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Question: What are the costs and utilisation of healthcare resources, their determinants, and quality of life for people attending outpatient physiotherapy after ankle fracture? Design: Longitudinal observational study. Participants: Ninety-four adults (2 dropouts) following cast removal after isolated ankle fracture attending outpatient physiotherapy at three hospitals in Sydney, Australia. Outcome measures: Costs incurred (direct healthcare costs and out-of-pocket costs) and utilisation of healthcare system resources were measured at 4, 8, 12, 16, 20, and 24 weeks. Quality of life was measured shortly after cast removal and at 4, 12, and 24 weeks. Factors known to influence costs and utilisation in other conditions (private health insurance, income level, gender, and pain) were also measured. Results: The total cost per person was AUD 735 (SD 876) over 24 weeks. Outpatient physiotherapy accounted for the highest costs in both direct healthcare (39%) and out-of-pocket (42%) costs. Less than 20% of participants sought private non-medical care in addition to receiving outpatient physiotherapy. None of the factors investigated had a significant influence on costs and utilisation. Quality of life score improved over the 24 weeks by a mean of 6.1 points out of 45 (95% CI 5.2 to 6.9), with most of the improvement occurring in the domain of independent living. Conclusion: Information on costs and utilisation of healthcare resources can be used to plan health services, eg, the number of physiotherapy sessions required after ankle fracture. Private health insurance, income level, gender, or pain did not influence the costs or the decision behind seeking care over and above publicly-provided physiotherapy. [ABSTRACT FROM AUTHOR]

Questions: Is loss of proprioception or loss of motor control related to functional ankle instability? Are proprioception and motor control related? Is there any difference in proprioception or motor control between ankles with different severity of functional ankle instability? Design: Cross-sectional, observational study. Participants: Twenty people aged between 18 and 40 years with functional ankle instability associated with a history of ankle sprain more than one month prior. Twenty age-matched controls with no functional ankle instability or history of ankle sprain. Outcome measures: Functional ankle instability was classified using the Cumberland Ankle Instability Tool, proprioception at the ankle was measured as movement detection at three velocities, and motor control was measured using the Landing Test and the Hopping Test. Results: There was little if any relation between proprioception (r = 0.14 to 0.03, 95% CI 0.40 to 0.25) or motor control (r = 0.08 to 0.07, 95% CI 0.35 to 0.20) and functional ankle instability. There was also little if any relation between proprioception and motor control except for a low correlation between movement detection at 0.1 deg/s and the Landing Test (r = 0.35, 95% CI 0.09 to 0.58). Furthermore, there was no difference between the ankles with or without functional ankle instability in proprioception or motor control. Conclusion: By greater than one month after ankle sprain, loss of proprioception does not make a major contribution to functional ankle instability. [ABSTRACT FROM AUTHOR]

Question: What is the effect of wearing splints at night to stretch the plantarflexors on dorsiflexion range of motion (ROM) in people with Charcot-Marie-Tooth disease?, Design: Randomised, assessor-blinded, cross-over trial., Participants: 14 people (1 dropout) aged 7 to 30 years with Charcot-Marie-Tooth disease Type 1A and with < or = 15 degrees dorsiflexion range of motion (ROM)., Intervention: A splint holding the ankle in maximum dorsiflexion was worn nightly on one leg for 6 weeks followed by the opposite leg for the subsequent 6 weeks., Outcome Measures: The primary outcome was dorsiflexion ROM; secondary outcomes were eversion ROM, and dorsiflexion, eversion, and inversion strength, measured before and after splinting, and three months later., Results: There was no significant difference between the experimental and the control intervention in terms of ROM or strength. Wearing the splint at night increased dorsiflexion ROM by 1 degree (95% CI -3 to 4; p = 0.72) and eversion ROM by 1 degree (95% CI -1 to 3; p = 0.28) compared to not wearing the splint. Wearing the splint increased dorsiflexion strength by 41 N (95% CI -53 to 135; p = 0.38), reduced eversion strength by 6 N (95% CI -112 to 101; p = 0.92) and reduced inversion strength by 8 N (95% CI -110 to 95; p = 0.88) compared to not wearing the splint., Conclusion: Wearing night splints does not increase ankle ROM or strength in people with Charcot-Marie-Tooth disease Type 1A.

Question: Are implementation strategies involving education any more effective than mere dissemination of clinical practice guidelines in changing physiotherapy practice and reducing patient disability after acute whiplash?, Design: Cluster-randomised trial., Participants: Twenty-seven physiotherapists from different private physiotherapy clinics and the 103 patients (4 dropouts) who presented to them with acute whiplash., Intervention: The implementation group of physiotherapists underwent education by opinion leaders about whiplash guidelines and the dissemination group had the guidelines mailed to them., Outcome Measures: The primary outcome was patient disability, measured using the Functional Rating Index, collected on admission to the trial and at 1.5, 3, 6 and 12 months. Physiotherapist knowledge about the guidelines was measured using a custom-made questionnaire. Physiotherapist practice and cost of care were measured by audit of patient notes., Results: There were no significant differences between groups for any of the patient outcomes at any time. The implementation patients had 0.6 points (95% CI -7.8 to 6.6) less disability than the dissemination patients at 12 months; 44% more physiotherapists in the implementation group reported that they prescribed two out of the five guideline-recommended treatments; and 32% more physiotherapists actually prescribed them. The cost of care for patients in the implementation group was $255 (95% CI -1505 to 996) less than for patients in the dissemination group., Conclusion: Although the active implementation program increased guideline-consistent practice, patient outcomes and cost of care were not affected.

