Measuring the physical activity level and pattern in daily life in persons with chronic fatigue syndrome/myalgic encephalomyelitis: a systematic review

Background: A lower activity level and imbalanced activity pattern are frequently observed in persons with chronic fatigue syndrome (CFS)/myalgic encephalomyelitis (ME) due to debilitating fatigue and post-exertional malaise (PEM). To provide an optimal treatment strategy, insight into a patient’s current physical activity level and pattern is necessary and identification of reliable and valid measures or scales measuring physical activity level and pattern in this population is warranted.

Objective: To identify measures or scales used to evaluate activity level and/or pattern in patients with CFS/ME and review their psychometric properties.

Methods: A systematic literature search was performed in the electronic databases PubMed and Web of Science until 12 October 2016. First, articles including relevant measures were identified. Secondly, psychometric properties of relevant measurement instruments were extracted and rated based on the COSMIN checklist.

Results: The review was performed and reported according to PRISMA statement. A total of 51 articles and 15 unique measurement instruments were found, but only three instruments have been evaluated in patients with CFS: the Chronic Fatigue Syndrome-Activity Questionnaire (CFS-AQ), Activity Pattern Interview (API) and International Physical Activity Questionnaire-Short Form (IPAQ-SF), all self-report instruments measuring physical activity level.

Conclusions: The IPAQ-SF, CFS-AQ and API are all equally capable of evaluating the physical activity level, but none of these are optimal to use. Although often used as gold standard to capture physical activity patterns, activity monitors have not yet been evaluated in these patients. More research is needed to evaluate the psychometric properties of existing instruments, including activity monitors.     

A double-blind placebo-controlled clinical investigation into pain reduction effect of placing the pain spot outside the intersection area of the two currents of interferential therapy compared to traditional method

Background: Interferential therapy (IFT) is applied to intersect in the painful area but no confirmed effect with this method. Experimentally, the highest voltage of IFT is induced outside the intersection of the two currents. Placing the painful area outside the intersection point (external application) would reveal a better effect.

Objectives: To examine the effect of external application in pain compared to traditional method.

Design: A double-blind placebo-controlled clinical investigation.

Setting: A public hospital.

Participants: 168 LBP subjects.

Interventions: Assignment: (1) external IFT, (2) placebo external IFT, (3) traditional IFT and (4) placebo traditional IFT. Groups 1 and 3 received 20 min of IFT at 100 Hz and groups 2 and 4 received sham IFT.

Main outcome measures: Before and after IFT session, pain severity (VAS), pressure threshold (PPT), pain distribution and ROM were assessed.

Results: IFT changed all outcomes similarly. VAS and ROM improved statistically, P < 0.03. A trend of better VAS reduced with active IFTs.

Conclusions: No therapeutic difference between the two methods.     

The creation of the diagnostic accuracy quality scale (DAQS)

Background:

The utility of a dedicated clinical test is dependent on the diagnostic accuracy values and the quality of the study in which the test was examined. Scales allow a summative scoring of bias within a study. At present, there are no scales advocated to measure the bias of diagnostic accuracy studies.

Objective:

The objective of this study was to create a new diagnostic accuracy quality scale (DAQS) that provides a quantitative summary of the methodological quality of studies evaluating clinical tests and measures.

Design:

The study used a four-round Delphi survey designed to create, revise, and develop consensus for a quality scale.

Methods:

The four-round Delphi involved a work team and a respondent group of experts. An initial round among the work team created a working document, which was then modified and revised, with opportunities to create new items threaded in the second round. Rounds III and IV involved voting on the importance of each of the proposed items and consensus development from the respondent group. Consensus for the selection of an item required a 75% approval for the importance of that item.

Results:

Sixteen individuals with a variety of research/professional backgrounds made up the respondent group. Modification and revision of the initial work team instrument created a scale with 21 items that reflected potential areas of methodological bias.

Limitations:

The new scale needs validation through weighted assessment. In addition, there was a large proportion of physical therapist/researchers on the work team and the respondent group.

Conclusions:

Systematic reviews allow summation of evidence for clinical tests and scales are essential to critique the quality of the articles included in the review. The DAQS may serve this role for diagnostic accuracy studies.     

