Individual Physiotherapy Research Articles

A randomized trial comparing a group exercise programme for back pain patients with individual physiotherapy in a severely deprived area

Purpose. To compare a group exercise programme known as the Back to Fitness programme with individual physiotherapy for patients with non-specific low back pain from a materially deprived area.Method. This was a randomized controlled trial including 237 physiotherapy patients with back pain lasting more than six weeks. Participants were allocated to either the Back to Fitness programme or to individual physiotherapy, and followed up at three months and 12 months after randomization. The main outcome measure was the Roland Disability Questionnaire. Secondary measures were: SF12, EQ5D, Pain Self-Efficacy Scale. Health care diaries recording patients' use of health care resources were also collected over a 12-month period.Results. There were no statistically significant differences in change scores between groups on the primary outcome measure at three months (CI − 2.24 to 0.49) and at 12 months (CI − 1.68 to 1.39). Only minor improvements in disability scores were observed in the Back to Fitness group at three months and 12 months respectively (mean change scores; − 0.89, − 0.77) and in the individual physiotherapy arm (mean change scores; − 0.02, − 0.63). Further analysis showed that patients from the most severely deprived areas were marginally worse at three month follow-up whereas those from more affluent areas tended to improve (CI 0.43 to 3.15).

Treadmill training more effective than Bobath training in improving walking following stroke

After recent stroke, does six weeks of aerobic treadmill training increase maximum walking speed and capacity more than Bobath walking training? Randomised, controlled trial with concealed allocation. Rehabilitation unit. Fifty patients were recruited within six weeks of their first supratentorial stroke. Eligibility criteria included ability to walk 12 m with intermittent help or stand-by, 50 to 75 years of age, a Barthel Index of 50 to 80, and participation in a 12-week rehabilitation program. Twenty-five patients were randomised to the treatment group and 25 to the control group. Each patient received 60 min of individual physiotherapy time per week day for six weeks. For patients in the treatment group, therapy consisted of 30 min of treadmill training and 30 min of Bobath walking training. During treadmill training, patients wore a harness to prevent falls and exercised at 60% of their heart rate reserve. Patients in the control group received 60 min of Bobath walking training. Other aspects of the rehabilitation programme were maintained in both groups according to individual needs. The primary outcomes were walking speed and capacity, measured at the end of the six week program and 12 weeks later. Speed was taken as the average of two trials of walking 10 m at maximum speed. Capacity was assessed using the six minute walk test. Secondary outcomes included gross motor functions and walking quality. From baseline to six weeks, speed increased 0.15 m/sec (95% CI 0.12 to 0.18) and capacity increased 34.9 m (95% CI 14.8 to 55) more in the treatment group than in the control group. From baseline to 12 weeks post-program, speed increased 0.22 m/sec (95% CI 0.12 to 0.32) and capacity increased 54.3 m (95% CI 29.8 to 78.2) more in the treatment group than in the control group. Secondary outcomes did not differ significantly at any time between groups. Treadmill training induces greater improvements in walking speed and distance than Bobath walking training in patients with moderate physical disability due to recent first stroke.

Lateral pelvic displacement during gait: abnormalities after stroke and changes during the first month of rehabilitation

Dodd KJ, Morris ME. Lateral pelvic displacement during gait: abnormalities after stroke and changes during the first month of rehabilitation. Arch Phys Med Rehabil 2003;84:1200–5. Objectives: To measure the amplitude and symmetry of lateral pelvic displacement (LPD) in patients with acute hemiparetic stroke; to assess the relationship between LPD and walking speed; and to quantify changes in LPD during 1- and 4-week intervals in the early stages of gait rehabilitation. Design: LPD amplitude and symmetry were measured in stroke patients on admission to acute rehabilitation, 1 week later, and at 4-week follow-up. Performance was compared with sex-, height-, and age-matched control subjects. Setting: Urban geriatric inpatient rehabilitation facility in Australia. Participants: Fifteen patients with a single-hemisphere stroke, confirmed by computed tomography, were compared with the data from 12 control subjects. Patients’ FIM™ instrument scores ranged from 54 to 124. Intervention: Gait rehabilitation involved twice-daily individual physical therapy sessions of 45 to 60 minutes, 5 days a week, incorporating whole and part practice, mental rehearsal, verbal feedback on performance, manual guidance, and strengthening techniques. Main Outcome Measures: Three-dimensional motion analysis of LPD amplitude and symmetry; and preferred walking speed over 10m. Results: Compared with controls, stroke patients initially showed increased amplitude of LPD, with no difference in LPD symmetry. A statistically significant linear relationship existed between walking speed and amplitude of LPD ( r=−.53; P=.04), yet not between walking speed and symmetry ( r=−.41, P=.13). Amplitude and symmetry values remained consistent during the 4-week period of rehabilitation. Conclusions: These results provide baseline LPD values for patients with acute hemiparetic stroke and demonstrate the relationship between LPD and walking speed. Change in LPD during inpatient rehabilitation was not uniform or predictable, particularly during longer periods. This highlights the need for therapists to regularly reassess each patient during the early rehabilitation phase after stroke, especially given that individual differences can be marked.

