Assessment of undergraduate physiotherapist clinical performance: investigation of educator inter-rater reliability

Objectives

To investigate the inter-rater reliability of physiotherapy educators in awarding clinical placement marks to undergraduate students using a standardised clinical placement assessment form.

Design

Inter-rater reliability study performed over five undergraduate physiotherapy clinical placements.

Setting

Five clinical sites associated with a BSc undergraduate physiotherapy programme.

Participants

Second and final year physiotherapy students who were on clinical placements (n = 86 paired assessments). Two physiotherapy educators (a practice tutor and a practice educator), equally involved in supervising the students over the placement period, marked each student blindly at the end of the placement.

Outcome measure

Marking was performed using a standardised clinical placement assessment form and guidelines. This form was developed by physiotherapy educators, and utilised previously published work in the area.

Results

Eighty-six paired assessment marks were analysed. Practice educators and practice tutors agreed on grades on 74% of occasions. The mean difference in marks (maximum of 100) between educators was −0.5 (95% confidence interval −1.1 to 0.2), and using the limits of agreement method, the results suggested that where two raters mark a student at the end of a clinical placement, the raters will be within 6.2 marks of each other on 95% of occasions. The intraclass correlation coefficient (ICC) for the overall mark was 0.84, indicating almost perfect agreement. Subsections of the form also had substantial agreement (patient management ICC, 0.75; professional development ICC, 0.75; organisation and management ICC, 0.81).

Conclusion

Physiotherapy educators demonstrated a high level of reliability in the assessment and marking of undergraduate physiotherapy student performance using a standardised clinical assessment form. This was evident over several sites and specialities.     

Hyperglycemia during acute coronary syndrome: A nurse-managed insulin infusion protocol for stricter and safer control

Background

Diabetic patients with acute coronary syndromes (ACS) might benefit from tight glycemic control by means of insulin infusion. Nurse-implemented insulin infusion protocols (IIP) are available but none validated in patients with ACS admitted to a coronary care unit (CCU).

Aims

To assess feasibility, effectiveness and safety of a new nurse-managed IIP (Desio Diabetes Diagram, DDD) for intensive glucose control in patients with suspected ACS and known diabetes or blood glucose (BG) > 200 mg/dL.

Methods and results

To reach and maintain a target BG level of 100-139 mg/dL we adopted a nomogram based on the percent changes in the insulin infusion rate according to the current BG value and the percent change from previous BG level.Ninety-one consecutive patients (53 men, mean age 69.7 ± 11.2 years) were treated with DDD IIP. Baseline BG was 202.2 ± 86.8 mg/dL. The median time to achieve the target was 3 h (Q1-Q3 2-5 h). Afterwards target BG levels were maintained for 70.4 ± 15.9% of the time. During 5004 h of insulin infusion BG never fell below 40 mg/dL.

Conclusions

The nurse-managed DDD IIP was easily implemented in our CCU and permitted strict and safe glycemic control in hyperglycemic patients with ACS.     

A study to determine the reliability of an ankle dorsiflexion weight-bearing device

Objectives

To investigate the inter-observer and intra-observer reliability of measurement of ankle movement during a weight-bearing dorsiflexion lunge in healthy and injured groups.

Setting

Defence Medical Rehabilitation Centre, UK.

Participants

Seventeen healthy subjects, 11 subjects with ankle injuries and three trained observers.

Design

Each observer assessed subjects on two separate test days, 7 days apart. Each measurement was repeated six times and the results were averaged. Limits of agreement and intra-class correlation coefficients were calculated to give a measure of reliability.

Main outcome measures

A measurement tool designed at the Defence Medical Rehabilitation Centre, UK.

Results

Intra-observer 95% limits of agreement ranged from ±3.30 to ±3.66 cm for the healthy group and from ±2.35 to ±3.85 cm for patients. The inter-observer limits of agreement ranged from ±1.57 to ±2.65 cm for healthy subjects and from ±0.87 to ±3.46 cm for patients.

Conclusions

Results indicate acceptable inter-observer and intra-observer reliability for use of this rehabilitation assessment tool to measure the weight-bearing dorsiflexion lunge range of ankle motion when results are averaged over six repetitions.     

First impressions: an information leaflet for patients attending a musculoskeletal outpatient department

Objective

The purpose of this work was to design and evaluate an information leaflet for new patients attending a physiotherapy outpatient department. This formed part of a wider agenda of improving the patients’ experience and increasing adherence to the Chartered Society of Physiotherapy's core standards.