Pain pattern classification and directional preference for patients with neck pain

Objectives:

Pain Pattern Classification (PPC) and Directional Preference (DP) have been shown to be predictive of health care outcomes and serve to guide orthopedic clinical decision making. We conducted a prospective, observational cohort study to verify the association between PPC, DP, and clinical outcomes.

Methods:

Clinical outcome measures including pain intensity and disability were completed at first examination and follow-up by 335 patients. A Pearson’s chi-squared test was used to determine differences in prevalence rates for the categorical variables, and two-sample t-tests were used to determine differences in rates for the continuous variables. A Tukey’s range test was used to determine differences in follow-up pain intensity and disability for neck pain dual-classification schemes.

Results:

The prevalence of DP was 82.4%. The prevalence of CEN, Non-CEN, and Non-Classifiable (NC) was 15.2%, 42.1%, and 25.1%, respectively. The prevalence of DP was lowest for patients with sub-acute symptoms and who were <45 years old. Patients classified as DP CEN had, on average 2.62 NDI units less than patients classified as Non-DP. Patients classified as DP CEN had, on average, 0.90 pain intensity units less than patients classified as Non-DP at follow-up. Patients who demonstrated DP CEN did not have clinically significant lower pain intensity or disability at follow-up than patients who demonstrated Non-DP.

Discussion:

The results of this investigation need to be interpreted with caution with respect to the study design and it’s subsequent strengths and limitations.

Level of Evidence:

1b.     

Yoga for pain and sleep quality in rheumatoid arthritis: study protocol for a pilot randomized controlled trial

Background:

Yoga is a popular complementary and alternative medicine (CAM) therapy among people with rheumatoid arthritis (RA), perceived as offering self-management options for physical and psychosocial symptoms associated with RA.

Objectives:

The primary aims of the current pilot study are (1) to assess the feasibility and safety of a relaxation-focused yoga intervention tailored for people with RA and (2) to estimate the effect of yoga on RA-related pain, sleep quality, functional disability, disease activity, quality of life, anxiety, depression, and fatigue.

Method:

Twenty-eight participants with at least minimum levels of RA-related pain and sleep disturbance will be recruited from a local public hospital database. Participants meeting inclusion criteria will be randomized into either a yoga group (receiving an 8-week program of once-weekly 75-minute relaxation-based yoga classes and thrice-weekly home practice), or a usual care control group. Outcomes will be assessed at baseline, 9, and 12 weeks. Feasibility is operationalized as acceptability (recruitment, adherence, participant retention, and participant satisfaction) and safety of the yoga intervention. Effect sizes for changes in pain, sleep quality, functional disability, disease activity, quality of life, mental health, and fatigue will be estimated.

Discussion:

Results of this pilot study will provide empirical data to determine if a larger, statistically powered main trial is feasible and safe in a national RA population. Additionally, participant feedback will provide information regarding further adaption and tailoring of the study protocol to a clinical RA population.

Trial registration:

Australian New Zealand Clinical Trials Registry ACTRN12612001019897 (registered 20/09/2012).     

Pharmacokinetic and pharmacodynamic changes in older adults and implications for palliative care

Background: As the population of older adults continues to increase, there will be an increase in the number of older patients requiring pain and symptom management in the setting of advanced, serious illness.

Objectives: To review age-related changes in pharmacokinetics and pharmacodynamics, and to put these changes in the context of providing palliative care to geriatric patients.

Method: Review of literature relevant to age-related changes in physiology, pharmacokinetics, and pharmacodynamics; and the practice of palliative care for geriatric patients.

Results: Multiple age related changes occur which affect the choice and dosing of medications, including those used for pain and symptom management.

Conclusion: The safe and effective management of symptoms in advanced illness for older adults depends on having a clear understanding of physical and metabolic changes and their impact of selection of drug therapy.     

Repetition of intentional drug overdose: a population-based study

Context: Intentional overdose is a leading method of self-harm and suicide, and repeat attempts strongly predict eventual death by suicide.

Objectives: To determine the risk of recurrence after a first intentional overdose. Secondary objectives included characterization of the temporal course and potential predictors of repeat overdose, a strong risk factor for death from suicide.

Methods: Design: Population-based cohort study.

Setting: Ontario, Canada, from 1 April 2002 to 31 March 2013.

Participants: All Ontario residents presenting to an emergency department after a first intentional overdose.

Main outcome measures: The incidence and timing of recurrent overdose.

