf stretching, and a concentric exercise program (OC group); and (3) orthoses wear, calf stretching, and an eccentric exercise program (OE group). The intervention was performed as a home exercise program with sets and repetitions as described above. A research investigator or a practicing physical therapist met with each participant separately for 30 minutes once per week for 10 weeks to assess the quality of exercise and to modify resistance as described below. During these sessions, all stretches and exercises were performed. Participants maintained an exercise record chart with the number of stretches and resistive exercises performed daily as well as reflections on their performance (ease or difficulty; if discomfort, then location and intensity). Members of the exercise groups were provided with a TibPost Loader that they used both at home and during weekly visits for the duration of the study.

30

f

Physical Therapy

Volume 89

O group. Participants in the O group wore custom-made foot orthoses and performed the calf stretches described earlier. OC group. In addition to wearing custom-made foot orthoses and performing calf stretches, participants in the OC group were instructed in a concentric exercise regimen with the TibPost Loader. The resistive exercise was performed slowly (5 seconds throughout the range of motion). A series of 3 sets of 15 repetitions were performed twice daily on the involved side. Rest periods between sets were 1 to 2 minutes long. The resistance, provided by Conforce springs, was set at 0.9 kg (2 lb) for the first week and increased within tolerance and ability by the research investigator at weekly meetings. The progression of resistance depended on participants’ reports of ease or difficulty and reports of symptoms and on their ability to maintain control over 3 sets of 15 repetitions, as assessed by observation during weekly meetings. When all 45 repetitions were performed with ease, minimal or no symptoms,

Number 1

and proper control, the resistance was increased. OE group. In addition to wearing custom-made foot orthoses and performing calf stretches, participants in the OE group were instructed in an eccentric exercise regimen with the TibPost Loader. All exercise parameters (ie, speed, repetitions, and rest periods) were the same as those described for the concentric intervention. Statistical Analyses Exploratory analyses revealed that the data were normally distributed. Two-way analyses of variance (ANOVAs) for each dependent variable determined the influence of testing session (before and after the intervention) and treatment intervention (O, OC, and OE groups). For variables for which randomization produced differences between groups at the initial assessment, repeated-measures analyses of covariance (ANCOVAs) with the initial scores as covariates were performed. The level of statistical significance was set at P⬍.05. All statistical analJanuary 2009

Posterior Tibial Tendon Dysfunction

Figure 2. Diagram of the posterior tibial tendon dysfunction randomized controlled trial, showing numbers of participants screened, randomized, retained, withdrawn, and excluded.

yses were performed with SPSS for Windows software, version 15.0.㛳

Results Recruitment and Retention To achieve the estimated sample size of 36 participants (12 per treatment arm, as determined by power calculations conducted during the study design process),33 we interviewed a total of 126 participants to establish their appropriateness for this research study (Fig. 2). Forty participants met the inclusion criteria and were enrolled in the study. Thirty-six participants completed the 12-week intervention and evaluations before and after the intervention. Four participants either withdrew or were excluded from the study. In brief, one elected to have surgery within the first month of beginning the intervention; the second did not return for testing after the intervention; the third began remodeling her house, an activity that was in conflict with the inclusion criteria; and the fourth 㛳

SPSS Inc, 233 S Wacker Dr, Chicago, IL 60606.

January 2009

continued playing tennis, resulting in increased symptoms and subsequent application of a plaster cast by her physician to provide for rest and unloading of the foot. Adherence and Progression of Resistive Exercise For the participants who remained in the study, the self-reported adherence rate for wearing orthoses outdoors was 100%. Adherence to twice-daily stretching and resistive exercise programs ranged from 39% to 98% (average⫽68%). There was no difference in adherence rates among the groups. Adherence to attending weekly physical therapist visits was 90% to 100%. The initial resistance to motion was set at 0.9 kg (2 lb) and was based on symptoms and ability to perform the motion in a controlled manner. At the completion of the intervention, participants in the OC group exercised with an average resistance of ⬃1.7 kg (3.7 lb; range⫽0.9 – 4.5 kg [2–10 lb]), and the corresponding average for those

in the OE group was ⬃5.6 kg (12.5 lb; range⫽4.5–9 kg [10 –20 lb]). Self-Reported Pain, Disability, and Activity Limitation FFI total score. When averaged across all groups, the mean (SD) FFI total scores significantly decreased, from 30.0 (17.7) before the intervention to 11.5 (12.8) after the intervention (P⬍.0001) (Tab. 2). The FFI total scores before and after the intervention were 30.5 (19.8) and 21.2 (19.5) for the O group, 23.9 (14.2) and 13.0 (9.5) for the OC group, and 35.6 (18.2) and 10.6 (8.5) for the OE group, respectively (Tab. 2). With the initial scores as covariates, a repeated-measures ANCOVA identified differences among the groups (P⫽.042) (Tab. 2). FFI pain subcategory. When averaged across all groups, the mean (SD) FFI pain subcategory scores significantly decreased, from 39.7 (19.3) before the intervention to 15.0 (13.9) after the intervention (P⬍.0001). The FFI pain subcategory

Volume 89

Number 1

Physical Therapy f

31

Posterior Tibial Tendon Dysfunction Table 2. Foot Functional Index Total Score and Scores for Pain, Disability, and Activity Limitation Subcategories for All Study Participants and for Each Group Before and After the 12-Week Interventiona Group All participants (N⫽36)

Time Relative to Intervention

Total

Pain Subcategory

Disability Subcategory

Activity Limitation Subcategory

Before

30.0 (24.2, 35.8)

39.7 (33.4, 46.0)

36.4 (27.7, 45.1)

13.7 (8.6, 18.8)

After

11.5 (7.3, 15.7)

15.0 (10.5, 19.5)

11.9 (6.7, 17.1)

7.6 (3.3, 11.9)

⬍.0001

⬍.0001

⬍.0001

.082

Before

30.5 (19.3, 41.7)

37.5 (25.8, 49.2)

34.7 (19.4, 50.0)

18.6 (6.5, 30.7)

After

21.2 (10.2, 32.2)

21.2 (10.2, 32.2)

19.9 (7.6, 32.2)

11.8 (2.1, 21.5)

Pb Orthoses (n⫽12)

Orthoses and concentric exercise (n⫽12)

Before

23.9 (15.9, 31.9)

34.8 (23.6, 46.0)

27.8 (16.6, 39.0)

9.2 (2.9, 15.5)

After

13.0 (7.6, 18.4)

13.0 (7.6, 18.4)

10.0 (3.2, 16.9)

5.9 (⫺1.1, 12.9)

Orthoses and eccentric exercise (n⫽12)

Before

35.6 (25.3, 45.9)

46.9 (37.3, 56.5)

46.6 (29.4, 63.8)

13.2 (6.1, 20.3)

After

10.6 (5.8, 15.4)

10.6 (5.8, 15.4)

5.9 (1.3, 10.5)

5.2 (0.1, 10.4)

.042

.048

.036

.648

c

P a b c

Reported as X (95% confidence interval [minimum, maximum]). P values for scores before the intervention versus scores after the intervention for all participants. P values for analyses of variance with the values before the intervention as covariates.

scores before and after the intervention were 37.5 (20.6) and 21.2 (19.5) for the O group, 34.8 (19.8) and 13.0 (9.5) for the OC group, and 46.9 (16.9) and 10.6 (8.5) for the OE group, respectively (Tab. 2). With the initial scores as covariates, a repeated-measures ANCOVA identified differences among the groups (P⫽.048) (Tab. 2). FFI disability subcategory. When averaged across all groups, the mean (SD) FFI disability subcategory scores significantly decreased, from 36.4 (26.6) before the intervention to 11.9 (15.8) after the intervention (P⬍.0001) (Tab. 2). The FFI disability subcategory scores before and after the intervention were 34.7 (27.1) and 19.9 (21.7) for the O group, 27.8 (19.8) and 10.0 (12.1) for the OC group, and 46.6 (30.4) and 5.9 (8.2) for the OE group, respectively (Tab. 2). With the initial scores as covariates, a repeated-measures ANCOVA identified differences among the groups (P⫽.036) (Tab. 2). FFI activity limitation subcategory. When averaged across all groups, the mean (SD) FFI activity 32

f

Physical Therapy

Volume 89

limitation subcategory scores decreased, but insignificantly, from 13.7 (15.7) before the intervention to 7.6 (13.3) after the intervention (P⫽.082) (Tab. 2). The FFI activity limitation subcategory scores before and after the intervention were 18.6 (21.4) and 11.8 (17.2) for the O group, 9.2 (11.1) and 5.9 (12.4) for the OC group, and 13.2 (12.5) and 5.2 (9.1) for the OE group, respectively (Tab. 2). A repeatedmeasures ANCOVA in which the covariates were the initial scores identified no difference among the groups (P⫽.648). 5-Minute Walk Test The data for distance walked in 5 minutes were normally distributed for all groups. A repeated-measures ANOVA identified no statistically significant difference between the testing distances walked in 5 minutes before and after the intervention (F3,33⫽0.175, P⫽.912). On average, however, the distance decreased 3.8% for the O group. In contrast, the distance increased an average of 13.2% for the OC group and an average of 2.6% for the OE group. These between-group variations did not

Number 1

reach the level of statistical significance (Tab. 3). Pain After 5-Minute Walk Test When averaged across treatment groups, the mean (SD) VAS pain ratings decreased immediately after the 5-Minute Walk Test, from 26.9 (23.1) before the intervention to 6.0 (9.7) after the intervention (P⫽.0001). No significant difference (P⫽.460) among the treatment groups was identified (Tab. 3).

Discussion This is the first randomized controlled trial reporting on the effectiveness of orthoses and tibialis posterior tendon–specific exercise in the management of PTTD. In 2001, “tendinitis” cases involved a median of 10 days away from work; in comparison, all nonfatal injury and illness cases involved 6 days away from work.34 In the present study, notable improvements in function and reductions in pain were documented in association with the use of custom-made orthoses. Concurrent participation in an exercise program that specifically targeted the poste-

January 2009

Posterior Tibial Tendon Dysfunction Table 3. Distance Traveled in the 5-Minute Walk Test and Pain After the 5-Minute Walk Test for All Study Participants and for Each Group Before and After the 12-Week Intervention X (SD) Time Relative to Intervention

5-Minute Walk Test Distance, m

Painb After 5-Minute Walk Test, mm

Before

441.7 (117.9)

26.9 (23.1)

After

458.1 (119.1)

6.0 (9.7)

.912

.0001

Orthoses (n⫽11)

Before

468.7 (133.4)

26.3 (21.7)

After

451.1 (148.0)

12.2 (13.7)

Orthoses and concentric exercise (n⫽11)

Before

423.5 (136.6)

29.0 (26.5)

After

479.6 (139.0)

2.6 (4.0)

Orthoses and eccentric exercise (n⫽12)

Before

433.7 (86.1)

25.4 (3.8)

After

445.1 (66.3)

3.4 (6.0)

.075

.460

Parametera All participants (N⫽34) Pc

Pd a

Two subjects (1 in the orthoses group and 1 in the orthoses and concentric exercise group) declined to participate in the functional test at the time of the initial evaluation because of an anticipated increase in pain. b As determined with the visual analog scale (0 mm⫽no pain and 100 mm⫽worst pain possible). c P values for scores before the intervention versus scores after the intervention for all participants. d P values for analyses of variance with the values before the intervention as covariates.

rior tibial tendon furthered the gains achieved. In the present study, we used a basic and social sciences-driven tendinopathy treatment model that emphasizes Education, Unloading of the faulty tendon, Reloading of the faulty tendon, and Prevention of future tendon-related problems (EdUReP model).35 All participants in the present study received education about their condition and calf muscle stretching as well as unloading of the tendon via the arch support provided through the custom-made orthoses. In addition, progressive reloading of the tibialis posterior tendon was initiated for participants randomly assigned to either the OE or the OC group. The loading was individualized and performance based to enable participants to progress at their own rates (as described above). Varying the mode of resistance training (ie, eccentric versus concentric) created an opportunity for different loads in the 2 conditions. Force caJanuary 2009

pabilities are typically 20% to 60% greater during eccentric actions than during isometric actions, and isometric force capabilities exceed concentric force capabilities.36 Therefore, participants in the OE group had the potential to resist larger loads than those in the OC group, thus subjecting their tendons to a higher overload. The overload principle speaks to the necessity to stress biologic tissues beyond their current thresholds to increase tolerance to subsequent stresses and avoid future injuries.37 Indeed, by the end of the 3-month exercise program, participants in the OE group had achieved a training load more than 3-fold greater than that of participants in the OC group (⬃5.6 kg [12.5 lb] and ⬃1.7 kg [3.7 lb], respectively). In the present study, we provided slow, controlled reloading of the tendon within its capabilities and within the participants’ pain tolerance. Exercises were performed with no pain reported. We believe that one of the factors contributing to the greater load tolerance during testing after

the intervention for the OE group than for the OC group may have been the impact of training at higher forces on remodeling of the degenerated tendon. Additional study in this area is required to determine the impact of eccentric versus concentric training on tibialis posterior tendon remodeling. Of note is the finding that participation in the exercise program did not result in an increase in symptoms. Movement of the tibialis posterior tendon through the unique pulley system as it abruptly wraps around the medial malleolus has been implicated as a possible mechanism of injury to the tendon.38 This suggestion has led to concerns in the clinical setting about whether it is safe to load the tendon in association with non-isometric contractions. Our findings suggest that both concentric training and eccentric training, when performed within the limits of a patient’s pain tolerance, are safe methods for loading the tendon.

Volume 89

Number 1

Physical Therapy f

33

Posterior Tibial Tendon Dysfunction Pain during functional activities is one of the main concerns for people with PTTD. In the present study, we captured self-reported pain under 2 conditions: first, as a recall of pain recently experienced during various functional activities (FFI pain subcategory), and second, immediately after completion of the 5-Minute Walk Test. When averaged across groups, FFI pain subcategory scores showed a significant improvement after the intervention (Tab. 2). This change also exceeded the minimum clinically important difference of 12.3 mm established for the FFI pain subcategory by Landorf and Radford for small samples of patients with plantar fasciitis.39 Although changes in the scores for all groups exceeded the 12.3-mm threshold, the OE group demonstrated the greatest improvement, with a change of 36.3 (16.8); the gains for the OC and O groups were more modest, at 21.7 (17.2) and 16.3 (20.6), respectively. Similarly, when averaged across groups, the VAS pain ratings after the 5-Minute Walk Test showed a significant improvement after the intervention that also exceeded the previously established minimum clinically important difference of 13 mm.40 Although changes in the scores for all groups exceeded the 13-mm threshold, the VAS pain ratings among the groups were not significantly different. A reduction in function is common in people with PTTD. To better understand the effects of the intervention on function, measures recorded for the FFI disability subcategory, distance traveled during the 5-Minute Walk Test, and FFI activity limitation subcategory were evaluated. The significant improvement in the disability subcategory scores after the intervention (Tab. 2) exceeded the minimum clinically important difference of 6.7 mm established by Landorf and Radford.39 Although changes in the scores for all groups exceeded 34

f

Physical Therapy

Volume 89

the 6.7-mm threshold, the OE group showed changes that were more than 2-fold greater than the changes showed by the OC and O groups (Tab. 2). Distance traveled during the 5-Minute Walk Test did not increase significantly after the intervention for all participants (Tab. 3). This result may have reflected the absence of a walking impairment at entry into the study, because the distances walked were close to 1 standard deviation of the values achieved by 22- to 54-year-old subjects who were healthy in the study by Simmonds et al.31 Similarly, the participants in the present study also were independent in all functional activities and reported that they continued to take part in social activities and work despite pain. These data were reflected in the relatively low scores documented for the FFI activity limitation subcategory both before and after the intervention for all groups (Tab. 2). No value for the minimum clinically important difference for this category of the FFI has been established. With respect to total foot function, FFI total scores improved significantly after the intervention when averaged across treatment groups, and the changes exceeded the minimum clinically important difference of 6.5 mm for this scale.39 Changes in the scores for all groups exceeded the minimum threshold, but the OE group demonstrated the greatest improvement, with a change of 28.3 (17.4) (Tab. 2); the gains for the OC and O groups were more modest, at 14.3 (13.5) and 12.8 (16.9), respectively. The duration of the intervention (3 months) may have influenced the rate of adherence among the participants. Poor adherence may explain the inferior outcomes for 2 participants identified as statistical outliers. For example, the outlier for the FFI total score in the OE group had the

Number 1

lowest score for adherence to exercise. The outlier for the FFI total score in the O group lost contact with the research team and, upon reassessment, admitted to not wearing the orthoses because she was more comfortable in open-toe sandals. One limitation of the present study arose from the random assignment of participants to the 3 intervention groups. Specifically, at pre-intervention testing, baseline FFI scores varied significantly among the 3 intervention groups. To account for these differences, we performed an ANCOVA to enable a comparison of post-intervention means after adjusting for the differences in the baseline scores. Despite larger apparent changes in scores between preintervention and post-intervention measurements for the OE group than for the OC group (Tab. 2), the design did not allow determination of whether the eccentric training resulted in greater improvements. Ultimately, both exercise groups achieved the same relative functional levels on the FFI after the intervention. Future studies in which subjects begin with equal baseline scores on the measures of interest should be conducted to determine whether eccentric exercise is superior to concentric exercise. The present work has additional implications for future studies. In particular, the finding of enhanced function in people who have PTTD and are undergoing strengthening exercises raises questions about the impact of this intervention on tendon remodeling. Additional work incorporating ultrasonography would be beneficial in exploring the impact of different modes of exercise training on tendon remodeling as well as measures of function and pain. Previous work on the Achilles tendon demonstrated improvements in tendon structure and reductions in January 2009

Posterior Tibial Tendon Dysfunction pain in association with an eccentric training program, but that work did not explore the collective impact on function. Ohberg and colleagues26 imaged the Achilles tendon using ultrasound before and after initiating an eccentric calf muscle training program in patients with Achilles tendinosis. Before treatment, the tendon showed localized widening, focal hypoechoic areas, and irregular structures in association with the painful area. After treatment, there was a significant decrease in tendon thickness (P⬍.005), and the structures were normal in 19 of the 26 tendons examined. Patients exhibiting decreased tendon pathology also reported decreased pain with loading of the Achilles tendon, indicating that ultrasonographic findings of hypoechoic areas and irregular structures may correlate with tendon pain during tendon loading activity. However, that study did not correlate the decreased tendon pathology with improvements in function. Future studies should extend these findings to patients with PTTD by exploring whether improvements in function and disability correlate with tendon pathology and to what extent either an eccentric or a concentric exercise intervention contributes to a successful outcome.

Conclusion Adults with stage I and II tibialis posterior tendinopathy exhibited significant increases in function and reductions in pain after participation in a 3-month intervention program that emphasized education and the use of custom-made orthoses. Simultaneous involvement in exercise that specifically targeted the tibialis posterior tendon furthered the improvements. Additionally, the OE group tolerated greater loading after the intervention. Additional work is needed to determine the impact of a focused tibialis posterior tendon exercise program on tendon remodeling in people with PTTD. Moreover, January 2009

the extent to which greater loading contributes to changes in tendon tissue quality should be explored in future studies. Dr Kulig, Dr Reischl, Dr Pomrantz, Dr Burnfield, Dr Mais-Requejo, and Dr Smith provided concept/idea/research design. Dr Kulig, Dr Pomrantz, and Dr Burnfield provided writing. Dr Kulig, Dr Pomrantz, and Dr Burnfield provided data analysis. Dr Kulig, Dr Reischl, Dr Pomrantz, and Dr Mais-Requejo provided data collection. Dr Kulig, Dr Reischl, and Dr Pomrantz provided project management. Dr Kulig provided fund procurement. Dr Reischl, Dr Mais-Requejo, Dr Thordarson, and Dr Smith provided subjects. Dr Reischl provided facilities/equipment and institutional liaisons. Dr Reischl, Dr Thordarson, and Dr Smith provided consultation (including review of manuscript before submission). The Institutional Review Board at the University of Southern California granted approval for this randomized controlled trial. This study was supported by a grant from the Orthopaedic Section of the American Physical Therapy Association to Dr Kulig. This work was presented as a poster at the Combined Sections Meeting of the American Physical Therapy Association; February 1–5, 2006; San Diego, California. This article was submitted August 22, 2007, and was accepted October 10, 2008. DOI: 10.2522/ptj.20070242

References 1 Johnson KA, Strom DE. Tibialis posterior tendon dysfunction. Clin Orthop. 1989; (239):196 –206. 2 Chao W, Wapner KL, Lee TH, et al. Nonoperative management of posterior tibial tendon dysfunction. Foot Ankle Int. 1996;17:736 –741. 3 Churchill RS, Sferra JJ. Posterior tibial tendon insufficiency: its diagnosis, management, and treatment. Am J Orthop. 1998;27:339 –347. 4 Geideman WM, Johnson JE. Posterior tibial tendon dysfunction. J Orthop Sports Phys Ther. 2000;30:68 –77. 5 Katchis SD. Posterior tibial tendon dysfunction. In: Ranawat CS, Positano RG, eds. Disorders of the Heel, Rearfoot and Ankle. New York, NY: Churchill Livingstone Inc; 1999:415– 416. 6 Mendicino SS. Posterior tibial tendon dysfunction: diagnosis, evaluation, and treatment. Clin Podiatr Med Surg. 2000;17: 33–54.

7 Supple KM, Hanft JR, Murphy BJ, et al. Posterior tibial tendon dysfunction. Semin Arthritis Rheum. 1992;22:106 –113. 8 Dyal CM, Feder J, Deland JT, Thompson FM. Pes planus in patients with posterior tibial tendon insufficiency: asymptomatic versus symptomatic foot. Foot Ankle Int. 1997;18:85– 88. 9 Yeap JS, Singh D, Birch R. Tibialis posterior tendon dysfunction: a primary or secondary problem? Foot Ankle Int. 2001;22: 51–55. 10 Myerson MS, Corrigan J. Treatment of posterior tibial tendon dysfunction with flexor digitorum longus tendon transfer and calcaneal osteotomy. Orthopedics. 1996;19:383–388. 11 Michelson J, Easley M, Wigley FM, Hellmann D. Posterior tibial tendon dysfunction in rheumatoid arthritis. Foot Ankle Int. 1995;16:156 –161. 12 Myerson MS, Solomon G, Shereff M. Posterior tibial tendon dysfunction: its association with seronegative inflammatory disease. Foot Ankle. 1989;9:219 –225. 13 Kettelkamp DB, Alexander HH. Spontaneous rupture of the posterior tibial tendon. J Bone Joint Surg Am. 1969;51:759 –764. 14 Mosier SM, Lucas DR, Pomeroy G, Manoli A II. Pathology of the posterior tibial tendon in posterior tibial tendon insufficiency. Foot Ankle Int. 1998;19:520 –524. 15 Mosier SM, Pomeroy G, Manoli A II. Pathoanatomy and etiology of posterior tibial tendon dysfunction. Clin Orthop Relat Res. 1999;(365):12–22. 16 Wapner KL, Chao W. Nonoperative treatment of posterior tibial tendon dysfunction. Clin Orthop Relat Res. 1999;(365): 39 – 45. 17 Kohls-Gatzoulis J, Angel JC, Singh D, et al. Tibialis posterior dysfunction: a common and treatable cause of adult acquired flatfoot. BMJ. 2004;329:1328 –1333. 18 Blake RL, Anderson K, Ferguson H. Posterior tibial tendinitis: a literature review with case reports. J Am Podiatr Med Assoc. 1994;84:141–149. 19 Key JA. Partial rupture of the tendon of the posterior tibial muscle. J Bone Joint Surg Am. 1953;35:1006 –1008. 20 Kulig K, Burnfield JM, Mais-Requejo S, et al. Selective activation of tibialis posterior: evaluation by magnetic resonance imaging. Med Sci Sports Exerc. 2004;36:862– 867. 21 Kulig K, Burnfield JM, Reischl S, et al. Effect of foot orthoses on tibialis posterior activation in persons with pes planus. Med Sci Sports Exerc. 2005;37:24 –29. 22 Komi PV. Neuromuscular performance: factors influencing force and speed production. Scand J Sports Sci. 1979;1:2–15. 23 Westing SH, Cresswell AG, Thorstensson A. Muscle activation during maximal voluntary eccentric and concentric knee extension. Eur J Appl Physiol Occup Physiol. 1991;62:104 –108.

Volume 89

Number 1

Physical Therapy f

35

Posterior Tibial Tendon Dysfunction 24 Mafi N, Lorentzon R, Alfredson H. Superior short-term results with eccentric calf muscle training compared to concentric training in a randomized prospective multicenter study on patients with chronic Achilles tendinosis. Knee Surg Sports Traumatol Arthrosc. 2001;9:42– 47. 25 Alfredson H, Pietila T, Jonsson P, Lorentzon R. Heavy-load eccentric calf muscle training for the treatment of chronic Achilles tendinosis. Am J Sports Med. 1998;26: 360 –366. 26 Ohberg L, Lorentzon R, Alfredson H. Eccentric training in patients with chronic Achilles tendinosis: normalised tendon structure and decreased thickness at follow up. Br J Sports Med. 2004;38:8 –11; discussion 11. 27 Williams DS, McClay IS. Measurements used to characterize the foot and the medial longitudinal arch: reliability and validity. Phys Ther. 2000;80:864 – 871. 28 Division of Nutrition, Physical Activity and Obesity, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention. BMI—Body Mass Index. Available at: http://www.cdc.gov/nccdphp/. Accessed October 13, 2008.

36

f

Physical Therapy

Volume 89

29 Budiman-Mak E, Conrad KJ, Roach KE. The Foot Function Index: a measure of foot pain and disability. J Clin Epidemiol. 1991;44:561–570. 30 Martin RL, Irrgang JJ. A survey of selfreported outcome instruments for the foot and ankle. J Orthop Sports Phys Ther. 2007;37:72– 84. 31 Simmonds MJ, Olson SL, Jones S, et al. Psychometric characteristics and clinical usefulness of physical performance tests in patients with low back pain. Spine. 1998; 23:2412–2421. 32 Scott J, Huskisson EC. Graphic representation of pain. Pain. 1976;2:175–184. 33 Kulig K, Pomrantz AB, Burnfield JM, et al. Non-operative management of posterior tibialis tendon dysfunction: design of a randomized clinical trial [NCT00279630]. BMC Musculoskelet Disord. 2006;7:49. 34 Bureau of Labor Statistics, US Department of Labor. Safety and Health Statistics Program. Survey of occupational injuries and illnesses. Nonfatal (OSHA recordable) injuries and illnesses. Case and demographic characteristics, 2001. Available at: http:// www.bls.gov/iif/oshwc/osh/case/ostb1222. txt. Accessed July 14, 2007.

Number 1

35 Davenport TE, Kulig K, Matharu Y, Blanco CE. The EdUReP model for nonsurgical management of tendinopathy. Phys Ther. 2005;85:1093–1103. 36 Hill AV. The dimensions of animals and their muscular dynamics. Sci Prog. 1950; 38:209 –230. 37 Hellenbrandt F, Houtz S. Mechanism of muscle training in man: experimental demonstration of the overload principle. Phys Ther Rev. 1956;36:371–383. 38 Josza L, Lehto MU, Jarvinen M, et al. A comparative study of methods for demonstration and quantification of capillaries in skeletal muscle. Acta Histochem. 1993;94: 89 –96. 39 Landorf KB, Radford JA. Minimal important difference: values for the Foot Health Status Questionnaire, Foot Function Index and Visual Analogue Scale. The Foot. 2008;18:15–19. 40 Todd KH, Funk KG, Funk JP, Bonacci R. Clinical significance of reported changes in pain severity. Ann Emerg Med. 1996; 27:485– 489.

January 2009

Posterior Tibial Tendon Dysfunction Appendix. Pictorial and Written Descriptions of Stretching Technique Provided to Each Participant

Instructions for Stretching Exercises 1. Perform a calf muscle stretch with a wedge and your knee straight

● ●

Hold for 30 seconds Repeat 3 times

2. Perform a calf muscle stretch with a wedge and your knee slightly bent

● ●

Hold for 30 seconds Repeat 3 times

Perform the above sequence twice daily Stretching Tips and Precautions: • Make sure that your foot on the side being stretched is pointing slightly inward.

• • • •

Take care that your feet have adequate arch support. You should only feel a mild stretch of your calf muscles or in the back of your knee. If you feel any foot pain, stop immediately, check your setup, and try again. If the pain persists, terminate the session and notify your therapist at your next visit.

January 2009

Volume 89

Number 1

Physical Therapy f

37

Research Report Does Continuing Education Improve Physical Therapists’ Effectiveness in Treating Neck Pain? A Randomized Clinical Trial Joshua A Cleland, Julie M Fritz, Gerard P Brennan, Jake Magel JA Cleland, PT, PhD, OCS, FAAOMPT, is Associate Professor, Department of Physical Therapy, Franklin Pierce University, 5 Chenell Dr, Concord, NH 03301 (USA); Physical Therapist, Rehabilitation Services, Concord Hospital, Concord, New Hampshire; and Faculty, Regis University Manual Therapy Fellowship Program, Denver, Colorado. Address all correspondence to Dr Cleland at: [email protected]. JM Fritz, PT, PhD, ATC, is Associate Professor, Department of Physical Therapy, University of Utah, Salt Lake City, Utah, and Clinical Outcomes Research Scientist, Intermountain Healthcare, Salt Lake City, Utah. GP Brennan, PT, PhD, is Director for Clinical Quality and Outcomes Research, Intermountain Healthcare. J Magel, PT, DSc, OCS, FAAOMPT, is Director, Intermountain Orthopedic and Spine Therapy, Intermountain Healthcare. [Cleland JA, Fritz JM, Brennan GP, Magel J. Does continuing education improve physical therapists’ effectiveness in treating neck pain? A randomized clinical trial. Phys Ther. 2009;89:38 – 47.] © 2009 American Physical Therapy Association

Post a Rapid Response or find The Bottom Line: www.ptjournal.org 38

f

Physical Therapy

Background and Purpose. Physical therapists often attend continuing education (CE) courses to improve their overall clinical performance and patient outcomes. However, evidence suggests that CE courses may not improve the outcomes for patients receiving physical therapy for the management of neck pain. The purpose of this study was to investigate the effectiveness of an ongoing educational intervention for improving the outcomes for patients with neck pain. Participants. The study participants were 19 physical therapists who attended a 2-day CE course focusing on the management of neck pain. All patients treated by the therapists in this study completed the Neck Disability Index (NDI) and a pain rating scale at the initial examination and at their final visit.

Methods. Therapists from 11 clinics were invited to attend a 2-day CE course on the management of neck pain. After the CE course, the therapists were randomly assigned to receive either ongoing education consisting of small group sessions and an educational outreach session or no further education. Clinical outcomes achieved by therapists who received ongoing education and therapists who did not were compared for both pretraining and posttraining periods. The effects of receiving ongoing education were examined by use of linear mixed-model analyses with time period and group as fixed factors; improvements in disability and pain as dependent variables; and age, sex, and the patient’s initial NDI and pain rating scores as covariates.

Results. Patients treated by therapists who received ongoing education experienced significantly greater reductions in disability during the study period (pretraining to posttraining) than those treated by therapists who did not receive ongoing training (mean difference⫽4.2 points; 95% confidence interval [CI]⫽0.69, 7.7). Changes in pain did not differ for patients treated by the 2 groups of therapists during the study period (mean difference⫽0.47 point; 95% CI⫽⫺0.11, 1.0). Therapists in the ongoing education group also used fewer visits during the posttraining period (mean difference⫽1.5 visits; 95% CI⫽0.81, 2.3). Discussion and Conclusion. The results of this study demonstrated that ongoing education for the management of neck pain was beneficial in reducing disability for patients with neck pain while reducing the number of physical therapy visits. However, changes in pain did not differ for patients treated by the 2 groups of therapists. Although it appears that a typical CE course does not improve the overall outcomes for patients treated by therapists attending that course, more research is needed to evaluate other educational strategies to determine the most clinically effective and cost-effective interventions.

Volume 89

Number 1

January 2009

Continuing Education and Treatment of Neck Pain

M

ore than 50% of all patients with neck pain are referred to physical therapists, and this population comprises approximately 25% of all patients seeking outpatient physical therapy for musculoskeletal conditions.1,2 An abundance of clinical evidence that should contribute to the effective and efficient management of neck pain has recently emerged.3–11 A classification system for the management of neck pain has been proposed to attempt to use the current best evidence to improve clinical decision making for physical therapists; this system entails subgrouping patients into categories for which interventions are matched to the specific clinical presentations.12 Preliminary evidence suggests that subgrouping patients and matching treatments to the subgroups may improve clinical outcomes.13 As is typical in clinical practice, it is likely that the transfer of this new evidence to patient care occurs at a slow and unpredictable rate.14 One explanation offered for the slow transfer of new evidence to clinical practice is the insufficiency of existing continuing education (CE) methods.15 The primary purpose of CE is to enhance the transfer of new knowledge and change clinician behaviors to lead to overall improvements in clinical performance and patient outcomes.16 Physical therapists frequently attend traditional CE courses, consisting of a few days of intensive training at a location away from their typical clinical environments, to acquire new skills with the goal of improving the quality of care provided to their patients.17,18 Other CE methods that have been used include the dissemination of written educational materials, ongoing audit and feedback of clinical performance, and educational outreach visits in which clinicians receive training in their professional settings.19,20 All of these methods appear to imJanuary 2009

prove overall clinician performance to various degrees; however, no data exist to suggest which CE interventions are most effective.19,21–23 Additionally, these results cannot be generalized because differences in professional roles, education, values, and status may affect the results of educational interventions.24 Although several educational strategies designed to enhance the transfer of evidence to clinical practice have been proposed,19 the impact of such strategies on patient outcomes has received little attention in the physical therapy literature. Recently, Brennan and colleagues25 found that a traditional 2-day CE course did not lead to improved outcomes for patients with neck pain treated by the attending therapists. The study did reveal that when therapists attended the CE course and then participated in a quality-improvement project involving ongoing audit and feedback, their patients’ clinical outcomes did improve. This result may indicate the need for a longitudinal approach involving feedback and follow-up with clinicians to affect clinical outcomes. The therapists in that study,25 however, were not randomly assigned to participate in the quality-improvement project but were selected by the researchers; this strategy could have biased the results.25 The purpose of this randomized clinical trial was to determine whether therapists who attended a traditional 2-day CE course and received ongoing education experienced better clinical outcomes for their patients with neck pain than therapists who only attended the 2-day CE course.