Design

A needs analysis was undertaken with existing patients to determine the content of the new leaflet. This was then tested for readability, reviewed by physiotherapy staff and evaluated by patients via a questionnaire.

Setting

The musculoskeletal outpatient physiotherapy department at Southampton General Hospital.

Participants

Patients referred to the outpatient physiotherapy service, plus all clinical and support staff employed in the musculoskeletal outpatient team.

Main outcome measures

Numerical Rating Scale and Gunning's Fog Index.

Results

Thirty-seven of 50 patients completed the needs analysis (74%), generating 42 ideas for the leaflet content. The definitive leaflet addressed one core standard and 16 specific criteria, and had a readability of grade 8.3, which is below the recommended maximum limit of grade 9 for health education leaflets. Using an 11-point Numerical Rating Scale, where 0 = of no benefit and 10 = extremely helpful, the mean rating for the leaflet from 29 of 100 patients was 8.6.

Conclusions

This work has produced a patient information leaflet for physiotherapy outpatients, a copy of which is freely available (electronically) from the author. The leaflet forms part of an ongoing commitment to improving the patients’ experience.     

Ambulatory oxygen therapy assessment: a comparative study of incremental shuttle and 6-minute walking tests

Background

Walking tests, such as the incremental shuttle walk test (ISWT) and the 6-minute walk test (6MWT), are recommended in the assessment of ambulatory oxygen for patients with chronic obstructive pulmonary disease (COPD). However, there is no evidence that these tests can be used interchangeably.

Objectives

To compare the ISWT and the 6MWT in COPD patients in terms of indication for ambulatory oxygen therapy.

Design

Crossover design.

Setting

Patients attended as outpatients.

Participants

Fifty patients with stable COPD (31 males; age 67 years, range 43 to 83 years); mean forced expiratory volume in 1 second 1.2 l [standard deviation (SD) 0.6 l] and 48.6% predicted (SD 23.4%).

Intervention

Patients performed both the ISWT and the 6MWT whilst breathing air. Breathlessness (Borg scale), percutaneous arterial oxygen saturation (SpO₂) and heart rate were measured before and after both tests.

Main outcome measures

Post-test SpO₂ and change from baseline.

Results

The mean change in saturation was −4.6% (SD 6.2%) and −2.8% (SD 5.3%) after the ISWT and the 6WMT, respectively. Using Bland and Altman plots, the limits of agreement for difference in change in SpO₂ (%) between the two tests were wide (−8.1 to 11.6) and clinically relevant. Sixteen patients (32%) and 13 patients (26%) met the criteria for ambulatory oxygen with the ISWT and the 6MWT, respectively (P = 0.32).

Conclusions

This study found a wide variation between differences in exercise oxygen desaturation after the ISWT compared with the 6MWT, supporting the premise that these tests should not be used interchangeably in the assessment of ambulatory oxygen for COPD patients.     

Feasibility of motor capability training at home in children with acquired brain injury

Objectives

Acquired brain injury (ABI) requires an extended recovery time and residual signs may be observed years after discharge. Supervised home-based motor training may present a viable option for continuing treatment of adult patients, but little information is available on home-based treatment in children. This study assessed the feasibility of home practice in children with ABI (1 or more years post-trauma). The efficacy of the programme was also evaluated.

Design

A non-randomised, self-control study with control and intervention periods.

Setting

Home-based exercise programme.

Participants

Nineteen children (mean age 12.5 ± 3.1 years).

Interventions

A 4-week daily training programme of step-up and sit-stand-sit exercises.

Main outcome measures

Feasibility was assessed by the number of participants who completed the programme. Efficacy was evaluated at different stages using 10-metre walking and 2-minute walking tests, and the balance subitems of the Bruininks-Oseretsky Test of Motor Proficiency. An energy expenditure index was calculated for walking. Performance scores were used to assess balance.

Results

Nine participants completed the study. The mean number of training sessions was 22 ± 8 of the 30 sessions originally scheduled. Major differences were noted between the experimental stages. Walking speed, endurance and balance improved significantly during the intervention period.

Conclusions

Continuing exercising at home may be a feasible and efficient option for a considerable proportion of ABI children who are compliant with a simple but challenging exercise programme. A randomised controlled trial with a larger sample is now required.     

