Can a professional development workshop with follow-up alter practitioner behaviour and outcomes for neck pain patients? A randomised controlled trial.

BACKGROUND: Continuing professional development (CPD) is a fundamental component of physiotherapy practice. Follow-up sessions provide opportunity for the refinement of skills developed during CPD workshops. However, it is necessary to identify if such opportunity translates to improved physiotherapist performance and patient outcomes. OBJECTIVES: To determine whether a traditional CPD workshop with a follow-up session with the educator is more likely to change physiotherapists' practice behaviour and patient outcomes than a traditional workshop with no opportunity for follow-up. DESIGN: A single-blind, randomised controlled trial. METHODS: Participants were stratified and randomly allocated to the intervention and control groups. The control group participated in a two-day workshop dedicated towards the management of neck disorders. The intervention group completed the two-day workshop and attended a five-hour follow-up session one month later. Outcome measures included self-reported physiotherapist practice behaviour and confidence, as well as patient clinical outcomes using the Neck Disability Index. RESULTS: While all participants exhibited changes in confidence and practice behaviours, between-group differences were not significant for any response (p > 0.05). There were also no significant differences between the groups in terms of patient outcomes (Neck Disability Index: F = 0.36, p = 0.56). CONCLUSION: A single follow-up session to a traditional workshop is insufficient to significantly influence practice behaviours or patient outcomes.

Primary sensory and motor cortex function in response to acute muscle pain: A systematic review and meta-analysis.

Acute muscle pain has both motor and sensory consequences, yet the effect of muscle pain on the primary sensory (S1) and motor (M1) cortices has yet to be systematically evaluated. Here we aimed to determine the strength of the evidence for (1) altered activation of S1/M1 during and after pain, (2) the temporal profile of any change in activation and (3) the relationship between S1/M1 activity and the symptoms of pain. In September 2015, five electronic databases were systematically searched for neuroimaging and electrophysiological studies investigating the effect of acute experimental muscle pain on S1/M1 in healthy volunteers. Demographic data, methodological characteristics and primary outcomes for each study were extracted for critical appraisal. Meta-analyses were performed where appropriate. Twenty-five studies satisfied the inclusion criteria. There was consistent evidence from fMRI for increased S1 activation in the contralateral hemisphere during pain, but insufficient evidence to determine the effect at M1. Meta-analyses of TMS and EEG data revealed moderate to strong evidence of reduced S1 and corticomotor excitability during and following the resolution of muscle pain. A comprehensive understanding of the temporal profile of altered activity in S1/M1, and the relationship to symptoms of pain, is hampered by differences in methodological design, pain modality and pain severity between studies. Overall, the findings of this review indicate reduced S1 and corticomotor activity during and after resolution of acute muscle pain, mechanisms that could plausibly underpin altered sensorimotor function in pain. WHAT DOES THIS REVIEW ADD?: We provide the first systematic evaluation of the primary sensory (S1) and motor (M1) cortex response to acute experimental muscle pain in healthy volunteers. We present evidence from a range of methodologies to provide a comprehensive understanding of the effect of pain on S1/M1. Through meta-analyses we evaluate the strength of evidence concerning the direction and temporal profile of the S1/M1 response to acute muscle pain.

Altered function of intracortical networks in chronic lateral epicondylalgia.

BACKGROUND: Lateral epicondylalgia (LE) is a musculotendinous condition characterized by persistent pain, sensorimotor dysfunction and motor cortex reorganization. Although there is evidence linking cortical reorganization with clinical symptoms in LE, the mechanisms underpinning these changes are unknown. Here we investigated activity in motor cortical (M1) intracortical inhibitory and facilitatory networks in individuals with chronic LE and healthy controls. METHODS: Surface electromyography was recorded bilaterally from the extensor carpi radialis brevis (ECRB) muscle of 14 LE (4 men, 41.5 ± 9.9 years) and 14 control participants (4 men, 42.1 ± 11.1 years). Transcranial magnetic stimulation of M1 was used to evaluate resting and active motor threshold, corticomotor output, short- (SICI) and long-latency intracortical inhibition (LICI) and intracortical facilitation (ICF) of both hemispheres. RESULTS: In individuals with LE, SICI (p = 0.005), ICF (p = 0.026) and LICI (p = 0.046) were less in the M1 contralateral to the affected ECRB muscle compared with healthy controls. Motor cortical threshold (rest: p = 0.57, active: p = 0.97) and corticomotor output (p = 0.15) were similar between groups. No differences were observed between individuals with LE and healthy controls for the M1 contralateral to the unaffected ECRB muscle. CONCLUSIONS: These data provide evidence of less intracortical inhibition mediated by both GABAA and GABAB receptors, and less intracortical facilitation in the M1 contralateral to the affected ECRB in individuals with LE compared with healthy controls. Similar changes were not present in the M1 contralateral to the unaffected ECRB. These changes may provide the substrate for M1 reorganization in chronic LE and could provide a target for future therapy. WHAT DOES THIS STUDY ADD: Lateral epicondylalgia (LE) is a common musculoskeletal condition characterized by elbow pain and sensorimotor dysfunction. The excitability and organization of the motor cortical representation of the wrist extensor muscles is altered in LE, but the mechanisms that underpin these changes are unknown. evidence of less intracortical inhibition mediated by both GABAA and GABAB receptors, and less intracortical facilitation mediated by NMDA receptors, in the M1 contralateral to the affected extensor carpi radialis brevis muscle in chronic LE compared with healthy controls. Altered activity in intracortical networks may contribute to altered motor cortex organization in LE and could provide a potential target for future treatments.