Method In June 2006, all physical therapists from 11 clinical sites within Intermountain Healthcare (IHC), a private, nonprofit health care system, were invited to attend a 2-day CE

course on the management of neck pain. The CE course was offered to all therapists at no charge, but attendance at the course was not mandatory. All physical therapists were informed that the CE course was part of a quality-improvement project investigating the most-effective methods for improving the outcomes for patients with neck pain and that their participation in the project was voluntary. The CE course was presented by 2 physical therapists, each of whom was an Orthopaedic Certified Specialist and had fellowship status in the American Academy of Orthopaedic Manual Therapy. The CE course was delivered over 2 days (4 hours per day) and focused on the management of neck pain with a previously developed classification system.12 All attending therapists completed a questionnaire that included age, sex, number of years of practice, specialist certification status, and residency or fellowship training. Additionally, all therapists were asked to score their level of confidence in the management of neck pain on a 5-point Likert scale ranging from not confident at all (0) to very confident (5). The CE course included both lectures (approximately 25%) and hands-on practical sessions (approximately 75%). The lecture portion included discussion of the current best evidence in support of the classification system for the management of neck pain.3–12 The practical sessions consisted of demonstration and practice of manual physical therapy techniques (thrust and nonthrust) directed at the cervical and thoracic spine, as well as therapeutic exercises targeting the deep neck flexor, lower trapezius, middle trapezius, and serratus anterior muscles. Details regarding the exact techniques demonstrated and practiced by the participants can be found elsewhere.26 We chose to focus on these

Volume 89

Number 1

Physical Therapy f

39

Continuing Education and Treatment of Neck Pain intervention strategies because of the evidence supporting their effectiveness for certain subgroups of patients,3–12 as well as our previous research13,25 and the research of others2,27 suggesting that the use of these interventions is unjustifiably low. All participants received a course manual that contained lecture notes related to the evidence for the use of the various interventions, as well as figures with detailed descriptions of each manual therapy technique and exercise covered. The course concluded with a questionand-answer session. Randomization After the 2-day CE course, all participating therapists who had treated at least 10 patients with neck pain in the preceding year were randomly assigned to 1 of 2 groups. All therapists were informed that they were not required to participate and that, if they declined, their data would not be included in the analysis of the quality-improvement project. Therapists who had not treated at least 10 patients with neck pain in the preceding year were not included in the study because we wanted to ensure that participating therapists had at least moderate exposure to this patient population. One group was randomly assigned to receive ongoing education in the use of the evidence-based interventions, and the second group received no further education organized by IHC beyond the CE course. Randomization was accomplished with a computer-generated random numbers table corresponding to numbers assigned to each participating therapist in alphabetical order of the last name; the individual performing the randomization was unaware of the random numbers table. Randomization to groups was performed after completion of the 2-day CE course to ensure that the instructors were unaware of the group assignments 40

f

Physical Therapy

Volume 89

when providing feedback on skill performance during the course. Because therapists in both groups worked in the same clinics, therapists assigned to the ongoing education group were specifically asked not to discuss with others the further education that they received in an attempt to minimize contamination bias. Educational Interventions Only therapists in the group randomly assigned to receive ongoing education received training beyond the 2-day course. The additional training included two 1.5-hour educational meetings provided by the same clinicians who delivered the 2-day CE course. These meetings occurred 4 and 7 weeks after the completion of the 2-day course. The meetings entailed review of the classification system for the management of neck pain, skill demonstration, and practice of previously learned techniques with feedback from the instructors. Therapists also had the opportunity to ask questions regarding skills that they had learned and to discuss the management of specific cases. In addition to the 2 educational meetings, all therapists randomly assigned to receive ongoing education participated in an outreach visit.19 The outreach visit included a 1-hour co-treatment of a patient with neck pain in the therapist’s own clinical practice setting with the principal investigator of the study. The therapist identified the patient for whom the co-treatment would occur on the basis of patient availability and the consent of the individual patient. After the co-treatment, the therapist and the principal investigator discussed the clinical presentation of the patient, assignment to the appropriate classification, and the therapist’s clinical decision-making process regarding management strategies. All therapists were encouraged to

Number 1

use interventions with evidence for effectiveness for the particular classification and to appropriately use techniques learned during the CE course. Therapists Thirty-eight therapists from 11 different IHC physical therapy clinics were initially invited to attend the CE course. A total of 30 therapists elected to attend and participate in the CE course. Of these, 1 therapist declined to participate in the qualityimprovement project, 1 therapist was switching his place of employment, and 9 therapists had treated fewer than 10 patients with neck pain in the preceding year and therefore were not included in the study. Therapists who were not included were younger (P⫽.03) and had less confidence (P⫽.02) in treating patients with neck pain (Fig. 1). The remaining 19 therapists (mean age⫽41.0 years, SD⫽7.6) were randomly assigned to the group receiving ongoing education (n⫽10; mean age⫽38.5 years, SD⫽8.0) or to the control group (n⫽9; mean age⫽43.8 years, SD⫽6.5), which received no further educational interventions. Four therapists (2 in each group) had obtained Orthopaedic Certified Specialist status. None of the therapists had completed a residency or fellowship training. The therapists’ average ratings for their pretraining level of confidence in the management of neck pain are shown in Figure 1. There was no significant difference (P⬎.05) for any variables between therapists in the ongoing education group and therapists in the control group. Each participating therapist received all components of the educational program to which he or she was assigned. Clinical Data Collection Clinical data were collected from the clinical outcomes database mainJanuary 2009

Continuing Education and Treatment of Neck Pain tained by the Rehabilitation Agency of IHC. Beginning in 2002, all outpatient physical therapy clinics in the Rehabilitation Agency began tracking clinical outcomes for all patients receiving physical therapy. In the clinical outcomes database, each new patient is entered by use of a Web-based application. At each visit, patients provide a condition-specific disability outcome score and a numeric pain rating (0 –10),28 and these values are entered into the database. The Neck Disability Index (NDI)29 is the condition-specific disability scale used for patients with a chief complaint of neck pain. Also included are the patient’s age, sex, symptom duration, and date of surgery (if applicable). The number of physical therapy visits, the duration of physical therapy services, typical costs billed for physical therapy, and insurance provider also can be obtained from the database. The sample of patients for this study was drawn from the clinical outcomes database for therapists who had treated at least 10 patients with neck pain in the preceding year and who attended the CE course. Data for all patients undergoing an episode of care for the treatment of neck pain between June 1, 2005, and June 15, 2006, were retrospectively extracted from the database to examine the pretraining clinical outcomes achieved by the therapists. Data for all patients undergoing an episode of care between August 1, 2006 (completion of educational intervention), and August 1, 2007, were extracted to examine the posttraining clinical outcomes achieved by the therapists. Patients who received treatment between June 15, 2006, and August 1, 2006, were not included in the analysis because this was the time frame during which the educational intervention occurred. Figure 2 outlines the timeline for study procedures. PaJanuary 2009

Figure 1. Characteristics of physical therapists. There was no significant difference (P⬎.05) for any variables between therapists in the ongoing education group and those in the control group. Age and experience are reported as X (SD) years. Confidence is reported as X (SD) scores. Sex and Orthopaedic Certified Specialist (OCS) are reported as number (percentage) of therapists.

tients receiving treatment for neck pain were identified as those for whom the NDI was used as the condition-specific disability scale. Data were excluded for patients who did not complete at least 2 physical therapy visits, who had an initial NDI score of less than 20%, or who had a surgery date recorded. Clinical Outcomes Clinical outcomes achieved by the therapists were assessed with the NDI and a numeric pain rating scale (NPRS). At each visit, all patients were given both the NDI and the

NPRS by an administrative staff member who was unaware of the present study and unaware of which therapists were participating in the quality improvement project. The NDI contains 10 items: 7 related to activities of daily living, 2 related to pain, and 1 related to concentration.30 Each item is scored from 0 to 5, and the total score is expressed as a percentage, with higher scores corresponding to greater disability. The NDI has been demonstrated to be a reliable and valid outcome measure for patients with neck pain31,32 and has been widely used in clinical trials of patients with neck pain.29,33–35 A

Figure 2. Timeline for study procedures.

Volume 89

Number 1

Physical Therapy f

41

Continuing Education and Treatment of Neck Pain change in the NDI score (NDI change score) was calculated for each patient included in the analysis by subtracting the final NDI score recorded for the patient from the initial NDI score. We also categorized each patient as achieving a minimum clinically important change (MCIC) on the NDI. The MCIC for the NDI has been defined as 5 points out of 50 (ie, 10 percentage points).32 Therefore, any patient whose NDI change score was ⱖ10% was categorized as achieving the MCIC. The NPRS was used to capture a patient’s perceived level of pain. Patients were asked to indicate the intensity of their current pain using an 11-point scale ranging from 0 (no pain) to 10 (worst pain imaginable).28 A change in the NPRS score (NPRS change score) was calculated for each patient by subtracting the final NPRS score recorded for the patient from the initial NPRS score. The MCIC for the NPRS has been reported to be 2 points.36 Therefore, all patients with an NPRS change score of ⱖ2 points were categorized as achieving the MCIC. Data Analysis Baseline patient variables were compared between patients treated in the pretraining period and those treated in the posttraining period, as well as between patients receiving treatment from a therapist in the ongoing education group and those receiving treatment from a therapist in the control group. Baseline comparisons were made with independent t tests for continuous data and with chi-square tests of independence for categorical data. The effects of physical therapists receiving ongoing education were examined by comparing the clinical outcomes for patients treated by therapists receiving ongoing education with the clinical outcomes for 42

f

Physical Therapy

Volume 89

patients treated by therapists in the control group. Linear mixed-model analyses were used to account for the possibility that patient outcome scores would not be independent but might be correlated on the basis of the physical therapist performing the treatment and the clinic within which the treatment occurred. A hierarchical approach considered patients nested within therapists, who were nested within clinics. The variables of therapist and clinic were modeled as random effects. A variance components covariance structure was used for the random effects. Time period (pretraining or posttraining), group (ongoing education or control), and the interaction between time period and group were modeled as fixed factors, and NDI change scores served as the dependent variable. Age, sex, and the patient’s initial NDI and NPRS scores were modeled as fixed-effect covariates. We examined the significance of the random effects in the model to determine whether the variance attributable to the clustering of patients within therapists and within clinics contributed to the model. We examined the coefficients for each of the fixed effects in the model, including the covariates, to determine which effects contributed to the model. The interaction between time period and group was examined to determine whether the NDI change scores for patients treated by therapists in the ongoing education group would differ from those for patients treated by therapists in the control group in the posttraining period but not in the pretraining period. A significant interaction term was analyzed further with planned pair-wise comparisons of the estimated marginal cell means. We planned to compare the NDI change scores for patients treated by therapists in the ongoing education and control groups during the pretraining and posttraining periods and

Number 1

to compare the NDI change scores for patients during the pretraining and posttraining periods within each group. A separate, hierarchical, mixedmodel analysis with the same methods as those described above was performed with NPRS change scores as the dependent variable. We also used chi-square tests to compare therapists in the ongoing education and control groups with regard to the proportions of patients achieving the MCIC for the NDI and NPRS. Mann-Whitney U tests were used to compare the 2 groups of therapists with regard to the duration of physical therapy and charges. Data analysis was performed with the SPSS version 13.0 statistical software package.*

Results During the study period, data for 90% of patients receiving physical therapy for the management of neck pain were entered into the clinical outcomes database. Throughout the pretraining and posttraining periods, 1,199 patients with neck pain were treated by therapists participating in the study. Of these patients, 260 were excluded from the analysis. Reasons for exclusion are shown in Figure 3. Of the 939 patients included in the analysis, 428 (45.6%) were treated during the pretraining period. There were no significant differences between patients treated during the pretraining period and those treated during the posttraining period (P⬎.05). Demographics for patients treated during the pretraining and posttraining periods are shown in Table 1. Of the patients included in the analysis, 528 (56.2%) were treated by therapists in the ongoing education group.

* SPSS Inc, 233 S Wacker Dr, Chicago, IL 60606.

January 2009

Continuing Education and Treatment of Neck Pain

Flow diagram representing the identification of eligible patients. NDI⫽Neck Disability Index.

tion group had a higher percentage of patients who achieved the MCIC for disability than therapists in the control group (64.0% versus 53.5%, P⫽.017). Therapists in the ongoing education group used fewer visits (mean difference⫽1.5; 95% CI⫽ 0.81, 2.3; P⬍.001) over a shorter duration (median⫽23 days and 28 days, respectively; P⫽.002) at lower costs (median⫽$599.76 and $735.83, respectively; P⫽.001) than therapists in the control group. There were no differences between groups in the percentages of patients achieving the MCIC for pain (Tab. 2).

Pretraining Period Of the 428 patients treated during the pretraining period, 245 (57.2%) were treated by therapists in the ongoing education group and 183 (42.8%) were treated by therapists in the control group. During the pretraining period, patients treated by therapists in the ongoing education group and those treated by therapists in the control group were statistically equivalent in terms of age, sex, number of visits received, and duration of physical therapy (Tabs. 1 and 2). Initial NDI scores were higher (mean difference⫽3.2; 95% confidence interval [CI]⫽0.65, 5.8; P⫽.014) for patients treated by therapists in the ongoing education group. Additionally, patients treated by therapists in the ongoing educa-

Effectiveness of Ongoing Education The linear mixed-model analysis examining NDI change scores did not reveal a significant effect for the variance attributable to therapists (variance estimate⫽1.76, P⫽.48) or clinics (variance estimate⫽0.15, P⫽.95). The residual variance estimate was 175.97; therefore, therapists and clinics explained very small percentages of the total variance in NDI change scores (0.99% and 0.084%, respectively). Examining the fixedeffect coefficients for the covariates in the model revealed that age (P⫽.62) and sex (P⫽.51) did not significantly contribute to the model. Coefficients for the baseline NDI score (P⬍.001) and baseline NPRS score (P⫽.004) were significant, indicating that these variables contrib-

Figure 3.

tion group tended to receive fewer visits (mean difference⫽1.1; 95% CI⫽⫺0.01, 2.1; P⫽.052). There was no difference between groups in the percentages of patients achieving the MCIC for pain or disability (P⬎.05). Posttraining Period Of the 511 patients treated during the posttraining period, 283 (55.4%) were treated by therapists in the ongoing education group and 228 (44.6%) were treated by therapists in the control group. During the posttraining period, patients treated by therapists in either group were statistically equivalent in terms of baseline demographics and pain rating and NDI scores (Tab. 1). Additionally, therapists in the ongoing educa-

Table 1. Characteristics of Patients Treated by Therapists Receiving and Therapists Not Receiving Ongoing Clinical Education Patients Treated by Therapists in Ongoing Education Group (nⴝ528) Characteristic Age, y, X (SD) Sex, no. (%) female Baseline Neck Disability Index score, X (SD) Baseline pain rating score, X (SD)

January 2009

Patients Treated by Therapists in Control Group (nⴝ411)

Pretraining Period (nⴝ245)

Posttraining Period (nⴝ283)

Pretraining Period (nⴝ183)

Posttraining Period (nⴝ228)

46.5 (16.9)

45.6 (16.1)

46.1 (17.1)

45.8 (17.1)

175 (71)

199 (70)

129 (70)

168 (74)

39.9 (13.4)

40.1 (15.3)

36.7 (13.4)

39.2 (13.8)

5.8 (2.1)

6.0 (2.2)

5.5 (2.1)

5.8 (2.0)

Volume 89

Number 1

Physical Therapy f

43

Continuing Education and Treatment of Neck Pain Table 2. Comparison of Outcome Measures for Patients Treated by Therapist Receiving and Therapists Not Receiving Ongoing Clinical Educationa Ongoing Education Group Parameter

Pretraining Period

Control Group

Posttraining Period

Pretraining Period

Posttraining Period

No. of physical therapy visits X (SD)

6.0 (3.6)b

5.8 (3.4)b

7.1 (6.7)b

7.3 (4.9)b

Median (interquartile range)

5 (3–8)

5 (5–7)

6 (4–9)

6 (4–9)

Duration of physical therapy (d) X (SD)

33.8 (30.7)

28.8 (22.4)b

36.5 (42.5)

35.6 (26.3)b

Median (interquartile range)

24 (13–47)

23 (14–40.8)

23 (14–42.3)

28 (18–50)

Physical therapy charges ($)

a b c

X (SD)

707.94 (427.22)

713.29b (446.70)

794.80 (495.60)

935.20b (678.20)

Median (interquartile range)

621.05 (387.3–892.6)

599.76 (399.0–903.7)

677.90 (449.4–976.4)

735.83 (462.8–1,188.8)

No. (%) of patients who achieved MCIC for NDI

133 (54.3)c

181 (64.0)b,c

102 (55.7)

122 (53.5)b

No. (%) of patients who achieved MCIC for pain rating

136 (55.5)

172 (60.8)

99 (54.1)

133 (58.3)

MCIC⫽minimum clinically important change, NDI⫽Neck Disability Index. Significant difference between therapists receiving and therapists not receiving ongoing clinical training. Significant difference between pretraining and posttraining periods.

uted to the prediction of patients’ NDI change scores. The fixed effect of time period was not significant (mean difference between adjusted mean NDI change scores in pretraining and posttraining periods⫽ ⫺0.74; 95% CI⫽⫺2.49, 1.01; P⫽.41). The fixed effect of group also was not significant (mean difference between adjusted mean NDI change scores for therapists in ongoing education and control groups⫽1.59; 95% CI⫽⫺0.82, 4.0; P⫽.18). The interaction between

time period and group was significant (P⫽.019).

ence⫽4.2; P⫽.019).

These results indicated that time period and therapists’ training were not significant predictors of NDI change scores. The combination of time period and training was a significant predictor, such that therapists in the ongoing education group achieved greater improvements in NDI change scores for their patients than therapists in the control group (mean differ-

Pair-wise comparisons of NDI change scores for various combinations of time period (pretraining or posttraining) and group (ongoing education or control) revealed no difference in NDI change scores between the ongoing education group and the control group during the pretraining period (P⫽.73). During the posttraining period, patients treated by therapists in the ongoing education group had higher NDI change scores than patients treated by therapists in the control group (adjusted mean difference⫽3.7; 95% CI⫽0.84, 6.5; P⫽.013) (Tab. 3).

Table 3. Pain and Disability Change Scores for Each Time Period and Differences Between Groups X (SD) Change Score for: Ongoing Education Group

Control Group

Pretraining period

11.6 (15.5)

12.1 (14.9)

⫺0.50 (⫺3.5, 2.5)

.73

Posttraining period

14.4 (15.8)

10.7 (15.7)

3.7 (0.84, 6.5)

.013

Parameter

Mean Difference in Change Scores (95% Confidence Interval)

P

Neck Disability Index

Pain rating

44

Pretraining period

2.0 (2.6)

2.0 (2.3)

⫺0.039 (⫺0.52, 0.44)

Posttraining period

2.3 (2.5)

1.9 (2.5)

0.38 (⫺0.057, 0.82)

f

Physical Therapy

Volume 89

Number 1

.87 .088

95%

CI⫽0.69,

7.7;

The linear mixed-model analysis examining NPRS change scores also revealed that the random effects of therapists and clinics (variance estimates ⬍0.0001, P⬎.05) and the covariates age (P⫽.44) and sex (P⫽.50) were not significant. Baseline NDI scores (P⫽.002) and base-

January 2009

Continuing Education and Treatment of Neck Pain line NPRS scores (P⬍.001) were significant covariates, indicating that these variables contributed to the prediction of patients’ NPRS change scores. The fixed effect of time period was not significant (mean difference between adjusted mean NPRS change scores in pretraining and posttraining periods⫽ ⫺0.005; 95% CI⫽ ⫺0.29, 0.28; P⫽.97). The fixed effect of group also was not significant (mean difference between adjusted mean NPRS change scores for therapists in ongoing education and control groups⫽0.032; 95% CI⫽ ⫺0.26, 0.32; P⫽.83). The interaction between time period and group was not significant (mean difference⫽0.47; 95% CI⫽ ⫺0.11, 1.0; P⫽.11). These results indicated that time period and therapists’ training and the interaction between these factors were not significant predictors of NPRS change scores. Pair-wise comparisons did not reveal significant differences in the pretraining or posttraining period on the basis of therapists’ training (Tab. 3).

Discussion The medical literature suggests that many CE strategies developed in an attempt to improve clinical performance have been only partially successful,19,21,22 indicating a need to critically examine the effectiveness of all CE strategies.37 We examined the effects of a 2-day CE course with or without an ongoing educational intervention on clinical outcomes achieved by physical therapists treating patients with neck pain. The results of this randomized trial indicated that therapists who received the ongoing educational intervention in addition to the 2-day CE course achieved significantly greater reductions in disability for their patients than therapists who only attended the 2-day CE course. However, changes in pain did not differ between the groups. January 2009

The findings of the present study are similar to those of our previous study25 showing that educational interventions including strategies for follow-up outreach visits to therapists were more effective for improving clinical outcomes than traditional educational interventions involving short courses of training without any follow-up strategies. These findings support the conclusions of other authors38 that the traditional strategy for CE, emphasizing short-term, intensive courses with no follow-up or individualized outreach, is ineffective for improving patient outcomes. However, it should be recognized that educational interventions including smallgroup sessions and individualized outreach are likely to be more costly than the traditional strategy.38 We did not examine the costeffectiveness of the ongoing educational intervention used in the present study. The costs associated with care provided by a therapist who received ongoing education during the posttraining period were significantly lower than those for care provided by a therapist in the control group (median⫽$599.76 and $735.83, respectively). We expect that these cost savings would exceed the costs associated with the ongoing educational intervention; however, this hypothesis has not been tested. The outcomes of CE interventions may cover numerous domains, including therapists’ behavioral changes or knowledge retention; satisfaction of the patient, therapist, or both; costs; and clinical outcomes.39 We did not capture the specific interventions delivered by the therapists in the present study and, therefore, cannot make inferences regarding the effectiveness of our CE interventions for facilitating behavioral changes in the participating therapists. It is unclear whether the therapists receiving the ongoing ed-

ucation actually treated patients in a manner more consistent with current best evidence or whether the use of manual therapy or specific strengthening interventions was increased. Previous research40 showed that changing clinicians’ behaviors or enhancing knowledge does not guarantee improved clinical outcomes. For example, a recent randomized trial investigated the effectiveness of an active intervention strategy for implementing evidencebased guidelines for the physical therapy management of low back pain.41 The results demonstrated that although the implementation strategy was effective in improving therapists’ adherence to treatment recommendations,41 there were no improvements in clinical outcomes or reductions in direct medical costs.42 This research illustrates that improved clinical outcomes cannot be inferred from seemingly positive changes in clinical behaviors. We agree with other authors43 who have chosen to prioritize clinical outcomes as the desired effect of any educational intervention strategy. From the results of the present study, we can only infer that the ongoing educational program led to improved clinical outcomes. The reasons explaining these changes are an important topic for further research. In the present study, several additional interventions were provided for therapists in the ongoing education group; these included smallgroup follow-up sessions and individualized feedback on performance. The design of the study could not isolate the effectiveness of the additional interventions independently; therefore, it is not possible to determine which components may have been responsible for the improved outcomes. A recent systematic review19 reported that qualityimprovement studies investigating the effects of multifaceted intervention strategies generally result in im-

Volume 89

Number 1

Physical Therapy f

45

Continuing Education and Treatment of Neck Pain proved care, but it is difficult to determine which components are critical to achieving the improvements. We believe that our ongoing educational intervention may have been successful because it was longitudinal in scope, with both individual and group follow-up sessions, and it was pragmatic for participating physical therapists because it occurred in their practice settings and provided feedback on patients they were treating. These factors have been reported by Greenhalgh and colleagues44 to be potential contributors to the success of an educational intervention strategy. However, further research is needed to investigate the optimal number and type of educational interventions needed to optimize clinical outcomes. There are limitations to the present study that should be considered. We had a finite amount of descriptive data on the therapists and patients included in the present study. There may be some patient or therapist characteristics that were not collected but may have affected the outcomes of this study. Psychosocial issues, including depression and fearavoidance beliefs, can affect the prognosis of patients with neck pain45,46 but were not captured in the present study. We were unable, therefore, to adjust for these factors. Although therapists in both groups were similar in terms of experience and training levels, other factors may affect outcomes. For example, if the classification approach to the management of neck pain was within the therapists’ clinical values, then adherence to such an approach might be more likely.47 Additionally, some physical therapists randomly assigned to different groups worked in the same clinics, a factor that could lead to contamination bias. We also collected pretraining data retrospectively, a factor that could introduce potential bias, because therapists 46

f

Physical Therapy

Volume 89

during that time period were not aware that they would be participating in a clinical trial. However, this bias would have been exhibited by both therapists receiving and therapists not receiving ongoing education and, therefore, would not have had a direct effect on differences between the groups at any time period.

Conclusion Awareness of the lack of translation of evidence to clinical practice has resulted in a search for moreeffective strategies for moving evidence into practice and improving patient care. Concerns about inadequate translation extend to the physical therapy profession, but little research has been reported on the outcomes of educational attempts to address these concerns.38 The results of the present study agree with those of other studies showing that a traditional approach to CE is generally ineffective for improving patient care. Alternatively, we found that an educational strategy involving a combination of individual and group sessions with ongoing outreach and feedback was beneficial in improving disability outcomes for patients with neck pain. Further research is needed to evaluate educational interventions and to determine the most clinically effective and cost-effective strategies. Dr Cleland and Dr Fritz provided concept/ idea/research design, writing, and data analysis. Dr Cleland, Dr Brennan, and Dr Magel provided data collection. Dr Cleland and Dr Brennan provided project management. Dr Brennan and Dr Magel provided participants. Dr Brennan provided facilities/equipment. All authors provided consultation (including review of manuscript before submission). The authors thank all of the therapists who agreed to participate in this clinical trial. They also thank Stephen Hunter, PT, Intermountain Healthcare Rehabilitation Agency Administrator, for his continued support in clinical research endeavors and quality improvement projects. The study was approved by the Institutional Review Board of Intermountain Healthcare.

Number 1

This article was received January 27, 2008, and was accepted August 18, 2008. DOI: 10.2522/ptj.20080033

References 1 Borghouts J, Janssen H, Koes B, et al. The management of chronic neck pain in general practice: a retrospective study. Scand J Prim Health Care. 1999;17:215–220. 2 Jette AM, Delitto A. Physical therapy treatment choices for musculoskeletal impairments. Phys Ther. 1997;77:145–154. 3 Cleland JA, Childs JD, McRae M, et al. Immediate effects of thoracic manipulation in patients with neck pain: a randomized clinical trial. Man Ther. 2005;10:127–135. 4 Cleland JA, Childs JD, Fritz JM, et al. Development of a clinical prediction rule for guiding treatment of a subgroup of patients with neck pain: use of thoracic spine manipulation, exercise, and patient education. Phys Ther. 2007;87:9 –23. 5 Hoving JL, Koes BW, de Vet HC, et al. Manual therapy, physical therapy, or continued care by a general practitioner for patients with neck pain: a randomized, controlled trial. Ann Intern Med. 2002; 136:713–722. 6 Jull G, Trott P, Potter H, et al. A randomized controlled trial of exercise and manipulative therapy for cervicogenic headache. Spine. 2002;27:1835–1843. 7 Cleland JA, Whitman JM, Fritz JM, et al. Manual physical therapy, cervical traction and strengthening exercises in patients with cervical radiculopathy: a case series. J Orthop Sports Phys Ther. 2005;35: 802– 811. 8 Waldrop MA. Diagnosis and treatment of cervical radiculopathy using a clinical prediction rule and a multimodal intervention approach: a case series. J Orthop Sports Phys Ther. 2006;36:152–159. 9 McKinney LA. Early mobilisation and outcome in acute sprains of the neck. BMJ. 1989;299:1006 –1008. 10 Rosenfeld M, Gunnarsson R, Borenstein P. Early intervention in whiplash-associated disorders: a comparison of two treatment protocols. Spine. 2000;25:1782–1787. 11 Ylinen J, Takala EP, Nykanen M, et al. Active neck muscle training in the treatment of chronic neck pain in women: a randomized controlled trial. JAMA. 2003;289: 2509 –2516. 12 Childs JD, Fritz JM, Piva SR, et al. Proposal of a classification system for patients with neck pain. J Orthop Sports Phys Ther. 2004;34:686 – 696. 13 Fritz JM, Brennan GP. Preliminary examination of a proposed treatment-based classification system for patients receiving physical therapy interventions for neck pain. Phys Ther. 2007;87:513–524. 14 Eccles M, Grimshaw J, Walker A, et al. Changing the behavior of healthcare professionals: the use of theory in promoting the uptake of research findings. J Clin Epidemiol. 2005;58:107–112.

January 2009

Continuing Education and Treatment of Neck Pain 15 Choudhry NK, Fletcher RH, Soumerai SB. Systematic review: the relationship between clinical experience and quality of health care. Ann Intern Med. 2005;142: 260 –273. 16 Cantillon P, Jones R. Does continuing medical education in general practice make a difference? BMJ. 1999;318: 1276 –1279. 17 Landers MR, McWhorter JW, Krum LL, et al. Mandatory continuing education in physical therapy: survey of physical therapists in states with and states without a mandate. Phys Ther. 2005;85:861– 871. 18 Tassone MR, Speechley M. Geographical challenges for physical therapy continuing education: preferences and influences. Phys Ther. 1997;77:285–295. 19 Grimshaw JM, Eccles MP, Thomas R, et al. Toward evidence-based quality improvement: evidence (and its limitations) of the effectiveness of guideline dissemination and implementation strategies 1966 – 1998. J Gen Intern Med. 2006;21(suppl 2):S14 –S20. 20 Tierney WM, Hui SL, McDonald CJ. Delayed feedback of physician performance versus immediate reminders to perform preventive care: effects on physician compliance. Med Care. 1986;24:659 – 666. 21 Grimshaw JM, Eccles MP, Tetroe J. Implementing clinical guidelines: current evidence and future implications. J Contin Educ Health Prof. 2004;24(suppl 1): S31–S37. 22 Grimshaw JM, Thomas RE, Maclennan G, et al. Effectiveness and efficiency of guideline dissemination and implementation strategies. Health Technol Assess. 2004;8: 1–72. 23 Sanson-Fisher RW, Grimshaw JM, Eccles MP. The science of changing providers’ behaviour: the missing link in evidencebased practice. Med J Aust. 2004;180: 205–216. 24 Cheater FM, Baker R, Reddish S, et al. Cluster randomized controlled trial of the effectiveness of audit and feedback and educational outreach on improving nursing practice and patient outcomes. Med Care. 2006;44:542–551. 25 Brennan GP, Fritz JM, Hunter SJ. Impact of continuing education interventions on clinical outcomes of patients with neck pain who received physical therapy. Phys Ther. 2006;86:1251–1262.

January 2009

26 Flynn TW, Whitman J, Magel J. Orthopaedic Manual Physical Therapy Management of the Cervical-Thoracic Spine and Rib Cage. San Antonio, TX: Manipulations Inc; 2000. 27 Jette DU, Jette AM. Physical therapy and health outcomes in patients with spinal impairments. Phys Ther. 1996;76:930 –941. 28 Jensen MP, Karoly P, Braver S. The measurement of clinical pain intensity: a comparison of six methods. Pain. 1986;27: 117–126. 29 Vernon H, Mior S. The Neck Disability Index: a study of reliability and validity. J Manipulative Physiol Ther. 1991;14: 409 – 415. 30 Wainner R, Fritz J, Irrgang J, et al. Reliability and diagnostic accuracy of the clinical examination and patient self-report measures for cervical radiculopathy. Spine. 2003;28:52– 62. 31 Hains F, Waalen J, Mior S. Psychometric properties of the Neck Disability Index. J Manipulative Physiol Ther. 1989;21:75– 80. 32 Stratford P, Riddle D, Binkley J, et al. Using the Neck Disability Index to make decisions concerning individual patients. Physiother Can. Spring 1999:107–112. 33 Giles LG, Muller R. Chronic spinal pain syndromes: a clinical pilot trial comparing acupuncture, a nonsteroidal antiinflammatory drug, and spinal manipulation. J Manipulative Physiol Ther. 1999; 22:376 –381. 34 McMorland G, Suter E. Chiropractic management of mechanical neck and low-back pain: a retrospective, outcome-based analysis. J Manipulative Physiol Ther. 2000; 23:307–311. 35 van Schalkwyk R, Parkin-Smith GF. A clinical trial investigating the possible effect of the supine cervical rotatory manipulation and the supine lateral break manipulation in the treatment of mechanical neck pain: a pilot study. J Manipulative Physiol Ther. 2000;23:324 –331. 36 Childs JD, Piva S, Fritz JM. Responsiveness of the numeric pain rating scale in patients with low back pain. Spine. 2004;30: 1331–1334. 37 Sales A, Smith J, Curran G, et al. Models, strategies, and tools: theory in implementing evidence-based findings into health care practice. J Gen Intern Med. 2006; 21(suppl 2):S43–S49.

38 Grimshaw JM, Shirran L, Thomas R, et al. Changing provider behavior: an overview of systematic reviews of interventions. Med Care. 2001;39:2– 45. 39 Glasgow RE, Goldstein MG, Ockene JK, et al. Translating what we have learned into practice: principles and hypotheses for interventions addressing multiple behaviors in primary care. Am J Prev Med. 2004;27:88 –101. 40 Umble KE, Cervero RM. Impact studies in continuing education for health professionals: a critique of the research syntheses. Eval Health Prof. 1996;19:148 –174. 41 Bekkering GE, van Tulder MW, Hendriks EJ, et al. Implementation of clinical guidelines on physical therapy for patients with low back pain: randomized trial comparing patient outcomes after a standard and active implementation strategy. Phys Ther. 2005;85:544 –555. 42 Hoeijenbos M, Bekkering T, Lamers L, et al. Cost-effectiveness of an active implementation strategy for the Dutch physiotherapy guideline for low back pain. Health Policy. 2005;75:85–98. 43 Sackett DL, Haynes RB, Guyatt GH, et al. Clinical Epidemiology: A Basic Science for Clinical Medicine. Boston, MA: Little, Brown & Co Inc; 1991. 44 Greenhalgh T, Robert G, Macfarlane F, et al. Diffusion of innovations in service organizations: systematic review and recommendations. Milbank Q. 2004;82: 581– 629. 45 Nederhand MJ, Ijzerman MJ, Hermens HJ, et al. Predictive value of fear avoidance in developing chronic neck pain disability: consequences for clinical decision making. Arch Phys Med Rehabil. 2004;85: 496 –501. 46 Landers MR, Creger RV, Baker CV, Stutelberg KS. The use of fear-avoidance beliefs and nonorganic signs in predicting prolonged disability in patients with neck pain. Man Ther. 2008;13:239 –248. 47 Foy R, Maclennan G, Grimshaw J, et al. Attributes of clinical recommendations that influence change in practice following audit and feedback. J Clin Epidemiol. 2002;55:717–722.

Volume 89

Number 1

Physical Therapy f

47

Continuing Education and Treatment of Neck Pain

Invited Commentary

Gwendolen Jull

Continuing education and professional development are hallmarks of professional practice. The concept of the 5-year half-life of knowledge in health care professions is well recognized,1 as is the fact that tertiary professional (entry-level) education does not fully prepare or equip new professionals for lifelong practice. The need for effective continuing professional development is no more evident than in the profession of physical therapy. Physical therapist practice has developed rapidly over recent decades, which genuinely challenges clinicians to provide contemporary management to their patients throughout their working life. Physical therapists around the world have recognized the need and assumed the responsibility for lifelong learning and, in most instances, have avidly embraced continuing professional development. Mandatory continuing education2 exists in many countries and often is linked to continuing professional registration. In recognition of the importance of continuing professional development, researchers continue to study the nature and experiences of, barriers to, and implementation strategies for continuing professional development of physical therapists in order to optimize the education experience.3,4 The research and evidence base of physical therapy has grown enormously, and the face of practice is changing as research informs the development of new assessment and treatment interventions. The efficacy of both new and traditional interventions has been rigorously examined. The Physiotherapy Evidence Database (PEDro)5 lists a notable 10,770 clinical trials of physical therapy interventions. Thus, there is increasing evidence to inform best practice for the management of patients with a

48

f

Physical Therapy

Volume 89

variety of disorders. Effective continuing professional development is a potent vehicle to translate this evidence into practice to improve patient outcomes. Not only do physical therapists need to maintain contemporary knowledge, but many assessment techniques and interventions also require high-level clinical reasoning and practical skills for competent implementation. Certainly, studies confirm that superior outcomes are achieved when it is a skilled practitioner who delivers specific exercises or exercise programs.6,7 Thus, it is reasonable that a popular continuing education format for physical therapists is practically orientated short courses where clinicians stand not only to gain new knowledge but also to learn practically from experts. Yet, few individuals have the skill-acquisition capabilities to be able to instantly perform and perfect complex manual skills. Certainly, Tiger Woods did not pick up a golf club one day and win the US Masters the next. There was significant coaching, practice, and reflection between these 2 events. Thus, in the physical therapy context, it is reasonable to question whether “once-off” short courses are adequate platforms for individuals to acquire the practical skills and clinical reasoning processes necessary to ultimately improve patient outcomes. The results of a preliminary noncontrolled study investigating this issue by Brennan et al8 showed that outcomes for patients did not improve after a short continuing education course on the management of neck pain. In contrast, improved clinical outcomes were noted in patients treated by course participants who subsequently were selected to be in-

Number 1

volved in a quality-improvement project involving ongoing audit and feedback of clinical interventions. Brennan and colleagues’ study8 had limitations, but the outcome clearly raised the question of whether a planned, ongoing education program following a short course could enhance clinical outcomes. This is the substance of Cleland and colleagues’ well-designed prospective randomized trial.9 The effect of ongoing education was investigated after clinicians had attended a 2-day (8 hours) continuing education course on the management of neck pain, following which participants were randomly assigned to receive or not to receive ongoing education. The primary outcome measure was of most clinical relevance, namely improvement in patient outcomes as measured by changes in Neck Disability Index (NDI) scores and pain ratings. The course content was evidence based and included lectures on current best evidence on a classification system for the management of neck disorders and a significant practical component consisting of manual therapy techniques and specific therapeutic exercise for cervical disorders. The ongoing education was a logical and appropriate design and covered theory, practical skills, and clinical application. It consisted of two 1.5-hour educational meetings (4 and 7 weeks after the course) in which the classification system and participant skills were revised and checked by the course instructor. Clinical application was mentored in a 1-hour co-treatment session of a patient by the clinician and instructor in the clinician’s normal work setting. The results of this randomized controlled trial demonstrated that pa-

January 2009

Continuing Education and Treatment of Neck Pain tients with neck pain treated by clinicians who received ongoing education had superior clinical outcomes in terms of changes in NDI scores. No improvement in clinical outcomes was observed in patients treated by those clinicians who did not receive ongoing education. This finding may not be totally unexpected, given Brennan and colleagues’ previous results,8 but ongoing education has not always resulted in superior patient outcomes. This is in evidence in the study by Rebbeck et al,10 who investigated the implementation of guidelines for the management of neck pain associated with a whiplash injury. The disparate findings suggest that the construct and content of the ongoing education may be crucial factors. The effectiveness of individual components of ongoing education could not be evaluated in the study by Cleland et al. The authors discuss these and other limitations, but accepting the results at this point, the study importantly provides evidence to drive change in the current internationally popular method of short, practical continuing education courses without any ongoing education. There are challenges ahead to determine the best methods of ongoing education to maximize the benefit of short courses. Methods are likely to incorporate a variety of formats to attain diverse goals, such as advancement and improvement of physical therapists’ knowledge and clinical reasoning and technical skills; evidence of translation of researchinformed practices to the clinical environment; and, importantly, enhanced clinical outcomes for patients. As highlighted by Cleland et al, the costs of educational methods must be rationalized with, for instance, enhanced patient outcomes and efficiencies in the cost of care. Additionally, there needs to be equity in access to ongoing January 2009

education following short continuing education courses, which may pose more challenges than encountered in Cleland and colleagues’ study of a relatively confined group of practitioners. Further research is necessary to determine the most-effective methods of delivery of continuing professional development suitable to a physical therapy context. There is merit in the methods of ongoing education used by Cleland et al. Reenforcement of knowledge, practice, feedback on performance, and reflection are factors that aid deeper learning. It is my view that a key component of the ongoing education was the co-treatment of a patient by the clinician and instructor, where new knowledge and skills were directly applied in the clinical setting. Although theory and practice may be very clear in a classroom, workload management and individual patient peculiarities may challenge the clinician’s ability to appropriately apply new knowledge and skills gained in a short course in his or her own practice setting. In such circumstances, it often is easier to revert to old ways. Certainly, personal experience is that students of specialty postgraduate course work master’s programs rate the value of supervised clinical practice as one of the strongest features of the programs. Costs, time, and accessibility issues for both course participants and instructors will limit this activity in relation to short, non-award continuing education courses, but alternatives can be found for this important “coal face” translation of new knowledge and skills to clinical practice. Peer mentoring and peer-assisted learning11 with patients should not be undervalued in this context. Course participants may have opportunities to meet and examine pa-

tients together as an ongoing education strategy. When distance is an issue, Internet conferencing facilities can be used with minimum cost. Not only are peer-mentoring methods relevant for novice learners, but, as has been witnessed in candidates’ preparation for final examinations for clinical specialization and Fellowship of the Australian College of Physiotherapists, peer-assisted learning with patients is a highly potent method of learning for experienced practitioners as well. Effective continuing education methods are necessary not only to assist clinicians in maintaining currency in practice, but also for training physical therapists to advance in rapidly changing scopes of practice. In various parts of the world, physical therapists are practicing as specialists, as extended-scope practitioners, or as the first-contact practitioners in the previously traditional medical settings such as hospital emergency departments and hospital orthopedic, pediatric, and neurosurgical clinics.12–14 Health care delivery is changing, and the changes at all levels require effective methods of continuing professional development. Cleland and colleagues’ research is timely, and it is hopefully the beginning of many future studies to evaluate best methods for delivery of effective continuing education for physical therapists. G Jull, MPhty, PhD, FACP, is Professor of Physiotherapy, The University of Queensland, Brisbane, Queensland, Australia, and President, Australian College of Physiotherapists. Address all correspondence to Dr Jull at: [email protected]. DOI: 10.2522/ptj.20080033.ic

References 1 Dubin S. Obsolescence or lifelong education: a choice for the professional. Am Psychol. 1972;27:496 – 498.

