Physical Therapy

Hall, Amanda, M.;Ferreira, Paulo, H.;Maher, Christopher, G.;Latimer,, Jane;Ferreira, Manuela, L.

doi: 10.2522/ptj.20090245pmid: 20576715

Background The working alliance, or collaborative bond, between client and psychotherapist has been found to be related to outcome in psychotherapy. Purpose The purpose of this study was to investigate whether the working alliance is related to outcome in physical rehabilitation settings. Data Sources A sensitive search of 6 databases identified a total of 1,600 titles. Study Selection Prospective studies of patients undergoing physical rehabilitation were selected for this systematic review. Data Extraction For each included study, descriptive data regarding participants, interventions, and measures of alliance and outcome—as well as correlation data for alliance and outcomes—were extracted. Data Synthesis Thirteen studies including patients with brain injury, musculoskeletal conditions, cardiac conditions, or multiple pathologies were retrieved. Various outcomes were measured, including pain, disability, quality of life, depression, adherence, and satisfaction with treatment. The alliance was most commonly measured with the Working Alliance Inventory, which was rated by both patient and therapist during the third or fourth treatment session. The results indicate that the alliance is positively associated with: (1) treatment adherence in patients with brain injury and patients with multiple pathologies seeking physical therapy, (2) depressive symptoms in patients with cardiac conditions and those with brain injury, (3) treatment satisfaction in patients with musculoskeletal conditions, and (4) physical function in geriatric patients and those with chronic low back pain. Limitations Among homogenous studies, there were insufficient reported data to allow pooling of results. Conclusions From this review, the alliance between therapist and patient appears to have a positive effect on treatment outcome in physical rehabilitation settings; however, more research is needed to determine the strength of this association. The relationship between patient and therapist traditionally has been viewed as an important determinant of treatment outcome and is considered central to the therapeutic process.1,2 More recently, this concept has been evaluated in research studies, where it is commonly referred to as the therapeutic alliance, helping alliance, or working alliance.3 For simplicity, this review will refer to this construct as the alliance. The construct of the alliance in therapeutic situations is derived from theories of transference first outlined by Freud in 1912 and refers to the sense of collaboration, warmth, and support between the client and therapist.4,5 Following on from this concept, Bordin1 in 1979 defined the 3 main components that contribute to the alliance construct as: (1) the therapist-patient agreement on goals of treatment, (2) the therapist-patient agreement on interventions, and (3) the affective bond between patient and therapist. Using this definition, researchers began to measure the alliance in clinical practice and formally assess its impact on treatment outcomes. The majority of this evaluation has been conducted in psychology, counseling, or general medicine settings, where the intervention is typically centered on a one-to-one interaction between the patient and the treating physician or therapist.3,6–12 The research to date has used a variety of different tools to measure the alliance, and there has been some argument that each tool represents conceptually different, although overlapping, constructs. Elvins and Green13 recently conducted an extensive review to investigate the conceptualization and measurement of the alliance. They identified a broad consensus as to the key concepts of the alliance among the various measures, but no single unifying alliance model or a single measure that comprehensively addressed all of the key concepts. The most successfully comprehensive measures of the alliance identified in the review were the Working Alliance Inventory (WAI), the Vanderbilt Scales, and the California Scales.13 Several research studies using the above-mentioned alliance measures have found that a positive alliance is associated with positive health outcomes for variables such as depression,14,15 anxiety,15 mood,16 interpersonal problems,17 and general psychological functioning.17 A meta-analytic review of 68 studies conducted in 2000 indicated that the weighted association of the alliance with overall outcome (including outcomes of mood, anxiety, and global assessment scales) was moderate (r=.22).3 In 2001, a further meta-analysis of the relationship between the alliance and the psychotherapy outcome included 90 independent clinical investigations, from which the author reported that the alliance may account for up to half of the beneficial effects of psychotherapy.7 In the medical profession, trust is seen as a global attribute of treatment relationships, encompassing satisfaction, communication, competency, and privacy,11 and has long been viewed as vital to cooperation with treatment and physician recommendations.18 Several studies attempted to measure how trust affects clinical outcomes and found that the patient's trust in his or her physician is positively correlated with self-reported measures of health status,19 symptom status,20 and overall quality of life.21 A recent high-quality study examined how patients’ trust in their physicians affected both self-report and “objective” measures of health status in 480 patients with diabetes.10 The authors reported that patient trust was positively correlated with stronger outcome expectations (r=.46, P<.01) and self-efficacy (r=.45, P<.01), which, in turn, predicted better treatment adherence, leading to better clinical outcomes of improved body mass index, blood glucose, blood lipids, and diabetes-related complications, as well as improved self-reports of mental and physical health. It would appear from the previous research that the alliance is positively associated with treatment outcome and could potentially be used as a predictor of treatment outcome in psychotherapy and general medicine settings. However, the degree to which the alliance relates to outcome in other treatment settings is not clear. Physical rehabilitation, like psychotherapy and general medicine, includes a high level of patient-clinician interaction; however, the characteristics of the patient population, as well as the intervention, are arguably different. It is plausible, therefore, that the relationship between the alliance and the outcome seen in psychotherapy or general medicine settings is not transferable to physical rehabilitation settings. It is thus of great importance to determine whether the alliance of rehabilitation therapists is similar to that of psychotherapists and general practitioners and whether this alliance influences outcome in the physical rehabilitation setting. To our knowledge, there has been no systematic review of the primary research in this area. The aims of this study were: (1) to identify and summarize studies that have used and analyzed the alliance as a predictor of outcome and adherence in physical rehabilitation settings and (2) to determine whether there is an association between the alliance and the treatment outcome of physical rehabilitation programs. We hypothesized that the patient-therapist alliance would have a positive correlation with treatment outcome. Method Data Sources and Searches An electronic database search using the search strategies outlined in Appendix 1 was conducted for 6 databases (EMBASE, PEDro, PsychINFO, MEDLINE, CINAHL, and LILACS) from the earliest record to February 2009. Citation tracking was performed by manually screening reference lists of eligible trials. Theses and conference proceedings also were included. Additionally, personal communication with content experts in the therapeutic alliance field was conducted. Study inclusion was not restricted by language. The search strategy and exclusion process are illustrated in the Figure. Figure Open in new tabDownload slide Search strategy and exclusion process. Figure Open in new tabDownload slide Search strategy and exclusion process. Study Selection From the titles identified by the search strategy, original studies were included if they: (1) were prospective, longitudinal studies (randomized controlled trials, controlled trials, or cohort studies); (2) included patients who were managed with physical rehabilitation and there were no restrictions to diagnosis; (3) included at least one measure of therapeutic alliance or therapist-patient interaction/bonding; and (4) used at least one measure of treatment outcome such as pain, disability, physical performance, quality of life, global perceived effect of treatment, and adherence. Physical rehabilitation is defined as an intervention that aims to enhance and restore functional ability and quality of life in those with physical impairments or disabilities. It can include a combination of physical modalities, therapeutic exercise, activities modification, assistive devices, orthoses, and prostheses. The interventions can be delivered by a single therapist or a combination of therapists in a multidisciplinary setting, including physical therapists, occupational therapists, psychologists, chiropractors, speech pathologists, and recreation therapists.22 Data Extraction and Quality Assessment For each included trial, 2 reviewers independently extracted quantitative data such as change or final scores and standard deviations for all relevant outcomes at all time points used in the study. In addition, correlation or regression coefficients and odds ratios for alliance and outcomes were extracted. For each included study, descriptive data regarding participants, interventions, measures of alliance, and other outcome measures were extracted. If different data were reported by the 2 reviewers, data were rechecked by both reviewers. If disagreement continued, a third author would arbitrate. However, a third author was not necessary, as consensus was reached for all extracted data. Studies meeting the eligibility criteria were assessed for methodological quality. The methodological quality of the studies was independently assessed by 2 authors using a checklist that comprised 7 criteria: use of a representative sample, having a defined sample, use of blinding, having a follow-up rate greater than 85%, appropriate choice of outcome measures, reporting outcome data at follow-up, and control for confounding via statistical adjustment. These criteria have been used in previous studies,23,24 and their inclusion in checklists for rating methodological quality has been recommended by a recent systematic review of quality assessment tools for observational studies25 and by the STROBE Statement.26 However, this scale was not designed to provide a quality score per se; thus, there is no score allocated to each individual study. Similarly, if different data were reported by the 2 reviewers, data were rechecked by both reviewers. If disagreement continued, a third reviewer was used to arbitrate. Data Synthesis and Analysis Studies were grouped according to the study population and outcome measure. Within each study population, meta-analyses were intended to be performed if 2 or more studies used similar measures of alliance and similar measures of outcome. Where there were not multiple studies with sufficient homogeneity, the correlation between alliance and outcome measure of the individual studies was reported. Results Included Studies A total of 1,600 unique titles were identified using multiple databases (ie, EMBASE, CINAHL, MEDLINE, PsychINFO, LILACS and PEDro), citation tracking, and contact with experts in the field. Titles were merged in EndNote X,* and sources included books, theses, abstracts, conference proceedings, and journal articles from both refereed and nonrefereed journals. Following the exclusion process, a total of 14 publications (13 distinct data sets) met the inclusion criteria.27–39 The 2 publications reporting on the same cohort33,34 are treated as 1 study. The 13 studies were published between 1990 and 2009; 10 were from published sources, and 3 were from unpublished doctoral dissertations or master's theses. A detailed description of the methodological quality of each study is presented in Table 1. Considering the possibility of missed articles in this search strategy, readers are encouraged to alert the corresponding author to any papers that have not been cited in this article for future updated reviews of this material. Table 1 Methodological Quality (Criteria Developed From Sanderson et al25 and STROBE Guidelines26)a Study . Representative Sample . Defined Sample . Blinding . Follow-up Rate >85% . Methods of Assessment . Outcome Data Reported . Statistical Adjustment . Alliance Rater . Outcome Rater . Schonberger et al (2006)35 ✔ ✘ T1 T1 ✔ ✔ ✔ ? Schonberger and colleagues (2006)33,34 ✔ ✘ P/T T ? ✔ ✔ ✔ Sherer et al (2007)36 ✔ ✘ P/T P ✔ ✔ ✔ ✔ Ferreira et al (2009)30 ✘ ✔ P P ✔ ✔ ✔ ✔ Beattie et al (2005)28 ✔ ? P P ✘ ✔ ✔ ✘ Zaproudina et al (2007)38 ✘ ✔ P p ✔ ✔ ✔ ✘ Zaproudina et al (2009)39 ✘ ✔ P/T P ✔ ✔ ✔ ✘ Higdon (1997)31 ✘ ✔ P/T P/T ✘ ✔ ? ✘ Mirsky (2002)32 ✘ ✔ P P ✘ ✔ ? ✘ Burns and Evon (2007)29 ✔ ✔ P P/T ✔ ✔ ? ✘ Slujis et al (1993)37 ✔ ✘ P/O P ? ? ? ✘ Ambady et al (2002)27 ✘ ✔ O P ✔ ✔ ✔ ✘ Walker (1990)40,b ? ✘ P/T P ✘ ✘ ✘ ✘ Control for bias Representative sample: participants were selected as consecutive or random cases Defined sample: description of participant source and inclusion and exclusion criteria Blinded outcome assessment: assessor was unaware of prognostic factors at the time of outcome assessment Follow-up >85%: outcome data were available for at least 85% of participants at one follow-up point Appropriate measurement of variables Methods of assessment: appropriate choice of outcome measures Outcome data reported: reporting of outcome data at follow-up Control for confounding Statistical adjustment: multivariable analysis conducted, with adjustment for potentially confounding factors Study . Representative Sample . Defined Sample . Blinding . Follow-up Rate >85% . Methods of Assessment . Outcome Data Reported . Statistical Adjustment . Alliance Rater . Outcome Rater . Schonberger et al (2006)35 ✔ ✘ T1 T1 ✔ ✔ ✔ ? Schonberger and colleagues (2006)33,34 ✔ ✘ P/T T ? ✔ ✔ ✔ Sherer et al (2007)36 ✔ ✘ P/T P ✔ ✔ ✔ ✔ Ferreira et al (2009)30 ✘ ✔ P P ✔ ✔ ✔ ✔ Beattie et al (2005)28 ✔ ? P P ✘ ✔ ✔ ✘ Zaproudina et al (2007)38 ✘ ✔ P p ✔ ✔ ✔ ✘ Zaproudina et al (2009)39 ✘ ✔ P/T P ✔ ✔ ✔ ✘ Higdon (1997)31 ✘ ✔ P/T P/T ✘ ✔ ? ✘ Mirsky (2002)32 ✘ ✔ P P ✘ ✔ ? ✘ Burns and Evon (2007)29 ✔ ✔ P P/T ✔ ✔ ? ✘ Slujis et al (1993)37 ✔ ✘ P/O P ? ? ? ✘ Ambady et al (2002)27 ✘ ✔ O P ✔ ✔ ✔ ✘ Walker (1990)40,b ? ✘ P/T P ✘ ✘ ✘ ✘ Control for bias Representative sample: participants were selected as consecutive or random cases Defined sample: description of participant source and inclusion and exclusion criteria Blinded outcome assessment: assessor was unaware of prognostic factors at the time of outcome assessment Follow-up >85%: outcome data were available for at least 85% of participants at one follow-up point Appropriate measurement of variables Methods of assessment: appropriate choice of outcome measures Outcome data reported: reporting of outcome data at follow-up Control for confounding Statistical adjustment: multivariable analysis conducted, with adjustment for potentially confounding factors a P=patient, T=therapist, T1=therapist rated retrospectively, O=observer, ✔=yes, ✘=no, ?=unclear. b Quality ratings are based on available abstract, as the full dissertation was unavailable. Open in new tab Table 1 Methodological Quality (Criteria Developed From Sanderson et al25 and STROBE Guidelines26)a Study . Representative Sample . Defined Sample . Blinding . Follow-up Rate >85% . Methods of Assessment . Outcome Data Reported . Statistical Adjustment . Alliance Rater . Outcome Rater . Schonberger et al (2006)35 ✔ ✘ T1 T1 ✔ ✔ ✔ ? Schonberger and colleagues (2006)33,34 ✔ ✘ P/T T ? ✔ ✔ ✔ Sherer et al (2007)36 ✔ ✘ P/T P ✔ ✔ ✔ ✔ Ferreira et al (2009)30 ✘ ✔ P P ✔ ✔ ✔ ✔ Beattie et al (2005)28 ✔ ? P P ✘ ✔ ✔ ✘ Zaproudina et al (2007)38 ✘ ✔ P p ✔ ✔ ✔ ✘ Zaproudina et al (2009)39 ✘ ✔ P/T P ✔ ✔ ✔ ✘ Higdon (1997)31 ✘ ✔ P/T P/T ✘ ✔ ? ✘ Mirsky (2002)32 ✘ ✔ P P ✘ ✔ ? ✘ Burns and Evon (2007)29 ✔ ✔ P P/T ✔ ✔ ? ✘ Slujis et al (1993)37 ✔ ✘ P/O P ? ? ? ✘ Ambady et al (2002)27 ✘ ✔ O P ✔ ✔ ✔ ✘ Walker (1990)40,b ? ✘ P/T P ✘ ✘ ✘ ✘ Control for bias Representative sample: participants were selected as consecutive or random cases Defined sample: description of participant source and inclusion and exclusion criteria Blinded outcome assessment: assessor was unaware of prognostic factors at the time of outcome assessment Follow-up >85%: outcome data were available for at least 85% of participants at one follow-up point Appropriate measurement of variables Methods of assessment: appropriate choice of outcome measures Outcome data reported: reporting of outcome data at follow-up Control for confounding Statistical adjustment: multivariable analysis conducted, with adjustment for potentially confounding factors Study . Representative Sample . Defined Sample . Blinding . Follow-up Rate >85% . Methods of Assessment . Outcome Data Reported . Statistical Adjustment . Alliance Rater . Outcome Rater . Schonberger et al (2006)35 ✔ ✘ T1 T1 ✔ ✔ ✔ ? Schonberger and colleagues (2006)33,34 ✔ ✘ P/T T ? ✔ ✔ ✔ Sherer et al (2007)36 ✔ ✘ P/T P ✔ ✔ ✔ ✔ Ferreira et al (2009)30 ✘ ✔ P P ✔ ✔ ✔ ✔ Beattie et al (2005)28 ✔ ? P P ✘ ✔ ✔ ✘ Zaproudina et al (2007)38 ✘ ✔ P p ✔ ✔ ✔ ✘ Zaproudina et al (2009)39 ✘ ✔ P/T P ✔ ✔ ✔ ✘ Higdon (1997)31 ✘ ✔ P/T P/T ✘ ✔ ? ✘ Mirsky (2002)32 ✘ ✔ P P ✘ ✔ ? ✘ Burns and Evon (2007)29 ✔ ✔ P P/T ✔ ✔ ? ✘ Slujis et al (1993)37 ✔ ✘ P/O P ? ? ? ✘ Ambady et al (2002)27 ✘ ✔ O P ✔ ✔ ✔ ✘ Walker (1990)40,b ? ✘ P/T P ✘ ✘ ✘ ✘ Control for bias Representative sample: participants were selected as consecutive or random cases Defined sample: description of participant source and inclusion and exclusion criteria Blinded outcome assessment: assessor was unaware of prognostic factors at the time of outcome assessment Follow-up >85%: outcome data were available for at least 85% of participants at one follow-up point Appropriate measurement of variables Methods of assessment: appropriate choice of outcome measures Outcome data reported: reporting of outcome data at follow-up Control for confounding Statistical adjustment: multivariable analysis conducted, with adjustment for potentially confounding factors a P=patient, T=therapist, T1=therapist rated retrospectively, O=observer, ✔=yes, ✘=no, ?=unclear. b Quality ratings are based on available abstract, as the full dissertation was unavailable. Open in new tab Participants The patient population's diagnoses varied among the studies, including brain injury (3/13), musculoskeletal conditions (6/13), cardiac conditions (1/13), and multiple pathologies such as systemic diseases, trauma and postoperative conditions, back pain, and neck and shoulder pain (3/13). Interventions and Treatment Outcome The length of treatment was reported in 7 of the 13 studies and varied from 4 to 16 weeks. In 9 of the 13 studies, the interventions were delivered by a single therapist, predominantly a registered physical therapist (8/9). The other 4 studies used multidisciplinary interventions administered by multiple therapists; the alliance was based on the relationship with the client's primary therapist, who was not specified. Various outcome measures were assessed in each study, and a detailed description of the measurement tool is provided in the descriptive summary for each study (Tab. 2). Table 2 Characteristics of Included Studies (Arranged by Patient Population)a Study . Study Type . n . Intervention Description . Alliance . Session Rated . Outcome . Client Rated . Therapist Rated . Observer Rated . Brain injury  Schonberger et al (2006)35 Cohort 98 14 weeks of multidisciplinary rehabilitation delivered by a physical therapist for patients with acquired brain injury Prigatano Scales/WAI-SF 3–4 Adherence r1=.76* Employment r1=.20*  Schonberger and colleagues (2006)33,34 Cohort 86 14 weeks of multidisciplinary rehabilitation delivered by a team of therapistsb for patients with acquired brain injury WAI-SF 3–4 Therapeutic success r=.63* r=.49* Depression r=.60*  Sherer et al (2007)36 Cohort 69 Multidisciplinary rehabilitation delivered by a team of therapistsb for patients with acquired brain injury CALPAS/Prigatano Scales 3–6 Disability r=.09# r=.31# OR=1.07 (95% 0=1.0–1.15) Attendance r=.47# r=.82# Productivity r=-.06# r=.38# Depression r=-.17# r=-.46# Musculoskeletal pain  Ferreira et al (2009)30 RCT 240 8 weeks of physical therapy for patients with chronic low back pain WAI-LF 3 Function b=0.17 (95% CI=0.07–0.28)* Global assessmentc b=0.08 (95% CI=0.03–0.13)*  Beattie et al (2005)28 CS 1,449 Physical therapy for patients with musculoskeletal pain conditions Med Risk internal factors 4–5 Treatment satisfaction r=.83*  Higdon (1997)31 Cohort 53 Physical rehabilitation delivered by an occupational therapist for patients with musculoskeletal pain conditions WAI-SF N/S Physical function r=.09–.27* Floor-bench lifts β=0.20*  Zaproudina et al (2007)38 RCT 105 5–10 sessions of physical therapy, traditional bone setting,d or massage therapy for patients with chronic neck pain 5-item questionnaire 2–3 Global assessment r2=.36–.47*  Zaproudina et al (2009)39 RCT 131 5–10 sessions of physical therapy or traditional bone setting for patients with chronic back pain 5-item questionnaire 2–3 Global assessment r2=. 30* Pain r2=. 30#  Mirsky (2002)32 Cohort 11 4 weeks of multidisciplinary rehabilitation delivered by a team of therapists for patients with chronic low back pain WAI-SF Last Other  Burns and Evon (2007)29 Cohort 79 12 weeks of outpatient cardiac rehabilitation delivered by a physical therapist for patients with cardiovascular disease WAI-SF N/S  Sluijs et al (1993)37 Cohort 695 Physical therapy for patients with multiple pathologiese Verbal behaviors N/S Adherencef Mean=2.51 (SD=0.5)g Mean=2.45 (SD=0.47)h  Ambady et al (2002)27 Cohort 48 Physical therapy for geriatric patients with various physical conditions Nonverbal cues First or last Activities of daily living r=.60*  Walker (1990)40 Cohort 96 Multidisciplinary rehabilitation for patients with chronic pain N/S N/S Study . Study Type . n . Intervention Description . Alliance . Session Rated . Outcome . Client Rated . Therapist Rated . Observer Rated . Brain injury  Schonberger et al (2006)35 Cohort 98 14 weeks of multidisciplinary rehabilitation delivered by a physical therapist for patients with acquired brain injury Prigatano Scales/WAI-SF 3–4 Adherence r1=.76* Employment r1=.20*  Schonberger and colleagues (2006)33,34 Cohort 86 14 weeks of multidisciplinary rehabilitation delivered by a team of therapistsb for patients with acquired brain injury WAI-SF 3–4 Therapeutic success r=.63* r=.49* Depression r=.60*  Sherer et al (2007)36 Cohort 69 Multidisciplinary rehabilitation delivered by a team of therapistsb for patients with acquired brain injury CALPAS/Prigatano Scales 3–6 Disability r=.09# r=.31# OR=1.07 (95% 0=1.0–1.15) Attendance r=.47# r=.82# Productivity r=-.06# r=.38# Depression r=-.17# r=-.46# Musculoskeletal pain  Ferreira et al (2009)30 RCT 240 8 weeks of physical therapy for patients with chronic low back pain WAI-LF 3 Function b=0.17 (95% CI=0.07–0.28)* Global assessmentc b=0.08 (95% CI=0.03–0.13)*  Beattie et al (2005)28 CS 1,449 Physical therapy for patients with musculoskeletal pain conditions Med Risk internal factors 4–5 Treatment satisfaction r=.83*  Higdon (1997)31 Cohort 53 Physical rehabilitation delivered by an occupational therapist for patients with musculoskeletal pain conditions WAI-SF N/S Physical function r=.09–.27* Floor-bench lifts β=0.20*  Zaproudina et al (2007)38 RCT 105 5–10 sessions of physical therapy, traditional bone setting,d or massage therapy for patients with chronic neck pain 5-item questionnaire 2–3 Global assessment r2=.36–.47*  Zaproudina et al (2009)39 RCT 131 5–10 sessions of physical therapy or traditional bone setting for patients with chronic back pain 5-item questionnaire 2–3 Global assessment r2=. 30* Pain r2=. 30#  Mirsky (2002)32 Cohort 11 4 weeks of multidisciplinary rehabilitation delivered by a team of therapists for patients with chronic low back pain WAI-SF Last Other  Burns and Evon (2007)29 Cohort 79 12 weeks of outpatient cardiac rehabilitation delivered by a physical therapist for patients with cardiovascular disease WAI-SF N/S  Sluijs et al (1993)37 Cohort 695 Physical therapy for patients with multiple pathologiese Verbal behaviors N/S Adherencef Mean=2.51 (SD=0.5)g Mean=2.45 (SD=0.47)h  Ambady et al (2002)27 Cohort 48 Physical therapy for geriatric patients with various physical conditions Nonverbal cues First or last Activities of daily living r=.60*  Walker (1990)40 Cohort 96 Multidisciplinary rehabilitation for patients with chronic pain N/S N/S a RCT=randomized controlled trial, CS=cross-sectional, WAI-SF=short-form Working Alliance Inventory containing 12 items from original 36 items, WAI-LF=long-form Working Alliance Inventory containing 36 items, CALPAS=California Psychotherapy Alliance Scale, N/S=not stated or unclear, r1=Cramer correlation (description in Appendix 2), r2=Spearman rho, MedRisk=MedRisk Instrument for Measuring Patient Satisfaction With Physical Therapy Care, OR=odds ratio, 95% CI=95% confidence interval. *P<.05. #Significance not reported. Note: more detailed descriptions of the tools used to measure alliance and the correlations between alliance and outcome are reported in Appendix 2. b Team of therapists includes physical therapist, occupational therapist, speech therapist, and neuropsychologist. c Global assessment refers to the patients’ self-report of their assessment of health status. d Traditional bone setting was delivered by an experienced Finnish traditional bone setter. e Multiple pathologies include systemic disease, trauma and postoperative conditions, nonradiating back pain, and neck and shoulder pain. f For analysis, the sample was divided into 2 groups based on adherence, and alliance scores were obtained in both groups. g Mean alliance score for compliant group. h Mean alliance score for noncompliant group. Open in new tab Table 2 Characteristics of Included Studies (Arranged by Patient Population)a Study . Study Type . n . Intervention Description . Alliance . Session Rated . Outcome . Client Rated . Therapist Rated . Observer Rated . Brain injury  Schonberger et al (2006)35 Cohort 98 14 weeks of multidisciplinary rehabilitation delivered by a physical therapist for patients with acquired brain injury Prigatano Scales/WAI-SF 3–4 Adherence r1=.76* Employment r1=.20*  Schonberger and colleagues (2006)33,34 Cohort 86 14 weeks of multidisciplinary rehabilitation delivered by a team of therapistsb for patients with acquired brain injury WAI-SF 3–4 Therapeutic success r=.63* r=.49* Depression r=.60*  Sherer et al (2007)36 Cohort 69 Multidisciplinary rehabilitation delivered by a team of therapistsb for patients with acquired brain injury CALPAS/Prigatano Scales 3–6 Disability r=.09# r=.31# OR=1.07 (95% 0=1.0–1.15) Attendance r=.47# r=.82# Productivity r=-.06# r=.38# Depression r=-.17# r=-.46# Musculoskeletal pain  Ferreira et al (2009)30 RCT 240 8 weeks of physical therapy for patients with chronic low back pain WAI-LF 3 Function b=0.17 (95% CI=0.07–0.28)* Global assessmentc b=0.08 (95% CI=0.03–0.13)*  Beattie et al (2005)28 CS 1,449 Physical therapy for patients with musculoskeletal pain conditions Med Risk internal factors 4–5 Treatment satisfaction r=.83*  Higdon (1997)31 Cohort 53 Physical rehabilitation delivered by an occupational therapist for patients with musculoskeletal pain conditions WAI-SF N/S Physical function r=.09–.27* Floor-bench lifts β=0.20*  Zaproudina et al (2007)38 RCT 105 5–10 sessions of physical therapy, traditional bone setting,d or massage therapy for patients with chronic neck pain 5-item questionnaire 2–3 Global assessment r2=.36–.47*  Zaproudina et al (2009)39 RCT 131 5–10 sessions of physical therapy or traditional bone setting for patients with chronic back pain 5-item questionnaire 2–3 Global assessment r2=. 30* Pain r2=. 