Accuracy of Manual Needle Placement for Gastrocnemius Muscle in Children With Cerebral Palsy Checked Against Ultrasonography

Yang EJ, Rha D, Yoo JK, Park ES. Accuracy of manual needle placement for gastrocnemius muscle in children with cerebral palsy checked against ultrasonography.

Objective

To investigate the accuracy of manual needle placement into gastrocnemius muscle (GCM) for botulinum toxin type A (BTX-A) injection in children with spastic cerebral palsy (CP).

Design

Prospective clinical study.

Setting

University-affiliated hospital.

Participants

A total of 272 injections in GCMs of 39 children with spastic CP who were scheduled to receive BTX-A injections in GCMs.

Intervention

Not applicable.

Main Outcome Measures

The accuracy of manual needle placement was checked against ultrasonography.

Results

The needle was accurately inserted into GCM muscles in 78.7% of cases. Accuracy was 92.6% into gastrocnemius medialis (GM) and 64.7% into gastrocnemuis lateralis (GL). Muscle thickness at the needle insertion site was significantly thinner in GL than GM. Accuracy of GL in the younger age group (<4y, 57.6%) was lower than in the older age group (≥4y, 78.1%). For GM, accuracy in both younger and older age groups was good (>90%).

Conclusions

Injection of the toxin into GCMs through the use of anatomic landmark was acceptable in GM, but not acceptable in GL, especially in young children.     

Diaphragm needle placement techniques evaluated in cadaveric specimens

Chiodo A, Goodmurphy C, Haig A. Diaphragm needle placement techniques evaluated in cadaveric specimens.

Objective

To evaluate the safest and most accurate method of diaphragm needle placement for electromyography.

Design

Single blinded study.

Setting

University anatomy laboratory.

Cadavers

Five cadavers.

Interventions

Needle placement in the diaphragm by an American Board of Electrodiagnostic Medicine physician, blinded dissection by a doctoral candidate anatomist.

Main Outcome Measures

Accurate needle placement in the diaphragm, proximity or penetration of organs, vessels, or nerves, defined as cautions (proximity) and dangers (penetration).

Results

The anterior axillary approach was most accurate at the above-the-seventh and eighth-rib locations. The risk of dangers of needle placement in the diaphragm was greater on the right than left side.

Conclusions

Needle placement in the diaphragm is safe and most accurate at the anterior axillary line superior to the eighth rib. If the side of needle placement does not matter for the study being done, the left side should be chosen because it leads to a lower risk of danger to the patient.     

Stress, coping and burn-out in nursing students

Aim

To explore the relationship between sources of stress and psychological burn-out and to consider the moderating and mediating role played sources of stress and different coping resources on burn-out.

Background

Most research exploring sources of stress and coping in nursing students construes stress as psychological distress. Little research has considered those sources of stress likely to enhance well-being and, by implication, learning.

Method

A questionnaire was administered to 171 final year nursing students. Questions were asked which measured sources of stress when rated as likely to contribute to distress (a hassle) and rated as likely to help one achieve (an uplift). Support, control, self-efficacy and coping style were also measured, along with their potential moderating and mediating effect on burn-out.

Findings

The sources of stress likely to lead to distress were more often predictors of well-being than sources of stress likely to lead to positive, eustress states. However, placement experience was an important source of stress likely to lead to eustress. Self-efficacy, dispositional control and support were other important predictors. Avoidance coping was the strongest predictor of burn-out and, even if used only occasionally, it can have an adverse effect on burn-out. Initiatives to promote support and self-efficacy are likely to have the more immediate benefits in enhancing student well-being.

Conclusion

Nurse educators need to consider how course experiences contribute not just to potential distress but to eustress. How educators interact with their students and how they give feedback offers important opportunities to promote self-efficacy and provide valuable support. Peer support is a critical coping resource and can be bolstered through induction and through learning and teaching initiatives.     

A prospective randomised controlled trial of spinal manipulation and ultrasound in the treatment of chronic low back pain

Objectives

To assess the short- and long-term effectiveness of spinal manipulation therapy, and to identify the effect of manipulation on lumbar muscle endurance in patients with chronic low back pain (LBP).

Design

A randomised controlled trial comparing manipulation and exercise treatment with ultrasound and exercise treatment.

Setting

An outpatient physiotherapy department.

Participants

One hundred and twenty patients with chronic LBP were allocated at random into the manipulation/exercise group or the ultrasound/exercise group.