Volume 89

Number 1

Physical Therapy f

49

Continuing Education and Treatment of Neck Pain 2 Landers M, McWhorter J, Krum L, Glovinsky D. Mandatory continuing education in physical therapy: survey of physical therapists in states with and states without a mandate Phys Ther. 2005;85: 861– 871. 3 French H, Dowds J. An overview of continuing professional development in physiotherapy. Physiotherapy. 2008;94: 190 –197. 4 Gunn H, Goding L. Continuing professional development of physiotherapists based in community primary care trusts: a qualitative study investigating perceptions, experiences and outcomes. Physiotherapy. 2008. doi:10.1016/j.physio.2007. 09.003. 5 Physiotherapy Evidence Database (PEDro). Available at: www.pedro.fhs. usyd.edu.au/. Accessed October 2008. 6 Friedrich M, Cermak T, Maderbacher P. The effect of brochure use versus therapist teaching on patients performing therapeutic exercise and on changes in impairment status. Phys Ther. 1996;76: 1082–1088.

50

f

Physical Therapy

Volume 89

7 Jull G, Sterling M, Kenardy J, Beller E. Does the presence of sensory hypersensitivity influence outcomes of physical rehabilitation for chronic whiplash? A preliminary RCT. Pain. 2007;129:28 –34. 8 Brennan G, Fritz J, Hunter S. Impact of continuing education interventions on clinical outcome measures of patients with neck pain who received physical therapy. Phys Ther. 2006;86:1251–1262. 9 Cleland JA, Fritz JM, Brennan GP, Magel J. Does continuing education improve physical therapists’ effectiveness in treating neck pain? A randomized clinical trial. Phys Ther. 2009;89:38 – 47. 10 Rebbeck T, Maher C, Refshauge K. Evaluating two implementation strategies for whiplash guideline in physiotherapy: a cluster-randomised trial. Aust J Physiother. 2006;52:165–174. 11 Secomb J. A systematic review of peer teaching and learning in clinical education. J Clin Nurs. 2008;17:703–716.

Number 1

12 Jibuike O, Paul-Taylor G, Maulvi S, et al. Management of soft tissue knee injuries in an accident and emergency department: the effect of the introduction of a physiotherapy practitioner. Emerg Med J. 2003;20:37–39. 13 Jull G, Moore A. Specialization in musculoskeletal physiotherapy: the Australian model. Man Ther. 2008;13:181–182. 14 Kersten P, McPherson K, Lattimer V, et al. Physiotherapy extended scope of practice: who is doing what and why? Physiotherapy. 2007;93:235–242.

January 2009

Research Report Effects of Early Progressive Eccentric Exercise on Muscle Size and Function After Anterior Cruciate Ligament Reconstruction: A 1-Year Follow-up Study of a Randomized Clinical Trial J Parry Gerber, Robin L Marcus, Leland E Dibble, Patrick E Greis, Robert T Burks, Paul C LaStayo

Background and Purpose. The authors previously reported that focused eccentric resistance training during the first 15 weeks following anterior cruciate ligament reconstruction (ACL-R) induced greater short-term increases in muscle volume, strength, and measures of function relative to standard rehabilitation. The purpose of this study was to evaluate the effects of early progressive eccentric exercise on muscle volume and function at 1 year after ACL-R. Participants and Methods. Forty patients who had undergone an ACL-R were randomly assigned to 1 of 2 groups: a group that received early progressive eccentric exercise (n⫽20) and a group that received standard rehabilitation (n⫽20). Seventeen participants in the eccentric exercise group and 15 participants in the standard rehabilitation group completed a 1-year follow-up. Magnetic resonance images of the thighs were acquired 1 year after ACL-R and compared with images acquired 3 weeks after surgery. Likewise, routine knee examinations, self-report assessments, and strength and functional testing were completed 1 year after surgery and compared with previous evaluations. A 2-factor analysis of variance for repeated measures (group ⫻ time) was used to analyze the data.

Results. Compared with the standard rehabilitation group, improvements in quadriceps femoris and gluteus maximus muscle volume in the involved lower extremity from 3 weeks to 1 year following ACL-R were significantly greater in the eccentric exercise group. Improvements in quadriceps femoris and gluteus maximus muscle volume were 23.3% (SD⫽14.1%) and 20.6% (SD⫽12.9%), respectively, in the eccentric exercise group and 13.4% (SD⫽10.3%) and 11.6% (SD⫽10.4%), respectively, in the standard rehabilitation group. Improvements in quadriceps femoris muscle strength and hopping distance also were significantly greater in the eccentric exercise group 1 year postsurgery. Discussion and Conclusions. A 12-week focused eccentric resistance training program, implemented 3 weeks after ACL-R, resulted in greater increases in quadriceps femoris and gluteus maximus muscle volume and function compared with standard rehabilitation at 1 year following ACL-R.

JP Gerber, PT, PhD, SCS, ATC, is Director, US Military–Baylor University Postgraduate Sports Medicine Residency Program, US Military Academy, Keller Army Community Hospital, West Point, NY 10996 (USA). Address all correspondence to Dr Gerber at: John.Gerber@us. army.mil. RL Marcus, PT, PhD, OCS, is Associate Professor, Department of Physical Therapy and Department of Exercise and Sport Science, University of Utah, Salt Lake City, Utah. LE Dibble, PT, PhD, ATC, is Associate Professor, Department of Physical Therapy and Department of Exercise and Sport Science, University of Utah. PE Greis, MD, is Associate Professor of Orthopedic Surgery, Department of Orthopedics, University of Utah. RT Burks, MD, is Associate Professor of Orthopedic Surgery, Department of Orthopedics, University of Utah. PC LaStayo, PT, PhD, is Associate Professor, Department of Physical Therapy, Department of Exercise and Sport Science, and Department of Orthopedics, University of Utah. [Gerber JP, Marcus RL, Dibble LE, et al. Effects of early progressive eccentric exercise on muscle size and function after anterior cruciate ligament reconstruction: a 1-year follow-up study of a randomized clinical trial. Phys Ther. 2009;89:51–59.] © 2009 American Physical Therapy Association Post a Rapid Response or find The Bottom Line: www.ptjournal.org

January 2009

Volume 89

Number 1

Physical Therapy f

51

Early Progressive Eccentric Exercise After ACL Reconstruction

T

he restoration of muscle volume and strength (force-generating capacity) following anterior cruciate ligament reconstruction (ACL-R) continues to be a rehabilitation challenge. Interventions that can safely and effectively overload muscle early are needed to minimize the residual atrophy and weakness that often are recalcitrant to standard management approaches. The application of progressive, high-force eccentric resistance is one such intervention that has been shown to safely increase muscle volume and strength in various populations, including individuals who have had an ACL-R.1– 8 We previously demonstrated that a 12-week focused eccentric resistance training program, implemented 3 weeks after ACL-R, could safely induce statistically significant and clinically meaningful short-term structural and functional changes in key muscle groups.1,2 Compared with a standard rehabilitation program, improvements in quadriceps femoris and gluteus maximus muscle volume were more than 2-fold greater with the addition of eccentric exercise training during the first 15 weeks following surgery. Likewise, significantly greater results in quadriceps femoris muscle strength and hopping distance were observed with eccentric exercise training compared with standard rehabilitation. Although these initial short-term results were positive and encouraging, the typical recovery period following ACL-R often approaches or exceeds 1 year in duration; thus, follow-up at that time is essential. The purpose of this study was to evaluate the effects of early progressive eccentric exercise on muscle volume and function at 1 year after ACL-R. We hypothesized that, compared with standard rehabilitation, an eccentrically biased rehabilitation program would result in significantly greater improvements in quadriceps femoris and gluteus maximus muscle volume of the involved thigh assessed 1 year 52

f

Physical Therapy

Volume 89

after surgery. Furthermore, we hypothesized that these muscle volume improvements would lead to superior results in quadriceps femoris muscle strength and performance on functional tests.

Materials and Method Participants The study sample consisted of the same patients who participated in our previous short-term study.1 Figure 1 illustrates the randomization process via a Consolidated Standards of Reporting Trials (CONSORT) diagram.9 Patients were included in the study if they were between 18 and 50 years of age, moderately active prior to injury (a score of ⱖ4 on the Tegner Activity Scale10), and willing to adhere to the 12-week training program (starting 3 weeks after surgery). Patients were excluded if they had had a previous fracture or reconstructive surgery in either lower extremity; an abnormal knee radiograph; or a concurrent injury to the posterior cruciate ligament or lateral collateral ligament, a grade III tear of the medial collateral ligament, or a significant articular cartilage lesion. Patients with large, vertical, longitudinal meniscus tears also were excluded. Those who had had a partial meniscectomy or a small meniscus repair were allowed to participate. Two surgeons performed all of the ligament reconstructions in the patients for this study, and each surgeon used an arthroscopically assisted technique with a semitendinosusgracilis tendon or bone-patellar tendonbone autograft. The graft selection was based on the patient’s desire or request after he or she had been educated about graft-type choice. The surgeons had a bias toward using bone-patellar tendon-bone grafts in younger patients and hamstring muscle grafts in older patients. All patients provided informed consent before participating.

Number 1

Eccentric and Standard Rehabilitation Programs A randomized matched design was used after the surgery to randomly assign patients to either an eccentric exercise group or a standard rehabilitation group. Participants were matched by graft type, sex, and age. The standard rehabilitation protocol that all participants followed was a criterionand time-based, 3-phase rehabilitation program at our institution that emphasized weight-bearing exercises, functional and resistance training, and early gains in knee range of motion.1 The exercise prescription was determined by the individual response to exercise. Specifically, if exercises were completed without an increase in knee pain or effusion, the participant was considered ready to progress. Other exercises subsequently were added or current exercises were continued at a higher intensity, frequency, or duration. After ACL-R, all participants completed 2 to 3 weeks of phase I exercises that focused on controlling pain and effusion, gaining full range of motion of the knee, and attaining basic quadriceps femoris muscle function. Beginning 3 weeks following surgery, participants in the eccentric exercise group continued with standard rehabilitation and began a 12-week, progressive, eccentrically induced, negative work exercise program using 1 of 2 recumbent eccentric exercise ergometers as described previously.1–3,8,11 During each exercise session, the negative work rate was visible on the computer monitor, and the total amount of negative work (measured in kilojoules) was recorded. The pedal speed was self-selected and ranged from 20 to 40 rpm. Participants were positioned on the ergometer so that the negative work would occur from approximately 20 to 60 degrees of knee flexion, effectively minimizing the possibility of a knee hyperextension injury. The intensity of exercise January 2009

Early Progressive Eccentric Exercise After ACL Reconstruction was based on the Borg Rating of Perceived Exertion Scale.12 The first session was 5 minutes in duration at a “very, very light” intensity. If a participant had a favorable individual response to exercise (ie, absence of increased knee pain, effusion, excessive fatigue, and so on), he or she was allowed to gradually progress to a “hard” intensity and a maximum duration of 30 minutes. Participants had to complete a minimum of 80% of the training sessions for their data to be included in the data analysis. Beginning 3 weeks postoperatively, the participants in the standard rehabilitation group continued with the standard rehabilitation protocol. In an attempt to equalize the total exercise time between the groups, the standard rehabilitation group was instructed to follow an exercise regimen similar to that used by the eccentric exercise group except that the standard rehabilitation group used a concentric ergometer (ie, gradually progressing to a “hard” intensity and a duration of 30 minutes). After the 12-week training program was complete (approximately 15 weeks following surgery), supervised rehabilitation was discontinued for both groups. Participants were instructed and encouraged to perform traditional progressive resistance exercises 2 to 3 times per week as a home exercise program and to gradually increase activity as tolerated until at least 1 year following ACL-R. Periodic routine physical evaluations were continued during this time. Determination of Muscle Volume by Magnetic Resonance Imaging A 1.5-T Signa LX magnetic resonance imaging instrument and body coil* was used to acquire a coronal scout scan and axial spin-echo T1-weighted images. Both thighs were scanned from the superior border of the fem* General Electric Medical Systems, 4855 W Electric Ave, Milwaukee, WI 53219-1628.

January 2009

Figure 1. A Consolidated Standards of Reporting Trials (CONSORT) diagram showing the flow of participants through each stage of the randomized trial, including the 1-year follow-up.

oral head to the tibiofemoral joint line while the participant lay supine in the scanner. The scans were acquired with an image matrix of 256 ⫻ 256; a field-of-view of 40 to 44 cm, depending on the size of the participant; a slice thickness of 8 mm; and an interslice distance of 15 mm. After electronic data transfer of magnetic resonance images, crosssectional areas were measured with use of MATLAB custom-written image-analysis software† on a desktop personal computer. Muscle vol† The MathWorks, 3 Apple Hill Dr, Natick, MA 01760-2098.

umes were determined by measuring muscle cross-sectional area in sequential axial sections across the length of the muscle.13 On each image, the entire muscle of interest (independent of skin, bone, and fat) was identified and captured. The cross-sectional area of each slice was automatically computed with use of the averaged gray-scale density of the captured muscle. The muscle volume was calculated by multiplying the average of 2 consecutive measurements of cross-sectional area by the slice thickness plus the interslice distance (23 mm) and then summing

Volume 89

Number 1

Physical Therapy f

53

Early Progressive Eccentric Exercise After ACL Reconstruction Table 1. Participant Characteristics of the Eccentric Exercise and Standard Rehabilitation Groups Before Anterior Cruciate Ligament Reconstructiona Eccentric Exercise Group (nⴝ20)

Variable Sex, male/female

12/8

Age (y), X⫾SD Height (cm), X⫾SD Body mass (kg), X⫾SD Tegner Activity Scale score, X⫾SD a

Standard Rehabilitation Group (nⴝ20) 12/8

29.3⫾8.6

29.3⫾9.7

176.6⫾9.3

174.7⫾10.3

78.0⫾17.0

76.5⫾12.4

6.7⫾1.3

6.8⫾1.7

No significant differences were observed between groups at the Pⱕ.05 level.

For this study, magnetic resonance image scans taken 1 year after surgery were compared with scans taken 3 weeks after surgery (prior to the training program). Because of the high correlation between muscle volume (in cubic centimeters) and peak cross-sectional area (in square centimeters) of the thigh musculature reported in the previous study (r 2⫽.95), only muscle volume is reported for the current study. The same investigator (JPG) performed all structural measurements in a highly reproducible manner (intraclass correlation coefficients⫽⬎.99).

KT-1000 device,‡ were completed 1 year following ACL-R. These examinations also included isokinetic strength testing and the single-leg hop-fordistance test. Quadriceps femoris and hamstring muscle strength (peak torque) were assessed with use of a Kin Com isokinetic dynamometer.§ Participants were tested concentrically at 60°/s in a seated position with the hips and knees in 90 degrees of flexion and the thighs, pelvis, and upper body firmly strapped to the seat of the dynamometer. Prior to testing, a warm-up consisting of 3 repetitions (at 50%, 75%, and 100% intensity) was completed. After a 1-minute rest period, the participants completed 3 separate trials at 100% intensity. The peak torques of the 3 trials were averaged, and the average was recorded. For the hop-for-distance test, the participants were instructed to hop as far as possible, always landing on the same leg. Hopping for maximal distance with each leg was tested 3 times, and the average of the 2 farthest hops was recorded. Participants also completed the Activities of Daily Living Scale of the Knee Outcome Survey,15 the Lysholm Knee Rating Scale, and the Tegner Activity Scale.

Knee Laxity Assessment and Functional Status In a similar manner as previously conducted,1 routine clinical examinations, which included an assessment of knee laxity with use of the

‡ MEDmetric Corp, 7542 Trade St, San Diego, CA 92121. § Isokinetic International, 6426 Morning Glory Dr, Harrison, TN 37341-9764.

those values across the length of the muscle. The validity of the volume measurement was determined by analysis of images obtained from a cadaveric thigh phantom that approximated the size of the quadriceps femoris muscle group. The volume of the phantom, measured by water displacement 5 hours after magnetic resonance imaging, was 100.7% of the magnetic resonancedetermined value. There was a 0.012% difference between repeated volume displacement measurements of the phantom by the same investigator.14

54

f

Physical Therapy

Volume 89

Number 1

Data Analysis Data were analyzed with SPSS software (version 13.0).储 Descriptive statistics for categorical variables and measures of central tendency for continuous variables were calculated to summarize the data. Tests for outliers and assumptions of the parametric statistical tests were performed. Assumptions of parametric testing were met, and all data were included for analysis. Separate 2-factor analyses of variance for repeated measures (group ⫻ time) were used to analyze the effects of time and group assignment and the group ⫻ time interaction for each of the dependent variables. Significance levels for all statistical analyses were set at ␣⬍.05. Post hoc examination of mean values was performed.

Results Thirty-two of the 40 enrolled participants completed all aspects of the study (Fig. 1). Of those not returning for the 1-year follow-up, 2 participants cited being too busy and 2 participants had moved out of the area. Four participants traumatically reinjured their involved knee between 4 and 12 months following initial ACL-R, causing graft disruption. These injuries were sustained by 2 male participants with patellar tendon autografts (1 in each group) and 2 female participants with semitendinosus-gracilis tendon autografts (1 in each group). Due to the number of participants who could not complete the 1-year follow-up, an intention-to-treat analysis was performed. Thus, all 40 participants were included for statistical analyses. Twenty individuals (10 in each intervention group) had ACL-R with the semitendinosus-gracillis tendon autograft, and that same number (10 individuals per group) had ACL-R with the bone-patellar tendon-bone autograft. Presurgical demographic and physical characteristics were similar between intervention groups (Tab. 1). 储

SPSS Inc, 233 S Wacker Dr, Chicago, IL 60606.

January 2009

Early Progressive Eccentric Exercise After ACL Reconstruction The presurgical evaluation was conducted the week before surgery (at a mean of 4.0 days [SD⫽2.6] in the eccentric exercise group and at a mean of 4.4 days [SD⫽2.4] in the standard rehabilitation group). The pretraining magnetic resonance image was obtained for each participant 3 weeks after ACL-R (eccentric exercise group: X⫽23.1 days [SD⫽ 4.0]; standard rehabilitation group: X⫽22.7 days [SD⫽3.9]). The followup magnetic resonance image and evaluation were conducted 1 year after ACL-R (eccentric exercise group: X⫽367.5 days [SD⫽19.2]; standard rehabilitation group: X⫽369.6 days [SD⫽17.2]). During the 1-year evaluation, 16 participants (9 in the eccentric exercise group and 7 in the standard rehabilitation group) reported that they had lifted weights for the lower extremity an average of 2 or more times per week over the past 6 to 9 months. Quadriceps Femoris Muscle Volume From 3 weeks after surgery (pretraining) to 1 year after surgery, quadriceps femoris muscle volume of the involved thigh increased significantly in both groups (time effect, P⬍.001). However, these structural increases were significantly greater, by more than 50%, in the eccentric exercise group compared with the standard rehabilitation group (group ⫻ time interaction, P⬍.01). Quadriceps femoris muscle volume improved 23.3% (SD⫽14.1%) in the eccentric exercise group and 13.4% (SD⫽10.3%) in the standard rehabilitation group (Tab. 2, Fig. 2). There was no significant group effect. Gluteus Maximus Muscle Volume The distal portion of the gluteus maximus muscle beginning from the superior border of the femoral head was available for analysis. From 3 weeks after surgery (pretraining) to 1 year after surgery, gluteus maximus muscle volume of the involved January 2009

Table 2. Muscle Volume (in Cubic Centimeters) Measured 3 Weeks (Pretraining) and 1 Year After Anterior Cruciate Ligament Reconstruction for the Eccentric Exercise Group (n⫽20) and the Standard Rehabilitation Group (n⫽20)a Muscle

Pretraining

1y

Eccentric exercise group

1,430⫾426

1,763⫾458b

Standard rehabilitation group

1,384⫾247

1,569⫾293

Eccentric exercise group

596⫾173

719⫾179b

Standard rehabilitation group

621⫾156

693⫾188

Eccentric exercise group

673⫾177

712⫾169

Standard rehabilitation group

651⫾151

687⫾173

Eccentric exercise group

87⫾31

80⫾35

Standard rehabilitation group

85⫾29

77⫾33

Quadriceps femoris

Gluteus maximus

Hamstring

Gracilis

Values are mean ⫾ standard deviation. Compared with pretraining values, muscle volume increases of the involved thigh at 1 year after anterior cruciate ligament reconstruction were significantly greater in the eccentric exercise group (Pⱕ.01). a

b

Figure 2. Quadriceps femoris and gluteus maximus muscle volume improvement of the involved lower extremity that occurred from 3 weeks after surgery (pretraining) to 1 year after surgery. Asterisk (*) indicates that statistical differences in muscle volume improvement were observed between the eccentric exercise (black bars) and standard rehabilitation (blue bars) groups (Pⱕ.05).

Volume 89

Number 1

Physical Therapy f

55

Early Progressive Eccentric Exercise After ACL Reconstruction Table 3. Functional Status Measurements Taken Preoperatively and 1 Year After Anterior Cruciate Ligament Reconstruction for the Eccentric Exercise Group (n⫽20) and the Standard Rehabilitation Group (n⫽20)a Measure

Pretraining

1y

Quadriceps femoris muscle strength (N䡠m) Eccentric exercise group

137⫾34

182⫾45b

Standard rehabilitation group

141⫾41

153⫾39

Eccentric exercise group

86⫾26

124⫾38

Standard rehabilitation group

82⫾25

107⫾25

Eccentric exercise group

71⫾13

107⫾31b

Standard rehabilitation group

69⫾14

83⫾34

Eccentric exercise group

71⫾10

94⫾6

Standard rehabilitation group

72⫾10

94⫾4

Eccentric exercise group

67⫾13

92⫾7

Standard rehabilitation group

64⫾10

92⫾4

Eccentric exercise group

5.8⫾2.5

1.7⫾1.6

Standard rehabilitation group

5.6⫾2.2

1.9⫾0.9

Hamstring muscle strength (N䡠m)

Single-leg hop (cm)

Activities of Daily Living Scale

Lysholm Knee Rating Scale

KT-1000 (mm)

Values are mean ⫾ standard deviation. Pretraining values were prior to surgery. KT-1000 results indicate the laxity difference between knees (manual maximum force). b Compared with pretraining values, quadriceps femoris muscle strength and hopping distance of the involved lower extremity at 1 year after anterior cruciate ligament reconstruction were significantly greater in the eccentric exercise group (Pⱕ.01). a

muscle volume of the involved thigh between groups (P⫽.70) (Tab. 2).

lower extremity increased significantly in both groups (time effect, P⬍.001). These structural increases were significantly greater, by more than 50%, in the eccentric exercise group (group ⫻ time interaction, P⬍.05). Volume improved 20.6% (SD⫽12.9%) in the eccentric exercise group and 11.6% (SD⫽10.4%) in the standard rehabilitation group (Tab. 2, Fig. 2). There was no significant group effect.

Gracilis Muscle Volume Gracilis muscle volume of the involved thigh decreased significantly in both groups (time effect, P⬍.01) from pretraining to the 1-year followup. There were no significant group or interaction effects in gracilis muscle volume of the involved thigh between groups (P⫽.62) (Tab. 2).

Hamstring Muscle Volume Hamstring muscle volume of the involved thigh increased significantly in both groups (time effect, P⬍.001) from pretraining to the 1-year followup. There were no significant group or interaction effects in hamstring

Knee Stability Assessment and Functional Status Functional status measurements are shown in Table 3. There were no significant differences in knee laxity, as measured with the KT-1000 device (with manual maximum force),

56

f

Physical Therapy

Volume 89

Number 1

between the eccentric exercise group (X⫽1.7 mm, SD⫽1.9) and the standard rehabilitation group (X⫽1.9 mm, SD⫽1.5) 1 year after ACL-R (P⫽.56). From presurgery to 1 year after surgery, quadriceps femoris muscle strength (peak torque) gains were significantly greater in the eccentric exercise group than in the standard rehabilitation group (time and group ⫻ time interaction effects, P⬍.01). The magnitude of improvement was approximately 33% in the eccentric exercise group and 9% in the standard rehabilitation group (Tab. 3). There was no significant group effect. From presurgery to 1 year after surgery, hopping distance increased by a significantly greater amount in the eccentric exercise group compared with the standard rehabilitation group (time and group ⫻ time interaction effects, P⬍.01). The magnitude of improvement was approximately 50% in the eccentric exercise group and 21% in the standard rehabilitation group (Tab. 3). There was no significant group effect. Compared with preoperative values, scores on the Activities of Daily Living Scale of the Knee Outcome Survey, the Lysholm Knee Rating Scale, and the Tegner Activity Scale improved significantly 1 year after surgery in both groups (time effect, P⬍.01), but no significant differences between groups were observed (group and group ⫻ time interaction effects).

Discussion In support of our primary hypothesis, this investigation demonstrated that the addition of progressive eccentric exercise, implemented 3 weeks after ACL-R, resulted in muscle volume and strength gains in key muscle groups 1 year after surgery that exceeded those changes following a standard rehabilitation program. January 2009

Early Progressive Eccentric Exercise After ACL Reconstruction The overall magnitude of improvement in quadriceps femoris and gluteus maximus muscle volume at 1 year was more than 50% greater in the eccentric exercise group. Overall functional improvement (quadriceps femoris muscle strength and hopping distance) also was significantly greater in the group that performed early focused eccentric exercise training. These findings reinforce the potential benefits that can be achieved from safely overloading muscle via high force-inducing resistance exercise during the early rehabilitation stages following ACL-R. In our previous publication,1 we reported that the magnitude of quadriceps femoris muscle atrophy of the involved thigh approached 25% to 30% just 3 weeks after ACL-R.1 From that point, those participants who performed standard rehabilitation exercises during the early 12-week training period achieved a quadriceps femoris muscle volume increase of 9%, whereas those participants who added early progressive resistance training achieved a quadriceps femoris muscle volume increase of 23%. Improvements in quadriceps femoris muscle volume 1 year after ACL-R in the current study were similar to the short-term improvements found in our previous study (approximately 13% improvement in the standard rehabilitation group and 23% improvement in the eccentric exercise group). Although the 1-year findings reinforce the importance of resistance training during the early rehabilitation stages following ACL-R, it is unknown whether implementing a similar intervention that utilizes high loads and induces high muscle forces during other time frames after ACL-R would lead to similar 1-year results. Optimizing muscle volume and strength gains after ACL-R is best accomplished by using an intervention designed to overload muscle. DeJanuary 2009

spite persistent muscle volume and strength deficits often observed years after ACL-R, some rehabilitation programs do not emphasize early resistance exercises if patients are content and improving functionally. Other programs may underdose the resistance exercises due to the reasonable concern for graft and joint safety. These factors may contribute to the 20% to 30% side-to-side quadriceps femoris muscle volume and strength deficits reported during the first 3 months following ACL-R and the approximate 10% deficits common at 1 year.16 –31 The eccentric resistance intervention in the current study, which utilized high loads and induced high muscle forces, was specifically designed to produce muscle overload.1,2,7 Through the gradual, progressive, and individualized nature of the resistance training, we observed the positive combination of effectiveness and safety as quadriceps femoris muscle volume and function improved while graft stability was maintained. We believe that an intervention specifically designed to safely overload muscle can be an ideal addition to rehabilitation programs early after ACL-R. The considerable clinical attention and effort toward mitigating quadriceps femoris muscle atrophy and weakness during the first 3 months following surgery suggest this is a critical time period for restoring muscle volume and function. The results of this study certainly support this notion. However, perhaps intervening with eccentric resistance training even sooner or prior to reconstruction is a reasonable clinical question to be explored. In this study, the majority of participants had surgery 4 to 6 weeks following rupture of the anterior cruciate ligament (ACL). Unfortunately, by that time (3 weeks after surgery), the quadriceps femoris muscle volume of the involved side was already more than 25% smaller than that of

the uninvolved side.1 Considering that the uninvolved quadriceps femoris muscle in all likelihood also atrophied because of decreased activity, total quadriceps femoris muscle atrophy of the involved side prior to the intervention was dramatic. Further research is necessary to determine whether an eccentric exercise training program prior to ACL-R could prevent the obligatory atrophy and strength loss often associated with ACL injuries. Timing and type of intervention (one specifically designed to overload muscle) are 2 important factors in preventing atrophy or restoring muscle volume and strength following ACL injury. Other neuromuscular factors also are important to consider. During weight-bearing activity (ie, gait, squats, leg press, eccentric ergometry), both the knee and hip extensors are active, but a shift toward a hip extensor strategy rather than a knee extensor strategy could develop.32,33 Although we intended for the eccentric ergometry intervention to be quadriceps femoris muscle specific, we made an early observation that gluteal muscles also were being loaded, as participants frequently reported soreness in the gluteal region as a result of training. Perhaps resistance exercises biased toward developing a pure knee extensor strategy (by isolating the quadriceps femoris muscle from the hip extensors via non–weight-bearing resistance training) may be helpful in restoring the proper knee-to-hip extensor relationship. Further research in this area is warranted. It is worth noting that we observed a significant decrease in gracilis muscle volume from pretraining to the 1-year follow-up. In our previous study,1 we noted that the decrease in gracilis muscle volume appeared to be graftdependent. Gracilis muscle volume was relatively unchanged in those individuals who had ACL-R with the

Volume 89

Number 1

Physical Therapy f

57

Early Progressive Eccentric Exercise After ACL Reconstruction bone-patellar tendon graft but was substantially decreased in those individuals who had ACL-R with the semitendinosus-gracilis tendon graft.1 Although it was not the purpose of this study to compare graft types, it appears that our previous statement would still apply at 1 year following ACL-R. Comparing gracilis muscle volume longitudinally between graft types after ACL-R would be an interesting topic for a future study. Limitations Several limitations characterize the current study. Only 80% of the original sample completed all aspects of the study up to the 1-year evaluation. However, because the directional short-term results of this smaller cohort were statistically supported at 1 year, we believe the current sample is an adequate representation of the original group. We also used an intentionto-treat analysis to be more conservative in our statistical approach. Another potential limitation in this study was the lack of a control group or a more-detailed description of resistance training-specific activities during the home exercise program that occurred from the posttraining evaluation to the 1-year evaluation. Considering that one group could have participated in a different training regimen than the other group during this period is a confounding variable, especially because measures of muscle volume and function were the primary outcome variables. The bottom line is that the differences observed at the 1-year follow-up cannot be solely attributed to the eccentric exercise training that was performed during weeks 3 to 15.

Conclusions This study demonstrated that the addition of progressive eccentric exercise, implemented 3 weeks after ACL-R, resulted in muscle volume and strength gains in key muscle groups 1 year after surgery that ex58

f

Physical Therapy

Volume 89

ceeded those changes following a standard rehabilitation program. The overall magnitude of improvement in quadriceps femoris and gluteus maximus muscle volume at 1 year was more than 50% greater in the eccentric exercise group compared with the standard rehabilitation group. Overall functional improvement (quadriceps femoris muscle strength and hopping distance) also was significantly greater in the group that performed early focused eccentric exercise training. These findings clearly emphasize the importance of progressive resistance training during the early rehabilitation stages following ACL-R and further suggest that adding a high-force eccentric exercise intervention is a viable option as part of a comprehensive rehabilitation program. All authors provided concept/idea/research design. Dr Gerber, Dr Marcus, Dr Dibble, and Dr LaStayo provided writing. Dr Gerber and Dr Marcus provided data collection. Dr Gerber, Dr Marcus, and Dr Dibble provided data analysis. Dr Gerber and Dr LaStayo provided project management and fund procurement. Dr Greis and Dr Burks provided participants. Dr Marcus, Dr Dibble, and Dr LaStayo provided facilities/equipment. Dr LaStayo provided institutional liaisons. Dr Marcus, Dr Dibble, Dr Greis, Dr Burks, and Dr LaStayo provided consultation (including review of manuscript before submission). This study received approval from the Institutional Review Board at the University of Utah. This research, in part, was presented at the Combined Sections Meeting of the American Physical Therapy Association; February 6 –9, 2008; Nashville, Tennessee. This study was funded, in part, by the American Physical Therapy Association Orthopedic Section Clinical Research Grant to Dr Gerber and Dr LaStayo. The opinions and assertions contained herein are the private views of the authors and are not to be construed as official or as reflecting the views of the Departments of the Army or Defense.