30#  Mirsky (2002)32 Cohort 11 4 weeks of multidisciplinary rehabilitation delivered by a team of therapists for patients with chronic low back pain WAI-SF Last Other  Burns and Evon (2007)29 Cohort 79 12 weeks of outpatient cardiac rehabilitation delivered by a physical therapist for patients with cardiovascular disease WAI-SF N/S  Sluijs et al (1993)37 Cohort 695 Physical therapy for patients with multiple pathologiese Verbal behaviors N/S Adherencef Mean=2.51 (SD=0.5)g Mean=2.45 (SD=0.47)h  Ambady et al (2002)27 Cohort 48 Physical therapy for geriatric patients with various physical conditions Nonverbal cues First or last Activities of daily living r=.60*  Walker (1990)40 Cohort 96 Multidisciplinary rehabilitation for patients with chronic pain N/S N/S Study . Study Type . n . Intervention Description . Alliance . Session Rated . Outcome . Client Rated . Therapist Rated . Observer Rated . Brain injury  Schonberger et al (2006)35 Cohort 98 14 weeks of multidisciplinary rehabilitation delivered by a physical therapist for patients with acquired brain injury Prigatano Scales/WAI-SF 3–4 Adherence r1=.76* Employment r1=.20*  Schonberger and colleagues (2006)33,34 Cohort 86 14 weeks of multidisciplinary rehabilitation delivered by a team of therapistsb for patients with acquired brain injury WAI-SF 3–4 Therapeutic success r=.63* r=.49* Depression r=.60*  Sherer et al (2007)36 Cohort 69 Multidisciplinary rehabilitation delivered by a team of therapistsb for patients with acquired brain injury CALPAS/Prigatano Scales 3–6 Disability r=.09# r=.31# OR=1.07 (95% 0=1.0–1.15) Attendance r=.47# r=.82# Productivity r=-.06# r=.38# Depression r=-.17# r=-.46# Musculoskeletal pain  Ferreira et al (2009)30 RCT 240 8 weeks of physical therapy for patients with chronic low back pain WAI-LF 3 Function b=0.17 (95% CI=0.07–0.28)* Global assessmentc b=0.08 (95% CI=0.03–0.13)*  Beattie et al (2005)28 CS 1,449 Physical therapy for patients with musculoskeletal pain conditions Med Risk internal factors 4–5 Treatment satisfaction r=.83*  Higdon (1997)31 Cohort 53 Physical rehabilitation delivered by an occupational therapist for patients with musculoskeletal pain conditions WAI-SF N/S Physical function r=.09–.27* Floor-bench lifts β=0.20*  Zaproudina et al (2007)38 RCT 105 5–10 sessions of physical therapy, traditional bone setting,d or massage therapy for patients with chronic neck pain 5-item questionnaire 2–3 Global assessment r2=.36–.47*  Zaproudina et al (2009)39 RCT 131 5–10 sessions of physical therapy or traditional bone setting for patients with chronic back pain 5-item questionnaire 2–3 Global assessment r2=. 30* Pain r2=. 30#  Mirsky (2002)32 Cohort 11 4 weeks of multidisciplinary rehabilitation delivered by a team of therapists for patients with chronic low back pain WAI-SF Last Other  Burns and Evon (2007)29 Cohort 79 12 weeks of outpatient cardiac rehabilitation delivered by a physical therapist for patients with cardiovascular disease WAI-SF N/S  Sluijs et al (1993)37 Cohort 695 Physical therapy for patients with multiple pathologiese Verbal behaviors N/S Adherencef Mean=2.51 (SD=0.5)g Mean=2.45 (SD=0.47)h  Ambady et al (2002)27 Cohort 48 Physical therapy for geriatric patients with various physical conditions Nonverbal cues First or last Activities of daily living r=.60*  Walker (1990)40 Cohort 96 Multidisciplinary rehabilitation for patients with chronic pain N/S N/S a RCT=randomized controlled trial, CS=cross-sectional, WAI-SF=short-form Working Alliance Inventory containing 12 items from original 36 items, WAI-LF=long-form Working Alliance Inventory containing 36 items, CALPAS=California Psychotherapy Alliance Scale, N/S=not stated or unclear, r1=Cramer correlation (description in Appendix 2), r2=Spearman rho, MedRisk=MedRisk Instrument for Measuring Patient Satisfaction With Physical Therapy Care, OR=odds ratio, 95% CI=95% confidence interval. *P<.05. #Significance not reported. Note: more detailed descriptions of the tools used to measure alliance and the correlations between alliance and outcome are reported in Appendix 2. b Team of therapists includes physical therapist, occupational therapist, speech therapist, and neuropsychologist. c Global assessment refers to the patients’ self-report of their assessment of health status. d Traditional bone setting was delivered by an experienced Finnish traditional bone setter. e Multiple pathologies include systemic disease, trauma and postoperative conditions, nonradiating back pain, and neck and shoulder pain. f For analysis, the sample was divided into 2 groups based on adherence, and alliance scores were obtained in both groups. g Mean alliance score for compliant group. h Mean alliance score for noncompliant group. Open in new tab Alliance Measurement Tools In the 13 studies, multiple instruments were used to measure the alliance between therapist and patient. The short-form WAI was used most often in the included studies (6/13). Five studies27,28,37–40 used alliance scales that are not commonly referred to in the literature. These scales either were created by the researchers for the specific study or were subscales within more general treatment questionnaires. In the sample of studies, patients were the most common raters of the alliance (12/13), followed by therapists (8/13) and observers (2/13). Alliance Score Predictor of Outcome Of the included studies, there was a wide range of patient diagnoses. Included studies were summarized in terms of diagnoses. Within the specific diagnostic groups, there was insufficient homogeneity between measurement of alliance and measurement of outcome to warrant pooling of data. The association between alliance and outcome, therefore, is described as reported in the individual studies. A summary of the included studies, including study characteristics and correlations (if stated), is reported in Table 2. A further detailed description of each included trial is presented in Appendix 2. Brain injury Three of the 13 studies included patients who were participating in brain injury rehabilitation programs. The rehabilitation program was similar among trials and commonly referred to as the postacute brain injury rehabilitation program (PABIR). It consisted of a multidisciplinary team working with the patient on achieving goals of improved physical, cognitive, and social function. The results from these studies are inconsistent. Two studies conducted by Schonberger and colleagues33–35 found significant positive associations between alliance and adherence, employment, physical training, depression, and therapeutic success. The study by Sherer et al36 found a positive correlation between alliance and program attendance but not between alliance and disability, productivity, or depression (Tab. 2). Musculoskeletal conditions Six of the 13 studies included patients with a diagnosis that falls under the category of musculoskeletal pain conditions, including chronic low back pain (3/6), chronic neck pain (1/6), and multiple diagnoses of musculoskeletal conditions (2/6). Various outcomes were measured in all studies. Significant positive associations were found between the alliance and the patient's global perceived effect of treatment,30,38,39 change in pain,32,39 physical function,30,31 patient satisfaction with treatment,28 depression,32 and general health status.32 Other conditions Each of the remaining 4 studies investigated the alliance in mixed populations, comprising patients with a variety of different conditions. Among these studies, 2 included correlation data, which found that the alliance was significantly positively associated with physical function and depression in geriatric patients with various physical function deficits27 and that a change in alliance was associated with a change in treatment adherence for patients with cardiac conditions.29 Discussion Influence of Alliance on Treatment Outcome The findings of this study suggest that the alliance between patient and therapist positively correlates with treatment outcome for people in physical rehabilitation settings, lending support to this study's hypothesis. The outcomes included in this review are: (1) ability to perform activities of daily living, (2) pain, (3) specific physical function tasks, (4) depression, (5) global assessment of physical health, (6) treatment adherence, and (7) treatment satisfaction. Unfortunately, a meta-analysis was not possible, and we are unable to provide a more precise estimate of the magnitude of association between the alliance and relevant treatment outcomes. The included studies recruited patients with a mix of diagnoses. Six of the 14 studies included patients with musculoskeletal pain conditions who were undergoing physical therapy or physical conditioning programs. These studies showed a consistent pattern of positive correlations between alliance and outcome. This positive correlation pattern also was seen for patients with other conditions, including cardiovascular disease, geriatric disability conditions, and general chronic pain conditions. However, this pattern was not consistent for patients diagnosed with brain injury, as one study36 reported that as client ratings and therapist ratings of alliance improved, outcomes of physical function, productivity, and depression declined. The authors suggested that this paradoxical effect, in comparison with the other studies, may have been due, in part, to the difference in the time at which the alliance was measured. The study measured alliance in the first 2 weeks of treatment, whereas the other 2 brain injury studies measured alliance either after the treatment program35 or at multiple points during the program33 and then used a mean score for correlation analysis. In both studies that found positive correlations, there was a longer time in which the feelings of bonding and perceptions of tasks and goals of treatments could be formed. Measurement of Alliance in Rehabilitation Settings It is clear from this review that the alliance has not been systematically investigated in the physical rehabilitation setting, as evidenced by the lack of consensus regarding the methods of measurement. Although 6 of the 13 studies used the WAI to measure alliance, overall 7 different tools were used across the 13 studies. To date, 3 of these measures have been validated in psychotherapy settings,13 and none have been validated for patients undergoing physical rehabilitation. Without appropriate clinimetric testing, it is difficult to assess whether each tool is measuring the same construct. However, because the tool used does not appear to influence the magnitude and direction of the correlation in different musculoskeletal samples, we would suggest there is some indirect evidence that the tools may be equally valid. There were some similarities in the methodological approach of the studies. The timing of alliance assessment was relatively consistent among studies, with 7 of 13 studies measuring the alliance during the second to fifth treatment sessions. This finding may be due, in part, to recommendations by Horvath that the alliance measured between the first and fifth treatment sessions or within the first third of treatment shows a stronger alliance-outcome association.7 Additionally, 12 of 13 studies included patient ratings of the alliance, 8 chose therapist ratings, and 2 chose observer ratings. This choice also may be due to conclusions from a previous meta-analysis that patients’ ratings of the alliance had a stronger correlation with outcome than therapists’ ratings in psychotherapy settings.3 However, based on the available data, we are unable to determine whether this is the case in physical rehabilitation settings. Recommendations Clinicians The results of this study suggest a positive alliance is associated with improved outcome. Although a few studies27,41 have attempted to identify the factors that influence the alliance, there is no conclusive evidence as to which factors are most important. The limited data would suggest that providing positive feedback, answering the patient's questions, and providing clear instructions for home practice are positively correlated with a good working alliance and satisfaction with treatment. Researchers The WAI was the most frequently used tool among the studies included in this review. There is some evidence that the WAI is appropriate for most research projects because it is well-triangulated measure with good validity data.13 These clinimetric properties, however, are based on its use in different populations undergoing psychotherapy, and further clinimetric testing of this questionnaire is needed to support its use in the physical rehabilitation setting. Conclusions The alliance has been previously shown to play a key role in influencing adherence to treatment advice as well as improving treatment outcome in psychotherapy and general medicine. Our review indicates that there are also several studies investigating the alliance in a physical rehabilitation setting, the majority of which include patients with musculoskeletal pain conditions. Although a meta-analysis could not be conducted, the results indicate a consistent positive correlation between the alliance and treatment outcomes of pain, disability, physical and mental health, and satisfaction with treatment. The findings also indicate that instruments used to measure the alliance have been developed for assessment in the psychotherapy setting. There is, therefore, an urgent need to develop a measure of the alliance construct that investigates the factors underlying the alliance in the physical rehabilitation setting before meaningful research regarding prediction of treatment outcome can be undertaken. Once appropriate measurement has been established, further prospective longitudinal studies in which the alliance is systematically measured are needed to obtain a more conclusive understanding of the relationship between the alliance and its effect on treatment outcome. The Bottom Line What do we already know about this topic? The therapeutic alliance between a patient and a treatment provider is positively correlated with treatment adherence and outcome in both general medicine and psychotherapy settings. What new information does this study offer? This systematic review found that a positive therapeutic alliance also consistently correlated with improved pain, disability, and treatment satisfaction in physical rehabilitation. However, the retrieved studies used a variety of alliance measures that were developed for use in psychotherapy and have not been tested for reliability and validity in physical rehabilitation. Development of measures validated for physical therapy settings have the potential not only to increase our understanding of interventions but also to increase their effectiveness. If you're a patient, what might these findings mean for you? In order to maximize the benefits of physical therapy, a patient-centered approach is recommended as the basis for the development of a good working relationship between physical therapist and patient, with enhanced effectiveness of communication regarding specific tasks required to achieve treatment goals. " The abstract of this article was presented orally at the Australian Physiotherapy Association Annual Meeting; October 1–5, 2009; Sydney, New South Wales, Australia. * " Thomson Reuters, 2141 Palomar Airport Rd, Suite 350, Carlsbad, CA 92011. References 1 Bordin ES . The generalizability of the psychoanalytic concept of the working alliance . Psychotherapy: Theory, Research, and Practice . 1979 ; 16 : 252 – 260 . 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Google Scholar Google Preview OpenURL Placeholder Text WorldCat COPAC Appendix 1 Search Strategies PsychINFO (therap$ adj5 alli$).mp. (work$ adj5 alli$).mp. trust.mp. (emot$ adj5 Bond$).mp. professional-patient relations.mp. therapist-patient relations.ab,ti,tw. interact.mp. rehab$.mp. Physiotherap$.mp. physical therapy.mp. 8 or 9 or 10 1 or 2 or 3 or 4 or 5 or 6 or 7 11 and 12 from 13 keep 1–10 MEDLINE and EMBASE (therap$ adj5 alli$).mp. (work$ adj5 alli$).mp. trust.mp. (emot$ adj5 Bond$).mp. professional-patient relations.mp. therapist-patient relations.ab,ti,tw. interact.mp. rehab$.mp. Physiotherap$.mp. physical therapy.mp. 8 or 9 or 10 1 or 2 or 3 or 4 or 5 or 6 or 7 11 and 12 CINAHL (therap$ adj5 alli$).mp. (work$ adj5 alli$).mp. trust.mp. (emot$ adj5 Bond$).mp. professional-patient relations.mp. therapist-patient relations.ab,ti,tw. interact.mp. rehab$.mp. Physiotherap$.mp. physical therapy.mp. 8 or 9 or 10 1 or 2 or 3 or 4 or 5 or 6 or 7 11 and 12 PEDro and LILACS search terms used: bond trust alliance in abstract PsychINFO (therap$ adj5 alli$).mp. (work$ adj5 alli$).mp. trust.mp. (emot$ adj5 Bond$).mp. professional-patient relations.mp. therapist-patient relations.ab,ti,tw. interact.mp. rehab$.mp. Physiotherap$.mp. physical therapy.mp. 8 or 9 or 10 1 or 2 or 3 or 4 or 5 or 6 or 7 11 and 12 from 13 keep 1–10 MEDLINE and EMBASE (therap$ adj5 alli$).mp. (work$ adj5 alli$).mp. trust.mp. (emot$ adj5 Bond$).mp. professional-patient relations.mp. therapist-patient relations.ab,ti,tw. interact.mp. rehab$.mp. Physiotherap$.mp. physical therapy.mp. 8 or 9 or 10 1 or 2 or 3 or 4 or 5 or 6 or 7 11 and 12 CINAHL (therap$ adj5 alli$).mp. (work$ adj5 alli$).mp. trust.mp. (emot$ adj5 Bond$).mp. professional-patient relations.mp. therapist-patient relations.ab,ti,tw. interact.mp. rehab$.mp. Physiotherap$.mp. physical therapy.mp. 8 or 9 or 10 1 or 2 or 3 or 4 or 5 or 6 or 7 11 and 12 PEDro and LILACS search terms used: bond trust alliance in abstract Open in new tab Search Strategies PsychINFO (therap$ adj5 alli$).mp. (work$ adj5 alli$).mp. trust.mp. (emot$ adj5 Bond$).mp. professional-patient relations.mp. therapist-patient relations.ab,ti,tw. interact.mp. rehab$.mp. Physiotherap$.mp. physical therapy.mp. 8 or 9 or 10 1 or 2 or 3 or 4 or 5 or 6 or 7 11 and 12 from 13 keep 1–10 MEDLINE and EMBASE (therap$ adj5 alli$).mp. (work$ adj5 alli$).mp. trust.mp. (emot$ adj5 Bond$).mp. professional-patient relations.mp. therapist-patient relations.ab,ti,tw. interact.mp. rehab$.mp. Physiotherap$.mp. physical therapy.mp. 8 or 9 or 10 1 or 2 or 3 or 4 or 5 or 6 or 7 11 and 12 CINAHL (therap$ adj5 alli$).mp. (work$ adj5 alli$).mp. trust.mp. (emot$ adj5 Bond$).mp. professional-patient relations.mp. therapist-patient relations.ab,ti,tw. interact.mp. rehab$.mp. Physiotherap$.mp. physical therapy.mp. 8 or 9 or 10 1 or 2 or 3 or 4 or 5 or 6 or 7 11 and 12 PEDro and LILACS search terms used: bond trust alliance in abstract PsychINFO (therap$ adj5 alli$).mp. (work$ adj5 alli$).mp. trust.mp. (emot$ adj5 Bond$).mp. professional-patient relations.mp. therapist-patient relations.ab,ti,tw. interact.mp. rehab$.mp. Physiotherap$.mp. physical therapy.mp. 8 or 9 or 10 1 or 2 or 3 or 4 or 5 or 6 or 7 11 and 12 from 13 keep 1–10 MEDLINE and EMBASE (therap$ adj5 alli$).mp. (work$ adj5 alli$).mp. trust.mp. (emot$ adj5 Bond$).mp. professional-patient relations.mp. therapist-patient relations.ab,ti,tw. interact.mp. rehab$.mp. Physiotherap$.mp. physical therapy.mp. 8 or 9 or 10 1 or 2 or 3 or 4 or 5 or 6 or 7 11 and 12 CINAHL (therap$ adj5 alli$).mp. (work$ adj5 alli$).mp. trust.mp. (emot$ adj5 Bond$).mp. professional-patient relations.mp. therapist-patient relations.ab,ti,tw. interact.mp. rehab$.mp. Physiotherap$.mp. physical therapy.mp. 8 or 9 or 10 1 or 2 or 3 or 4 or 5 or 6 or 7 11 and 12 PEDro and LILACS search terms used: bond trust alliance in abstract Open in new tab Appendix 2 Detailed Description of Included Studiesa Study . Descriptive Summary of Findings . Schonberger et al (2006)35 Alliance was measured by the therapist retrospectively in December 2002. At this time, follow-up outcome data on the client’s employment and physical activity status also were collected via telephone interview. Alliance was correlated with the follow-up employment and physical activity status, as well as with adherence, during the intervention. Both the physical therapist’s and the neuropsychologist’s ratings of the alliance were significantly related to adherence (Cramer correlations=.76 and .79, P<.001 for both) and employment status (Cramer correlations=.20 [P=.05] and .43 [P<.01]), but neither rating was significantly related to weekly physical training (Cramer correlations=.17 [P=.11] and .17 [P=.10]). (Note: Schonberger et al dichotomized the alliance data into “good or excellent” or “poor or fair” and stated that they used the Cramer statistic, which has been recommended for analysis when a variable has 2 categories.42) Schonberger and colleagues (2006)33,34 The client-rated WAI “bond” subscale score (mean score collected over 4 time points during a 14-week rehabilitation program) was highly correlated with change scores of pretreatment and posttreatment outcomes of depression (r=.60, P=.001) and therapeutic success (r=.63, P=.01), as measured with the European Brain Injury Questionnaire.b (Teasdale 1997). The therapist-rated WAI “bond” subscale score also was correlated with therapeutic success (r=.49, P=.05). Correlations with the other outcomes were not given, and efforts to contact authors for data were unsuccessful. Sherer et al (2007)36 Multivariable linear regression models were used for each outcome with CALPAS-patient, CALPAS-family, and CALPAS-therapist. None of the alliance measures were found to be a significant predictor of functional status at discharge. The patient-rated perception of alliance was negatively associated with program completion (OR=0.93, 95% CI=0.87–0.99, P=.02) and productivity status (OR=0.93, 95% CI=0.88–0.99, P=.02). Contrary to this, the stronger the family-rated alliance, the greater the likelihood of higher productivity status at discharge (OR=1.07, 95% CI=1.00–1.15, P=.05). Contact with the authors also provided Pearson r correlations (P values were not reported) with treatment outcomes for the client-rated CALPAS scores and therapist-rated Prigatano Alliance Scale scores. These results indicate the client-rated alliance was positively correlated with attendance (r=.47) but not with disability (r=−.09) or productivity at discharge (r=−.06), and there was a negative correlation with depression (r=−.17). The therapist-rated alliance scores showed a similar pattern, with a positive correlation with attendance (r=.82) and negative correlations with disability (r=−.31), productivity at discharge (r=−.38), and depression scores (r=−.46). The strength of each of these correlations is consistently greater when the alliance is rated by the therapist, possibly suggesting that perhaps the therapist may overrate the alliance or have an expectation bias that is not shared by the client. However, in this article, the therapists and clients used different scales to rate the alliance, which may account for the difference; the therapists used the Prigatano Alliance Scale, and the clients used the CALPAS scale, and these scales appear to measure slightly different aspects of the alliance. The Prigatano Alliance Scale uses items that are based more on attendance and adherence to treatment recommendations rather than the relationship between therapist and client, as seen in the CALPAS. Ferreira et al (2009)30 Linear regression models were used to investigate the ability of the alliance to predict outcome and response to treatment. Results indicated that the alliance was a significant predictor of global perceived effect (b=0.08, CI=0.03–0.13, P=.001) and physical function (b=0.17, CI=0.07–0.28, P=.001). Beattie et al (2005)28 Pearson r correlations were calculated to measure the association between the alliance and patient satisfaction with treatment. The MedRisk Instrument for Measuring Patient Satisfaction With Physical Therapy Care28 was used, which includes 6 items related to the patient-therapist interaction as internal factors, 3 items related to administration (termed external factors), and 2 items that measure the outcome of patient satisfaction with treatment. The internal factor score was significantly correlated with patient satisfaction (r=.830, P<.01), as was the external factor score (r=.715, P<.01). With regard to the individual items, patient satisfaction correlated strongly with the therapist answering patient’s questions (r=.803, P<.01), the therapist giving detailed instructions regarding home program (r=.768, P<.01), and the therapist respecting the patient (r=.761, P<.01). Higdon (1997)31 Pearson r correlation and multiple regression were used to measure the association between the alliance and the change scores in various physical function tasks. Results indicate a positive correlation varying from r=.09 to r=.27. Alliance also was shown to be a significant predictor of floor-bench lifts (β=0.27). Zaproudina et al (2007)38 Spearman rho correlations were calculated to measure the association of the alliance with global assessment of treatment. The alliance was evaluated by patients using a 5-item questionnaire measuring the therapist’s ability to communicate and to interact with the patient during the treatment sessions. The alliance was significantly correlated with the global assessment scores (r=.36–.47, P<.001). Zaproudina et al (2009)39 Spearman rho correlations were calculated to measure the association between the alliance and global assessment of treatment. The alliance was evaluated by patients using a 5-item questionnaire measuring the therapist’s ability to communicate and to interact with the patient during the treatment sessions. Results indicate a statistically significant correlation between the alliance and global assessment of treatment (r=.28–.30, P<.01), as well as changes in pain (r=.30). Mirsky (2002)32 The alliance was intended to be correlated with outcomes of depression, pain intensity, and general health status, as stated in the methods. However, the results were not reported in the article. Attempts to contact the author for the data were unsuccessful. Burns and Evon (2007)29 The alliance and treatment outcome were measured 3 times: at the beginning of treatment, at the middle of treatment, and at the end of treatment. The authors used 3 subscales of the WAI. They used the “bond” subscale score as one measure of alliance and combined the goal and task subscale scores into one score as a second measure of alliance. For analysis, only change scores of the alliance and change scores of the outcomes were correlated and reported in the results. Therefore, the relationship between the actual alliance score and the change score of the outcomes is not known. Ambady et al (2002)27 Pearson r correlations were calculated to measure the association of treatment outcome with 4 alliance variables. The alliance variables were rated by an observer from video footage of the first or last therapy sessions. Distancing (uninvolved behavior) on part of the physical therapist significantly predicted decreased the patient’s capacity to perform activities of daily living at discharge (r=−.34, P<.01) and at 3-month follow-up (r=−.35, P<.01). Distancing and therapist’s professionalism significantly predicted an increased level of depression at discharge (r=−.27 [P<.05] and r=−.35 [P<.01], respectively). Therapist’s professionalism and nervousness predicted decreases in mobility at the 3-month follow-up (r=−.51 and r=−.52, P<.01). A further analysis of the specific nonverbal behaviors (including smile, frown, nod, head shake, shrug, forward lean, look at, and sit) as predictors of outcome revealed that facial expressiveness (including smiling, nodding, and frowning) was associated with improvements in activities of daily living at discharge (r=.60, P<.001) and at the 3-month follow-up (r=.58, P<.001). Slujis et al (1993)37 The alliance was rated by an observer using an audiotaped physical therapy session. For analysis, the sample was divided into 2 groups based on adherence, and the alliance scores were reported in both groups. The difference between the alliance scores in both groups was not statistically significant (P=.111), and the authors concluded that there was no association with treatment adherence. Walker (1990)40 The electronic search identified the abstract of this study, which is part of an unpublished doctoral dissertation. The abstract states that there several significant correlations between the client-rated working alliance score and both the client-rated and therapist-rated outcome measure scores. However, the abstract provides no information on the alliance tool, type of outcome, or correlation coefficient data. Attempts to contact the author