Physiotherapy Practice and Research

BACKGROUND: Cervical dystonia is the most common form of focal dystonia. Due to limitations of established surgical and pharmacological interventions for the treatment of cervical dystonia, various non-pharmacological and non-surgical interventions are being considered as alternative or adjunct treatment options. The aim of this systematic review was to assess the quality of evidence for the use of these interventions and their effectiveness in clinical practice. METHODS: Major databases including MEDLINE, CINAHL, PEDro and PsycINFO were searched for articles published in English from January 1996 to July 2013. A manual search of reference lists was also conducted. Two independent reviewers evaluated the methodological quality of included studies using Sackett's level of evidence and Structured Effectiveness Quality Evaluation Scale (SEQES). RESULTS: Ten studies were included in the review, four of which were at Sackett's level of evidence 2b. The single randomized control trial was under powered so definitive conclusions based on non-significant results could not be drawn. The two studies with the next highest level of evidence combined physical therapy with Botox injections, and demonstrated significant improvement in dystonia severity, pain and physical functioning. Half the studies reviewed were case studies. CONCLUSIONS: There is low to moderate evidence supporting the effectiveness of physical therapy in the treatment of cervical dystonia. Limitations included the methodological approaches employed in several of these studies. There is a need for further research to establish the effectiveness of physical therapy and other alternative non-surgical and non-pharmacological interventions for improving the long-term management of cervical dystonia.

BACKGROUND: Low back pain (LBP) is commonly reported in people with hip osteoarthritis (OA) and is a poor prognostic indicator of outcome in OA. This study aimed to identify the clinical features associated with LBP in people with hip OA attending orthopaedic and rheumatology clinics. METHODS: A cross-sectional study was undertaken. Twenty-four people with radiographically confirmed OA were recruited and completed self-report questionnaires for hip and LBP severity (Visual Analogue Scale), hip-related disability (Western Ontario and McMaster Universities Osteoarthritis Index) and back-related disability (Roland Morris Disability Questionnaire). Physical examination comprised spinal palpation, pelvic girdle pain provocation tests and hip and spinal range of motion tests. Between-group (presence/absence of LBP) differences in self-report and physical examination items were compared using Mann-Whitney U and Chi-squared tests. RESULTS: A total of 16/24 (66.7%) patients reported LBP. Those with LBP were younger, reported more pain locations and had higher self-report pain and disability. On physical examination, people with LBP and OA hip had reduced hip flexion, greater pain provocation with hip abduction, hip lateral rotation, spinal palpation and a greater number of painful pelvic girdle tests and spinal level palpation. CONCLUSIONS: Assessment of patients with hip OA should incorporate examination of the lumbar spine and pelvic regions. It appears from our study that LBP is a common co-morbidity in those with OA of the hip and may indicate greater severity of hip disease, although the small sample size limits interpretation of results. Further research should investigate the exact relationships between presence of LBP and hip OA.

PURPOSE: The aim of this study was to identify how Cauda Equina Syndrome (CES) symptoms may be more effectively identified by patients along with their experiences with clinicians. Patient's symptoms and understandings of their condition were explored, including issues associated with bladder, bowel and sexual function. METHOD: An interpretive research paradigm using a narrative approach was adopted utilising qualitative one-to-one semi-structured interviews. Narrative research is a useful way to explore patients' perceptions of and the meanings attached to CES symptoms. The clinical setting was within an NHS Foundation Trust in an industrial town in the Northwest of England. Participants were recruited from the population of patients who, in the preceding 18 months had attended the Orthopaedic service for care related to CES. New cases presenting during the data collection period were also eligible for inclusion. Ten patients consented, 7 females and 3 males, average age 58.5 years (range 33–72). All interview data was transcribed and subjected to narrative analysis. The narrative analysis explored perceptions of and the meanings associated with the personal and emotional aspects of the participant's pain and symptoms, along with how these aspects of the participants experiences were relayed to the clinician or affected their interaction with clinicians. RESULTS: Narrative analysis identified two key issues to be essential in facilitating timely diagnosis of CES a) clinician's knowledge of signs and symptoms and an awareness of these by patients b) communication about these signs and symptoms using a language understandable to both patients and clinicians.

OBJECTIVES: To explore knowledge and perceptions of Joint Hypermobility (JHM) and Joint Hypermobility Syndrome (JHS) amongst paediatric physiotherapists and to determine training needs. DESIGN: National online survey. SETTING AND PARTICIPANTS: UK paediatric physiotherapists were surveyed through the interactive website of the Chartered Society of Physiotherapy (iCSP). INTERVENTION: A previously validated, self-report questionnaire with minor modifications was distributed nationally via iCSP. RESULTS: Ninety-one questionnaires were completed with representation from all NHS regions. 84% (76/91) of respondents had 6 or more years of experience. Fifty-one percent (46/91) of physiotherapists had received no pre- or post-registration training about JHS. Seventy-nine percent (72/91) were confident in their ability to diagnose JHM, while 54% (49/91) were confident in their ability to diagnose JHS. The physiotherapists had better knowledge of the articular features than the non-articular features of JHS with mean knowledge scores of 63.8% and 54.7% respectively. Eighty percent (73/91) of physiotherapists perceived JHS to have significant impact on quality of life. Education and reassurance, home exercises, proprioception, closed chain exercises, postural education and orthotics, were perceived by more than 80% respondents as effective. Ninety-seven percent (88/91) indicated a need for continuing professional development (CPD) training. CONCLUSIONS: The majority of respondents considered JHS to impact significantly on quality of life. Participants had greater confidence in diagnosing JHM than JHS and had better knowledge of the articular features than the non-articular features of JHS. Results suggest that undergraduate and CPD education is required to facilitate greater understanding of the assessment and management of this multi-system condition.