Non-specific musculoskeletal disorders in patients in primary care: subgroups with different outcome patterns

Patients with non-specific musculoskeletal disorders are considered to be a heterogeneous group with multifactorial problems. Appropriate and effective treatments for these patients have been hard to find. The purpose of this study was to identify subgroups of patients with different patterns of treatment outcome and to find possible predictors of outcome. A total of 78 patients, 64 females and 14 males, with non-specific musculoskeletal disorders were recruited consecutively to three different treatment approaches, Body Awareness Therapy, Feldenkrais, and conventional, individual physiotherapy in primary care. The outcome variables were calculated as effect-size values and consisted of dynamic balance; pain measurements according to pain drawing and MPI; psychological variables such as psychological distress and self-image; and health related factors with regard to quality of life, self-efficacy and sense of coherence. A cluster analysis revealed three subgroups of patients with significantly different treatment outcomes, which were systematically related to the treatment approach. With Body Awareness Therapy and Feldenkrais, the possibility to achieve positive treatment effects increased significantly in comparison to individual physiotherapy.

Physical Therapy for Adhesive Capsulitis: Systematic review

Summary Objective To review recent research on the efficacy of physical therapy for patients with adhesive capsulitis. Design Search of Medline and CINAHL databases for studies published between January 1990 and December 2000. Inclusion criteria Non-operative experimental or descriptive research-based outcomes studies of physical therapy. Main outcome measures Methodological quality scoring using 16 predetermined criteria with 100% (16/16) indicating highest quality. Results Quality scores of the 12 studies that met inclusion criteria ranged from 38% to 69% (mean 54%). By design, scores were highest for the reviewed retrospective and randomised controlled studies. Conclusions How efficacious physical therapy is for patients with adhesive capsulitis is uncertain. Reviewed studies suggest that many patients treated with physical therapy benefited from reduced symptoms, increased mobility, and/or functional improvement. However, the lack of rigour and poor standardisation of terminology, methodology, and outcome measurements in these investigations undermines their validity and clinical application. More rigorous investigations are needed to compare the effects and costs of individual physical therapy interventions.

Comparison of Group and Individual Physiotherapy for Female Urinary Incontinence in Primary Care: Pilot study

