Developing a revised definition of the Bobath concept.

OBJECTIVE: This study was developed as a consensus-building exercise within the International Bobath Instructors Training Association (IBITA) to develop a revised definition of the Bobath concept. METHODS: A three-phase design utilizing (a) focus groups, (b) survey methods, and, (c) real-time Delphi. This paper details Phase 1 and 2. RESULTS: Forty IBITA members participated in five focus groups. Eight broad themes were developed from the focus groups from which the survey statements were developed. There was a high level of agreement on all nine survey statements identifying overarching constructs and on 12 of the 13 statements identifying unique aspects of Bobath clinical practice. Lower scores were attributed to lack of understanding of the term humanistic, Bobath clinical practice addressing multiple domains such as impairments, activities, and participation and limited agreement on the description of the term "placing." CONCLUSION: Focus groups and a web-based survey were successful in soliciting the opinions of IBITA members on themes and statements of importance for the development of a revised Bobath definition. The results of Phase 1 and 2 will inform Phase 3, a real-time Delphi, to gain consensus within IBITA on statements on which a revised Bobath definition is to be based.

GLA:D® Back group-based patient education integrated with exercises to support self-management of back pain - development, theories and scientific evidence.

BACKGROUND: Clinical guidelines recommend that people with back pain be given information and education about their back pain, advice to remain active and at work, and exercises to improve mobility and physical activity. Guidelines, however, rarely describe how this is best delivered. The aim of this paper is to present the development, theories, and underlying evidence for 'GLA:D Back' - a group education and exercise program that translates guideline recommendations into a clinician-delivered program for the promotion of self-management in people with persistent/recurrent back pain. METHODS: GLA:D Back, which included a rationale and objectives for the program, theory and evidence for the interventions, and program materials, was developed using an iterative process. The content of patient education and exercise programs tested in randomised trials was extracted and a multidisciplinary team of expert researchers and clinicians prioritised common elements hypothesised to improve back pain beliefs and management skills. The program was tested on eight people with persistent back pain in a university clinic and 152 patients from nine primary care physiotherapy and chiropractic clinics. Following feedback from the clinicians and patients involved, the working version of the program was created. RESULTS: Educational components included pain mechanisms, pain modulation, active coping strategies, imaging, physical activity, and exercise that emphasised a balance between the sum of demands and the individual's capacity. These were operationalised in PowerPoint presentations with supporting text to aid clinicians in delivering two one-hour patient education lectures. The exercise program included 16 supervised one-hour sessions over 8 weeks, each comprising a warm-up section and eight types of exercises for general flexibility and strengthening of six different muscle groups at four levels of difficulty. The aims of the exercises were to improve overall back fitness and, at the same time, encourage patients to explore variations in movement by incorporating education content into the exercise sessions. CONCLUSION: From current best evidence about prognostic factors in back pain and effective treatments for back pain, research and clinical experts developed a ready-to-use structured program - GLA:D® Back - to support self-management for people with persistent/recurrent back pain.

Quiet dissent: The attitudes, beliefs and behaviours of UK osteopaths who reject low back pain guidance - A qualitative study.

INTRODUCTION: Clinical guidelines are derived from best research evidence and aim to: improve quality of non-specific low back pain (nsLBP) management and identify patients at risk of suffering chronic pain. However, guideline discordant attitudes and beliefs have been identified in healthcare students and practitioners, including osteopaths. DESIGN: A qualitative approach with elements of grounded theory was used to explore underlying attitudes and beliefs of practitioners/students working in a British osteopathic education institution. All participants rejected guideline recommendations for managing nsLBP. A constant comparative method was used to code and analyse emergent themes from transcript data. SUBJECTS: Purposive sampling identified 5 clinic tutors and 7 students; all participated in semi-structured interviews. INTERPRETATION: Our central theme was a 'Precedence of Osteopathy' over medicine and other manual therapies. Three subthemes were: 1) beliefs about self; 2) perceptions of others; 3) attitudes to guidelines and research. CONCLUSION: Participants possess a strong professional identity fostered by their education. This bestows autonomy, authority and distinctness upon them. The central theme was modelled as a lens through which participants viewed research: the evidence pyramid appears inverted, explaining why participants value expert opinion above all other evidence. Guidelines and research are perceived to threaten professional identity. In contractual situations that oblige practitioners to follow guidelines management, perhaps reflecting a pragmatic response to health-care market forces, clinical practice is modified. Developing further understanding of osteopaths' attitudes and beliefs and behaviour in respect of evidence-based guidance in education is important to enhance the quality of clinical practice in osteopathy.