Peripheral electrical stimulation to induce cortical plasticity: a systematic review of stimulus parameters.

Peripheral electrical stimulation (ES) is commonly used as an intervention to facilitate movement and relieve pain in a variety of conditions. It is widely accepted that ES induces rapid plastic change in the motor cortex. This leads to the exciting possibility that ES could be used to drive cortical plasticity in movement disorders, such as stroke, and conditions where pain affects motor control. This paper aimed to critically review the literature to determine which parameters induced cortical plasticity in healthy individuals using ES. A literature search located papers that assessed plasticity in the primary motor cortex of adult humans. Studies that evaluated plasticity using change in the amplitude of potentials evoked by transcranial magnetic stimulation of the motor cortex were included. Details from each study including sample size, ES parameters and reported findings were extracted and compared. Where data were available, Cohen's standardised mean differences (SMD) were calculated. Nineteen studies were located. Of the parameters evaluated, variation of the intensity of peripheral ES appeared to have the most consistent effect on modulation of excitability of corticomotor pathway to stimulated muscles. There was a trend for stimulation above motor threshold to increase excitability (SMD 0.79 mV, CI -0.10 to 1.64). Stimulation below motor threshold, but sufficient to induce sensory perception, produced conflicting results. Further studies with consistent methodology and larger subject numbers are needed before definitive conclusions can be drawn. There also appeared to be a time effect. That is, longer periods of ES induced more sustained changes in cortical excitability. There is insufficient evidence to determine the effect of other stimulation parameters such as frequency and waveform. Further research is needed to confirm whether modulation of these parameters affects plastic change.

A national study of the availability and use of electrophysical agents by Australian physiotherapists.

Electrophysical agents (EPAs) are a core part of physiotherapy practice and entry level education. With the increase in the number of EPAs over time, their availability and use in contemporary physiotherapy practice is an important consideration when determining entry level curricula. Thus, the aim of the study was to ascertain the current availability and usage of EPAs in Australian physiotherapy practice. A purpose-designed questionnaire was mailed to all registered physiotherapists in Australia. A response rate of 27% was obtained (n=3,538). Nonresponder analyses indicated that the results were representative of the total population of Australian physiotherapists. Over 70% of respondents had access to ultrasound, cold packs/ice, heat packs, electrical stimulation for sensory stimulation, and interferential therapy. Two main groups of EPAs were used relatively frequently. The first group was used daily or monthly by 60% of respondents (ultrasound, hot packs, and cold packs/ice), and a second group (electromyographic and pressure biofeedback, interferential therapy, and electrical stimulation for sensory stimulation) was used on a daily or monthly basis by between 30% and 45% of the sample. A group of EPAs, including ultraviolet light, microwave, and shortwave diathermy, was not used by over 90% of the sample. The study has provided contemporary national data on EPA availability and use in Australia.

The availability and usage frequency of real time ultrasound by physiotherapists in South Australia: an observational study.

BACKGROUND AND PURPOSE: Real time ultrasound (RTUS) is an emerging imaging modality in physiotherapy. Anecdotal evidence suggests that it is being used as an assessment and biofeedback tool for various deep core stabilizing muscles. However, how and why physiotherapists use RTUS in the clinical setting has not yet been reported. Therefore, this study aimed to establish the availability and usage frequency of RTUS by physiotherapists in South Australia. In addition, the study aimed to describe how physiotherapists were using RTUS and how they were educated in its use. METHOD: A questionnaire was developed and mailed to all physiotherapists registered with the Physiotherapy Board of South Australia (n = 1328) between February and March 2007. RESULTS: A response rate of 50% was achieved with 664 completed usable questionnaires returned. At the current time, only a small proportion of respondents used RTUS (11.6%), while slightly more had access to a machine (19.4%). RTUS was used most commonly for assessment (88.3%) and biofeedback (87.0%) of the abdominal (94.7%), pelvic floor (72.7%) and multifidus (54.5%) muscles. Of all respondents, 26.7% had trained in its use with most completing two hours or less of training. CONCLUSIONS: This is the first published study to describe how and why physiotherapists are using RTUS in clinical practice. RTUS appears to be a relatively uncommon modality potentially limited by insufficient access to equipment and educational opportunities. The findings highlight a greater need for education and training in the use of RTUS for physiotherapy practice.