Number 1

This article was received January 29, 2007, and was accepted September 8, 2008. DOI: 10.2522/ptj.20070189

References 1 Gerber JP, Marcus RL, Dibble LE, et al. Effects of early progressive eccentric exercise on muscle structure after anterior cruciate ligament reconstruction. J Bone Joint Surg Am. 2007;89:559 –570. 2 Gerber JP, Marcus RL, Dibble LE, et al. Safety, feasibility, and efficacy of negative work exercise via eccentric muscle activity following anterior cruciate ligament reconstruction. J Orthop Sports Phys Ther. 2007;37:10 –18. 3 Gerber JP, Marcus RL, Dibble LE, et al. Early application of negative work via eccentric ergometry following anterior cruciate ligament reconstruction: a case report. J Orthop Sports Phys Ther. 2006; 36:298 –307. 4 Hortobagyi T, Barrier J, Beard D, et al. Greater initial adaptations to submaximal muscle lengthening than maximal shortening. J Appl Physiol. 1996;81:1677–1682. 5 Hortobagyi T, Dempsey L, Fraser D, et al. Changes in muscle strength, muscle fibre size and myofibrillar gene expression after immobilization and retraining in humans. J Physiol. 2000;524:293–304. 6 Hortobagyi T, Hill JP, Houmard JA, et al. Adaptive responses to muscle lengthening and shortening in humans. J Appl Physiol. 1996;80:765–772. 7 LaStayo PC, Ewy GA, Pierotti DD, et al. The positive effects of negative work: increased muscle strength and decreased fall risk in a frail elderly population. J Gerontol A Biol Sci Med Sci. 2003;58: M419 –M424. 8 LaStayo PC, Pierotti DJ, Pifer J, et al. Eccentric ergometry: increases in locomotor muscle size and strength at low training intensities. Am J Physiol Regul Integr Comp Physiol. 2000;278:R1282–R1288. 9 Moher D, Schulz KF, Altman DG. The CONSORT statement: revised recommendations for improving the quality of reports of parallel-group randomized trials. Ann Intern Med. 2001;134:657– 662. 10 Tegner Y, Lysholm J. Rating systems in the evaluation of knee ligament injuries. Clin Orthop Relat Res. 1985;(198):43– 49. 11 LaStayo PC, Reich TE, Urquhart M, et al. Chronic eccentric exercise: improvements in muscle strength can occur with little demand for oxygen. Am J Physiol. 1999;276(2 Pt 2):R611–R615. 12 Noble BJ, Borg GA, Jacobs I, et al. A category-ratio perceived exertion scale: relationship to blood and muscle lactates and heart rate. Med Sci Sports Exerc. 1983;15:523–528. 13 Tracy BL, Ivey FM, Metter JE, et al. A more efficient magnetic resonance imagingbased strategy for measuring quadriceps muscle volume. Med Sci Sports Exerc. 2003;35:425– 433.

January 2009

Early Progressive Eccentric Exercise After ACL Reconstruction 14 Dibble LE, Hale TF, Marcus RL, et al. Highintensity resistance training amplifies muscle hypertrophy and functional gains in persons with Parkinson’s disease. Mov Disord. 2006;21:1444 –1452. 15 Irrgang JJ, Snyder-Mackler L, Wainner RS, et al. Development of a patient-reported measure of function of the knee. J Bone Joint Surg Am. 1998;80:1132–1145. 16 Arangio GA, Chen C, Kalady M, et al. Thigh muscle size and strength after anterior cruciate ligament reconstruction and rehabilitation. J Orthop Sports Phys Ther. 1997;26:238 –243. 17 Bach BR, Jones GT, Sweet FA, et al. Arthroscopy-assisted anterior cruciate ligament reconstruction using patellar tendon substitution: two- to four-year followup results. Am J Sports Med. 1994;22: 758 –767. 18 Ejerhed L, Kartus J, Sernert N, et al. Patellar tendon or semitendinosus tendon autografts for anterior cruciate ligament reconstruction: a prospective randomized study with a two-year follow-up. Am J Sports Med. 2003;31:19 –25. 19 Elmqvist LG, Lorentzon R, Johansson C, et al. Knee extensor muscle function before and after reconstruction of anterior cruciate ligament tear. Scand J Rehabil Med. 1989;21:131–139. 20 Eriksson K, Hamberg P, Jansson E, et al. Semitendinosus muscle in anterior cruciate ligament surgery: morphology and function. Arthroscopy. 2001;17:808 – 817.

January 2009

21 Feller JA, Webster KE. A randomized comparison of patellar tendon and hamstring tendon anterior cruciate ligament reconstruction. Am J Sports Med. 2003;31: 564 –573. 22 Grant JA, Mohtadi NG, Maitland ME, et al. Comparison of home versus physical therapysupervised rehabilitation programs after anterior cruciate ligament reconstruction: a randomized clinical trial. Am J Sports Med. 2005;33:1288 –1297. 23 Hamada M, Sino K, Horibe S, et al. Singleversus bi-socket anterior cruciate ligament reconstruction using autogenous multiplestranded hamstring tendons with endoButton femoral fixation: a prospective study. Arthroscopy. 2001;17:801– 807. 24 Jansson KA, Linko E, Sandelin J, et al. A prospective randomized study of patellar versus hamstring tendon autografts for anterior cruciate ligament reconstruction. Am J Sports Med. 2003;31:12–18. 25 Jarvela T, Kannus P, Latvala K, et al. Simple measurements in assessing muscle performance after an ACL reconstruction. Int J Sports Med. 2002;23:196 –201. 26 Mattacola CG, Perrin DH, Gansneder BM, et al. Strength, functional outcome, and postural stability after anterior cruciate ligament reconstruction. J Athl Train. 2002; 37:262–268. 27 Meighan AA, Keating JF, Will E. Outcome after reconstruction of the anterior cruciate ligament in athletic patients: a comparison of early versus delayed surgery. J Bone Joint Surg Br. 2003;85:521–524.

28 Risberg MA, Holm I, Steen H, et al. The effect of knee bracing after anterior cruciate ligament reconstruction: a prospective, randomized study with two years follow-up. Am J Sports Med. 1999;27:76 – 83. 29 Rosenberg TD, Franklin JL, Baldwin GN, et al. Extensor mechanism function after patellar tendon graft harvest for anterior cruciate ligament reconstruction. Am J Sports Med. 1992;20:519 –525. 30 Snyder-Mackler L, Ladin Z, Schepsis AA, et al. Electrical stimulation of the thigh muscles after reconstruction of the anterior cruciate ligament: effects of electrically elicited contraction of the quadriceps femoris and hamstring muscles on gait and on strength of the thigh muscles. J Bone Joint Surg Am. 1991;73:1025–1036. 31 Williams GN, Snyder-Mackler L, Barrance PJ, et al. Muscle and tendon morphology after reconstruction of the anterior cruciate ligament with autologous semitendinosusgracilis graft. J Bone Joint Surg Am. 2004; 86:1936 –1946. 32 Ferber R, Osternig LR, Woollacott MH, et al. Gait mechanics in chronic ACL deficiency and subsequent repair. Clin Biomed (Bristol Avon). 2002;17:274 –285. 33 Salem GJ, Salina R, Harding FV. Bilateral kinematic and kinetic analysis of the squat exercise after anterior cruciate ligament reconstruction. Arch Phys Med Rehabil. 2003;84:1211–1216.

Volume 89

Number 1

Physical Therapy f

59

Research Report

Stepping Responses of Infants With Myelomeningocele When Supported on a Motorized Treadmill Caroline Teulier, Beth A Smith, Masayoshi Kubo, Chia-Lin Chang, Victoria Moerchen, Karin Murazko, Beverly D Ulrich C Teulier, PhD, is Postdoctoral Fellow, Developmental Neuromotor Control Laboratory, Division of Kinesiology, University of Michigan, 401 Washtenaw Ave, Ann Arbor, MI 48109-2214 (USA). Address all correspondence to Dr Teulier at: [email protected]. BA Smith, PT, DPT, is PhD candidate, Developmental Neuromotor Control Laboratory, Division of Kinesiology, University of Michigan. M Kubo, PT, ScD, is Assistant Professor, Department of Physical Therapy, Niigata University of Health and Welfare, Niigata, Japan. CL Chang, PT, PhD, is Research Associate, Department of Physical Medicine and Rehabilitation, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania. V Moerchen, PT, PhD, is Assistant Professor, Department of Human Movement Science, University of Wisconsin—Milwaukee, Milwaukee, Wisconsin. K Murazko, MD, is Chair and Professor, Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan. BD Ulrich, PhD, is Professor and Dean, Developmental Neuromotor Control Laboratory, Division of Kinesiology, University of Michigan. [Teulier C, Smith BA, Kubo M, et al. Stepping responses of infants with myelomeningocele when supported on a motorized treadmill. Phys Ther. 2009;89:60 –72.]

Background and Purpose. Infants with myelomeningocele (MMC) have difficulty with, and show delays in, acquiring functional skills, such as walking. This study examined whether infants with MMC will respond to treadmill practice by producing stepping patterns or at least motor activity during the first year after birth. This study also compared the stepping trajectories of infants with MMC across age with those of infants with typical development (TD) to analyze the characteristics of the development of stepping patterns in infants with MMC early in life.

Participants. Twelve infants with MMC (lumbar and sacral lesions) and 12 infants with TD were the participants in this study.

Methods. The infants were tested on a treadmill at ages 1, 3, 6, 9, and 12 months, with no treadmill practice between test sessions. Infants were supported on the treadmill for twelve 20-second trials. A digital camera and behavior coding were used to determine step rate, interlimb stepping patterns, step parameters, and motor activity level.

Results. Treadmill practice elicited steps in infants with MMC (14.4 steps/minute during the year) but less so than in infants with TD (40.8 steps/minute). Responsiveness was affected by lesion level but varied markedly among infants. Interlimb stepping was less readily alternating, but step parameters were similar to those produced by their peers with TD. Finally, holding infants with MMC on a moving treadmill resulted in greater motor activity (17% during the year) than holding infants on a nonmoving treadmill. Discussion and Conclusion. Infants with MMC responded to the treadmill by stepping (but less so than infants with TD) and showing increased motor activity, but they demonstrated a different developmental trajectory. Future studies are needed to explore the impact of enhancing sensory input during treadmill practice to optimize responses in infants with MMC.

© 2009 American Physical Therapy Association Post a Rapid Response or find The Bottom Line: www.ptjournal.org 60

f

Physical Therapy

Volume 89

Number 1

January 2009

Stepping Responses in Myelomeningocele

M

yelomeningocele (MMC) is the most common neural tube defect in the United States, affecting 1,500 to 2,000 of the more than 4 million babies born in the country each year.1 In recent years, the incidence of MMC has decreased in many developed countries as a function of improved prepregnancy health care for women of parenting age and folic acid dietary supplementation. However, the incidence remains as high as 8 in 1,000 in India and 1.5 in 1,000 in Mexico.2– 4 This disorder frequently results in numerous neuromusculoskeletal complications, including paraparesis, neurogenic bowel and bladder, hydrocephalus, and cognitive issues. In this study, we focus, in particular, on the issue of lower-limb function. For children born with MMC, walking onset is delayed by an average of 2 years compared with that in their peers with typical development (TD). Walking in children born with MMC comes with a high energy cost, high motion variability (such as pelvic obliquity and hip rotation5), and often the need for braces, orthoses, or both to manage the impact of paresis.6 – 8 The likelihood that infants with MMC will walk is affected by the level at which the functional lesion occurs. Current data suggest a 20% chance of walking for those born with lesions at a high lumbar level, 80% for infants with lesions at a low lumbar level, and 90% for infants with lesions at the sacral level.8,9 Unfortunately, by late childhood to early adolescence, many children with MMC are unable to maintain upright locomotion for community mobility and transition to wheelchair use; this transition introduces or reinforces significant comorbidities, such as scoliosis and obesity.10,11 The possibilities for nonsurgical early therapeutic interventions that January 2009

might help infants with MMC acquire stronger and better functional control of their lower limbs have largely been neglected. Medical studies that describe the spontaneous leg activity of infants with MMC have been done. Ultrasound examinations of 16- to 24-week-old fetuses with thoracic, lumbar, and sacral MMC lesions have indicated that these fetuses are as active as fetuses with TD, showing flexion and extension movements of their hips and knees.12–14 However, in the weeks after birth, rather than showing increased leg activity, infants with MMC exhibit decreased leg activity.15,16 Although this decreased activity after birth is not surprising, it is encouraging to note that 4- to 6-month-old infants with MMC will respond to contexts that encourage activity, such as a specially designed chair, by increasing their frequency of spontaneous leg movement.17 The fact that infants with MMC will show active neuromotor responses to environmental manipulations is encouraging. Current theory and empirical data indicate that for infants, generally, early exploration and spontaneous motor activity drive the development of motor control and the organization of underlying neural structures.18 –21 Through their own activity, infants create recurrent and reciprocal cycles of sensorimotor input and output via the central and peripheral nervous systems. Through these perception-action cycles, the capacity of populations of neurons to be activated in a coordinated and functional manner is strengthened. Because MMC involves damage to the spinal cord, the number of intact motor units available to initiate and sustain activity and the number of sensory receptor pathways are reduced.22,23 The task of gaining strength (force-generating capacity) and control not only is metabolically more demanding but also may require more cycles of neurological ac-

tivity over time to build a foundation of organized and functional neuromotor pathways.20,24 One potential way in which to assist the development of leg control in babies with MMC is to create an environment that encourages them to produce more cycles of leg activity, in particular, patterns of movement that relate to functional behavior, such as walking. In previous studies, Ulrich and colleagues25–27 showed that infants with TD respond to being supported upright on a small motorized treadmill by producing wellcoordinated and adaptive stepping patterns. Subsequently, Ulrich and colleagues28 –31 demonstrated that infants with Down syndrome also are able to step when supported on a treadmill, but with a delay in the age of onset of responsiveness compared with their peers with TD. Furthermore, it was shown that treadmill training significantly reduces the delay in walking onset for infants with Down syndrome and improves the quality of gait for toddlers.28 –31 Therefore, in this study, we asked a much-needed question about whether the use of a treadmill might provide experience and input relevant to and usable by the neuromotor systems of infants with spinal sensorimotor lesions that are incomplete in nature. Specifically, our goal was to determine whether infants with MMC are able to increase their step rate or at least their motor activity level (moving in any manner) when supported on a motorized treadmill during the first year after birth. We also compared the quantity of stepping (step rate) and the quality of stepping (interlimb stepping patterns and step parameters) in infants with MMC across age with those in infants with TD to identify the characteristics of the development of stepping patterns in infants with MMC. In addition, for the group with MMC, we examined the rela-

Volume 89

Number 1

Physical Therapy f

61

Stepping Responses in Myelomeningocele Table. Medical and Anthropometric Characteristics of Participantsa Participant No.

Surgery

Fusion Level

1

EU

L1–L2

Y

2

IU

L2–L3

Y

3

EU

L3

Y

Y

4

EU

L3

Y

Y

5

EU

L4

Y

Y

6

IU

L4

7

IU

L4

8

EU

L4–L5

9

EU

L5–S1

10

EU

L5–S1

11

EU

L5–S1

12

EU

S1

MMC group

X

Hydrocephalus

Shunt

Arnold-Chiari Malformation

Clubfeet

Y

Birth Weight (kg)

Birth Length (cm)

37

3.52

53.34

34

2.10

44.45

38

3.06

47.00

Y

Y

40

3.81

54.61

Y

Y

38

3.46

48.26

Y

Y

Y

37

3.77

50.80

Y

Y

Y

37

3.12

50.17

38

3.27

45.72

37.5

3.52

55.88

36.5

2.95

48.90

37

2.83

48.26

36.5

3.71

49.53

37.21

3.26

49.74

Y

Y

Y

SD TD group

Gestational Age (wk)

X SD

1.39

0.49

3.47

39.21

3.58

52.30

0.81

0.44

2.58

a

EU⫽extrautero (surgery to close myelomeningocele performed after birth), IU⫽intrautero (surgery to close myelomeningocele performed in utero), Y⫽yes, MMC group⫽infants with myelomeningocele, TD group⫽infants with typical development.

tionship between neuromotor damage (on the basis of the level of the lesion) and stepping trajectories.

Method Participants Twelve infants with MMC and 12 infants with TD were enrolled in our longitudinal study at 1 month of age (7 girls and 5 boys in each group). Infants with both MMC and chromosomal or central nervous system abnormalities not known to be associated with MMC were excluded. Lesion levels were limited to lumbar and sacral and were based on the fusion sites recorded by hospitals (Table). Infants with TD were without known cognitive, sensory, or motor impairments (on the basis of parental reports). One additional baby with MMC and 1 additional baby with TD were tested but were excluded from this study because they moved from the geographical area or their parents did not want to continue with the study. 62

f

Physical Therapy

Volume 89

Infants with MMC were referred by physicians at the University of Michigan and Toledo, Ohio, hospital systems. Parents gave written informed consent for their infants to participate in this study and completed a medical status and history form (including shunt status, level of lesion, and surgeries). Infants with TD were recruited through newspaper advertisements, fliers, and word-of-mouth communication in the Ann Arbor, Michigan, area. Procedure Infants visited our laboratory to be tested at 1, 3, 6, 9, and 12 months of age and at walking onset. For babies born more than 2 weeks before their due date, we used corrected ages for test sessions and analyses. During each session, we tested infants in 3 conditions: newborn stepping, treadmill stepping, and supine spontaneous movement. In this report, we address only the second and most extensive testing condi-

Number 1

tion, treadmill stepping. To prepare infants for testing, we removed their clothing and diaper. We placed reflective markers (8-mm diameter at ages 1 and 3 months; 18-mm diameter at ages 6 months and on) bilaterally on the iliac crest, greater trochanter, knee joint, malleolus, and ventral surface of the third metatarsophalangeal joint. We placed preamplified bipolar electromyograph electrodes over the muscle bellies of the left gastrocnemius, tibialis anterior, rectus femoris, and biceps femoris muscles. The treadmill stepping condition consisted of a custom-made motorized treadmill placed on a large table (73 cm high, 118 cm wide, and 190 cm long) surrounded by 6 motion capture cameras and a digital video camera. The treadmill had a frame measuring 18 cm high, 42 cm wide, and 82 cm long; a smooth belt surface (30 cm wide); and adjustable speed control. We placed 3 Peak January 2009

Stepping Responses in Myelomeningocele Motus* real-time cameras on each side of the table to capture the movements of each leg. A digital video camera (60 Hz) was placed at the side of the table perpendicular to the treadmill motion and with the height adjusted to the baby’s size to videotape stepping behavior. The data from this digital video camera, as well as the data from the motion capture system and the electromyograph, were synchronized and recorded with the Peak Motus cameras. We held infants upright so that their feet rested on the belt of the treadmill in a partial body-weightsupported position for twelve 20second trials, split into 2 sets of 6 trials (Fig. 1). Between sets, infants were given a break, and breaks were taken throughout testing as needed. During trials 1 and 12, the belt of the treadmill was not moving. For trials 2 through 6 and 7 through 11, the belt was moving and the speed was increased in increments of 0.038 m䡠s⫺1, from 0.068 m䡠s⫺1 to 0.22 m䡠s⫺1. Speed adaptations will be assessed in a separate article in preparation. For this article, we collapsed data across speed within each test session for each baby.

Figure 1. Photograph of a 1-month-old infant being held on the small motorized treadmill.

After testing, we measured total body weight and length, and for each leg, we measured length (greater trochanter to lateral malleolus), thigh, and shank circumference. Because the neuromotor outcomes of spinal lesions in babies with MMC often are asymmetrical, we classified each leg as more or less affected on the basis of the infants’ medical records. When no differences were reported, we assigned the right leg as the less-affected leg.

* Peak Performance Technologies, 7388 S Revere Pkwy #901, Centennial, CO 80112.

January 2009

Volume 89

Number 1

Physical Therapy f

63

Stepping Responses in Myelomeningocele Data Reduction For the purposes of the present investigation, only data collected with the digital video camera during the treadmill testing are presented here to focus on the quantity and quality of the stepping of the babies when supported on the treadmill during the first year of life. For determination of the occurrence and temporal aspects of steps, as well as the baby’s general level of motor activity, the digital video data were behaviorally coded using frame-by-frame (60-Hz) analysis of each trial with Peak Motus computer software. Before coders (2 of the study authors and 4 student assistants) could begin working on data for this study, they had to obtain a coefficient of agreement of .85 (interobserver reliability coefficient, kappa) through comparison of their work with that of previously validated coders for the same set of trials by using training tapes. Step rate. First, coders counted the number of steps produced in each trial. Because portions of some trials could not be completed as a result of infants’ fussiness or other reasons, we calculated the rate of steps to allow comparisons among infants and among ages. The rate of steps was defined as the total number of steps taken per session for each baby divided by the total number of seconds spent on the treadmill during moving-belt trials. Two infants with MMC missed one visit; we interpolated the points surrounding this event to create a surrogate value for this visit for longitudinal analysis purposes. Two infants with TD missed the treadmill data collection session at 12 months. Because they stepped continuously at 9 months and it was not reasonable to expect further improvement, we used their performance values for 9 months at 12 months.

64

f

Physical Therapy

Volume 89

Interlimb stepping patterns. Coders were trained to recognize 4 interlimb stepping patterns: alternating (a step of one leg overlaps a step of the opposite leg), single (a step of one leg does not overlap a step of the other leg), parallel (both legs swing forward simultaneously), and double (a “stutter step” within a series of alternating steps). For these patterns, we calculated the 4 types of steps produced at each visit for each baby as a percentage of the total steps. Step parameters. Coders identified the time (frame) when events occurred: toe-off, touch-down, and end of stance for alternating steps only. To account for developmental differences in body size, we normalized stride cycle and swing- and stance-phase durations by leg length and transformed the data to dimensionless variables with the following formula: normalized cycle duration ⫽ cycle duration/(gravity/leg length)2.32 For alternating steps, the part of the infant’s foot that made contact at touch-down and during mid-stance was coded as toe, flat, heel, lateral, or medial. Next, the percentage of each foot posture that was used for touch-down and midstance was calculated. Motor activity level. Motor activity level was coded for all nonmoving-belt and moving-belt trials to describe infants’ movement levels even if they did not respond to the treadmill with steps. We used 2 categories of activity: (1) overall activity, which reflected movement of any limbs, trunk, or head, and (2) leg activity, which reflected only leg behavior. Overall activity was scored every 5 seconds with 1 of 3 values: 0⫽no movement, 0.5⫽small movement, and 1⫽clear movement of arms, legs, head, or any of these parts. Leg activity was scored every 5 seconds with dichotomous values: 0⫽no leg movement and 1⫽clear leg

Number 1

movement. Next, we transformed the scores obtained at each session to a percentage for each infant on the basis of the maximal score possible for baseline trials and movingbelt trials. Data Analysis We used SPSS version 14.0 statistical software† for statistical analyses. The general linear model procedure was used to conduct multivariate analyses of variance (MANOVAs) and analyses of variance (ANOVAs) for repeated measures. The Huynh-Feldt epsilon correction for multiple comparisons (we report degrees of freedom rounded to the nearest whole number) was used to determine statistical significance, which was set at P⬍.05. The effect size for each ANOVA is reported as eta square (␩2). Only statistics for results that were statistically significant are presented.

Results Participant Characteristics We used a 2 (group) ⫻ 5 (age) MANOVA for repeated measures on age to compare groups on overall body size. Dependent variables were height, weight, and the ponderal index: (3公weight/height ⫻100). Only a significant age effect emerged (Wilks lambda⫽0.12, F12,227⫽82.83, P⬍.001). Post hoc ANOVA results showed significant increases in body weight (F2,49⫽444.86, P⬍.001, ␩2⫽ .95) and body length (F3,73⫽666.62, P⬍.001, ␩2⫽.97) and a significant decrease in the ponderal index (F2,64⫽38.24, P⬍.001, ␩2⫽.26) with age. We used a 2 (group) ⫻ 2 (leg) ⫻ 5 (age) MANOVA for repeated measures on age to compare groups on leg measures. Dependent variables were leg length, thigh circumference, and shank circumference. † SPSS Inc, 233 S Wacker Dr, Chicago, IL 60606.

January 2009

Stepping Responses in Myelomeningocele Both main effects were significant: age (Wilks lambda⫽0.03, F12,439⫽ 100.92, P⬍.001) and group (Wilks lambda⫽0.66, F3,40⫽6.79, P⬍.001). The age ⫻ group interaction also was significant (Wilks lambda⫽0.88, F12,439⫽1.84, P⫽.04). None of the post-hoc ANOVAs for individual dependent variables resulted in a significant interaction effect. We obtained a main effect of age for leg length (F3,113⫽519.7, P⬍.001, ␩2⫽.92), thigh circumference (F3,132⫽238.6, P⬍.001; ␩2⫽.85), and shank circumference (F3,108⫽378.9, P⬍.001, ␩2⫽.90). The main effect of group was significant for both leg length (F1,42⫽4.85, P⫽.03, ␩2⫽.10) and shank circumference (F1,42⫽14.74, P⬍.001, ␩2⫽.26). For leg length and shank circumference, values were higher for infants with TD than for infants with MMC. Inspection of the means suggests that each group showed very similar values at month 1 (19.4 and 19.6 cm for leg length for the infants with MMC and the infants with TD, respectively; 12.5 and 13.0 cm for shank circumference for the infants with MMC and the infants with TD, respectively). With age, the difference was greater (27.9 and 28.6 cm for leg length for the infants with MMC and the infants with TD, respectively; 17.6 and 19.3 cm for shank circumference for the infants with MMC and the infants with TD, respectively, at 12 months). Although not reaching the level of a significant univariate interaction, those values, in combination, may have resulted in the multivariate interaction effect reported above. Step Rate For our primary topic of interest, the infants’ step rate, we used a 2 (group) ⫻ 5 (age) ANOVA for repeated measures on age with step rate as the dependent variable. We found a significant age effect (F3,80⫽10.45, P⬍.001, ␩2⫽.32), a significant group effect (F1,22⫽21.3, January 2009

P⬍.001, ␩2⫽.49), and an age ⫻ group interaction (F3,80⫽4.58, P⫽.003, ␩2⫽.17). Figures 2A and 2B display step rates across months for each infant as well as group means for infants with TD and infants with MMC, respectively. Infants with TD clearly showed an increase in step rate over time, shifting from high variability across individuals at month 1 to highly similar step rates by months 9 and 12. Infants in the MMC group did not show a change in the step rate over time and maintained high interindividual variability throughout the year. To better understand the variability in the MMC group, we divided infants into 3 subgroups on the basis of lesion level and current published research suggesting the inherent likelihood of these babies remaining community walkers into adulthood. Longitudinal studies of cohorts observed into adulthood33,34 suggested that for subjects with lesions above L3, the prognosis was not likely to be walking in adulthood. For subjects with L4 lesions, there seemed to be a 50% rate of community walking; this rate was as high as 90% for subjects with L5 and sacral lesions. On the basis of these published data, we classified babies with L1, L2, and L3 lesions as having high-level lesions; infants with L4 lesions as having middle-level lesions; and infants with L5 or sacral lesions as having lowlevel lesions. Figures 2C, 2D, and 2E show that the step rate tended to increase as the level of the lesion decreased. Infants with high-level lesions clearly produced the fewest steps, with little change with age and low variability. Infants with middle- and low-level lesions showed more improvement but also higher variability. Interlimb Stepping Patterns To examine differences in interlimb stepping patterns, we ran a 2 (group) ⫻ 5 (age) MANOVA for re-

peated measure on age and the following dependent variables: percentages of alternating, single, parallel, and double steps. We obtained significant group (Wilks lambda⫽0.44, F4,19⫽5.95, P⫽.003) and age (Wilks lambda⫽0.64, F16,260⫽ 2.59, P⫽.001) effects. Post-hoc ANOVAs were conducted for individual dependent variables. Means for each stepping pattern by group over time are shown in Figure 3. For alternating steps, we found significant group (F1,22⫽24.14, P⬍.001, ␩2⫽.52), age (F4,88⫽8.02, P⬍.001, ␩2⫽.27), and interaction (F4,88⫽ 4.27, P⬍.001, ␩2⫽.16) effects. Infants with TD produced more alternating steps than their peers with MMC. Both groups showed an increase in alternating steps with age, but infants with TD showed a considerably greater increase over time than infants with MMC. For single steps, one significant effect emerged: the main effect of group (F1,22⫽18.59, P⬍.001, ␩2⫽.46). Infants with MMC generated more single steps than their peers with TD. The main effects of group and age were significant for parallel steps (F1,22⫽5.43, P⫽.029, ␩2⫽.20 and F4,88⫽3.80, P⫽.007, ␩2⫽.15, respectively). Infants with MMC produced more parallel steps than their peers with TD, but both groups showed a decrease over time in the proportion of all steps that were parallel steps. Step Parameters We examined the parameters of infants’ alternating steps, the ones most similar to the interlimb stepping pattern used in walking. We included infants’ data only if they produced more than 4 alternating steps per session. Thus, for infants with MMC, sample sizes were 6 for month 9, 7 for months 6 and 12, and 8 for months 1 and 3. For infants with TD, the sample size was 12 throughout. Missing values for infants with MMC precluded calculating statistics.

Volume 89

Number 1

Physical Therapy f

65

Stepping Responses in Myelomeningocele

Figure 2. Number of steps taken per second across age, by groups and individuals: typical development (TD) (A), myelomeningocele (MMC) (B), and MMC with lesions at high (C), middle (D), and low (E) levels. (Continued)

66

f

Physical Therapy

Volume 89

Number 1

January 2009

Stepping Responses in Myelomeningocele Figure 4A shows the values for step parameters across age: dimensionless cycle, swing phase and stance phase durations, and percent stance phase per cycle. The data suggested that the temporal parameters of alternating steps did not differ between groups. Both groups tended to show small increases in cycle duration and percent stance phase with increasing age. Figures 4B and 4C show foot posture at touch-down for infants with TD and MMC, respectively. At the end of the swing phase, the first contact for 60% of both groups was made with the toes or the flat part of the feet (soles). During the stance phase (Figs. 4D and 4E), both groups settled onto the flat part of the feet with greater frequency over time. Infants with MMC were more likely than their peers with TD to make initial contact with the lateral part of the feet at touchdown (20%) and during the stance phase (19%).

Figure 2. Continued

Motor Activity Level To compare the motor activity levels of infants during moving-belt and nonmoving-belt conditions, we ran a 2 (group) ⫻ 5 (age) ⫻ 2 (condition) MANOVA for repeated measures on age. Dependent variables were overall activity and leg activity. We found significant main effects of group (Wilks lambda⫽0.80, F2,43⫽5.39, P⫽.008) and condition (Wilks lambda⫽0.50, F2,43⫽21.88, P⬍.001) and a significant age ⫻ group interaction (Wilks lambda⫽0.92, F8,350⫽1.20, P⫽.046). These results suggested that the groups differed in motor activity levels, with infants with TD moving more than their peers with MMC; however, the difference changed as infants grew older. Furthermore, both groups engaged in more motor activity when the belt was moving than when the support surface was stationary. The post-hoc ANOVA for leg activity resulted in a significant condition ef-

January 2009

Volume 89

Number 1

Physical Therapy f

67

Stepping Responses in Myelomeningocele fect (F1,44⫽21.72, P⬍.001, ␩2⫽.33) and an age ⫻ group interaction effect (F3,283⫽2.92, P⫽.023, ␩2⫽.06). For overall activity, the post-hoc ANOVA resulted only in a significant condition effect (F1,44⫽40.05, P⬍.001, ␩2⫽.48). Examination of means showed that leg activity for infants with TD remained stable over time, whereas infants with MMC showed a period of decreased leg activity—about 10% in each condition— beyond ages 6 and 9 months. The condition effect for both motor activity level variables revealed an increase during moving-belt trials compared with nonmoving-belt trials. On average, across months, infants with TD showed a 26% increase in overall activity when supported on the moving belt compared with the nonmoving belt. For infants with MMC, the average increase in overall activity was 18%. Leg activity increased by 22% in infants with TD and 16% in infants with MMC.

Discussion Overall, our data showed that during the first year of life, supporting infants with MMC upright on the moving belt of a motorized treadmill elicits stepping patterns in addition to increased overall motor activity. In previous studies, researchers reported less leg activity in infants with MMC than in their peers with TD.15,17,35 Our current data parallel these earlier reports and extend them by demonstrating that although treadmill practice elicited stepping patterns in infants with MMC, their step rate, like their motor activity level, was lower than that of their peers with TD and the distribution of their interlimb stepping patterns was different from that of their peers. Early signs of the impact of reduced motor activity in the legs may be evident in our finding of emergent group differences in leg size, which were the only significant anthropo68

f

Physical Therapy

Volume 89

Figure 3. Distribution of stepping patterns produced by infants with typical development (TD) (A) and infants with myelomeningocele (MMC) (B) across age: alternating (AL), double (DO), parallel (PA), and single (SI).

metric differences that we observed. At 1 month, leg length and shank circumference were similar between groups, but differences increased over time, such that the legs of infants with MMC were shorter and smaller in mass by the end of the first year. Although such growth impairment is typically attributed to impaired innervation, it may also be attributable, in part, to the lessfrequent exposure of bones to the compression forces generated by repeated muscle contractions, which are known to facilitate bone growth. As a group, infants with MMC had a step rate lower than that of infants with TD, clearly exposing their mus-

Number 1

cles to less contractile force over time than that seen in infants with TD. Still, they averaged approximately 48 steps per session (or 14.4 steps per minute), which is not a trivial number. However, their group mean step rate seemed quite flat across the year, whereas all infants with TD showed an increase in the step rate over time. Lesion level clearly affected both the step rate and the developmental trajectory across individual babies. Infants with the highest-level lesions (L1–L3), in particular, showed a very low step rate over time. We propose that the lack of improvement for infants in this subgroup over time represents a marked delay in the development of January 2009

Stepping Responses in Myelomeningocele

Figure 4. Step parameters by group across age. (A) Normalized cycle duration, swing duration, stance duration, and percent stance. (B and C) Mean percentages of lateral or medial (L/M), heel (H), toe (T), or flat (F) part of foot making contact at touch-down for infants with typical development (TD) (B) and infants with myelomeningocele (MMC) (C). (D and E) Mean percentages of lateral or medial (L/M), heel (H), toe (T), or flat (F) part of foot in contact with belt during mid-stance (mid-ST) for infants with TD (D) and infants with MMC (E).

January 2009

Volume 89

Number 1

Physical Therapy f

69

Stepping Responses in Myelomeningocele muscle strength and limb control compared with development in their peers, rather than an innate lack of a capacity for development. From the follow-up data that we collected for our infants with MMC after 12 months of age, we know that 3 of the 4 infants in this subgroup attained the ability to walk by using walkers to provide postural support (at 24 months, 29 months, and 44 months). Their high-level lesions likely caused the most depressed rate of development because of the increased degree of loss of sensorimotor units.36 Ulrich et al37 observed a similar delay in response to bodyweight-supported treadmill practice in a study involving infants with Down syndrome. When given sufficient time, the infants showed improved stepping, particularly when provided with treadmill practice.28,29 We predict that at least 3 of our infants with high-level MMC would have responded with more steps on the treadmill had we continued to monitor their behavior beyond the first 12 months after birth. Infants with MMC also demonstrated higher variability in their step rate than infants with TD, as individuals and as a group, and they showed several unique developmental trajectories during the first year of life. These findings are important for several reasons. First, the variability in stepping trajectories reinforced the notion that lesion level, while relevant, is a poor predictor, in isolation, of sensorimotor responsiveness at any point in time for individual babies with MMC.38 Other factors (such as shunt revisions, joint and ligament structures, specific medications, and overall family support resources) interact to make such predictions complex and difficult. Second, variability in infants with TD, but not in those with MMC, resolved markedly by the second half of the first year. This resolution, according to neuromotor development 70

f

Physical Therapy

Volume 89

theory and data, occurs because infants’ spontaneous activity drives the organization of sensorimotor control and, thus, stable patterns of movement.20,21,39 Infants with TD are spontaneously quite active, whereas infants with MMC have decreased leg movements. Thus, infants with MMC seem to be caught in a cycle of inherently less spontaneous activity, which slows their rate of improvement in neuromotor control, which contributes to delays in acquiring functional motor skills and even nonfunctional behavioral responses, such as supported stepping. In addition to the inherent neural and physiological problems in babies with MMC, the medical procedures designed ultimately to improve outcomes, such as castings, joint surgeries, or even shunt surgeries, often interrupt progress in the short term. Last, but perhaps most germane to motor development, the effects of congenital disruption of the spinal cord on motor and sensory communications between the periphery and the brain vary from mild to severe across individuals. When sensory feedback is decreased and motor unit input to muscles is reduced, the effects on establishing a repertoire of movement patterns and control may be inconsistent and varied. The processes of perceiving and acting may require even more repetitions than usual for babies with MMC to learn to control behavior. Such babies must “work harder” to build control and strength, an effort that may tax the motivation that is normally reinforced when active infants who are healthy perceive the impact of their actions on the environment.40 – 43 Although infants with MMC responded to treadmill practice by stepping, they also showed a developmental trajectory of interlimb stepping patterns that was different from that of their peers over time.