Results: We followed 81,675 patients discharged from hospital after a first intentional overdose. Overall, 13,903 (17.0%) returned with a repeat overdose after a median interval of 288 (inter-quartile range: 62 to 834) days. Of these, 4493 (5.5%) had multiple repeat episodes. Factors associated with repeat self-poisoning included psychiatric care in the preceding year (adjusted hazard ratio [aHR] 1.55; 95% confidence interval [CI] 1.50 to 1.61), alcohol dependence (aHR 1.41; 95% CI 1.35 to 1.46) and documented depression (aHR 1.39; 95% CI 1.34 to 1.44). Female sex, rural residence, lower socioeconomic status, ingestion of psychoactive drugs and younger age were also weakly associated with repeat overdose.

Discussion: Hospital presentation for repetition of intentional overdose is common, with recurrent episodes often far removed from the first. While several factors predict overdose repetition, none is particularly strong.

Conclusion: Secondary prevention initiatives should be implemented for all individuals who present to the emergency department and survive intentional overdose.     

The effect on the patient flow in a local health care after implementing reverse triage in a primary care emergency department: a longitudinal follow-up study

Objective: Reverse triage means that patients who are not considered to be in need of medical services are not placed on the doctor’s list in an emergency department (ED) but are sent, after face-to-face evaluation by a triage nurse, to a more appropriate health care unit. It is not known how an abrupt application of such reverse triage in a combined primary care ED alters the demand for doctors’ services in collaborative parts of the health care system.

Design: An observational study.

Setting: Register-based retrospective quasi-experimental longitudinal follow-up study based on a before–after setting in a Finnish city.

Subjects: Patients who consulted different doctors in a local health care unit.

Main outcome measures: Numbers of monthly visits to different doctor groups in public and private primary care, and numbers of monthly referrals to secondary care ED from different sources of primary care were recorded before and after abrupt implementation of the reverse triage.

Results: The beginning of reverse triage decreased the number of patient visits to a primary ED doctor without increasing mortality. Simultaneously, there was an increase in doctor visits in the adjacent secondary care ED and local private sector. The number of patients who came to secondary care ED without a referral or with a referral from the private sector increased.

Conclusions: The data suggested that the reverse triage causes redistribution of the use of doctors’ services rather than a true decrease in the use of these services.     

Thrust joint manipulation utilization by U.S. physical therapists*

Study Design: Online survey study.

Objective: To determine physical therapists’ utilization of thrust joint manipulation (TJM) and their comfort level in using TJM between the cervical, thoracic, and lumbar regions of the spine. We hypothesized that physical therapists who use TJM would report regular use and comfort providing it to the thoracic and lumbar spines, but not so much for the cervical spine.

Background: Recent surveys of first professional physical therapy degree programs have found that TJM to the cervical spine is not taught to the same degree as to the thoracic and lumbar spines.

Methods: We developed a survey to capture the required information and had a Delphi panel of 15 expert orthopedic physical therapists review it and provide constructive feedback. A revised version of the survey was sent to the same Delphi panel and consensus was obtained on the final survey instrument. The revised survey was made available to any licensed physical therapists in the U.S.A. using an online survey system, from October 2014 through June 2015.

Results: Of 1014 responses collected, 1000 completed surveys were included for analysis. There were 478 (48%) males; the mean age of respondents was 39.7 ± 10.81 years (range 24–92); and mean years of clinical experience was 13.6 ± 10.62. A majority of respondents felt that TJM was safe and effective when applied to lumbar (90.5%) and thoracic (91.1%) spines; however, a smaller percentage (68.9%) felt that about the cervical spine. More therapists reported they would perform additional screening prior to providing TJM to the cervical spine than they would for the lumbar and thoracic spines. Therapists agreed they were less likely to provide and feel comfortable with TJM in the cervical spine compared to the thoracic and lumbar spines. Finally, therapists who are male; practice in orthopedic spine setting; are aware of manipulation clinical prediction rules; and have manual therapy certification, are more likely to use TJM and be comfortable with it in all three regions.

Conclusion: Results indicate that respondents do not believe TJM for the cervical spine to be as safe and efficacious as that for the lumbar and thoracic spines. Further, they are more likely to perform additional screening, abstain from and do not feel comfortable performing TJM for the cervical spine.