Objective To compare the effectiveness of group versus individual management on physical symptoms and quality of life in female urinary incontinence (FUI). Design A pragmatic randomised controlled trial with blinded assessment. Setting A community physiotherapy department accepting primary and tertiary referrals. Participants Forty-four women (mean age 50 years) with clinical symptoms of stress and/or urge incontinence (median duration of symptoms 3 years 7 months) presenting to physiotherapy. Interventions Three educational group sessions or one 45-minute individual treatment. Main outcome measures Blinded assessments at baseline and at 12-14 weeks after treatment included a perineal pad test, seven-day bladder chart, incontinence impact questionnaire and symptom severity index and visual analogue scale (VAS). Results At baseline there were no statistically significant differences between the two treatment arms. After treatment both groups had, on average, improved over baseline on all outcome measures. Group treatment (which was more cost-effective) appeared better for self-rated symptoms than individual sessions, but this did not reach statistical significance. Conclusion Physiotherapy for FUI appears effective. The trends in favour of group intervention seen in this study may reach statistical significance in larger studies. Such studies are feasible, but should also assess the cost-effectiveness and acceptability to women of the two approaches. To compare the effectiveness of group versus individual management on physical symptoms and quality of life in female urinary incontinence (FUI). A pragmatic randomised controlled trial with blinded assessment. A community physiotherapy department accepting primary and tertiary referrals. Forty-four women (mean age 50 years) with clinical symptoms of stress and/or urge incontinence (median duration of symptoms 3 years 7 months) presenting to physiotherapy. Three educational group sessions or one 45-minute individual treatment. Blinded assessments at baseline and at 12-14 weeks after treatment included a perineal pad test, seven-day bladder chart, incontinence impact questionnaire and symptom severity index and visual analogue scale (VAS). At baseline there were no statistically significant differences between the two treatment arms. After treatment both groups had, on average, improved over baseline on all outcome measures. Group treatment (which was more cost-effective) appeared better for self-rated symptoms than individual sessions, but this did not reach statistical significance. Physiotherapy for FUI appears effective. The trends in favour of group intervention seen in this study may reach statistical significance in larger studies. Such studies are feasible, but should also assess the cost-effectiveness and acceptability to women of the two approaches.

Physical and exercise therapy for treatment of the rheumatoid hand

To study the short-term effects of physical therapy (ice massage or wax packs, thermal baths, and faradic hand baths) and exercise therapy on the rheumatoid hand. The effect of individual physical therapy and exercise therapy programs was evaluated in 50 randomly selected rheumatoid arthritis inpatients (38 women and 12 men). Mean patient age (+/- SD) was 47.94 +/- 11.22 years, and mean disease duration was 5.04 +/- 4.80 years. The control group consisted of 50 randomly selected rheumatoid arthritis outpatients (37 women and 13 men; mean age 48.46 +/- 10.65 years, mean duration of disease 5.23 +/- 4.89 years) who at the time of the investigation were not receiving any physical or exercise therapy. The clinical indices used for evaluation of inflammation included erythrocyte sedimentation rate (ESR), pain intensity, proximal interphalangeal (PIP) joint size, and Ritchie articular index. Hand grip strength, palmar tip-to-tip and key pinch finger strength, finger range of motion, and activities of daily living (ADL) were the parameters used to assess the functional hand status. The study was single-blinded and of 3 weeks duration. In the physical therapy treated group, there was an improvement for most of the observed indices from baseline parameters that achieved statistical significance (P < 0.01 and P < 0.005) after the 3-week study period. ESR and PIP joint size improved clinically but failed to reach statistical significance. Patients had a more significant improvement in hand pain, joint tenderness, and ADL score (P < 0.005) than in range of motion (P < 0.01). All parameters in the control group slightly deteriorated over the study period. At least in the short term, physical and, particularly, exercise therapy produce a favorable improvement in the functional status of the rheumatoid hand.

