Cost-effectiveness of manual therapy versus physiotherapy in patients with sub-acute and chronic neck pain: a randomised controlled trial.

PURPOSE: To evaluate the cost-effectiveness of manual therapy according to the Utrecht School (MTU) in comparison with physiotherapy (PT) in sub-acute and chronic non-specific neck pain patients from a societal perspective. METHODS: An economic evaluation was conducted alongside a 52-week randomized controlled trial, in which 90 patients were randomized to the MTU group and 91 to the PT group. Clinical outcomes included perceived recovery (yes/no), functional status (continuous and yes/no), and quality-adjusted life-years (QALYs). Costs were measured from a societal perspective using self-reported questionnaires. Missing data were imputed using multiple imputation. To estimate statistical uncertainty, bootstrapping techniques were used. RESULTS: After 52 weeks, there were no significant between-group differences in clinical outcomes. During follow-up, intervention costs (ß:€-32; 95 %CI: -54 to -10) and healthcare costs (ß:€-126; 95 %CI: -235 to -32) were significantly lower in the MTU group than in the PT group, whereas unpaid productivity costs were significantly higher (ß:€186; 95 %CI:19-557). Societal costs did not significantly differ between groups (ß:€-96; 95 %CI:-1975-2022). For QALYs and functional status (yes/no), the maximum probability of MTU being cost-effective in comparison with PT was low (≤0.54). For perceived recovery (yes/no) and functional status (continuous), a large amount of money must be paid per additional unit of effect to reach a reasonable probability of cost-effectiveness. CONCLUSIONS: From a societal perspective, MTU was not cost-effective in comparison with PT in patients with sub-acute and chronic non-specific neck pain for perceived recovery, functional status, and QALYs. As no clear total societal cost and effect differences were found between MTU and PT, the decision about what intervention to administer, reimburse, and/or implement can be based on the preferences of the patient and the decision-maker at hand. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT00713843.

Speech pathology interventions in patients with neuromuscular diseases: a systematic review.

PURPOSE: A systematic review was conducted to summarize and evaluate the literature on the effectiveness of speech pathology interventions in adults with neuromuscular diseases. METHOD: Databases searched included the Cochrane Database of Systematic Reviews, the Cochrane Central Register of Controlled Trials, MEDLINE, CINAHL, EMBASE, PsycINFO and PubMed. A total of 1,772 articles were independently screened on title and abstract by 2 reviewers. RESULTS: No randomized controlled trials or clinical controlled trials were found. Four other designs were included. Only one study on oculopharyngeal muscle dystrophy (OPMD) appeared to have sufficient methodological quality. There is evidence indicating that correction of head position in patients with OPMD improves swallowing efficiency (level III evidence). CONCLUSION: Despite 1,772 studies, there is only evidence of level III regarding the effectiveness of speech pathology interventions in patients with OPMD. Recommendations for future research are given.

Optimizing referral of patients with neuromuscular disorders to allied health care.

BACKGROUND AND PURPOSE: To report the predictive validity of the perceived limitations in activities and need questionnaire (PLAN-Q), a screening instrument to support neurologists to select patients with neuromuscular disorders (NMD) for referral for a one-off consultation by occupational therapist (OT), physical therapist (PT) and speech therapist (ST). METHODS: In a cross-sectional validation study, 102 patients with various NMD participated. Patients received a one-off consultation by an expert OT, PT and ST and filled out the PLAN-Q. Therapists rated the appropriateness of the one-off consultations based on need, available treatment and patient's motivation. Receiver Operation Characteristic analysis and multivariate logistic regression analysis were used to obtain a PLAN-Q based prediction model for the appropriateness of the one-off consultations. RESULTS: Probability for a one-off OT consultation increased from 64% to 78% (95% CI: 69-85%). Prior test probability for a one-off ST consultation increased from 44% to 61% (95% CI: 48-73%). Prior test probability for one-off PT consultation could not be increased. CONCLUSION: Screening patients with NMD using the PLAN-Q may assist neurologists in selecting the appropriate patients for a one-off consultation by OT and ST. Unlike our expectations the screening did not guide referral for a one-off consultation by PT.

Influence of behaviour and risk factors on motor performance in preterm infants at age 2 to 3 years.