for the full manuscript were unsuccessful. Study . Descriptive Summary of Findings . Schonberger et al (2006)35 Alliance was measured by the therapist retrospectively in December 2002. At this time, follow-up outcome data on the client’s employment and physical activity status also were collected via telephone interview. Alliance was correlated with the follow-up employment and physical activity status, as well as with adherence, during the intervention. Both the physical therapist’s and the neuropsychologist’s ratings of the alliance were significantly related to adherence (Cramer correlations=.76 and .79, P<.001 for both) and employment status (Cramer correlations=.20 [P=.05] and .43 [P<.01]), but neither rating was significantly related to weekly physical training (Cramer correlations=.17 [P=.11] and .17 [P=.10]). (Note: Schonberger et al dichotomized the alliance data into “good or excellent” or “poor or fair” and stated that they used the Cramer statistic, which has been recommended for analysis when a variable has 2 categories.42) Schonberger and colleagues (2006)33,34 The client-rated WAI “bond” subscale score (mean score collected over 4 time points during a 14-week rehabilitation program) was highly correlated with change scores of pretreatment and posttreatment outcomes of depression (r=.60, P=.001) and therapeutic success (r=.63, P=.01), as measured with the European Brain Injury Questionnaire.b (Teasdale 1997). The therapist-rated WAI “bond” subscale score also was correlated with therapeutic success (r=.49, P=.05). Correlations with the other outcomes were not given, and efforts to contact authors for data were unsuccessful. Sherer et al (2007)36 Multivariable linear regression models were used for each outcome with CALPAS-patient, CALPAS-family, and CALPAS-therapist. None of the alliance measures were found to be a significant predictor of functional status at discharge. The patient-rated perception of alliance was negatively associated with program completion (OR=0.93, 95% CI=0.87–0.99, P=.02) and productivity status (OR=0.93, 95% CI=0.88–0.99, P=.02). Contrary to this, the stronger the family-rated alliance, the greater the likelihood of higher productivity status at discharge (OR=1.07, 95% CI=1.00–1.15, P=.05). Contact with the authors also provided Pearson r correlations (P values were not reported) with treatment outcomes for the client-rated CALPAS scores and therapist-rated Prigatano Alliance Scale scores. These results indicate the client-rated alliance was positively correlated with attendance (r=.47) but not with disability (r=−.09) or productivity at discharge (r=−.06), and there was a negative correlation with depression (r=−.17). The therapist-rated alliance scores showed a similar pattern, with a positive correlation with attendance (r=.82) and negative correlations with disability (r=−.31), productivity at discharge (r=−.38), and depression scores (r=−.46). The strength of each of these correlations is consistently greater when the alliance is rated by the therapist, possibly suggesting that perhaps the therapist may overrate the alliance or have an expectation bias that is not shared by the client. However, in this article, the therapists and clients used different scales to rate the alliance, which may account for the difference; the therapists used the Prigatano Alliance Scale, and the clients used the CALPAS scale, and these scales appear to measure slightly different aspects of the alliance. The Prigatano Alliance Scale uses items that are based more on attendance and adherence to treatment recommendations rather than the relationship between therapist and client, as seen in the CALPAS. Ferreira et al (2009)30 Linear regression models were used to investigate the ability of the alliance to predict outcome and response to treatment. Results indicated that the alliance was a significant predictor of global perceived effect (b=0.08, CI=0.03–0.13, P=.001) and physical function (b=0.17, CI=0.07–0.28, P=.001). Beattie et al (2005)28 Pearson r correlations were calculated to measure the association between the alliance and patient satisfaction with treatment. The MedRisk Instrument for Measuring Patient Satisfaction With Physical Therapy Care28 was used, which includes 6 items related to the patient-therapist interaction as internal factors, 3 items related to administration (termed external factors), and 2 items that measure the outcome of patient satisfaction with treatment. The internal factor score was significantly correlated with patient satisfaction (r=.830, P<.01), as was the external factor score (r=.715, P<.01). With regard to the individual items, patient satisfaction correlated strongly with the therapist answering patient’s questions (r=.803, P<.01), the therapist giving detailed instructions regarding home program (r=.768, P<.01), and the therapist respecting the patient (r=.761, P<.01). Higdon (1997)31 Pearson r correlation and multiple regression were used to measure the association between the alliance and the change scores in various physical function tasks. Results indicate a positive correlation varying from r=.09 to r=.27. Alliance also was shown to be a significant predictor of floor-bench lifts (β=0.27). Zaproudina et al (2007)38 Spearman rho correlations were calculated to measure the association of the alliance with global assessment of treatment. The alliance was evaluated by patients using a 5-item questionnaire measuring the therapist’s ability to communicate and to interact with the patient during the treatment sessions. The alliance was significantly correlated with the global assessment scores (r=.36–.47, P<.001). Zaproudina et al (2009)39 Spearman rho correlations were calculated to measure the association between the alliance and global assessment of treatment. The alliance was evaluated by patients using a 5-item questionnaire measuring the therapist’s ability to communicate and to interact with the patient during the treatment sessions. Results indicate a statistically significant correlation between the alliance and global assessment of treatment (r=.28–.30, P<.01), as well as changes in pain (r=.30). Mirsky (2002)32 The alliance was intended to be correlated with outcomes of depression, pain intensity, and general health status, as stated in the methods. However, the results were not reported in the article. Attempts to contact the author for the data were unsuccessful. Burns and Evon (2007)29 The alliance and treatment outcome were measured 3 times: at the beginning of treatment, at the middle of treatment, and at the end of treatment. The authors used 3 subscales of the WAI. They used the “bond” subscale score as one measure of alliance and combined the goal and task subscale scores into one score as a second measure of alliance. For analysis, only change scores of the alliance and change scores of the outcomes were correlated and reported in the results. Therefore, the relationship between the actual alliance score and the change score of the outcomes is not known. Ambady et al (2002)27 Pearson r correlations were calculated to measure the association of treatment outcome with 4 alliance variables. The alliance variables were rated by an observer from video footage of the first or last therapy sessions. Distancing (uninvolved behavior) on part of the physical therapist significantly predicted decreased the patient’s capacity to perform activities of daily living at discharge (r=−.34, P<.01) and at 3-month follow-up (r=−.35, P<.01). Distancing and therapist’s professionalism significantly predicted an increased level of depression at discharge (r=−.27 [P<.05] and r=−.35 [P<.01], respectively). Therapist’s professionalism and nervousness predicted decreases in mobility at the 3-month follow-up (r=−.51 and r=−.52, P<.01). A further analysis of the specific nonverbal behaviors (including smile, frown, nod, head shake, shrug, forward lean, look at, and sit) as predictors of outcome revealed that facial expressiveness (including smiling, nodding, and frowning) was associated with improvements in activities of daily living at discharge (r=.60, P<.001) and at the 3-month follow-up (r=.58, P<.001). Slujis et al (1993)37 The alliance was rated by an observer using an audiotaped physical therapy session. For analysis, the sample was divided into 2 groups based on adherence, and the alliance scores were reported in both groups. The difference between the alliance scores in both groups was not statistically significant (P=.111), and the authors concluded that there was no association with treatment adherence. Walker (1990)40 The electronic search identified the abstract of this study, which is part of an unpublished doctoral dissertation. The abstract states that there several significant correlations between the client-rated working alliance score and both the client-rated and therapist-rated outcome measure scores. However, the abstract provides no information on the alliance tool, type of outcome, or correlation coefficient data. Attempts to contact the author for the full manuscript were unsuccessful. a WAI=Working Alliance Inventory, CALPAS=California Psychotherapy Alliance Scale, OR=odds ratio, 95% CI=95% confidence interval. b Teasdale TW, Christensen AL, Willmes K, et al. Subjective experience in brain-injured patients and their close relatives: a European Brain Injury Questionnaire study. Brain Inj. 1997;11:543–563. Open in new tab Detailed Description of Included Studiesa Study . Descriptive Summary of Findings . Schonberger et al (2006)35 Alliance was measured by the therapist retrospectively in December 2002. At this time, follow-up outcome data on the client’s employment and physical activity status also were collected via telephone interview. Alliance was correlated with the follow-up employment and physical activity status, as well as with adherence, during the intervention. Both the physical therapist’s and the neuropsychologist’s ratings of the alliance were significantly related to adherence (Cramer correlations=.76 and .79, P<.001 for both) and employment status (Cramer correlations=.20 [P=.05] and .43 [P<.01]), but neither rating was significantly related to weekly physical training (Cramer correlations=.17 [P=.11] and .17 [P=.10]). (Note: Schonberger et al dichotomized the alliance data into “good or excellent” or “poor or fair” and stated that they used the Cramer statistic, which has been recommended for analysis when a variable has 2 categories.42) Schonberger and colleagues (2006)33,34 The client-rated WAI “bond” subscale score (mean score collected over 4 time points during a 14-week rehabilitation program) was highly correlated with change scores of pretreatment and posttreatment outcomes of depression (r=.60, P=.001) and therapeutic success (r=.63, P=.01), as measured with the European Brain Injury Questionnaire.b (Teasdale 1997). The therapist-rated WAI “bond” subscale score also was correlated with therapeutic success (r=.49, P=.05). Correlations with the other outcomes were not given, and efforts to contact authors for data were unsuccessful. Sherer et al (2007)36 Multivariable linear regression models were used for each outcome with CALPAS-patient, CALPAS-family, and CALPAS-therapist. None of the alliance measures were found to be a significant predictor of functional status at discharge. The patient-rated perception of alliance was negatively associated with program completion (OR=0.93, 95% CI=0.87–0.99, P=.02) and productivity status (OR=0.93, 95% CI=0.88–0.99, P=.02). Contrary to this, the stronger the family-rated alliance, the greater the likelihood of higher productivity status at discharge (OR=1.07, 95% CI=1.00–1.15, P=.05). Contact with the authors also provided Pearson r correlations (P values were not reported) with treatment outcomes for the client-rated CALPAS scores and therapist-rated Prigatano Alliance Scale scores. These results indicate the client-rated alliance was positively correlated with attendance (r=.47) but not with disability (r=−.09) or productivity at discharge (r=−.06), and there was a negative correlation with depression (r=−.17). The therapist-rated alliance scores showed a similar pattern, with a positive correlation with attendance (r=.82) and negative correlations with disability (r=−.31), productivity at discharge (r=−.38), and depression scores (r=−.46). The strength of each of these correlations is consistently greater when the alliance is rated by the therapist, possibly suggesting that perhaps the therapist may overrate the alliance or have an expectation bias that is not shared by the client. However, in this article, the therapists and clients used different scales to rate the alliance, which may account for the difference; the therapists used the Prigatano Alliance Scale, and the clients used the CALPAS scale, and these scales appear to measure slightly different aspects of the alliance. The Prigatano Alliance Scale uses items that are based more on attendance and adherence to treatment recommendations rather than the relationship between therapist and client, as seen in the CALPAS. Ferreira et al (2009)30 Linear regression models were used to investigate the ability of the alliance to predict outcome and response to treatment. Results indicated that the alliance was a significant predictor of global perceived effect (b=0.08, CI=0.03–0.13, P=.001) and physical function (b=0.17, CI=0.07–0.28, P=.001). Beattie et al (2005)28 Pearson r correlations were calculated to measure the association between the alliance and patient satisfaction with treatment. The MedRisk Instrument for Measuring Patient Satisfaction With Physical Therapy Care28 was used, which includes 6 items related to the patient-therapist interaction as internal factors, 3 items related to administration (termed external factors), and 2 items that measure the outcome of patient satisfaction with treatment. The internal factor score was significantly correlated with patient satisfaction (r=.830, P<.01), as was the external factor score (r=.715, P<.01). With regard to the individual items, patient satisfaction correlated strongly with the therapist answering patient’s questions (r=.803, P<.01), the therapist giving detailed instructions regarding home program (r=.768, P<.01), and the therapist respecting the patient (r=.761, P<.01). Higdon (1997)31 Pearson r correlation and multiple regression were used to measure the association between the alliance and the change scores in various physical function tasks. Results indicate a positive correlation varying from r=.09 to r=.27. Alliance also was shown to be a significant predictor of floor-bench lifts (β=0.27). Zaproudina et al (2007)38 Spearman rho correlations were calculated to measure the association of the alliance with global assessment of treatment. The alliance was evaluated by patients using a 5-item questionnaire measuring the therapist’s ability to communicate and to interact with the patient during the treatment sessions. The alliance was significantly correlated with the global assessment scores (r=.36–.47, P<.001). Zaproudina et al (2009)39 Spearman rho correlations were calculated to measure the association between the alliance and global assessment of treatment. The alliance was evaluated by patients using a 5-item questionnaire measuring the therapist’s ability to communicate and to interact with the patient during the treatment sessions. Results indicate a statistically significant correlation between the alliance and global assessment of treatment (r=.28–.30, P<.01), as well as changes in pain (r=.30). Mirsky (2002)32 The alliance was intended to be correlated with outcomes of depression, pain intensity, and general health status, as stated in the methods. However, the results were not reported in the article. Attempts to contact the author for the data were unsuccessful. Burns and Evon (2007)29 The alliance and treatment outcome were measured 3 times: at the beginning of treatment, at the middle of treatment, and at the end of treatment. The authors used 3 subscales of the WAI. They used the “bond” subscale score as one measure of alliance and combined the goal and task subscale scores into one score as a second measure of alliance. For analysis, only change scores of the alliance and change scores of the outcomes were correlated and reported in the results. Therefore, the relationship between the actual alliance score and the change score of the outcomes is not known. Ambady et al (2002)27 Pearson r correlations were calculated to measure the association of treatment outcome with 4 alliance variables. The alliance variables were rated by an observer from video footage of the first or last therapy sessions. Distancing (uninvolved behavior) on part of the physical therapist significantly predicted decreased the patient’s capacity to perform activities of daily living at discharge (r=−.34, P<.01) and at 3-month follow-up (r=−.35, P<.01). Distancing and therapist’s professionalism significantly predicted an increased level of depression at discharge (r=−.27 [P<.05] and r=−.35 [P<.01], respectively). Therapist’s professionalism and nervousness predicted decreases in mobility at the 3-month follow-up (r=−.51 and r=−.52, P<.01). A further analysis of the specific nonverbal behaviors (including smile, frown, nod, head shake, shrug, forward lean, look at, and sit) as predictors of outcome revealed that facial expressiveness (including smiling, nodding, and frowning) was associated with improvements in activities of daily living at discharge (r=.60, P<.001) and at the 3-month follow-up (r=.58, P<.001). Slujis et al (1993)37 The alliance was rated by an observer using an audiotaped physical therapy session. For analysis, the sample was divided into 2 groups based on adherence, and the alliance scores were reported in both groups. The difference between the alliance scores in both groups was not statistically significant (P=.111), and the authors concluded that there was no association with treatment adherence. Walker (1990)40 The electronic search identified the abstract of this study, which is part of an unpublished doctoral dissertation. The abstract states that there several significant correlations between the client-rated working alliance score and both the client-rated and therapist-rated outcome measure scores. However, the abstract provides no information on the alliance tool, type of outcome, or correlation coefficient data. Attempts to contact the author for the full manuscript were unsuccessful. Study . Descriptive Summary of Findings . Schonberger et al (2006)35 Alliance was measured by the therapist retrospectively in December 2002. At this time, follow-up outcome data on the client’s employment and physical activity status also were collected via telephone interview. Alliance was correlated with the follow-up employment and physical activity status, as well as with adherence, during the intervention. Both the physical therapist’s and the neuropsychologist’s ratings of the alliance were significantly related to adherence (Cramer correlations=.76 and .79, P<.001 for both) and employment status (Cramer correlations=.20 [P=.05] and .43 [P<.01]), but neither rating was significantly related to weekly physical training (Cramer correlations=.17 [P=.11] and .17 [P=.10]). (Note: Schonberger et al dichotomized the alliance data into “good or excellent” or “poor or fair” and stated that they used the Cramer statistic, which has been recommended for analysis when a variable has 2 categories.42) Schonberger and colleagues (2006)33,34 The client-rated WAI “bond” subscale score (mean score collected over 4 time points during a 14-week rehabilitation program) was highly correlated with change scores of pretreatment and posttreatment outcomes of depression (r=.60, P=.001) and therapeutic success (r=.63, P=.01), as measured with the European Brain Injury Questionnaire.b (Teasdale 1997). The therapist-rated WAI “bond” subscale score also was correlated with therapeutic success (r=.49, P=.05). Correlations with the other outcomes were not given, and efforts to contact authors for data were unsuccessful. Sherer et al (2007)36 Multivariable linear regression models were used for each outcome with CALPAS-patient, CALPAS-family, and CALPAS-therapist. None of the alliance measures were found to be a significant predictor of functional status at discharge. The patient-rated perception of alliance was negatively associated with program completion (OR=0.93, 95% CI=0.87–0.99, P=.02) and productivity status (OR=0.93, 95% CI=0.88–0.99, P=.02). Contrary to this, the stronger the family-rated alliance, the greater the likelihood of higher productivity status at discharge (OR=1.07, 95% CI=1.00–1.15, P=.05). Contact with the authors also provided Pearson r correlations (P values were not reported) with treatment outcomes for the client-rated CALPAS scores and therapist-rated Prigatano Alliance Scale scores. These results indicate the client-rated alliance was positively correlated with attendance (r=.47) but not with disability (r=−.09) or productivity at discharge (r=−.06), and there was a negative correlation with depression (r=−.17). The therapist-rated alliance scores showed a similar pattern, with a positive correlation with attendance (r=.82) and negative correlations with disability (r=−.31), productivity at discharge (r=−.38), and depression scores (r=−.46). The strength of each of these correlations is consistently greater when the alliance is rated by the therapist, possibly suggesting that perhaps the therapist may overrate the alliance or have an expectation bias that is not shared by the client. However, in this article, the therapists and clients used different scales to rate the alliance, which may account for the difference; the therapists used the Prigatano Alliance Scale, and the clients used the CALPAS scale, and these scales appear to measure slightly different aspects of the alliance. The Prigatano Alliance Scale uses items that are based more on attendance and adherence to treatment recommendations rather than the relationship between therapist and client, as seen in the CALPAS. Ferreira et al (2009)30 Linear regression models were used to investigate the ability of the alliance to predict outcome and response to treatment. Results indicated that the alliance was a significant predictor of global perceived effect (b=0.08, CI=0.03–0.13, P=.001) and physical function (b=0.17, CI=0.07–0.28, P=.001). Beattie et al (2005)28 Pearson r correlations were calculated to measure the association between the alliance and patient satisfaction with treatment. The MedRisk Instrument for Measuring Patient Satisfaction With Physical Therapy Care28 was used, which includes 6 items related to the patient-therapist interaction as internal factors, 3 items related to administration (termed external factors), and 2 items that measure the outcome of patient satisfaction with treatment. The internal factor score was significantly correlated with patient satisfaction (r=.830, P<.01), as was the external factor score (r=.715, P<.01). With regard to the individual items, patient satisfaction correlated strongly with the therapist answering patient’s questions (r=.803, P<.01), the therapist giving detailed instructions regarding home program (r=.768, P<.01), and the therapist respecting the patient (r=.761, P<.01). Higdon (1997)31 Pearson r correlation and multiple regression were used to measure the association between the alliance and the change scores in various physical function tasks. Results indicate a positive correlation varying from r=.09 to r=.27. Alliance also was shown to be a significant predictor of floor-bench lifts (β=0.27). Zaproudina et al (2007)38 Spearman rho correlations were calculated to measure the association of the alliance with global assessment of treatment. The alliance was evaluated by patients using a 5-item questionnaire measuring the therapist’s ability to communicate and to interact with the patient during the treatment sessions. The alliance was significantly correlated with the global assessment scores (r=.36–.47, P<.001). Zaproudina et al (2009)39 Spearman rho correlations were calculated to measure the association between the alliance and global assessment of treatment. The alliance was evaluated by patients using a 5-item questionnaire measuring the therapist’s ability to communicate and to interact with the patient during the treatment sessions. Results indicate a statistically significant correlation between the alliance and global assessment of treatment (r=.28–.30, P<.01), as well as changes in pain (r=.30). Mirsky (2002)32 The alliance was intended to be correlated with outcomes of depression, pain intensity, and general health status, as stated in the methods. However, the results were not reported in the article. Attempts to contact the author for the data were unsuccessful. Burns and Evon (2007)29 The alliance and treatment outcome were measured 3 times: at the beginning of treatment, at the middle of treatment, and at the end of treatment. The authors used 3 subscales of the WAI. They used the “bond” subscale score as one measure of alliance and combined the goal and task subscale scores into one score as a second measure of alliance. For analysis, only change scores of the alliance and change scores of the outcomes were correlated and reported in the results. Therefore, the relationship between the actual alliance score and the change score of the outcomes is not known. Ambady et al (2002)27 Pearson r correlations were calculated to measure the association of treatment outcome with 4 alliance variables. The alliance variables were rated by an observer from video footage of the first or last therapy sessions. Distancing (uninvolved behavior) on part of the physical therapist significantly predicted decreased the patient’s capacity to perform activities of daily living at discharge (r=−.34, P<.01) and at 3-month follow-up (r=−.35, P<.01). Distancing and therapist’s professionalism significantly predicted an increased level of depression at discharge (r=−.27 [P<.05] and r=−.35 [P<.01], respectively). Therapist’s professionalism and nervousness predicted decreases in mobility at the 3-month follow-up (r=−.51 and r=−.52, P<.01). A further analysis of the specific nonverbal behaviors (including smile, frown, nod, head shake, shrug, forward lean, look at, and sit) as predictors of outcome revealed that facial expressiveness (including smiling, nodding, and frowning) was associated with improvements in activities of daily living at discharge (r=.60, P<.001) and at the 3-month follow-up (r=.58, P<.001). Slujis et al (1993)37 The alliance was rated by an observer using an audiotaped physical therapy session. For analysis, the sample was divided into 2 groups based on adherence, and the alliance scores were reported in both groups. The difference between the alliance scores in both groups was not statistically significant (P=.111), and the authors concluded that there was no association with treatment adherence. Walker (1990)40 The electronic search identified the abstract of this study, which is part of an unpublished doctoral dissertation. The abstract states that there several significant correlations between the client-rated working alliance score and both the client-rated and therapist-rated outcome measure scores. However, the abstract provides no information on the alliance tool, type of outcome, or correlation coefficient data. Attempts to contact the author for the full manuscript were unsuccessful. a WAI=Working Alliance Inventory, CALPAS=California Psychotherapy Alliance Scale, OR=odds ratio, 95% CI=95% confidence interval. b Teasdale TW, Christensen AL, Willmes K, et al. Subjective experience in brain-injured patients and their close relatives: a European Brain Injury Questionnaire study. Brain Inj. 1997;11:543–563. Open in new tab Author notes " All authors provided concept/idea/research design. Ms Hall, Dr P.H. Ferreira, and Professor Maher provided writing. Ms Hall, Dr P.H. Ferreira, Professor Maher, and Dr M.L. Ferreira provided data collection and analysis. Professor Maher provided project management. Dr Latimer provided facilities/equipment. Dr P.H. Ferreira, Professor Maher, Dr Latimer, and Dr M.L. Ferreira provided consultation (including review of manuscript before submission). © 2010 American Physical Therapy Association

Rutten, Geert, M.;Degen,, Saskia;Hendriks, Erik, J.;Braspenning, Jozé, C.;Harting,, Janneke;Oostendorp, Rob, A.