Physiotherapy in Intensive Care: Towards an Evidence-Based Practice

In most hospitals in developed countries, physiotherapy is seen as an integral part of the management of patients in ICUs. The precise role that physiotherapists play in the ICU varies considerably from one unit to the next, depending on factors such as the country in which the ICU is located, local tradition, staffing levels, training, and expertise. The referral process is one example of this variation, whereby in some ICUs, physiotherapists assess all patients, whereas in other ICUs, patients are seen only after referral from medical staff. 1 The most common techniques used by physiotherapists in the ICU are positioning, mobilization, manual hyperinflation (MH), percussion, vibrations, suction, cough, and various breathing exercises. 1‐7 Some physiotherapists routinely treat most, if not all, ICU patients with a combination of these techniques, 1 regardless of the patient’s underlying pathophysiologic condition, with the intention of preventing pulmonary complications, whereas other physiotherapists use such techniques selectively when they believe they are specifically indicated. As the cost associated with the management of ICU patients is very high, the requirement for all those who work in ICUs, including physiotherapists, to provide evidence-based practice is mandatory. The aim of this article is to review the evidence regarding the effectiveness of physiotherapy for patients in the ICU and thus provide a framework for evidence-based practice. Potential areas for future research are also discussed. This review is primarily concerned with the management of intubated, mechanically ventilated, adult patients. The role of physiotherapy for nonintubated patients, including those receiving noninvasive mechanical ventilation, and pediatric patients is beyond the scope of this review. Initially, a description of the individual physiotherapy treatment techniques and their physiologic rationale will be provided. The literature review of the effectiveness of physiotherapy for intubated patients receiving mechanical ventilation in the ICU will then be discussed under the following headings: pulmonary function; hemodynamic and metabolic factors; the incidence of pulmonary complications; the clinical course of pulmonary conditions; overall outcome; and the effectiveness of the individual components of physiotherapy. Evidence concerning the effectiveness of continuous rotational therapy, which can be considered a type of physical therapy, will be reviewed in the treatment technique research section. In view of the large number of studies identified in some of these areas, details of each study will not be provided. Instead, selected studies that are considered to be landmark studies or characteristic of those conducted in the area will be described. Subsequent to the literature review, recommendations for evidence-based practice for physiotherapy in the ICU are considered under the following headings: prevention of pulmonary complications; treatment of pulmonary conditions and complications; short-term benefits; selection of individual treatment techniques; and monitoring required during physiotherapy. To ensure that the major relevant articles were reviewed, literature searches were performed using a CD-ROM version of the databases MEDLINE and CINAHL (Cumulative Index to Nursing and Allied Health Literature) with appropriate subject headings and keywords, including physical therapy, intensive

EFFECTIVENESS OF IN-PATIENT REHABILITATION FOR SUB-CHRONIC AND CHRONIC LOW BACK PAIN BY AN INTEGRATIVE GROUP TREATMENT PROGRAM (SWISS MULTICENTRE STUDY)

In this multicentre intervention study, we compared an integrated group treatment program which combines psychological and education methods into a more active training approach, with the traditional individual approach of physiotherapy and physical procedures for sub-chronic and chronic low back pain. Our 411 patients had a 4-week inpatient treatment: 243 patients in an experimental program and 168 in a traditional program. Outcomes of 283 patients were assessed 3 months and 1 year after entry. The dropout rate was 31.1%. Both conditions demonstrated favourable initial effects on functional and psychological parameters, but the integrated approach showed better long-term results for work rehabilitation than the traditional approach. The most successful patients (n = 58) were younger and had a higher educational level in comparison to the unsuccessful subgroup (n = 71). The main conclusion is that an integrated approach promoting self control and behaviour change through educational measures achieves better long-term results than the traditional individual physiotherapy approach.

Regression of back and posterior pelvic pain after pregnancy.

A prospective, consecutive cohort analysis of the regression of the incidence and intensity of back and posterior pelvic pain after delivery in pregnant women was done. To identify back and posterior pelvic pain from mid-pregnancy to 5 months after delivery and to illustrate differences between these two pain types. Chronic back pain may start during a pregnancy, and regression of unspecified back pain after delivery may be slow and incomplete. Few studies have distinguished back pain from posterior pelvic pain in pregnancy, and no study has presented follow-up data after delivery with respect to pain types. One hundred and sixty four of 368 pregnant women studied had back or posterior pelvic pain and were offered individual group physiotherapy and training. The women were observed until 5 months after delivery. Standardized clinical examination protocols and questionnaires were used. Posterior pelvic pain was experienced by 124 women, and back pain was experienced by 40 women during pregnancy. After delivery, however, back pain was more common. Pain intensity was higher among women with posterior pelvic pain during pregnancy, whereas after delivery pain intensity was higher among women with back pain. A correlation was found between the presence of high pain intensity during pregnancy and little regression of pain after delivery. One of every three pregnant women studied experienced posterior pelvic pain, and one of every nine women experienced back pain. Posterior pelvic pain was more intense during pregnancy, and back pain was more intense and more common after delivery. High pain intensity in pregnancy indicated a bad prognosis.