The aim of this cross-sectional study was to determine the influence of test-taking behaviour and risk factors for delayed motor performance in 437 preterm infants (244 males, 193 females; < or = 32 weeks of gestation) at the corrected age of 2 to 3 years (mean 29mo [SD 3.3]). Other mean (SD) sample demographics were: postmenstrual age 29(+5) weeks (1(+5)), range 25(+0)-32(+0); birthweight 1213.7g (331.7), range 468-2350; and days in the neonatal intensive care unit 21.1 (21.3), range 1-165. Children (n=23) with a severe disability were excluded. We assessed motor performance and behaviour during testing with the Motor Scale and the Behaviour Rating Scale (BRS) of the Bayley Scales of Infant Development, 2nd edition (BSID-II). Risk factors were tested against delayed motor performance as the dependent variable in binary logistic regression analysis. Median score on the Motor Scale in terms of the BSID-II Psychomotor Developmental Index (PDI) was 86. 'Delayed' motor performance was observed in 46.5% of the children tested, and behaviour was 'not-optimal' in 31.4%. The Motor Scale and BRS scores were significantly correlated (r(s)=0.62, p<0.01). Risk factors for delayed motor performance were: neonatal convulsions (odds ratio [OR] 4.5; 95% confidence interval [CI] 1.6-12.9), low maternal educational level (OR 3.3; 95% CI 1.7-6.5), male sex (OR 2.8; 95% CI 1.8-4.3), and chronic lung disease (OR 2.1; 95% CI 1.1- 4.1). We conclude that preterm infants are at high risk of delayed motor performance and non-optimal test-taking behaviour.

Construct validity of instruments measuring impairments in body structures and function in rheumatic disorders: which constructs are selected for validation? A systematic review.

PURPOSE: This paper focuses on the construct validity of instruments measuring impairments in body structures and function in rheumatic disorders. The objective is: 1) to make an inventory of constructs, based on the domains of the International Classification of Functioning, Disabilities and Health problems (ICF), against which instruments measuring impairments in body structures and function were validated; 2) to analyse whether validation against a similar construct resulted in higher correlation coefficients than validation against a dissimilar construct. METHODS: In a systematic review papers were identified in which instruments measuring impairments in body structures and function for patients with rheumatic disorders were validated. The instruments identified were assessed on their methodological properties and the constructs against which they were validated. Subsequently, pooled (interclass) correlations of similar constructs and dissimilar constructs against which was validated were compared. An instrument was decided to have good construct validity, if the correlation coefficient was 0.50 or higher, and the measurement instrument in question is validated against similar constructs. RESULTS: In total 216 papers were identified analysing the validity of 42 different instruments. Only 16% of these instruments were validated against instruments that represent the most similar construct. In general, estimates of construct validity were lower when validated against dissimilar constructs, except for instruments measuring impairments in mental functions. CONCLUSION: There is a trend that validation against a similar construct yields higher correlation coefficients than validation against a dissimilar construct. If an instrument measuring impairments is validated against the most similar construct, and a criterion of r > 0.50 is applied, only 10 out of the 42 identified instruments turned out to be valid.

Effect on the process of care of an active strategy to implement clinical guidelines on physiotherapy for low back pain: a cluster randomised controlled trial.

OBJECTIVES: To evaluate the effect on the process of care of an active strategy to implement clinical guidelines on physiotherapy for low back pain. DESIGN: A cluster randomised controlled trial comparing an active strategy with standard dissemination. SETTING: Primary care physiotherapy practices. PARTICIPANTS: 113 physiotherapists were randomly allocated to receive the guidelines by mail (control group) or to receive an additional active strategy (intervention group) which consisted of a multifaceted programme including education, discussion, role playing, feedback, and reminders. MAIN OUTCOME MEASURES: Adherence to the guidelines was measured by means of individual patients' forms recording the treatment completed by the physiotherapist. The forms were assessed using an algorithm based on the number of treatment sessions, treatment goals, interventions, and patient education. RESULTS: Physiotherapists in the intervention group more often correctly limited the number of treatment sessions for patients with a normal course of back pain (OR 2.39; 95% CI 1.12 to 5.12), more often set functional treatment goals (OR 1.99; 95% CI 1.06 to 3.72), more often used mainly active interventions (OR 2.79; 95% CI 1.19 to 6.55), and more often gave adequate patient education (OR 3.59; 95% CI 1.35 to 9.55). They also adhered more to all four criteria (OR 2.05; 95% CI 1.15 to 3.65). CONCLUSIONS: The active strategy moderately improved adherence to the guidelines. Active strategies are recommended to implement the clinical guidelines on physiotherapy for low back pain.