doi: 10.2522/ptj.20090173pmid: 20488978

Background Various guidelines for the management of low back pain have been developed to enhance the effectiveness and efficiency of care. Evidence that guideline-adherent care results in better health outcomes, however, is not conclusive. Objective The main objective of this study was to assess whether a higher percentage of adherence to the Dutch physical and manual therapy guidelines for low back pain is related to improved outcomes. The study further explored whether this relationship differs for the individual steps of the process of care and for distinct subgroups of patients. Design This was an observational prospective cohort study (2005–2006) in the Netherlands that included a sample of 61 private practice therapists and 145 patients. Methods Therapists recorded the process of care and the number of treatment sessions in Web-based patient files. Guideline adherence was assessed using quality indicators. Physical functioning was measured by the Dutch version of the Quebec Back Pain and Disability Scale, and average pain was measured with a visual analog scale. Relationships between the percentage of guideline adherence and outcomes of care were evaluated with regression analyses. Results Higher percentages of adherence were associated with fewer functional limitations (β=−0.21, P=.023) and fewer treatment sessions (β=−0.27, P=.005). Limitations The relatively small self-selected sample might limit external validity, but it is not expected that the small sample greatly influenced the internal validity of the study. Larger samples are required to enable adequate subgroup analyses. Conclusions The results indicate that higher percentages of guideline adherence are related to better improvement of physical functioning and to a lower utilization of care. A proper assessment of the relationship between the process of physical therapy care and outcomes may require a comprehensive set of process indicators to measure guideline adherence. Low back pain can be seen as a largely self-limiting problem, considering the improvements in pain and disability in the first 3 months after onset.1 Once the back pain becomes recurrent or chronic, it is associated with long-term disability and, consequently, with a significant socioeconomic burden: about 80% of health care and social costs related to low back pain are attributed to the 10% of patients with chronic pain and disability.2 The management of low back pain in primary care varies substantially among medical and health care professionals within a country,3 as well as among countries.4 Various guidelines for the management of low back pain have been developed to enhance the effectiveness and efficiency of care.4–7 Because these guidelines are based on a combination of evidence and consensus among experts, it is assumed that guideline adherence will improve the quality of care. However, a review of studies in professions allied to medicine showed only limited evidence for a favorable relationship between guideline adherence and health outcomes and could not draw firm conclusions due to the poor methods of the studies.8 Another review that assessed the effectiveness of tailored interventions to change physicians’ performance and the effects on health outcomes found no consistency in the results and concluded that the effect remained uncertain.9 Despite these findings, there is some evidence that greater guideline adherence in the treatment of patients with low back pain might be advantageous from a cost perspective.7,10,11 The number of studies examining the relationship between guideline adherence and clinical outcomes so far has been limited.12 In addition, previous studies10,11,13 used a limited number of criteria to evaluate the management of low back pain by physical therapists, for instance, 4 criteria focusing on treatment aim, number of sessions, use of active interventions, and providing adequate advice13 or the single criterion of whether an activating treatment is applied.11 However, the comprehensiveness of the physical therapy process of care for patients with low back pain generally leads to a large number of guideline recommendations. Translation of these guideline recommendations into a set of quality indicators makes the various aspects of the process of care measurable14–16 and, therefore, might yield a more valid impression of routine physical therapist practice. Consequently, using a set of quality indicators might enable a more legitimate assessment of the relationship between guideline adherence and the effectiveness and utilization of care. The main objective of the present study was to assess whether a higher percentage of adherence to the recommendations of the Dutch physical therapy guideline for nonspecific low back pain5 and the Dutch manual therapy guideline for nonspecific low back pain6 (subsequently referred to as low back pain) is related to improved outcomes of care. As the primary focus of the guidelines is to restore physical functioning and social participation, we expected that a higher percentage of adherence to the guideline recommendations, in the short term, would be especially associated with improved physical functioning and, to a lesser extent, with a decrease in pain. The second objective was to explore whether this relationship was equal for different subgroups of patients. Because another focal point of the guidelines is the role of psychosocial factors that could impede patients’ recovery process, we hypothesized that in particular patients with chronic low back pain would benefit from higher levels of guideline-adherent care. The final objective was to explore to what extent the level of adherence to the individual steps in the process of care, distinguished in the guidelines, differed in their relationship to health-related outcomes. Method Study Design and Study Sample Data were collected in an observational prospective cohort study from September 2005 to February 2006. Private practices in the south of the Netherlands were invited to participate if they had a contract with the commissioning health insurance company, had a minimum of 2,000 treatment sessions a year, and employed at least 3 physical therapists. Invitations were sent to 442 eligible practices (Figure). After attending a general information meeting, during which the aim and design of the study were explained and a Web-based patient documentation system (Web-based EPD) was demonstrated, 233 physical therapists and manual physical therapists from 122 practices were preregistered for participation. Therapists were eligible for participation if they were willing to include at least 5 consecutive patients in the study during the enrollment period. They were instructed to ask the first patient of each week to participate and to encourage the patients to complete the questionnaires used to measure the health-related outcomes. Figure Open in new tabDownload slide Flow chart of participants’ responses and reasons for nonresponse and dropout. Figure Open in new tabDownload slide Flow chart of participants’ responses and reasons for nonresponse and dropout. Of the 98 physical therapists who started to record the care provided to patients, 77 produced 231 complete patient records. The final sample consisted of 61 physical therapists and 145 patients for whom a complete patient record was available and who additionally completed the outcome questionnaires at baseline (ie, before treatment) and after treatment. Reasons for nonresponse and dropout are listed in the Figure. Patients who enrolled in the study had been referred for physical therapy intervention by a general practitioner or a medical specialist due to a primary or recurrent episode of low back pain. No rigorous inclusion criteria concerning the low back pain were applied in order to include a group of patients who reflected the nonspecific low back pain population in daily practice. The patients were diagnosed with nonspecific low back pain by the physical therapists. Nonspecific low back pain is defined as low back pain without a specified physical cause (eg, nerve root compression, trauma, infection, tumor).17 Patients were included only if they were able to read and understand Dutch. Patients received verbal and written information on all aspects of the study and gave written consent at their inclusion. Measurement The use of quality indicators to measure the performance of health care professionals is a common approach in various medical disciplines.18,19 We, therefore, developed a set of quality indicators to measure the percentage of guideline adherence for the present study. Quality indicators have been defined as measurable elements of practice performance for which there is evidence or consensus that they can be used to assess the quality, and thus change the quality, of care provided.20 They are related to structures, processes, or outcomes of care.21 The present study focused on process and outcome indicators, which were based on the recommendations for each of the steps of the diagnostic and treatment process of care as described in the Dutch physical therapy and manual therapy guidelines for low back pain (see eAppendix 1 available at ptjournal.apta.org). The set was developed in an iterative consensus procedure (for a detailed description, see eAppendix 2 available at ptjournal.apta.org). The application of such a procedure is expected to result in a set of indicators with content validity.14 Various quality requirements, such as relevance, reliability, and feasibility, were taken into account.14,16 Process indicators were directly derived from a Web-based EPD, which was developed for this purpose (see eAppendix 2) because the quality of ordinary patient registration generally is poor.22,23 The EPD replaced the usual patient file of the participating physical therapists. During the patients’ visits, the therapists recorded their actual proceedings for the diagnostic and treatment process (see eAppendix 1). Algorithms that followed the decision process of the guidelines were formulated for every indicator in order to transform the data on the process of care recorded in the EPD into indicator scores.14 One point was scored for each process indicator that was adhered to. The overall percentage of guideline adherence and the percentages of adherence for the various steps of the therapeutic process were calculated using the “patient average method.”24 In this method, the percentage of indicators that are successfully met for each patient are computed. These scores then are averaged across all patients. The automated scoring procedure, implemented through the Web-based EPD, was assumed to avoid issues of intraobserver and interobserver reliability.14 The outcome indicator of physical functioning was measured by means of the Dutch version of the Quebec Back Pain and Disability Scale (QBPDS), a 20-item self-report questionnaire with a score ranging from 0 to 100.25 A higher score on the QBPDS means more limitations. The QBPDS has construct validity (r=.80–.91 with the Roland Disability Questionnaire) and test-retest reliability (intraclass correlation coefficient=.90) for patients with chronic low back pain.25 Average pain was measured with a visual analog scale (VAS),26 which scored the level of pain in millimeters, with 0 mm for no pain and 100 mm for unbearable pain. The VAS has construct validity (r=.91 with a numerical pain rating scale)27 and high test-retest reliability (intraclass correlation coefficient=.97).28 The number of treatment sessions was scored as reported in the Web-based EPD. Demographic variables of the physical therapists, such as age, sex, practice experience, and work situation, were recorded in the EPD. The same was done with the patients’ age, sex, employment situation, educational level, and living conditions. Because the transition from acute to persistent low back pain is supposed to be influenced by psychosocial factors such as coping and catastrophizing,29 the Pain Coping and Cognition List (PCCL) was included in the EPD. The PCCL is a 42-item self-report questionnaire, in Dutch, developed to assess pain coping, internal and external pain control perceptions, and catastrophizing. The score per subscale ranges from 1 to 6. A higher score on a subscale means a higher extent of pain coping, internal or external pain control perceptions, or catastrophizing. The internal consistency of the 4 subscales is high (Cronbach alpha=.80–.84). Based on correlations with various other measurement instruments for these constructs (r≥.30), the PCCL shows acceptable validity.30 Data Analysis Descriptive statistics were used to assess the percentage of overall adherence and the percentage of adherence for each step of the diagnostic and treatment processes. The effectiveness of the treatment was assessed by comparing the pretreatment and posttreatment scores for the outcome indicators using a paired-samples t test. The relationship between the percentage of guideline adherence and outcome indicators was determined with multiple linear regression analyses. To avoid overfitting of the model due to the relatively small sample, we applied the full model approach, meaning that all independent variables were entered in the model and that no exclusion of variables was allowed on the basis of statistical calculations.31,32 To avoid bias due to regression to the mean, instead of using change scores as dependent variables, the use of analysis of covariance has been recommended.33,34 In analysis of covariance, posttreatment scores are included as dependent variables and pretreatment scores are entered as covariates. The percentage of guideline adherence was entered as the main independent variable. The pretreatment scores on 2 of the outcome variables, the QBPDS and the VAS, were included as covariates, along with other variables that have repeatedly been identified as prognostic factors for health outcomes, persistent disability, or the transition from acute to persistent disability due to low back pain, that is: the duration of the current episode of low back pain (<1 week, >5 years), the extent of catastrophizing,29,35 the patient's age,35,36 and having a paid job (yes/no).35 Because clinical expertise has been shown to be related to better diagnostic37 and treatment38 success, the extent of the therapist's practice experience (<5 years, >30 years) also was included. As recommended in the guidelines, we also added the psychosocial variables of external pain control perceptions and coping. A similar procedure was followed for the number of treatment sessions as the third outcome variable. Based on previous findings,39 external pain control perceptions, coping, and having a paid job were excluded from the model, and having received previous physical therapy treatment (yes/no), the patient's sex, and the therapist's working hours (full-time, part-time) were included. The association between the percentage adherence to the various steps of the care process and the outcome indicators was explored in regression analyses for every step separately. Posttreatment scores on the outcome indicators were used as the dependent variable, and the percentages of guideline adherence for each of the steps as the independent variable. The pretreatment scores on health-related outcomes were entered as a covariate in the analyses. The limited number of cases in the subgroups made us use nonparametric statistics to further explore the association between the percentage of overall guideline adherence and the outcome indicators for the subgroups of patients with acute (6 weeks), subacute (6–12 weeks), and chronic (12 weeks) low back pain. Thus, our analyses were based on the median percentage of guideline adherence, and we used Spearman correlations instead of multiple linear regression analyses to assess the relationship between the percentage of guideline adherence and the absolute change scores of the health outcomes. All statistical analyses were performed using SPSS version 15 for Windows.* Cohen's classification for the behavioral sciences was used as a criterion for the effect size of the correlation: rs=.10 is small, rs=.30 is medium, and rs=.50 is large.40 Role of the Funding Source The study was funded by CZ, a health insurance company in the Netherlands. Results Responses and Characteristics of Participants The physical therapists (n=61) were an average of 42 years of age, 67% were male, and 66% owned their practice. The median practice experience was 16 to 20 years. The mean age of the patients (n=145) was 48 years, 51% were male, and 57% had a lower-to-average educational level. They were diagnosed by the physical therapists as having acute (50.4%), subacute (23.3%), or chronic (24.8%) low back pain. The remaining 1.5% of the patients could not be classified. Adherence The mean overall guideline adherence was 67.2% (Tab. 1), meaning that, on average, physical therapists had positive scores on nearly 17 of the 25 indicators per patient. Adherence rates were less than 55% in 8.8% of the cases and higher than 75% in 34.3% of the cases. The percentage of adherence ranged from 2.2% to 99.3% for the individual steps of the diagnostic process and from 47.5% to 88.1% for the individual steps of the therapeutic process. We did not find higher percentages of adherence for those steps of the care process that included indicators with higher levels of evidence. Table 1 Individual Quality Indicators per Step of the Process of Care, Their Level of Evidence, and the Mean Percentage of Adherence for the Entire Therapeutic Process and for the Individual Steps . Level of Evidencea . % Adherence (SD) . Entire therapeutic process 67.2 (8.6) Phases of therapeutic process/individual steps (no. of indicators)  Diagnostic phase   1 Referral (1) 2.2 (14.7)    Contact physician if information on referral is lacking (eg, reason for referral, medical examination data, indication for physical therapy or manual therapy) IV   2 History taking (7) 60.5 (10.1)    Assessment of patient’s specific request for help IV    Use of ICFb III    Use of measurement instrument II    Assessment of low back pain course IV    Assessment of “yellow flags” and coping strategies IV    Presence of “red flags” IV    Assessment of supplementary treatment IV   3 Patient profile (2) 99.3 (6.0)    Assessment of patient profile II    Contact physician in case of contraindications IV   4 Examination objectives (1) 32.8 (47.1)    Examination objectives in agreement with patient profile IV   5 Examination (1) 45.5 (50.0)    Examination performed in agreement with objectives II–IV   6 Analysis (3) 91.5 (14.6)    Assessment of indication for physical therapy IV    Indication of prognosis III    Referral to physician in case of insufficient results or if no results are expected IV  Treatment phase   7 Treatment plan (2) 47.5 (33.4)    Treatment plan in agreement with patient profile III    Patient participation in treatment plan III   8 Treatment (2) 55.1 (38.0)    Treatment strategies in agreement with patient profile I-II    No. of sessions in agreement with patient profile IV   9 Evaluation (4) 88.1 (19.9)    Regular/systematic evaluation of treatment objectives IV    Adjustment of treatment objectives, if necessary IV    Contact physician in case of insufficient results IV    Final evaluation on the basis of treatment objectives (with measurement instruments) IV(II)   10 Closure (2) 73.4 (31.5)    Written report to referring physician IV    Arrangement of aftercare IV . Level of Evidencea . % Adherence (SD) . Entire therapeutic process 67.2 (8.6) Phases of therapeutic process/individual steps (no. of indicators)  Diagnostic phase   1 Referral (1) 2.2 (14.7)    Contact physician if information on referral is lacking (eg, reason for referral, medical examination data, indication for physical therapy or manual therapy) IV   2 History taking (7) 60.5 (10.1)    Assessment of patient’s specific request for help IV    Use of ICFb III    Use of measurement instrument II    Assessment of low back pain course IV    Assessment of “yellow flags” and coping strategies IV    Presence of “red flags” IV    Assessment of supplementary treatment IV   3 Patient profile (2) 99.3 (6.0)    Assessment of patient profile II    Contact physician in case of contraindications IV   4 Examination objectives (1) 32.8 (47.1)    Examination objectives in agreement with patient profile IV   5 Examination (1) 45.5 (50.0)    Examination performed in agreement with objectives II–IV   6 Analysis (3) 91.5 (14.6)    Assessment of indication for physical therapy IV    Indication of prognosis III    Referral to physician in case of insufficient results or if no results are expected IV  Treatment phase   7 Treatment plan (2) 47.5 (33.4)    Treatment plan in agreement with patient profile III    Patient participation in treatment plan III   8 Treatment (2) 55.1 (38.0)    Treatment strategies in agreement with patient profile I-II    No. of sessions in agreement with patient profile IV   9 Evaluation (4) 88.1 (19.9)    Regular/systematic evaluation of treatment objectives IV    Adjustment of treatment objectives, if necessary IV    Contact physician in case of insufficient results IV    Final evaluation on the basis of treatment objectives (with measurement instruments) IV(II)   10 Closure (2) 73.4 (31.5)    Written report to referring physician IV    Arrangement of aftercare IV a Level I=systematic review or >2 high-quality randomized controlled trials (RCTs), level II=2 high-quality RCTs, level III=1 high-quality noncontrolled study, level IV=expert opinion. b ICF=International Classification of Functioning, Disability and Health. Open in new tab Table 1 Individual Quality Indicators per Step of the Process of Care, Their Level of Evidence, and the Mean Percentage of Adherence for the Entire Therapeutic Process and for the Individual Steps . Level of Evidencea . % Adherence (SD) . Entire therapeutic process 67.2 (8.6) Phases of therapeutic process/individual steps (no. of indicators)  Diagnostic phase   1 Referral (1) 2.2 (14.7)    Contact physician if information on referral is lacking (eg, reason for referral, medical examination data, indication for physical therapy or manual therapy) IV   2 History taking (7) 60.5 (10.1)    Assessment of patient’s specific request for help IV    Use of ICFb III    Use of measurement instrument II    Assessment of low back pain course IV    Assessment of “yellow flags” and coping strategies IV    Presence of “red flags” IV    Assessment of supplementary treatment IV   3 Patient profile (2) 99.3 (6.0)    Assessment of patient profile II    Contact physician in case of contraindications IV   4 Examination objectives (1) 32.8 (47.1)    Examination objectives in agreement with patient profile IV   5 Examination (1) 45.5 (50.0)    Examination performed in agreement with objectives II–IV   6 Analysis (3) 91.5 (14.6)    Assessment of indication for physical therapy IV    Indication of prognosis III    Referral to physician in case of insufficient results or if no results are expected IV  Treatment phase   7 Treatment plan (2) 47.5 (33.4)    Treatment plan in agreement with patient profile III    Patient participation in treatment plan III   8 Treatment (2) 55.1 (38.0)    Treatment strategies in agreement with patient profile I-II    No. of sessions in agreement with patient profile IV   9 Evaluation (4) 88.1 (19.9)    Regular/systematic evaluation of treatment objectives IV    Adjustment of treatment objectives, if necessary IV    Contact physician in case of insufficient results IV    Final evaluation on the basis of treatment objectives (with measurement instruments) IV(II)   10 Closure (2) 73.4 (31.5)    Written report to referring physician IV    Arrangement of aftercare IV . Level of Evidencea . % Adherence (SD) . Entire therapeutic process 67.2 (8.6) Phases of therapeutic process/individual steps (no. of indicators)  Diagnostic phase   1 Referral (1) 2.2 (14.7)    Contact physician if information on referral is lacking (eg, reason for referral, medical examination data, indication for physical therapy or manual therapy) IV   2 History taking (7) 60.5 (10.1)    Assessment of patient’s specific request for help IV    Use of ICFb III    Use of measurement instrument II    Assessment of low back pain course IV    Assessment of “yellow flags” and coping strategies IV    Presence of “red flags” IV    Assessment of supplementary treatment IV   3 Patient profile (2) 99.3 (6.0)    Assessment of patient profile II    Contact physician in case of contraindications IV   4 Examination objectives (1) 32.8 (47.1)    Examination objectives in agreement with patient profile IV   5 Examination (1) 45.5 (50.0)    Examination performed in agreement with objectives II–IV   6 Analysis (3) 91.5 (14.6)    Assessment of indication for physical therapy IV    Indication of prognosis III    Referral to physician in case of insufficient results or if no results are expected IV  Treatment phase   7 Treatment plan (2) 47.5 (33.4)    Treatment plan in agreement with patient profile III    Patient participation in treatment plan III   8 Treatment (2) 55.1 (38.0)    Treatment strategies in agreement with patient profile I-II    No. of sessions in agreement with patient profile IV   9 Evaluation (4) 88.1 (19.9)    Regular/systematic evaluation of treatment objectives IV    Adjustment of treatment objectives, if necessary IV    Contact physician in case of insufficient results IV    Final evaluation on the basis of treatment objectives (with measurement instruments) IV(II)   10 Closure (2) 73.4 (31.5)    Written report to referring physician IV    Arrangement of aftercare IV a Level I=systematic review or >2 high-quality randomized controlled trials (RCTs), level II=2 high-quality RCTs, level III=1 high-quality noncontrolled study, level IV=expert opinion. b ICF=International Classification of Functioning, Disability and Health. Open in new tab Outcome Indicators The differences between pretreatment and posttreatment scores for both of the health-related outcomes were statistically significant. The mean pretreatment and posttreatment scores for the QBPDS were 40.5 and 21.3, respectively, and the VAS scores for average pain were 56.9 and 22.9, respectively. The utilization of care was expressed by a mean number of treatment sessions of 6.70 (SD=3.2). Associations Between Process and Outcome Indicators Across the entire study sample, a higher percentage of guideline-adherent care was negatively related to the posttreatment score on the QBPDS (P=.02; Tab. 2). That is, a higher percentage of guideline adherence resulted in fewer limitations in functioning after the treatment episode. No such association was observed for VAS scores for average pain (P=.50). A higher percentage of guideline adherence was negatively related to the number of treatment sessions (P=.00), indicating that a higher level of guideline-adherent care was associated with lower utilization. Table 2 Association Between Outcome Indicators and Percentage of Guideline Adherence, With Correction for Other Potentially Influential Factorsa Dependent/ Independent Variables . QBPDS (R2=21.2%) . VAS Average Pain (R2=7.2%) . No. of Treatment Sessions (R2=18.7%) . B . β . P . 95% CI . B . β . P . 95% CI . B . β . P . 95% CI . Constant 10.85 −21.31, 43.00 12.01 −39.85, 63.88 9.64 3.65, 15.62 % guideline adherence (0–100) −0.35 −0.21** .023 −0.65, −0.05 −0.17 −0.07 .499 −0.65, 0.32 −0.09 −0.27† .005 −0.16, −0.03 QBPDS score at baseline (0–100) 0.21 0.22** .043 0.01, 0.41 0.12 0.09 .447 −0.19, 0.43 0.01 0.05 .663 −0.03, 0.05 VAS pain score at baseline (0–100) 0.01 0.02 .851 −0.13, 0.16 0.11 0.11 .343 −0.12, 0.33 0.00 0.01 .945 −0.03, 0.03 PT practice experience (<5 y, >30 y) 0.68 0.08 .372 −0.82, 2.18 2.34 0.19* .057 −0.07, 4.75 0.30 0.18* .068 −0.02, 0.62 Duration of current LBP-episode (<1 week, >5 y) 0.34 0.05 .615 −1.00, 1.68 0.33 0.03 .758 −1.80, 2.46 0.25 0.17* .079 −0.03, 0.53 Patient’s age 0.13 0.13 .314 −0.13, 0.40 −0.16 −0.10 .458 −0.57, 0.26 −0.00 −0.01 .917 −0.04, 0.04 Catastrophizing (1–6) 3.02 0.17 .105 −0.64, 6.68 −0.57 −0.02 .847 −6.43, 5.28 −0.10 −0.03 .791 −0.83, 0.64 Paid job (yes/no) −0.84 −0.03 .827 −8.46, 6.78 0.92 0.20 .881 −11.26, 13.11 External pain control perception (1–6) 0.70 0.04 .682 −2.67, 4.06 1.09 0.04 .694 −4.37, 6.54 Pain coping (1–6) 1.75 0.10 .297 −1.56, 5.06 1.37 0.05 .602 −3.82, 6.55 Previous physical therapy treatment (yes/no) 0.41 0.07 .502 −0.80, 1.62 PT working hours (full-time/part-time) −0.93 −0.14 .170 −2.27, 0.41 Patient’s sex (male/female) 0.35 0.06 .594 −0.81, 1.52 Dependent/ Independent Variables . QBPDS (R2=21.2%) . VAS Average Pain (R2=7.2%) . No. of Treatment Sessions (R2=18.7%) . B . β . P . 95% CI . B . β . P . 95% CI . B . β . P . 95% CI . Constant 10.85 −21.31, 43.00 12.01 −39.85, 63.88 9.64 3.65, 15.62 % guideline adherence (0–100) −0.35 −0.21** .023 −0.65, −0.05 −0.17 −0.07 .499 −0.65, 0.32 −0.09 −0.27† .005 −0.16, −0.03 QBPDS score at baseline (0–100) 0.21 0.22** .043 0.01, 0.41 0.12 0.09 .447 −0.19, 0.43 0.01 0.05 .663 −0.03, 0.05 VAS pain score at baseline (0–100) 0.01 0.02 .851 −0.13, 0.16 0.11 0.11 .343 −0.12, 0.33 0.00 0.01 .945 −0.03, 0.03 PT practice experience (<5 y, >30 y) 0.68 0.08 .372 −0.82, 2.18 2.34 0.19* .057 −0.07, 4.75 0.30 0.18* .068 −0.02, 0.62 Duration of current LBP-episode (<1 week, >5 y) 0.34 0.05 .615 −1.00, 1.68 0.33 0.03 .758 −1.80, 2.46 0.25 0.17* .079 −0.03, 0.53 Patient’s age 0.13 0.13 .314 −0.13, 0.40 −0.16 −0.10 .458 −0.57, 0.26 −0.00 −0.01 .917 −0.04, 0.04 Catastrophizing (1–6) 3.02 0.17 .105 −0.64, 6.68 −0.57 −0.02 .847 −6.43, 5.28 −0.10 −0.03 .791 −0.83, 0.64 Paid job (yes/no) −0.84 −0.03 .827 −8.46, 6.78 0.92 0.20 .881 −11.26, 13.11 External pain control perception (1–6) 0.70 0.04 .682 −2.67, 4.06 1.09 0.04 .694 −4.37, 6.54 Pain coping (1–6) 1.75 0.10 .297 −1.56, 5.06 1.37 0.05 .602 −3.82, 6.55 Previous physical therapy treatment (yes/no) 0.41 0.07 .502 −0.80, 1.62 PT working hours (full-time/part-time) −0.93 −0.14 .170 −2.27, 0.41 Patient’s sex (male/female) 0.35 0.06 .594 −0.81, 1.52 a PT=physical therapist, QBPDS=Quebec Back Pain and Disability Scale, VAS=visual analog scale, LBP=low back pain, 95% CI=95% confidence interval. * P<.10, ** P<.05, + P<.01. Open in new tab Table 2 Association Between Outcome Indicators and Percentage of Guideline Adherence, With Correction for Other Potentially Influential Factorsa Dependent/ Independent Variables . QBPDS (R2=21.2%) . VAS Average Pain (R2=7.2%) . No. of Treatment Sessions (R2=18.7%) . B . β . P . 95% CI . B . β . P . 95% CI . B . β . P . 95% CI . Constant 10.85 −21.31, 43.00 12.01 −39.85, 63.88 9.64 3.65, 15.62 % guideline adherence (0–100) −0.35 −0.21** .023 −0.65, −0.05 −0.17 −0.07 .499 −0.65, 0.32 −0.09 −0.27† .005 −0.16, −0.03 QBPDS score at baseline (0–100) 0.21 0.22** .043 0.01, 0.41 0.12 0.09 .447 −0.19, 0.43 0.01 0.05 .663 −0.03, 0.05 VAS pain score at baseline (0–100) 0.01 0.02 .851 −0.13, 0.16 0.11 0.11 .343 −0.12, 0.33 0.00 0.01 .945 −0.03, 0.03 PT practice experience (<5 y, >30 y) 0.68 0.08 .372 −0.82, 2.18 2.34 0.19* .057 −0.07, 4.75 0.30 0.18* .068 −0.02, 0.62 Duration of current LBP-episode (<1 week, >5 y) 0.34 0.05 .615 −1.00, 1.68 0.33 0.03 .758 −1.80, 2.46 0.25 0.17* .079 −0.03, 0.53 Patient’s age 0.13 0.13 .314 −0.13, 0.40 −0.16 −0.10 .458 −0.57, 0.26 −0.00 −0.01 .917 −0.04, 0.04 Catastrophizing (1–6) 3.02 0.17 .105 −0.64, 6.68 −0.57 −0.02 .847 −6.43, 5.28 −0.10 −0.03 .791 −0.83, 0.64 Paid job (yes/no) −0.84 −0.03 .827 −8.46, 6.78 0.92 0.20 .881 −11.26, 13.11 External pain control perception (1–6) 0.70 0.04 .682 −2.67, 4.06 1.09 0.04 .694 −4.37, 6.54 Pain coping (1–6) 1.75 0.10 .297 −1.56, 5.06 1.37 0.05 .602 −3.82, 6.55 Previous physical therapy treatment (yes/no) 0.41 0.07 .502 −0.80, 1.62 PT working hours (full-time/part-time) −0.93 −0.14 .170 −2.27, 0.41 Patient’s sex (male/female) 0.35 0.06 .594 −0.81, 1.52 Dependent/ Independent Variables . QBPDS (R2=21.2%) . VAS Average Pain (R2=7.2%) . No. of Treatment Sessions (R2=18.7%) . B . β . P . 