The effect of low-Dye taping on peak plantar pressures of normal feet during gait.

This study investigated whether low-Dye anti-pronation taping altered peak plantar pressures of normal feet during gait. The Emed-AT-2 platform system was used to measure peak plantar pressures. Forty subjects performed two sets of six walks over the Emed-AT-2 forceplate. One set of walks was performed barefoot whilst the other set was performed with the low-Dye tape applied to the right foot. Computer software divided the heel, midfoot and forefoot into six areas (masks) for analysis. The mean for the peak plantar pressures (N/cm(2)) of each of these masks was determined for both sets of walks. Paired t-tests found a significant difference between the barefoot and taped peak plantar pressures in each of the six masks. Overall low-Dye anti-pronation taping significantly altered the peak plantar pressures of normal feet during gait. Of particular interest was that a significant reduction in mean peak plantar pressure was observed in the medial midfoot (1.4 N/cm(2)) whilst a significant increase occurred in the lateral midfoot (2.6 N/cm(2)).

Hip fracture rates in South Australia: into the next century.

BACKGROUND: Fractures of the femoral neck already represent a major public health problem in Australia. This situation is set to worsen as the population ages. The present study estimates the number of patients over 50 years of age with femoral neck fractures that is expected to impact on the South Australian healthcare service into the next century. METHODS: Population projections from the Australian Bureau of Statistics 1996 census were combined with age- and gender-specific incidence rates for fractures of the femoral neck for persons over the age of 50 in South Australia. Projections for the expected number of hip fractures in this State were then calculated. RESULTS: Assuming there are no changes in the age- and gender-specific incidence of fracture rates, the number of fractures in South Australia is estimated to increase by approximately 66% by the year 2021 and 190% by 2051. CONCLUSION: Based on the population projections and the assumption that conditions contributing to hip fractures remain constant, the number of fractured neck of femurs will increase in far greater proportion than the overall population in the next century. The results of the present study indicate the serious implications for the South Australian healthcare system if there is no reduction in incidence rates.

Shoulder impingement syndrome: preoperative health status.

Eighty-one patients with chronic shoulder impingement resistant to conservative treatment completed a generic quality-of-life questionnaire (SF-36) and shoulder-specific questionnaire (Simple Shoulder Test [SST]). SF-36 data were compared with those of an Australian normative data set. Patients with chronic shoulder impingement were found to be significantly lower in all health dimensions of the SF-36 than the normal population. Results from the SST test indicated that patients were functionally very limited, particularly in being unable to work full time at their usual job and being unable to lift a weight above the head. Our results indicate that chronic shoulder impingement results in significant functional disability and a reduction in quality of life. Baseline descriptive data of this nature are important, because they provide a point of comparison for the effect of different conditions and for determining the effect of surgical treatment.

Arthroscopic subacromial decompression: responsiveness of disease-specific and health-related quality of life outcome measures.

Twenty-eight patients who presented with stage II or early stage III impingement syndrome were evaluated before and after decompression surgery to examine the sensitivity and responsiveness of health-related quality of life and disease-specific measures. The outcome instruments used included the Medical Outcomes Study SF36 health survey; the Constant-Murley shoulder scoring system (CM), the University of California at Los Angeles shoulder rating scale (UCLA) and visual analogue scales (VAS) for pain. Preoperative and short-term postoperative evaluations showed significant improvements in all outcome instruments, including pain and physical role dimensions of the SF36. However, the UCLA and VAS pain scores were confirmed as the most responsive and sensitive measures to short-term change following arthroscopic decompression.

Intraarticular fractures of the distal radius treated with metaphyseal external fixation. Early clinical results.

Twenty-two patients with unstable Frykman grade 7 or 8 intra-articular fractures of the distal radius were treated with an external fixator. The distal pins were inserted into the distal radial fracture fragments, permitting movement of the wrist and hand. Eleven patients were male and 11 female, with a mean age of 50 years. All patients had regained full function with good range of motion at mean final follow-up of 12 months. However function, pain and range of motion had returned to acceptable levels 4 weeks after removal of the external fixator. This method of external fixation provides a reliable method of maintaining fracture reduction whilst allowing early return of function.

Primary total knee replacement: short-term outcomes in an Australian population.

This study evaluated the short-term outcome of primary total knee replacement, using standard and reliable outcome measures, for osteoarthritis in an Australian population. This study also compared the pre-operative health status of the patient population with population norms using a quality of life questionnaire. Using the medical outcome study (MOS) 36-item short form health survey (SF-36), there was a statistically significant improvement in physical functioning and bodily pain in males and bodily pain, vitality, role-emotional and mental health in females (P < 0.05). A statistically significant improvement was also seen in Knee Society Scores following surgery for both males and females (P < 0.05). Comparison of pre-operative SF-36 data to age-matched Australian normative values demonstrate that female patients requiring total knee replacement were significantly below the norms in virtually all health dimensions while males were significantly below the norms in mainly physical health dimensions (P < 0.01).