Number 1

Overall, infants with MMC were less likely to produce alternating steps at all ages than infants with TD; this finding was true even for those with lesions at the lowest levels (L5 and sacral). Throughout the 12-month study period, infants with MMC continued to produce a large proportion of parallel steps, with both legs moving in synchrony, or single steps, in which one leg stepped but the other did not. The ability to initiate and control alternating movements of the legs is critical to developing functional skills such as creeping and walking. We argue that the difficulty in developing rhythmic coupled oscillation is derived not only from innervation asymmetries but also from the infants’ diminished spontaneous efforts to explore with their legs.35 Asymmetrical movements are typical early in life and in the treadmill context.26 By 6 to 7 months of age, infants with TD increase strength and control. Then their capacity to shift control from one interlimb organization to another and to respond to the dynamics of the supported treadmill context becomes strongly dominated by an alternating organization. In contrast to interlimb stepping patterns, the step parameters of infants with MMC seemed quite similar to those of their peers with TD. Perhaps this is because within the step motion, the legs tend to conform to their pendular qualities, with movement being influenced by gravity and motion-dependent torque as well as the dynamic motion of the treadmill belt under the feet.44,45 It seems that when a step cycle is elicited in infants with MMC in this situation, the outcome is a pattern that has many of the parameters that are desirable in steps that produce locomotion. Step cycle duration as well as the proportions of the cycle represented by swing and stance were similar between the groups. Where individual steps differ more between groups is in the part of the foot that makes January 2009

Stepping Responses in Myelomeningocele contact with the surface at touchdown. It is clear that anomalies of joints, in particular, club foot, heighten the tendency to make first contact with the lateral part of the foot. However, although lateral contact occurred more often, both groups showed significant postural variability and a great deal of toe contact at initial touch-down as well as contact with the flat part of the foot. During stance, infants with MMC, like their peers with TD, tended to show decreased lateral contact and an increase in the likelihood that the flat part of the foot supported body weight. Finally, our results showed that at each age infants in both groups produced more motor activity (either with their entire body or with their legs only) when the treadmill belt was moving than when the belt was not moving. This result indicates that treadmill practice seems to be able to increase the level of activity of the population with MMC, both for strong steppers and for weak steppers. This is an important discovery for a population known to have decreased levels of motor activity.23,35 This result, added to the capacity of this population to respond to the treadmill with stepping during the first year of life, suggests the possibility of using treadmill practice as an additional therapy for infants with MMC. In the present study, babies were in contact with the moving belt for a total of only 3.3 minutes per test session. Increasing the duration of each session and repeating the exposure on multiple days per week may accelerate the infants’ developmental processes. That is, providing babies with more opportunities to accumulate experience in an upright, partial body-weight-bearing movement situation may facilitate the development of bone and joint tissue and help the babies develop neuromotor control of their legs.

January 2009

Study Limitations The present study had several limitations. Infants with MMC typically came to our laboratory before or after a checkup at the university hospital. Some parents drove a distance to the university; thus, whether their laboratory visit occurred before or after the hospital checkup, infants may not have been tested at an optimal point for energy and arousal levels, compared with infants with TD. These factors could have added to the decreased levels of activity in the infants with MMC. We were able to obtain only lesion level, which may not be as meaningful for behavior as true neurological level. We also would like to have had a larger sample to allow regression analysis to examine relationships between factors such as intrautero versus extrautero surgery, shunts, and revisions and the infants’ early motor performance and subsequent locomotor outcomes. Two infants started but did not complete the study; one family moved to a different state (infant in the TD group), and one family indicated that they had schedule conflicts (infant in the MMC group).

Conclusion Our results showed that partial bodyweight-bearing treadmill practice can increase leg activity and, specifically, elicit stepping patterns in infants with MMC at an average rate of 14.4 steps per minute. Responsiveness varied among infants and was affected by lesion level but was not uniquely predicted by it. Interlimb stepping was less readily alternating, but the within-limb step parameters seemed quite similar to those produced by infants with TD. Our next goal is to examine ways to modify treadmill practice to enable infants with MMC to respond with more steps than in the current testing paradigm. Subsequently, we plan to examine the potential for practice stepping on a treadmill, with human

support like that provided here, to generate positive outcomes—such as increasing muscle and cardiovascular strength, bone density, and the neuromotor control needed for upright locomotion—for infants with MMC. Dr Ulrich provided concept/idea/research design, project management, fund procurement, facilities/equipment, and institutional liaisons. Dr Teulier provided writing and data analysis. Dr Smith, Dr Kubo, Dr Chang, Dr Moerchen, and Dr Ulrich provided data collection. Dr Murazko provided participants. Approval for this study was granted by the Institutional Review Board at the University of Michigan. This research was funded by grant R01HD047567 awarded to Dr Ulrich by the National Institute of Child Health and Human Development, National Institutes of Health. This work was presented orally at the annual meeting of the American Academy of Physical Medicine and Rehabilitation; September 27–30, 2007; Boston, Massachusetts; at the 19th annual meeting of the European Academy of Childhood Disability; June 14 –16, 2007; Groningen, the Netherlands; and at the conference of the North American Society for the Psychology of Sport and Physical Activity; June 7–9, 2007; San Diego, California. This article was received April 21, 2008, and was accepted October 16, 2008. DOI: 10.2522/ptj.20080120

References 1 Spina Bifida Fact Sheet. Bethesda, MD: National Institute of Neurological Disorders and Stroke; 2007. NIH Publication No. 07–309. 2 Cherian A, Seena S, Bullock RK, Antony AC. Incidence of neural tube defects in the least-developed area of India: a populationbased study. Lancet. 2005;366:930 –931. 3 Lary JM, Edmonds LD. Prevalence of spina bifida at birth—United States, 1983–1990: a comparison of two surveillance systems. MMWR CDC Surveill Summ. 1996;45: 15–26. 4 International Clearinghouse for Birth Defects Monitoring Systems. World Atlas for Birth Defects/International Centre for Birth Defects of the International Clearinghouse for Birth Defects Monitoring Systems. 2nd ed. Geneva, Switzerland: World Health Organization; 2003.

Volume 89

Number 1

Physical Therapy f

71

Stepping Responses in Myelomeningocele 5 Duffy CM, Hill AE, Cosgrove AP, et al. Three dimensional analysis in spina bifida. J Pediatr Orthop. 1996;16:786 –791. 6 Huber-Okrainec J, Dennis M, Brettschneider J, Spiegler BJ. Neuromotor speech deficits in children and adults with spina bifida and hydrocephalus. Brain Lang. 2002;80:592– 602. 7 Bartonek A, Eriksson M, Saraste H. Heart rate and walking velocity during independent walking in children with low and midlumbar myelomeningocele. Pediatr Phys Ther. 2002;14:185–190. 8 Williams EN, Broughton NS, Menelaus MB. Age-related walking in children with spina bifida. Dev Med Child Neurol. 1999;41: 446 – 449. 9 Iborra J, Pages E, Cuxart A. Neurological abnormalities, major orthopaedic deformities and ambulation analysis in a myelomeningocele population in Catalonia (Spain). Spinal Cord. 1999;37:351–357. 10 van den Berg-Emons HJ, Bussman JB, Brobbel AS, et al. Everyday physical activity in adolescents and young adults with myelomeningocele as measured with a novel activity monitor. J Pediatr. 2001;139:880 – 886. 11 Christopher RJ. Woodhouse myelomeningocele: neglected aspects. Pediatr Nephrol. 2008;23:1223–1231. 12 Hobbins JC, Grannum PA, Berkowitz RL, et al. Ultrasound in the diagnosis of congenital anomalies. Am J Obstet Gynecol. 1979;134:331–345. 13 Korenromp MJ, van Gool JD, Bruinese HW, Kriek R. Early fetal leg movements in myelomeningocele. Lancet. 1986;1: 917–918. 14 Warsof SL, Abramowicz JS, Sayegh SK, Levy DL. Lower limb movements and urologic function in fetuses with neural tube and other central nervous system defects. Fetal Ther. 1988;3:129 –134. 15 Sival DA, Begeer JH, Staal-Schreinemachers AL, et al. Perinatal motor behaviour and neurological outcome in spina bifida aperta. Early Hum Dev. 1997;50: 27–37. 16 Sival DA, van Weerden TW, Vles JS, et al. Neonatal loss of motor function in human spina bifida aperta. Pediatrics. 2004;114: 427– 434. 17 Chapman D. Context effects on the spontaneous leg movements of infants with spina bifida. Pediatr Phys Ther. 2002;14: 62–73. 18 Johnson MH. Functional brain development in humans. Nat Rev Neurosci. 2001;2:475– 483.

72

f

Physical Therapy

Volume 89

19 Johnson MH. Functional brain development during infancy. In: Bremmer G, Fogel A, eds. Blackwell Handbook of Infant Development. Malden, MA: Blackwell Publishing; 2004:169 –190. 20 Sporns O, Edelman GM. Solving Bernstein’s problem: a proposal for the development of coordinated movement by selection. Child Dev. 1993;64:960 –981. 21 Thelen E, Smith LB. A Dynamic Systems Approach to the Development of Cognition and Action. Cambridge, MA: MIT Press; 1994. 22 Oakeshott P, Hunt GM, Whitaker RH, Kerry S. Perineal sensation: an important predictor of long-term outcome in open spina bifida. Arch Dis Child. 2007;92:67– 70. 23 Sival DA, Brouwer OF, Bruggink JLM, et al. Movement analysis in neonates with spina bifida aperta. Early Hum Dev. 2006;82: 227–234. 24 Elman J, Bates E, Johnson M, et al. Rethinking Innateness. Cambridge, MA: MIT Press; 1996. 25 Ulrich BD, Jensen JL, Thelen E, et al. Adaptive dynamics of the leg movement patterns of human infants, II: treadmill stepping in infants and adults. J Mot Behav. 1994;26:313–324. 26 Thelen E, Ulrich BD. Hidden skills: a dynamic systems analysis of treadmill stepping during the first year. Monogr Soc Res Child Dev. 1991;56:1–98; discussion 99 –104. 27 Thelen E, Ulrich BD, Niles D. Bilateral coordination in human infants: stepping on a split-belt treadmill. J Exp Psychol Hum Percept Perform. 1987;13:405– 410. 28 Ulrich BD, Ulrich DA, Collier DH, Cole EL. Developmental shifts in the ability of infants with Down syndrome to produce treadmill steps. Phys Ther. 1995;75: 14 –23. 29 Ulrich DA, Ulrich BD, Angulo-Kinzler RM, Yun J. Treadmill training of infants with Down syndrome: evidence-based developmental outcomes. Pediatrics. 2001;108: 84 –93. 30 Ulrich DA, Lloyd MC, Tiernan CW, et al. Effects of intensity of treadmill training on developmental outcomes and stepping in infants with Down syndrome: a randomized trial. Phys Ther. 2008;88:114 –122. 31 Wu J, Looper J, Ulrich BD, et al. Effects of different treadmill interventions on walking onset and gait patterns in infants with Down syndrome. Dev Med Child Neurol. 2007;49:839 – 845. 32 Ulrich BD, Haehl V, Buzzi UH, et al. Modeling dynamic resource utilization in populations with unique constraints: preadolescents with and without Down syndrome. Hum Mov Sci. 2004;23: 133–156.

Number 1

33 Bowman RM, McLone DG, Grant JA, et al. Spina bifida outcome: a 25-year prospective. Pediatr Neurosurg. 2001;34:114 –120. 34 Hunt GM, Oakeshott P. Outcome in people with open spina bifida at age 35: prospective community-based cohort study. BMJ. 2003;326:1365–1366. 35 Rademacher N, Black DP, Ulrich BD. Early spontaneous leg movements in infants born with and without myelomeningocoele. Pediatr Phys Ther. 2008;20:137–145. 36 Lomax-Bream LE, Barnes M, Copeland K, et al. The impact of spina bifida on development across the first 3 years. Dev Neuropsychol. 2007;31:1–20. 37 Ulrich BD, Ulrich DA, Collier DH. Alternating stepping patterns: hidden abilities of 11-month-old infants with Down syndrome. Dev Med Child Neurol. 1992;34: 233–239. 38 Bartonek A, Saraste H. Factors influencing ambulation in myelomeningocele: a crosssectional study. Dev Med Child Neurol. 2001;43:253–260. 39 Angulo Barroso RM, Tiernan C. Motor systems development. In: Nelson CA, Luciana M, eds. Handbook of Developmental Cognitive Neuroscience. 2nd ed. Cambridge, MA: MIT Press. In press. 40 Adolph KE, Eppler MA, Gibson EJ. Crawling versus walking infants’ perception of affordances for locomotion over sloping surfaces. Child Dev. 1993;64:1158 –1174. 41 Goldfield EC, Kay BA, Warren WH Jr. Infant bouncing: the assembly and tuning of action systems. Child Dev 1993;64:1128 – 1142. 42 Rovee-Collier C. Information pick-up by infants: what is it, and how can we tell? J Exp Child Psychol. 2001;78:35– 49; discussion 98 –106. 43 Sommerville JA, Woodward AL. Pulling out the intentional structure of action: the relation between action processing and action production in infancy. Cognition. 2005;95:1–30. 44 Cavagna GA, Franzetti P, Fuchimoto T. The mechanics of walking in children. J Physiol. 1983;343:323–339. 45 Holt KG, Saltzman E, Ho CL, et al. Discovery of the pendulum and spring dynamics in the early stages of walking. J Mot Behav. 2006;38:206 –218.

January 2009

Research Report

Lower-Extremity Strength Differences Predict Activity Limitations in People With Chronic Stroke Patricia Kluding, Byron Gajewski

Background. Body system impairments following stroke have a complex relationship with functional activities. Although gait and balance deficits are welldocumented in people after stroke, the overlapping influence of body impairments makes it difficult to prioritize interventions.

Objective. This study examined the relationship between prospectively selected measures of body function and structure (body mass index, muscle strength, sensation, and cognition) and activity (gait speed, gait endurance, and functional balance) in people with chronic stroke.

Design. This was a cross-sectional, observational study. Methods. Twenty-six individuals with mean (SD) age of 57.6 (11) years and time after stroke of 45.4 (43) months participated. Four variables (body mass index, muscle strength difference between the lower extremities, sensation difference between the lower extremities, and Mini-Mental Status Exam score) were entered into linear regression models for gait speed, Six-Minute Walk Test distance, and Berg Balance Scale score.

P Kluding, PT, PhD, is Assistant Professor, Department of Physical Therapy and Rehabilitation Science, School of Allied Health, University of Kansas Medical Center, 3056 Robinson Hall, Mailstop 2002, 3901 Rainbow Blvd, Kansas City, KS 66160 (USA). Address all correspondence to Dr Kluding at: [email protected]. B Gajewski, PhD, is Associate Professor, Department of Biostatistics, Schools of Medicine and Nursing, University of Kansas Medical Center. [Kluding P, Gajewski B. Lowerextremity strength differences predict activity limitations in people with chronic stroke. Phys Ther. 2009;89:73– 81.] © 2009 American Physical Therapy Association

Results. Lower-extremity strength difference was a significant individual predictor for gait speed, gait endurance, and functional balance. Cognition significantly predicted only gait speed. Limitations. The authors did not include all possible factors in the model that may have influenced gait and balance in these individuals.

Conclusions. Strength deficits in the hemiparetic lower extremity should be an important target for clinical interventions to improve function in people with chronic stroke.

Post a Rapid Response or find The Bottom Line: www.ptjournal.org January 2009

Volume 89

Number 1

Physical Therapy f

73

Predicting Activity Limitations in Chronic Stroke

T

he consequences of stroke can be understood in the context of the International Classification of Functioning, Disability and Health (ICF) model.1,2 In this model, health condition represents both healthy body systems and disorders or disease. This concept includes the damage that occurs in the brain tissue as a result of an ischemic blockage or hemorrhagic stroke, as well as other comorbidities. This damage often affects performance at the level of body function and structures in the ICF model, including motor weakness in a hemiparetic pattern, hypertonicity, impaired motor control, sensory loss, decreased cognition, and the effects of deconditioning.3 Together, these problems in body function and structures interact to produce problems with execution of tasks, classified as activity in the ICF model. Activities such as walking and functional balance ability influence a person’s participation or ability to partake fully in life situations in the complete environment.1 Mobility is one of the subdomains of activity and participation in the ICF model that is of specific concern to physical therapists.1 Gait deficits in people who have had a stroke are well-documented and include both decreased walking speed4,5 and decreased walking endurance.6 Standing balance also can be affected by a stroke and may influence functional mobility and increase the risk for falling.7 The overlapping influence of impairments in different body systems following a stroke makes it difficult to identify interventions and determine the prognosis for improvements in function. Previous research has examined the influence of various impairments on gait speed, gait endurance, and balance in people with chronic stroke, as summarized below. Gait speed has been found to be a strong determinant of community 74

f

Physical Therapy

Volume 89

mobility. One study showed that 39.3% of people living at home after a stroke were not able to walk to shopping venues or other places of interest in the community,4 and gait speed has been found to discriminate among self-reported levels of community ambulation.4,5 Several researchers8 –11 have found correlations among measures of muscle strength (force-generating capacity), balance, daily ambulatory activity, aerobic fitness, hypertonicity, and lower-extremity motor control with short-distance (7–10 m) walking speed in people who have survived a stroke. Regression models have identified several variables that may explain the amount of variation in gait speed in people with stroke. These factors include muscle strength of individual muscle groups in the paretic limb,12–14 muscle power of the nonparetic knee extensors,12 sensation,14 self-efficacy,13 and sex.13 The Six-Minute Walk Test (6MWT) is a standardized test of walking endurance that can be used as a test of submaximal exercise capacity in people with stroke.6 Reference equations for 6MWT distance in elderly people who are healthy have been established based on sex, body mass index (BMI), and age.15,16 In people with stroke, predictive factors include knee extension strength of the paretic leg, hypertonicity, balance, fast-paced gait speed, and aerobic fitness.9,17,18 Measures of strength in other muscle groups, level of motor recovery, sensation, or cognition have not been reported in a regression model for prediction of 6MWT distance in people with stroke. In addition to impaired gait mobility, people may have decreased functional balance following a stroke, as measured by the Berg Balance Scale (BBS).19 –21 Measurements of walking speed, aerobic fitness, daily ambulatory activity, and cognitive status have been found to correlate with

Number 1

BBS scores in people with chronic stroke.7,10 Some researchers have evaluated BBS scores in a regression analysis as a potential predictor for falls or gait function,7,10 but limited information is available on what factors may predict BBS score as an indicator of functional balance. These studies have consistently found that individual measures of lower-extremity strength are important predictors of function following stroke, although a measure of overall hemiparetic leg weakness in comparison with the strong side has not been evaluated. There is some evidence that measures of general strength deficits in the lower limb are more closely related to functional outcome than measures of individual muscle function,22–24 although none of these studies used regression analysis. Furthermore, although there is some indication that BMI, sensation, and cognition may be important, these measures have not been assessed as potential predictors of function in people with stroke. It is important to identify which impairments in body function and structures are the strongest contributors to functional loss for people with chronic stroke in order to provide an appropriately targeted intervention. Although formal rehabilitation, in our current health care system, commonly ends after the first few months following a stroke, recent research has indicated that intense practice opportunities (eg, several hours per day for 2 weeks) can induce functional recovery25–29 and can even induce neural changes in people who had a stroke years previously.30 The purpose of this study was to examine the relationship between prospectively selected measures of body function and structure (BMI, muscle strength, sensation, and cognition) and activity (gait speed, gait endurance, and functional balance) in people with January 2009

Predicting Activity Limitations in Chronic Stroke Table 1. Participant Characteristics and Activity-Level Measuresa

Age (y)

Time Since Stroke (mo)

1

56

11

Male

Left

2

63

36

Male

Right

3

68

36

Male

Right

18

4

45

28

Female

Right

5

50

12

Male

Right

6

55

10

Male

Left

7

55

32

Male

Right

8

79

52

9

58

168

10

54

32

Male

11

70

31

Female

12

52

58

Male

13

52

140

Female

14

73

16

Female

Left

15

34

20

Female

Left

16

36

45

Female

17

63

16

Female

18

47

15

19

70

40

20

58

11

Male

Right

18

570

6

55

21

50

28

Female

Left

29

104

26

44

22

64

108

Male

Right

25

213

13

36

23

57

18

Male

Left

27

183

14

47

24

75

48

Male

Left

27

76

20

42

25

56

132

Female

Left

29

351

9

53

Male

Left

Participant No.

a

26

58

38

Mean (SD)

57.6 (11)

45.4 (42.8)

Sex

Affected Side of Body

MMSE Score

6MWT Distance (m)

10-m Walk Time (s)

BBS Score

26

160

21

28

159

39

34

152

24

44

27

221

14

54

26

91

22

35

259

12

49

64

48

33

32

14

Male

Right

23

Female

Right

23

137

43

Left

28

100

25

Left

18

9

60

7

Right

21

244

13

48

Right

24

259

16

45

27

85

30

20

29

344

9

53

Left

30

219

14

52

Right

25

116

24

50

Female

Left

30

107

21

44

Female

Right

25

479

7

51

30

358

8

54

24.96 (4.4)

202.4 (134.3)

21.1 (13.1)

42.5 (11.8)

MMSE⫽Mini-Mental Status Exam, 6MWT distance⫽distance covered during the Six-Minute Walk Test, BBS⫽Berg Balance Scale.

chronic stroke. We hypothesized that differences in these body function and structure measurements would predict measurements of activity in a linear regression model.

Method An institutionally approved informed consent form was signed by all individuals prior to their participation in this study. All testing was performed in a single session for each participant, with rests provided during the testing as requested by the participants. January 2009

Participants A convenience sample of 26 people with chronic stroke was recruited for this study from a local stroke support organization. Volunteers were included in this study if they had a chronic stroke (at least 6 months prior to the study) and were able to transfer from a sitting position to a standing position and walk 9.1 m (30 ft) without assistance. A description of participant characteristics (54% male, 50% right-side stroke) and activity-level measurements are provided in Table 1.

Body Function and Structure Measurements Four measures of body function or structure were prospectively selected to be included in the regression model as potential predictors of gait and balance function: (1) BMI, (2) difference in muscle strength between the lower extremities, (3) difference in sensation between the lower extremities, and (4) cognition. These measures were selected because, although previous research7,12–15 suggests that these

Volume 89

Number 1

Physical Therapy f

75

Predicting Activity Limitations in Chronic Stroke Table 2. Summary of Muscle Strength Testing Procedures Using a Handheld Dynamometer and Reliability Correlation Coefficients (N⫽26) Muscle Group

a

Testing Position

Dynamometer Placement

Reliability Coefficienta

Hip flexors

Sitting, knees at 90° of flexion, shank vertical to floor, thigh raised 10° off seat

Front thigh just proximal to knee joint

Less-affected side: .93 More-affected side: .98

Knee extensors

Sitting, hips and knees at 90° of flexion, shank vertical to floor, heel slightly off floor

Anterior shank just proximal to ankle

Less-affected side: .94 More-affected side: .98

Knee flexors

Sitting, hips and knees at 90° of flexion, shank vertical to floor, heel slightly off floor

Posterior shank just proximal to ankle

Less-affected side: .85 More-affected side: .98

Ankle dorsiflexors

Sitting, hips and knees at 90° of flexion, shank vertical to floor, heel touching floor

Dorsal surface of the foot, proximal to the first metatarsophalangeal joint

Less-affected side: .95 More-affected side: .98

Hip abductors

Supine, hips and knees straight and in neutral rotation

Lateral aspect of thigh proximal to knee joint

Less-affected side: .97 More-affected side: .94

Intraclass correlation coefficient (3,1) was used to calculate reliability of 2 strength measurements.

may be important variables, they have not been fully investigated with prediction models in people with stroke. BMI. Body weight (in pounds) was measured using a portable scale, and height (in inches) was measured using a tape measure taped to a wall. Pounds and inches were converted to kilograms and meters. Body mass index was calculated using the equation: weight (kg)/[height (m)]2.31 Muscle strength. Five major muscle groups in the bilateral lower extremities were tested using a handheld dynamometer (MicroFET*): hip flexors, hip abductors, knee flexors, knee extensors, and ankle dorsiflexors. The force pad of the dynamometer was held perpendicular to the limb segment, and participants were instructed to push against the dynamometer with maximal force for a count of 5. The desired movement was demonstrated to the participants, and their understanding was confirmed before starting. The lessaffected lower limb was tested first, followed by the more-affected limb. Each muscle group was tested twice, and the average was used for analysis. Reliability for this type of * Hoggan Health Industries, 8020 S 1300 West, West Jordon, UT 84088.

76

f

Physical Therapy

Volume 89

that of the less-affected side to give an indication of the difference in strength between the 2 sides.

dynamometer has been established previously,32,33 but we assessed the test-retest reliability for these individuals with stroke using our procedures. Each participant was tested twice within each session, with a short rest between tests. One primary tester (PK) performed the majority of strength tests, and she was assisted by 2 other physical therapists. The testing position, dynamometer placement, and reliability coefficient (intraclass correlation coefficient [3,1])34 for each muscle group tested are described in Table 2. A composite strength score for each lower extremity was calculated by adding together strength values for hip flexion, hip abduction, knee extension, knee flexion, and ankle dorsiflexion for each extremity.35,36 The composite value for the moreaffected side was subtracted from

Sensation. A 5.07/10-g SemmesWeinstein monofilament was used to test sensation in both distal lower extremities.37,38 Each participant was positioned supine with shoes and socks removed. A practice trial was given to the participant on the upper extremity of the less-involved side to instruct the participant in the expected sensation. With eyes closed, the participant was instructed to respond “yes” when he or she felt the monofilament pressure on the plantar surface of the foot. Pressure was applied until the filament bent slightly for 2 seconds for a total of 10 repetitions on each foot, alternating between the least-calloused plantar aspect of the first and fifth metatarsals.

Table 3. Descriptive Statistics of Independent Variablesa

Measure Mean SD

a

BMI (kg/m2)

Strength Difference (kg)

Sensation Difference

MMSE

28.96

67.92

2.88

24.96

6.6

59.3

3.2

4.4

Minimum

18.2

⫺26.5

0

14

Maximum

45.1

235.4

10

30

n

26

26

25

24

BMI⫽body mass index, MMSE⫽Mini-Mental Status Exam.

Number 1

January 2009

Predicting Activity Limitations in Chronic Stroke The number of correct responses on each foot was recorded. The difference in sensation between the 2 sides also was calculated by subtracting the number of correct responses out of 10 for the more-affected side from that of the less-affected side. A sensation difference score of 0 indicates no difference between the sides, and a larger number indicates a greater difference. Cognition. The Folstein MiniMental Status Exam (MMSE) was administered to each participant.39 The MMSE is a general screen for dementia and tests orientation, memory, attention, language, and ability to follow instructions. The highest possible score is 30. Activity Measurements Three measures of functional mobility were used, as described below. Gait speed. Self-selected walking speed was measured by having the participants walk at a comfortable pace over a 10-m distance. Participants were permitted to use any assistive devices or orthoses they preferred. Time (in seconds) was measured with a stopwatch, and the average time for 2 trials was recorded. Gait endurance. The 6MWT was used as a measure of walking endurance, using a 30.48-m (100-ft) walkway. Participants were instructed to cover as much ground as possible during the 6 minutes and were permitted to stop and rest, if needed. They were permitted to use their typical assistive devices or orthoses. Standardized encouragement (eg, “You are doing well, keep up the good work.”) was provided to each participant at 1-minute intervals. If the participant requested a rest, the timer was not stopped during the rest, and standardized statements (eg, “It has been ___ minutes. Rest as long as you need to, and let me know when we can get started again.”) January 2009

were read to the participant. Total distance walked (in meters) was recorded. Functional balance. The BBS was used as a measure of balance.19 On the BBS, performance of each of 14 items, ranging in difficulty from sitting unsupported to standing on one foot, is rated on a 4-point scale, for a maximum possible score of 56. Data Analysis We used SPSS 15.0 for Windows† for analysis of all data. Histograms for each variable were analyzed for normal distributions, and scatterplots were analyzed for outlying scores. Correlations among variables were calculated with the Pearson correlation coefficient. Linear regression models with 4 predictors (BMI, strength difference, sensation difference, and MMSE) were calculated for 10-m walk time, 6MWT distance, and BBS scores. The validity of each model was assessed through analysis of colinearity statistics (variance inflation factor) and Q-Q plots of unstandardized residuals, as well as Cook’s distance (influence points) values for each participant. Data for participants with any missing data were not entered into the regression analysis (case deletion). A .05 level of significance was used for all statistical tests. Role of the Funding Source This study was not funded.

Results Descriptive Statistics and Correlations Twenty-one of the 26 participants completed all of the testing. Five participants did not complete the full assessment because of time constraints, and only the values of the tests that were completed were entered into the analysis. The values for † SPSS Inc, 233 S Wacker Dr, Chicago, IL 60606.

each of the independent variables are presented in Table 3. Significant correlations were noted among several of the variables, as noted in Table 4. With regard to the relationship between activity limitations and body function impairments, gait speed (10-m walk time) was significantly correlated with strength difference and MMSE, gait endurance (6MWT distance) was significantly correlated with strength difference, and balance (BBS) was significantly correlated with strength difference. Gait Speed The result of the linear regression model for the 10-m walk time with 4 variables (BMI, strength difference, sensation difference, and MMSE) was statistically significant, with strength difference and MMSE score as significant individual factors. The sensation difference variable approached significance (P⫽.06) in this model. The result of this model is presented in Table 5. Gait Endurance The linear regression model for the 6MWT distance with 4 variables (BMI, strength difference, sensation difference, and MMSE) was not significant, but strength difference was significant as an independent factor (Tab. 5). Functional Balance The linear regression model for the BBS score with 4 variables (BMI, strength difference, sensation difference, and MMSE) approached significance (P⫽.06), with strength difference as a significant independent factor. Difference in sensation did approach significance in this model (P⫽.06).

Discussion and Conclusions The difference in strength between the lower extremities and mental status (MMSE) were found to be significantly correlated to gait speed (10-m walk time), and both factors were

Volume 89

Number 1

Physical Therapy f

77

Predicting Activity Limitations in Chronic Stroke Table 4. Pearson Correlation Among Variablesa

Variable BMI

c

MMSE Score

6MWT Distance (m)

10-m Walk Time (s)

.20

1.00

⫺.30

.09

MMSE score

.08

⫺.12

⫺.09

1.00

10-m walk distance

.22

.50b

⫺.10

⫺.51b

1.00

6MWT distance

⫺.19

⫺.48b

.07

.06

⫺.74c

BBS score

⫺.12

⫺.51c

.18

.34

⫺.83c

Sensation difference

b

Sensation Difference

BBS Score

1.00

Strength difference

a

Strength Difference (kg)

BMI (kg/m2)

1.00

1.00 .67c

1.00

BMI⫽body mass index, MMSE⫽Mini-Mental Status Exam, 6MWT⫽Six-Minute Walk Test, BBS⫽Berg Balance Scale. P ⱕ .05. P ⱕ .01.

significant individual predictors of gait speed in our regression model. The relationship between lowerextremity strength and gait speed is supported by previous studies that examined this relationship with the strength and power of individual muscle groups.12–14 In these studies, strength or power of the paretic knee extensors,12,13 hip flexors and plantar flexors,14 and the nonparetic knee extensors12 were found to predict gait speed in people with stroke. The different muscles identified in each of these studies may be partially explained by the strong relationship in weakness among muscle groups in an individual participant. The likely correlation among strength val-

ues for individual muscle groups may have influenced the regression models. Furthermore, none of these previous studies used values that indicated the magnitude of interlimb differences in muscle strength. Our study showed that a single measure that was intended to capture the weakness in the entire lower limb compared with the nonparetic lower extremity was a strong independent predictor of gait speed after stroke. The influence of mental status (MMSE) on gait speed has not been reported previously for people with stroke. However, various measures of mental status (ie, the MMSE, a depression symptom score, and mea-

sures of positive and negative affect and mood) have been found to predict 6MWT distance in elder people who were healthy.40,41 Our study included participants with a wide range of MMSE scores, with several of the participants scoring below 24, which indicates risk of dementia42 but which also may have been due to the presence of aphasia. We are fairly confident that even participants with low MMSE scores were able to follow the very simple instructions for the gait speed tests (ie, walk at a comfortable pace). The MMSE is used primarily as a screening measure for dementia, and its usefulness to ascertain overall mental status is limited. Furthermore, the

Table 5. Adjusted R2 Values for Gait Speed (10-m Walk Distance), Gait Endurance (Six-Minute Walk Test [6MWT] Score), and Balance (Berg Balance Scale [BBS] Score) and Weights (B), Probability Values, and Confidence Intervals (CI) for Significant Predictors of Body Mass Index (BMI), Strength Difference, Sensation Difference, and Mini-Mental Status Exam Score Measure Adjusted R2

6MWT Distance

BBS Score

.442

.085

.261

F

5.36

1.51

2.85

P

.01

.24

.06

Independent Variable

78

10-m Walk Time

B

P

BMI

0.1

.38

Strength difference

0.1

.01

Sensation difference

⫺1.2

.06

MMSE score

⫺1.4

.005

f

Physical Therapy

Volume 89

Number 1

CI

0.02, 0.2

⫺2.4, ⫺0.4

B

P

⫺0.5

.45

⫺1.1

.02

CI

⫺2.1, ⫺0.1

B

P

0.2

.31

⫺0.1

.01

6.44

.26

1.3

.06

⫺0.001

.5

0.7

.11

CI

⫺0.2, ⫺0.01

January 2009

Predicting Activity Limitations in Chronic Stroke difficulty in distinguishing cognitive deficits from communication deficits in this population may complicate the interpretation of our findings. Future work should screen for aphasia and include more-comprehensive cognitive and psychological assessments to determine the true nature of the relationship between gait speed and mental status in people with stroke. The difference in strength between the lower extremities was found to be significantly correlated with gait endurance (6MWT distance). Although the overall regression model for gait endurance was not significant, a 1-sided test was used to assess the individual predictors, which revealed a significant relationship for strength difference. Previous researchers9,17 have found paretic knee extension strength to be a significant predictor in regression models of gait endurance in people with stroke. Improvements in motor recovery (Fugl-Meyer test score) also have been found to predict improvements in gait endurance over a 3-month period in people who are higher functioning following subacute stroke.43 The strength difference between the lower extremities correlated with balance (BBS) and was found to be a significant individual predictor for BBS score. The difference in lowerextremity sensation approached significance as a predictor of functional balance as well as gait speed. However, the sensation variable did not demonstrate strong or significant correlations with any of these measures. The influence of sensation and strength on predicting BBS score in people with stroke has not been reported previously. Our model included 4 independent variables that we hypothesized would influence gait and balance function in people with chronic stroke. Two January 2009

of these independent variables (sensation and strength) were calculated by taking the difference in scores between the 2 lower limbs. An advantage of this difference score is that it may be a valid marker for the construct of hemiparetic severity. This between-limb comparison provides unique insight, as compared with other studies (eg, Pohl et al43) that have utilized single-limb measures (such as Fugl-Meyer test scores) as an indication of hemiparetic severity after stroke. These single-limb scores do not allow for any comparison between sides. One limitation of this approach is the difficultly interpreting this score, as a lower difference score could mean that both limbs were equally weak or lacking in sensation. Several different methods have been reported in the literature for the calculation of strength deficit scores.22,24,44 Measurements of strength difference expressed as a percentage of body weight have been found to be valid,44 although no change in correlation was apparent when comparing strength measurements normalized and not normalized to body weight.22 Other strategies have been used to express strength difference as a ratio or percentage of the strong side or of predicted normal reference values.22,24,44 However, when values are expressed as ratios or percentages, an appreciation of the absolute numbers is lost. For example, a 10% difference could mean any range of values, depending on the baseline strength. The simple subtraction measure used in our study to describe strength deficit is similar to that used in the study by Pohl et al45 to calculate “cost” in comparing 2 different conditions. In calculating the total strength score of each limb, we did not include hip extension because of the difficulty obtaining a standard position for testing hip extension with

the handheld dynamometer. Although other researchers also have excluded hip extension from calculation of composite leg strength scores,36 certainly the inclusion of hip extension might influence the relationship of these scores to functional tasks. Another limitation of our study is that we did not include factors in our regression model that have been shown to correlate with gait and balance function in people with stroke, such as age, hypertonicity, aerobic fitness, self-efficacy, and sex.9,11,13,17 We did not focus on the relationship between balance and gait in this study, although it is likely that balance has an influence on gait function, as previously reported in people with subacute and chronic stroke.10,43 The relationship that we found between the gait and balance measures in our participants may have influenced our regression models. We considered 3 tasks as components of activity using the ICF model: gait speed, gait endurance, and functional balance. Consequently, 3 regressions were fit. Another possible approach for future work would be to expand the database so that activity limitations can be treated as a latent variable. This would allow a structural equation modeling framework to be used in order to promote parsimony (one dependent variable) while reducing measurement error by incorporation of 3 manifest variables. Although our study demonstrated statistical significance with several of the predictors, only moderately strong correlations were found. These suggested modifications to the analysis should further clarify the factors that predict activity limitations. A larger sample size (N⫽100) would be required to take advantage of such an approach. A larger data set also would allow us to include more than 4 independent

Volume 89

Number 1

Physical Therapy f

79

Predicting Activity Limitations in Chronic Stroke variables and test for interactions in the regression analyses. The strong influence of the difference in lower-extremity strength on gait speed, gait endurance, and functional balance indicates that overall strength deficits in the hemiparetic lower extremity should be an important target for clinical interventions. Improvements in measures of isometric torque to make the values between the lower extremities more similar should lead to improvements in function. Several comprehensive rehabilitation approaches have been reported to improve strength of the hemiparetic lower extremity, such as home-based exercise,46 general fitness training,47,48 and task-oriented exercise.49 Investigating whether strength training alone can improve muscle strength and function would be an important area of future research. The potential impact of cognitive status on gait function also is an interesting area to explore further. Dr Kluding provided concept/idea/research design, writing, data collection, and project management. Dr Gajewski provided consultation (including review of manuscript before submission). Both authors provided data analysis. The authors thank the American Stroke Foundation for their assistance with recruitment and for use of their facilities for data collection. This study was approved by the Human Subjects Committee of the University of Kansas Medical Center. This article was received August 15, 2007, and was accepted September 14, 2008. DOI: 10.2522/ptj.20070234

References 1 World Health Organization. International Classification of Functioning, Disability and Health; 2002. Available at: http:// www.who.int/classifications/icf/en/. Accessed February 23, 2008. 2 Jette AM. Toward a common language for function, disability, and health. Phys Ther. 2006;86:726 –734.