95% CI . B . β . P . 95% CI . B . β . P . 95% CI . Constant 10.85 −21.31, 43.00 12.01 −39.85, 63.88 9.64 3.65, 15.62 % guideline adherence (0–100) −0.35 −0.21** .023 −0.65, −0.05 −0.17 −0.07 .499 −0.65, 0.32 −0.09 −0.27† .005 −0.16, −0.03 QBPDS score at baseline (0–100) 0.21 0.22** .043 0.01, 0.41 0.12 0.09 .447 −0.19, 0.43 0.01 0.05 .663 −0.03, 0.05 VAS pain score at baseline (0–100) 0.01 0.02 .851 −0.13, 0.16 0.11 0.11 .343 −0.12, 0.33 0.00 0.01 .945 −0.03, 0.03 PT practice experience (<5 y, >30 y) 0.68 0.08 .372 −0.82, 2.18 2.34 0.19* .057 −0.07, 4.75 0.30 0.18* .068 −0.02, 0.62 Duration of current LBP-episode (<1 week, >5 y) 0.34 0.05 .615 −1.00, 1.68 0.33 0.03 .758 −1.80, 2.46 0.25 0.17* .079 −0.03, 0.53 Patient’s age 0.13 0.13 .314 −0.13, 0.40 −0.16 −0.10 .458 −0.57, 0.26 −0.00 −0.01 .917 −0.04, 0.04 Catastrophizing (1–6) 3.02 0.17 .105 −0.64, 6.68 −0.57 −0.02 .847 −6.43, 5.28 −0.10 −0.03 .791 −0.83, 0.64 Paid job (yes/no) −0.84 −0.03 .827 −8.46, 6.78 0.92 0.20 .881 −11.26, 13.11 External pain control perception (1–6) 0.70 0.04 .682 −2.67, 4.06 1.09 0.04 .694 −4.37, 6.54 Pain coping (1–6) 1.75 0.10 .297 −1.56, 5.06 1.37 0.05 .602 −3.82, 6.55 Previous physical therapy treatment (yes/no) 0.41 0.07 .502 −0.80, 1.62 PT working hours (full-time/part-time) −0.93 −0.14 .170 −2.27, 0.41 Patient’s sex (male/female) 0.35 0.06 .594 −0.81, 1.52 a PT=physical therapist, QBPDS=Quebec Back Pain and Disability Scale, VAS=visual analog scale, LBP=low back pain, 95% CI=95% confidence interval. * P<.10, ** P<.05, + P<.01. Open in new tab In terms of the individual steps of the process of care, higher percentages of adherence for analysis (P=.04) and evaluation (P=.00; Tab. 3) were related to fewer limitations in functioning posttreatment. No such associations were observed for VAS scores for average pain. Higher adherence rates for treatment plan (P=.05), treatment (P=.00), and evaluation (P=.01) were associated with lower utilization. Table 3 Associations Between Percentage of Adherence to the Individual Steps of the Process of Care and Outcome Indicatorsa Steps of the Process . Outcome Indicators . QBPDS . VAS Average Pain . No. of Sessions . Diagnostic phase  Referral 0.02 −0.04 0.02  History taking −0.16* −0.08 0.02  Patient profile 0.02 0.08 0.03  Examination objectives −0.03 −0.06 −0.01  Examination −0.05 0.03 0.00  Analysis −0.17** −0.01 −0.02 Treatment phase  Treatment plan 0.01 −0.11 −0.02**  Treatment −0.08 0.01 −0.03‡  Evaluation −0.30† −0.11 −0.03**  Closure −0.03 0.00 0.02* Steps of the Process . Outcome Indicators . QBPDS . VAS Average Pain . No. of Sessions . Diagnostic phase  Referral 0.02 −0.04 0.02  History taking −0.16* −0.08 0.02  Patient profile 0.02 0.08 0.03  Examination objectives −0.03 −0.06 −0.01  Examination −0.05 0.03 0.00  Analysis −0.17** −0.01 −0.02 Treatment phase  Treatment plan 0.01 −0.11 −0.02**  Treatment −0.08 0.01 −0.03‡  Evaluation −0.30† −0.11 −0.03**  Closure −0.03 0.00 0.02* a Regression coefficients (β) corrected for baseline scores on outcome indicators. QBPDS=Quebec Back Pain and Disability Scale, VAS=visual analog scale. * P<.10, ** P<.05, †P<.01, ‡P<.001. Open in new tab Table 3 Associations Between Percentage of Adherence to the Individual Steps of the Process of Care and Outcome Indicatorsa Steps of the Process . Outcome Indicators . QBPDS . VAS Average Pain . No. of Sessions . Diagnostic phase  Referral 0.02 −0.04 0.02  History taking −0.16* −0.08 0.02  Patient profile 0.02 0.08 0.03  Examination objectives −0.03 −0.06 −0.01  Examination −0.05 0.03 0.00  Analysis −0.17** −0.01 −0.02 Treatment phase  Treatment plan 0.01 −0.11 −0.02**  Treatment −0.08 0.01 −0.03‡  Evaluation −0.30† −0.11 −0.03**  Closure −0.03 0.00 0.02* Steps of the Process . Outcome Indicators . QBPDS . VAS Average Pain . No. of Sessions . Diagnostic phase  Referral 0.02 −0.04 0.02  History taking −0.16* −0.08 0.02  Patient profile 0.02 0.08 0.03  Examination objectives −0.03 −0.06 −0.01  Examination −0.05 0.03 0.00  Analysis −0.17** −0.01 −0.02 Treatment phase  Treatment plan 0.01 −0.11 −0.02**  Treatment −0.08 0.01 −0.03‡  Evaluation −0.30† −0.11 −0.03**  Closure −0.03 0.00 0.02* a Regression coefficients (β) corrected for baseline scores on outcome indicators. QBPDS=Quebec Back Pain and Disability Scale, VAS=visual analog scale. * P<.10, ** P<.05, †P<.01, ‡P<.001. Open in new tab We found no difference in the median percentage of guideline adherence (68%; Tab. 4) among the 3 subgroups of patients with acute (n=69), subacute (n=32), and chronic (n=34) low back pain. The relationship between the percentage of guideline adherence and outcome indicators was strongest for patients with chronic low back pain, showing a medium to large negative correlation with the posttreatment scores on the QBPDS (rs=−.38; P<.05), the VAS scores for average pain (rs=−.45; P<.01), and the number of treatment sessions (rs=−.37; P<.05). For the subgroup with acute low back pain, we found only a medium negative correlation (rs=−.30; P<.05) between the percentage of guideline adherence and the number of visits. All negative correlations indicate that higher percentages of guideline adherence were associated with fewer limitations in functioning, lower levels of pain posttreatment, or fewer visits. For the subgroup with subacute low back pain, no significant correlations were found. Table 4 Patient Characteristics, Adherence Scores, and Correlations of Adherence With Outcome Indicators for 3 Subgroups of Patientsa Subgroup . Patient Characteristics . Median % Adherence . Correlation of % Adherence and Difference Scores on Outcome Indicators . Age (y), Mean (SD) . Sex (% Male) . Employment Status (% Paid Job) . QBPDS . VAS, Average Pain . No. of Sessions . Acute low back pain (<6 wk) n=69 46.3 (15.7) 60 62 68 −.20 −.06 −.30* Subacute low back pain (6–12 wk) n=32 48.2 (12.5) 42 66 68 −.15 −.14 −.28 Chronic low back pain (>12 wk) n=34 51.4 (12.3) 44 44 68 −.38* −.45** −.37* Subgroup . Patient Characteristics . Median % Adherence . Correlation of % Adherence and Difference Scores on Outcome Indicators . Age (y), Mean (SD) . Sex (% Male) . Employment Status (% Paid Job) . QBPDS . VAS, Average Pain . No. of Sessions . Acute low back pain (<6 wk) n=69 46.3 (15.7) 60 62 68 −.20 −.06 −.30* Subacute low back pain (6–12 wk) n=32 48.2 (12.5) 42 66 68 −.15 −.14 −.28 Chronic low back pain (>12 wk) n=34 51.4 (12.3) 44 44 68 −.38* −.45** −.37* a Number of patients for subgroups do not add up to number of total group due to missing information. QBPDS=Quebec Back Pain and Disability Scale, VAS=visual analog scale. *P<.05, **P<.01. b Spearman rs. Open in new tab Table 4 Patient Characteristics, Adherence Scores, and Correlations of Adherence With Outcome Indicators for 3 Subgroups of Patientsa Subgroup . Patient Characteristics . Median % Adherence . Correlation of % Adherence and Difference Scores on Outcome Indicators . Age (y), Mean (SD) . Sex (% Male) . Employment Status (% Paid Job) . QBPDS . VAS, Average Pain . No. of Sessions . Acute low back pain (<6 wk) n=69 46.3 (15.7) 60 62 68 −.20 −.06 −.30* Subacute low back pain (6–12 wk) n=32 48.2 (12.5) 42 66 68 −.15 −.14 −.28 Chronic low back pain (>12 wk) n=34 51.4 (12.3) 44 44 68 −.38* −.45** −.37* Subgroup . Patient Characteristics . Median % Adherence . Correlation of % Adherence and Difference Scores on Outcome Indicators . Age (y), Mean (SD) . Sex (% Male) . Employment Status (% Paid Job) . QBPDS . VAS, Average Pain . No. of Sessions . Acute low back pain (<6 wk) n=69 46.3 (15.7) 60 62 68 −.20 −.06 −.30* Subacute low back pain (6–12 wk) n=32 48.2 (12.5) 42 66 68 −.15 −.14 −.28 Chronic low back pain (>12 wk) n=34 51.4 (12.3) 44 44 68 −.38* −.45** −.37* a Number of patients for subgroups do not add up to number of total group due to missing information. QBPDS=Quebec Back Pain and Disability Scale, VAS=visual analog scale. *P<.05, **P<.01. b Spearman rs. Open in new tab Discussion This study examined the association between adherence to the Dutch physical therapy and manual therapy guidelines for low back pain and 3 short-term outcomes: the patient's physical functioning, level of pain, and the number of treatment sessions per episode of care. The average rate of overall guideline adherence was 67%, and higher percentages of adherence were associated with more favorable posttreatment scores on physical functioning (ie, greater effectiveness of care) and fewer treatment sessions (ie, lower utilization of care). It seems reasonable, therefore, to conclude that higher adherence rates contributed to greater efficiency of care. No such association was found between the percentage of guideline adherence and the level of pain. Further explorations indicated that the individual steps of the process of care might differ in their importance for the effectiveness and efficiency of care. Finally, our results suggest that the relationship between guideline adherence rates and treatment outcomes may be different for the different subgroups of patients with low back pain. This study demonstrates that a higher percentage of adherence to the Dutch guidelines for low back pain is associated with better clinical outcomes. This finding may be attributed to the more comprehensive set of process indicators we used to measure guideline adherence compared with a previous study that also examined this relationship.7 The set of indicators was informed by all guideline recommendations and processed by means of an iterative consensus procedure14 with experts and practicing physical therapists to achieve content validity.41 As a consequence, these indicators may be considered to yield a more detailed and adequate reflection of the complex process of delivering guideline-adherent care.15 Less detailed assessments in the past may have concealed the actual relationship between physical therapists’ practical performance and health-related outcomes. The use of quality indicators additionally enabled the demonstration of differences in the percentage of adherence to recommendations in the individual steps of the physical therapy process described in the Dutch guidelines, as well as the possibility that these individual steps may not have the same importance for either the effectiveness or the efficiency of care. A second, and perhaps even more important, explanation for our positive findings may be the relatively high average percentage of adherence (67%) in our study compared with other studies.10,11,13 In this perspective, it can be argued that guideline adherence rates should exceed a certain threshold before guideline adherence can result in improved health-related outcomes. This view is supported by a US study that focused on the relationship to the use of an activating treatment,11 which is a consistent recommendation in guidelines for low back pain.4,42,43 The US study set the threshold for guideline-adherent care at 75% and observed a larger improvement in terms of pain and disability for patients with low back pain whose care was found to exceed this threshold. In addition, it can be argued that larger differences in guideline adherence rates are needed to identify a relationship with health-related outcomes. This view is in accordance with the findings of a previous Dutch randomized clinical trial that did not find a difference in improvement of physical functioning or pain between patients cared for by 2 groups of physical therapists who showed a moderate difference of 12% in guideline adherence.7 The sample size in the present study, however, did not allow us to perform the analyses needed to corroborate these explanations. In our study, the posttreatment scores for physical functioning and average pain were explained only to a limited extent, despite the inclusion of both the percentage of guideline adherence and the various factors that have been found to be associated with health outcomes of patients with low back pain. First, this finding might be due to the fact that low back pain is a complex problem, with many factors not within the direct reach of physical therapy treatment, thus influencing its onset and prognosis.29,44–48 Second, different patient categories may seriously confound the assessment of the relationship between guideline adherence rates and health-related outcomes for patients with low back pain. Our subgroup analysis suggested that patients with chronic low back pain may benefit more from guideline-adherent care than patients with acute or subacute low back pain. One explanation for this finding may be the active approach used in the guidelines, which has been shown to be more effective for patients with chronic low back pain.49 Another explanation is that acute low back pain, due to its more favorable natural course,1,50 may have favorable treatment results, irrespective of the focus of the physical therapy approach. However, the internal validity of our subgroup analysis is limited due to potential confounding from uncontrolled covariates. Larger samples are needed to enable the more sophisticated analyses required to properly assess the relationship between guideline adherence and patient outcomes for various subgroups of patients with low back pain. The favorable association we found between the percentage of guideline adherence and the utilization of care confirms the findings of previous studies.11,13 However, as observed previously,10 the mean number of treatment sessions for patients with acute low back pain still exceeded the recommendation in the guidelines of 2 or 3 treatment sessions that include coaching and advice.6,51 This recommendation was based on the estimation that a large percentage of patients with low back pain would recover spontaneously in 4 to 6 weeks.52 More recent research, however, has demonstrated a less favorable prognosis for low back pain.1,50,53 Consequently, the current recommendation might be too optimistic and may be taken into reconsideration during the current revision of the guidelines. Two limitations of the study should be discussed. First, the participating therapists were a self-selected sample. Despite an instruction meeting, the availability of a help desk, and an e-mail and telephone reminder, there was a considerable nonresponse and dropout rate: a number of physical therapists did not start recording or did not complete the records they started. Compared with the national data,54 male participants, therapists working full-time, and practice owners were overrepresented in our final sample. Therefore, the external validity of the study may be limited. However, none of these demographic factors were associated with the outcome indicators, and therapists who only recorded the care process did not differ in terms of their average percentage of adherence from physical therapists whose patients also completed all outcome questionnaires. Concerning our primary objective of examining the association between the percentage of guideline adherence and 3 short-term outcomes of care, it seems reasonable, therefore, to assume that the selectivity of the final sample did not greatly influence the internal validity of our study. Second, apart from the self-selected sample, the external validity of the study may be limited due to the relatively small sample size. A major reason for the low participation rate was the use of a rather extensive EPD. Despite the systematic, iterative consensus procedure we used to assess the relevance and validity of the set of quality indicators, a full Delphi procedure might further reduce the number of indicators without losing content validity.14 A reduced number of indicators, in turn, could improve the feasibility of the set, allowing for a more user-friendly EPD that would be more suitable for daily practice. Because a major barrier to start recording the care provided to patients appeared to be the fact that (Web-based) EPDs are not yet standard procedure in private practice physical therapy in the Netherlands, such more convenient EPDs, in turn, may contribute substantially to the larger study samples that are needed to further explore the relationship between guideline adherence rates and health-related outcomes of care. Keeping in mind these limitations, some practical implications can be suggested. In order to improve the effectiveness and efficiency of care, physical therapists might put effort into improving the steps of the process that relate most strongly to patient outcomes. Our findings indicate that they should primarily engage in a regular evaluation; that is, they should frequently monitor the results of their treatment on health-related outcomes and, if necessary, adjust their treatment objectives or treatment strategies. Second, therapists should plan and implement a treatment that suits the applicable patient profile. In consultation with the patient, they should base their treatment plan and treatment strategies on the findings from the diagnostic phase: whether the low back pain is subacute, acute, or chronic; whether its course is normal or delayed; and whether any delay is associated with psychosocial factors. For instance, patients with acute low back pain and a normal course mostly require only adequate information and advice during a limited number of sessions, whereas patients with chronic low back pain with a delayed course in the presence of psychosocial factors may benefit most from an activating approach and strategies aimed at changing inadequate cognitions and coping strategies during a longer treatment episode. Further recommendations for practice improvement require more profound analyses that yield a better understanding of the relationships between patient outcomes and the individual steps of the process of care. Such analyses, however, require studies with larger samples sizes. Conclusions In this study, a higher percentage of adherence to the Dutch physical therapy and manual therapy guidelines for low back pain was related to a better treatment effect with respect to physical functioning and lower utilization of care. Additionally, our findings imply that not every step in the process of care is of equal importance for the effectiveness and the efficiency of care. Larger samples are required to adequately test hypotheses about differences in the relationship between guideline adherence rates and health-related outcomes of care for various subgroups of patients with low back pain. A proper assessment of the relationship between the process of physical therapy care and health-related outcomes may require a comprehensive set of process indicators to measure guideline adherence rates, as only such a set may yield the required valid impression of routine physical therapist practice. The Bottom Line What do we already know about this topic? Although various evidence-based clinical guidelines for low back pain have been developed to enhance the effectiveness and efficiency of care, evidence that guideline-adherent care results in better health-related outcomes is inconclusive. What new information does this study offer? Adherence to the Dutch physical therapy guidelines for low back pain was measured with 25 quality indicators based on the guidelines’ recommendations. The results showed that greater guideline adherence was associated with greater improvement in physical functioning, lower utilization of care, and fewer treatment sessions. If you’re a patient, what might these findings mean for you? Patients with low back pain should be informed about evidence-based care in a comprehensible way. This enables them to ask for guideline-adherent care when they enter the physical therapy clinic. " The Medical Ethics Committee of Radboud University Nijmegen Medical Centre in the Netherlands authorized the study. " The results of this study, in part, were presented orally at the 15th International Congress of the World Confederation for Physical Therapy, June 2–6, 2007, Vancouver, British Columbia, Canada, and at the Dutch National Physiotherapy Conference, November 9–10, 2007. " The study was funded by CZ, a health insurance company in the Netherlands. References 1 Pengel LHM Herbert RD Maher CG Refshauge KM . Acute low back pain: systematic review of its prognosis . BMJ . 2003 ; 327 : 323 – 325 . Google Scholar Crossref Search ADS PubMed WorldCat 2 Nachemson A Waddell G Norlund A . Epidemiology of neck and low back pain . 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Accessed December 17, 2005. 43 van Tulder MW Becker A Bekkering GE , et al. . European guidelines for the management of acute nonspecific low back pain in primary care . 2005 ; Available at: http://www.backpaineurope.org/web/files/WG1_Guidelines.pdf. Accessed December 17, 2005 . 44 van Tulder MW Koes BW Bombardier C . Low back pain . Best Pract Res Clin Rheumatol . 2002 ; 16 : 761 – 775 . Google Scholar Crossref Search ADS PubMed WorldCat 45 Manek NJ MacGregor AJ . Epidemiology of back disorders: prevalence, risk factors, and prognosis . Curr Opin Rheumatol . 2005 ; 17 : 134 – 140 . Google Scholar PubMed OpenURL Placeholder Text WorldCat 46 Oleske DM Lavender SA Andersson GB , et al. . Risk factors for recurrent episodes of work-related low back disorders in an industrial population . Spine (Phila PA 1976) . 2006 ; 31 : 789 – 798 . Google Scholar Crossref Search ADS PubMed WorldCat 47 McBeth J Jones K . Epidemiology of chronic musculoskeletal pain . Best Pract Res Clin Rheumatol . 2007 ; 21 : 403 – 425 . Google Scholar Crossref Search ADS PubMed WorldCat 48 Foster NE Bishop A Thomas E , et al. . Illness perceptions of low back pain patients in primary care: What are they, do they change and are they associated with outcome? Pain . 2008 ; 136 ( 1–2 ): 177 – 187 . Google Scholar Crossref Search ADS PubMed WorldCat 49 Heymans MW van Tulder MW Esmail R , et al. . Back schools for nonspecific low back pain: a systematic review within the framework of the Cochrane Collaboration Back Review Group . Spine (Phila Pa 1976) . 2005 ; 30 : 2153 – 2163 . Google Scholar Crossref Search ADS PubMed WorldCat 50 Hestbaek L Leboeuf-Yde C Manniche C . Low back pain: what is the long-term course? A review of studies of general patient populations . Eur Spine J . 2003 ; 12 : 149 – 165 . Google Scholar Crossref Search ADS PubMed WorldCat 51 Bekkering GE Hendriks HJM Koes BW , et al. . KNGF-richtlijn Lage-rugpijn . Nederlands Tijdschrift voor Fysiotherapie . 2001 ; 111 ( 3 suppl ): 1 – 24 . OpenURL Placeholder Text WorldCat 52 Waddell G Feder G McIntosh A , et al. . Manual therapy rounds . J Man Manip Ther . 1998 ; 6 : 151 – 153 . Google Scholar Crossref Search ADS WorldCat 53 Hestbaek L Leboeuf-Yde C Engberg M , et al. . The course of low back pain in a general population: results from a 5-year prospective study . J Manipulative Physiol Ther . 2003 ; 26 : 213 – 219 . Google Scholar Crossref Search ADS PubMed WorldCat 54 Kenens R Hingstman L . Cijfers uit de registratie van fysiotherapeuten. Peiling 1 januari 2008 . Available at: http://www.nivel.nl/beroepenindezorg/. Accessed January 29, 2010 . Author notes " Mr Rutten, Ms Degen, Dr Hendriks, Dr Braspenning, and Dr Oostendorp provided concept/idea/research design. Mr Rutten, Dr Hendriks, Dr Braspenning, Dr Harting, and Dr Oostendorp provided writing. Mr Rutten and Ms Degen provided data collection. Mr Rutten provided data analysis. Dr Hendriks provided institutional liaisons. Dr Oostendorp provided project management, fund procurement, and facilities/equipment. Ms Degen, Dr Hendriks, Dr Braspenning, Dr Harting, and Dr Oostendorp provided consultation (including review of manuscript before submission). © 2010 American Physical Therapy Association

Tate, Jeremiah, J.;Milner, Clare, E.

doi: 10.2522/ptj.20080281pmid: 20558567

Background Biofeedback has been used in rehabilitation settings for gait retraining. Purpose The purpose of this review was to summarize and synthesize the findings of studies involving real-time kinematic, temporospatial, and kinetic biofeedback. The goal was to provide a general overview of the effectiveness of these forms of biofeedback in treating gait abnormalities. Data Sources Articles were identified through searches of the following databases: MEDLINE, CINAHL (Cumulative Index to Nursing and Allied Health Literature), and Cochrane Central Register for Controlled Trials. All searches were limited to the English language and encompassed the period from 1965 to November 2007. Study Selection Titles and abstracts were screened to identify studies that met the following requirements: the study included the use of kinematic, temporospatial, or kinetic biofeedback during gait training, and the population of interest showed abnormal movement patterns as a result of a pathology or injury. Data Extraction All articles that met the inclusion criteria were assessed by use of the Methodological Index for Nonrandomized Studies. Data Synthesis Seven articles met the inclusion criteria and were included in the review. Effect sizes were calculated for the primary outcome variables for all studies that provided enough data. Effect sizes generally suggested moderate to large treatment effects for all methods of biofeedback during practice. Limitations Several of the studies lacked adequate randomization; therefore, readers should exercise caution when interpreting authors’ conclusions. Conclusions Each biofeedback method appeared to result in moderate to large treatment effects immediately after treatment. However, it is unknown whether the effects were maintained. Future studies should ensure adequate randomization of participants and implementation of motor learning concepts and should include retention testing to assess the long-term success of biofeedback and outcome measures capable of demonstrating coordinative changes in gait and improvement in function. Biofeedback was first introduced in the literature more than 30 years ago as a training tool used in rehabilitation settings to facilitate normal movement patterns after injury.1 Since then, biofeedback has been used primarily in rehabilitation settings for the treatment of gait abnormalities in adults after stroke.2–12 Biofeedback also has been used to facilitate the normalization of gait patterns in children with cerebral palsy13 and in adults after amputation,14 after spinal cord injuries,15 after hip fractures,14 and after total hip14,16 and knee14 joint replacements. Biofeedback is a technique that typically uses electronic equipment to provide a client with auditory signals, visual signals, or both regarding internal physiological events, both normal and abnormal (eg, heart rate, blood pressure, and level of muscle activity).17 During biofeedback for gait retraining, the client is provided with augmented information (eg, kinematics, kinetics, and electromyography) regarding physiological responses. Additionally, biofeedback provides clinicians with a useful tool for giving clients instructions on how to modify movement patterns. Thus, biofeedback complements the already present internal feedback (ie, visual, auditory, and proprioceptive feedback) and acts as a “sixth sense.”18 Biofeedback typically is provided instantaneously to the learner (ie, in real time), whereas other methods of external feedback (eg, verbal and video feedback) are provided some time after the movement. More recently, a resurgence of interest in real-time feedback has developed because of the expansion of technology related to kinematic19 and kinetic14,16 biofeedback. Electromyographic biofeedback may be the most popular method of providing biofeedback and has been used frequently in gait retraining after stroke. However, meta-analyses of electromyographic biofeedback studies of people after stroke have concluded that little evidence supports its use in addition to conventional physical therapy.20,21 Other forms of biofeedback, such as kinematic,2,8,9 temporospatial,6,7 and kinetic,14,16 also have been developed and used in rehabilitation settings for gait retraining. It remains unknown whether these methods are effective in treating gait abnormalities. Therefore, the purpose of this systematic review was to summarize and synthesize the findings of studies involving real-time kinematic, temporospatial, and kinetic biofeedback. This effort provided a general overview of the effectiveness of these forms of biofeedback in treating gait abnormalities. Method Data Sources and Searches Three electronic databases were searched in a systematic fashion to identify relevant articles: MEDLINE, CINAHL (Cumulative Index to Nursing and Allied Health Literature), and Cochrane Central Register for Controlled Trials. All searches were limited to the English language and encompassed the period from 1965 to November 2007. The following key words were used in the searches: feedback, biofeedback, walking, ambulation, and gait. Key words were combined to identify studies involving biofeedback and gait. Table 1 shows the specific key words and combinations of key words used in each search. Each review article that was identified by MEDLINE also was manually searched to identify other potential articles. Table 1 Results of Searches of Electronic Databases Database . Key Words . No. of Studies . MEDLINE (1) feedback; (2) biofeedback; (3) 1 or 2; (4) walka; (5) ambula; (6) walking; (7) gait; (8) 4 or 5 or 6 or 7; (9) 3 and 8 504 CINAHL (1) feedback; (2) biofeedback; (3) 1 or 2; (4) walka; (5) ambula; (6) walking; (7) gait; (8) 4 or 5 or 6 or 7; (9) 3 and 8 162 Cochrane (1) feedback; (2) biofeedback; (3) 1 or 2; (4) walking; (5) ambulation; (6) gait; (7) 4 or 5 or 6; (8) 3 and 7 85 Database . Key Words . No. of Studies . MEDLINE (1) feedback; (2) biofeedback; (3) 1 or 2; (4) walka; (5) ambula; (6) walking; (7) gait; (8) 4 or 5 or 6 or 7; (9) 3 and 8 504 CINAHL (1) feedback; (2) biofeedback; (3) 1 or 2; (4) walka; (5) ambula; (6) walking; (7) gait; (8) 4 or 5 or 6 or 7; (9) 3 and 8 162 Cochrane (1) feedback; (2) biofeedback; (3) 1 or 2; (4) walking; (5) ambulation; (6) gait; (7) 4 or 5 or 6; (8) 3 and 7 85 a Limit: English language. Open in new tab Table 1 Results of Searches of Electronic Databases Database . Key Words . No. of Studies . MEDLINE (1) feedback; (2) biofeedback; (3) 1 or 2; (4) walka; (5) ambula; (6) walking; (7) gait; (8) 4 or 5 or 6 or 7; (9) 3 and 8 504 CINAHL (1) feedback; (2) biofeedback; (3) 1 or 2; (4) walka; (5) ambula; (6) walking; (7) gait; (8) 4 or 5 or 6 or 7; (9) 3 and 8 162 Cochrane (1) feedback; (2) biofeedback; (3) 1 or 2; (4) walking; (5) ambulation; (6) gait; (7) 4 or 5 or 6; (8) 3 and 7 85 Database . Key Words . No. of Studies . MEDLINE (1) feedback; (2) biofeedback; (3) 1 or 2; (4) walka; (5) ambula; (6) walking; (7) gait; (8) 4 or 5 or 6 or 7; (9) 3 and 8 504 CINAHL (1) feedback; (2) biofeedback; (3) 1 or 2; (4) walka; (5) ambula; (6) walking; (7) gait; (8) 4 or 5 or 6 or 7; (9) 3 and 8 162 Cochrane (1) feedback; (2) biofeedback; (3) 1 or 2; (4) walking; (5) ambulation; (6) gait; (7) 4 or 5 or 6; (8) 3 and 7 85 a Limit: English language. Open in new tab Study Selection One reviewer (J.J.T.) screened titles and abstracts identified during electronic and manual searches to determine eligibility. In the event that the title or abstract did not provide enough information, the article was obtained for full review. Published articles were considered for initial inclusion in the review if the following requirements were met: the study included the use of kinematic, temporospatial, or kinetic biofeedback during gait training and the population