Primary Care Physiotherapy Research Articles

Intertester reliability of a classification system for shoulder pain

Objective To describe and determine the intertester reliability of a newly developed classification system of shoulder syndrome recognition. Design Intertester reliability study. Setting Fourteen primary care physiotherapy clinics. Participants Two hundred and fifty-five patients with shoulder pain. Inclusion criterion: presence of shoulder pain aring within the glenohumeral or associated joints and structures. Exclusion criteria: previous shoulder surgery, surgical candidates, recognised malignancy, systemic illness, or concurrent cervical pain and/or radiculopathy. Intervention Examiners were 55 physiotherapists who were arranged in pairs; each patient received two independent and blinded assessments, one by each of the paired physiotherapists. This shoulder classification approach contains three main clinical syndromes: Pattern 1 (impingement pain), Pattern 2 (acromioclavicular joint pain) and Pattern 3 (shoulder pain: frozen shoulder, glenohumeral arthritis, massive cuff tear, subscapularis tear, painful laxity, post-traumatic instability, internal derangement). Main outcome measures Percentage agreement and Cohen's kappa coefficient. Results The mean age of patients was 46.6 years (standard deviation 16.3, range 16 to 86), and 57% were male. Physiotherapists agreed on the pattern of shoulder pain for 205 of the 255 shoulders assessed (agreement rate 80%); the kappa coefficient was 0.664 (95% confidence interval 0.622 to 0.706; P < 0.001). Of the 205 agreements, Pattern 1 was the most common condition; physiotherapists agreed on this pattern for 139 patients (68%). Both physiotherapists diagnosed Pattern 2 for 20 patients and Pattern 3 for 46 patients. Conclusion This clearly defined system uses key elements of the history and examination to classify patients with shoulder pain. The kappa coefficient denotes good reproducibility.

Neuropathic Pain Mechanisms in Patients with Chronic Sports Injuries: A Diagnostic Model Useful in Sports Medicine?

The pathophysiology of chronic sports injuries such as overuse or tendinopathy remains largely unknown. With this exploratory study, we aim to detect signs of sensitization of the nervous system. Sensitization is an indication of the involvement of neuropathic mechanisms in patients with chronic sports injuries. Sensory descriptors were assessed by means of a neuropathic pain questionnaire (DN4-interview) and by three methods of sensory testing. The test results were integrated in a scoring system. Patients were recruited from an outpatient clinic of a University Medical Centre and at primary care physical therapy practices. Fifteen athletes with a unilateral chronic sports injury were included. All subjects filled out the seven-items of the DN4-interview to assess sensory descriptors. Next, the presence of brush-evoked allodynia was assessed and pain thresholds with Von Frey monofilaments and a pressure algometer were measured in all patients to determine signs of sensitization. Based on the scoring system, in 4 out of 15 patients (27%) the presence of sensitization could be detected. In two other patients, signs of hypoalgesia were observed. The involvement of sensitization as an explanation for the pain in chronic sports injuries is credible in a considerable proportion of patients. With respect to treatment, the establishment of such neuropathic pain mechanisms is of clinical significance.

Primary Care Physical Therapy in People With Fibromyalgia: Opportunities and Boundaries Within a Monodisciplinary Setting

Despite the fact that people with fibromyalgia syndrome (FMS) frequently are seen by primary care physical therapists, guidelines for the management of FMS are based primarily on outcomes from multidisciplinary and tertiary care treatment studies. Few data addressing the treatment of patients with FMS in primary care currently are available. The evidence-based guidelines on the management of FMS are based, in part, on evidence from studies examining physical therapy treatment components alone (eg, aerobic exercise, education). Thus, the recommendations can be applied to primary care physical therapy. Primary care physical therapy for patients with FMS should include education, aerobic exercise, and strengthening exercise. For other treatment components such as passive treatments, activity management, and relaxation, less evidence currently is available to advocate their use in primary care physical therapy. Superior results are to be expected when various treatment components are combined.