Força muscular respiratória e pico de fluxo expiratório de pacientes com bronquiectasia submetidos à reabilitação respiratória / Respiratory muscle strength and peak expiratory flow in patients with bronchiectasis underwent pulmonary rehabilitation / La fuerza muscular respiratoria y el flujo espiratorio máximo en pacientes con bronquiectasias en rehabilitación respiratoria

Este estudio tuvo como objetivo evaluar la fuerza muscular respiratoria y el flujo espiratorio máximo en pacientes con bronquiectasias en rehabilitación respiratoria. Método. Clínico, experimental, en el que, una vez verificados los criterios de inclusión y exclusión, la muestra se dividió aleatoriamente en: grupo experimental (GE, n = 13, edad = 60 ± 14,86 años) - que fueron tratados con rehabilitación respiratoria dos veces por semana, con una duración de 40 minutos por sesión, por 12 semanas y el grupo de control (GC, n = 13, edad = 58 ± 13,90 años) - los pacientes tratados con clínica conservadora de seguimiento permanecieron sin tratamiento durante el período de estudio, porque eran parte de una lista de espera para el servicio. Las variables dependientes del estudio fueron la fuerza muscular respiratoria (MIP - Presión de MIP-espiratorio - MEP) y el flujo espiratorio máximo (FEM), medida por el manómetro y el pico de flujo ®, respectivamente. El nivel de significación se fijó en p <0,05. Resultados. En la comparación dentro de los grupos, hubo un aumento significativo sólo en las variables de GE, a saber: MIP (cmH2O Δ = 18,08, p <0,001); MEP (cmH2O Δ = 12,31, p <0,001) y el FEM (Δ = 26,77 l / min, p = 0,016). En la comparación entre los grupos, hubo incremento satisfactorio en el post-test, el GE frente al GC en el MIP y la MEP (p = 0,005). Conclusiones. Por lo tanto, parece que la terapia física propuesta influencia en el aumento de la fuerza muscular respiratoria y del flujo espiratorio máximo en pacientes con bronquiectasia(AU)

Objetivo. Este estudio tuvo como objetivo evaluar la fuerza muscular respiratoria y el flujo espiratorio máximo en pacientes con bronquiectasias en rehabilitación respiratoria. Método. Clínico, experimental, en el que, una vez verificados los criterios de inclusión y exclusión, la muestra se dividió aleatoriamente en: grupo experimental (GE, n = 13, edad = 60 ± 14,86 años) - que fueron tratados con rehabilitación respiratoria dos veces por semana, con una duración de 40 minutos por sesión, por 12 semanas y el grupo de control (GC, n = 13, edad = 58 ± 13,90 años) - los pacientes tratados con clínica conservadora de seguimiento permanecieron sin tratamiento durante el período de estudio, porque eran parte de una lista de espera para el servicio. Las variables dependientes del estudio fueron la fuerza muscular respiratoria (MIP - Presión de MIP-espiratorio - MEP) y el flujo espiratorio máximo (FEM), medida por el manómetro y el pico de flujo®, respectivamente. El nivel de significación se fijó en p <0,05. Resultados. En la comparación dentro de los grupos, hubo un aumento significativo sólo en las variables de GE, a saber: MIP (cmH2O Δ = 18,08, p <0,001); MEP (cmH2O Δ = 12,31, p <0,001) y el FEM (Δ = 26,77 l / min, p = 0,016). En la comparación entre los grupos, hubo incremento satisfactorio en el post-test, el GE frente al GC en el MIP y la MEP (p = 0,005). Conclusiones. Por lo tanto, parece que la terapia física propuesta influencia en el aumento de la fuerza muscular respiratoria y del flujo espiratorio máximo en pacientes con bronquiectasia

