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Jennifer Hewitt,1 Kathryn M Refshauge,1 Stephen Goodall,2 Timothy Henwood,3 Lindy Clemson1 1Faculty of Health Sciences, University of Sydney, 2Centre for Health Economic Research and Evaluation, University of Technology, Sydney, NSW, 3University of Queensland/Blue Care Research and Practice Development Centre, The University of Queensland, Brisbane, QLD, Australia Introduction: Falls are common among older adults. It is reported that approximately 60% of residents of aged care facilities fall each year. This is a major cause of morbidity and mortality, and a significant burden for health care providers and the health system. Among community dwelling older adults, exercise appears to be an effective countermeasure, but data are limited and inconsistent among studies in residents of aged care communities. This trial has been designed to evaluate whether the SUNBEAM program (Strength and Balance Exercise in Aged Care) reduces falls in residents of aged care facilities. Research question: Is the program more effective and cost-effective than usual care for the prevention of falls? Design: Single-blinded, two group, cluster randomized trial. Participants and setting: 300 residents, living in 20 aged care facilities. Intervention: Progressive resistance and balance training under the guidance of a physiotherapist for 6 months, then facility-guided maintenance training for 6 months. Control: Usual care. Measurements: Number of falls, number of fallers, quality of life, mobility, balance, fear of falling, cognitive well-being, resource use, and cost-effectiveness. Measurements will be taken at baseline, 6 months, and 12 months. Analysis: The number of falls will be analyzed using a Poisson mixed model. A logistic mixed model will be used to analyze the number of residents who fall during the study period. Intention-to-treat analysis will be used. Discussion: This study addresses a significant shortcoming in aged care research, and has potential to impact upon a substantial health care problem. Outcomes will be used to inform care providers, and guide health care policies. Keywords: balance, strength, training, falls, nursing care, cost-effectiveness

OBJECTIVES: To analyse use of conventional and complementary and alternative (CAM) practitioners and self-prescribed CAM amongst mid-age Australian women with back pain. DESIGN: Self-completion postal surveys completed in 2004 and 2007, of the mid-age cohort of the Australian Longitudinal Study on Women's health. Questions asked for written responses about the use of conventional practitioners, CAM practitioners and self-prescribed CAM for treatment of back pain. SETTING: Analysis of cross-sectional and longitudinal survey data (n=9820), conducted as part of the Australian Longitudinal Study on Women's Health (ALSWH), which was designed to investigate multiple factors affecting the health and well being of women over a 20-year period. MAIN OUTCOME MEASURE: Women were asked if they had sought help for back pain in the previous twelve months. RESULTS: The prevalence of back pain was 54.8% (n=5383). The percentage of women who sought help for their back pain was 17.3% (n=1700). Of the women who sought help for back pain, 2% consulted with a CAM practitioner only, 35% consulted a conventional practitioner only and 63% with both a conventional and CAM practitioner. CONCLUSIONS: Back pain is prevalent amongst mid-age Australian women, although only one third sought help. Women who sought help for their back pack were high users of CAM (practitioners and self-prescribed) and conventional care providers, consulting a CAM practitioner in complement with conventional biomedical consultations rather than as an alternative. Further research is needed to explore the complex contemporary landscapes of back pain negotiation and management. [ABSTRACT FROM AUTHOR]

Purpose: To determine if bioimpedance spectroscopy (BIS) could detect localised lymphoedema of the arm and to compare BIS measurements with equivalent measures of limb volume by perometry.Methods: Women with mild to severe upper limb lymphoedema (n = 29) and women with no history of lymphoedema (n = 11) participated. Commencing at the ulnar styloid of the wrist, 4 × 10 cm segment measurements were made of each arm using both BIS and perometry.Results: Average BIS inter-limb ratios for the total arm and each arm segment were higher than comparable perometry measures in women with lymphoedema, but similar to perometry measures for women without lymphoedema. Limits of agreement analysis showed that the mean difference between methods varied according to segment measured, ranging from 8.5% for the uppermost segment of the arm to 16.6% for the forearm segment just below the elbow. For all limb segments, there was a positive bias towards BIS measurements, which increased as lymphoedema severity increased.Conclusion: BIS can be used for localised measurement of lymphoedema. Because it is specific to extracellular fluid, BIS is more sensitive to localised lymphoedema than perometry. [ABSTRACT FROM AUTHOR]