BACKGROUND: Generalised joint hypermobility (GJH) is common in the general population and may not confer any adverse symptoms. Joint Hypermobility Syndrome (JHS) is a connective tissue disorder that often runs in families and may present with a complex array of signs and symptoms. JHS is under-recognised and often poorly managed by the medical and physiotherapy professions. OBJECTIVES: The primary aim of this study was to investigate the prevalence of GJH and JHS in patients attending a Musculoskeletal Triage Clinic. Secondary aims of this study were to explore the health-related quality of life, pain levels, primary pain area and number of painful joints in patients with and without JHS. METHOD: A cross-sectional study design was used. The participant population included a convenience sample from patients attending a Musculoskeletal Triage Clinic based in a Primary Care setting in London. The main outcome tools were the Beighton Score, Brighton Criteria, the EQ-5D-5 L and the Visual Analogue Scale (VAS). RESULTS: A total of 150 participants were recruited into the study. GJH was recorded in 19% of participants and JHS was recorded in 30% of participants. Participants with JHS reported a greater number of painful joints (p < 0.05) than those without. No difference was found in the EQ-5D-5 L and the global VAS scores between the group with JHS and the group without. Participants with JHS (p < 0.01) were found to be more likely to present with wrist/hand pain as their main problem compared to those without JHS. CONCLUSIONS: This study found GJH in 19% and JHS in 30% of participants attending a Musculoskeletal Triage Clinic. This study also found that patients with JHS are likely to present with a greater number of painful joints and are more likely to present with wrist/hand pain as their main problem than those without JHS.

STUDY DESIGN: Retrospective diagnostic test study (N = 120). BACKGROUND: Due to reorganisation of healthcare provision to meet rising demands, traditional medical roles such as the diagnosis of meniscal tears is now being undertaken by Extended Scope Practitioners (ESP) with a background in physiotherapy. There are limited studies supporting the diagnostic expertise of these clinicians. OBJECTIVE: To compare diagnostic accuracy of Orthopaedic Extended Scope Practitioners (ESP, N = 7) with Consultant Orthopaedic Surgeons (COS, N = 3) in the diagnosis of meniscal tears of the knee. METHODS: The records of 120 patients seen by seven ESP and three COS between July 2006 and July 2007 were accessed. The initial diagnosis given was compared with the findings at MRI scan. Sensitivity (Sn), specificity (Sp), accuracy (Acc), positive predictive value (PPV) and negative predictive value (NPV) were calculated for each profession. A Pearson's chi squared test (χ²) was undertaken to determine if there was a statistically significant difference between ESP and COS in the proportions of patients with the clinical diagnosis of a meniscal tear that was subsequently confirmed at MRI scan. RESULTS: ESP had higher Sensitivity, Accuracy and Positive Predictive Value (82.5%, 77.7%, and 82.9%) than COS (70%, 71.6%, and 77.4%) but lower Specificity and Negative Predictive Value (65%, 65%) than COS (75%, 66.5%). Pearson's χ² analysis showed that there was no significant difference between these groups in the proportions of patients correctly diagnosed as having a meniscal tear (p = 0.19, χ² = 1.726). CONCLUSION: In the diagnosis of meniscal tears in a single Orthopaedic clinic, ESP appeared to possess diagnostic capability comparable with COS.

BACKGROUND: The quadriceps fatigue test is used to measure the progressive, exercise-induced, decline in the quadriceps maximal torque generating capacity over the course of time as an indicator of quadriceps fatigue. Reliability of this test has not been reported. PURPOSES: To determine: (1) test-retest reliability of the quadriceps fatigue test and (2) the relationship between quadriceps activation failure (QAF) and the quadriceps fatigue. METHODS: Nineteen volunteers with no history of knee impairments participated in two testing sessions. The quadriceps fatigue test was performed using repeated isometric quadriceps contractions at 50% of maximum voluntary isometric contraction (MVIC) torque. MAIN RESULTS: The quadriceps fatigue test demonstrated good test-retest reliability (ICC's of 0.92 (95% CI = 0.81 to 0.96) for the MVIC rate of decline at 5 minutes and 0.89 (95% CI = 0.75 to 0.95) for the MVIC rate of decline at total time. The results indicate that the quadriceps fatigue was due to “central fatigue”. Increased rate of decline of MVIC torque (i.e., more fatigue) was associated with higher magnitude of QAF (r = 0.52). CONCLUSION: In healthy individuals, the quadriceps fatigue test demonstrated good test-retest reliability. Quadriceps activation failure may play an important role on quadriceps fatigue mechanisms.