Interventions

Both groups were given a programme of exercises. In addition, one group received spinal manipulation therapy and the other group received therapeutic ultrasound.

Main outcome measures

Pain intensity, functional disability, lumbar movements and muscle endurance were measured shortly before treatment, at the end of the treatment programme and 6 months after randomisation using surface electromyography.

Results

Following treatment, the manipulation/exercise group showed a statistically significant improvement (P = 0.001) in pain intensity [mean 16.4 mm, 95% confidence interval (CI) 6.1-26.8], functional disability (mean 8%, 95% CI 2-13) and spinal mobility (flexion: mean 9.4 mm, 95% CI 5.5-13.4; extension: mean 3.4 mm, 95% CI 1.0-5.8). There was no significant difference (P = 0.068) between the two groups in the median frequency of surface electromyography (multifidus: mean 6.8 Hz, 95% CI 1.24-14.91; iliocostalis: mean 2.4 Hz, 95% CI 2.5-7.1), although a significant difference (P = 0.013) was found in the median frequency slope of surface electromyography in favour of spinal manipulation for multifidus alone (mean 0.3, 95% CI 0.1-0.5). A significant difference was also found between the two groups in favour of the manipulation/exercise group at 6-month follow-up.

Conclusions

Although improvements were recorded in both groups, patients receiving manipulation/exercise showed a greater improvement compared with those receiving ultrasound/exercise at both the end of the treatment period and at 6-month follow-up.     

Validity of the 6-minute walk test for assessing heart rate recovery after an exercise-based cardiac rehabilitation programme

Objectives

To compare heart rate responses in the 6-minute walk test and the treadmill exercise test before and after an exercise-based cardiac rehabilitation programme.

Design

Prospective cohort study.

Setting

Hospital-based cardiac rehabilitation programme in Hong Kong.

Participants

Thirty patients (mean age 62.1 ± 8.5 years, 20 males) with stable ischaemic heart disease.

Interventions

Eight-week exercise-based cardiac rehabilitation programme involving upper and lower limb aerobic and resistance training.

Main outcome measures

Six-minute walk test and treadmill exercise test before and after the exercise programme.

Results

Comparing parameters before and after the exercise programme, the peak heart rate in the 6-minute walk test increased (median of 105 beats per minute (bpm), interquartile range 96.8-116.5 versus 110 bpm, interquartile range 100.5-124.5, P = 0.006), while heart rate recovery improved in each 30-second interval of a 2-minute recovery period. The distance covered during the 6-minute walk increased from a mean of 486.3 m (±standard deviation 113.9 m) to 552.5 m (±standard deviation 111.9 m) (P < 0.001). Rating of perceived exertion during the 6-minute walk test decreased from a median of 14 (interquartile range 13-15) to 13 (interquartile range 13-13) (P = 0.001). Heart rate recovery following treadmill exercise testing improved during the 30-second periods from 60 to 90 seconds and from 90 to 120 seconds of recovery. Metabolic equivalents increased during treadmill testing from a median of 7.0 (interquartile range 5.8-8.6) to 8.6 (interquartile range 7-8.6) (P < 0.001).

Conclusions

Both treadmill exercise and 6-minute walk tests demonstrated improvements in heart rate recovery and increases in achieved workload following exercise training. This suggests that the 6-minute walk test is a valid tool to assess heart rate recovery following such a programme.     

Physiotherapy management of osteoarthritis of the hip: a survey of current practice in acute hospitals and private practice in the Republic of Ireland

Objective

To identify the current management of osteoarthritis of the hip by physiotherapists in private practice and acute hospital settings in the Republic of Ireland.

Design

Cross-sectional postal questionnaire survey.

Participants

Physiotherapists in 35 acute hospitals (n = 150) and a random selection of physiotherapists in private practice (n = 172) in the Republic of Ireland were surveyed.

Results

A valid response rate of 65% (n = 210) was achieved. The most common intervention used by therapists was exercise therapy (210/210, 100%), followed by education (207/210, 99%), manual therapy (202/210, 96%), thermal agents (154/210, 73%) and electrotherapy (130/210, 62%). Hydrotherapy and acupuncture were used by 29% (61/210) and 18% (38/210) of respondents, respectively. Statistical differences in these interventions between public and private settings existed only for thermal agents (P = 0.001) and acupuncture (P = 0.002). A total of 84% (177/210) of those surveyed used outcome measures, most commonly pain severity scales (163/210, 78%). Osteoarthritis-specific questionnaires (33/210, 16%) and quality of life (16/210, 8%) measures were used less frequently.