Question: Which interventions for non-specific neck pain are effective in reducing pain or disability? Design: Systematic review with meta-analysis of randomised controlled trials. Participants: Adults with non-specific neck pain. Intervention: All interventions for neck pain that were evaluated in trials with a placebo, minimal- or no-intervention control. Outcome measures: Pain and disability outcomes (0-100 scale) at the conclusion of a course of treatment (short term), and in the medium (3 to 9 months) and long (> 9 months) term. Results: 33 trials were identified. The interventions with significant short-term effects on pain were manipulation (MD -22, 95% CI -32 to -11), multimodal intervention (MD -21, 95% CI -34 to -7), specific exercise (MD -12, 95% CI -22 to -2), combination orphenadrine/paracetamol (MD -17, 95% CI -32 to -2), and manual therapy (MD -12, 95% CI -16 to -7). There was a significant short-term effect on disability for acupuncture (MD -8, 95% CI -13 to -2) and manual therapy (MD -6, 95% CI -11 to -2). Treatment with laser therapy resulted in better pain outcomes at medium-term follow-up but not at short-term follow-up. No other intervention demonstrated medium- or long-term effects. Conclusion: Some conservative interventions for neck pain are effective in the short term. Few interventions that have been investigated have shown longer term effects that are better than placebo or minimal intervention. [ABSTRACT FROM AUTHOR]

BACKGROUND: There is limited information on the clinimetric properties of questionnaires of activity limitation in people after ankle fracture. OBJECTIVE: The purpose of this study was to investigate the clinimetric properties of the Lower Extremity Functional Scale, an activity limitation questionnaire, in people with ankle fracture. DESIGN: This was a measurement study using data collected from 2 previous randomized controlled trials and 1 inception cohort study. METHODS: Participants with ankle fracture (N=306) were recruited within 7 days of cast removal. Data were collected at baseline and at short- and medium-term follow-ups. Internal consistency and construct validity were assessed using Rasch analysis. Concurrent validity, responsiveness, and floor and ceiling effects were evaluated. RESULTS: The Lower Extremity Functional Scale demonstrated high internal consistency (alpha > .90). The variance in activity limitation explained by the items was high (98.3%). Each item had a positive correlation with the overall scale, and most items supported the unidimensionality of the scale. These findings suggest that the scale has high internal consistency and construct validity. The scale also demonstrated high concurrent validity and responsiveness in the short term and no floor or ceiling effects. However, the scale would benefit from more-challenging items, as evident at the medium-term follow-up. Limitations: This was a secondary analysis of existing data sets. CONCLUSION: The Lower Extremity Functional Scale is a useful tool to monitor activity limitation in people with ankle fracture up to the short-term follow-up. More- difficult items may need to be added to improve the responsiveness of the scale for longer-term follow-up. [ABSTRACT FROM AUTHOR]

Purpose. To develop and psychometrically test a Brazilian-Portuguese version of the Cumberland Ankle Instability Tool (CAIT), the only questionnaire that provides a numeric measure for functional ankle instability. Methods. The CAIT was translated and adapted into Brazilian-Portuguese according to the Guidelines for the process of cross-cultural adaptation of self report measures. The Brazilian-Portuguese version of the CAIT was tested for internal consistency, test-retest reliability, ceiling and floor effects and responsiveness in 131 participants. Participants were recruited from the general community in Brazil (N = 101, community group) and from those seeking treatment for an ankle sprain from 2 clinics in Brazil (N = 30, treatment group). Results. The Brazilian-Portuguese version of the CAIT had high internal consistency (Cronbach [alpha] = 0.86 for right ankles and 0.88 for left ankles), reliability (ICC = 0.95, 95% CI 0.93-0.97); and good responsiveness (ES = 0.75, 95% CI 0.49-1.00). No ceiling or floor effects were observed. Conclusions. The Brazilian-Portuguese version of the CAIT is as reliable as the English version of the questionnaire, has high internal consistency and good responsiveness. It thus provides the first tool that can be used to assess functional ankle instability by clinicians and researchers working among Brazilian-Portuguese speakers. [ABSTRACT FROM AUTHOR]