Psychometric properties of the Tampa Scale for kinesiophobia and the fear-avoidance beliefs questionnaire in acute low back pain.

The transition from acute to chronic low back pain (LBP) is influenced by many interacting factors. Pain-related fear, as measured by the Tampa Scale for Kinesiophobia (TSK) and the Fear-Avoidance Beliefs Questionnaire (FABQ), is one of these factors. The objectives of this study were to investigate, in a population with acute LBP, the reliability of TSK and FABQ through evaluation of the internal consistency, the test-retest reliability, and the concurrent validity between TSK and FABQ. One hundred and Seventy-Six patients suffering LBP for no longer than 4 weeks completed a Visual Analogue Scale for pain (VAS), the TSK, the FABQ, and a socio-demographic questionnaire. Each patient completed the VAS, TSK, and FABQ twice within 24 h. Internal consistency of TSK and FABQ scores range from alpha=0.70 to 0.83. Test-retest reliability ranges from r(s)=0.64 to 0.80 (P<0.01). Concurrent validity is moderate, ranging from r(s) =0.33 to 0.59 (P<0.01). It may be concluded that in a population with acute LBP, both the TSK and the FABQ are reliable measures of pain-related fear. In the clinical setting they may provide the practitioner a means of identifying pain-related fear in a patient with acute LBP.

The development of a screening instrument to select patients at risk of residual complaints after lumbar disc surgery.

AIM: A considerable number of patients who undergo surgery for a lumbosacral radicular syndrome (LRS) continue to experience disability, pain, and loss of work capacity. The goal of the study is to develop a brief screening instrument to identify these patients at risk of residual complaints. METHODS: In a prospective study of 277 patients, the predictors for the outcomes disability, pain, and loss of work capacity were investigated. The best predictive model was constructed using a stepwise selection procedure (forward selection), which calculates the discriminative power of the model. Based on the relationship between regression coefficients, a clinical prediction rule was derived that predicted the probability of residual complaints after surgery for LRS. RESULTS: At 6 month follow-up 141 patients (51%) had residual complaints. The discriminative power of the instrument was .78 (AUC). The "Nijmegen Outcome of Lumbar Disc surgery Screening-instrument" (NOLDS) was based on the variables "lower education level", "younger age", "pain 3 days postoperatively", "passive pain coping", and "fear of movement/(re)injury". CONCLUSION: The results of the study are promising, showing that a brief clinical screening instrument can be used to identify patients at risk of residual complaints at 6 months after surgery for LRS. The early identification of patients at risk having residual complaints may make it possible to start tailored treatment early in the rehabilitation process.

Quality indicators indicate good adherence to the clinical practice guideline on "Osteoarthritis of the hip and knee" and few prognostic factors influence outcome indicators: a prospective cohort study.

BACKGROUND: Evaluation with quality indicators of adherence to the clinical practice guideline on "Osteoarthritis of the hip and knee" and of treatment outcomes. AIM: Furthermore to determine prognostic factors for outcome indicators. DESIGN: Prospective cohort study. POPULATION: Twenty-seven well informed physical therapists recorded patient and treatment characteristics of 103 community-dwelling patients referred by a general practitioner diagnosed with osteoarthritis of hip or knee. METHODS: With selected process and outcome indicators adherences to the guideline and treatment outcomes were assessed. Prognostic factors were calculated for Algofunctional Index (AI) and Visual Analogue Scale (VAS) for pain (decreases of ≤25% indicating "poor outcome"), number of sessions (>12) and duration of treatment (>6 weeks), using multivariate logistic regression models. RESULTS: Process indicators showed that information & advice was given to 95% of the patients and functions and activities were exercised in 97% respectively 87%. Aftercare was arranged for 46% of the patients, that was clearly lower than the benchmark of 90%. Outcome indicators VAS-pain and AI decreased by 45% and 36%, respectively. The combination ">12 months" duration of complaints and age ≥65" was associated with a "poor outcome" on AI (OR 2.53; 95% CI 1.01-6.38). Co-morbidity (OR 2.8; 95% CI 1.17-6.88), and "VAS-pain at baseline ≥51 mm" (OR 3.1; 95% CI 1.34-7.23) were associated with a higher number of treatment sessions. CONCLUSION AND CLINICAL REHABILITATION IMPACT: and Quality indicators showed that a group of well-informed physical therapists could to a large extent adhere to key recommendations of the guideline and that clinically relevant improvements were obtained in terms of pain and physical functioning. Prognostic factors for poorer outcome on outcome indicators were comorbidity, a higher pain score at baseline and the combination ">12 months' duration of complaints and age ≥65".