Objective. This research aimed to evaluate the respiratory muscle strength and peak expiratory flow in patients with bronchiectasis undergoing respiratory rehabilitation. Method. Clinical trial where, after scrutiny of inclusion and exclusion criteria, the sample was divided randomly into experimental group (EG, n = 13, age = 60 ± 14.86 years) - who underwent treatment with respiratory rehabilitation twice week, lasting 40 minutes per session, at 12 weeks and control group (CG, n = 13, age = 58 ± 13.90 years) - patients with conservative clinical follow-up without therapy during the period of research because they were part of a waiting list for care. The dependent variables of the study were respiratory muscle strength (maximal inspiratory pressure - MIP- expiratory pressure - MEP) and peak expiratory flow (PEF), measured by the manometer and the peak flow®, respectively. The level of significance was set at p < 0.05. Results. In within groups comparison, there was a significant increase only in the EG variables, namely: MIP (Δ = 18.08 cm H2O, p < 0.001) and MEP (cmH2O Δ = 12.31, p < 0.001) and PEF (Δ = 26.77 l / min, p = 0.016). In the between groups comparison, increased satisfactory post-test, GE, compared to GC in MIP and MEP (p = 0.005). Conclusion. it appears that physical therapy influences the proposed increase in respiratory muscle strength and peak expiratory flow in patients with bronchiectasis(AU)

Maximizing usability of evidence in rehabilitation practice: tips for researchers.

The ultimate goal of rehabilitation research is to improve the lives of people with disabilities; yet, little research is implemented into clinical practice. The objectives of the current article are to serve as a guide for rehabilitation researchers regarding factors that contribute to translation of the evidence base in clinical practice, to highlight some common problems encountered by clinicians when trying to implement evidence-based treatments, and to provide tips that researchers can use to enhance the likelihood of their research products being used in clinical practice. The impact of clinician and environmental factors on use of evidence-based medicine are reviewed. Practical issues encountered by clinicians when attempting to translate evidence-based findings into practice are highlighted by discussing 2 areas of research: compensatory strategies for memory impairment after brain injury and use of electrical stimulation for weakness and paralysis in persons with spinal cord injury. The article closes with a series of tips to assist researchers in translating findings to clinicians.

Closing the gap between ethics knowledge and practice through active engagement: an applied model of physical therapy ethics.

Physical therapist practice has a distinct focus that is holistic (ie, patient centered) and at the same time connected to a range of other providers within health care systems. Although there is a growing body of literature in physical therapy ethics knowledge, including clinical obligations and underlying philosophical principles, less is known about the unique ethical issues that physical therapists encounter, and how and why they make ethical decisions. As moral agents, physical therapists are required to make autonomous clinical and ethical decisions based on connections and relationships with their patients, other health care team members, and health institutions and policies. This article identifies specific ethical dimensions of physical therapist practice and highlights the development and focus of ethics knowledge in physical therapy over the last several decades. An applied ethics model, called the "active engagement model," is proposed to integrate clinical and ethical dimensions of practice with the theoretical knowledge and literature about ethics. The active engagement model has 3 practical steps: to listen actively, to think reflexively, and to reason critically. The model focuses on the underlying skills, attitudes, and actions that are required to build a sense of moral agency and purpose within physical therapist practice and to decrease gaps between the ethical dimensions of physical therapist practice and physical therapy ethics knowledge and scholarship. A clinical case study is provided to illustrate how the ethics engagement model might be used to analyze and provide insight into the ethical dimensions of physical therapist practice.

Impact of oral assessment on physiotherapy students' learning in practice.

Given that all of us are potential users of health and social care services, the rigorous assessment of student health professionals in practice should be of common interest. However, rigorous assessment of practice-based learning is notoriously challenging. One would expect assessment in the context of the workplace to be an indicator of fitness for purpose and for practice. However, some indication that health professional students, including physiotherapists, are less fit for practice on qualification than might be desirable suggests a need to rethink assessment practices. Drawing on insights from students, clinical educators, and university visiting tutors in the United Kingdom, this article offers a rationale for combining assessment by observation of performance with a formal oral assessment. We argue that complementarity between the two types of assessment when combined means they allow us to gain a holistic impression of the student's overall performance. We illustrate how the oral component of assessment influences how students go about learning and highlight its perceived 'added value' in terms of helping students prepare for employment. Our findings are theorised in terms of the extent to which assessment aligns with learning activities and learning outcomes, which we believe is vital in health professional programmes. The purpose of this qualitative study was to explore the views of students, clinical educators, and university visiting tutors on assessment strategies used in clinical practice. Our objectives were to develop our understanding of the contribution made by each element of assessment to our overall view of student capability. On this basis we would determine whether both assessment components were deemed necessary by all of the stakeholders.

Low back pain research priorities: a survey of primary care practitioners.