STUDY DESIGN: Controlled laboratory study using a cross-sectional design. OBJECTIVES: To investigate the relationship between postural control and functional ankle instability during a hop-landing task, and to investigate whether postural control is altered in people with functional ankle instability. METHODS AND MEASURES: Sixty volunteers classified by the Cumberland Ankle Instability Tool (CAIT) scores formed the external control group (CAIT score, >/= 28, n = 31) and the instability group (CAIT score, .05) between the CAIT scores and the TTS for ankle inversion (r = -0.25), dorsiflexion (r = -0.04), summated EMG (r = -0.13) and proportion of movement in the frontal plane (r = 0.005). Participants in the instability group took longer to regain stability in inversion and displayed greater inversion variability prejump than the control group (P = .05 and .009, respectively). CONCLUSIONS: Ankle inversion control is affected in people with functional ankle instability in tasks of postural control after landing from a hop. J Orthop Sports Phys Ther. 2008;38(12):782-789, published online 24 October 2008. doi:10.2519/jospt.2008.2766. [ABSTRACT FROM AUTHOR]

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]

Purpose. To assess whether muscle strength, power and endurance at the affected shoulder were reduced in women treated for breast cancer. Secondly, we assessed whether muscle performance was explained by management or other symptoms. Methods. Participants were 40 women (mean +/- SD: 56.7 +/- 11.6 yr) who had completed all treatments for breast cancer at least 6 m previously. We measured dynamic concentric strength at one repetition maximum (1RM), endurance at 90%1RM, and power through a range of 40 - 100% 1RM for shoulder protractors, extensors and retractors. Strength and endurance, but not power, were measured for shoulder flexors. Additionally, maximal grip strength, passive shoulder range of motion and arm circumference were measured. Self-reported symptoms were recorded using a questionnaire. Results. Shoulder protractors (p = 0.011), retractors (p = 0.007), and extensors (p = 0.009), but not flexors, were significantly weaker on the affected side compared to the unaffected side. Muscle power and endurance at the shoulder and grip strength were not impaired. Inter-limb differences in muscle strength were not explained by the surgical and medical management of the cancer. Self-reported weakness correlated poorly with our measures of muscle strength. Conclusions. Long-term weakness occurs about the shoulder secondary to treatment for breast cancer. Strategies to prevent weakness need to be considered. [ABSTRACT FROM AUTHOR]

STUDY DESIGN: Control laboratory study consisting of preintervention and postintervention measurements. OBJECTIVE: To determine the effects of a putting practice session on the kinematics of full golf swings made by skilled male golfers. BACKGROUND: Skilled golfers perform putting practice for prolonged periods. The combination of sustained trunk flexion with minimal trunk motion may affect the endurance capacity of the trunk extensor muscles. Because of their important role in the golf swing, any impairment of the trunk extensors may negatively influence full-swing kinematics, but this has not been previously evaluated. METHODS AND MEASURES: Three-dimensional swing kinematics and holding time on the Biering-Sørensen test of isometric trunk extensor endurance were evaluated in 29 skilled male golfers before and after performing a 40-minute putting task. RESULTS: After the intervention, peak segmental speeds were reduced and total swing duration increased (mean ± SD, 36 ± 55 milliseconds). There were reductions in the magnitude of pelvis and torso axial rotation during the downswing (mean ± SD, -2.3° ± 2.6° and -2.3° ± 4.7°, respectively). The peak difference between torso rotation and pelvis rotation during early downswing was also significantly reduced by 0.9° ± 2.0° (P<.05). The effects on pelvis and torso rotation were smallest for golfers with higher body mass index (BMI). Holding time on the Biering-Sørensen test after putting practice was significantly reduced by 25.7 ± 23.8 seconds (P = .01). CONCLUSION: Changes in swing kinematics observed following 40 minutes of putting practice might have resulted from fatigue-related impairment of the trunk extensor muscles, a view supported by the poorer performance on the postintervention Biering-Sørensen test. Results showed that swing kinematics of golfers with high BMI were least affected by the putting practice. LEVEL OF EVIDENCE: Harm, level 5. [ABSTRACT FROM AUTHOR]