Conclusions

The importance of exercise therapy, education and manual therapy in the management of osteoarthritis of the hip was demonstrated. There was little difference overall in the physiotherapy management of osteoarthritis of the hip between public and private settings. The use of these interventions compared to known scientific evidence is discussed. Although there was high usage of outcome measures, hip osteoarthritis-specific outcomes and quality of life measures were not commonly used. This survey identified interventions most commonly used in clinical practice including exercise, education and manual therapy, and highlights a need for further research to evaluate the effectiveness of such interventions.     

Are patients who refer themselves to physiotherapy different from those referred by GPs? Results of a national trial

Objectives

To establish if there are differences in the profile of patients who refer themselves to physiotherapy compared with patients referred by or at the suggestion of their general practitioner (GP) in a range of primary care settings.

Design of study

Quasi-experimental.

Setting

Twenty-nine general practices throughout Scotland.

Participants

Three thousand and ten patients (>16 years of age) and 100 physiotherapists.

Method

Self-referral was introduced in each site. The demographic and clinical data relating to all referrals collated over a full year were compared by referral group (self-referrals, GP-suggested referrals and GP referrals).

Results

There was no relationship between gender or age group and referral group, but other differences in the profile were found. The groups differed in terms of their presenting condition and its severity (P = 0.027). Greater proportions of patients who referred at the suggestion of their GP and patients who self-referred presented with low back and neck conditions (54% versus 43%, P < 0.001). Self-referrers reported having their symptoms for less than 14 days to a greater extent than the other groups (14% versus 9% and 10%, P = 0.011). Non-preferential treatment waiting time to physiotherapy also differed, with 44% of patients who self-referred being seen within 2 weeks of referral compared with 36% of patients who referred at the suggestion of their GP (P < 0.001). Self-referrers were absent from work in lower proportions (20% versus 28% and 28%, P = 0.048) and were absent for half the mean time (2.5 days versus 6 days). They also completed their treatment in greater proportions (76% versus 69% and 72%, P = 0.002). Although all groups experienced the same mean number of physiotherapy contacts (n = 4), patients who referred at the suggestion of their GP had a proportionally lower contact rate with 65% having four or less contacts compared with 55% of patients who self-referred and 51% of patients referred by their GP (P < 0.001). There was no difference in the outcome determined by physiotherapists or patients.

Conclusions

Patients who refer to physiotherapy at the suggestion of their GP and patients who self-refer appear to have a different profile from patients who are referred by their GP.     

Comparison of the analgesic efficacy of interferential therapy and transcutaneous electrical nerve stimulation

Objective

To compare the analgesic efficacy of interferential therapy (IFT) and transcutaneous electrical nerve stimulation (TENS) using an experimental cold pain model.

Design

Randomised controlled trial with repeated measures design.

Setting

University research laboratory.

Participants

Twenty healthy subjects.

Interventions

IFT and TENS applied to each subject on different days.

Main outcome measures

Cold pain threshold (time), intensity and unpleasantness (visual analogue scales).

Results

The mean cold pain threshold with a TENS intervention was higher than that with IFT. A training effect was evident as subjects’ responses become more consistent with repeated exposure to stimulation and the testing procedure. Using data from the second testing sessions, the differences in pain threshold between IFT and TENS for the two during-intervention (T3 and T4) measures were statistically significant (T3 difference in the means 5.9 seconds, 99% confidence interval 3.1 to 8.7 seconds; T4 difference in the means 6.6 seconds, 99% confidence interval 3.8 to 9.4 seconds). No significant differences were identified in pain intensity and unpleasantness ratings.

Conclusions

TENS is more effective than IFT at increasing cold pain thresholds in healthy subjects, and this effect increases with repeated exposures. Future trials should include a familiarisation session prior to testing to increase the consistency of subjects’ responses. The clinical implications of these effects need investigation.     

Validity and Responsiveness of the Care and Needs Scale for Assessing Support Needs After Traumatic Brain Injury

So C, Tate RL, Aird V, Allaous J, Browne S, Carr B, Coulston C, Diffley L, Gurka J, Hummell J. Validity and responsiveness of the Care and Needs Scale for assessing support needs after traumatic brain injury.

Objective

To investigate the validity and responsiveness of the Care and Needs Scale (CANS), which was designed to assess support needs of people with traumatic brain injury (TBI).