Deficit and change in gait velocity during rehabilitation after stroke

Objective: To quantify the initial deficit, change, and outcome in gait velocity during inpatient rehabilitation following stroke. Design: The initial deficit on admission to rehabilitation was quantified by comparing 42 stroke patients with 42 controls matched by gender and age. The change in the stroke patients during the next 8 weeks was quantified and gait outcome was compared with functional and normal criteria. Setting: Patients were referred from four inpatient rehabilitation centers at the time of admission following a median of 16.5 days in the acute hospital. Patients: Selection criteria: ability to give informed consent; unilateral first stroke; ability to walk 10 meters. Intervention: Patients participated in a median of 17.38 hours of individual physical therapy including a median of 6.92 hours of gait training during the 8 weeks. Main Outcome Measure: Gait velocity. Results: Gait velocity was initially 38.6% (26.7m/min SD = 14.9) of the performance of controls and improved to 55.1% (38.1m/min). At outcome only 24% exceeded the 5th percentile of controls (48.1m/min) or the velocity required to cross the typical signalled intersection (46.2m/min). The change was only 26% of the initial deficit. Fifty-five percent of the patients improved beyond the 95% confidence intervals surrounding the error of measuring change. Indices of responsiveness indicated that there was a high signal-to-noise ratio and a robust effect size. Conclusion: Gait velocity discriminated the effect of stroke and the change during rehabilitation.

Spinal muscular atrophy type II (intermediary) and III (Kugelberg-Welander). Evolution of 50 patients with physiotherapy and hydrotherapy in a swimming pool.

We added hydrotherapy to 50 patients with spinal muscular atrophy (SMA) who were being treated with individual conventional physiotherapy. Hydrotherapy performed at an approximate temperature of 30 degrees Celsius, twice a week, for thirty minutes in children and forty-five minutes in adults during a 2-year period. The outcome derived from this combined modality of treatment was rated according to physiotherapeutic evaluations, the MMT (Manual Muscular Test), and the Barthel Ladder. Patients were reevaluated at 2-month intervals. After two years of ongoing treatment, we were able to observe that the deformities in hip, knee and foot were progressive in all SMA Type II patients, and in some Type III. Muscle strength stabilized in most SMA Type III patients, and improved in some. MMT was not done in SMA Type II. In all patients we were able to detect an improvement in the Barthel Ladder scale. This study suggests that a measurable improvement in the quality of daily living may be obtained in patients with SMA Types II and III subjected to conventional physiotherapy when associated with hydrotherapy.

Therapeutic effects of individual physical therapy in ankylosing spondylitis related to duration of disease.

Physical therapy in ankylosing spondylitis (AS) is considered important for maintaining or improving mobility, fitness, functioning, and global health. We studied the influence of disease duration on the short term effects of supervised individual therapy. One hundred forty-four AS outpatients (modified New York Criteria; mean age: 43 years; median duration of disease: 4 years; range: 0-33) received 12 supervised individual treatments in a 6-week course of 30 minutes. Endpoints were: spinal mobility (thoracic and lumbar flexion and extension, chest expansion, cervical rotation), fitness (maximum work capacity by ergometry), functioning (Sickness Impact Profile (SIP) and the Functional Index (FI)), and global patient assessment of change on a visual analogue scale. After 6 weeks patients had improved in all endpoints, but only significantly in rotation (8 degrees, 10%), fitness (6 watt, 4%), and SIP (0.6, 14%; t-test, p < 0.05). Global patient assessment improved by 1.1 (22%). Plots of change scores and disease duration showed no evident relation. We also divided the population into two groups, with the median disease duration as a cut-off. No relevant difference in improvement was found between 'short duration' and 'long duration' groups (t-test of change scores, p > 0.05). In addition, no relevant correlation was found between change scores and disease duration (p > 0.01). It may be concluded that irrespective of disease duration, short term supervised individual therapy is effective in AS, slightly improving mobility, fitness, functioning and global health.

VARIABILITY AMONG GERIATRICIANS IN THE EVALUATION OF FUNCTIONAL DISABILITIES AND REHABILITATION NEEDS OF THE ELDERLY

A formal variability study has been carried out in a geriatric hospital in Genoa, Italy, in order to estimate the degree of agreement between geriatricians in disability and functional assessment, recommendation for rehabilitation treatments, need for mobility and daily activities aids, and decisions about optimal place of treatment (own home, sheltered housing, old peoples' home, nursing home). Sixteen long-stay geriatric patients, average age 83 years, were visited by eight geriatricians, a patient receiving from two to five visits. The participating physicians could visit the patients at their leisure, had access to clinical records and could interview a nurse well acquainted with the patient. A marked variability was observed for most items, e.g. the agreement concerning the recommendation for individual physiotherapy was only 52%. The results of this study may not be generalized to other situations and to actual practice; however, variability studies of this kind, that assess diagnosis habits, treatment and managerial decisions at the same time, may be useful to pinpoint the most important problems and to stimulate professionals' participation in proper Quality Assurance projects.