Clinical Relevance: Our research reveals there is a discrepancy between utilization of TJM at different spinal levels. This research provides an opportunity to address variability in clinical practice among physical therapists utilizing TJM.     

Quality indicators for the diagnosis and antibiotic treatment of acute respiratory tract infections in general practice: a RAND Appropriateness Method

Objective: To develop quality indicators for the diagnosis and antibiotic treatment of acute respiratory tract infections, tailored to the Danish general practice setting.

Design: A RAND/UCLA Appropriateness Method was used.

Setting: General practice.

Subjects: A panel of nine experts, mainly general practitioners, was asked to rate the relevance of 64 quality indicators for the diagnosis and antibiotic treatment of acute respiratory tract infections based on guidelines. Subsequently, a face-to-face meeting was held to resolve misinterpretations and to achieve consensus.

Main outcome measures: The experts were asked to rate the indicators on a nine-point Likert scale. Consensus of appropriateness for a quality indicator was reached if the overall panel median rating was 7–9 with agreement.

Results: A total of 50 of the 64 proposed quality indicators attained consensus. Consensus was achieved for 12 indicators focusing on the diagnostic process and 19 indicators focusing on the decision about antibiotic treatment and choice of antibiotics, respectively.

Conclusion: These newly developed quality indicators may be used to strengthen Danish general practitioners’ focus on their management of patients with acute respiratory tract infections and to identify where there is a need for future quality improvements.     

Content and bibliometric analyses of the Journal of Manual & Manipulative Therapy

Background:

Article characteristics and trends have been elucidated for other physical therapy-focused journals using content and bibliometric analysis. These findings are important for assessing the current state of a journal and for guiding future publication of research. To date, these analyses have not been performed for the Journal of Manual & Manipulative Therapy (JMMT).

Objective:

To describe content and trends for articles published in JMMT over a 20-year period (1993–2012).

Methods:

Journal articles were coded using previously-established domains (article type, participant type, research design, study purpose, and clinical condition). Total publications and proportion of publications based on domain were described. Articles specific to manual therapy intervention were examined and compared to data from other physical therapy-focused journals. Impact by citation and author was examined using bibliometric software.

Results:

Journal of Manual & Manipulative Therapy was found to have a recent acceleration in the number of articles published annually. Over time, topical reviews have decreased in favor of research reports. However, rigorous study designs have represented only a small portion of total journal content, and case reports have maintained a consistent publication presence. Manual therapy intervention articles in JMMT are predominantly case designs, however are similar in characteristics to manual therapy intervention articles published in other physical therapy-focused journals. For JMMT articles overall and manual therapy intervention articles across journals, young to middle-aged symptomatic adults with low back and/or neck pain were the most common study participants.

Discussion:

Increases in the number of papers and a move toward research reports were observed in JMMT over the 20-year period. Considerations for the future were outlined, including the publication of articles with more rigorous research designs. Manual therapy research for adolescents and older adults and for upper and lower extremity conditions should also be considered as priorities for the future.     

The effectiveness of cervical versus thoracic thrust manipulation for the improvement of pain,disability, and range of motion in patients with mechanical neck pain

Background:

Many patients present to physical therapy with mechanical neck pain. Cervical and thoracic manipulations are being utilized in treating this impairment, but minimal evidence as to which technique is superior exists in the literature.

Objective:

The purpose of this systematic review is to identify whether cervical or thoracic manipulation is more effective at improving pain, range of motion (ROM), and disability in patients with mechanical neck pain.

Methods:

A comprehensive search of published literature from seven search engines (PubMed, ProQuest, PEDro, CINAHL, Healthsource, Cochrane Library, SPORTDiscus) yielded 13 studies that examined the effectiveness of either cervical manipulations, thoracic manipulations, or cervical and thoracic manipulations to relieve the effects of mechanical neck pain. Eleven of the studies included were randomized controlled trials (RCTs), while two were secondary analyses of RCTs. Each study was assessed using the PEDro scale and found to be of fair to high research quality.

Results:

The studies included in this systematic review produced both positive clinical and statistical differences in pain, disability, and ROM following manipulations of the cervical or thoracic spine.

Conclusion:

There is limited high-quality research directly comparing the two interventions, so determining whether cervical or thoracic thrust manipulation is superior cannot be concluded from this systematic review alone. However, based on the results found in this review, cervical and thoracic thrust manipulations are equally valuable in relieving pain, disability, and improving ROM for a patient with mechanical neck pain in the short term.     