of interest showed abnormal movement patterns as a result of a pathology or injury. Figure 1 shows a flow diagram of the systematic review process. Figure 1 Open in new tabDownload slide Flow diagram of the systematic review process. Figure 1 Open in new tabDownload slide Flow diagram of the systematic review process. Data Extraction and Quality Assessment All articles that met the inclusion criteria were assessed by 2 reviewers (J.J.T. and C.E.M.) using the Methodological Index for Nonrandomized Studies (MINORS).22 The MINORS instrument has been determined to be valid and reliable in assessing the methodological quality of both randomized and nonrandomized studies.22 Scores on the MINORS range from 0 to 24 for randomized studies and 0 to 16 for nonrandomized studies. The following methodological items are assessed with the MINORS instrument: aim of the study, inclusion of consecutive participants, prospective data collection, appropriate outcome assessments, unbiased assessments of outcomes, appropriate follow-up, attrition, and sample size. In addition, the quality of the comparison group and statistical analyses in randomized trials only are assessed. Furthermore, the 2 reviewers clarified the intent of the questions concerning the inclusion of consecutive participants and prospective data collection to improve interrater reliability. The purpose of the question concerning the inclusion of consecutive participants was to judge whether inclusion and exclusion criteria were included in the study. The purpose of the question regarding prospective data collection was to judge whether the study was descriptive (score of 0) or prospective (score of 1 or 2). The delineation between scores of 1 and 2 for prospective quality was based on whether the study demonstrated 1 or more specific a priori aims and hypotheses. The MINORS scores were averaged across the 2 reviewers to enable the ranking of studies. A histogram of the studies and their MINORS scores was created to assist in determining a cutoff point, based on the natural clustering of groups, for inclusion in the review (Fig. 2). Figure 2 Open in new tabDownload slide Histogram of scores on the Methodological Index for Nonrandomized Studies.22 Figure 2 Open in new tabDownload slide Histogram of scores on the Methodological Index for Nonrandomized Studies.22 Data Synthesis and Analysis A meta-analysis was not performed because of the wide variety of study designs, methodologies, and outcome variables. Effect sizes (ESs) were calculated for the primary outcome variables for all studies that provided enough data. Effect sizes were calculated by subtracting the mean score at the baseline from the mean score after treatment and then dividing the result by a standard deviation resulting from pooling of the baseline and treatment standard deviations.23 Effect sizes were used in this review to provide a means of evaluating treatment success because they are not directly affected by sample size but take into account within-group variability. Effect sizes were standardized on the basis of the work of Cohen (small=.02, moderate=0.5, and large=0.8).23 All ESs represented comparisons of the mean posttreatment and follow-up (if applicable) scores with the mean baseline scores for each of the biofeedback and control groups. The ES for change over time in the biofeedback group was then compared with that in the control group. Percent differences also were calculated to aid in the interpretation of studies that did not provide enough data to calculate ESs. Results Study Identification A search of the MEDLINE database identified a total of 504 articles, a search of the CINAHL database identified 162 articles, and a search of the Cochrane Central Register of Controlled Trials identified 85 articles. In total, 666 individual articles were identified by these databases. Fifty-eight of these articles were identified as potentially relevant, and their full texts were retrieved. After an initial review by the first reviewer (J.J.T.), 35 of these articles were excluded because they did not meet the inclusion criteria. Both reviewers assessed the remaining 23 studies using the MINORS instrument. Of the 23 articles assessed, 7 achieved a score of 16 or greater out of a possible 24 and were included in the review (Fig. 1). A cutoff point of 16 was identified qualitatively on observation of the histogram as a natural breakpoint between clusters of studies (Fig. 2). Tables 2, 3, and 4 summarize the characteristics of the included studies with regard to participant population, sample sizes, participant ages, treatment protocols, presence of masking and retention tests, quantitative variables, functional outcome measures, and conclusions drawn by the authors. Table 2 Characteristics of Electrogoniometer Studies Study . Study Populationa . No. of Participants (Experimental Group/Control Group) . Age (y) . Treatment Protocol . Masking . Method of Delivery . Follow-up (wk) . Quantitative Variables . Functional Outcome . Improvementb . Time (min) . Frequency . Duration . Ceceli et al8 Adult CVA 26/15 Median=49.5/54 30 Daily 10 d No Auditory/ visual 24 Cadence, no of recurvations/50 steps None Yes Morris et al9 Adult CVA 13/13 X̅=64/64 (range=33–74) 45 5×/wk 4 wk/block No Auditory 4 Peak knee hyperextension, gait speed, single-limb stance symmetry Gait recovery (Motor Assessment Scale) Yes Colborne et al2 Adult CVA 8 (repeated measures) Not reported 30 2×/wk 4 wk/block No Auditory 4 Gait speed, stride length, stride time, knee angle at heel-strike, knee angle at 50% swing, ankle angle of motion, push-off impulse, swing ratio (affected/unaffected), weight ratio (affected/ unaffected) None Yes Study . Study Populationa . No. of Participants (Experimental Group/Control Group) . Age (y) . Treatment Protocol . Masking . Method of Delivery . Follow-up (wk) . Quantitative Variables . Functional Outcome . Improvementb . Time (min) . Frequency . Duration . Ceceli et al8 Adult CVA 26/15 Median=49.5/54 30 Daily 10 d No Auditory/ visual 24 Cadence, no of recurvations/50 steps None Yes Morris et al9 Adult CVA 13/13 X̅=64/64 (range=33–74) 45 5×/wk 4 wk/block No Auditory 4 Peak knee hyperextension, gait speed, single-limb stance symmetry Gait recovery (Motor Assessment Scale) Yes Colborne et al2 Adult CVA 8 (repeated measures) Not reported 30 2×/wk 4 wk/block No Auditory 4 Gait speed, stride length, stride time, knee angle at heel-strike, knee angle at 50% swing, ankle angle of motion, push-off impulse, swing ratio (affected/unaffected), weight ratio (affected/ unaffected) None Yes a CVA=cerebrovascular accident. b Statistically significant improvement in experimental group vs control group, as concluded by study authors. Open in new tab Table 2 Characteristics of Electrogoniometer Studies Study . Study Populationa . No. of Participants (Experimental Group/Control Group) . Age (y) . Treatment Protocol . Masking . Method of Delivery . Follow-up (wk) . Quantitative Variables . Functional Outcome . Improvementb . Time (min) . Frequency . Duration . Ceceli et al8 Adult CVA 26/15 Median=49.5/54 30 Daily 10 d No Auditory/ visual 24 Cadence, no of recurvations/50 steps None Yes Morris et al9 Adult CVA 13/13 X̅=64/64 (range=33–74) 45 5×/wk 4 wk/block No Auditory 4 Peak knee hyperextension, gait speed, single-limb stance symmetry Gait recovery (Motor Assessment Scale) Yes Colborne et al2 Adult CVA 8 (repeated measures) Not reported 30 2×/wk 4 wk/block No Auditory 4 Gait speed, stride length, stride time, knee angle at heel-strike, knee angle at 50% swing, ankle angle of motion, push-off impulse, swing ratio (affected/unaffected), weight ratio (affected/ unaffected) None Yes Study . Study Populationa . No. of Participants (Experimental Group/Control Group) . Age (y) . Treatment Protocol . Masking . Method of Delivery . Follow-up (wk) . Quantitative Variables . Functional Outcome . Improvementb . Time (min) . Frequency . Duration . Ceceli et al8 Adult CVA 26/15 Median=49.5/54 30 Daily 10 d No Auditory/ visual 24 Cadence, no of recurvations/50 steps None Yes Morris et al9 Adult CVA 13/13 X̅=64/64 (range=33–74) 45 5×/wk 4 wk/block No Auditory 4 Peak knee hyperextension, gait speed, single-limb stance symmetry Gait recovery (Motor Assessment Scale) Yes Colborne et al2 Adult CVA 8 (repeated measures) Not reported 30 2×/wk 4 wk/block No Auditory 4 Gait speed, stride length, stride time, knee angle at heel-strike, knee angle at 50% swing, ankle angle of motion, push-off impulse, swing ratio (affected/unaffected), weight ratio (affected/ unaffected) None Yes a CVA=cerebrovascular accident. b Statistically significant improvement in experimental group vs control group, as concluded by study authors. Open in new tab Table 3 Characteristics of Temporospatial Biofeedback Studies Study . Study Populationa . No. of Participants (Experimental Group/Control Group) . Age (y) . Protocol . Masking . Method of Delivery . Follow-up . Quantitative Variables . Functional Outcome . Improvementb . Time (min) . Frequency . Duration . Aruin et al6 Adult CVA 8/8 X̅=65 50 Daily 10 d No Auditory None Step width None Yes Montoya et al7 Adult CVA 9/5 X̅=64/60 45 2×/wk 4 wk No Auditory/visual None Step length (paretic limb) None Yes Study . Study Populationa . No. of Participants (Experimental Group/Control Group) . Age (y) . Protocol . Masking . Method of Delivery . Follow-up . Quantitative Variables . Functional Outcome . Improvementb . Time (min) . Frequency . Duration . Aruin et al6 Adult CVA 8/8 X̅=65 50 Daily 10 d No Auditory None Step width None Yes Montoya et al7 Adult CVA 9/5 X̅=64/60 45 2×/wk 4 wk No Auditory/visual None Step length (paretic limb) None Yes a CVA=cerebrovascular accident. b Statistically significant improvement in experimental group vs control group, as concluded by study authors. Open in new tab Table 3 Characteristics of Temporospatial Biofeedback Studies Study . Study Populationa . No. of Participants (Experimental Group/Control Group) . Age (y) . Protocol . Masking . Method of Delivery . Follow-up . Quantitative Variables . Functional Outcome . Improvementb . Time (min) . Frequency . Duration . Aruin et al6 Adult CVA 8/8 X̅=65 50 Daily 10 d No Auditory None Step width None Yes Montoya et al7 Adult CVA 9/5 X̅=64/60 45 2×/wk 4 wk No Auditory/visual None Step length (paretic limb) None Yes Study . Study Populationa . No. of Participants (Experimental Group/Control Group) . Age (y) . Protocol . Masking . Method of Delivery . Follow-up . Quantitative Variables . Functional Outcome . Improvementb . Time (min) . Frequency . Duration . Aruin et al6 Adult CVA 8/8 X̅=65 50 Daily 10 d No Auditory None Step width None Yes Montoya et al7 Adult CVA 9/5 X̅=64/60 45 2×/wk 4 wk No Auditory/visual None Step length (paretic limb) None Yes a CVA=cerebrovascular accident. b Statistically significant improvement in experimental group vs control group, as concluded by study authors. Open in new tab Table 4 Characteristics of Kinetic Biofeedback Studies Study . Study Populationa . No. of Participants (Experimental Group/Control Group) . Age (y) . Protocol . Masking . Method of Delivery . Follow-up . Quantitative Variables . Functional Outcome . Improvementb . Time (min) . Frequency . Duration . Isakov14 Amputation, THR, TKR, hip fracture 24/18 X̅=62/66 30 4 sessions 14 d No Auditory None Weight bearing None Yes White and Lifeso16 THR 12/8/8c X̅=51/60/ 70c 15 3×/wk 8 wk No Verbal/visual None Symmetry indexes for peak force during loading, loading rate, and vertical impulse; rate of perceived exertion Harris Hip Score Yesd Study . Study Populationa . No. of Participants (Experimental Group/Control Group) . Age (y) . Protocol . Masking . Method of Delivery . Follow-up . Quantitative Variables . Functional Outcome . Improvementb . Time (min) . Frequency . Duration . Isakov14 Amputation, THR, TKR, hip fracture 24/18 X̅=62/66 30 4 sessions 14 d No Auditory None Weight bearing None Yes White and Lifeso16 THR 12/8/8c X̅=51/60/ 70c 15 3×/wk 8 wk No Verbal/visual None Symmetry indexes for peak force during loading, loading rate, and vertical impulse; rate of perceived exertion Harris Hip Score Yesd a THR=total hip replacement, TKR=total knee replacement. b Statistically significant improvement in experimental groups vs control group, as concluded by study authors. c Biofeedback experimental group/no-treatment control group/no-biofeedback experimental group. d Authors reported statistically significant improvements in both the biofeedback and no-biofeedback experimental groups. Open in new tab Table 4 Characteristics of Kinetic Biofeedback Studies Study . Study Populationa . No. of Participants (Experimental Group/Control Group) . Age (y) . Protocol . Masking . Method of Delivery . Follow-up . Quantitative Variables . Functional Outcome . Improvementb . Time (min) . Frequency . Duration . Isakov14 Amputation, THR, TKR, hip fracture 24/18 X̅=62/66 30 4 sessions 14 d No Auditory None Weight bearing None Yes White and Lifeso16 THR 12/8/8c X̅=51/60/ 70c 15 3×/wk 8 wk No Verbal/visual None Symmetry indexes for peak force during loading, loading rate, and vertical impulse; rate of perceived exertion Harris Hip Score Yesd Study . Study Populationa . No. of Participants (Experimental Group/Control Group) . Age (y) . Protocol . Masking . Method of Delivery . Follow-up . Quantitative Variables . Functional Outcome . Improvementb . Time (min) . Frequency . Duration . Isakov14 Amputation, THR, TKR, hip fracture 24/18 X̅=62/66 30 4 sessions 14 d No Auditory None Weight bearing None Yes White and Lifeso16 THR 12/8/8c X̅=51/60/ 70c 15 3×/wk 8 wk No Verbal/visual None Symmetry indexes for peak force during loading, loading rate, and vertical impulse; rate of perceived exertion Harris Hip Score Yesd a THR=total hip replacement, TKR=total knee replacement. b Statistically significant improvement in experimental groups vs control group, as concluded by study authors. c Biofeedback experimental group/no-treatment control group/no-biofeedback experimental group. d Authors reported statistically significant improvements in both the biofeedback and no-biofeedback experimental groups. Open in new tab Biofeedback Protocol Generally, there was a large range in the structures of the treatment protocols. The mean treatment time in all studies was 35 minutes, with a range of 15 to 50 minutes, and the mean treatment frequency was 4 times per week, with a range of twice per week to daily treatments. The mean treatment duration was 3.5 weeks, with a range of 1.5 to 8 weeks. The mean cumulative biofeedback time per study (ie, treatment time × treatment frequency × treatment duration) was 397 minutes, with a range of 120 to 900 minutes. Kinematic Biofeedback In 3 studies, kinematic biofeedback was provided with electrogoniometers (Tab. 2). All 3 studies involved analysis of the effect of kinematic biofeedback in participants who had had a stroke. Ceceli et al8 and Morris et al9 analyzed the effectiveness of providing participants (n=41 and 26, respectively) with kinematic biofeedback of the knee compared with conventional physical therapy in efforts to minimize genu recurvatum. Colborne et al2 investigated the effectiveness of providing participants (n=8) with kinematic biofeedback for the ankle in attempts to improve ankle control. Outcome measures included gait speed,2,8,9 number of recurvations,8 and symmetry.2,9 Ceceli et al8 assigned participants to either an experimental group (n=26) or a control group (n=15). Both groups received conventional therapy that consisted of pelvis and hip control exercises, weight shifting, and gait training. In addition, participants in the experimental group received kinematic biofeedback for 10 daily sessions, each lasting 30 minutes. Posttreatment data were collected for participants in the experimental group at the end of the 10 days of biofeedback training; data were collected for participants in the control group at the time of discharge. In the study by Morris et al,9 participants received treatment in 2 separate phases, lasting 4 weeks each. Participants in the experimental group (n=13) received kinematic biofeedback during the first phase and conventional physical therapy during the second phase. Kinematic biofeedback of the involved knee was provided to participants during standing and gait training for 30 to 45 minutes per treatment session. Participants in the control group (n=13) received conventional physical therapy during both phases. Outcome data were collected for all participants at baseline and after each treatment phase. Colborne et al2 used a 3-period crossover design to assess the effectiveness of kinematic biofeedback. The 8 participants received 1 of 3 treatments: kinematic biofeedback, electromyographic biofeedback, and conventional physical therapy. Conventional physical therapy was given during either the first phase (n=4) or the last phase (n=4). Each treatment phase lasted 4 weeks and consisted of biweekly treatment sessions, each lasting 30 minutes. No washout periods were included between treatments. Gait speed data were collected for all participants at baseline, after each treatment phase, and at a 1-month follow-up. Ceceli et al8 found that participants in the experimental group showed a statistically significant decrease in the number of recurvations compared with the control group immediately after treatment—from 45 to 8 recurvations, an 83% decrease, for the experimental group, and from 49 to 39 recurvations, a 19% decrease, for the control group. Additionally, participants were asked to return for a 6-month follow-up. However, we did not calculate ESs or percent differences for 6-month follow-up data because of the poor participant follow-up rate (<50%); with a low follow-up rate, the data might not be a good representation of the data for all participants. Morris et al9 reported a moderate effect for increased gait speed in the experimental group (increase of 0.10 m/s, ES=0.50, 33% increase) but no effect in the control group (increase of 0.01 m/s, ES=0.08, 5% increase) after the first treatment phase. Both groups had similar baseline gait velocities (0.33 m/s in the experimental group and 0.30 m/s in the control group). Both groups showed statistically significant reductions in peak knee extension during stance, although no group difference was noted. After the second treatment phase, a large increase in gait speed was reported in the experimental group (increase of 0.23 m/s, ES=1.45, 75% increase), but only a small change was reported in the control group (increase of 0.10 m/s, ES=0.46, 37% increase). Additionally, participants in the experimental group showed a statistically significant decrease in peak knee extension compared with participants in the control group. Effect sizes and percent differences for peak knee extension could not be calculated because of a lack of data. Colborne et al2 found that kinematic biofeedback training resulted in a moderate increase in gait speed (increase of 0.11 m/s, ES=0.51, 23% increase) but that conventional therapy resulted in only a small improvement (increase of 0.08 m/s, ES=0.37, 17% increase). Participants in both of those treatment groups had the same baseline gait speed (0.48 m/s). We did not interpret the follow-up data because carryover effects for either or both treatment methods might have occurred as a result of the crossover design of the study.24 Temporospatial Biofeedback In 2 studies, temporospatial biofeedback was provided for participants after stroke (Tab. 3). Aruin et al6 investigated the effectiveness of biofeedback regarding the base of support in 16 participants, and Montoya et al7 analyzed the effectiveness of biofeedback regarding step length in 14 participants. Biofeedback was provided in efforts to improve the base of support6 and the symmetry of step length.7 Outcome measures included step width6 and step length.7 Aruin et al6 randomly placed participants in either an experimental group (n=8) or a control group (n=8). Both groups received conventional physical therapy twice daily for 25 minutes for 10 days. Conventional physical therapy consisted of weight shifting, trunk stabilization, lower-extremity muscle facilitation, and gait training. Participants in the experimental group received biofeedback on their base of support through sensors placed around the proximal leg. These sensors provided participants with an auditory signal when their base of support was below an established threshold. Data on the base of support were collected for all participants at baseline and 10 days after the start of treatment. Montoya et al7 placed participants in either an experimental group (n=9) or a control group (n=5). Participants in the experimental group received biofeedback 2 times per week for 4 weeks for a total of 8 sessions. Participants in the control group practiced walking at the same dosage but without biofeedback. Both groups also participated in a standardized rehabilitation program while enrolled in the study. Step-length biofeedback, with visual and auditory signals provided from a lighted walkway, was provided to participants in the experimental group. Step-length data were collected for all participants at baseline and at the beginning and the end of each treatment session (n=8). Aruin et al6 reported large improvements in step width in both the experimental group and the control group. However, the experimental group showed a larger improvement in step width (increase of 0.07 m, ES=12.7, 78% increase) than the control group (increase of 0.03 m, ES=8.57, 30% increase). Both groups had similar baseline step widths (0.09 m in the experimental group and 0.10 m in the control group). Effect sizes for both groups were quite large because of very small reported standard deviations. Montoya et al7 also reported large improvements in step length in both the experimental group and the control group. Likewise, the experimental group showed a larger improvement in step length (increase of 0.26 m, ES=11.1, 79% increase) than the control group (increase of 0.12 m, ES=2.49, 43% increase). Both groups had similar baseline step lengths (0.34 m in the experimental group and 0.28 m in the control group). Again, ESs for both groups were quite large because of small reported standard deviations. Neither study included a follow-up assessment. Kinetic Biofeedback Participants were provided with kinetic biofeedback in 2 studies (Tab. 4). Isakov14 investigated the effectiveness of kinetic biofeedback in a disparate group of participants (n=42) who had undergone a total hip or knee replacement or a recent amputation or had had a femoral neck fracture. White and Lifeso16 analyzed the effectiveness of kinetic biofeedback in participants (n=28) after a total hip replacement. Biofeedback was provided either to increase the overall amount of weight placed on an involved lower extremity14 or to promote kinetic symmetry between limbs.16 Outcome measures included changes in weight bearing14 and symmetry for the peak force during the loading phase, loading rate, and vertical impulse.16 White and Lifeso16 also included a functional outcome measure, the Harris Hip Score.25 Isakov14 randomly assigned participants to an experimental group (n=24) or a control group (n=18). Participants in the experimental group received biofeedback for 30 minutes in 4 physical therapy sessions during a 2-week period. Participants in the control group received conventional gait therapy to promote full weight bearing. Participants were given kinetic biofeedback through an in-shoe device that provided auditory feedback to promote an increase in weight bearing during gait training. Kinetic data were collected for all participants at baseline and immediately after treatment. White and Lifeso16 assigned participants to 1 of 3 groups: a biofeedback group (n=12), a no-biofeedback comparison group (n=8), and a no-treatment control group (n=8). Participants in the biofeedback and no-biofeedback comparison groups trained on a treadmill 3 times per week for 8 weeks for a total of 24 sessions. Participants were given kinetic biofeedback through a monitor that provided real-time visual displays of bar graphs representing the peak force during the first half of stance (ie, the loading response). In addition, participants receiving biofeedback were given verbal cues aimed at improving kinetic symmetry. Outcome data were collected for all participants at baseline and after treatment. Isakov14 reported a statistically significant difference between the experimental group and the control group in improvements in weight bearing during gait. The average increase in weight bearing in participants in the experimental group was 7.9 kg, but participants in the control group did not show a meaningful change (increase of 0.7 kg). Effect sizes and percent differences could not be calculated because of a lack of critical variables. White and Lifeso16 reported that participants in the biofeedback group showed significant improvements in symmetry for the loading rate (decrease of 15%, ES=4.0, 62% improvement in symmetry) and vertical impulse (decrease of 6.1%, ES=4.7, 80% improvement in symmetry). Participants in the no-biofeedback comparison group also showed an improvement in loading rate symmetry (decrease of 9.1%, ES=1.46, 35% improvement in symmetry) but showed no change in peak force or vertical impulse. No changes in symmetry indices for any of the outcome measures were noted for participants in the no-treatment control group. Neither study included a follow-up assessment. Discussion The specific aim of this review was to summarize and synthesize the findings of studies involving real-time kinematic, temporospatial, and kinetic biofeedback. The goal was to provide a general overview of the effectiveness of these forms of biofeedback in treating gait abnormalities. Effect sizes and percent differences suggested that kinematic, temporospatial, and kinetic biofeedback resulted in moderate to large short-term treatment effects, indicating greater success for biofeedback than for conventional therapy. Kinematic and temporospatial biofeedback training interventions were used for participants after stroke, whereas kinetic biofeedback was used for participants who had undergone a total hip or knee replacement or an amputation or had had a recent hip fracture. This review highlights the need for further research on real-time biofeedback to determine whether kinematic, temporospatial, or kinetic biofeedback or a combination of these techniques results in motor learning. Only 3 of the 7 studies included a long-term follow-up assessment.2,8,9 Morris et al9 reported that treatment effects were even larger at a 4-week follow-up assessment than they were immediately after treatment. They believed that this result might have been due to participants who received biofeedback having difficulty transferring gait changes from the feedback condition to the testing condition (no feedback). Morris et al9 further suggested that lower performance at the assessment immediately after treatment than at the 4-week follow-up assessment might have been due to participants becoming dependent on receiving biofeedback in order to alter gait effectively. The control group did not experience this effect because the testing condition was similar to the training condition. It was first suggested by Salmoni et al26 that concurrent feedback could impede motor learning by preventing the processing of other sensory information. The follow-up assessment by Colborne et al2 was limited by the crossover design of the study, which made it difficult to separate the individual effects of the treatments. Likewise, the follow-up assessment by Ceceli et al8 was limited because of a poor response rate (<50%), which limited the demonstration of any potential learning effects. Therefore, the long-term successes of kinematic, temporospatial, and kinetic biofeedback methods are unclear at present. The results of Morris et al9 might indicate that positive changes can be maintained, at least for a few weeks. However, it is impossible to generalize about whether motor learning truly occurred in the balance of the studies reviewed because of a lack of retention testing across the studies. Because the purpose of biofeedback is to promote the learning of a meaningful and permanent change in gait, such follow-up testing should be included in future research. The treatment protocols for each method varied in terms of treatment time per session, treatment frequency (ie, sessions per week), and treatment duration (ie, total number of weeks). Some investigators chose a shorter treatment time per session (ie, 15–30 minutes) and a lower treatment frequency (ie, 2 or 3 sessions per week),2,14,16 whereas another study with a similar treatment time per session had daily treatment.8 Moreover, some studies with a longer treatment time per session (ie, 45–50 minutes) had a variety of treatment frequencies, ranging from as little as 2 times per week to daily treatment.6,7,9 In several studies, biofeedback treatment was combined with standard physical therapy, so that the actual duration of the biofeedback treatment was not specifically reported. Therefore, we are unable to suggest an optimal biofeedback treatment protocol on the basis of the body of literature included in this review. Future studies should incorporate treatment protocols founded on sound physiological principles and reflecting common scheduling practices currently used in health care. Limitations of Existing Studies Randomized controlled designs are regarded as the gold standard in terms of providing the best evidence about the effectiveness of a particular treatment. The majority of the studies included in this review had control groups.6–9,14,16 Despite the presence of a control group, the results of a few studies should be interpreted with caution. The study by White and Lifeso16 had inadequate randomization. In that study, differences in age among the no-treatment control group (60 years), the no-biofeedback comparison group (70 years), and the biofeedback group (51 years) could have resulted in age being a confounding factor. Furthermore, the biofeedback and no-feedback comparison groups differed from the control group in terms of baseline function as defined by the Harris Hip Score.25 Isakov14 provided data only for pretest and posttest changes and did not provide the exact baseline and posttreatment data. Therefore, we could not determine whether the treatment and control groups had similar baseline values for the outcome variables. Potential baseline differences might be confounding factors affecting the outcome of retraining studies and could lead to misleading conclusions about the effects of biofeedback. Colborne et al2 used a crossover design, in which participants acted as their own control and received both biofeedback and conventional therapy during the study. This study design might have limited the ability to fully separate the treatment effects of biofeedback and conventional therapy and might also have made it difficult to identify which treatment was the source of any permanent changes (ie, motor learning). Interactive or additive effects of physical therapy, biofeedback, and time might have occurred. None of the studies explicitly included motor learning concepts in the study design. Winstein et al27 reported that concurrent feedback led to good performance on a partial–weight-bearing task during the acquisition phase. However, the removal of this guidance led to a degradation of performance during retention testing. This phenomenon is well known in the motor learning literature. In particular, Swinnen28 suggested that researchers regularly expose learners to nonaugmented conditions to avoid dependence on augmented feedback. White and Lifeso16 were the only investigators to expose participants to nonaugmented conditions. In that study, participants receiving biofeedback walked in 5-minute blocks for a total of 15 minutes. During each block, participants walked for 3 minutes with feedback and for 2 minutes without feedback. Motor learning principles suggest that this type of design would be a key component of a successful program. Janelle et al29 tested a novel method of presenting augmented feedback to participants by allowing them to self-control feedback scheduling. The results of that study indicated that participants in the self-control group performed better on retention tests than participants who received different forms of scheduled or random feedback. They suggested that self-controlled feedback provides an environment in which participants play a more active role in their learning, thus resulting in improved motor performance and motor learning. The majority of the studies included only immediate retention testing after biofeedback intervention. Therefore, their results were limited to providing evidence of short-term changes in motor performance. It is possible that temporary practice effects associated with biofeedback training had yet to subside and thus influenced the results. The inclusion of longer-term retention intervals (eg, 6-months or 1 year) in biofeedback study designs is essential to determining whether motor learning has occurred as a result of the biofeedback. In all of the studies assessing gait changes after kinematic biofeedback in participants after stroke, gait speed was used as the primary outcome measure. Schmid et al30 reported that significant gains in gait speed were associated with meaningful improvements in function and quality of life. However, gait speed alone does not reveal changes in coordination in walking or reflect motor learning. Gait outcome measures such as the Tinetti Performance-Oriented Mobility Assessment31 and the Gait Assessment Rating Scale32 can provide some additional information regarding changes in movement patterns on the basis of a clinical evaluation. Recent advances in technology also have made it possible for researchers and clinicians to collect temporospatial values more easily by using tools such as the GAITRite System* or the GaitMat II.