Academic tenure: what does it mean?

Tenure is an integral aspect of academia. Because tenured faculty give esteem to individual physical therapy programs and to the profession as a whole, understanding the process of attaining tenure is vital to all physical therapy educators. Tenure in universities is described, and the process of attaining tenure is outlined. Criteria for tenure, factors related to transfer of faculty between universities, and considerations for terminating tenured faculty are also discussed. Departmental chairmen have a responsibility to ensure that the faculty members understand the tenure process and are given the opportunity to meet tenure criteria.

Role of Physical Therapists in Physical Activity Programs in Nursing Homes: A Survey

A survey was conducted to help define the role of physical therapists in physical activity programs in nursing homes. Questionnaires were completed by 64 physical therapists working in nursing homes of 130--150 bed capacity. The major factors studied were employment status, work-time at the facility, interprofessional relationships, and available equipment and space. Of the respondents, 43.7 percent were involved in physical activity programs, the most common roles being staff instruction and consultation. Only a small percentage of the time was used for programs; most of the time was occupied with individual physical therapy treatment. The principal types of programs with physical therapist involvement were ambulation and gait training, bed exercises, and general group exercises. Equipment and space seemed adequate. Physical therapists were likely to be involved in physical activity programs if: 1) they were employed by the nursing homes, were paid on a salary basis, worked at the nursing homes full-time or nearly full-time, and did not work elsewhere; 2) such programs were mentioned during discussion of the work agreement; and 3) the coordinator of the physical activity programs was an occupational therapist or a nurse rather than an activities director or recreational therapist.

Leibes??bungen mit Spina bifida - Kindern an der Sonderschule f??r K??rperbehinderte (Grundschule)

With a rate of 0.5-1/1,000 of the total number of births in West Germany, spina bifida is next to cerebral paresis one of the most frequent congenital defects. Altogether, fifty places in special schools are needed per one million of inhabitants for spina bifida children. The loss of physical unctions is comparable to that in the case of paraplegia. The variety of medical and psychological problems makes the cooperation of highly different branches of study indispensible in a rehabilitation team (neurosurgeon, neuropediatrician, urologist, orthopaedist, pediatrician, educator, social worker, physical therapist). Each team member must be informed about the complete rehabilitation plan. These children's shortage of environmental experience is mainly due to their backwardness as regards motoric development, which cannot be recovered by means of individual physical therapy alone. On the other hand, additional, specifically selected and organised physical education makes possible the necessary mobility and social experiences. By giving the children exercises suitable for their ages it is hoped to achieve a late maturation and stabilization of the personality. In choosing the exercises it is first of all necessary to go back to the so-called fundamental activities like climbing, hanging by one's hands, sliding, pushing oneself up off the ground, swinging or throwing and catching, before going on to wheel-chair sports. Wheel-chair sport promises a varied selection for group exercises (games) and for everyday use. Using the wheel-chair as sports equipment, it is possible for persons with other types of locomotive handicaps to be integrated into the group. For physical education in special schools the pupils whould be arranged into groups according to their ability in order to keep the groups as homogenous and the children's chances as equal as possible. The most important teaching criteria are in this case: the creation of a happy atmosphere, a high degree of clarity, the fulfilment of individual inclinations, the encouragement of independence, the development of community life and the fulfilment of everyday tasks. In swimming, the spina bifida child differs from the normal child in his greater initial fear and in the existence of contractions, a scoliosis, hyperlordosis or -kyphosis due to the resultant instability of the water. Because of this, specifically oriented swim- and work-aids must be used. The didactic procedure is then the same as in the case of normal children. After the child's familiarity with and safety in the water is assured, one can proceed to individual swimming techniques and in a few cases to sport swimming. Bacteriological examination of the water did not yield any results which could cause objection on the grounds of hygiene.