Design

Two samples of community clients (n=38, n=30) were recruited to examine concurrent, convergent/divergent, and discriminant validity. The ability of the CANS to detect change over a 6-month period from the time of inpatient rehabilitation discharge (predictive validity and responsiveness) was investigated in a third sample of 40 rehabilitation inpatients.

Setting

Two Brain Injury Rehabilitation Units in Sydney, Australia.

Participants

People (N=108) aged between 16 and 70 years admitted for rehabilitation after TBI.

Interventions

Not applicable.

Main Outcome Measures

The CANS, Supervision Rating Scale, FIM, Sydney Psychosocial Reintegration Scale, and Disability Rating Scale.

Results

Evidence for concurrent validity was shown with fair to moderate correlation coefficients between the CANS and measures of supervision, functional independence, and psychosocial functioning (absolute value, r_s=.43-.68; P<.01). Support for convergent and divergent validity was provided by correlation coefficients that were higher for measures tapping similar constructs (absolute value, r_s=46; P<.01) but lower for measures of dissimilar constructs (absolute value, r_s=.07-.26; not significant). In addition, the CANS discriminated between levels of injury severity, functional independence, and overall functioning (P<.01). In terms of predictive validity and responsiveness, CANS scores at inpatient rehabilitation discharge predicted the participant's functioning 6 months later.

Conclusions

These results show the CANS is a valid and responsive tool and, together with its previously shown reliability, is suitable for routine application in clinical and research practice.     

Emergency skill training--a randomized controlled study on the effectiveness of the 4-stage approach compared to traditional clinical teaching

Introduction

The “4-stage approach” has been widely accepted for practical skill training replacing the traditional 2 stages (“see one, do one”). However, the superior effectiveness of the 4-stage approach was never proved.

Objectives

To evaluate whether skill training with the 4-stage approach results in shorter performance time needed for a successful percutaneous needle-puncture cricothyroidotomy, and consequently in a reduced number of attempts needed to perform the skill in <60 s compared to traditional teaching.

Trial design

Randomized controlled single-blinded parallel group study at the University Hospital Bern.

Methods

With IRB approval and informed consent 128 undergraduate medical students were randomized in four groups: traditional teaching, no stage 2, no stage 3, and 4-stage approach for the training of cricothyroidotomy. Everyone watched a video of the cricothyroidotomy as stage 1 followed by skill training in the respective teaching group. Participants had to perform the cricothyroidotomy 10 times on skin-covered pig larynxes. Performance time was measured from skin palpation to trachea ventilation. Study participants filled out a self-rating on competency during the training.

Results

Performance time for each attempt was comparable in all groups and improved similarly to reach a performance time of <60 s. Self-rating revealed that all groups felt equally competent throughout.

Conclusions

Even if the 4-stage approach is widely accepted and used as a didactic method for skill teaching we could not find evidence that its use or omitting stage 2 or 3 results in superior learning of an emergency skill compared to traditional teaching.     

A study to compare the effects of massage and static touch on experimentally induced pain in healthy volunteers

Objective

To investigate the hypoalgesic effects of massage on experimental pain.

Design

A cross-over intervention study separated by a 24-hour washout period. During each experiment, participants completed five cold-induced pain tests, two before the intervention and three during the intervention. During each test, participants immersed their hand in iced water and reported the first sensation of pain and pain intensity after a further 30 seconds.

Setting

Laboratory setting.

Participants

A volunteer sample of 30 university staff and students without known pathology, recruited from noticeboard advertisements.

Interventions

Participants received massage in one experiment and static touch in the other experiment. Interventions were administered to the ipsilateral arm for 4 minutes immediately before the hand was immersed in iced water.

Main outcome measures

Time to pain threshold and the odds of a reduction in pain intensity and an increase in pain relief.

Results

A mixed model analysis was used to establish how measures varied, according to baseline, during static touch and during massage. Massage increased the pain threshold by a factor of 1.08 (95% confidence interval 0.99-1.17) compared with static touch, but this failed to reach statistical significance (P = 0.088). Massage was more likely to result in a report of low pain intensity than static touch (odds ratio 0.26, 95% confidence interval 0.10-0.71, P = 0.007). Massage was more likely to result in a state of high pain relief than static touch (odds ratio 7.7, 95% confidence interval 3.0-19.8, P < 0.001).

