A multidimensional scaling analysis of the techniques that physiotherapists use

Ultrasound combined transcutaneous electrical nerve stimulation (UltraTENS) versus phonophoresis of piroxicam (PhP) in symptomatic knee osteoarthritis: A randomized double-blind, controlled trial

BACKGROUND

Ultrasound combined with transcutaneous electrical nerve stimulation (UltraTENS) and phonophoresis of piroxicam (PhP) are combined modality therapy that frequently used in musculoskeletal pain including knee osteoarthritis (OA). But it is lack of a good clinical trial to prove and compare their effects.

OBJECTIVE

To compare the effects of UltraTENS with PhP on mild to moderate degree of symptomatic knee OA.

METHODS

Sixty-one patients (55 women), mean age of 63.4 ± 8.1 y, 50-90 mm VAS of knee pain and Kellgren-Lawrence score of grade I-III were randomly allocated into UltraTENS and PhP (N = 31 and 30, respectively). The UltraTENS group received a combined ultrasound with TENS program and a non-drug gel, whereas the PhP group got an ultrasound program with piroxicam gel and sham TENS. All patients were treated for a total of 10 sessions, consisting of five times per week and 10 min per session. Before and after treatment, patients were evaluated knee pain by using the 100-mm VAS and functional performance by Western Ontario and McMaster Universities Osteoarthritis (WOMAC) index.

RESULTS

The UltraTENS and PhP groups experienced considerable improvement in both VAS and total WOMAC scores post-treatment (P< 0.001). The PhP had better VAS of pain and WOMAC scores but no statistical significance.

CONCLUSIONS

Results show that UltraTENS and PhP were effective for relieving pain and improve functionality knee OA without significant differences between their effects.

The feasibility of a randomised controlled trial of physiotherapy for adults with joint hypermobility syndrome

BACKGROUND

Joint hypermobility syndrome (JHS) is a heritable disorder associated with laxity and pain in multiple joints. Physiotherapy is the mainstay of treatment, but there is little research investigating its clinical effectiveness.

OBJECTIVES

To develop a comprehensive physiotherapy intervention for adults with JHS; to pilot the intervention; and to conduct a pilot randomised controlled trial (RCT) to determine the feasibility of conducting a future definitive RCT.

DESIGN

Patients' and health professionals' perspectives on physiotherapy for JHS were explored in focus groups (stage 1). A working group of patient research partners, clinicians and researchers used this information to develop the physiotherapy intervention. This was piloted and refined on the basis of patients' and physiotherapists' feedback (stage 2). A parallel two-arm pilot RCT compared 'advice' with 'advice and physiotherapy' (stage 3). Random allocation was via an automated randomisation service, devised specifically for the study. Owing to the nature of the interventions, it was not possible to blind clinicians or patients to treatment allocation.

SETTING

Stage 1 - focus groups were conducted in four UK locations. Stages 2 and 3 - piloting of the intervention and the pilot RCT were conducted in two UK secondary care NHS trusts.

PARTICIPANTS

Stage 1 - patient focus group participants (n = 25, three men) were aged > 18 years, had a JHS diagnosis and had received physiotherapy within the preceding 12 months. The health professional focus group participants (n = 16, three men; 14 physiotherapists, two podiatrists) had experience of managing JHS. Stage 2 - patient participants (n = 8) were aged > 18 years, had a JHS diagnosis and no other musculoskeletal conditions causing pain. Stage 3 - patient participants for the pilot RCT (n = 29) were as for stage 2 but the lower age limit was 16 years.

INTERVENTION

For the pilot RCT (stage 3) the advice intervention was a one-off session, supplemented by advice booklets. All participants could ask questions specific to their circumstances and receive tailored advice. Participants were randomly allocated to 'advice' (no further advice or physiotherapy) or 'advice and physiotherapy' (an additional six 30-minute sessions over 4 months). The physiotherapy intervention was supported by a patient handbook and was delivered on a one-to-one patient-therapist basis. It aimed to increase patients' physical activity through developing knowledge, understanding and skills to better manage their condition.

MAIN OUTCOME MEASURES

Data from patient and health professional focus groups formed the main outcome from stage 1. Patient and physiotherapist interview data also formed a major component of stages 2 and 3. The primary outcome in stage 3 related to the feasibility of a future definitive RCT [number of referrals, recruitment and retention rates, and an estimate of the value of information (VOI) of a future RCT]. Secondary outcomes included clinical measures (physical function, pain, global status, self-reported joint count, quality of life, exercise self-efficacy and adverse events) and resource use (to estimate cost-effectiveness). Outcomes were recorded at baseline, 4 months and 7 months.

RESULTS

Stage 1 - JHS is complex and unpredictable. Physiotherapists should take a long-term holistic approach rather than treating acutely painful joints in isolation. Stage 2 - a user-informed physiotherapy intervention was developed and evaluated positively. Stage 3 - recruitment to the pilot RCT was challenging, primarily because of a perceived lack of equipoise between advice and physiotherapy. The qualitative evaluation provided very clear guidance to inform a future RCT, including enhancement of the advice intervention. Some patients reported that the advice intervention was useful and the physiotherapy intervention was again evaluated very positively. The rate of return of questionnaires was low in the advice group but reasonable in the physiotherapy group. The physiotherapy intervention showed evidence of promise in terms of primary and secondary clinical outcomes. The advice arm experienced more adverse events. The VOI analysis indicated the potential for high value from a future RCT. Such a trial should form the basis of future research efforts.