A Randomized Controlled Trial Comparing Manipulation With Mobilization for Recent Onset Neck Pain

Leaver AM, Maher CG, Herbert RD, Latimer J, McAuley JH, Jull G, Refshauge KM. A randomized controlled trial comparing manipulation with mobilization for recent onset neck pain. Objective To determine whether neck manipulation is more effective for neck pain than mobilization. Design Randomized controlled trial with blind assessment of outcome. Setting Primary care physiotherapy, chiropractic, and osteopathy clinics in Sydney, Australia. Participants Patients (N=182) with nonspecific neck pain less than 3 months in duration and deemed suitable for treatment with manipulation by the treating practitioner. Interventions Participants were randomly assigned to receive treatment with neck manipulation (n=91) or mobilization (n=91). Patients in both groups received 4 treatments over 2 weeks. Main Outcome Measure The number of days taken to recover from the episode of neck pain. Results The median number of days to recovery of pain was 47 in the manipulation group and 43 in the mobilization group. Participants treated with neck manipulation did not experience more rapid recovery than those treated with neck mobilization (hazard ratio=.98; 95% confidence interval, .66–1.46). Conclusions Neck manipulation is not appreciably more effective than mobilization. The use of neck manipulation therefore cannot be justified on the basis of superior effectiveness.

Primary care randomized clinical trial: Manual therapy effectiveness in comparison with TENS in patients with neck pain

This study investigated effectiveness of manual therapy (MT) with transcutaneous electrical nerve stimulation (TENS) to reduce pain intensity in patients with mechanical neck disorder (MND). A randomized multi-centered controlled clinical trial was performed in 12 Primary Care Physiotherapy Units in Madrid Region. Ninety patients were included with diagnoses of subacute or chronic MND without neurological damage, 47 patients received MT and 43 TENS. The primary outcome was pain intensity measured in millimeters using the Visual Analogue Scale (VAS). Also disability, quality of life, adverse effects and sociodemographic and prognosis variables were measured. Three evaluations were performed (before, when the procedure finished and six months after). Seventy-one patients (79%) completed the follow-up measurement at six months. In more than half of the treated patients the procedure had a clinically relevant “short term” result after having ended the intervention, when either MT or TENS was used. The success rate decreased to one-third of the patients 6 months after the intervention. No differences can be found in the reduction of pain, in the decrease of disability nor in the quality of life between both therapies. Both analyzed physiotherapy techniques produce a short-term pain reduction that is clinically relevant.

Short and mid-term results of a comprehensive treatment program for longstanding adductor-related groin pain in athletes: A case series

Objective To evaluate short and mid-term results of active physical therapy in athletes with longstanding groin pain. Design Case series. Setting Primary care physical therapy practice. Participants A total of 44 athletes suffering longstanding adductor-related groin pain. Intervention A combination of passive (joint mobilization) and active (exercises) physical therapy interventions. Main outcome measurements Return to (the same level of) sports, restriction in sports, and recurrence. Results Directly after treatment, return to the same level and type of sport was successful in 38 athletes (86%), and without symptoms in 34 athletes (77%). At 6.5–51 months follow up, 10/38 (26%) of those that returned to sports had experienced a relapse; 22 (50%) athletes were able to participate in sports without any restrictions at the mid-term follow-up. Conclusions For athletes with longstanding groin pain, short term results of physical therapy seem positive, whereas mid-term results are moderately positive. The risk for recurrence is high.

