Physiotherapy Practice and Research

On April 25, 2015, a 7.8 magnitude earthquake occurred in Nepal; then on the afternoon of May 12, 2015, the small Himalayan nation experienced a second 7.3 magnitude earthquake. As of the writing of this commentary, the estimate of casualties has surpassed 8,500 making it the deadliest natural disaster in Nepal over the past 80 years. Technological advancesin emergency medicine and emergency preparedness have increased the likelihood of surviving a disaster. The result, however, is that populations often survive with complex disabilities that the health infrastructure struggles to accommodate in the early post-disaster period. Nepal had a relatively poor infrastructure for people with disabilities before the earthquake, and the health system will now will be challenged to meet their needs into the future. In this commentary, we argue that there were at least three main lessons learned for the rehabilitation sector following the 2015 earthquake. First, rehabilitation can facilitate earlier discharge from hospitals thereby improving the overall institutional capacity to treat a higher number of patients; second, rehabilitation can prevent secondary musculoskeletal, integumentary and pulmonary complications; and third, rehabilitation improves function so that individuals can have better access to other essential post-disaster services. While rehabilitation may not directly save ‘lives’ following a natural disaster such as an earthquake, it does save ‘life’ among the survivors. In our opinion, and given what we have learned regarding the role of rehabilitation in Nepal and other disasters, we argue that it is unethical and immoral not to integrate rehabilitation into disaster response.

BACKGROUND: Patients with anterior cruciate ligament (ACL) rupture are functionally categorized as copers and non-copers. This differentiation is a determinant factor for designing treatment plan and interpretation of scientific data when ACL deficient subjects are scrutinized. Different procedures have been introduced to differentiate copers from non-copers. However, the majority utilize hop test which can be detrimental to the injured knee. Moreover, hop test may be strongly influenced by confidence and current pain. Therefore, some patients may deny or do not do their best during hop test in order not to further damage their affected knee. Introducing alternative criteria would be helpful in safe and efficient discrimination between copers and non-copers.

PURPOSE: The aim of the present study was to determine whether various subscales of the Knee injury and Osteoarthritis Outcome Score (KOOS) could be considered as possible predictive values in order to differentiate copers from non-copers.

MATERIALS AND METHODS: Thirty-four subjects with ACL rupture participated in this study. The patients subdivided into copers and non-copers based on the number of giving way episodes, global rating of function and six meter timed hop test. Receiver operating characteristics (ROC) analysis were constructed on the subscales of the KOOS to verify whether these subscales could be considered as potential predictive values to differentiate copers from non-copers.

RESULTS: Five subjects (14.7%) were categorized as copers and 29 (85.3%) as non-copers. The area under the curve (AUC) of the KOOS subscales, namely, symptom, pain, daily activity, sport/recreation and quality of life demonstrated 0.83, 0.87, 0.81, 0.91 and 0.92, respectively.

CONCLUSION: All subscales of the KOOS questionnaire can be used as good predictive values along with any other criteria to differentiate copers from non-copers.

BACKGROUND: The direct anterior (DA) total hip arthroplasty (THA) is a minimally invasive procedure that accesses the hip joint from the anterior aspect of the hip by retracting instead of incising muscles during surgery. The lack of soft tissue damage is thought to result in an accelerated return of strength and function.

PURPOSE: The purpose of this study was to identify when participants undergoing DA regained normal strength and function.

METHODS: Twenty DA and 14 controls participated in this prospective study. Maximum isometric hip strength was measured in all hip motions using a hand-held dynamometer. Function was assessed using the Timed Up and Go (TUG) test and the Trendelenburg Single-Leg Balance (SLB) test. Data were collected at pre-operation, three and six weeks, and three months post-operation.

MAIN RESULTS: At three and six weeks post-operation, all strength values except for hip adduction were significantly lower than the control group. By three months, only hip external rotation remained significantly lower in the DA group (p = 0.04; DA: 0.86 ± 0.54 N/BW, Control: 1.22 ± 0.37 N/BW). At three and six weeks post-operation, all strength values except for hip extension and external rotation were more asymmetrical than the control group. By three months post operation, only hip flexion remained more asymmetrical (p = 0.03, DA: –1.11 ± 2.04, Control: 0.55 ± 2.24). There were significant time effects for Trendelenburg SLB test (p = 0.04) and TUG (p = 0.003), but post hoc testing revealed no further differences.

CONCLUSIONS: The results indicate that an emphasis on improving hip flexion and external rotation strength may be valuable in regaining normal strength and function in the DA population.

BACKGROUND: Hybrid Assistive Limb (HAL) is a new robotics walking training device consisting of a wearable robot that interactively provides motion according to the wearer’s voluntary drive. The ability of HAL to enhance walking speed has not been clarified in sub-acute people with stroke, and few studies have focused on changes in walking pattern.