CONCLUSION

A future definitive RCT of physiotherapy for JHS seems feasible, although the advice intervention should be made more robust to address perceived equipoise and subsequent attrition.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN29874209.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 20, No. 47. See the NIHR Journals Library website for further project information.

Transcutaneous electrical nerve stimulation as an adjunct to education and exercise for knee osteoarthritis: a randomized controlled trial

OBJECTIVE

To determine the additional effects of transcutaneous electrical nerve stimulation (TENS) for knee osteoarthritis (OA) when combined with a group education and exercise program (knee group).

METHODS

The study was a randomized, sham-controlled clinical trial. Patients referred for physiotherapy with suspected knee OA (confirmed using the American College of Rheumatology clinical criteria) were invited. Exclusion criteria included comorbidities preventing exercise, previous TENS experience, and TENS contraindications. Prospective sample size calculations required 67 participants in each trial arm. A total of 224 participants (mean age 61 years, 37% men) were randomized to 3 arms: TENS and knee group (n = 73), sham TENS and knee group (n = 74), and knee group (n = 77). All patients entered an evidence-based 6-week group education and exercise program (knee group). Active TENS produced a "strong but comfortable" paraesthesia within the painful area and was used as much as needed during the 6-week period. Sham TENS used dummy devices with no electrical output. Blinded assessment took place at baseline and 3, 6, 12, and 24 weeks. The primary outcome was the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) function subscale at 6 weeks. Secondary outcomes included WOMAC pain, stiffness, and total scores; extensor muscle torque; global assessment of change; exercise adherence; and exercise self-efficacy. Data analysis was by intent to treat.

RESULTS

All outcomes improved over time (P < 0.05), but there were no differences between trial arms (P > 0.05). All improvements were maintained at 24-week followup.

CONCLUSION

There were no additional benefits of TENS, failing to support its use as a treatment adjunct within this context.

Therapeutic approaches to fibromyalgia syndrome in the United Kingdom: a survey of occupational therapists and physical therapists

BACKGROUND AND PURPOSE

This study sought information from occupational therapists (OTs) and physical therapists (PTs) working in rheumatology in the UK on their usual methods of treatment and management of patients with fibromyalgia syndrome (FMS).

METHODS

Data were gathered by self-completion questionnaire on: work setting; referrals of FMS patients; usual treatment objectives; assessment and treatment approaches; perceived responsiveness of patients; and other perceptions of the management of FMS. Most data were in the form of frequency counts, with some ordinal scales and open responses.

RESULTS

Responses were obtained from 142 therapists (71% response rate), of whom 47 OTs and 39 PTs managed patients with FMS. The foremost therapeutic objective was increased functional ability for OTs, and increased exercise tolerance and general fitness for PTs. Pain reduction or management was rated as the second objective for both groups. An endurance-based exercise program and energy conservation techniques were the most frequently utilized interventions. Patients with FMS were thought to be 'moderately responsive' to physical management. Predictors of outcome were considered to be largely psychosocial, rather than physical, in nature.

CONCLUSION

These data provide a preliminary profile of current practice in the management of FMS among UK therapists and indicate certain differences in approach between OTs and PTs.

Multidimensional scaling analysis of techniques used by physiotherapists in Southeast Australia: a cross-national replication

Much of the research concerning techniques used by physiotherapists has focused upon electrothermal agents, so neglecting fundamental questions concerning practice and differences in technique use. A recent study in England addressed these deficits, and determined that techniques were used in ordered combinations, which differentiate the profession into 'typologies' or specialities. The purpose of the present study was to determine whether a similar picture would emerge in Australia, and to determine the type and extent of technique use amongst Australian physiotherapists. This replication study comprised a questionnaire survey of 141 hospital physiotherapists working in Southeast Australia. Information concerning the range and frequency of techniques used over the preceding six months was obtained. Descriptive analyses indicated high frequency use of exercise therapy, manipulation, heat packs, massage and ultrasound. Multidimensional scaling revealed a clear structure concerning combination use of techniques, and a coherent typology based on this usage. Differentiation of the profession according to the typologies supports the specialist areas identified in England, namely respiratory, neurological and orthopaedic/musculoskeletal physiotherapy. A further subdivision of the latter was possible in Australia, with the emergence of both a manipulative speciality, and an exercise rehabilitation speciality. While this study confirms the findings of the earlier research, it identifies important differences in practice between Australia and England.

The occupational prestige of physiotherapy: perceptions of student physiotherapists in Australia

Within the framework of occupational prestige assessment, this survey was carried out amongst future physiotherapists in Australia to determine their perceived standing of physiotherapy relative to a range of occupations including several within the medical field. A questionnaire was administered to 258 undergraduate physiotherapy students. Twelve occupations were rated on six dimensions, ie levels of income, education, social standing, responsibility and usefulness, and the proportion of women. The results indicate that amongst future physiotherapists in Australia, their profession possesses relatively high status, together with solicitor, doctor and judge, and is differentiated from the proximate professions of nurse and chiropractor. These results are similar to those obtained from the Australian public, and are in distinct contrast to the perceptions of the profession that emerged amongst physiotherapy students in England. Physiotherapy in Australia is held in high esteem - it has a clear identity and professional status, and is likely to be seen as a desirable future occupation for both genders.