† A 3-dimensional analysis also can provide researchers and clinicians with a detailed kinematic and kinetic gait analysis. However, this type of analysis requires more expensive equipment and advanced training. Two of the 7 studies included functional outcome measures to assess improvements in function related to gait retraining.9,16 In the study by Morris et al,9 participants were assessed after stroke with the Motor Assessment Scale,33 and White and Lifeso16 assessed participants after total hip replacement by using the Harris Hip Score.25 Functional outcome measures specific to a participant population may be helpful in indicating quality of life and thus positive changes in function associated with biofeedback training. Limitations of This Systematic Review The results of this systematic review are limited to studies that were written in the English language and included in the MEDLINE, CINAHL, and Cochrane databases or the reference lists of review articles identified in those databases. Other studies may exist outside these resources. Selection bias is another potential limitation of systematic reviews. However, we attempted to minimize this limitation by using the MINORS instrument, which was designed to assess the methodological quality of both randomized and nonrandomized studies. Although nonrandomized studies were not included in this review, we did not make a specific methodological decision to exclude them; they were indirectly excluded as a result of their low MINORS scores. Publication bias is another potential limitation of any type of literature review. Frequently, only studies demonstrating positive results are submitted to peer-reviewed journals and published. This situation may bias results toward positive treatment effects. However, this limitation is impossible to quantify. Clinical Implications On the basis of the current literature, there are insufficient data to make a recommendation in the form of a clinical practice guideline. Despite this shortcoming, we recommend that clinicians using real-time biofeedback select outcome measures capable of revealing changes in coordination during walking. Additionally, clinicians should consider incorporating motor learning principles into their treatment protocols to provide clients with a practice environment that promotes motor learning. Clinicians should consider using faded feedback schedules along with random and variable practice to promote improved performance during retention testing.34 Clinicians should also consider informing clients about the potential negative aspect of concurrent feedback to minimize its impact on learning.28 Future Directions Few studies have investigated the effectiveness of real-time kinematic, temporospatial, and kinetic biofeedback. Despite the small number of studies, this systematic review indicated that these methods of biofeedback were capable of providing moderate to large short-term treatment effects. Therefore, future research is warranted to provide clarity regarding the potential long-term benefits of real-time biofeedback for gait retraining. On the basis of the results of this systematic review, several recommendations for future research can be made. Future work should include adequate randomization to ensure that both experimental and control groups are equivalent at baseline, before biofeedback intervention. Researchers should incorporate existing motor learning concepts into study designs to minimize the negative effects of real-time feedback while maximizing the benefits. Future studies also should include multiday retention testing (eg, at 6 months or 1 year) to assess the learning of gait changes. Evidence of permanent changes (ie, motor learning) is urgently needed to support the continued use of biofeedback in rehabilitation settings. To obtain such evidence, researchers should include outcome measures that provide more information about coordination during gait and overall walking function. Conclusions Real-time kinematic, temporospatial, and kinetic biofeedback appears to result in short-term moderate to large treatment effects. However, it is unknown whether treatment changes are maintained. Several studies lacked adequate randomization, a fact that should caution readers when interpreting the authors’ conclusions. Future studies should ensure adequate randomization of participants as well as the implementation of motor learning concepts and the inclusion of retention testing to assess the long-term success of biofeedback. They also should include outcome measures capable of demonstrating coordinative changes in gait and improvements in function. The Bottom Line What do we already know about this topic? Over the past 30 years, many different types of real-time biofeedback have been used by both researchers and clinicians in the treatment of gait abnormalities in different patient groups. What new information does this study offer? This systematic review of published studies involving real-time kinematic, temporospatial, or kinetic biofeedback found consistent evidence of short-term improvements in gait. However, no conclusive evidence was found regarding the long-term effects of real-time biofeedback. If you’re a patient, what might these findings mean for you? Some patients with specific gait abnormalities may benefit from the use of real-time biofeedback. However, patients should keep in mind that it is still unknown whether the short-term changes are retained in the longer term. * " EQ Inc, PO Box 16, Chalfont, PA 18914. † " CIR Systems Inc, 60 Garlor Dr, Havertown, PA 19083. References 1 Basmajian JV Kukulka CG Narayan MG Takebe K . Biofeedback treatment of foot-drop after stroke compared with standard rehabilitation technique: effects on voluntary control and strength . Arch Phys Med Rehabil . 1975 ; 56 : 231 – 236 . Google Scholar PubMed OpenURL Placeholder Text WorldCat 2 Colborne GR Olney SJ Griffin MP . Feedback of ankle joint angle and soleus electromyography in the rehabilitation of hemiplegic gait . Arch Phys Med Rehabil . 1993 ; 74 : 1100 – 1106 . Google Scholar Crossref Search ADS PubMed WorldCat 3 Intiso D Santilli V Grasso MG , et al. . Rehabilitation of walking with electromyographic biofeedback in foot-drop after stroke . Stroke . 1994 ; 25 : 1189 – 1192 . Google Scholar Crossref Search ADS PubMed WorldCat 4 Binder SA Moll CB Wolf SL . Evaluation of electromyographic biofeedback as an adjunct to therapeutic exercise in treating the lower extremities of hemiplegic patients . Phys Ther . 1981 ; 61 : 886 – 893 . Google Scholar Crossref Search ADS PubMed WorldCat 5 Burnside IG Tobias HS Bursill D . Electromyographic feedback in the remobilization of stroke patients: a controlled trial . Arch Phys Med Rehabil . 1982 ; 63 : 217 – 222 . Google Scholar PubMed OpenURL Placeholder Text WorldCat 6 Aruin AS Hanke TA Sharma A . Base of support feedback in gait rehabilitation . Int J Rehabil Res . 2003 ; 26 : 309 – 312 . Google Scholar PubMed OpenURL Placeholder Text WorldCat 7 Montoya R Dupui P Pages B Bessou P . Step-length biofeedback device for walk rehabilitation . Med Biol Eng Comput . 1994 ; 32 : 416 – 420 . Google Scholar Crossref Search ADS PubMed WorldCat 8 Ceceli E Dursun E Cacki A . Comparison of joint-position biofeedback and conventional therapy methods in genu recurvatum after stroke: 6 months’ follow-up . Eur J Phys Med Rehabil . 1996 ; 6 : 141 – 144 . OpenURL Placeholder Text WorldCat 9 Morris ME Matyas TA Bach TM Goldie PA . Electrogoniometric feedback: its effect on genu recurvatum in stroke . Arch Phys Med Rehabil . 1992 ; 73 : 1147 – 1154 . Google Scholar PubMed OpenURL Placeholder Text WorldCat 10 Cozean CD Pease WS Hubbell SL . Biofeedback and functional electric stimulation in stroke rehabilitation . Arch Phys Med Rehabil . 1988 ; 69 : 401 – 405 . Google Scholar PubMed OpenURL Placeholder Text WorldCat 11 Mandel AR Nymark JR Balmer SJ , et al. . Electromyographic versus rhythmic positional biofeedback in computerized gait retraining with stroke patients . Arch Phys Med Rehabil . 1990 ; 71 : 649 – 654 . Google Scholar PubMed OpenURL Placeholder Text WorldCat 12 Bradley L Hart BB Mandana S , et al. . Electromyographic biofeedback for gait training after stroke . Clin Rehabil . 1998 ; 12 : 11 – 22 . Google Scholar Crossref Search ADS PubMed WorldCat 13 Colborne GR Wright FV Naumann S . Feedback of triceps surae EMG in gait of children with cerebral palsy: a controlled study . Arch Phys Med Rehabil . 1994 ; 75 : 40 – 45 . Google Scholar PubMed OpenURL Placeholder Text WorldCat 14 Isakov E . Gait rehabilitation: a new biofeedback device for monitoring and enhancing weight-bearing over the affected lower limb . Eura Medicophys . 2007 ; 43 : 21 – 26 . Google Scholar PubMed OpenURL Placeholder Text WorldCat 15 Petrofsky JS . The use of electromyogram biofeedback to reduce Trendelenburg gait . Eur J Appl Physiol . 2001 ; 85 : 491 – 495 . Google Scholar Crossref Search ADS PubMed WorldCat 16 White SC Lifeso RM . Altering asymmetric limb loading after hip arthroplasty using real-time dynamic feedback when walking . Arch Phys Med Rehabil . 2005 ; 86 : 1958 – 1963 . Google Scholar Crossref Search ADS PubMed WorldCat 17 Basmajian JV . Introduction: principles and background . In: Basmajian JV ed. Biofeedback: Principles and Practice for Clinicians . 3rd ed. Baltimore, MD : Williams & Wilkins ; 1989 : 1 – 4 . Google Scholar Google Preview OpenURL Placeholder Text WorldCat COPAC 18 Bottomley JM . Biofeedback: connecting the mind and body . In: Davis CM ed. Complementary Therapies in Rehabilitation . 2nd ed. Thorofare, NJ : Slack Inc ; 2003 : 131 – 156 . Google Scholar Google Preview OpenURL Placeholder Text WorldCat COPAC 19 Davis IS . Gait retraining in runners . Orthopedic Physical Therapy . 2005 ; 17 : 8 – 13 . OpenURL Placeholder Text WorldCat 20 Woodford H Price C . EMG biofeedback for the recovery of motor function after stroke . Cochrane Database Syst Rev . 2007 ; 2 : CD004585 . OpenURL Placeholder Text WorldCat 21 Moreland JD Thomson MA Fuoco AR . Electromyographic biofeedback to improve lower extremity function after stroke: a meta-analysis . Arch Phys Med Rehabil . 1998 ; 79 : 134 – 140 . Google Scholar Crossref Search ADS PubMed WorldCat 22 Slim K Nini E Forestier D , et al. . Methodological Index for Non-randomized Studies (MINORS): development and validation of a new instrument . ANZ J Surg . 2003 ; 73 : 712 – 716 . Google Scholar Crossref Search ADS PubMed WorldCat 23 Cohen J . Statistical Power Analysis for the Behavioral Sciences . 2nd ed. Hillsdale, NJ : Lawrence Erlbaum Associates ; 1988 . Google Scholar Google Preview OpenURL Placeholder Text WorldCat COPAC 24 Woods JR Williams JG Tavel M . The two-period crossover design in medical research . Ann Intern Med . 1989 ; 110 : 560 – 566 . Google Scholar Crossref Search ADS PubMed WorldCat 25 Harris WH . Traumatic arthritis of the hip after dislocation and acetabular fractures: treatment by mold arthroplasty—an end-result study using a new method of result evaluation . J Bone Joint Surg Am . 1969 ; 51 : 737 – 755 . Google Scholar Crossref Search ADS PubMed WorldCat 26 Salmoni AW Schmidt RA Walter CB . Knowledge of results and motor learning: a review and critical reappraisal . Psychol Bull . 1984 ; 95 : 355 – 386 . Google Scholar Crossref Search ADS PubMed WorldCat 27 Winstein CJ Pohl PS Cardinale C , et al. . Learning a partial-weight-bearing skill: effectiveness of two forms of feedback . Phys Ther . 1996 ; 76 : 985 – 993 . Google Scholar Crossref Search ADS PubMed WorldCat 28 Swinnen SP . Information feedback for motor skill learning: a review . In: Zelaznik HN ed. Advances in Motor Learning and Control . Champaign, IL : Human Kinetics ; 1996 : 37 – 65 . Google Scholar Google Preview OpenURL Placeholder Text WorldCat COPAC 29 Janelle CM Kim J Singer RN . Subject-controlled performance feedback and learning of a closed motor skill . Percept Mot Skills . 1995 ; 81 : 627 – 634 . Google Scholar Crossref Search ADS PubMed WorldCat 30 Schmid A Duncan PW Studenski S , et al. . Improvements in speed-based gait classifications are meaningful . Stroke . 2007 ; 38 : 2096 – 2100 . Google Scholar Crossref Search ADS PubMed WorldCat 31 Tinetti ME . Performance-oriented assessment of mobility problems in elderly patients . J Am Geriatr Soc . 1986 ; 34 : 119 – 126 . Google Scholar Crossref Search ADS PubMed WorldCat 32 Wolfson L Whipple R Amerman P Tobin JN . Gait assessment in the elderly: a gait abnormality rating scale and its relation to falls . J Gerontol . 1990 ; 45 : M12 – M19 . Google Scholar Crossref Search ADS PubMed WorldCat 33 Carr JH Shepherd RB Nordholm L Lynne D . Investigation of a new motor assessment scale for stroke patients . Phys Ther . 1985 ; 65 : 175 – 180 . Google Scholar Crossref Search ADS PubMed WorldCat 34 Rose DJ Christina RW . Augmented Feedback and Motor Learning: A Multilevel Approach to the Study of Motor Control and Learning . 2nd ed. San Francisco, CA : Benjamin Cummings ; 2006 : 291 – 320 . Google Scholar Google Preview OpenURL Placeholder Text WorldCat COPAC Author notes " Both authors provided concept/idea/research design, writing, and data analysis. Mr Tate provided data collection. © 2010 American Physical Therapy Association

Blaney,, Janine;Lowe-Strong,, Andrea;Rankin,, Jane;Campbell,, Anna;Allen,, James;Gracey,, Jackie

doi: 10.2522/ptj.20090278pmid: 20558566

Background Despite the evidence to support exercise as an effective management strategy for patients with cancer-related fatigue (CRF), many of the general cancer population are sedentary. Objective The aim of this study was to explore the barriers to and facilitators of exercise among a mixed sample of patients with CRF. Design An exploratory, descriptive, qualitative design was used. Methods Purposive sampling methods were used to recruit patients with CRF who were representative of the cancer trajectory, that is, survivors of cancer and patients in palliative care who were recently diagnosed and undergoing treatment. Focus group discussions were transcribed verbatim and analyzed using a grounded theory approach. Lower-level concepts were identified and ordered into subcategories. Related subcategories then were grouped to form the main categories, which were linked to the core category. Results Five focus groups were conducted with 26 participants. Within the core category of the cancer rehabilitation journey were 3 main categories: (1) exercise barriers, (2) exercise facilitators, and (3) motivators of exercise. Exercise barriers were mainly related to treatment side effects, particularly fatigue. Fatigue was associated with additional barriers such as physical deconditioning, social isolation, and the difficulty of making exercise a routine. Environmental factors and the timing of exercise initiation also were barriers. Exercise facilitators included an exercise program being group-based, supervised, individually tailored, and gradually progressed. Exercise motivators were related to perceived exercise benefits. Conclusions Individuals with CRF have numerous barriers to exercise, both during and following treatment. The exercise facilitators identified in this study provide solutions to these barriers and may assist with the uptake and maintenance of exercise programs. These findings will aid physical therapists in designing appropriate exercise programs for patients with CRF. Cancer-related fatigue (CRF) is defined as “a persistent, subjective sense of physical, emotional, or cognitive tiredness or exhaustion related to cancer and cancer treatment that is not proportionate to activity and interferes with normal functioning.”1 It is thought to affect between 70% and 100% of patients with cancer2 and is commonly acknowledged as the most troublesome side effect of cancer and its treatment,3,4 which has a great impact on patients’ global quality of life (QoL).5 An interest in and drive to manage CRF have evolved over recent years, likely due to the realization of the scale and burden of CRF and the classification of cancer as a chronic illness6 within an aging population.7 Recent research has refuted previous recommendations of using rest as a management strategy for CRF due to its detrimental effects on the musculoskeletal system,8,9 cardiopulmonary fitness,10 and functional status11 and has progressed to the opposite end of the continuum by advocating exercise and physical activity. Exercise has been the most studied management modality12 and has shown positive results in decreasing fatigue13–16 and improving physical functioning,17–19 cardiopulmonary functioning,20 and QoL status,15,21,22 thus counteracting the side effects induced by surgery and anti-cancer treatments. Despite these positive findings, at least one third of patients with cancer decrease their levels of physical activity following diagnosis,23 which often is not reinstated, even years after treatment has ended.24 Additionally, a recent population-based study showed that up to 70% of patients with cancer were not meeting the US national recommendations for exercise.25 Because many factors may influence this decline in physical activity and progression toward sedentary living, researchers have initiated the groundwork and begun to qualitatively explore the reasons behind this decline. Although existing research in this area provides some insight into this phenomenon, it remains at an early stage for several reasons. First, much of the research has focused on the barriers to and facilitators of exercise among patients with breast cancer26–31 or colorectal cancer32 who were either exercising independently27 or had participated in an exercise intervention trial.3,26,30,32,33 Such findings may not be transferable to the general population with cancer, as exercise does not currently appear as an integral part of cancer care.34 Second, although CRF has been reported as one of the main barriers to exercise among patients with cancer,35–37 all of the aforementioned studies failed to recruit patients who were experiencing fatigue or failed to report whether they were experiencing fatigue at the time the research was conducted. Furthermore, although it is thought that fatigue intensity may vary by cancer stage,38many of the aforementioned studies did not identify the staging of their samples.3,27,28,31 Therefore, the aim of the current study was to address these important methodological issues by exploring the barriers to and facilitators of exercise among patients who were experiencing CRF and were representative of the cancer trajectory. We also aimed to elicit information that would assist oncology physical therapists and researchers with the future design and delivery of exercise programs for individuals with CRF. Method The data reported in this article were part of a broader qualitative study that explored the overall experience of CRF and its impact on QoL.39 This article, however, addresses the specific issues surrounding the barriers to and facilitators of exercise for patients with CRF. To address the aims of the study, an exploratory, descriptive, qualitative design was undertaken, using focus groups as a data collection strategy. To ensure participants were representative of the cancer trajectory (ie, patients recently diagnosed with cancer, survivors of cancer, and patients in palliative care) and to gain multiple viewpoints, purposive sampling methods were used across 3 sites. Patients who were recently diagnosed and undergoing treatment were recruited through the Regional Cancer Centre in Belfast. Survivors of cancer were those who had completed treatment and were members of a local supportive care charity. Patients in palliative care were recruited through a local hospice at a day therapy unit that provided multidisciplinary palliative care services. Eligible participants were those over 18 years of age, with a previous or current diagnosis of cancer, and who were identified as having CRF as defined by the National Comprehensive Cancer Network (NCCN).1 Participants were asked to score their fatigue on the Oncology Nursing Society (ONS) Fatigue Scale. The ONS Fatigue Scale is a number or picture visual analog scale ranging from 0 (“no fatigue”) to 10 (“the worst fatigue”) and categorizes fatigue as mild (1–3), moderate (4–6), or severe (7–10). To ensure participants were purely experiencing CRF, individuals diagnosed with a fatigue-related comorbidity (eg, multiple sclerosis, fibromyalgia, chronic fatigue syndrome) were excluded. Once interested individuals were screened for their eligibility, procedures of informed consent were undertaken. Those individuals who consented were invited to attend a focus group at the site from which they were recruited. Prior to the focus group commencing, participants completed a short, investigator-developed questionnaire that gathered information on fatigue intensity (ONS Fatigue Scale), frequency, demographic and medical information, and physical activity levels before and after diagnosis. For the duration of the focus groups, participants were seated in a circular format. Each focus group was conducted by an experienced and independent facilitator and audiorecorded. The first half of the discussions explored participants’ experience with CRF and its impact on QoL. Participants were asked “If you were to describe CRF to someone who knew nothing about it, what would you say?” and probing questions were used to elaborate on the important points raised. However, the focus of the current article is concerned with the second half of the focus groups, which used an interview guide (Tab. 1) to investigate the barriers to and facilitators of exercise. The interview guide was based on social cognitive theory (SCT)40 constructs as defined by Glanz et al41 and advocated by Rogers et al.31 Social cognitive theory is based on a model of triadic reciprocality in which behavioral, cognitive, and personal factors and environmental events all act as determinants of each other,40 whereby self-efficacy is the central concept.42 Five focus groups were conducted to reach saturation: 2 with survivors of cancer, 2 with patients in palliative care, and 1 with patients who were recently diagnosed and undergoing treatment. Each focus group discussion lasted an average of 76 minutes (range=69–84), with 3 to 8 people in each group. Table 1 Interview Guide Social Cognitive Theory Constructsa . Explanation of Constructs . Questions Based on the Social Cognitive Theory Constructs . Behavioral capability Knowledge and skill required to take part in physical activity What type of exercise or physical activity (eg, walking, cycling, swimming) did you enjoy in the past or at present? Do you think you could carry out this type of exercise or physical activity if having a bad day with fatigue? Environment External factors influencing physical activity What do you feel are the main issues that would prevent you from exercising or taking part in a physical activity? Can anything be done to overcome these issues? Self-efficacy Confidence in a person’s ability to take part in physical activity If an exercise program were designed to suit your preferences and needs, how confident would you be in participating? Think back over the period from when you were diagnosed, through treatment, and up until now. When do you feel would be the ideal time to take part in an exercise program, if at all? Expectations Anticipatory outcomes of physical activity What do you think the benefits of exercising would be? Expectancies Value of the outcome What would be the most important exercise benefit for you personally? Self-control and performance Goal-directed behavior or performance What exercise goals, if any, would you set for yourself at present? Why would these goals be important? Reinforcement Responses to a person’s physical activity behavior that increase or decrease the likelihood of reoccurrence How would you feel if you achieved your exercise goals? How would you motivate yourself to reach your goals (eg, rewards, benefit to health)? Observational learning Occurs by watching the outcome of others’ behavior What do you think could be gained through group exercise? Social Cognitive Theory Constructsa . Explanation of Constructs . Questions Based on the Social Cognitive Theory Constructs . Behavioral capability Knowledge and skill required to take part in physical activity What type of exercise or physical activity (eg, walking, cycling, swimming) did you enjoy in the past or at present? Do you think you could carry out this type of exercise or physical activity if having a bad day with fatigue? Environment External factors influencing physical activity What do you feel are the main issues that would prevent you from exercising or taking part in a physical activity? Can anything be done to overcome these issues? Self-efficacy Confidence in a person’s ability to take part in physical activity If an exercise program were designed to suit your preferences and needs, how confident would you be in participating? Think back over the period from when you were diagnosed, through treatment, and up until now. When do you feel would be the ideal time to take part in an exercise program, if at all? Expectations Anticipatory outcomes of physical activity What do you think the benefits of exercising would be? Expectancies Value of the outcome What would be the most important exercise benefit for you personally? Self-control and performance Goal-directed behavior or performance What exercise goals, if any, would you set for yourself at present? Why would these goals be important? Reinforcement Responses to a person’s physical activity behavior that increase or decrease the likelihood of reoccurrence How would you feel if you achieved your exercise goals? How would you motivate yourself to reach your goals (eg, rewards, benefit to health)? Observational learning Occurs by watching the outcome of others’ behavior What do you think could be gained through group exercise? a Social cognitive theory constructs adapted from Glanz et al.41 Open in new tab Table 1 Interview Guide Social Cognitive Theory Constructsa . Explanation of Constructs . Questions Based on the Social Cognitive Theory Constructs . Behavioral capability Knowledge and skill required to take part in physical activity What type of exercise or physical activity (eg, walking, cycling, swimming) did you enjoy in the past or at present? Do you think you could carry out this type of exercise or physical activity if having a bad day with fatigue? Environment External factors influencing physical activity What do you feel are the main issues that would prevent you from exercising or taking part in a physical activity? Can anything be done to overcome these issues? Self-efficacy Confidence in a person’s ability to take part in physical activity If an exercise program were designed to suit your preferences and needs, how confident would you be in participating? Think back over the period from when you were diagnosed, through treatment, and up until now. When do you feel would be the ideal time to take part in an exercise program, if at all? Expectations Anticipatory outcomes of physical activity What do you think the benefits of exercising would be? Expectancies Value of the outcome What would be the most important exercise benefit for you personally? Self-control and performance Goal-directed behavior or performance What exercise goals, if any, would you set for yourself at present? Why would these goals be important? Reinforcement Responses to a person’s physical activity behavior that increase or decrease the likelihood of reoccurrence How would you feel if you achieved your exercise goals? How would you motivate yourself to reach your goals (eg, rewards, benefit to health)? Observational learning Occurs by watching the outcome of others’ behavior What do you think could be gained through group exercise? Social Cognitive Theory Constructsa . Explanation of Constructs . Questions Based on the Social Cognitive Theory Constructs . Behavioral capability Knowledge and skill required to take part in physical activity What type of exercise or physical activity (eg, walking, cycling, swimming) did you enjoy in the past or at present? Do you think you could carry out this type of exercise or physical activity if having a bad day with fatigue? Environment External factors influencing physical activity What do you feel are the main issues that would prevent you from exercising or taking part in a physical activity? Can anything be done to overcome these issues? Self-efficacy Confidence in a person’s ability to take part in physical activity If an exercise program were designed to suit your preferences and needs, how confident would you be in participating? Think back over the period from when you were diagnosed, through treatment, and up until now. When do you feel would be the ideal time to take part in an exercise program, if at all? Expectations Anticipatory outcomes of physical activity What do you think the benefits of exercising would be? Expectancies Value of the outcome What would be the most important exercise benefit for you personally? Self-control and performance Goal-directed behavior or performance What exercise goals, if any, would you set for yourself at present? Why would these goals be important? Reinforcement Responses to a person’s physical activity behavior that increase or decrease the likelihood