BACKGROUND: Despite the large amount of time and money which has been devoted to low back pain research, successful management remains an elusive goal and low back pain continues to place a large burden on the primary care setting. One reason for this may be that the priorities for research are often developed by researchers and funding bodies, with little consideration of the needs of primary care practitioners. This study aimed to determine the research priorities of primary care practitioners who manage low back pain on a day-to-day basis. METHODS: A modified-Delphi survey of primary care practitioners was conducted, consisting of three rounds of questionnaires. In the first round, 70 practitioners who treat low back pain were each asked to provide up to five questions which they would like answered with respect to low back pain in primary care. The results were collated into a second round questionnaire consisting of 39 priorities, which were rated for importance by each practitioner on a likert-scale. The third round consisted of asking the practitioners to rank the top ten priorities in order of importance. RESULTS: Response rates for the modified-Delphi remained above 70% throughout the three rounds. The ten highest ranked priorities included the identification of sub-groups of patients that respond optimally to different treatments, evaluation of different exercise approaches in the management of low back pain, self-management of low back pain, and comparison of different treatment approaches by primary care professions treating low back pain. CONCLUSION: Practitioners identified a need for more information on a variety of topics, including diagnosis, the effectiveness of treatments, and identification of patient characteristics which affect treatment and recovery.

Manual forces applied during cervical mobilization.

OBJECTIVE: Manual therapists routinely use passive accessory mobilization techniques to treat patients with mechanical neck disorders, but little is known about the manual forces applied. The aim of this study was to quantify the manual forces applied to the cervical spine during joint mobilization. METHODS: Ten physiotherapists performed posterior-to-anterior mobilizations to C2 and C7 (both centrally and unilaterally, 1 right and 1 left, grades I-IV) on a single asymptomatic male subject. Manual forces were measured in 3 planes using an instrumented treatment table. RESULTS: The instrumented table showed excellent reliability (intraclass correlation coefficient [2,1], 0.99; 95% confidence interval, 0.97-1.00) and accuracy (mean absolute error; vertical force, 1.1 N; SD, 1.5). There were considerable differences between therapists for mean peak force, force amplitude, and oscillation frequency for each technique and grade. Mean peak forces (grade I, 21.8 N; SD, 15.0; grade II, 34.9 N; SD, 20.9; grade III, 58.2 N; SD, 27.5; grade IV, 61.0 N; SD, 29.9) were considerably lower than previously reported lumbar mobilization forces. Intratherapist repeatability for all mobilization parameters was high. Force amplitude and oscillation frequency measures indicated that therapists generally adhered to the published definitions of the grades of mobilization when applying force, but when asked, provided quite different definitions of the grades. CONCLUSIONS: This study provides preliminary evidence that cervical mobilization forces vary considerably between therapists, but intratherapist repeatability is high.

Measuring physiotherapists' guideline adherence by means of clinical vignettes: a validation study.

RATIONALE, AIMS AND OBJECTIVES: To assess the criterion validity of paper-and-pencil vignettes to assess guideline adherence by physiotherapists in the Netherlands. The evidence-based physiotherapy practice guideline for low back pain was used as an example. METHODS: Four vignettes were constructed and pre-tested. Three vignettes were found to represent an adequate case-mix. They described one patient with specific low back pain, one with non-specific low back pain and a normal recovery process and one with non-specific low back pain and a delay in the recovery process. Invited to participate were 113 primary care physiotherapists who had joined an randomized controlled trial study 8 months before, in which guideline adherence had been measured by means of semi-structured treatment recording forms. The criterion validity was determined with Spearman's r(s), using Cohen's classification for the behavioural sciences to categorize its effect size. RESULTS: Of the 72 physiotherapists who agreed to participate, 39 completed the questions on the vignettes. In the end, both adherence measures were available for 34 participants, providing 102 vignettes and 268 recording forms. Mean guideline adherence scores were 57% (SD = 17) when measured by vignettes and 74% (SD = 15) when measured by recording forms. Spearman's r(s) was 0.31 (P = 0.036), which, according to Cohen's classification, is a medium effect size. CONCLUSION: Vignettes are of acceptable validity, and are an inexpensive and manageable instrument to measure guideline adherence among large groups of physiotherapists. Further validation studies could benefit from the use of standardized patients as a gold standard, a more diverse case mix to better reflect real physiotherapy practice, and the inclusion of longitudinal vignettes that cover the patients' course of treatment.