Goals Of Work: Radiotherapy is routinely used in the treatment of early breast cancer, particularly in women who have undergone lumpectomy. Its impact on the quality of life of patients is important and is taken into consideration when making informed choices about treatment from both a patient's and health professional's point of view. This study reports on the quality of life of women at baseline, the completion of radiotherapy and 7 months after the completion of radiotherapy.Materials and Methods: European Organisation for Research and Treatment of Cancer (EORTC) QLQ-C-30 and BR-23 questionnaires were used to evaluate quality of life of 61 women treated with radiotherapy for breast cancer. Additionally, demographic and treatment variables were analysed in relation to quality of life outcomes to determine if there were any significant predictors of quality of life.Main Results: There was no difference in quality of life of women at baseline, completion and 7 months after completion of radiotherapy. Fatigue and breast symptoms increased during radiotherapy but returned to baseline levels at 7 months. Fatigue was the strongest predictor of poor quality of life in women after radiotherapy.Conclusion: Women retain a high quality of life and return to baseline function by 7 months after radiotherapy. Treatment may best be targeted to alleviate fatigue and breast symptoms during radiotherapy. [ABSTRACT FROM AUTHOR]

OBJECTIVE: To identify intrinsic predictors of lateral ankle sprain. DESIGN: Prospective cohort study. SETTING: A performing arts secondary school and a dance school. PARTICIPANTS: One hundred fifteen adolescent dancers (94 female and 21 male) entered the study. One ankle of each dancer was randomly assigned to a test group (n = 114), and the other was assigned to a validation group (n = 112). PREDICTORS: Eighteen measures, including age, dance history, previous ankle sprain, ankle and foot laxity and range of motion, and balance from test ankles were entered into a backwards stepwise Cox regression model. The model generated with the test group was used to predict ankle sprains in the validation group. MAIN OUTCOME MEASURE: Time to first lateral ankle sprain. RESULTS: An increased risk of sprain in the test group was predicted by younger age [hazard ratio (HR) = 0.65, 95% CI 0.45-0.94], previous sprain of the contralateral ankle (HR = 3.76, CI 1.24-11.40), increased passive inversion range (HR = 1.06, CI 1.00-1.12), and inability to balance on demipointe (HR = 3.75, CI 1.02-13.73). Of these predictors, only previous sprain of the contralateral ankle significantly predicted ankle sprain in the validation group (HR = 3.90, CI 1.49-10.22). The predictive accuracy of this variable was not strong (positive likelihood ratio of 2.01 and negative likelihood ratio of 0.45). CONCLUSION: A history of previous lateral ankle sprain is associated with an increase in the risk of future sprain of the contralateral ankle. [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]

OBJECTIVE: To determine if differences in balance and recovery would be found between controls and participants with unilateral or bilateral functional ankle instability (FAI). DESIGN: Cross-Sectional Study. SETTING: University laboratory and Community premises. PARTICIPANTS: Twenty healthy participants(C), 19 participants with unilateral FAI [both the uninjured (UC) and unstable ankle (UI) were included] and 22 participants with bilateral FAI (BI). MAIN OUTCOME MEASURES: Balance was measured in single leg stance as: number of part foot lifts in 30 s; magnitude of medio-lateral ankle movement in two foot positions; and ability to balance on the ball of the foot. Recovery was determined by time to return to baseline medio-lateral ankle movement after a 15 degree inversion perturbation. RESULTS: The controls lifted the foot fewer times than the other three groups [C = 12.7 +/- 1.8 (mean +/- SE) foot lifts, UC = 22.9 +/- 2.5, UI = 25.1 +/- 2.3, and BI = 21.1 +/- 2.2, t-test, P = 0.006] and recovered significantly faster than the unstable ankles [C = 1.53 +/- 0.42 sec (median +/- SE), UI = 2.34 +/- 0.30 sec, BI = 2.15 +/- 0.70 sec, P < 0.02]. With FAI measured by the Cumberland Ankle Instability Tool, the external control group balanced on demi-pointe better than both instability groups (P < 0.05), and recovered quicker than all groups. CONCLUSION: There are differences in balance and recovery between external controls and participants with both unilateral and bilateral FAI but not between the legs of participants with unilateral FAI. [ABSTRACT FROM AUTHOR]