Conclusion

Massage produced hypoalgesic effects on experimental pain in healthy volunteers.     

Effect of spectators on the performance of a physiotherapy exercise

Objective

To investigate the effect of spectators on the performance of a physiotherapy exercise.

Design

Observational study.

Setting

Research laboratory, Trinity College Dublin.

Participants

Forty adult volunteer subjects (36 females, four males). As there were only four males, these were excluded from the analysis.

Interventions

Subjects were observed and timed while performing single leg stance in two conditions 48 hours apart; once with the investigator present (investigator condition) and once with the investigator and three spectators present (spectator condition).

Main outcome measure

Duration of single leg stance in seconds.

Results

The mean duration of single leg stance, for females, under the investigator condition was 173 seconds [95% confidence interval (CI) 131 to 214], while that of the spectator condition was 168 seconds (95%CI 128 to 208). The mean difference between the two conditions was 5 seconds (95%CI −21 to 31). This was not statistically significant using a paired t-test (P = 0.686).

Conclusions

Female performance of a straightforward exercise such as single leg stance was not affected by the presence of three spectators.     

Development and Validation of Participation and Positive Psychologic Function Measures for Stroke Survivors

Bode RK, Heinemann AW, Butt Z, Stallings J, Taylor C, Rowe M, Roth EJ. Development and validation of participation and positive psychologic function measures for stroke survivors.

Objective

To evaluate the reliability and validity of Neurologic Quality of Life (NeuroQOL) item banks that assess quality-of-life (QOL) domains not typically included in poststroke measures.

Design

Secondary analysis of item responses to selected NeuroQOL domains.

Setting

Community.

Participants

Community-dwelling stroke survivors (n=111) who were at least 12 months poststroke.

Interventions

Not applicable.

Main Outcome Measures

Five measures developed for 3 NeuroQoL domains: ability to participate in social activities, satisfaction with participation in social activities, and positive psychologic function.

Results

A single bank was developed for the positive psychologic function domain, but 2 banks each were developed for the ability-to-participate and satisfaction-with-participation domains. The resulting item banks showed good psychometric properties and external construct validity with correlations with the legacy instruments, ranging from .53 to .71. Using these measures, stroke survivors in this sample reported an overall high level of QOL.

Conclusions

The NeuroQoL-derived measures are promising and valid methods for assessing aspects of QOL not typically measured in this population.     

A multiconvergent approach to the rehabilitation of patients with chronic fatigue syndrome: a comparative study

Objectives

This study investigated the efficacy of a rehabilitation technique for the treatment of chronic fatigue syndrome that was developed by a physiotherapist. Data collected retrospectively from a pilot study indicated that patients benefited from this multiconvergent approach, so further assessments were warranted.

Design

Treatment efficacy was assessed by comparing the primary and secondary outcome measures of patients attending multiconvergent therapy (MCT) with those of patients attending relaxation therapy and a group of non-intervention controls.

Setting

The active treatment took place at a clinic within the physiotherapy outpatient unit. Relaxation therapy and all assessments were conducted at the psychology unit.

Participants

Thirty-five participants, fitting the Centers for Disease Control and Prevention criteria for chronic fatigue syndrome, were recruited from two outpatient clinics and an existing patient panel.

Intervention

Patients were assigned to either MCT (n = 12) or relaxation therapy (n = 14). Nine participants who received general medical care were used as a comparison group.

Main outcome measures

The Karnofsky performance scale was used as the primary outcome measure of function. Secondary outcome measures assessing overall improvement in patient condition, fatigue and disability levels were also administered.

Results

A significant percentage of the patients attending the MCT sessions showed improvement in the primary outcome score used to measure the success of the treatment (MCT = 83%, relaxation = 21%, controls = 0; P < 0.001). A significant percentage of this group also reported improvement in their overall condition (MCT = 92%, relaxation = 64%, controls = 22%; P < 0.001), lower fatigue levels (MCT = 83%, relaxation = 57%, controls = 11%; P < 0.001) and lower levels of disability (MCT = 75%, relaxation = 43%, controls = 11%; P = 0.032) immediately post-therapy. In addition, these improvements were maintained at 6-month follow-up.

Conclusions

Outcomes from this small preliminary study were encouraging. The multiconvergent approach produced significant improvements for standardised primary and secondary outcome measures. Further research is required to examine the efficacy of this approach over time, and its effectiveness on a larger scale within the primary healthcare setting using additional therapists trained in the technique.