Quality indicators for physiotherapy in Parkinson's disease.

AIM: The aim of this study was to develop quality indicators for physiotherapy in Parkinson's disease (PD) according to international criteria. METHODS: Indicators were based on an evidence-based guideline for physiotherapy in PD. Guideline recommendations were transformed into indicators and rated for their relevance by an expert panel. Relevant indicators were incorporated into a questionnaire termed ''Quality Indicators for Physiotherapy in PD'' (QIP-PD). The QIP-PD was piloted among 105 physiotherapists. The adjusted version was evaluated in 46 physiotherapists with specific expertise in PD and in 795 general physiotherapists. The following clinimetric aspects of the QIP-PD were tested: completeness of answers, response distribution, internal consistency, and discriminative power. The reliability of the QIP-PD was evaluated by interviews among a randomly selected cohort of 32 PD experts and 32 general physiotherapists. RESULTS: The expert panel selected 16 indicators, which were transformed into an adjusted 17-item QIP-PD. The adjusted QIP-PD was completed by 41 expert physiotherapists and 286 general physiotherapists. Comple-teness of item scores ranged from 95-98%. Six items were excluded from the final analyses as they showed ceiling effect among both groups, or lacked discriminative power. The total QIP-PD score for the 11 items was significantly higher for expert physiotherapists (35.1+/-4.2) compared to general physiotherapists (22.2+/-7.7; P=0.01). Internal consistency was good (Crohnbach's alpha 0.84). QIP-PD scores of therapists and interviewers (correlated using Intraclass Correlations Coefficients) ranged from 0.63 to 0.75. CONCLUSIONS: The QIP-PD is a relevant, feasible, valid, discriminative and reliable instrument to measure adherence to guidelines for physiotherapy in PD. In addition, the results underscore that quality improvement interventions for physiotherapy in PD are needed, as guideline adherence is suboptimal in physiotherapists without specific PD expertise.

Pressure algometry in manual therapy.

SUMMARY. The pressure pain threshold (PPT), i.e. the least stimulus intensity at which a subject perceives pain, was studied in 30 patients with chronic unilateral pain in the shoulder and arm region.Fourteen trigger points were investigated on both sides of the body using pressure algometry. Eight paravertebral points and six points in the shoulder and arm region were evaluated. Each location was examined twice. The patients were tested by one examiner.The intraobserver reliability of PPT measurements was considered to be good. The Intraclass Correlation Coefficients of reliability (ICC), based on two repeated PPT measurements varied between 0.64 and 0.96. The painful side of the body was found to be more sensitive than the non-painful side, although there was not always a significant difference at the 0.05 level. The PPT was found to be higher in males than in females (P < 0.05). Females demonstrated lower PPTs than males at each trigger point. It was established that pressure tenderness varies over individual trigger points. Significant regional differences in PPT values were observed (P < 0.05). PPT values decreased in a cranial direction in the spine and in a caudal direction in the upper limb.Although the authors expected to find segmentally reduced PPT values on the painful side of the body, a generalized reduction of PPT values was present at all peripheral and spinal segmental sites. Some correlations between segmentally related trigger points were found by factor analysis. Copyright 1996 Harcourt Publishers Ltd.

Upper cervical instability: are clinical tests reliable?

SUMMARY. The aim of this preliminary study was to investigate the reliability of a selection of manual tests used for the examination of instability of the upper cervical region. Eleven children with Down's syndrome were examined by four independent examiners with different levels of experience in manual therapy. Three tests as described by Van der El (1992) were used: the lateral displacement test, the Sharp-Purser test, and the upper cervical flexion test. Scores of tests and retests were statistically analysed by calculating the percentage of agreement, and Brennan and Prediger's modified kappa, and with the binomial test. The results showed a significant agreement between test and retest for the upper cervical flexion test in three out of four investigators. Agreement between investigators was significant in four out of six combinations between two investigators, and near to significant for this test (P(bin) =.07) in the two remaining combinations. The other two investigated tests and the total score showed no tendancy towards a consistent level of significant intra- or interobserver reliability. Copyright 1997 Harcourt Publishers Ltd.