Validating clinical reasoning: a question of perspective, but whose perspective?

This paper explores the notion of validity from different perspectives and addresses its integration with clinical reasoning. Whilst valuing the evidence-based practice (EBP) perspective in our quest for validation of practice, the authors posit that other perspectives may provide added value through their potential for offering validity in differing circumstances. The reality of the EBP aspiration is discussed and nuances within the evolved term 'research-enhanced practice' are shared. Validity theory applied through different perspectives may, it is argued help to get to grips with the balancing act of validating manual therapy practice.

Spinal manipulation for low-back pain: a treatment package agreed to by the UK chiropractic, osteopathy and physiotherapy professional associations.

Trials of manipulative treatment have been compromised by, amongst other things, different definitions of the therapeutic procedures involved. This paper describes a spinal manipulation package agreed by the UK professional bodies that represent chiropractors, osteopaths and physiotherapists. It was devised for use in the UK Back pain Exercise And Manipulation (UK BEAM) trial--a national study of physical treatments in primary care funded by the Medical Research Council and the National Health Service Research and Development Programme. Although systematic reviews have reported some beneficial effects of spinal manipulation for low-back pain, due to the limited methodological quality of primary studies and difficulties in defining manipulation, important questions have remained unanswered. The UK BEAM trial was designed to answer some of those questions. Early in the design of the trial, it was acknowledged that the spinal manipulation treatment regimes provided by practitioners from the three professions shared more similarities than differences. Because the trial design specifically precluded comparison of the effect between the professions, it was necessary to devise a homogenous package representative of, and acceptable to, all three. The resulting package is 'pragmatic', in that it represents what happens to most people undergoing manipulation, and 'explanatory' in that it excludes discipline-specific variations and other ancillary treatments.

Conceptual models for implementing biopsychosocial theory in clinical practice.

The integration of the biopsychosocial model into manual therapy practice is challenging for clinicians, especially for those who have not received formal training in biopsychosocial theory or its application. In this masterclass two contemporary models of health and disability are presented along with a model for organizing clinical knowledge, and a model of reasoning strategies that will assist clinicians in their understanding and application of biopsychosocial theory. All four models emphasise the importance of understanding and managing both the psychosocial and the biomedical aspects of patients' problems. Facilitating change in patients' (and clinicians') perspectives on pain and its biopsychosocial influences requires them to reflect on their underlying assumptions and the basis of those beliefs. Through this reflective process perspectives will be transformed, and for clinicians, in time, different management practices will emerge.

[Long-term evaluation of effectiveness for selected chest physiotherapy methods used in the treatment of cystic fibrosis]. / Dlugofalowa ocena skutecznosci wybranych metod fizjoterapii klatki piersiowej stoswanych w leczeniu chorych na mukowiscydoze.

The aim of this study was a long-term analysis of efficiency of selected chest physiotherapy methods used in the treatment of children with CF. We studied 80 CF children (39 male, 41 female), mean age ll.44yrs (range 6-18 yrs), with varying degree of severity. The study was carried out during 7 months. The subjects were assigned into four groups. Group had conventional postural drainage with clapping (33 patients, age x-11.12), group II- conventional postural drainage with clapping and vibration (16 patients, age x-11.25), group III - active cycle of breathing technique (18 patients, age x-10.5), group IV Flutter (13 patients, age x- 13.77). All patients had three physiotherapy sessions a day. We measured: FEV1 FVC, FEV1/FVC, MEF 25-7 %, PEF, before and after the study. In the group with postural drainage with clapping we observed statistically significant decrease of all studied parameters. The use of additional vibration improved FVC and FEV1/FVC values but the improvement was not statistically significant. FEV1, PEF and MEF 25 %, were significantly lower. Statistically significant increase of all studied parameters was observed in patients using ACBT. In the Flutter group we observed increase of FEV1 and FVC values. The other parameters were decreased without statistical significance. Analysis of variance of pulmonary function parameters between groups demonstrated significant differences in FEV1, PEF and MEF 50% between postural drainage with vibration and active cycle of breathing technique. Significant differences have also been shown in PEF between postural drainage with clapping and active cycle of breathing technique. We conclude that: 1) postural drainage with clapping is less effective compared with the other studied techniques.2) The use of additional vibration did not bring about improvement of drainage efficiency. Vibration increased airways resistance. 3) Flatter device may be less effective in peripheral airways clearance.