OBJECTIVES: To assess clinical availability of HAL in sub-acute stroke stage, we conduct a multi single-case study.

METHOD: An A-B-A single case study design was used in 4 patients. The intervention was conventional training in period A1 for 5 weeks and period A2 for 4 or 5 weeks and training with HAL and conventional training in period B for 5 weeks. The primary outcomes were maximum walking speed (MWS), cadence, and mean step length assessed each week. The secondary outcomes were Functional Ambulation Category, Berg Balance Scale, Fugl-Meyer Motor Assessment, and asymmetry rate in single-limb support time, as assessed before and after period B.

RESULTS: The significant increases in MWS was found in three patients through period B. The cadence, mean step length, FAC and AR were also increased in one, three, two and two patients, respectively.

CONCLUSIONS: It was found that HAL training of people with sub-acute stroke is an effective walking training to enhance the walking speed with the change of walking pattern in our clinical setting. Further studies are needed including control trials to analyze satirical difference.

BACKGROUND: Physiotherapists play a fundamental role in managing adults with hypermobility and hypermobility syndrome (HMS). Access to training and its influence on the physiotherapy treatment of hypermobile adults is unknown.

OBJECTIVES: The purpose of this study was to: i) Explore UK physiotherapists’ knowledge of hypermobility and HMS in adults. ii) Establish the relationship between knowledge and training or experience. iii) Investigate the future training preferences of physiotherapists in this area.

DESIGN: A nationwide online survey.

METHODS: A cross-sectional survey design collected quantitative and qualitative data. A validated hypermobility questionnaire was adapted and distributed as a self-administered electronic survey. A panel of expert practitioners confirmed face validity.

PARTICIPANTS: UK physiotherapists, experienced in treating adults with musculoskeletal conditions were invited to participate via purposive and snowball sampling of relevant professional networks and clinical interest groups.

ANALYSIS: Microsoft Excel and SPSS were used to analyse data. Chi-squared analysis was used to explore relevant associations. Thematic coding of qualitative data was quantitatively analysed.

RESULTS: 244 Physiotherapists participated. A significant association was found between training and knowledge of HMS (P < 0.001). Furthermore, training was associated with increased clinical confidence in both assessment (P < 0.001), and management (P < 0.001) of the condition. However, 51% of physiotherapists reported having no training in hypermobility, only 10% had undergone training in hypermobility at undergraduate level and 95% requested further training.

CONCLUSION: There are significant gaps in training received by UK physiotherapists’ in the assessment and management of HMS, despite the significant association observed between training and the degree of clinical confidence and knowledge reported.

Spinal pathology commonly features in physiotherapy caseloads and a detailed knowledge of the features of Cauda Equina Syndrome (CES) is essential. While CES is a rare presentation, if missed the consequences of permanent bladder, bowel and sexual dysfunction are devastating. CES has a varied presentation in terms of chronology and symptomatology, leading to difficulty in accurate diagnosis in a clinical setting. The case study of a 48 year old female who developed CES while attending physiotherapy is presented. Her subjective and physical examination findings together with her lumbar Magnetic Resonance Imaging (MRI) findings are outlined. The patient underwent an L₅/S₁ subtotal laminectomy and discectomy and the patient’s status at eight months post-operatively is presented. A comprehensive review of the aetiology, sub-classifications and clinical features of CES is also provided.

BACKGROUND: There has been considerable debate surrounding both the surgical and conservative management of Achilles tendon rupture. There is now a trend towards conservative management however there is no consensus on the best method for this. The aim of this study was to evaluate the clinical and functional outcomes of the conservative management of Achilles tendon rupture using functional dynamic bracing within a functional rehabilitation programme.

METHODS: This was a case-series (an uncontrolled before-after) study, and 25 participants with acute Achilles tendon rupture were recruited. The intervention was a conservative management programme with functional dynamic bracing and functional rehabilitation. The primary outcome measure was re-rupture. Secondary outcome measures were the change in EQ-5D-5L VAS and index scores between commencement of management and 6 months follow up, and the Achilles Tendon Total Rupture Score (ATRS) at 6 months follow up.

RESULTS: No re-ruptures occurred in those participants who complied with the programme (0/21). There were statistically significant positive changes in the EQ-5D-5L VAS with a mean (95% CI) difference pre-post treatment of 12.9 (4.2 to 21.6), p = 0.006. The EQ-5D-5L index scores also significantly improved (Wilcoxon signed-rank test p < 0.001). The mean (SD) ATRS score at 6 months follow up was 76.9 (19.9).

CONCLUSIONS: The results of this study show management of Achilles tendon rupture using functional dynamic bracing within a functional rehabilitation programme produces good clinical outcomes. This study strengthens the evidence base for this conservative intervention in Achilles tendon ruptures.