Measuring Psychosocial Variables in Patients With (Sub) Acute Low Back Pain Complaints, at Risk for Chronicity

A validation study of the Acute Low Back Pain Screening Questionnaire Dutch Language Version (ALBPSQ-DLV). To determine internal consistency, construct and convergent validity of the ALBPSQ-DLV in a population of patients with (sub) acute low back pain (LBP) referred to primary care physical therapy in The Netherlands. Viewing LBP as a multifactorial biopsychosocial syndrome enhances the need for validating instruments for screening psychosocial variables in patients with LBP. The ALBPSQ has been specifically constructed as a self-administered screening instrument, based on variables that have been suggested as a risk factor in the literature. A total of 69 patients with (sub) acute LBP were recruited. Internal consistency of the ALBPSQ-DLV was determined by calculating Cronbach alpha. Construct validity was determined by applying exploratory factor analysis. Convergent validity was assessed by calculating Pearson's correlation coefficients between domains of ALBPSQ-DLV and Dutch language versions of the Fear Avoidance Beliefs Questionnaire, Tampa Scale for Kinesiophobia, Pain Coping Inventory, Quebec Back Pain Disability Scale, and the Visual Analogue Scale of pain intensity. Internal consistency of the ALBPSQ-DLV was 0.81. Values of the various subscales ranged between 0.48 and 0.88. Convergent validity was confirmed by moderate to good correlation coefficients (P = 0.01) between the scores on the subscales and the constructs of pain, disability, fear-avoidance beliefs, kinesiophobia, and coping (r = 0.38-0.64). Exploratory factor analysis, suppressing absolute values less than 0.40, revealed components which were in agreement with the various domains of the original ALBPSQ. The internal consistency and both construct and convergent validity of the ALBPSQ-DLV are well established in a Dutch population of 69 patients with (sub) acute nonspecific LBP referred to primary care physical therapy.

Evaluating patient care communication in integrated care settings: application of a mixed method approach in cerebral palsy programs

In this study, we evaluated patient care communication in the integrated care setting of children with cerebral palsy in three Dutch regions in order to identify relevant communication gaps experienced by both parents and involved professionals. A three-step mixed method approach was used starting with a questionnaire to identify communication links in which parents experienced gaps. In subsequent in-depth interviews with parents and focus group meetings with professionals underlying factors were evaluated. In total, 197 parents completed the questionnaire (response 67%); 6% scored negative on parent-professional communication, whereas 17% scored negative on inter-professional communication, especially between the rehabilitation physician and primary care physiotherapy (16%) and (special) education/day care (15%). In-depth interviews among a subset of 20 parents revealed various sources of dissatisfaction such as lack of cooperation and patient centeredness, inappropriate amount of information exchange and professional use of parents as messenger of information. Focus group meetings revealed that professionals recognized these gaps. They attributed them to capacity problems, lack of interdisciplinary guidelines and clear definition of roles, but also a certain hesitance for contact due to unfamiliarity with involved professionals in the care network. Parents particularly identified gaps in inter-professional communication between (rehabilitation) hospitals and primary care settings. Involved professionals recognized these gaps and primarily attributed them to organizational factors. Improvement initiatives should focus on these factors as well as facilitation of low-threshold contact across the patient's care network.

Clinical prediction rule for spinal manipulation does not discriminate patients in an Australian physiotherapy primary care setting

Clinical prediction rule for spinal manipulation does not discriminate patients in an Australian physiotherapy primary care setting

Cultural adaptation and validation of the Persian version of the Disabilities of the Arm, Shoulder and Hand (DASH) outcome measure