Drug-related problems and changes in drug utilization after medication reviews in nursing homes in Oslo,Norway

Objective: We describe the drug-related problems (DRPs) identified during medication reviews (MRs) and the changes in drug utilization after MRs at nursing homes in Oslo, Norway. We explored predictors for the observed changes.

Design: Observational before-after study.

Setting: Forty-one nursing homes.

Intervention: MRs performed by multidisciplinary teams during November 2011 to February 2014.

Subjects: In all, 2465 long-term care patients.

Main outcome measures: DRPs identified by explicit criteria (STOPP/START and NORGEP) and drug–drug interaction database; interventions to resolve DRPs; drug use changes after MR.

Results: A total of 6158 DRPs were identified, an average of 2.6 DRPs/patient, 2.0 for regular and 0.6 for pro re nata (prn) drugs. Of these patients, 17.3% had no DRPs. The remaining 82.7% of the patients had on average 3.0 DRPs/patient. Use of unnecessary drugs (43.5%), excess dosing (12.5%) and lack of monitoring of the drug use (11%) were the most frequent DRPs. Opioids and psychotropic drugs were involved in 34.4% of all DRPs. The mean number of drugs decreased after the MR from 6.8 to 6.3 for regular drugs and from 3.0 to 2.6 for prn drugs. Patients with DRPs experienced a decrease of 1.1 drugs after MR (0.5 for regular and 0.6 for prn drugs). The reduction was most pronounced for the regular use of antipsychotics, antidepressants, hypnotics/sedatives, diuretics, antithrombotic agents, antacid drugs; and for prn use of anxiolytics, opioids, hypnotics/sedatives, metoclopramide and NSAIDs.

Conclusion: The medication review resulted in less drug use, especially opioids and psychotropic drugs.     

Patient trajectories in a Norwegian unit of municipal emergency beds

Objective: The Coordination reform was implemented in Norway from 2012, aiming at seamless patient trajectories. All municipalities are required to establish emergency care beds (MEBs) to avoid unnecessary hospital admissions. We aimed to examine occupancy rate, patient characteristics, diagnoses and discharge level of municipal care in a small MEB unit.

Design: Cross-sectional, observational study.

Setting: A two-bed emergency care unit.

Subjects: All patients admitted to the unit during one year.

Main outcome measures: Patients’ age and gender, comorbidity, main diagnoses and municipal care level on admission and discharge, diagnostic and therapeutic initiatives, occupancy rate.

Results: Sixty admissions were registered, with total bed occupancy 194 days, and an occupancy rate of 0.27. The patients (median age 83 years, 57% women) had mostly infections, musculoskeletal symptoms or undefined conditions. Some 48% of the stays exceeded three days and 43% of the patients were subsequently transferred to nursing homes or hospitals.

Conclusion: Occupancy rate was low. Patient selection was not according to national standards, and stays were longer. Many patients were transferred to nursing homes, indicating that the unit was an intermediate pathway or a short cut to institutional care. It is unclear whether the unit avoided hospital admissions.     

A randomized clinical trial to compare the immediate effects of seated thoracic manipulation and targeted supine thoracic manipulation on cervical spine flexion range of motion and pain

Design:

Randomized clinical trial.

Objectives:

To determine the effectiveness of seated thoracic manipulation versus targeted supine thoracic manipulation on cervical spine pain and flexion range of motion (ROM). There is evidence that thoracic spine manipulation is an effective treatment for patients with cervical spine pain. This evidence includes a variety of techniques to manipulate the thoracic spine. Although each of them is effective, no research has compared techniques to determine which produces the best outcomes.

Methods:

A total of 39 patients with cervical spine pain were randomly assigned to either a seated thoracic manipulation or targeted supine thoracic manipulation group. Pain and flexion ROM measures were taken before and after the intervention.

Results:

Pain reduction (post-treatment–pre-treatment) was significantly greater in those patients receiving the targeted supine thoracic manipulation compared to the seated thoracic manipulation (P<0·05). Although not significant, we did observe greater improvement in flexion ROM in the targeted supine thoracic manipulation group. The results of this study indicate that a targeted supine thoracic manipulation may be more effective in reducing cervical spine pain and improving cervical flexion ROM than a seated thoracic manipulation. Future studies should include a variety of patients and physical therapists (PTs) to validate our findings.     