Anterior cruciate ligament (ACL) rupture is a common sporting injury, often managed surgically with patella-tendon or hamstrings-gracilis autograft. Some people who sustain the injury, request information about their prognosis if they choose to forgo surgery and opt for conservative management. Numerous studies provide data on the prognosis of conservatively managed ACL injuries. These studies have not been systematically reviewed. Thus, the aims of this systematic review are to describe the natural history and clinical course of function and proprioception in the conservatively managed ACL-deficient knee, and to identify prognostic factors. We searched MEDLINE, CINAHL, EMBASE, SportDiscus, PEDro and the Cochrane Central Register of Clinical Trials without language restrictions from the earliest record available up to July 2006. We also searched the Science Citation Index, and iteratively searched bibliographies for prospective studies of outcomes (>6 months follow-up) of conservatively managed complete ACL tears. Six criteria were used to assess the methodological quality of included studies. The main outcome measures were self-reported measures of knee function, activity level, performance in functional tasks and knee proprioception. Fifteen studies of variable methodological quality were included in the review. On average, patients with mixed or isolated ACL-deficient knees reported good knee function (87/100 Lysholm knee scale) at follow-up duration of 12-66 months. On average, functional performance assessed with the hop-for-distance test, was in the normal range. From pre-injury to follow-up there was a reduction in Tegner activity level of 21.3%. According to the methods used in the assessed studies, conservatively managed ACL-deficient knees have a good short-to mid-term prognosis in terms of self-reported knee function and functional performance. However, subjects reduced their activity levels on average by 21% following injury. [ABSTRACT FROM AUTHOR]

BACKGROUND: Despite the large amount of time and money which has been devoted to low back pain research, successful management remains an elusive goal and low back pain continues to place a large burden on the primary care setting. One reason for this may be that the priorities for research are often developed by researchers and funding bodies, with little consideration of the needs of primary care practitioners. This study aimed to determine the research priorities of primary care practitioners who manage low back pain on a day-to-day basis. METHODS: A modified-Delphi survey of primary care practitioners was conducted, consisting of three rounds of questionnaires. In the first round, 70 practitioners who treat low back pain were each asked to provide up to five questions which they would like answered with respect to low back pain in primary care. The results were collated into a second round questionnaire consisting of 39 priorities, which were rated for importance by each practitioner on a likert-scale. The third round consisted of asking the practitioners to rank the top ten priorities in order of importance. RESULTS: Response rates for the modified-Delphi remained above 70% throughout the three rounds. The ten highest ranked priorities included the identification of sub-groups of patients that respond optimally to different treatments, evaluation of different exercise approaches in the management of low back pain, self-management of low back pain, and comparison of different treatment approaches by primary care professions treating low back pain. CONCLUSION: Practitioners identified a need for more information on a variety of topics, including diagnosis, the effectiveness of treatments, and identification of patient characteristics which affect treatment and recovery. [ABSTRACT FROM AUTHOR]

Objective: To evaluate the effect of conservative interventions on clinically relevant outcome measures for patients with subacute low back pain. This is particularly important because effective treatment for subacute low back pain will prevent the transition to chronic low back pain, a condition that is largely responsible for the high health care costs of low back pain. Design: Systematic review of randomized controlled trials. Main outcome measures: Methodological quality of each trial was assessed. Effect sizes and 95% confidence intervals were calculated for pain and disability and risk ratios for return to work. Results: Thirteen trials were located, evaluating the following interventions: manipulation, back school, exercise, advice, transcutaneous electrical nerve stimulation (TENS), hydrotherapy, massage, corset, cognitive behavioural treatment and co-ordination of primary health care. Most studies were of low quality and did not show a statistically significant effect of intervention. For the strict duration of low back pain (six weeks to three months), no evidence of high internal validity was found but when other methodological criteria were considered, evidence was found for the efficacy of advice. Furthermore, there is evidence that when a broader view is taken of the duration of subacute low back pain (seven days to six months), other treatments (e.g.manipulation, exercise, TENS) may be effective. Conclusions: Our review identified a major gap in the evidence for interventions that are currently recommended in clinical practice guidelines for the treatment of subacute low back pain. Lack of a uniform definition of subacute low back pain further limited current evidence. [ABSTRACT FROM AUTHOR]