Objective: To translate and validate the Persian version of the Disabilities of the Arm, Shoulder and Hand (DASH) outcome measure (Persian DASH). Design: Cultural translation and psychometric testing. Setting: Outpatient departments of orthopaedics surgery, primary care settings, rehabilitation medicine and physical therapy. Subjects: Two hundred and seventy-one consecutive Persian-speaking patients with upper extremity disorders including subacromial impingement syndrome, rotator cuff disease, epicondylitis, ulnar nerve entrapment, bursitis, instability, carpal tunnel syndrome, tenosynovitis and adhesive capsulitis. Methods: The translation and cultural adaptation of the original questionnaire was carried out in accordance with published guidelines. The participants were asked to complete a questionnaire booklet including the Persian DASH, the Short Form General Health Survey (SF-36) and a visual analogue scale (VAS) of pain. In addition, 31 randomly selected patients were asked to complete the questionnaire 48 hours later for the second time. Results: Cronbach's alpha coefficient for the Persian DASH was 0.96. The Persian DASH showed excellent test—retest reliability with intraclass correlation coefficient equal to 0.82 (P<0.01). The correlation between the Persian DASH and the functional scales of the Iranian SF-36 showed desirable results indicating a good convergent validity (Pearson's coefficients ranged from -0.25 to -0.72; P<0.001). The correlation between the Persian DASH and the visual analogue scale was 0.52 (P<0.01). Conclusions: The Persian DASH is a reliable and valid instrument to measure functional status in Persian-speaking patients with upper extremity disorders in Iran. It is simple and easy to use and now can be applied in clinical settings and future outcome studies in Iran and other Persian-speaking communities.

Views on Exercise Maintenance: Variations Among Patients With Rheumatoid Arthritis

Individuals with rheumatoid arthritis (RA) often have to make changes in exercise behavior in order to gain and sustain health benefits. The purpose of this study was to explore and describe ways of understanding exercise maintenance among individuals with RA who had already started to exercise. Fourteen women and 4 men with RA of at least 2 years' duration, selected from 4 hospitals or primary health care physical therapy clinics, participated. They had exercised regularly at least twice weekly during the previous 2 months with various levels of support from a physical therapist, and they had attempted to exercise without support outside of the health care environment during the previous year. A phenomenographic approach was used to analyze semistructured interviews. A pattern of categories of descriptions was constructed based on the participants' conceptions and ways of understanding the phenomenon of exercise maintenance. Five categories were identified: "external control," "sticks and carrots," "a joint venture," "the easy way," and "on one's own terms." The categories became clear by elucidating 2 aspects related to exercise maintenance: (1) the way the participants talked about and experienced the type of support needed and (2) personal factors. The results highlight the importance of finding the proper context and support for each patient's needs. Furthermore, preparing for exercise maintenance by strengthening the patient's beliefs in his or her ability to exercise in different settings, by discussing pros and cons of exercise, and by exploiting the patient's ability to adapt and continue exercise outside of the health care environment might be valuable.

Ensayo clínico aleatorizado en pacientes con cervicalgia mecánica en atención primaria: terapia manual frente a electroestimulación nerviosa transcutánea

To compare the effectiveness of manual therapy (MT) versus transcutaneous electrical nervous stimulation (TENS) in reducing the intensity of pain in patients with subacute or chronic neck pain (NP) attended at primary care physiotherapy units (PCPU). Randomised clinical trial. Thirteen PCPU in 4 health districts of the Community of Madrid, Spain. Ninety patients with subacute or chronic NP attended. Lost after intervention: 3. At random, 47 patients were allocated to MT treatment and 43 to TENS. Social and demographic characteristics and prognosis variables in the intervention groups were measured. Intensity of pain before and after intervention was calculated by mean values on the analogue visual scale (present moment, average and worst pain of the last 2 weeks). Side-effects were also measured. Difference between before-and-after pain was 21.83 mm (95% CI, 13.71-29.95) for the group treated with Transcutaneous electrical nervous stimulation and 22.87 mm (95% CI, 17.11-28.64) for manual therapy. The difference in averages on comparing the 2 procedures for improvement was 1.04 (95% CI, -8.66% to 10.75%). TENS and MT significantly reduce patients' perceived intensity of pain, although there were no differences between the 2 groups.There are no conclusive results for the alternative physiotherapy treatments that determine a clear strategy of intervention.