80

f

Physical Therapy

Volume 89

3 Duncan PW, Zorowitz R, Bates B, et al. Management of adult stroke rehabilitation care: a clinical practice guideline. Stroke. 2005;36:e100 – e143. 4 Lord SE, McPherson K, McNaughton HK, et al. Community ambulation after stroke: how important and obtainable is it and what measures appear predictive? Arch Phys Med Rehabil. 2004;85:234 –239. 5 Perry J, Garrett M, Gronley JK, Mulroy S. Classification of walking handicap in the stroke population. Stroke. 1995;26: 982– 989. 6 Eng JJ, Dawson AS, Chu KS. Submaximal exercise in persons with stroke: test-retest reliability and concurrent validity with maximal oxygen consumption. Arch Phys Med Rehabil. 2004;85:113–118. 7 Harris JE, Eng JJ, Marigold DS, et al. Relationship of balance and mobility to fall incidence in people with chronic stroke. Phys Ther. 2005;85:150 –158. 8 Kelly JO, Kilbreath SL, Davis GM, et al. Cardiorespiratory fitness and walking ability in subacute stroke patients. Arch Phys Med Rehabil. 2003;84:1780 –1785. 9 Patterson SL, Forrester LW, Rodgers MM, et al. Determinants of walking function after stroke: differences by deficit severity. Arch Phys Med Rehabil. 2007;88:115– 119. 10 Michael KM, Allen JK, Macko RF. Reduced ambulatory activity after stroke: the role of balance, gait, and cardiovascular fitness. Arch Phys Med Rehabil. 2005;86:1552– 1556. 11 Eng JJ, Chu KS, Dawson AS, et al. Functional walk tests in individuals with stroke: relation to perceived exertion and myocardial exertion. Stroke. 2002;33:756 –761. 12 Bohannon RW, Walsh S. Nature, reliability, and predictive value of muscle performance measures in patients with hemiparesis following stroke. Arch Phys Med Rehabil. 1992;73:721–725. 13 LeBrasseur N, Sayers S, Ouellette M, Fielding R. Muscle impairments and behavioral factors mediate functional limitations and disability following stroke. Phys Ther. 2006;86:1342–1350. 14 Nadeau S, Arsenault A, Gravel D, Bourbonnais D. Analysis of the clinical factors determining natural and maximal gait speeds in adults with stroke. Am J Phys Med Rehabil. 1999;78:123–130. 15 Enright PL, Sherrill DL. Reference equations for the six-minute walk in healthy adults. Am J Resp Critical Care Med. 1998;158:1384 –1387. 16 Poh H, Eastwood PR, Cecins NM, et al. Six-minute walk distance in healthy Singaporean adults cannot be predicted using reference equations derived from Caucasian populations. Respirology. 2006;11: 211–216. 17 Pang MYC, Eng JJ, Dawson AS. Relationship between ambulatory capacity and cardiorespiratory fitness in chronic stroke: influence of stroke-specific impairments. Chest. 2005;127:495–501.

Number 1

18 Tang A, Sibley KM, Bayley MT, et al. Do functional walk tests reflect cardiorespiratory fitness in sub-acute stroke? J NeuroEng Rehabil. 2006;3:23. 19 Berg K, Wood-Dauphine´e SL, Williams JI. The Balance Scale: reliability assessment with elderly residents and patients with an acute stroke. Scand J Rehabil Med. 1995;27:27–36. 20 Smith PS, Hembree JA, Thompson ME. Berg Balance Scale and functional reach: determining the best clinical tool for individuals post acute stroke. Clin Rehabil. 2004;18:811– 818. 21 Mackintosh SFH, Hill K, Dodd KJ, et al. Falls and injury prevention should be part of every stroke rehabilitation plan. Clin Rehabil. 2005;19:441– 451. 22 Bohannon RW. Strength deficits also predict gait performance in patients with stroke. Percept Mot Skills. 1991;73:146. 23 Bohannon RW, Andrews AW. Relationships between impairments in strength of limb muscle actions following stroke. Percept Mot Skills. 1998;87:1327–1330. 24 Boissy P, Bourbonnais D, Carlotti MM, et al. Maximal grip force in chronic stroke subjects and its relationship to global upper extremity function. Clin Rehabil. 1999;13:354 –362. 25 Taub E, Wolf SL. Constraint-induced movement techniques to facilitate upper extremity use in stroke patients. Top Stroke Rehabil. 1997;3:38 – 61. 26 Wolf SL, Winstein CJ, Miller JP, et al. Effect of constraint-induced movement therapy on upper extremity function 3 to 9 months after stroke: The EXCITE randomized clinical trial. JAMA. 2006;296:2095–2104. 27 Macko RF, Ivey FM, Forrester LW, et al. Treadmill exercise rehabilitation improves ambulatory function and cardiovascular fitness in patients with chronic stroke: a randomized, controlled trial. Stroke. 2005;36:2206 –2211. 28 Sullivan KJ, Knowlton BJ, Dobkin BH. Step training with body weight support: effect of treadmill speed and practice paradigms on poststroke locomotor recovery. Arch Phys Med Rehabil. 2002;83:683– 691. 29 Miller EW, Quinn ME, Seddon PG. Body weight support treadmill and overground ambulation training for two patients with chronic disability secondary to stroke. Phys Ther. 2002;82:53– 61. 30 Liepert J, Bauder H, Wolfgang HR, et al. Treatment induced cortical reorganization after stroke in humans. Stroke. 2000;31: 1210 –1216. 31 Centers for Disease Control and Prevention. BMI—Body Mass Index: About BMI for Adults. Available at: http://www.cdc. gov/nccdphp/dnpa/bmi/adult_BMI/about_ adult_BMI.htm. Accessed March 2, 2007. 32 Li RC, Jasiewicz JM, Middleton J, et al. The development, validity, and reliability of a manual muscle testing device with integrated limb position sensors. Arch Phys Med Rehabil. 2006;87:411– 417. 33 Bohannon RW. Measuring knee extensor muscle strength. Am J Phys Med Rehabil. 2001;80:13–18.

January 2009

Predicting Activity Limitations in Chronic Stroke 34 Portney L, Watkins MP. Foundations of Clinical Research: Applications to Practice. 2nd ed. Upper Saddle River, NJ: Prentice Hall Health; 2000. 35 Sullivan KJ, Brown DA, Klassen T, et al. Effects of task-specific locomotor and strength training in adults who were ambulatory after stroke: results of the STEPS randomized clinical trial. Phys Ther. 2007;87:1580 –1602. 36 Andrews AW, Bohannon RW. Discharge function and length of stay for patients with stroke are predicted by lower extremity muscle force on admission to rehabilitation. Neurorehabil Neural Repair. 2001;15:93–97. 37 Rahman M, Griffin SJ, Rathmann W, Wareham NJ. How should peripheral neuropathy be assessed in people with diabetes in primary care? A population-based comparison of four measures. Diabet Med. 2003;20:368. 38 Perkins BA, Zinman B, Olaleye D, Bril V. Simple screening tests for peripheral neuropathy in the diabetes clinic. Diabet Care. 2001;24:250.

January 2009

39 Jackson JE, Ramsdell JW. Use of the MMSE to screen for dementia in elderly outpatients. J Am Geriatr Soc. 1988;36:662. 40 Lord SR, Menz HB. Physiologic, psychologic, and health predictors of 6-minute walk performance in older people. Arch Phys Med Rehabil. 2002;83:907–911. 41 Enright PL, McBurnie MA, Bittner V, et al. The 6-min walk test: a quick measure of functional status in elderly adults. Chest. 2003;123:387–398. 42 Brodaty H, Low LF, Gibson L, Burns K. What is the best dementia screening instrument for general practitioners to use? Am J Geri Psych. 2006;14:391– 400. 43 Pohl PS, Perera S, Duncan PW, et al. Gains in distance walking in a 3-month follow-up post stroke: what changes? Neurorehabil Neural Repair. 2004;18:30. 44 Hsu AL, Tang PF, Jan MH. Test-retest reliability of isokinetic muscle strength of the lower extremities in patients with stroke. Arch Phys Med Rehabil. 2002;83:1130 – 1137. 45 Pohl PS, McDowd JM, Filion D, et al. Task switching after stroke. Phys Ther. 2007;87:66 –76.

46 Duncan PW, Studenski S, Richards L, et al. Randomized clinical trial of therapeutic exercise in subacute stroke. Stroke. 2003;34:2173–2180. 47 Pang MYC, Harris JE, Eng JJ. A communitybased upper-extremity group exercise program improves motor function and performance of functional activities in chronic stroke: a randomized controlled trial. Arch Phys Med Rehabil. 2006;87: 1–9. 48 Teixeira-Salmela L, Olney S, Nadeau S, Brouwer B. Muscle strengthening and physical conditioning to reduce impairment and disability in chronic stroke survivors. Arch Phys Med Rehabil. 1999;80: 1211–1218. 49 Yang Y, Wang R, Lin K, et al. Task-oriented progressive resistance strength training improves muscle strength and functional performance in individuals with stroke. Clin Rehabil. 2006;20:860 – 870.

Volume 89

Number 1

Physical Therapy f

81

Case Report Physical Therapist Management of Acute and Chronic Low Back Pain Using the World Health Organization’s International Classification of Functioning, Disability and Health Sean D Rundell, Todd E Davenport, Tracey Wagner SD Rundell, PT, DPT, OCS, is Physical Therapist, Portland Sports Medicine and Spine Physical Therapy, 1610 SE Glenwood St, Portland, OR 97202 (USA). Address all correspondence to Dr Rundell at: [email protected]. TE Davenport, PT, DPT, OCS, is Assistant Professor, Department of Physical Therapy, Thomas J. Long School of Pharmacy and Health Sciences, University of the Pacific, Stockton, California, and Clinical Specialist, Department of Physical Medicine and Rehabilitation, Kaiser Permanente Woodland Hills Medical Center, Woodland Hills, California. T Wagner, PT, MPT, OCS, is Clinical Specialist, Department of Physical Medicine and Rehabilitation, Kaiser Permanente Woodland Hills Medical Center, and Clinical Mentor, Residency in Orthopaedic Physical Therapy, Kaiser Permanente Southern California. [Rundell SD, Davenport TE, Wagner T. Physical therapist management of acute and chronic low back pain using the World Health Organization’s International Classification of Functioning, Disability and Health. Phys Ther. 2009;89: 82–90.] © 2009 American Physical Therapy Association

Background and Purpose. The World Health Organization’s Classification of Functioning, Disability and Health (WHO-ICF) model was developed to describe, classify, and measure function in health care practice and research. Recently, this model has been promoted as a successor to the Nagi model by some authors in the physical therapy literature. However, conceptual work in demonstrating use of the WHO-ICF model in physical therapist management of individual patients remains sparse. The purpose of this case report series is to demonstrate the application of the WHO-ICF model in clinical reasoning and physical therapist management of acute and chronic low back pain. Case Description. Two patients, 1 with acute low back pain and 1 with chronic low back pain, were treated pragmatically using the WHO-ICF model and other applicable models of clinical reasoning. Intervention. Manual therapy, exercise, and education interventions were directed toward relevant body structure and function impairments, activity limitations, and contextual factors based on their hypothesized contribution to functioning and disability.

Outcome. Both patients demonstrated clinically significant improvements in measures of pain, disability, and psychosocial factors after 3 weeks and 10 weeks of intervention, respectively.

Discussion. The WHO-ICF model appears to provide an effective framework for physical therapists to better understand each person’s experience with his or her disablement and assists in prioritizing treatment selection. The explicit acknowledgment of personal and environmental factors aids in addressing potential barriers. The WHO-ICF model integrates well with other models of practice such as Sackett’s principles of evidence-based practice, the rehabilitation cycle, and Edwards and colleagues’ clinical reasoning model. Future research should examine outcomes associated with the use of the WHO-ICF model using adequately designed clinical trials.

Post a Rapid Response or find The Bottom Line: www.ptjournal.org 82

f

Physical Therapy

Volume 89

Number 1

January 2009

Low Back Pain and the WHO-ICF Model

L

ow back pain (LBP) is among the most ubiquitous and expensive health conditions affecting the developed world.1– 4 Low back pain also is among the most common musculoskeletal conditions treated by physical therapists.5 As a complex biopsychosocial phenomenon, the application of the medical model to describe LBP has challenged the identification of optimal treatments. Disability models provide useful patient-centered schema that assist clinicians in understanding the influences and relationships among LBP, its hypothetical contributing factors, and its resultant disability. Disablement models such as the Nagi model can help a clinician evaluate and prioritize the components that may be most responsive to interventions to reduce disability,6,7 and they can be helpful in determining needs, matching interventions to health states, and evaluating outcomes.8,9 The World Health Organization’s International Classification of Functioning, Disability and Health (WHO-ICF) model was developed to simplify the process of describing, classifying, and measuring function and health. It provides a method that considers biological, individual, and social contributions that can be used across clinical practice and research. The WHO-ICF model has 2 main components (Fig. 1). The first part is functioning and disability, which is further divided into body functions and structures, activities, and participation. Body functions and structures are assessed in terms of change in physiological function and anatomical structure. Activity is the execution of a task or action, and participation is defined as involvement in life affairs. Functioning is the positive aspect of these components, and disability is the negative aspect. Each component can be broken down into categories relating to functioning and disability. The second main component of the January 2009

Figure 1. World Health Organization’s International Classification of Functioning, Disability and Health model.

WHO-ICF model includes a classification system to further describe environmental and personal contextual factors that can influence functioning and disability.10 The WHO-ICF model is thought to retain certain advantages over the Nagi model. First, the WHO-ICF model explicitly acknowledges bidirectional relationships among domains of function and contextual factors. In addition, the WHO-ICF model’s description of contextual factors would appear to reinforce physical therapists’ consideration of patients’ affective, social, and environmental factors that contribute to the physical therapist’s prognosis. These advantages have contributed to the WHO-ICF model being advocated in the physical therapy literature11,12 as a potential successor to

the Nagi model. The WHO-ICF model already has been applied to describe certain chronic conditions, such as LBP, in order to derive “core sets” and “brief core sets” that use consistent language.8,13 However, the WHO-ICF model’s usefulness to clinical reasoning in individual patient cases remains unclear. The purpose of this case report series is to demonstrate the use of the WHO-ICF framework in the management of acute and chronic LBP.

Patient 1 (Chronic LBP) History The patient was a 53-year-old woman with a chief concern of a 28-year history of LBP. She reported an insidious onset of symptoms that had progressively worsened and had become constant during the last 3 years. Pain intensity, as measured

Volume 89

Number 1

Physical Therapy f

83

Low Back Pain and the WHO-ICF Model with a numeric pain rating scale,14 –16 was 5/10 at intake, 10/10 at worst, and 3/10 at best. Lifting, bending forward, and sitting for 15 to 20 minutes aggravated symptoms. The patient described the symptoms as variable from day to day, but typically worse at the end of the day. She estimated her sleep was interrupted by 50% because of her LBP. Symptoms eased with heat, massage, and over-the-counter ibuprofen. Associated symptoms included an intermittent ache along the paraspinal musculature and an intermittent ache to throbbing pain radiating from the lateral hips to the anterior thighs. She also reported occasional bilateral numbness of the entire foot at night and upon waking. The patient reported having no saddle paresthesia, change in bowel and bladder function, or generalized weakness or incoordination of her lower extremities.

pressive symptoms; and her FearAvoidance Belief Questionnaire (FABQ)21,22 work subscale score was 2/42, suggesting minimal fearavoidance behavior concerning work activities. However, her FABQ physical activity subscale score was 20/24, indicating high fear-avoidance behavior concerning physical activity outside of work. The Lower Back Activity Confidence Scale (LoBACS)23,24 revealed scores of 49%, 90%, and 100% for the perceived ability to function in activities of daily living and work activities, self-regulate symptoms, and perform therapeutic exercises, respectively.

Other medical history included an appendectomy, tonsillectomy, hysterectomy, hypertension, hypercholesterolemia, and depression. Her depressive symptoms were being treated with bupropion hydrochloride (150 mg twice daily). Other current medications included lisinopril (10 mg once daily) and hydrochlorothiazide (25 mg once daily) for hypertension, metoclopramide (10 mg once daily) for gastroesophageal reflux, and lamotrigine (200 mg once daily) for stabilizing mood. The patient’s work activities included lifting and carrying boxes of files and sitting at a computer. Her hobbies included gardening. The patient’s goals were to garden and perform all work duties with a pain level of ⱕ4/10.

The patient was observed to have decreased lumbar lordosis, posterior pelvic tilt, and forward head in a standing position. Decreased hip extension during terminal stance bilaterally and increased frontal-plane motion of the pelvis during midstance were noted during observational gait assessment. Patellar reflexes were 1⫹ bilaterally, and Achilles reflexes could not be elicited. Myotomal and dermatomal function were normal. Standing lumbar active range of motion (AROM)25 revealed increased left-sided pain with flexion but normal excursion. Extension, right side bending, and left side bending did not reproduce symptoms, although excursion was decreased. Passive range of motion (PROM) during a right straight leg raise (SLR), as measured with bubble inclinometry, was 52 degrees, with reproduction of right gluteal pain, but sensitizing using dorsiflexion was negative. Left SLR was positive at 60 degrees for familiar back pain, and sensitizing with dorsiflexion was positive.

Examination At intake, the patient’s Oswestry Low Back Disability Questionnaire (ODQ)15,17,18 score was 18/50, her Beck Depression Index (BDI)19,20 was 8/63, indicating minimal de-

Hip extension PROM during a Thomas test, as measured using bubble inclinometry with the knee flexed,26 revealed right hip extension lacking 15 degrees and left hip extension lacking 18 degrees. Man-

84

f

Physical Therapy

Volume 89

Number 1

ual muscle tests of the hip revealed bilateral gluteus medius muscle strength (force-generating capacity) was 3/5 and gluteus maximus muscle strength was ⬍3/5.27 Abdominal performance testing, which was conducted as described by Sahrmann,28 showed level 0.3 was the highest level performed correctly, where level 2 indicates adequate strength and control. Hypomobility and reproduction of greater left-sided pain than right-sided pain were noted with posterior-anterior pressures at L4-L5 and L5-S1.29,30 Evaluation Based on the initial examination data, the mediators influencing the patient’s chronic LBP were categorized using the WHO-ICF model (Tab. 1). We hypothesized that hip muscle performance and length impairments observed resulted in poor segmental stabilization and consequent LBP, causing limitations in the activities of lifting and carrying and maintaining body positions. Difficulties with these activities were hypothesized to negatively affect her participation in employment duties and leisure activities. They also were thought to be involved in a cycle that promoted further impaired muscle power functions and reduced joint mobility. Another important hypothesized bidirectional relationship was between the personal factor of her high FABQ physical activity score and her activity limitations. We hypothesized that fear-avoidance beliefs acted as a potential barrier to her physical activities. Conversely, we thought that the pain experienced during these activities reinforced her avoidance beliefs concerning them. The personal factor of low self-efficacy concerning daily living and work activities was thought to be another factor contributing to her activity limitations. Going in the other direction, the pain and limitation with physical activiJanuary 2009

Low Back Pain and the WHO-ICF Model Table 1. The World Health Organization’s International Classification of Functioning, Disability and Health (WHO-ICF) Model Applied to the Evaluation of Patient 1 (Chronic Low Back Pain)a Body Structures and Functions Patient’s perspective

Physical therapist’s perspective

Activities

Participation

●

Pain in back and thighs

●

Lifting

●

Unable to garden

●

Foot numbness

●

Bending

●

Decreased work tolerance

●

Sitting 20 min

●

Interrupted sleep

1. Reduced muscle power functions (b730)

1. Lifting and carrying objects (d430)

1. Remunerative employment (d850)

2. Reduced mobility of joint functions (b710)

2. Maintaining body position (d410)

2. Recreation and leisure (d920)

3. Gait pattern function (b770) Contextual Factors Personal ●

Temperament and personality functions: fear-avoidance behavior for physical activities and perceived ability to function in activities of daily living and work activities

Environmental ●

Design construction and buildings products and technology of buildings for private use (e155)

●

Products and technology for employment (e135)

●

Labor and employment services, systems, and policies (e590)

a

The physical therapist’s perspective includes the ranked WHO-ICF categories within each of the components. Hip muscle performance and length deficits were ranked as the primary body structures and functions to be treated because of their degree of impairment found during the examination. They were hypothesized to result in poor spinal segmental stabilization and consequent low back pain, which principally contributed to the patient’s activity limitations of lifting and carrying and maintaining body positions and her participation restrictions in employment and leisure. The personal contextual factor of fear of physical activity was addressed as a secondary factor that also contributed to activity limitations and participation restrictions.

ties likely reduced her perceived ability to perform them. Her work environment, involving low shelves and filing cabinets, and the distance required to transport files were environmental factors that may have negatively influenced her participation in work duties. Intervention The patient was educated on her physical therapist’s diagnosis, prognosis, and plan of care. She was seen for 4 visits over 10 weeks. Patient education and graded exercise were used to address her avoidance of physical activity. Specifically, she was educated during the initial visit that pain did not signal harm, to maintain a consistent activity pace, and to stay as active as tolerable. This was reinforced during discussions in subsequent visits. Graded exercise consisted of beginning a daily program of walking for 15 minutes and progressing the duration every couJanuary 2009

ple days. To address decreased abdominal muscle power function, she was instructed in supine abdominal drawing-in.28 Quarter squats without allowing knee valgus were prescribed for muscle performance impairments of her hip lateral rotators and abductors, and a hip flexor stretch was prescribed to address her impairment of hip extension. On follow-up visits, interventions focused on contract-relax procedures to the rectus femoris and iliopsoas muscles. Abdominal bracing in a supine position was progressed in intensity to bracing with alternate marching.28 Prone hip extension AROM with knee flexion was added to strengthen the hip extensors, and squatting was progressed in depth and resistance provided. Outcome At 10 weeks, the patient reported that she was able to bend and carry charts at work for a full day without

increased pain. She regularly sat at work for 30 minutes without pain. Her worst pain was reported as 3/10. Her ODQ score was 6/50. Hip flexion with the Thomas test was 6 degrees on the left and 10 degrees on the right. Abdominal strength was graded as level 0.4.28 The patient canceled a follow-up appointment at 14 weeks and subsequently was contacted by telephone. Final questionnaires revealed an ODQ score of 2/50, a BDI of 4/63, an FABQ work subscale score of 0/42, and an FABQ physical activity subscale score of 6/24. The patient’s LoBACS scores were 87%, 100%, and 100% for the functional, self-regulatory, and exercise subscales, respectively. Pain intensity, as measured with a numeric pain rating scale, was 2/10 at worst. The patient global rating of change scale31 revealed a perception of “much improved.”

Volume 89

Number 1

Physical Therapy f

85

Low Back Pain and the WHO-ICF Model

Patient 2 (Acute LBP) History The patient was a 38-year-old female computer programmer. Her chief concern was a 14-day history of intermittent right lumbar “burning and pressure.” The patient’s symptoms were characterized by a sudden onset when standing after sitting for 3 hours at her computer. She rated her symptoms as 8/10 at worst, 0/10 at best, and 5/10 at the time of her examination. Aggravating activities included sitting 2 hours or longer, sleeping supine for 1 hour or longer, jogging longer than 45 minutes, and weight bearing on her right lower extremity. She usually awakened without pain in the morning and experienced her symptoms after sitting at work. Her symptoms continued to worsen throughout the day. She also reported a secondary concern of burning right lateral leg pain that she experienced intermittently during the last year. This pain began insidiously 1 year previously, concurrently with multiple brief episodes of LBP. Her episodic LBP resolved, but the leg pain remained aggravated with jogging, driving or prolonged sitting. At the time of intake, she reported that her leg pain increased as her right LBP increased. Her symptoms eased with changing positions from sitting or supine, using her elliptical machine, and using her abdominal exercise equipment. She slept without disturbance in a side-lying position. The patient stated that her pain intensity had diminished since initial onset. She reported having no numbness or paresthesias in her lower extremities, change in bowel or bladder function, saddle paresthesia, or weakness or incoordination in the lower extremities. Significant medical history included anxiety disorder and depression. Medications included ibuprofen (600 mg 3 times daily, as needed) for pain and inflammation, nortriptyline (600 mg 3 86

f

Physical Therapy

Volume 89

times daily) for depressive symptoms, methylprednisolone (4 mg once daily) for inflammation, fexofenadine (60 mg once daily) for allergies, and norethindrone (35 mg once daily) for contraception. Her work activities were sitting at a computer 8 hours a day, and she had a 1-hour commute to and from work. Her exercise program included jogging, using the elliptical machine, and abdominal curls with a floor-exercise apparatus. The patient’s goal was to sit 5 hours at work unlimited by pain. Examination The patient’s initial Roland-Morris Disability Questionnaire (RMQ)15,18,32 score was 5/24. The RMQ was selected prior to the case due to its sensitivity to change in people with acute LBP.18 The patient’s FABQ scores were 18/42 for the work subscale and 9/24 for the physical activity subscale, indicating low fear-avoidance beliefs. Her LoBACS scores were 86%, 100%, and 90% for the function, self-regulatory, and exercise subscales, respectively. The patient displayed decreased thoracic kyphosis, increased lumbar lordosis, and greater prominence of the right lumbar paraspinal musculature with visual postural assessment. Initial pain in a standing position was 1/10 located at the right lumbar spine and lateral leg. During right single-leg stance, the patient had increased lumbar pain and increased pelvic drop with trunk rotation. Left single-leg stance was pain-free with a level pelvis. Myotomal lower-quarter strength screening revealed the L1-L5 innervated muscles were graded as 5/5 and equal bilaterally. The S1 myotome testing demonstrated 8 unilateral heel-raises on the left and 6 unilateral heel-raises on the right, with right heel-raise performance limited by leg pain rather than weakness. Dermatomal light touch was normal. Patellar and

Number 1

Achilles tendon deep tendon reflex tests were 2⫹ bilaterally. Lumbar AROM revealed flexion was normal and status quo. Extension was limited with increased right lumbar pain at end-range. Left side bending was limited, and her right lumbar pain was worse at end-range. Right side bending was normal and status quo. Prone hip medial (internal) rotation PROM was 56 degrees on the left and 54 degrees on the right, and lateral (external) rotation was 46 degrees on the left and 48 degrees on the right. Straight leg raise was negative with 96 degrees of PROM on the left. Straight leg raise on the right was positive for reproduction of LBP at 88 degrees, and it was unchanged with dorsiflexion sensitizers. Tenderness and restrictions were noted with palpation of the right lumbar paraspinals. The right L5-S1 segment was hypomobile and reproduced her lumbar pain. The left L5-S1 segment was hypomobile and pain-free. The L1–2 through L4 –5 segments had normal mobility, which was painful on the right and pain-free on the left. Evaluation Based on the initial examination data, the mediators influencing the patient’s acute LBP were categorized and ranked above using the ICF model (Tab. 2). The patient met 4 of the 5 criteria that predict success with manipulation in patients with LBP, and she did not have any signs of nerve root compression. Research suggesting she had a 92% chance of a successful outcome with lumbopelvic manipulation prioritized her reduced mobility of joint functions as the primary body function limitation.33 We hypothesized that the reduced mobility of joint function at L5–S1 on the right and the resulting sensations of pain were contributing to her limitations with maintaining body positions and movement. Her limited movement and sensation of pain contributed to her restrictions in regular recreation activities. The January 2009

Low Back Pain and the WHO-ICF Model Table 2. The World Health Organization’s International Classification of Functioning, Disability and Health (WHO-ICF) Model Applied to the Evaluation of Patient 2 (Acute Low Back Pain)a Body Structures and Functions Patient’s perspective

Physical therapist’s perspective

Activities

Participation

●

Pain in back

●

Sitting 2 h

●

Limited exercise program

●

Pain in leg

●

Lying supine 1 h

●

Interruption of work

●

Jogging 45 min

1. Reduced mobility of joint functions (b710)

1. Maintaining body position (d410)

1. Recreation and leisure (d920)

2. Sensation of pain (b280)

2. Moving around (b455)

2. Remunerative employment (d850)

3. Control of voluntary movement functions (b760) 4. Neural tissue provocation Contextual Factors Personal ●

No personal factors were deemed to be barriers as measured by the selected questionnaires

●

Facilitators: activity level and continuation of exercise

Environmental ●

Health professionals (e355)

●

Products and technology for employment (e135)

●

Labor and employment services, systems, and policies (e590)

●

Transportation services, systems, and policies (e590)

a

Mobility of joint functions and sensation of pain were ranked as the primary body functions because the patient met the clinical prediction rule for manipulation. It was hypothesized that these impaired body functions were contributing to her limitations with maintaining body positions and movement, thereby restricting her participation in regular recreational activities. Neural provocation was prioritized next because the slump test reproduced her leg pain. Control of voluntary movement functions was considered to reduce the likelihood of reoccurring episodes of low back pain.

contextual factor of the health care professional’s awareness and application of research evidence was thought to positively mediate her rehabilitation. A significant bidirectional relationship in this case was between the requirement of sitting at a computer for 8 hours for employment and her sensation of pain. Pain limited her ability to maintain this body position, but the duration of sitting required for her work led to increased pain intensity. The patient was given an excellent prognosis due to the strong research evidence for her improvement with manipulation. Intervention The patient received 3 treatment sessions over 23 days. She was educated on her physical therapist’s diagnosis, prognosis, and plan of care. The initial intervention involved a left sideJanuary 2009

lying manipulation technique directed at L5–S1 on the right to improve mobility of joint function and reduce sensation of pain.34 Subsequently, the patient was instructed in a home exercise program of left side lying with right trunk rotation AROM. She was educated on sitting posture and ergonomics for computer use to address the potential environmental barrier of prolonged sitting at a computer for work. During the second visit, the side-lying manipulation was repeated. Further examination revealed a negative SLR, but slump testing was positive for LBP and increased right leg pain. The patient was instructed in a selfadministered AROM exercise in the test position to address the associated reduced nerve mobility and sensation of pain. She was instructed to take a standing break from sitting every hour at work to minimize the

environmental barrier of sitting for work. During visit 2, testing of prone hip extension with knee extended on the right revealed anterior pelvic rotation and right ilium anterior rotation in the transverse plane, indicating a lack of lumbopelvic neuromuscular control. This was the only remaining impaired body function at visit 3. The patient was prescribed prone hip extension stabilization exercise to address this impairment. Outcome Immediate improvement was demonstrated after the initial manipulation, with 0/10 lumbar and leg pain in standing, no pain with lumbar extension AROM, decreased pain with left side-bending AROM, and no pain with right single-leg stance. At the second visit, her right LBP and leg pain were less intense (ie, 2/10 at worst). Extension created right lum-

Volume 89

Number 1

Physical Therapy f

87

Low Back Pain and the WHO-ICF Model bar pain at end-range, and right L5–S1 accessory motion was still painful and hypomobile. She was able to sit 5 hours at work without LBP, and her RMQ score was 1/24. During the final visit, the patient reported no pain since the day of the last treatment. She was working a full day and returned to jogging without pain. Her final RMQ score was 0/24. Her LoBACS scores were 91%, 100%, and 100% for the function, self-regulatory, and exercise subscales, respectively. Her FABQ scores were 5/42 for the work subscale and 4/24 for the physical activity subscale. Re-examination demonstrated normal lumbar AROM, normal and pain-free accessory motion testing, and a negative slump test. The patient was discharged from physical therapy with all goals met.