Progressive degeneration of the anterior cruciate ligament (ACL) deficient knee may be partly due to chondral trauma at the time of ACL rupture and repeat episodes of subluxation, but also due to aberrant kinematics altering the wear pattern at the tibiofemoral interface. The hypothesis that altered kinematics, represented by the tibiofemoral contact pattern, would be associated with articular cartilage degeneration in ACL-deficient knees was tested in a cross-sectional study of 23 subjects with a history of > 10 years ACL deficiency without knee reconstruction. Subjects were aged 31 to 67 years. Eleven were male, 12 were female. Sagittal magnetic resonance imaging (MRI) scans enabled tibiofemoral contact mapping as subjects performed a closed-chain leg-press. Images were acquired at 15 degree intervals from 0 degrees to 90 degrees knee flexion. Articular cartilage degeneration was assessed by diagnostic MRI and where possible, arthroscopy. The ACL-deficient knees had a posterior tibiofemoral contact pattern on the tibial plateau compared to the healthy knees (F((1,171)) = 9.2, p = 0.003). The difference appeared to be seen in the medial compartment (F((1,171)) = 3.2, p = 0.07), though this failed to reach significance. Articular cartilage degeneration in the medial compartment was related to the variation of the tibiofemoral contact pattern (r = -0.53, p = 0.01). Articular cartilage degeneration was not related to time since injury (r = -0.16, p = 0.65). The association between aberrant kinematics and degenerative change may stimulate thinking on the role of dynamic stability and neuromuscular co-ordination in joint protection.

This study assessed whether sense of movement is impaired at the ankle in persons post-stroke who are able to walk independently. Eleven chronic post-stroke subjects (> 4 months post stroke) who were ambulatory with or without walking aids and living within the community, and 10 healthy age-matched control subjects volunteered to participate. Proprioceptive acuity at the ankle, measured by sense of movement, was tested at three velocities, 0.1, 0.5, and 2.5 deg/sec, in random order. In addition, ankle range of motion and the distance that subjects walked in 6 minutes were assessed. Stroke subjects were significantly poorer (p < 0.001) at detecting movement at the affected ankle compared with either the unaffected ankle or with the control group at each of the velocities tested. Six out of 11 stroke subjects demonstrated significant impairment in movement detection compared to controls. The usual primary impairments following stroke are loss of strength and loss of co-ordination. However, reduced proprioceptive acuity at the affected ankle may also contribute to a person's ability to position and load the foot during walking. This could explain the moderate relationship found between proprioceptive acuity and walking endurance in persons following stroke (Spearman's rho = 0.63 to 0.77).

Manipulation of the cervical spine is one of the few potentially life-threatening procedures performed by physiotherapists. Is it worth the risk? A comparison of risks versus benefits indicates that at present, the risks of cervical manipulation outweigh the benefits: manipulation has yet to be shown to be more effective for neck pain and headache than other interventions such as mobilisation, whereas the risks, although infrequent, are serious. This analysis is of particular concern because the conditions for which manipulation is indicated are benign and usually self-limiting. Because physiotherapists have legal and ethical obligations to the community to avoid foreseeable harm and provide optimum care, it may be prudent to determine who in our profession should perform cervical manipulation. That is, the profession could restrict the practice of cervical spine manipulation. Although all registered physiotherapists in Australia are entitled to perform cervical manipulation, few choose to use this intervention. Therefore, it might be feasible to encourage those practitioners who wish to use cervical manipulation to undertake formal education programs. Such a requirement could be embodied in a code of practice that discourages those without formal training from performing cervical manipulation. By taking such measures, we could ensure that our profession exercises wisdom in its monitoring and use of cervical manipulation.

Cervical manipulation occasionally causes serious vertebrobasilar complications. The usual cause is vertebral artery dissection, however in some cases there has been no obvious arterial injury. The present paper reviews the mechanisms by which complications occur, particularly when the applied force is trivial or there is no injury to the vertebral arteries, and the factors that increase risk of complications. In addition, implications are drawn for use of the recently revised Australian Physiotherapy Association (APA) guidelines. In the absence of vertebral artery rupture, complications are proposed to arise from vasospasm, haemostasis, endothelial injury or turbulent flow. These mechanisms have a sound scientific basis but have yet to be demonstrated as specifically causing vertebrobasilar complications. The most important risk factors for vertebrobasilar complications appear to be prior trauma to the vertebral arteries and symptoms of vertebrobasilar ischaemia from previous manipulation. There is weak evidence that hypoplasia of the vertebral arteries also increases the risk of complications. Neither general vascular factors nor pre-existing degenerative conditions of the cervical spine increase risk of vertebrobasilar complications. The procedures described in the APA guidelines test adequacy of total cerebral perfusion during cervical movements rather than patency of the vertebral arteries or their susceptibility to injury. The guidelines may therefore indicate potential for surviving a complication from manipulation. They may also identify patients at risk of complications from minor trauma. It is recommended that the procedures described in the APA guidelines be applied prior to every manipulation, and that manipulation be avoided in the presence of any signs of vertebrobasilar insufficiency.