Physiotherapists’ and general practitioners’ views of self-referral and physiotherapy scope of practice: results from a national trial

Aim To establish the views of physiotherapists and general practitioners (GPs) on self-referral and physiotherapy scope of practice. Design Survey questionnaire design utilising both qualitative and quantitative questioning. Setting Twenty-six general practices throughout Scotland. Participants Sixty-four physiotherapists and 97 GPs with direct experience of implementing systems of self-referral to physiotherapy in primary care in Scotland. Method Questionnaires containing a mix of open and closed questions were distributed at the end of a year-long data collection period of a national trial (2003–2005). Responses were analysed by clinician group: GPs and physiotherapists. Results An overall response rate of 73% (117/161) was achieved. High levels of comfort with, and confidence in, physiotherapists acting as first point of contact practitioners were reported by 96% (67/70) of GPs, and just 6% (3/47) of physiotherapists reported not being comfortable. More than 78% (91/117) of all clinicians indicated that there could be possible and definite benefits for musculoskeletal patients if physiotherapists were involved in monitoring and prescribing non-steroidal anti-inflammatory drugs, issuing sickness certificates and requesting X-rays, although this was more strongly supported by physiotherapists (>88% vs >63%; P < 0.001). Seventy-eight percent (35/47) of physiotherapist respondents felt that physiotherapists could accept self-referrals very ably, 47% (21/47) felt that not all physiotherapists were sufficiently experienced, and 16% (7/47) reported the need for additional training before physiotherapists could undertake this role. Only 34% (16/47) of physiotherapists felt that the public understood what physiotherapy is and what it can offer. Conclusion The concept of physiotherapists working as first point of contact practitioners is strongly supported by the majority of GPs and physiotherapists. Potential benefits for patients were identified if physiotherapists undertook extended roles with regard to other aspects of musculoskeletal management. There is a need to address both professional and public awareness of physiotherapy and self-referral specifically.

Economic Evaluation of an Intensive Group Training Protocol Compared With Usual Care Physiotherapy in Patients With Chronic Low Back Pain

Economic evaluation from a societal perspective conducted alongside a randomized controlled trial with a follow-up of 52 weeks. To evaluate the cost effectiveness and cost utility of an intensive group training protocol compared with usual care physiotherapy in patients with nonspecific chronic low back pain. The intensive group training protocol combines exercise therapy, back school, and behavioral principles. Two studies found a significant reduction in absenteeism for a graded activity program in occupational health care. This program has not yet been evaluated in a primary care physiotherapy setting. Participating physical therapists in primary care recruited 114 patients with chronic nonspecific low back pain. Eligible patients were randomized to either the protocol group or the guideline group. Outcome measures included functional status (Roland Morris Disability Questionnaire), pain intensity (11-point numerical rating scale), general perceived effect and quality of life (EuroQol-5D). Cost data were measured with cost diaries and included direct and indirect costs related to low back pain. After 52 weeks, the direct health care costs were significantly higher for patients in the protocol group, largely due to the costs of the intervention. The mean difference in total costs amounted to [Euro sign] 233 (95% confidence interval: [Euro sign] -2.185; [Euro sign] 2.764). The cost-effectiveness planes indicated no significant differences in cost effectiveness between the 2 groups. The results of this economic evaluation showed no difference in total costs between the protocol group and the guideline group. The differences in effects were small and not statistically significant. At present, national implementation of the protocol is not recommended.

High cost-benefit of early team-based biomedical and cognitive-behaviour intervention for long-term pain-related sickness absence

To report the results from a prospective, cognitive-behavioural team-based, individually geared, low-intensity, rehabilitation programme, randomly assigned to care-seekers in primary care physiotherapy with new pain-related sick leave, and to examine a possible reduction in social security expenditure. A total of 194 care-seekers were included in a stepwise procedure from November 2000 to February 2002. Control group n = 381. The median number of days of sick leave in the intervention group was 22 during the first 6-month period. After 180 days 5.2% were still on sick leave and after 360 days 4.2%. The comparable figures in the control group were 30 days, 9.7% and 7.2%, respectively. Reductions in social security expenditure were statistically significant from the fourth month. As predicted, clinically relevant subgroups contributed differently to this reduction, both early and later on. The overall problem for one-third of the subgroups was insufficient co-ordination from the employer and the social security executive. It was possible to reduce the social security expenditure in this setting. The intervention costs were balanced out during the first year. A large potential for further cost reductions was identified in increased implementation of workplace-based return-to-work interventions.