Discussion The WHO-ICF model is characterized by a bidirectional flow of information rather than hierarchical organization of its domains. This was demonstrated with several hypothesized bidirectional relationships in the 2 cases. The WHO-ICF model appears to provide an effective framework for physical therapists to better understand each person’s experience with his or her disablement and assist in prioritizing treatment selection. It is notable that the health condition identified in this case series was LBP, which is a symptom-based condition rather than a specific, tissue-based pathology.35 The WHOICF model assisted in identifying body structure and function deficits and activity limitations. Interventions directed at these impairments, contextual factors, and limitations addressed the health condition and appeared to affect activity and participation. For example, the hip muscle performance and length deficits observed in the patient with chronic LBP were hypothesized to result in poor segmental stabilization 88

f

Physical Therapy

Volume 89

and consequent LBP. The WHO-ICF model may predict the potential success of physical therapy interventions for other symptom-based health conditions in which a specific, tissue-based pathology is unclear. Patients in this case report series benefited from the WHO-ICF model’s explicit acknowledgment of personal and environmental factors as important contributors to disablement through their interaction with the physical domains. For the patient with chronic LBP, a belief related to avoidance of physical activity was a negative personal factor. Recognizing this negative personal factor allowed the therapist to direct specific educational interventions designed to reduce her fear-avoidance behavior and secondarily her participation restrictions. Environmental factors also played a large role in both cases. In the patient with chronic LBP, the structural setup of her workspace, the use of a computer for work, and the requirements that she transport files contributed to her participation at work. The requirement that the woman with acute LBP sit and work at a computer 8 hours a day for her job greatly played a part in her disability. Existing clinical reasoning models were used concurrently with the organization of function provided by the WHO-ICF model (Fig. 2). For example, Edwards and colleagues’ clinical reasoning model36 was used to organize the appropriate performance of the functions of the physical therapist. A hypothesis was developed from history and physical examination data, the therapist’s knowledge, and the patient’s experience. After the evaluation, the therapist selected the best possible interventions based on research, clinical experience, and patient preference that matched the previously selected components. Reassessment oc-

Number 1

curred by monitoring the effectiveness of the interventions using various outcome assessments from the examination to measure change in activities and participation. Questionnaires with acceptable psychometrics allowed accurate measurement of patient perceptions in order to evaluate and modify the hypotheses developed within the WHO-ICF framework as the rehabilitation cycles continued. In addition to the concept of the rehabilitation cycle, evidence-based practice principles were used to identify the best possible examination, evaluation, and intervention strategies.37 Classifying acute LBP into treatment-based categories based on clinical presentation has been associated with superior outcomes compared with nonmatched treatments.33,38 Clearly, although the WHO-ICF provides a powerful new tool for physical therapists, existing clinical reasoning models may be expected to retain complementary roles in the clinical reasoning process by physical therapists. This case report provided 2 examples of the application of the WHOICF model in patients with LBP. It provides preliminary evidence for the clinical utility of the bidirectional relationships among the WHO-ICF model’s domains, explicit acknowledgment of personal and environmental factors that affect disablement, and potential complementary clinical reasoning models. Future research is necessary to apply the WHO-ICF model to other body regions and health conditions common in physical therapist practice. This research should establish the clinical effectiveness of its application and derive core sets that may be useful for optimal education, research, and reimbursement. Dr Rundell and Dr Davenport provided concept/idea/project design, writing, and data

January 2009

Low Back Pain and the WHO-ICF Model

Figure 2. Integrated model of physical therapist clinical reasoning incorporating the World Health Organization’s International Classification of Functioning, Disability and Health (WHO-ICF) model, with important concepts from Sackett’s principles of evidence-based practice,37 the rehabilitation cycle, and Edwards and colleagues’ clinical reasoning model of physical therapists.36

analysis. Ms Wagner assisted in the project design. Dr Rundell provided data collection, project management, and patients. Dr Davenport and Ms Wagner provided consultation (including review of manuscript before submission). Dr Rundell completed this case report series in partial fulfillment of the requirements of

January 2009

the Kaiser Permanente Southern California Orthopaedic Physical Therapy Residency. The authors thank Joe Godges, PT, DPT, OCS, for his insightful comments regarding an early version of the manuscript. The authors also gratefully recognize Kris M Keller, PT, Department Administrator, and Justin W Hamilton, PT, MPT, OCS, for their administrative support of this project. The authors

affirm that they have no financial affiliation or involvement with any commercial organization that has a direct financial interest in any matter included in the article. This article was received April 16, 2008, and was accepted October 3, 2008. DOI: 10.2522/ptj.20080113

Volume 89

Number 1

Physical Therapy f

89

Low Back Pain and the WHO-ICF Model References 1 Deyo RA, Mirza SK, Martin BI. Back pain prevalence and visit rates: estimates from US national surveys, 2002. Spine. 2006;31: 2724 –2727. 2 Hashemi L, Webster BS, Clancy EA, Volinn E. Length of disability and cost of workers’ compensation low back pain claims. J Occup Environ Med. 1997;39:937–945. 3 Loney PL, Stratford PW. The prevalence of low back pain in adults: a methodological review of the literature. Phys Ther. 1999; 79:384 –396. 4 Walker BF, Muller R, Grant WD. Low back pain in Australian adults: prevalence and associated disability. J Manipulative Physiol Ther. 2004;27:238 –244. 5 Jette AM, Smith K, Haley SM, Davis KD. Physical therapy episodes of care for patients with low back pain. Phys Ther. 1994;74:101–110; discussion 110 –105. 6 Jette AM, Assmann SF, Rooks D, et al. Interrelationships among disablement concepts. J Gerontol A Biol Sci Med Sci. 1998;53:M395–M404. 7 Jette AM, Keysor JJ. Disability models: implications for arthritis exercise and physical activity interventions. Arthritis Rheum. 2003;49:114 –120. 8 Stucki G, Cieza A, Ewert T, et al. Application of the International Classification of Functioning, Disability and Health (ICF) in clinical practice. Disabil Rehabil. 2002; 24:281–282. 9 Stucki G, Ewert T, Cieza A. Value and application of the ICF in rehabilitation medicine. Disabil Rehabil. 2003;25:628 – 634. 10 International Classification of Functioning, Disability and Health: ICF. Geneva, Switzerland: World Health Organization; 2001. 11 Irrgang JJ, Godges J. Use of the International Classification of Functioning and Disability to develop evidence-based practice guidelines for treatment of common musculoskeletal conditions. Orthopaedic Physical Therapy Practice. 2006; 18(4):24 –25. 12 Jette AM. The changing language of disablement. Phys Ther. 2005;85:118 –119. 13 Cieza A, Stucki G, Weigl M, et al. ICF Core Sets for low back pain. J Rehabil Med. 2004(44 suppl):69 –74. 14 Childs JD, Piva SR, Fritz JM. Responsiveness of the numeric pain rating scale in patients with low back pain. Spine. 2005;30:1331–1334.

90

f

Physical Therapy

Volume 89

15 Grotle M, Brox JI, Vollestad NK. Concurrent comparison of responsiveness in pain and functional status measurements used for patients with low back pain. Spine. 2004;29:E492–E501. 16 Von Korff M, Jensen MP, Karoly P. Assessing global pain severity by self-report in clinical and health services research. Spine. 2000;25:3140 –3151. 17 Fairbank JC, Couper J, Davies JB, O’Brien JP. The Oswestry low back pain disability questionnaire. Physiotherapy. 1980; 66:271–273. 18 Lauridsen HH, Hartvigsen J, Manniche C, et al. Responsiveness and minimal clinically important difference for pain and disability instruments in low back pain patients. BMC Musculoskelet Disord. 2006;7:82. 19 Beck AT, Steer RA, Brown GK. Beck Depression Inventory II Manual. San Antonio, TX: The Psychological Corporation; 1996. 20 Hiroe T, Kojima M, Yamamoto I, et al. Gradations of clinical severity and sensitivity to change assessed with the Beck Depression Inventory-II in Japanese patients with depression. Psychiatry Res. 2005;135:229 –235. 21 Swinkels-Meewisse EJ, Swinkels RA, Verbeek AL, et al. Psychometric properties of the Tampa Scale for Kinesiophobia and the Fear-Avoidance Beliefs Questionnaire in acute low back pain. Man Ther. 2003;8:29 –36. 22 Waddell G, Newton M, Henderson I, et al. A Fear-Avoidance Beliefs Questionnaire (FABQ) and the role of fear-avoidance beliefs in chronic low back pain and disability. Pain. 1993;52:157–168. 23 Davenport TE, Cleland JA, Lewthwaite R, et al. Responsiveness of the Low Back Activity Confidence Scale in a subgroup of patients with low back pain: preliminary analyses. Paper presented at: Combined Sections Meeting of the American Physical Therapy Association; February 6 –9, 2008; Nashville, TN. 24 Yamada KA, Lewthwaite R, Popovich JM, et al. The Low Back Activity Confidence Scale (LoBACS): development and preliminary reliability and validity. Paper presented at: Combined Sections Meeting of the American Physical Therapy Association; February 14 –18, 2007; Boston, MA. 25 Waddell G, Somerville D, Henderson I, Newton M. Objective clinical evaluation of physical impairment in chronic low back pain. Spine. 1992;17:617– 628.

Number 1

26 Van Dillen LR, McDonnell MK, Fleming DA, Sahrmann SA. Effect of knee and hip position on hip extension range of motion in individuals with and without low back pain. J Orthop Sports Phys Ther. 2000;30: 307–316. 27 Kendall FP, McCreary EK, Provance PG, et al. Muscles: Testing and Function. 5th ed. Baltimore, MD: Lippincott Williams & Wilkins; 2007. 28 Sahrmann SA. Diagnosis and Treatment of Movement Impairment Syndromes. St Louis, MO: Mosby; 2001. 29 Maher CG, Adams R. Reliability of pain and stiffness assessments in clinical manual lumbar spine examination. Phys Ther. 1994;74:801– 809; discussion 809 – 811. 30 Maher CG, Latimer J, Adams R. An investigation of the reliability and validity of posteroanterior spinal stiffness judgments made using a reference-based protocol. Phys Ther. 1998;78:829 – 837. 31 Davidson M, Keating JL. A comparison of five low back disability questionnaires: reliability and responsiveness. Phys Ther. 2002;82:8 –24. 32 Roland M, Morris R. A study of the natural history of back pain, part I: development of a reliable and sensitive measure of disability in low-back pain. Spine. 1983; 8:141–144. 33 Childs JD, Fritz JM, Flynn TW, et al. A clinical prediction rule to identify patients with low back pain most likely to benefit from spinal manipulation: a validation study. Ann Intern Med. 2004;141: 920 –928. 34 Gibbons P, Tehan P. Manipulation of the Spine, Thorax and Pelvis: An Osteopathic Perspective. 2nd ed. Chatswood, NSW, Australia: Churchill Livingstone; 2005. 35 Davenport TE, Watts HG, Kulig K, Resnik C. Current status and correlates of physicians’ referral diagnoses for physical therapy. J Orthop Sports Phys Ther. 2005;35: 572–579. 36 Edwards I, Jones M, Carr J, et al. Clinical reasoning strategies in physical therapy. Phys Ther. 2004;84:312–330; discussion 331–315. 37 Sackett D, Straus S, Richardson W, et al. Evidence-Based Medicine: How to Practice and Teach EBM. 2nd ed. Edinburgh, Scotland: Churchill Livingstone; 2000. 38 Fritz JM, George S. The use of a classification approach to identify subgroups of patients with acute low back pain: interrater reliability and short-term treatment outcomes. Spine. 2000;25:106 –114.

January 2009

HEALTH CONDITION

ACTIVITY

Contextual Factors: Environment & Personal BODY FUNCTION AND STRUCTURE

PARTICIPATION

Perspective

Advancements in Contemporary Physical Therapy Research: Use of Mixed Methods Designs Lauren Rauscher, Bruce H Greenfield The purpose of this article is to advocate for the use of mixed methods designs in contemporary physical therapist research. Mixed methods designs are used for collecting, analyzing, and mixing both quantitative and qualitative data in a single study or series of studies to both explain and explore specific research problems, thereby enriching the breadth and depth of understanding phenomena. These designs are particularly well suited for physical therapist researchers to reveal the complexity of disablement, rehabilitation, and recovery processes. Although contextual factors influence a person’s health condition and recovery, they remain empirically less understood and underexplored by physical therapist researchers. To address this gap, the authors describe various combinations of quantitative and qualitative methods and data within a single study or set of related studies and the decisions that underlie the uses of these combinations. They include examples from current physical therapist research and applications from the International Classification of Functioning, Disability and Health (ICF) model. They argue that the rigorous application of quantitative and qualitative methods and data can propel physical therapist research and practice forward by stimulating new research questions, creating a holistic understanding of patient injury and rehabilitation, and contributing to innovative, complex treatment interventions.

L Rauscher, PhD, is Assistant Professor (Sociology), Department of Human Development, California State University–Long Beach, Long Beach, California. BH Greenfield, PT, PhD, OCS, is Assistant Professor, Division of Physical Therapy, Department of Rehabilitation Medicine, Emory University School of Medicine, 1441 Clifton Rd NE, Atlanta, GA 30322 (USA). Address all correspondence to Dr Greenfield at: [email protected]. [Rauscher L, Greenfield BH. Advancements in contemporary physical therapy research: use of mixed methods designs. Phys Ther. 2009; 89:91–100.] © 2009 American Physical Therapy Association

Post a Rapid Response or find The Bottom Line: www.ptjournal.org January 2009

Volume 89

Number 1

Physical Therapy f

91

Use of Mixed Methods Designs

M

ixed methods research designs have gained popularity in health care professions such as nursing, health services, and public health over the last few decades due to their utility in applied research, the high-quality inferences they yield, and the overall complexity they reveal.1–3 Their strength also lies in their ability to cross-validate results and offset the limitations of using only one methodological approach. Physical therapy is a health care profession responsible for restoring function in patients who often present complex movement impairments that are influenced by ongoing personal and social factors. As such, mixed methods research provides physical therapists with opportunities to broaden their scope and depth of understanding patients’ illness, injury, and rehabilitation. In mixed methods designs, researchers use both quantitative and qualitative methods and data in combination in a single study or set of related studies.2,4 –9 Although quantitative research is particularly effective for examining causal relationships among variables and making predictions, it often fails to illuminate the context within which these relationships occur and does not address questions of “how” and “why” particular relationships among variables exist. Qualitative methods can explore social and behavioral issues related to both illness and rehabilitation at a deeper level than quantitative methods allow,10 –12 such as understanding the meaning of pain, injury, and disease from the individuals’ lived experiences and how these meanings differ across specific contexts.13–16 Although qualitative projects enable scholars to extend and refine theory, they include fewer cases than quantitative research, thereby minimizing generalizability of findings to larger populations.

92

f

Physical Therapy

Volume 89

Combining these methods, therefore, allows researchers to capitalize on the strengths of each. Standardized measures and secondary analyses can confirm hypotheses and predict rehabilitation participation and treatment outcomes,17 and an interpretive and naturalistic approach enables in-depth understandings of patients’ experiences and the larger contexts that shape their injury, treatment, and rehabilitation.18 Mixed methods are especially well suited to studying the complex processes of disablement in the World Health Organization’s International Classification of Functioning, Disability and Health (ICF),19 namely the dynamic relationships between physical and psychosocial contextual factors that influence recovery.20 In turn, findings from these research designs promise to shape physical therapy treatment interventions. Recent studies have illustrated that physical therapist researchers are indeed drawing on the strengths that mixing quantitative and qualitative methods offers, primarily by conducting interviews with a small subset of respondents after collecting survey data from a larger patient population.21,22 This type of mixed methods design—a Quantitative-qualitative design*—is but one of several ways to integrate various types of methods and data into physical therapist research.3 The purpose of this perspective article is to differentiate mixed methods design options and highlight the justifications that underlie them. We hope to encourage physical therapist researchers to examine and expand their options for mixed methods research in physical therapy by addressing the processes

* Capital letters are used to denote priority in research design maps to specify the researcher’s intentions concerning which type of data has priority in a given study (ie, Quantitative-qualitative, Qualitative-quantitative, Quantitative-Qualitative) (Figure).

Number 1

and procedures for choosing specific designs. These designs imply that researchers have a wide range of methodological skill sets; yet, we acknowledge that being an “expert” in both quantitative and qualitative methods may be unrealistic. Although additional training in methodological research requires significant time (which often is in short supply), mixed methods designs present physical therapist researchers with opportunities for collaborative and interdisciplinary work to offset any limitations they may face regarding their own methodological training. To address the aims of this article, we begin with a discussion of key factors to consider when conducting mixed methods research in terms of purpose, priority, sequencing, and integrating quantitative and qualitative methods and data. We then focus on 3 specific mixed methods designs: (1) sequential explanatory, in which quantitative methods are followed by qualitative methods; (2) sequential exploratory, a qualitative to quantitative design; and (3) concurrent triangulation, the simultaneous use of qualitative and quantitative methods to capture greater complexity in one study. We provide strategies to justify the choice of using a mixed methods design and include examples from current physical therapist research and applications from the ICF model to demonstrate their benefits.

Factors for Choosing a Mixed Methods Design Strategy The key question has become not whether it is acceptable or legitimate to combine methods, but how they will be combined to be mutually supportive and how findings achieved through different methods will be integrated.23(p9)

January 2009

Use of Mixed Methods Designs Choosing how best to integrate different methods to create a coherent analysis that yields a more in-depth understanding than might be gained from using one method remains at the center of mixed methods research. The challenge of combining methodological approaches (with fundamentally different philosophical underpinnings) that are mutually supportive and enrich our understanding of phenomena mandates that researchers create a systematic and theoretically meaningful plan to mix methods.3 Careful consideration and explicit articulation of a project’s purpose constitutes the first step in deciding on a mixed methods plan. Next, researchers must make 3 key decisions before deciding which design strategy is most appropriate for a project: (1) the priority given to the quantitative and qualitative data and methods, (2) the sequence of implementation of methods for data collection, and (3) the phases in which the data and findings will be integrated. Underlying the choices regarding each of these factors is the aim of the overall project. Purpose As in all research, the first step in creating an appropriate mixed methods study design is that researchers must provide a clear statement regarding their research aims (see Creswell24 for sample purpose scripts). Mixed methods designs are most appropriate when researchers have a specific issue or problem that is best understood through both explanation and exploration. These designs are equipped to simultaneously document large-scale patterns, isolate factors that influence outcomes, and identify causal relationships among variables while capturing detailed nuances of an issue based on focused observations of participants’ lives and uncovering how participants experience and understand par-

January 2009

Figure. Mixed methods designs. Quan⫽quantitative, qual⫽qualitative. Capital letters are used to denote priority in research design maps to specify the researcher’s intentions concerning which type of data has priority in a given study (ie, Quan-qual, Qual-quan, Quan-Qual).

ticular phenomena.25 Mixed methods designs require researchers to adopt a pragmatic stance toward valid knowledge claims so that they can collect and integrate different types of data through diverse methods by which to understand phenomena more comprehensively.6,17,25 Some of the research questions in mixed methods studies are aimed at hypothesis testing and understanding patterns across and within large groups, which are best captured through quantitative methods.3 During this phase of mixed methods projects, researchers use deductive logic to test a priori hypotheses with reliable, closed-ended measures and statistical procedures that determine associations among variables. Data are controlled, isolated, mea-

sured, and tested to make predictions about specific, standardized outcomes. For these questions, health researchers draw from wellestablished methods such as experiments, quasi-experiments, correlational studies, and survey research.26 Other research questions within the same study (or research program) aim for a deeper and naturalistic understanding of phenomena from the perspective of participants, constituting qualitative inquiries. Phenomenology, grounded theory, ethnography, realistic tales, case studies, and biographies enable researchers to study unexplored topics, generate and extend theories, and focus on the context in which phenomena are created, maintained, and changed.27 These methods stress the social con-

Volume 89

Number 1

Physical Therapy f

93

Use of Mixed Methods Designs struction of reality and the interactive processes through which meaning is created.14 Thick description occurs when researchers are close to participants, particularly through focused observations.28 Data collection and analyses occur simultaneously in a systematic, iterative fashion, where each process mutually informs the other.29 Researchers must specify the extent to which each of the study aims matters for the project, as they influence the next steps researchers take regarding the priority, sequence, and integration of the qualitative and quantitative methods and data. For example, the researchers’ principal aim may be to study physical functioning and disability in patients who underwent total hip replacement. These researchers also may be interested in exploring racial and ethnic differences at a deeper level to discern how structural and cultural factors influence recovery processes related to patient-provider relationships. As we discuss below, these 2 particular aims best lend themselves to a mixed methods design that prioritizes quantitative data and sequences it before the qualitative data collection (quantitative-qualitative design), combining the 2 forms of data in the results phase.3 Priority Once a researcher decides that a mixed methods design is appropriate to address the purposes of the study, the focus turns to the priority of the data and methods such that it is congruent with the research aims. Priority concerns the emphasis that researchers give to the collection, analysis, and interpretation of the quantitative or qualitative data.1–3 Some studies place greater emphasis on quantitative methods and data, other studies place greater emphasis on qualitative methods and data, and some studies prioritize both equally.

94

f

Physical Therapy

Volume 89

To reiterate, the aim of a project guides decisions about the emphasis placed on the different types of data in a project. That is, if a study’s primary aim is discovery, exploration, or thick description and meaning, the qualitative component of the study takes priority. In contrast, if the research aim centers on testing hypotheses or generalizing findings to larger populations, priority is given to the quantitative component of the project. A project that emphasizes the contributions of both deductive hypothesis testing (explaining) and inductive discovery (exploring) will give equal priority to both components.3 Camp et al21 offers one example from the physical therapy literature of a study that prioritizes quantitative data using a mixed methods design. Their study sought to assess the impact of a structured pulmonary rehabilitation program on physical and quality-of-life changes in 150 patients with chronic obstructive pulmonary disease. In this study, Camp et al created a close-ended survey comprising standardized outcome measures, including the Chronic Respiratory Questionnaire, the Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36), and spirometry. Following the survey, they conducted semistructured interviews to explore the personal experiences of 7 patients in the pulmonary program. Camp et al21 prioritized the quantitative survey data because their primary aim was to demonstrate the effectiveness and generalizability of their structured pulmonary program. They used the interview data to explore participants’ perceptions of the intervention program and to address a second aim of their study, which was to understand how patients attributed their changes in physical functioning and quality of life to this particular program. Thus, Camp and colleagues used the indepth qualitative data to interpret how

Number 1

and why specific patterns of changes occurred during the course of the program according to their patients. That is, the qualitative data collected after the survey data helped identify mechanisms that contributed to the quantitative findings they emphasized. Currently, most physical therapist researchers often prioritize quantitative data and methods by testing hypotheses related to the physical domains of body functioning, physical impairments, and the extent to which patients can participate in different activities or are restricted from doing so.22,30 However, questions that are related to perceptual and structural domains within the ICF model (or questions derived from the researcher’s clinical practice) lend themselves to qualitative research, thus providing physical therapist researchers a theoretical platform on which to prioritize qualitative data and methods. More specifically, qualitative methods allow insight into social and economic contexts that often are not revealed through standardized quantitative measures. Consider, for instance, the following hypothetical example. Some patient profiles may suggest that the process of recovery from a minor injury will be relatively smooth and adherence to treatment plans will be high. Such profiles show that patients are young, have stable employment complete with health insurance coverage, are married with children, report low depression scores on the Beck Depression Inventory, and have personal transportation for appointments. Moreover, notes from patient files convey patients’ genuine desire to heal quickly. Previous quantitative research provides robust evidence that these psychosocial variables positively affect recovery. However, clinical practice and recent research reports may document a growing trend among this group that shows the opposite—adherence to treatment plans is low January 2009

Use of Mixed Methods Designs and recovery is slow among a group of patients where it should be high. This anomaly provides researchers an opportunity to identify the personal and environmental factors shaping this group of patients’ health conditions. Thus, the study aims to “dig” beneath the surface of standardized patient profiles and explore why this trend exists. Qualitative interviewing methods complement this aim in that they allow researchers to ask patients open-ended questions about their lives. The interview data may reveal that women have little time to devote to exercising outside of their physical therapy sessions, given responsibilities to job and family. We may learn that many of the women interviewed are part of the “sandwich generation,” caring not only for her children but also for aging family members who can no longer live independently. Thus, findings may reveal significant constraints on women’s own time. Despite a desire to follow the prescriptions of their providers, some of these women are unable to take time off from work for routine appointments, given how short-staffed their offices are. By probing deeper, we may learn that women are grateful to have a job, given the tight labor market in their communities, and cannot afford to lose it, given the rising interest rates on home mortgages. Thus, these interviews and patient narratives can reveal how the demands of everyday life and social relationships deterred those patients from adhering to treatment. By prioritizing qualitative methods, researchers gain a more in-depth understanding of people’s lives and empirically reveal the paths through which social and economic factors shape health conditions as posited in the ICF model. Unlike quantitative measures, qualitative depth is achieved through a smaller sample of patients, and findings are not January 2009

generalizable to larger populations.31 By following this qualitative phase with quantitative methods and a larger patient sample (a Qualitativequantitative design), researchers can identify the frequency and extent to which these pressures affect their patients more broadly. Implementation Implementation refers to the sequence of data collection (sequentially or concurrently) in a particular study. Again, the project aim directs the sequencing choice for the order of particular method procedures. Researchers use a sequential process when one phase contributes to or clarifies another phase.3 The ICF framework illustrates dynamic and reciprocal pathways through which physical, contextual, and personal factors influence illness (and rehabilitation) experiences and health outcomes.20 Following theoretical logic of the ICF, researchers may choose to perform in-depth interviews in a specific patient population to help formulate items for a questionnaire to use in a larger-scale study, creating a qualitative-quantitative sequence. A study by Mancuso et al32 provides an excellent example of how qualitative data collection and analyses can help develop quantitative measures. In this project, participants were asked open-ended questions about their expectations for surgery and the importance of each expectation prior to their surgeries. Specifically, the authors used qualitative interviews in the first phase of developing a patient-derived knee expectations survey after knee surgeries. Patients were asked, “What are your expectations of the surgery you are going to have for your knee?” and “How important is each expectation?”

A sample of 377 patients† completed these interviews, and Mancuso et al32 identified a total of 1,161 expectations. Analyses revealed that expectations varied by patient characteristics: younger patients were more concerned about improvements in sports performances and for the knee to be “back the way it was” before symptoms started. In contrast, older patients were more likely to prioritize pain relief and improved walking ability. Patients with less education were more likely to expect psychological improvement and pain relief; whereas patients with more education were more likely to desire improvement in sports performance. Mancuso et al32 transformed these data into categories of patient expectations and developed a valid and reliable questionnaire to use preoperatively to direct patient education, share decision making, and provide a framework for setting reasonable goals. Specifically, the authors generated a 17-item survey for patients undergoing total knee replacement and a 21-item survey for patients undergoing other types of knee surgeries. Therefore, the qualitative data provided the basis for a patient-derived template used by orthopedic surgeons to guide discussions about patient goals based on age, educational level, and types of surgery. As stated above, many physical therapist researchers conduct mixed methods research using a quantitativequalitative sequence, whereby textual or narrative data clarify and expand on statistical findings from a larger population. Pizzari et al22 conducted this type of mixed methods sequence by selecting 11 patients with anterior cruciate ligament (ACL) reconstruc† This constitutes a large data set for qualitative research. Such a sample size is possible, given that these researchers included 2 openended questions rather than use a qualitative method such as grounded theory or ethnography.

Volume 89

Number 1

Physical Therapy f

95

Use of Mixed Methods Designs tions for a qualitative study using interviews at an average of 4.8 months into a rehabilitation process. They selected participants from a larger quantitative research project analyzing the adherence-outcome relationship in ACL rehabilitation. In the larger study, adherence was measured through scores of attendance at physical therapy appointments, therapist ratings of patient adherence during appointments, and selfreported adherence to home-exercise programs. Based on these quantitative data, the authors stratified patients into 2 groups (patients who were adherent and patients who were nonadherent, particularly with respect to their home programs). The subsequent interviews occurred with a small sample of both patient groups to provide a greater understanding of contextual factors that influence rehabilitation, namely psychological states and environmental constraints. Significant psychological factors included self-motivation, maintaining interest in rehabilitation, and fear of physical reinjury. The respondents who were adherent told stories that reflected greater self-direction and interest in and enjoyment of rehabilitation, whereas the nonadherent participants used phrases such as “boring more than anything” to describe their home exercises. Patients who were nonadherent consistently spoke about their fear associated with return to sport and talked about delaying the return to sport despite assurances from their physical therapists. Patients who were nonadherent also discussed environmental factors that shaped their home program, such as the extended length of the rehabilitation process, isolation of the program, lack of perceived effectiveness of the exercises, and lack of equipment. In combination, the quantitativequalitative sequence enabled Pizzari et al22 to first classify selected pa96

f

Physical Therapy

Volume 89

tients from a large patient population as adherent or nonadherent to rehabilitation. Follow-up interviews then allowed the authors the advantage to more fully learn about patients’ experiences of ACL injury and to identify emotional influences (eg, fear) and psychosocial needs (eg, emotional support) that shaped completion of their rehabilitation. The findings gleaned from the qualitative work are key to patients’ successful rehabilitation. Sequencing the quantitative methods and data first does not imply that researchers place priority or emphasis on them. Rather, the methods and data work together to provide a more comprehensive understanding of the needs of patients with ACL injuries. These examples show how physical therapist researchers incorporate open-ended questions and interviews into their study designs. This form of data collection reflects the predominant way that rehabilitation researchers, to date, use qualitative methods in mixed methods designs. Open-ended questions, however, are not inherently grounded in qualitative methods. They also do not reflect the range and depth of interpretive methods that prioritize meaning, subjectivities, context, and depth. In fact, there is a wide range of methods associated with qualitative research that are each grounded in their own procedures and processes for collecting and analyzing data. Researchers who routinely draw from these qualitative methods are highly trained and skilled in the theoretical underpinnings, application, and methods for analyses. Grounded theory,29 ethnography,28 narrative research,33 and phenomenology12,34,35 provide physical therapist researchers with various options to study qualitative research questions. Data from different sources, such as clinical observations, health policy documents, pa-

Number 1

tient diaries, and focus group interviews, can be collected and analyzed in addition to individual interviews. Analyzing these data qualitatively enables a much deeper understanding of phenomena than a few open-ended questions allow. Collaborating with qualitative researchers in the health and social sciences, thus, becomes particularly appealing to physical therapist researchers who want to use mixed methods but are not trained in the breadth of qualitative methods. Integration Integration remains one of the most important factors to consider in mixed methods research. The integration of data is the point or points in the project where the researcher combines the 2 types of data.3 This can occur during the data collection, analyses, or interpretation and results phases, or at a combination of points. That is, questions of where, when, and how data will be combined in meaningful ways remain central to mixed methods research. The justification for integration is to provide internal coherence to the results for a more complex and complete analysis. Integration can be a daunting process for researchers using mixed methods. Bryman36 conducted interviews with a number of mixed methods researchers and found a tendency toward non-integration in several studies. These studies reported either quantitative or qualitative data or gave more attention to only one type of data. Researchers identified several barriers to integration, including a tendency to think of qualitative and quantitative research as discrete domains that inhibit mixed methods altogether, the nature of the audience (ie, basic scientists, traditional health researchers, and clinicians who are more comfortable with quantitative measures and outcomes), and the methodological training of the researchers. January 2009

Use of Mixed Methods Designs Woolhead et al30 provide an example of successful integration from physical therapist research. In their study of patients after knee surgery (including total hip replacement), they integrated qualitative and quantitative questions during data collection and then drew from both sets of data during the results phase. More specifically, they purposively sampled 10 patients across demographic characteristics and conducted interviews with them 6 months after their surgeries. During semistructured interview sessions centered on their postsurgical experiences, patients also rated their operation outcomes along a Likert scale as excellent (2), very good (3), or good (4). Although the majority of the patients (n⫽9) stated that their total hip replacement operation was good to excellent, the interview data showed that almost all of the patients (n⫽8) indicated they still experienced continued pain and immobility. The qualitative data also help us understand this anomaly by showing that patients’ perceptions of functional outcomes were closely related to quality-of-life issues including their community and personal faith. For example, 1 patient, although in as much pain after the operation as before the operation, stated that she had a good outcome because her recovery process coincided with her move from a lonely neighborhood to a more community-spirited neighborhood. Other patients made sense of their pain and immobility within their religious beliefs, stating that their pain was “God’s way of trying to make them a better person.” Thus, in this study, the authors’ simultaneous use of both qualitative data and quantitative data illuminated the ways that people make sense of their illness experience and outcomes in relation to current life issues.

January 2009

Mixed Methods Designs Although there is a good deal of flexibility in “mixing” the key factors discussed above into various designs, we elaborate on 3 specific designs that are particularly salient for physical therapist research. Experts in mixed methods (eg, Creswell and colleagues,3,5,24 Tashakkori and colleagues1,2,17) have provided templates of these designs for novice or less-experienced mixed methods researchers and have advocated the use of maps to represent these designs in research proposals, articles, and reports. These maps visually demonstrate the specific ways in which researchers choose to combine and integrate qualitative and quantitative methods, which can be especially helpful for grant reviewers and funding agencies (Figure). Sequential Explanatory A sequential explanatory design is perhaps the most straightforward and common mixed methods design in health studies. As such, it may best resonate with the current climate of physical therapist research. Following the norms of medical and health research, the purpose of this design is to explain phenomena and confirm hypotheses using standardized (and, therefore, comparable) measures with relatively large samples. Thus, in a sequential explanatory design, priority is given to the quantitative data. Both Camp et al21 and Pizzari et al22 used a sequential explanatory design. Accordingly, both research groups gave priority to the quantitative research; they collected and analyzed their quantitative data first through survey methods. Camp et al collected standardized outcomes related to their pulmonary intervention program, whereas Pizzari et al quantitatively measured scores of physical therapy attendance. Both studies also followed this phase with qualitative data collection and analyses and incorporated the results of these inquiries to bolster and expand

the main quantitative findings. Therefore, the integration of quantitative data with qualitative data occurred during the interpretation and results stage. Qualitative findings complemented the quantitative findings and generally helped interpret the findings from the quantitative component of the project. These 2 examples show how following quantitative methods with qualitative methods allows researchers to expand upon patients’ experiences that were initially assessed using closed-ended measures. This type of sequential design can help ensure construct validity and explore additional contextual variables that affect patients’ experience scale scores. A sequential explanatory design also is useful in when quantitative findings yield unexpected results that require further elaboration. For instance, researchers may conduct observations or interviews to explore anomalies, outliers, or nonstatistically significant findings from a survey or experiment. Theoretically, domains and relationships among them in the ICF can help researchers think about factors that contributed to the unanticipated findings in their quantitative analyses. As noted earlier, this model is particularly useful for thinking through underexplored interactions with contextual variables or for exploring the presence of outliers in large-scale quantitative samples. A weakness associated with a sequential explanatory design is the time it requires to conduct 2 separate phases of data collection and analyses and then integrate numerical and thematic or textual data into a coherent whole (Figure). Sequential Exploratory A sequential exploratory design structurally resembles the sequential explanatory design. That is, data collection and analyses occur in 2 distinct phases, one following the other, with data integration occurring at the interpretation and results phase. The

Volume 89

Number 1

Physical Therapy f

97

Use of Mixed Methods Designs purpose of research that uses a sequential exploratory design differs, however, in that such studies focus on discovery rather than explanation or confirmation. Thus, priority is given to the qualitative data, and qualitative data collection and thematic analysis precede quantitative data collection and analyses.3 Sequential exploratory designs provide the opportunity for researchers to begin with a broad focus and refine it over the course of the study. Indeed, by inverting the common Quantitative-qualitative sequence, new foci are possible. Interviews and systematic observations can lead to new, patient-driven research questions that can be followed with quantitative methods. This type of mixed methods design also is helpful when researchers are developing a new instrument, as illustrated in the study by Mancuso et al.32 Their open-ended interviews with patients prior to surgery laid the foundation for the development of a reliable and valid survey of patient expectations about surgical outcomes. Their priority on exploration (thus privileging the qualitative component of their design) fits with the study’s aim on patient expectations, which are inextricably linked to meaning and subjectivity that cannot be captured through closed-ended questions. Focus groups provide another qualitative method through which patients can identify issues to be later assessed in a survey with a larger sample to test reliability and validity of the emerging patient-centered items affecting their disability experiences, rehabilitation, and recovery. In some cases, focus groups generate conversations among patient participants in ways that lead to more information than one-on-one interviewing.

98

f

Physical Therapy

Volume 89

Additionally, researchers can probe major environmental issues within the ICF model, such as access to health care, in ways that expand current standardized measures. Access to care remains important to the majority of patients, yet manifests differently across various contexts. Patients living in a densely populated urban area may experience chronic strains related to difficult-to-navigate public transportation (eg, congested subways and buses, schedules), which may affect their access to clinics and ability to keep rehabilitation appointments. Rural residents also may experience difficulty with access to clinics, but it may be due to the geographic distance they must travel to urban or suburban centers for routine appointments. Both situations speak to the built structural environments in which people live, but each would require different tactics for addressing their limitations in accessing care. If various types of access to care surface during focus groups, then each of the particular types can be included as response categories in a survey instrument distributed to larger groups of patients. The weakness of this design again relates to the extensive time it takes to conduct 2 distinct phases of data collection and analyses. Concurrent Triangulation Researchers use a concurrent triangulation design when they want to explain phenomena and explore process-related dynamics at the same time. From the outset, a project using this design begins with research questions that are both deductive and inductive. Thus, concurrent triangulation refers to the simultaneous collection and analyses of both qualitative and quantitative data. Ideally, priority is given to both types of data, and integration can occur at different levels. The strength of this design is its potential for capturing the immediacy of the qualitative and quantitative processes of disability experiences or for

Number 1

gaining a complex understanding of quantitative measures. For instance, a researcher can incorporate significant open-ended questions in a structured survey instrument so that both qualitative and quantitative data are collected in the same instrument. Alternately, a structured survey instrument with standardized measures can be distributed to a larger sample while focus groups are simultaneously conducted with smaller subsamples of the larger population to explore questions that are not easily quantifiable. In this type of design, the justification for collecting and analyzing 2 distinct types of data centers on the way each can offset the limitations of the other, and their combination allows researchers to ask “what,” “how,” and “why” questions at the same time. Concurrent designs can capture the complexity of multiple factors presented in the ICF model and help create the process paths through which they operate in a study. For instance, quantitative methods and data may be best suited to isolate and identify the most-effective interventions that address changes in body functions and structures (impairments) related to outcomes in activities (function) or participation (disabilities) in patients with frozen shoulders or rotator cuff injuries. Standardized physical therapy outcome measures that are quantifiable might best identify the extent of the injury, predict outcomes, or investigate the degree to which specific treatment interventions facilitate healing or functional outcomes (physical therapy versus surgery), the time it takes for recovery, and how different treatment options affect other types of body functioning, such as blood pressure, cardiovascular strength, and the like. Qualitative methods can probe the meaning of the injury to a patient and the patient’s values related to particular outcomes, frustrations of January 2009

Use of Mixed Methods Designs rehabilitation, and concerns related to function. Understanding both body functioning and the patient’s perspectives about functioning can inform physical therapists about psychosocial elements of recovery that perhaps require modifications of current strategies and progression of rehabilitation. A weakness of a concurrent triangulation design is that researchers must be trained in both types of research.