Identification of the affected ear in lateral canal benign paroxysmal positional vertigo

Background:

The effective management of lateral canal benign paroxysmal positional vertigo (LC-BPPV) is dependent upon the accurate identification of the affected ear. The supine roll test is the gold standard for diagnosing LC-BPPV. However, in some cases, the elicited nystagmus has a similar intensity when the head is rolled to the right or to the left.

Objectives:

The purpose of this systematic review was to determine the effectiveness of accessory diagnostic procedures, used in conjunction with the supine roll test, at accurately identifying the affected ear in individuals with LC-BPPV.

Methods:

The following databases were searched: (1) CINAHL Plus with Full Text, (2) ProQuest Medical Library, and (3) MEDLINE. The following search terms were used: (1) ‘lateral canal’ OR ‘horizontal canal’ AND (2) ‘positional vertigo’ OR ‘positioning vertigo’ OR ‘positional nystagmus’ OR ‘positioning nystagmus’. Evidence level was examined with the Oxford Centre for Evidence-Based Medicine 2011 levels of evidence method, and methodological rigour was examined with the QUADAS method.

Results:

A database search originally identified 1348 records, and nine studies were ultimately included in the qualitative synthesis. This systematic review revealed four index tests that, when used in conjunction with the supine roll test, were able to accurately identify the affected ear in a majority of individuals with LC-BPPV.

Conclusions:

The pseudo-spontaneous test was found to be slightly superior to the other three index tests in terms of eliciting nystagmus during its administration and identifying the same affected ear as the supine roll test.     

Effects of cervical manipulation on pain,grip force control,and upper extremity muscle activity: a randomized controlled trial

Objectives: Individuals with neck pain experience disrupted grip force control when performing manipulative tasks. Manipulative physical therapy might decrease pain and change the activity of surrounding muscles; however, its effect on upper limb motor control remains undetermined. This study aims to analyze the effects of cervical manipulation on pressure pain threshold (PPT), upper extremity muscle activity along with grip force control in individuals with neck pain.

Methods: Thirty subjects with neck pain were instructed to grasp and lift an object before and after cervical (n = 15) or sham (n = 15) manipulation. The patients’ PPT, electromyographic (EMG) activity of the upper extremity/scapular muscles, and grip force control were analyzed before and after one session of manipulation.

Results: No significant differences were found in the grip force control, PPT and EMG activity variables between groups.

Discussion: These results suggest that a single session of cervical manipulation may not modify upper limb motor control, more specifically grip force control and EMG activity, in patients with cervical pain. Future studies should investigate potential changes in grip force control in patients with different features of neck pain and/or by applying long-term treatment.

Level of Evidence: 1b.     

The effects of whole-body vibration (WBV) intervention on body functions,activity limitations,and participation restrictions in people with neurological conditions

Background:

Vibration intervention has recently become a popular modality in professional sport and fitness and has also been suggested to offer potential in augmenting exercises in the rehabilitation field for various neurological conditions.

Objectives:

The main objective of this review was to assess the effects of whole-body vibration (WBV) intervention on body functions, activity limitations, and participation restrictions in people with neurological conditions. The second objective was to assist healthcare professionals in their clinical practice by evaluating the main parameters of WBV intervention that may be of benefit.

Methods:

Electronic databases (EMBASE, Academic Search Complete, AMED, MEDLINE, CINAHL Plus, SPORTDiscus, PEDro, and Cochrane library) were searched. Intervention studies with a comparison group, investigating the effect of WBV intervention on people with neurological conditions, were included. The methodological quality of papers was independently assessed by two raters using the Physiotherapy Evidence Database scale.

Results:

Sixteen randomized controlled trials (RCTs) were included. Only one paper was considered ‘excellent’ methodological quality study (9 out of 10 points). Four studies evaluated changes when WBV was compared to no intervention and two found significant improvements for strength, gait, and balance. Twelve compared WBV to other interventions and only two found significant differences in favour of the WBV group, for strength and gait.

Conclusion:

The cumulative findings for strength, balance, and gait suggest that while groups improve following WBV, this improvement is not consistently greater than either no intervention or a comparison intervention. This suggests insufficient evidence to support the effects of WBV training.