The Pain Belief Screening Instrument (PBSI): Predictive validity for disability status in persistent musculoskeletal pain

Purpose. To evaluate the predictive validity of a screening instrument measuring disability, self-efficacy, fear of movement and catastrophizing, for disability status in patients with musculoskeletal pain in primary health care physical therapy. Development over time of pain-related disability, pain intensity, self-reported work capacity and overall daily function for subgroups of patients was also investigated.Method. Prospective and correlational study, where patients (n = 168) with a pain-duration of 4 weeks or more completed the questionnaires and their cases were followed for 8 months to assess the variables of interest. For predictive validity of the screening instrument discriminant analyses were conducted. The development over time for subgroups was analysed by comparing scores at the first and second measurement.Results. The PBSI correctly classified 72% of the subjects as High-disabled (n = 33) or Low-disabled (n = 110), as measured with the Pain Disability Index (Wilks' lambda = 0.848, p < 0.005). For pain intensity, self-reported changes in work capacity and overall daily function the discriminant analyses were not significant. The High-disability group had increased disability, unchanged pain intensity and decreased work capacity and daily function after 8 months.Conclusion. The predictive validity of the PBSI for disability was confirmed. In clinical use the PBSI could serve as a mean to obtain supplementary and clinically useful information.

No difference in cost-effectiveness of intensive group training for chronic back pain compared with usual physiotherapy care

Is an intensive group training protocol costeffective compared to usual care physiotherapy for chronic low back pain? Economic evaluation alongside a randomised controlled trial comparing two physiotherapy interventions for chronic low back pain. Primary care physiotherapy clinics in and around Amsterdam, the Netherlands, involving 85 physiotherapists. 114 participants with a new episode of non-specific low back pain of more than 12 weeks duration and aged 18 to 65 years were included. Patients with specific spinal pathology were excluded. Participants in the intensive group performed 10 individual and 20 group sessions consisting of graded exercises and back school based on behavioural principles. Those allocated to usual care received an average of 9 sessions of individual physiotherapy treatments according to the Royal Dutch College for Physiotherapy Low Back Pain Guidelines. Treatment effectiveness was measured using the following pre-specified outcomes: functional status (24-item Roland-Morris Disability Questionnaire), pain intensity (11-point numerical rating scale), general perceived effect (6-point GPE scale) and quality of life (EuroQol-5D) at baseline, 6, 13, 26, and 52 weeks after randomisation, with 89% followup at 1 year. Diaries were used to measure costs associated with utilisation of health care, non-health care, medications, and loss of productivity due to work absenteeism. Multilevel analyses were performed to determine the difference in effects. The mean differences in costs between groups and 95% confidence intervals (CIs) were obtained by bias corrected and accelerated bootstrapping. Quality of life was expressed in utilities based on the Dutch tariff. The differences in effects were small and not significant. Although the direct health care costs were higher for the intensive training group, (between-group difference per patient €233, 95% CI 2185 to 2764), there were no differences between the groups in terms of total health costs. The intensive group training protocol is not cost-effective compared with usual care physiotherapy carried out according to the guidelines. Whilst there is no clinical contraindication to the use of the intensive group training program, the results do not support implementation of the intensive program for back pain in primary care in the Netherlands.