Conclusion The purposes of this article were to describe several mixed methods designs and to illustrate how these designs apply to different physical therapist research purposes and study aims. In general, studies that seek to explain and explore phenomena are particularly amenable to designs that combine quantitative and qualitative methods. We advocate that these designs offer physical therapists a tool to stimulate new research questions, create a holistic understanding of patient injury and rehabilitation, and contribute to innovative, complex treatment interventions. More specifically, we suggest that the complexity of the disablement experience in the current ICF model is better understood through the examination and exploration of the interactions of physical, personal, and environmental factors through mixed methods. Moreover, this research approach can foster relationships between physical therapists and researchers in other disciplines, expanding collaborations that we believe are consistent with nationally funded research endeavors. The 3 mixed methods models presented—sequential explanatory, sequential exploratory, and concurrent triangulation—provide physical therapist researchers with options for mixing methods. The choice for which design is most suitable rests with the original purposes or aims of the study. Based on the research aim, researchJanuary 2009

ers then make decisions about the priority of data and methods, the ways in which different methods are sequenced in a study or research program, and how quantitative and qualitative data will be integrated. Both authors provided concept/idea/project design and writing. Dr Rauscher provided project management. Dr Greenfield provided consultation (including review of manuscript before submission). The authors thank Bianca Wilson, Heather Jamerson, and Brenda Greene for comments on an early draft of the manuscript. This article was received August 16, 2007, and was accepted October 9, 2008. DOI: 10.2522/ptj.20070236

References 1 Tashakkori A, Teddlie C, eds. Handbook of Mixed Methods in Social and Behavioral Research. Thousand Oaks, CA: Sage; 2003. 2 Tashakkori A, Creswell J. The new era of mixed methods. Journal of Mixed Methods Research. 2007;1(1):3– 8. 3 Creswell J, Plano V. Designing and Conducting Mixed Methods Research. Thousand Oaks, CA: Sage; 2007. 4 Tashakkori A, Teddlie C. Mixed Methodology: Combining Qualitative and Quantitative Approaches. Thousand Oaks, CA: Sage; 1998. 5 Creswell J, Fetters MD, Ivankova NV. Designing a mixed methods study in primary care. Ann Fam Med. 2004;2:7–12. 6 Onweugbuzie AJ, Leech NL. On becoming a pragmatic researcher: the importance of combining quantitative and qualitative research methodologies. International Journal Social Research Methodology. 2005;8:375–387. 7 Sale JEM, Lohfeld LH, Brazil K. Revisiting the quantitative-qualitative debate: implications for mixed-methods research. Quality and Quantity. 2002;36:43–53. 8 Morse J. Principles of mixed methods and multimethod research design. In: Tashakkori A, Teddlie C, eds. Handbook of Mixed Methods Social and Behavioral Research. Thousand Oaks, CA: Sage; 2003. 9 Johnson RB, Onwuegbuzie AJ. Mixed methods research: a research paradigm whose time has come. Educational Researcher. 2004;33(7):14 –26.

10 Patton MQ. Qualitative Evaluation and Research Methods. 2nd ed. Thousand Oaks, CA: Sage; 1990. 11 Shepard K, Jensen GM, Schmoll BJ, et al. Alternate Approaches to research in physical therapy: positivism and phenomenology. Phys Ther. 1993;73:34 – 43. 12 Jensen GM. Qualitative methods in physical therapy research: a form of disciplined inquiry. Phys Ther. 1989;69:492–500. 13 Dudgeon B, Gerrard BC, Jensen M, et al. Physical disability and the experience of chronic pain. Arch Phys Med Rehabil. 2002;83:229 –235. 14 Denzin NK, Lincoln YS, eds. Collecting and Interpreting Qualitative Methods. Thousand Oaks, CA: Sage; 1998. 15 Eurenius E, Biguet G, Christina H. Attitudes toward physical activity among people with rheumatoid arthritis. Physiother Theory Pract. 2003;19:53– 62. 16 Maclean N, Pandora P, Wolfe C, Rudd A. Qualitative analysis of stroke patients’ motivation for rehabilitation. Br Med J. 2000;321:1054 –1054. 17 Tashakkori A, Creswell J. Exploring the nature of research questions in mixed methods research. Journal of Mixed Methods Research. 2007;1:207–211. 18 Huston P, Rowan M. Qualitative studies: their role in medical research. Can Fam Physician. 1998;44:2453–2458. 19 International Classification of Functioning, Disability and Health: ICF. Geneva, Switzerland: World Health Organization; 2001. 20 Jette AM. Toward a common language for function, disability, and health. Phys Ther. 2006;86:726 –734. 21 Camp G, Appleton J, Reid WD. Quality of life after pulmonary rehabilitation: assessing change using quantitative and qualitative methods. Phys Ther. 2000;80:986 –995. 22 Pizzari T, McBurney H, Taylor N, Feller J. Adherence to anterior cruciate ligament rehabilitation: a qualitative analysis. J Sports Rehabil. 2002;(11):90 –102. 23 Office of Behavioral and Social Science Research. Qualitative Methods in Health Research: Opportunities and Considerations in Application and Review. Bethesda, MD: National Institutes of Health; 1999. 24 Creswell J. Research Design: Qualitative, Quantitative, and Mixed Methods Approaches. 2nd ed. Thousand Oaks, CA: Sage; 2004. 25 Morgan DL. Paradigms lost and pragmatism regained: methodological implications of combining qualitative and quantitative methods. Journal of Mixed Methods Research. 2007;1(1):48 –76. 26 Campbell D, Stanley JC. Experimental and Quasi-Experimental Designs for Research. Boston, MA: Houghton Mifflin Co; 1963. 27 Creswell J. Qualitative Inquiry and Research Design: Choosing Among Five Traditions. Thousand Oaks, CA: Sage; 1998.

Volume 89

Number 1

Physical Therapy f

99

Use of Mixed Methods Designs 28 Geertz P. The Interpretation of Cultures. New York, NY: Basic Books; 1973. 29 Strauss A, Corbin J. Basics of Qualitative Research: Techniques and Procedures for Developing Grounded Theory. 2nd ed. Thousand Oaks, CA: Sage; 1998. 30 Woolhead G, Donovan J, Deippe P. Outcomes of total knee replacement: a qualitative study. Rheumatology (Oxford). 2005;44:1032–1037. 31 Lincoln Y, Guba E. Naturalistic Inquiry. Thousand Oaks, CA: Sage; 1985.

100

f

Physical Therapy

Volume 89

32 Mancuso C, Sculco TP, Wickiewicz TL, et al. Patients’ expectations of knee surgery. J Bone Joint Surg Am. 2001;83:1005–1012. 33 Sparkes AC. Telling Tales in Sport and Physical Activity: A Qualitative Journey. Champaign, IL: Human Kinetics Inc; 2002. 34 Moustakas C. Phenomenological Research Methods. Thousand Oaks, CA: Sage; 1994.

Number 1

35 Benner P. The tradition and skill of interpretative phenomenology in studying health, illness, and caring practices. In: Benner P, ed. Interpretive Phenomenology: Embodiment, Caring, and Ethics in Health and Illness. Thousand Oaks, CA: Sage; 1994:99 –127. 36 Bryman A. Barriers to integrating quantitative and qualitative research. Journal of Mixed Methods Research. 2007;1(1):8 –22.

January 2009

Letters to the Editor Sexuality and Health Care: Are We Training Physical Therapy Professionals to Address Their Clients’ Sexuality Needs? According to Couldrick, “Sexuality is an integral part of being human.”1(p493) Sexual well-being of clients is regarded as a health care concern, which is highlighted in the International Classification of Functioning, Disability and Health2 (ICF) and is referred to in the United Kingdom Department of Health publication Choosing Health: A White Paper.3 Because the issue is increasingly being considered as an integral component of the total well-being of an individual, it is important that health care professionals address it.4–7 Addressing clients’ sexuality requires a multidisciplinary approach and is not the responsibility of a single professional.4 However, clients’ sexuality sometimes is not addressed in clinical settings. One probable, yet understandable, reason for this is that health care professionals, including physical therapists, feel embarrassed to discuss their clients’ sexual needs.8–10 There is a need to provide adequate sexuality training to new graduates and for professionals currently in practice in order to best place them to address their clients’ sexuality needs. Sexuality is gaining increasing recognition for being more than “having sex” and includes making relationships, self-esteem, tactile expressions, and the need for closeness. In the literature, it is described as a dynamic process that has a psychosocial element.5,11 Hospital admission may affect an individual’s concept of his or her sexuality as it impinges on the individual’s self-concept, self-esteem, and social relationships. Some patients may have the desire to have

January 2009

more information regarding sexual function but at the same time are reluctant to ask health care professionals about it.12 Davis and Taylor4 advocated for health care professionals to take the first step. Furthermore, it is clear from the literature that addressing clients’ sexuality requires a multidisciplinary approach and is not the responsibility of a single professional,4,13 yet the health care professions are ambiguous about the issue of addressing client sexuality.1,14 Physical therapists are holistic practitioners,15 as they play a major role in the total rehabilitation of patients, including sexual rehabilitation.15,16 However, recent multicentric studies with physical therapist students and other health care professional students identified that sexuality is an uncomfortable issue to discuss with patients.8,10 It has been proposed that the absence of attention to sexuality in the undergraduate training of health care professionals could be a key factor in explaining why professionals are uncomfortable addressing this patient need.6,7,17

by the interaction of biological, psychological, social, economic, political, cultural, ethical, legal, historical, and religious and spiritual factors.

The ICF is a comprehensive framework and identifies sexual wellbeing as a factor, and this is evident from some of the categories that are dedicated to this important issue. The World Health Organization defines sexuality as a central aspect of being human throughout life and encompasses sex, gender identities and roles, sexual orientation, eroticism, pleasure, intimacy, and reproduction.18 Sexuality is experienced and expressed in thoughts, fantasies, desires, beliefs, attitudes, values, behaviors, practices, roles, and relationships. Although sexuality can include all of these dimensions, not all of them are always experienced or expressed. Sexuality is influenced

S Sengupta, OT, MSc (Trainee), PG Dip Rehab, PGDDRM, BSc (OT), is Specialist Occupational Therapist, The Royal Orthopaedic Hospital, Bristol Road South, Birmingham, and Post Graduate Trainee, Oxford Brookes University, Jack Straw Lane, Oxfordshire, United Kingdom.

Inclusion of sexuality in education of health care professionals can contribute to integrating this important issue as a routine aspect of practice. Education may prompt physical therapist students and students in other health care professions to no longer assume that patients do not want to talk about sexuality, which would further lower their level of embarrassment in addressing the issue with their clients. In addition, perhaps the development of new graduates who are well equipped to discuss sexuality would enable the issue to be addressed in clinical settings more frequently. Sexuality is an important issue that needs to be highlighted, and if physical therapists truly want to deliver holistic care, then they surely need to address their clients’ sexual needs. Subhajit Sengupta, Dikaios Sakellariou

D Sakellariou, OT, MSc (OT), is Lecturer of Occupational Therapy, Cardiff University, Cardiff, United Kingdom.

References 1 Couldrick L. Sexual issues within occupational therapy, part 1: attitudes and practice. British Journal of Occupational Therapy. 1998;61:493–496. 2 World Health Organization. International Classification of Functioning, Disability and Health (ICF). Available at: http:// www.who.int/classification/icf/en/. Accessed June 19, 2008. 3 Department of Health. Choosing Health: A White Paper. London, United Kingdom: The Stationary Office; 2004.

Volume 89 Number 1 Physical Therapy „ 101

Letters to the Editor 4 Davis S, Taylor B. From PLISSIT to ExPLISSIT. In: Davis S, ed. Rehabilitation: The Use of Theories and Models in Practice. Edinburgh, United Kingdom: Churchill Livingstone; 2006:chap 6. 5 Sakellariou D, Algado SS. Sexuality and occupational therapy: exploring the link. British Journal of Occupational Therapy. 2006;69:350–356. 6 Sengupta S, Davis S, Stubbs B. Let’s talk about sexuality: whose responsibility is it? International Journal of Therapy and Rehabilitation. 2008;15:286–287. 7 Sengupta S, Stubbs B. Sexuality and healthcare: can we carry on ignoring the issue? British Journal of Occupational Therapy. 2008;71:269. 8 Pynor R, Weerakoon P, Jones MK. A preliminary investigation of physiotherapy students’ attitudes towards issues of sexuality in clinical practice. Physiotherapy. 2005;91:42–48. 9 Jones MK, Weerakoon P, Pynor RA. Survey of occupational therapy students’ attitudes towards sexual issues in clinical practice. Occup Ther Int. 2005;12: 95–106. 10 Weerakoon P, Jones MK, Pynor R, Kilburn-Watt E. Allied health professional students’ perceived level of comfort in clinical situations that have sexual connotations. J Allied Health. 2004;33:189–193. 11 Wells P. No sex please, I’m dying: a common myth explored. European Journal of Palliative Care. 2002;9:119–122. 12 Stern SH, Fuchs MD, Ganz SB, et al. Sexual function after total hip arthroplasty. Clin Orthop Relat Res. 1991;269:228–235. 13 Sexuality and Sexual Health in Nursing Practice. London, United Kingdom: Royal College of Nursing; 2000. 14 Watson C. Sexual roles in nursing care. Nursing (Lond). 1991;4:13–14. 15 Evans R, Halar E, DeFreece A, Larsen GL. Multidisciplinary approach to sex education of spinal cord-injured patients. Phys Ther. 1976;56:541–545. 16 Summerville P, McKenna K. Sexuality education and counselling for individuals with a spinal cord injury: implications for occupational therapy. British Journal of Occupational Therapy. 1998;61:275–279.

17 Pollard N, Sakellariou D. Sex and occupational therapy: contradictions or contraindications. British Journal of Occupational Therapy. 2007;70:362–365. 18 World Health Organization. Draft working definition. 2002. Available at: https://vle. brookes.ac.uk/webct/urw/lc102116011. tp0/cobaltMainFrame.dowebct. Assessed August 12, 2007. [DOI: 10.2522/ptj.2009.89.1.101]

Congratulations on the Diabetes Special Issue! You are to be commended for this excellent special issue of PTJ concerned with diabetes. Given the apparent expertise of the physical therapists involved as authors of many of the papers in this issue, it is both amazing and tragic that the American Diabetes Association still fails to acknowledge physical therapists as members of the diabetes health care team (see www.diabetes.org/ whos-who-on-your-health-careteam/your-health-care-team.jsp). Hopefully this special issue will inspire more of our colleagues to become further involved in diabetes prevention and management. John O Barr JO Barr, PT, is President, Section on Geriatrics, APTA.

[DOI: 10.2522/ptj.2009.89.1.102.1]

Editor Response You have hit on a key tension: our profession is uniquely qualified to make an impact on this population, yet we have not been centrally involved in diabetes prevention and management. As a profession, we seem to have focused on treating the impairments and complications secondary to diabetes, but we have not been heavily involved in prevention and management of the disease. I have attended several American Diabetes Association conferences and have been surprised to see few physical therapists involved in this important professional organization. The papers in this special issue provide a wide spectrum of information about opportunities (from the subcellular level to the policy level) where physical therapists can and should be involved in this critical problem. I hope the Special Issue helps to spur our involvement and that physical therapists are recognized not only for treating the complications of diabetes, but also for helping people with diabetes increase their exercise and physical activity level safely to prevent and control their disease. Thank you for your letter. Michael J Mueller MJ Mueller, PT, PhD, FAPTA, was Guest Editor, Diabetes Special Issue. He is Associate Professor, Program in Physical Therapy and Department of Radiology, Washington University School of Medicine, St Louis, Missouri.

[DOI: 10.2522/ptj.2009.89.1.102.2]

102 ■

Physical Therapy Volume 89 Number 1

January 2009

Letters to the Editor 4 Davis S, Taylor B. From PLISSIT to ExPLISSIT. In: Davis S, ed. Rehabilitation: The Use of Theories and Models in Practice. Edinburgh, United Kingdom: Churchill Livingstone; 2006:chap 6. 5 Sakellariou D, Algado SS. Sexuality and occupational therapy: exploring the link. British Journal of Occupational Therapy. 2006;69:350–356. 6 Sengupta S, Davis S, Stubbs B. Let’s talk about sexuality: whose responsibility is it? International Journal of Therapy and Rehabilitation. 2008;15:286–287. 7 Sengupta S, Stubbs B. Sexuality and healthcare: can we carry on ignoring the issue? British Journal of Occupational Therapy. 2008;71:269. 8 Pynor R, Weerakoon P, Jones MK. A preliminary investigation of physiotherapy students’ attitudes towards issues of sexuality in clinical practice. Physiotherapy. 2005;91:42–48. 9 Jones MK, Weerakoon P, Pynor RA. Survey of occupational therapy students’ attitudes towards sexual issues in clinical practice. Occup Ther Int. 2005;12: 95–106. 10 Weerakoon P, Jones MK, Pynor R, Kilburn-Watt E. Allied health professional students’ perceived level of comfort in clinical situations that have sexual connotations. J Allied Health. 2004;33:189–193. 11 Wells P. No sex please, I’m dying: a common myth explored. European Journal of Palliative Care. 2002;9:119–122. 12 Stern SH, Fuchs MD, Ganz SB, et al. Sexual function after total hip arthroplasty. Clin Orthop Relat Res. 1991;269:228–235. 13 Sexuality and Sexual Health in Nursing Practice. London, United Kingdom: Royal College of Nursing; 2000. 14 Watson C. Sexual roles in nursing care. Nursing (Lond). 1991;4:13–14. 15 Evans R, Halar E, DeFreece A, Larsen GL. Multidisciplinary approach to sex education of spinal cord-injured patients. Phys Ther. 1976;56:541–545. 16 Summerville P, McKenna K. Sexuality education and counselling for individuals with a spinal cord injury: implications for occupational therapy. British Journal of Occupational Therapy. 1998;61:275–279.

17 Pollard N, Sakellariou D. Sex and occupational therapy: contradictions or contraindications. British Journal of Occupational Therapy. 2007;70:362–365. 18 World Health Organization. Draft working definition. 2002. Available at: https://vle. brookes.ac.uk/webct/urw/lc102116011. tp0/cobaltMainFrame.dowebct. Assessed August 12, 2007. [DOI: 10.2522/ptj.2009.89.1.101]

Congratulations on the Diabetes Special Issue! You are to be commended for this excellent special issue of PTJ concerned with diabetes. Given the apparent expertise of the physical therapists involved as authors of many of the papers in this issue, it is both amazing and tragic that the American Diabetes Association still fails to acknowledge physical therapists as members of the diabetes health care team (see www.diabetes.org/ whos-who-on-your-health-careteam/your-health-care-team.jsp). Hopefully this special issue will inspire more of our colleagues to become further involved in diabetes prevention and management. John O Barr JO Barr, PT, is President, Section on Geriatrics, APTA.

[DOI: 10.2522/ptj.2009.89.1.102.1]

Editor Response You have hit on a key tension: our profession is uniquely qualified to make an impact on this population, yet we have not been centrally involved in diabetes prevention and management. As a profession, we seem to have focused on treating the impairments and complications secondary to diabetes, but we have not been heavily involved in prevention and management of the disease. I have attended several American Diabetes Association conferences and have been surprised to see few physical therapists involved in this important professional organization. The papers in this special issue provide a wide spectrum of information about opportunities (from the subcellular level to the policy level) where physical therapists can and should be involved in this critical problem. I hope the Special Issue helps to spur our involvement and that physical therapists are recognized not only for treating the complications of diabetes, but also for helping people with diabetes increase their exercise and physical activity level safely to prevent and control their disease. Thank you for your letter. Michael J Mueller MJ Mueller, PT, PhD, FAPTA, was Guest Editor, Diabetes Special Issue. He is Associate Professor, Program in Physical Therapy and Department of Radiology, Washington University School of Medicine, St Louis, Missouri.

[DOI: 10.2522/ptj.2009.89.1.102.2]

102 ■

Physical Therapy Volume 89 Number 1

January 2009

Letters to the Editor 4 Davis S, Taylor B. From PLISSIT to ExPLISSIT. In: Davis S, ed. Rehabilitation: The Use of Theories and Models in Practice. Edinburgh, United Kingdom: Churchill Livingstone; 2006:chap 6. 5 Sakellariou D, Algado SS. Sexuality and occupational therapy: exploring the link. British Journal of Occupational Therapy. 2006;69:350–356. 6 Sengupta S, Davis S, Stubbs B. Let’s talk about sexuality: whose responsibility is it? International Journal of Therapy and Rehabilitation. 2008;15:286–287. 7 Sengupta S, Stubbs B. Sexuality and healthcare: can we carry on ignoring the issue? British Journal of Occupational Therapy. 2008;71:269. 8 Pynor R, Weerakoon P, Jones MK. A preliminary investigation of physiotherapy students’ attitudes towards issues of sexuality in clinical practice. Physiotherapy. 2005;91:42–48. 9 Jones MK, Weerakoon P, Pynor RA. Survey of occupational therapy students’ attitudes towards sexual issues in clinical practice. Occup Ther Int. 2005;12: 95–106. 10 Weerakoon P, Jones MK, Pynor R, Kilburn-Watt E. Allied health professional students’ perceived level of comfort in clinical situations that have sexual connotations. J Allied Health. 2004;33:189–193. 11 Wells P. No sex please, I’m dying: a common myth explored. European Journal of Palliative Care. 2002;9:119–122. 12 Stern SH, Fuchs MD, Ganz SB, et al. Sexual function after total hip arthroplasty. Clin Orthop Relat Res. 1991;269:228–235. 13 Sexuality and Sexual Health in Nursing Practice. London, United Kingdom: Royal College of Nursing; 2000. 14 Watson C. Sexual roles in nursing care. Nursing (Lond). 1991;4:13–14. 15 Evans R, Halar E, DeFreece A, Larsen GL. Multidisciplinary approach to sex education of spinal cord-injured patients. Phys Ther. 1976;56:541–545. 16 Summerville P, McKenna K. Sexuality education and counselling for individuals with a spinal cord injury: implications for occupational therapy. British Journal of Occupational Therapy. 1998;61:275–279.

17 Pollard N, Sakellariou D. Sex and occupational therapy: contradictions or contraindications. British Journal of Occupational Therapy. 2007;70:362–365. 18 World Health Organization. Draft working definition. 2002. Available at: https://vle. brookes.ac.uk/webct/urw/lc102116011. tp0/cobaltMainFrame.dowebct. Assessed August 12, 2007. [DOI: 10.2522/ptj.2009.89.1.101]

Congratulations on the Diabetes Special Issue! You are to be commended for this excellent special issue of PTJ concerned with diabetes. Given the apparent expertise of the physical therapists involved as authors of many of the papers in this issue, it is both amazing and tragic that the American Diabetes Association still fails to acknowledge physical therapists as members of the diabetes health care team (see www.diabetes.org/ whos-who-on-your-health-careteam/your-health-care-team.jsp). Hopefully this special issue will inspire more of our colleagues to become further involved in diabetes prevention and management. John O Barr JO Barr, PT, is President, Section on Geriatrics, APTA.

[DOI: 10.2522/ptj.2009.89.1.102.1]

Editor Response You have hit on a key tension: our profession is uniquely qualified to make an impact on this population, yet we have not been centrally involved in diabetes prevention and management. As a profession, we seem to have focused on treating the impairments and complications secondary to diabetes, but we have not been heavily involved in prevention and management of the disease. I have attended several American Diabetes Association conferences and have been surprised to see few physical therapists involved in this important professional organization. The papers in this special issue provide a wide spectrum of information about opportunities (from the subcellular level to the policy level) where physical therapists can and should be involved in this critical problem. I hope the Special Issue helps to spur our involvement and that physical therapists are recognized not only for treating the complications of diabetes, but also for helping people with diabetes increase their exercise and physical activity level safely to prevent and control their disease. Thank you for your letter. Michael J Mueller MJ Mueller, PT, PhD, FAPTA, was Guest Editor, Diabetes Special Issue. He is Associate Professor, Program in Physical Therapy and Department of Radiology, Washington University School of Medicine, St Louis, Missouri.

[DOI: 10.2522/ptj.2009.89.1.102.2]

102 ■

Physical Therapy Volume 89 Number 1

January 2009

Corrections Marcus RL, Smith S, Morrell G, et al. “Comparison of combined aerobic and high-force eccentric resistance exercise...” Phys Ther. 2008;88:1345–1354. Table 3 contains incorrect footnote symbols for within-group differences for thigh lean tissue and body mass index (BMI) in both the AE/RE and AE groups. The 95% confidence interval for thigh intramuscular fat (IMF) in the AE group also is incorrect. The corrected table is shown below. The Journal regrets the errors. Table 3. Outcomes for Glucose Control, Muscle Structure, Physical Performance, Muscle Damage, and Body Mass Indexa AE/RE Group (nⴝ7) Variable HbA1c (%) Thigh lean tissue (cm2) Thigh IMF (cm2) 6MWT distance (m) BMI (kg/m2) CK (U/L) Thigh pain VAS score

Pretraining X (SD)

Posttraining X (SD)

7.1 (1.2)

6.5 (1.3)

142.9 (33.2)

158.0 (35.2)

32.7 (8.4)

31.6 (7.1)

AE Group (nⴝ8)

Within-Group Difference (95% CI) ⫺0.59 (⫺1.5 to 0.28)b 15.1 (7.6 to 22.5)

b,c

⫺1.2 (⫺2.6 to 0.26)b 45.5 (7.5 to 83.6)

b

554.5 (59.3)

600.0 (51.9)

35.0 (6.0)

33.2 (5.8)

160.0 (173.3)

145.1 (120.5)

⫺14.9 (⫺80.1 to 50.4)

2.0 (2.3)

0.0 (0.0)

⫺2.0 (⫺4.13 to 0.13)

⫺1.9 (⫺3.2 to ⫺0.56)b,c

Pretraining X (SD)

Posttraining X (SD)

Within-Group Difference (95% CI)

6.3 (1.2)

6.0 (1.1)

⫺0.31 (⫺0.60 to ⫺0.03)b

138.1 (39.3)

132.7 (41.4)

⫺5.6 (⫺10.4 to 0.76)b,c

32.3 (8.7)

30.2 (9.2)

⫺2.2 (⫺3.5 to ⫺0.85)b

520.3 (33.0)

550.2 (55.9)

29.9 (⫺7.7 to 67.5)b

29.8 (4.4)

30.0 (4.2)

92.5 (46.9)

108.5 (57.1)

0.10 (⫺0.55 to 0.75)b,c 15.7 (⫺14.1 to 45.5)

Data not collected

a

AE/RE group⫽subjects who participated in a combined aerobic and eccentric resistance exercise program, AE group⫽subjects who participated in a program of aerobic exercise only, HbA1c⫽glycosylated hemoglobin, IMF⫽intramuscular fat, 6MWT⫽Six-Minute Walk Test, BMI⫽body mass index, CK⫽creatine kinase, VAS⫽visual analog scale. b Significant (P⬍.05) time effect. c Significant (P⬍.05) interaction (group ⫻ time) effect.

[DOI: 10.2522/ptj.20080124.cx]

Bell AL, Cavorsi J. “Noncontact ultrasound therapy…” Phys Ther. 2008;88:1517–1524. The text of the “f” footnote of Table 3 should read: P value for comparison of >75% granulation tissue at start of treatment vs end of treatment. [DOI: 10.2522/ptj.20080009.cx]

January 2009

Volume 89 Number 1 Physical Therapy „ 103

Corrections Marcus RL, Smith S, Morrell G, et al. “Comparison of combined aerobic and high-force eccentric resistance exercise...” Phys Ther. 2008;88:1345–1354. Table 3 contains incorrect footnote symbols for within-group differences for thigh lean tissue and body mass index (BMI) in both the AE/RE and AE groups. The 95% confidence interval for thigh intramuscular fat (IMF) in the AE group also is incorrect. The corrected table is shown below. The Journal regrets the errors. Table 3. Outcomes for Glucose Control, Muscle Structure, Physical Performance, Muscle Damage, and Body Mass Indexa AE/RE Group (nⴝ7) Variable HbA1c (%) Thigh lean tissue (cm2) Thigh IMF (cm2) 6MWT distance (m) BMI (kg/m2) CK (U/L) Thigh pain VAS score

Pretraining X (SD)

Posttraining X (SD)

7.1 (1.2)

6.5 (1.3)

142.9 (33.2)

158.0 (35.2)

32.7 (8.4)

31.6 (7.1)

AE Group (nⴝ8)

Within-Group Difference (95% CI) ⫺0.59 (⫺1.5 to 0.28)b 15.1 (7.6 to 22.5)

b,c

⫺1.2 (⫺2.6 to 0.26)b 45.5 (7.5 to 83.6)

b

554.5 (59.3)

600.0 (51.9)

35.0 (6.0)

33.2 (5.8)

160.0 (173.3)

145.1 (120.5)

⫺14.9 (⫺80.1 to 50.4)

2.0 (2.3)

0.0 (0.0)

⫺2.0 (⫺4.13 to 0.13)

⫺1.9 (⫺3.2 to ⫺0.56)b,c

Pretraining X (SD)

Posttraining X (SD)

Within-Group Difference (95% CI)

6.3 (1.2)

6.0 (1.1)

⫺0.31 (⫺0.60 to ⫺0.03)b

138.1 (39.3)

132.7 (41.4)

⫺5.6 (⫺10.4 to 0.76)b,c

32.3 (8.7)

30.2 (9.2)

⫺2.2 (⫺3.5 to ⫺0.85)b

520.3 (33.0)

550.2 (55.9)

29.9 (⫺7.7 to 67.5)b

29.8 (4.4)

30.0 (4.2)

92.5 (46.9)

108.5 (57.1)

0.10 (⫺0.55 to 0.75)b,c 15.7 (⫺14.1 to 45.5)

Data not collected

a

AE/RE group⫽subjects who participated in a combined aerobic and eccentric resistance exercise program, AE group⫽subjects who participated in a program of aerobic exercise only, HbA1c⫽glycosylated hemoglobin, IMF⫽intramuscular fat, 6MWT⫽Six-Minute Walk Test, BMI⫽body mass index, CK⫽creatine kinase, VAS⫽visual analog scale. b Significant (P⬍.05) time effect. c Significant (P⬍.05) interaction (group ⫻ time) effect.

[DOI: 10.2522/ptj.20080124.cx]

Bell AL, Cavorsi J. “Noncontact ultrasound therapy…” Phys Ther. 2008;88:1517–1524. The text of the “f” footnote of Table 3 should read: P value for comparison of >75% granulation tissue at start of treatment vs end of treatment. [DOI: 10.2522/ptj.20080009.cx]

January 2009

Volume 89 Number 1 Physical Therapy „ 103

Scholarships, Fellowships, and Grants News from the Foundation for Physical Therapy Foundation Awards $150,000 in Research Grants and Doctoral Scholarships The Foundation for Physical Therapy recently awarded $120,000 in research grants to physical therapists to evaluate the effectiveness of physical therapy interventions. In October 2008, the Foundation’s Scientific Review Committee reviewed grant applications; in December, the Board of Trustees awarded three $40,000 grants to the following individuals for research projects to begin in January 2009: Susanne Morton, PT, PhD, University of Iowa, for her project “Motor Adaptation: A Novel Method for Retraining Locomotion Following Stroke.” Morton will investigate the extent to which abnormal walking patterns can be improved by using motor adaptation in persons with stroke. Motor adaptation works by manipulating some aspect of the environment or the feedback given, producing a gradual adjustment of movements with practice. Results from this work may provide direct information about how walking is modified by visual information and may provide valuable insight for the development of novel rehabilitation interventions based on motor adaptation strategies for recovery of walking impairments, such as asymmetry, in individuals with stroke. This 1-year grant was generously funded by the 20th Marquette Challenge, co-sponsored by the University of Pittsburgh. The Marquette Challenge is an annual grassroots student fundraising effort coordinated by physical therapist students from across the country.

January 2009

Michael Lewek, PT, PhD, University of North Carolina at Chapel Hill, for his project, “Biomechanical Influences on Motor Learning during Locomotor Retraining PostStroke.” The overall goal of this 1-year pilot project is to gather preliminary evidence to test the hypothesis that using variable practice during training will maintain more consistent limb movements during training (aim 1) and result in improved coordination and overground gait speed during retention and transfer testing, respectively (aim 2), compared with training at a constant speed for individuals with chronic (>6 months) stroke. The grant awarded to Lewek was funded by the Geriatric Endowment Fund, made possible by generous gifts from APTA’s Section on Geriatrics.

Foundation Announces Florence P Kendall Doctoral Scholarship Recipients

Jill Heathcock, PT, MPT, PhD, Ohio State University, for her project, “Training in Infants with Neonatal Stroke.” The goal of this 2-year project is to determine the effects of a play-based physical therapy program on how babies who have had a stroke learn to reach out and touch a toy. This work will give clinicians, including physical therapists, occupational therapists, and pediatricians, an earlier and specific treatment protocol for young babies with reaching delay. Heathcock’s grant was funded by the Pediatric Endowment Fund, made possible with generous gifts from APTA’s Section on Pediatrics.

• Elisa Gonzalez-Rothi, PT, DPT, University of Florida

The Foundation for Physical Therapy’s Board of Trustees recently awarded a total of $30,000 in doctoral scholarships to 6 physical therapists. Recipients of the $5,000 Florence P Kendall Doctoral Scholarships for the 2008–2009 academic year are: • Odessa Addison, PT, DPT, University of Utah • Eric Anson, PT, MPT, University of Maryland, College Park • Keith Avin, PT, MS, DPT, University of Iowa • Michael Bade, PT, MPT, University of Colorado Denver Health Science Center

• Virginia Little, PT, MS, NCS, University of Florida.

Paris’ “Make Waves” Campaign Raises $52,000 Stanley Paris, PT, PhD, FAPTA, raised awareness of the Foundation and the need for physical therapy research through his attempt to swim the English Channel last summer. More than 500 people donated more than $52,000 in honor of his effort! Paris gave numerous interviews for articles in magazines, newspapers, and health Web sites and blogs. According to Paris, “At each opportunity I have stressed that we are the profession of choice for the restoration, maintenance, and enhancement of human function. I have stressed that there is no need to slow down at middle

Volume 89 Number 1 Physical Therapy ■ 105

Scholarships, Fellowships, and Grants age and that in fact by maintaining a fit, healthy, and productive lifestyle there is much more that can be enjoyed.” Paris, who successfully swam the Channel twice in the 1980s, made it past the halfway point on July 26 before ending his 7-hour, 40-minute swim because of severe leg cramps and nausea. A second attempt in September was canceled due to deteriorating weather conditions as the Channel swimming season came to a close. You can read more about Paris’ journey to swim the English Channel at www.stanleyparis.blogspot.com. If you would like to make a donation in honor of Paris’ effort, visit the Foundation’s Web site, www. FoundationForPhysicalTherapy.org and click “Donate Now.”

Foundation Offers New Fellowship in Health Services Applications are being accepting until January 27, 2009, for the Foundation for Physical Therapy’s newly created fellowship in health services. The New Investigator Fellowship Training Initiative (NIFTI) in Health Services Research offers $72,000 in salary support for each of the 2 years of the program, half provided by the Foundation and half from the sponsoring institution. For guidelines and the online application, go to www. FoundationForPhysicalTherapy. com. Click on “Program Information” at left, then “Fellowships.”

The fellowship is designed to enable the new investigator to develop research skills necessary to conduct high-quality, independent research to advance his or her capacity to examine optimal health services delivery outcomes in physical therapy, including cost analysis of various rehabilitation interventions. Training will focus on issues related to health care delivery, health services management, assessment of health care needs, evaluation of health markets and services, health economics, and the impact of health policies. In addition to the new fellowship in health services, other grants currently open for applications until January 27 are the 2009 Promotion of Doctoral Studies (PODS) I and II and the 2009 NIFTI.

Session to Offer Advice on Applying for Foundation Funding Members of the Foundation for Physical Therapy’s Scientific Review Committee (SRC) will offer suggestions for preparing a successful grant, scholarship, or fellowship application during an educational session at the Combined Sections Meeting in Las Vegas on Tuesday, February 10, 10:30 AM to 12:15 PM in Coral C.

Get Hooked. Get Evidence for Your Practice. Patient clinical scenarios for conditions commonly seen in practice are now available to provide immediate access to evidence of effectiveness of physical therapy interventions. APTA members can search the clinical scenarios and search the database of more than 4,800 extractions of research articles at www.hookedonevidence.org.

www.hookedonevidence.org

Grant seekers can meet in an informal, roundtable format to discuss any of the four Foundation’s funding opportunities: Florence P Kendall Doctoral Scholarships; PODS I and II; NIFTI and NIFTI in Health Services; and research grants. Scientific Review Committee members who will lead the discussions include: John Buford, PT, PhD, Linda Van Dillen, PT, Jeff Houck, PT, PhD, and Carolynn Patten, PT, PhD. [DOI: 10.2522/ptj.2009.89.1.105]

106 ■

Physical Therapy Volume 89 Number 1

January 2009