Comment on: A prospective double-blind placebo-controlled randomized trial of ultrasound in the physiotherapy treatment of shoulder pain

Objective. To compare the effectiveness of manual therapy and ultrasound (US) with manual therapy and placebo ultrasound (placebo US) in the treatment of new episodes of unilateral shoulder pain referred for physiotherapy. Methods. In a multicentre, double blind, placebo-controlled randomized trial, participants were recruited with a clinical diagnosis of unilateral shoulder pain from nine primary care physiotherapy departments in Birmingham, UK. Recruitment took place from January 1999 to September 2001. Participants were 18 yrs old and above. Participants all received advice and home exercises and were randomized to additionally receive manual therapy plus US or manual therapy plus placebo US. The primary outcome measure was the Shoulder Disability Questionnaire (SDQ-UK). Outcomes were assessed at baseline, 2 weeks, 6 weeks and 6 months. Analysis was by intention to treat. Results. A total of 221 participants (mean age 56 yrs) were recruited. 113 participants were randomized to US and 108 to placebo US. There was 76% follow up at 6 weeks and 71% at 6 months. The mean (95% CI) reduction in SDQ scores at 6 weeks was 17 points (13-26) for US and 13 points (9-17) for placebo US (P = 0.06). There were no statistically significant differences at the 5% level in mean changes between groups at any of the time points. Conclusions. The addition of US was not superior to placebo US when used as part of a package of physiotherapy in the short-term management of shoulder pain. This has important implications for physiotherapy practice.

Participación de los fisioterapeutas de Atención Primaria en las reuniones de los equipos de los centros de salud en Castilla y León

Aim To show the present situation regarding participation of Primary Care physiotherapists in the meetings of EAP (Primary Care Teams) of the C.S. (Health Centres) in Castilla y León. Procedure A rigorous data collecting has been designed among the population of Primary Care physiotherapists in Castilla y León, finally getting the opinions of about 70% of them. The questionnaire includes 42 questions. A number of them are of a quantitative type, others are ordinal to measure the level of satisfaction in different professional aspects while others are YES/NO questions. Location The collection of data was made in Zamora, on 28 of May during a break at XIII conference of Primary Care Physiotherapy in Castilla y León. Participants 72 physiotherapists met at this conference from a total of 92 (78.3 %). 87.5% of the attendants answered the questionnaire which amounts to 68.5 % of the total number in Castilla y León. Main measurements The job was focused on the analysis of 5 YES/NO sets (I take part in the meetings, I would like to, I think I have some contributions in the organization, clinical meetings and teaching) relating them to personal data of age, sex, the province where he/she works and the type of centre (urban or rural). Results Habitual participation of Primary Care physiotherapists in Health Centres meetings is rather low at present (31.03 %) as opposed to a very high proportion of the questioned physiotherapists (93.88 %) who say to be willing to take part in them. Conclusions The body of physiotherapists participate in very few meetings but the majority of them are motivated to take part in them.

A prospective double blind placebo-controlled randomized trial of ultrasound in the physiotherapy treatment of shoulder pain

To compare the effectiveness of manual therapy and ultrasound (US) with manual therapy and placebo ultrasound (placebo US) in the treatment of new episodes of unilateral shoulder pain referred for physiotherapy. In a multicentre, double blind, placebo-controlled randomized trial, participants were recruited with a clinical diagnosis of unilateral shoulder pain from nine primary care physiotherapy departments in Birmingham, UK. Recruitment took place from January 1999 to September 2001. Participants were 18 yrs old and above. Participants all received advice and home exercises and were randomized to additionally receive manual therapy plus US or manual therapy plus placebo US. The primary outcome measure was the Shoulder Disability Questionnaire (SDQ-UK). Outcomes were assessed at baseline, 2 weeks, 6 weeks and 6 months. Analysis was by intention to treat. A total of 221 participants (mean age 56 yrs) were recruited. 113 participants were randomized to US and 108 to placebo US. There was 76% follow up at 6 weeks and 71% at 6 months. The mean (95% CI) reduction in SDQ scores at 6 weeks was 17 points (13-26) for US and 13 points (9-17) for placebo US (P = 0.06). There were no statistically significant differences at the 5% level in mean changes between groups at any of the time points. The addition of US was not superior to placebo US when used as part of a package of physiotherapy in the short-term management of shoulder pain. This has important implications for physiotherapy practice.