of reoccurrence How would you feel if you achieved your exercise goals? How would you motivate yourself to reach your goals (eg, rewards, benefit to health)? Observational learning Occurs by watching the outcome of others’ behavior What do you think could be gained through group exercise? a Social cognitive theory constructs adapted from Glanz et al.41 Open in new tab Data Analysis Questionnaire data were input into the Statistical Package for the Social Sciences for Windows (version 14),* and descriptive statistics were generated. All audio recordings were transcribed verbatim and validated by a second researcher through direct comparisons of the audio recordings and the transcriptions. To add methodological rigor to the study and reduce researcher bias, independent analysis was carried out by both the first author and the focus group facilitator, and a consensus was reached. Data were analyzed manually using the constant comparative analysis of grounded theory, which involved the continual questioning of what was occurring in the data.43 Such questioning allows the objectivity and sensitivity of the data to be upheld and reduces researcher bias.43 During the initial process of open coding, transcripts were analyzed line by line, allowing the data to be fractured and identifying emerging lower-level concepts.43 These concepts were highlighted and labeled within the text. Memos were used to record initial thoughts and ideas surrounding lower-levels concepts as their properties and dimensions materialized. Axial coding (Figure) then allowed the data to be reassembled,43 whereby lower-level concepts were extracted and conceptually grouped into subcategories and then categories. Following these procedures, selective coding was undertaken to examine the existing categories and their subcategories and arrive at a central theme or core category that provides a refined and integrated meaning to the relationships between the categories and the core category.43 A summary of the findings was mailed to the participants, along with supporting quotations for their validation and comments. All participants who responded (n=14) agreed with the proposed findings. Figure Open in new tabDownload slide The cancer rehabilitation journey. HCP=health care professional, GP=general practitioner, ST=short-term, LT=long-term. Figure Open in new tabDownload slide The cancer rehabilitation journey. HCP=health care professional, GP=general practitioner, ST=short-term, LT=long-term. Role of the Funding Source This study was supported by the Department for Employment and Learning, Northern Ireland. Results A total of 26 participants with CRF (16 female, 10 male) took part in the study: 12 were survivors of cancer, 10 were patients in palliative care, and 4 were patients who were recently diagnosed and undergoing treatment. All participants were of Caucasian ethnicity, with a mean age of 55 years (range=39–83). Table 2 details participants’ demographic and medical characteristics and the intensity and frequency of CRF experienced. Most participants had worked in a clerical (30.8%) or customer service (15.4%) environment and were either retired (42.3%) or on long-term sick leave (30.8%). In terms of medical characteristics, there was a range of diagnoses and staging; however, most of the sample had been diagnosed with breast cancer (46.2%) and had either stage III (38.5%) or stage IV (30.8%) disease. The majority had been treated with a combination of chemotherapy and radiotherapy (57.7%), and the mean time since completion of treatment was 19.09 months (range=0–92). In terms of CRF, the mean score on the ONS Fatigue Scale was 6.23 (range=2–10), with most participants experiencing either moderate (50.0%) or severe (42.3%) fatigue on a daily basis (80.8%). Table 2 Participant Demographic and Medical Information Variable . Patients in Palliative Care (n=10) . Survivors of Cancer (n=12) . Patients Recently Diagnosed (n=4) . Total (N=26) n (%) . Occupation  Clerical 1 5 2 8 (30.8)  Customer service 3 1 0 4 (15.4)  Managerial 1 2 0 3 (11.5)  Educational 0 2 1 3 (11.5)  Homemaker 2 1 0 3 (11.5)  Domestic service 2 0 0 2 (7.7)  Manual 1 0 1 2 (7.7)  Unemployed 0 1 0 1 (3.9) Work status  Retired 7 3 1 11 (42.3)  Long-term sick leave 2 3 3 8 (30.8)  Part-time 0 3 0 3 (11.5)  Full-time 0 2 0 2 (7.7)  Homemaker 1 1 0 2 (7.7) Marital status  Married 6 11 4 21 (80.9)  Single 2 1 0 3 (11.5)  Divorced 1 0 0 1 (3.8)  Widowed 1 0 0 1 (3.8) Oncology Nursing Society Fatigue Scale  Mild (1–3) 1 0 1 2 (7.7)  Moderate (4–6) 3 9 1 13 (50.0)  Severe (7–10) 6 3 2 11 (42.3) Frequency of fatigue  Every day 9 11 1 21 (80.9)  Every other day 1 0 2 3 (11.5)  Weekly 0 1 1 2 (7.7) Cancer diagnosis  Breast 4 6 2 12 (46.3)  Prostate 2 3 0 5 (19.3)  Colorectal 1 0 0 1 (3.8)  Cervical 1 0 0 1 (3.8)  Non-Hodgkin lymphoma 0 1 0 1 (3.8)  Lymphoma 1 2 0 3 (11.6)  Bladder 0 0 1 1 (3.8)  Leukemia 0 0 1 1 (3.8)  Information missing 1 0 0 1 (3.8) Staging  I 0 1 0 1 (3.8)  II 0 3 0 3 (11.5)  III 2 5 3 10 (38.5)  IV 7 1 0 8 (30.8)  Information missing 1 2 1 4 (15.4) Treatment received  Chemotherapy alone 1 1 1 3 (11.5)  Radiotherapy alone 2 3 0 5 (19.2)  Chemotherapy and radiotherapy 6 6 3 15 (57.7)  information missing 1 2 0 3 (11.5) Completion of treatment (mo)  Undergoing treatment 3 0 4 7 (26.9)  <6 1 4 0 5 (19.2)  6–12 0 1 0 1 (3.8)  13–24 2 1 0 3 (11.5)  25–36 2 1 0 3 (11.5)  >48 1 3 0 4 (15.4)  information missing 1 2 0 3 (11.5) Variable . Patients in Palliative Care (n=10) . Survivors of Cancer (n=12) . Patients Recently Diagnosed (n=4) . Total (N=26) n (%) . Occupation  Clerical 1 5 2 8 (30.8)  Customer service 3 1 0 4 (15.4)  Managerial 1 2 0 3 (11.5)  Educational 0 2 1 3 (11.5)  Homemaker 2 1 0 3 (11.5)  Domestic service 2 0 0 2 (7.7)  Manual 1 0 1 2 (7.7)  Unemployed 0 1 0 1 (3.9) Work status  Retired 7 3 1 11 (42.3)  Long-term sick leave 2 3 3 8 (30.8)  Part-time 0 3 0 3 (11.5)  Full-time 0 2 0 2 (7.7)  Homemaker 1 1 0 2 (7.7) Marital status  Married 6 11 4 21 (80.9)  Single 2 1 0 3 (11.5)  Divorced 1 0 0 1 (3.8)  Widowed 1 0 0 1 (3.8) Oncology Nursing Society Fatigue Scale  Mild (1–3) 1 0 1 2 (7.7)  Moderate (4–6) 3 9 1 13 (50.0)  Severe (7–10) 6 3 2 11 (42.3) Frequency of fatigue  Every day 9 11 1 21 (80.9)  Every other day 1 0 2 3 (11.5)  Weekly 0 1 1 2 (7.7) Cancer diagnosis  Breast 4 6 2 12 (46.3)  Prostate 2 3 0 5 (19.3)  Colorectal 1 0 0 1 (3.8)  Cervical 1 0 0 1 (3.8)  Non-Hodgkin lymphoma 0 1 0 1 (3.8)  Lymphoma 1 2 0 3 (11.6)  Bladder 0 0 1 1 (3.8)  Leukemia 0 0 1 1 (3.8)  Information missing 1 0 0 1 (3.8) Staging  I 0 1 0 1 (3.8)  II 0 3 0 3 (11.5)  III 2 5 3 10 (38.5)  IV 7 1 0 8 (30.8)  Information missing 1 2 1 4 (15.4) Treatment received  Chemotherapy alone 1 1 1 3 (11.5)  Radiotherapy alone 2 3 0 5 (19.2)  Chemotherapy and radiotherapy 6 6 3 15 (57.7)  information missing 1 2 0 3 (11.5) Completion of treatment (mo)  Undergoing treatment 3 0 4 7 (26.9)  <6 1 4 0 5 (19.2)  6–12 0 1 0 1 (3.8)  13–24 2 1 0 3 (11.5)  25–36 2 1 0 3 (11.5)  >48 1 3 0 4 (15.4)  information missing 1 2 0 3 (11.5) Open in new tab Table 2 Participant Demographic and Medical Information Variable . Patients in Palliative Care (n=10) . Survivors of Cancer (n=12) . Patients Recently Diagnosed (n=4) . Total (N=26) n (%) . Occupation  Clerical 1 5 2 8 (30.8)  Customer service 3 1 0 4 (15.4)  Managerial 1 2 0 3 (11.5)  Educational 0 2 1 3 (11.5)  Homemaker 2 1 0 3 (11.5)  Domestic service 2 0 0 2 (7.7)  Manual 1 0 1 2 (7.7)  Unemployed 0 1 0 1 (3.9) Work status  Retired 7 3 1 11 (42.3)  Long-term sick leave 2 3 3 8 (30.8)  Part-time 0 3 0 3 (11.5)  Full-time 0 2 0 2 (7.7)  Homemaker 1 1 0 2 (7.7) Marital status  Married 6 11 4 21 (80.9)  Single 2 1 0 3 (11.5)  Divorced 1 0 0 1 (3.8)  Widowed 1 0 0 1 (3.8) Oncology Nursing Society Fatigue Scale  Mild (1–3) 1 0 1 2 (7.7)  Moderate (4–6) 3 9 1 13 (50.0)  Severe (7–10) 6 3 2 11 (42.3) Frequency of fatigue  Every day 9 11 1 21 (80.9)  Every other day 1 0 2 3 (11.5)  Weekly 0 1 1 2 (7.7) Cancer diagnosis  Breast 4 6 2 12 (46.3)  Prostate 2 3 0 5 (19.3)  Colorectal 1 0 0 1 (3.8)  Cervical 1 0 0 1 (3.8)  Non-Hodgkin lymphoma 0 1 0 1 (3.8)  Lymphoma 1 2 0 3 (11.6)  Bladder 0 0 1 1 (3.8)  Leukemia 0 0 1 1 (3.8)  Information missing 1 0 0 1 (3.8) Staging  I 0 1 0 1 (3.8)  II 0 3 0 3 (11.5)  III 2 5 3 10 (38.5)  IV 7 1 0 8 (30.8)  Information missing 1 2 1 4 (15.4) Treatment received  Chemotherapy alone 1 1 1 3 (11.5)  Radiotherapy alone 2 3 0 5 (19.2)  Chemotherapy and radiotherapy 6 6 3 15 (57.7)  information missing 1 2 0 3 (11.5) Completion of treatment (mo)  Undergoing treatment 3 0 4 7 (26.9)  <6 1 4 0 5 (19.2)  6–12 0 1 0 1 (3.8)  13–24 2 1 0 3 (11.5)  25–36 2 1 0 3 (11.5)  >48 1 3 0 4 (15.4)  information missing 1 2 0 3 (11.5) Variable . Patients in Palliative Care (n=10) . Survivors of Cancer (n=12) . Patients Recently Diagnosed (n=4) . Total (N=26) n (%) . Occupation  Clerical 1 5 2 8 (30.8)  Customer service 3 1 0 4 (15.4)  Managerial 1 2 0 3 (11.5)  Educational 0 2 1 3 (11.5)  Homemaker 2 1 0 3 (11.5)  Domestic service 2 0 0 2 (7.7)  Manual 1 0 1 2 (7.7)  Unemployed 0 1 0 1 (3.9) Work status  Retired 7 3 1 11 (42.3)  Long-term sick leave 2 3 3 8 (30.8)  Part-time 0 3 0 3 (11.5)  Full-time 0 2 0 2 (7.7)  Homemaker 1 1 0 2 (7.7) Marital status  Married 6 11 4 21 (80.9)  Single 2 1 0 3 (11.5)  Divorced 1 0 0 1 (3.8)  Widowed 1 0 0 1 (3.8) Oncology Nursing Society Fatigue Scale  Mild (1–3) 1 0 1 2 (7.7)  Moderate (4–6) 3 9 1 13 (50.0)  Severe (7–10) 6 3 2 11 (42.3) Frequency of fatigue  Every day 9 11 1 21 (80.9)  Every other day 1 0 2 3 (11.5)  Weekly 0 1 1 2 (7.7) Cancer diagnosis  Breast 4 6 2 12 (46.3)  Prostate 2 3 0 5 (19.3)  Colorectal 1 0 0 1 (3.8)  Cervical 1 0 0 1 (3.8)  Non-Hodgkin lymphoma 0 1 0 1 (3.8)  Lymphoma 1 2 0 3 (11.6)  Bladder 0 0 1 1 (3.8)  Leukemia 0 0 1 1 (3.8)  Information missing 1 0 0 1 (3.8) Staging  I 0 1 0 1 (3.8)  II 0 3 0 3 (11.5)  III 2 5 3 10 (38.5)  IV 7 1 0 8 (30.8)  Information missing 1 2 1 4 (15.4) Treatment received  Chemotherapy alone 1 1 1 3 (11.5)  Radiotherapy alone 2 3 0 5 (19.2)  Chemotherapy and radiotherapy 6 6 3 15 (57.7)  information missing 1 2 0 3 (11.5) Completion of treatment (mo)  Undergoing treatment 3 0 4 7 (26.9)  <6 1 4 0 5 (19.2)  6–12 0 1 0 1 (3.8)  13–24 2 1 0 3 (11.5)  25–36 2 1 0 3 (11.5)  >48 1 3 0 4 (15.4)  information missing 1 2 0 3 (11.5) Open in new tab As detailed in Table 3, there were considerable changes in participants’ physical activity levels pre-diagnosis to post-diagnosis. Before diagnosis, 61.5% of the participants were engaging in exercise 3 or more times per week, which is a stark contrast to after diagnosis, as only 19.2% of participants were managing this amount of activity. Similarly, 50.0% of the participants perceived themselves as “very active” before diagnosis, whereas none of the sample felt “very active” after diagnosis. The majority felt they were either “not active” (38.5%) or “a little active” (34.6%). These findings notwithstanding, 65.4% had managed to reinstate some level of physical activity. Table 3 Pre-diagnosis and Post-diagnosis Physical Activity Levels of Patients . Physical Activity Status . Patients in Palliative Care (n=10) . Survivors of Cancer (n=12) . Patients Recently Diagnosed (n=4) . Total (N=26) n (%) . Pre-diagnosis Perceived activity  Not active 0 0 0 0  A little active 0 1 0 1 (3.8)  Average 2 4 0 6 (23.1)  Above average 2 4 0 6 (23.1)  Very active 6 3 4 13 (50.0) Frequency of activity (per week)  None 1 2 0 3 (11.5)  1–2 3 4 0 7 (26.9)  3–4 3 3 2 8 (30.8)  5–7 2 3 2 7 (26.9)  >7 1 0 0 1 (3.8) Post-diagnosis Perceived activity  Not active 4 5 1 10 (38.5)  A little active 3 4 2 9 (34.6)  Average 3 1 1 5 (19.2)  Above average 0 2 0 2 (7.7)  Very active 0 0 0 0 Frequency of activity (per week)  None 5 3 1 9 (34.6)  1–2 3 7 2 12 (46.2)  3–4 0 1 1 2 (7.7)  5–7 2 1 0 3 (11.5)  >7 0 0 0 0 . Physical Activity Status . Patients in Palliative Care (n=10) . Survivors of Cancer (n=12) . Patients Recently Diagnosed (n=4) . Total (N=26) n (%) . Pre-diagnosis Perceived activity  Not active 0 0 0 0  A little active 0 1 0 1 (3.8)  Average 2 4 0 6 (23.1)  Above average 2 4 0 6 (23.1)  Very active 6 3 4 13 (50.0) Frequency of activity (per week)  None 1 2 0 3 (11.5)  1–2 3 4 0 7 (26.9)  3–4 3 3 2 8 (30.8)  5–7 2 3 2 7 (26.9)  >7 1 0 0 1 (3.8) Post-diagnosis Perceived activity  Not active 4 5 1 10 (38.5)  A little active 3 4 2 9 (34.6)  Average 3 1 1 5 (19.2)  Above average 0 2 0 2 (7.7)  Very active 0 0 0 0 Frequency of activity (per week)  None 5 3 1 9 (34.6)  1–2 3 7 2 12 (46.2)  3–4 0 1 1 2 (7.7)  5–7 2 1 0 3 (11.5)  >7 0 0 0 0 Open in new tab Table 3 Pre-diagnosis and Post-diagnosis Physical Activity Levels of Patients . Physical Activity Status . Patients in Palliative Care (n=10) . Survivors of Cancer (n=12) . Patients Recently Diagnosed (n=4) . Total (N=26) n (%) . Pre-diagnosis Perceived activity  Not active 0 0 0 0  A little active 0 1 0 1 (3.8)  Average 2 4 0 6 (23.1)  Above average 2 4 0 6 (23.1)  Very active 6 3 4 13 (50.0) Frequency of activity (per week)  None 1 2 0 3 (11.5)  1–2 3 4 0 7 (26.9)  3–4 3 3 2 8 (30.8)  5–7 2 3 2 7 (26.9)  >7 1 0 0 1 (3.8) Post-diagnosis Perceived activity  Not active 4 5 1 10 (38.5)  A little active 3 4 2 9 (34.6)  Average 3 1 1 5 (19.2)  Above average 0 2 0 2 (7.7)  Very active 0 0 0 0 Frequency of activity (per week)  None 5 3 1 9 (34.6)  1–2 3 7 2 12 (46.2)  3–4 0 1 1 2 (7.7)  5–7 2 1 0 3 (11.5)  >7 0 0 0 0 . Physical Activity Status . Patients in Palliative Care (n=10) . Survivors of Cancer (n=12) . Patients Recently Diagnosed (n=4) . Total (N=26) n (%) . Pre-diagnosis Perceived activity  Not active 0 0 0 0  A little active 0 1 0 1 (3.8)  Average 2 4 0 6 (23.1)  Above average 2 4 0 6 (23.1)  Very active 6 3 4 13 (50.0) Frequency of activity (per week)  None 1 2 0 3 (11.5)  1–2 3 4 0 7 (26.9)  3–4 3 3 2 8 (30.8)  5–7 2 3 2 7 (26.9)  >7 1 0 0 1 (3.8) Post-diagnosis Perceived activity  Not active 4 5 1 10 (38.5)  A little active 3 4 2 9 (34.6)  Average 3 1 1 5 (19.2)  Above average 0 2 0 2 (7.7)  Very active 0 0 0 0 Frequency of activity (per week)  None 5 3 1 9 (34.6)  1–2 3 7 2 12 (46.2)  3–4 0 1 1 2 (7.7)  5–7 2 1 0 3 (11.5)  >7 0 0 0 0 Open in new tab From the qualitative data, 3 major categories emerged: (1) exercise barriers, (2) exercise facilitators, and (3) motivators of exercise, each linked to the core category of the cancer rehabilitation journey (Figure). Quotations are provided in the text to highlight findings. The quotations are labeled with codes and identification numbers to ensure anonymity of the participants. Thus, patients in palliative care are coded as PC, survivors of cancer are coded as CS, and patients who were recently diagnosed and undergoing treatment are coded as RD. Exercise Barriers As an overview, the main barriers that participants reported generally could be linked back to the side effects of treatment (Figure). Fatigue and physical deconditioning were major exercise barriers that contributed to participants’ feelings of social isolation and difficulty making exercise a routine and strongly influenced participants’ opinions as to the most appropriate time to begin an exercise program following diagnosis. Other barriers were related to environmental factors such as cost and the lack of exercise facilities tailored to patients with cancer. Main side effects of treatment The main side effects of surgery and anticancer treatments were fatigue, compromised immunity, skin sensitivity, loss of range of movement, and incontinence. Side effects of surgery mainly were associated with loss of range of upper-limb movement in the case of survivors of breast cancer and with the incontinence issues that surround survivors of prostate cancer after surgery or treatment. These incontinence issues were inferred by the male participants in the group rather than being spoken about openly, which likely was due to their embarrassment at female participants being present. Such findings suggest that certain exercise barriers may be cancer- and sex-specific. Some participants also suggested they were limited in the type of exercise they could choose, in particular swimming, due to skin sensitivity following radiotherapy and a compromised immune system as a result of chemotherapy. The main barrier to exercise, however, was the overwhelming and debilitating physical sensation of CRF, which the participants described as “a complete shutdown,” “weakness,” “exhaustion,” “unrelenting,” and “uncontrollable.” Although the participants could identify the enjoyment and benefits attached to exercise, they quickly emphasized the limitations that fatigue had placed on them in terms of physical activity. The following excerpts demonstrate that these limitations were apparent across all subgroups. You say to yourself, “Well, I should be doing this [exercise]” … you see to get up out of the chair and do it (puffs). (PC2) I walked continually, all of the time…. I loved walking, and I went to Curves (female-only gym) 2 or 3 times a week…. I could hardly walk 5 minutes now. (CS5) … the energy you know it takes to even get up and get ready in the morning. (RD1) Additional side effects of treatment Many participants expressed a lack of confidence regarding their self-image and identity following surgery. Survivors of breast cancer were particularly self-conscious about wearing prostheses in public, which they felt also limited their choice of exercise (eg, swimming, aerobics, gym). This was a similar situation for survivors of prostate cancer, as incontinence issues imposed both social and physical limitations regarding exercise. Lack of confidence also was apparent with regard to safety and fear of falling. This lack of confidence was inherently linked to physical deconditioning and was particularly evident among patients in palliative care, many of whom described difficulties with their mobility and balance, experienced shortness of breath, or simply lacked confidence to exercise independently. I find now that I’m not really having the confidence to walk on my own. (PC2) Across all subgroups, there was a lack of motivation, which also was associated with fatigue and physical deconditioning. For some participants, this was a battle between the mind and body, as there was a desire to be active but also an urge to give in to the overwhelming sensation of fatigue. Well, the heart is willing [to exercise], but the flesh is weak, so that's really what it boils down to. (PC3) This lack of motivation, coupled with the existing aforementioned barriers, made the thought of exercising a daunting task. Some participants even found it difficult to have an interest in anything, particularly things they would have previously enjoyed, making it more difficult to instigate new and even old exercise behaviors. You knew what you were like [before having fatigue], you were active, you were into things, you had a bit of a particular interest, a particular hobby. Now, you find … you can’t be bothered. (PC3) Physical deconditioning All participants in this study experienced some form of physical deconditioning, which most likely was a result of their experiences of fatigue and decline in physical activity (Tab. 3). Physical deconditioning was highlighted through their comparisons of their previous and current physical abilities and their descriptions of low exercise tolerance levels. This physical deconditioning was further emphasized as even the simplest of activities proved extremely difficult, and engaging in these activities often had repercussions. I walked everywhere, I loved walking, you know. I pay for it [now], if I go [for] a walk one day, the next day I’m in bed. (CS1) Many participants used rest and sleep as a means of coping with fatigue, and others had been advised to rest by a health care professional. Furthermore, the recommendation of rest would have presented itself as an additional exercise barrier. As outlined in the previous quotation (CS1), some participants reported having negative side effects following exercise, such as increased levels of fatigue and muscle soreness. Such side effects were handled predominantly by taking further rest, which would have had a counterproductive effect on any health gains obtained, or for some participants, would have created fear-avoidance behaviors. I think that's what puts me off exercise, [be]cause I know how I am going to feel afterwards. (CS3) There was a general consensus among patients in palliative care as to the enormous challenge that exercise presented. For some of these participants, exercise was classed as walking “from the back to the front door” (PC6). Other participants summarized it as “a battle, sounds like a whole day's work” (PC7), that they would not contemplate: “I know at times … I know how I feel, you wouldn’t even consider it [exercise]” (PC3). Environmental factors and difficulty establishing routine As many of the participants in this study were either retired or on long-term sick leave, the cost of using facilities at a leisure center posed as an additional barrier, in particular for those patients who were recently diagnosed. The participants further expressed that such leisure facilities were not tailored toward patients with cancer. Additionally, they emphasized the possibility of not being able to routinely avail themselves of a gym membership, due to fatigue and its unpredictability and their physically deconditioned state. I couldn’t afford to join a gym and… not only to use half of the equipment but, there's days that I just couldn’t go, I might be weak. (RD4) What you can achieve one day, you might not the next, you know every day could be different. (CS2) Such statements highlight the difficulty patients with CRF may face in initiating and maintaining exercise. Furthermore, recently diagnosed patients and some survivors of cancer expressed that the acute side effects of treatment and attending treatment appointments, in particular consecutive radiotherapy sessions, could interfere with an exercise regimen. Timing of introduction to exercise There were conflicting views across subgroups as to the ideal time to initiate an exercise program. Most of the patients who were recently diagnosed and some survivors of cancer suggested that during and up to a year following treatment would be an inappropriate time to initiate or commit to exercise. This view was mainly attributed to their fatigue and physical deconditioning. It definitely would’ve been a good year before I’d of been fit for any exercise at all. (CS6) In contrast to this view, the remaining survivors of cancer and some of patients in palliative care tended to advocate an earlier start, either at diagnosis or in the shorter term following treatment, with emphasis placed on the physical and psychological benefits they felt could be gained from exercise. Exercise Facilitators Supervised, individualized, group-based exercise program Almost all participants emphasized that an exercise program should be supervised by a trained health care professional, whereby they could avail themselves of the health care professional's knowledge, guidance, and feedback, and in particular the professional's motivational support. I think it's hard to do on your own…. I suppose you need somebody to give you a prod or you need somebody to tell you, “Yes, you’re right,” and “Yes, you should be doing this” and to work with you maybe. (CS3) These facilitators seemed to offer assurance that they would not be prescribed exercise that would prove detrimental to them. This assurance of their well-being echoed through to their ideal exercise setting, as many participants advocated a hospital-based exercise program. Most participants stated they would prefer to exercise with other patients with cancer, as they would have undergone a similar path since diagnosis and treatment and be of similar fitness levels. These factors would provide an opportunity for peer support, shared experiences, a sense of belonging, and subjective norms. If I went to a normal class, I would feel very peculiar … and I think you need to feel that you are surrounded by people that at least have some idea… of what you are going through. (CS2) Conversely, due to the aforementioned incontinence issues, some survivors of prostate cancer indicated that group exercise would not be appropriate for them. Exercising was something they preferred to do at home, but with some professional input and support. Participants across all subgroups placed great emphasis on the need for an exercise program to be tailored to the individual according to his or her abilities, age, and medical or treatment variables. They also added that any exercise should be gradually progressed and include realistic goal setting. Additionally, some survivors of cancer suggested that setting up a patient/professional commitment contract would oblige them to regularly attend an exercise program. Motivators of Exercise Perceived benefits of exercise All participants could identify the potential benefits of exercise, from both previous and current experiences. Due to the many side effects of treatment, but in particular fatigue, participants wanted to gain a sense of achievement and regain a sense of normality. They recognized exercise as a potential way of delivering these benefits and a progression away from their illness and toward recovery. That feeling of achievement when you do something like that, like walk half a mile to the petrol station or cycle round the block, it's an enormous sense of achievement when you’re sick like this. (RD2) I loved walking, I mean that was always my … one escape from everything … I suppose it was being normal you know, like you want to be normal again. (CS5) Interestingly, although participants earlier identified the negative side effects of exercise and endorsed them as exercise barriers, they could identify the positive side effects of exercise and associated them with being motivational. Many participants discussed the positive impact previous exercise had on their physical and mental well-being and viewed the fatigue associated with exercise as a pleasant and more “normal” or natural experience, compared with that of CRF. Many participants across all subgroups had gained weight since being diagnosed with cancer. Interestingly, they attributed their weight gain to being a side effect of chemotherapy, as opposed to a decline in their physical activity levels. The participants, however, expressed that exercise could act as a means of losing weight and thus give them the motivation to exercise. Additional exercise motivators were improved breathing, improved well-being, and decreased stress or form of release. Discussion Exercise Barriers This qualitative study gives a unique insight into the barriers to and facilitators of exercise from the perspective of patients who were recently diagnosed and undergoing treatment, survivors of cancer, and patients in palliative care, all of whom had CRF. It is evident from our findings that the main barriers to exercise can be attributed to the side effects of treatment, in particular fatigue, which supports previous research findings.3,27–29,31,35 Few of the exercise barriers described by the participants in this study can be isolated from each other; rather, they are interlinked and can have a ripple effect (Figure). Fatigue was at the center of the majority of barriers experienced by the participants; this finding was particularly evident within the subcategory of physical deconditioning. The combination of fatigue and participants’ feeling physically deconditioned undoubtedly contributed to the decline in their physical activity levels from before diagnosis to after diagnosis. This decline in physical activity may have contributed to the negative side effects of exercise, breathlessness, and balance problems experienced by the participants. The experience of fatigue, physical deconditioning, and the decline in physical activity levels can become cyclical events,44 exacerbated by the fact the participants used or were advised to use rest and sleep as a management strategy. Prolonged rest and sleep can contribute to muscle deconditioning and disuse atrophy,8 causing increased effort and sensations of fatigue.45 Winningham et al11 summarized this relationship through their psychobiological-entropy model, whereby a combination of pre-existing conditions, environmental influences, and cancer and its treatment can lead to decreased activity, secondary fatigue, and decreased functional status, which ultimately can lead to disability. The fact that none of the participants in this study had been given any appropriate advice on how to manage fatigue highlights how such events could easily become a reality for patients with CRF. Overcoming barriers such as fatigue and physical deconditioning presented an enormous challenge to participants that obviously could have had a negative impact on their interest and motivation to exercise. Lack of motivation to exercise has been previously reported as an exercise barrier among patients with cancer.27,29 Smets and colleagues46 recognized reduced activity and reduced motivation as 2 of the 5 dimensions of CRF (ie, general fatigue, physical fatigue, reduced activity, reduced motivation, and mental fatigue). Further complicating the scenario, participants felt that they would find difficulty in making exercise a routine part of their lives, especially due to the unpredictability of fatigue and the variability of its intensity from day to day. Additionally, participants who were undergoing treatment and some survivors of cancer felt that initiating and maintaining an exercise regimen would prove too difficult while coping with the side effects of treatment and attending regular treatments and review appointments. Taking these barriers into consideration then poses the question as to the most appropriate time for patients to initiate exercise. A systematic review carried out by Cramp and Daniel47 showed that there was statistically significant reduction in fatigue with patients both during and following treatment. Considering the participants’ varied opinions surrounding this timing issue, the most obvious resolution is to offer an exercise program to patients in all phases of care, which can be accessed when they feel it is appropriate. This approach has been advocated by the NCCN,48 whose guidelines recommend that physical activity enhancement should be available to patients from the commencement of treatment to end of life. Environmental factors such as the cost and feasibility of exercising in local leisure centers, plus the fact that the participants felt there was a lack of specialized exercise services available to them, raise additional barriers to exercise initiation and maintenance. Cost has been reported previously as an exercise barrier31 and presents itself as a major issue. Like many participants in this study, patients who have been recently diagnosed, survivors of cancer, and patients in palliative care within our society may be forced to take long-term sick leave or retirement, which can have a direct impact on their financial situation. Bennett et al49 conducted a questionnaire survey with survivors of cancer to assess their changes in employment and household income following a diagnosis of cancer. They found that 40% of the respondents reduced their working hours or quit working as a result of their cancer diagnosis or side effects of treatment. Furthermore, a decrease in household income was reported by 37% of the respondents. These findings make explicit the barriers associated with the cost of joining a gym or using leisure center facilities, and they further support the recommendation of the NCCN guidelines48 that exercise programs for patients with CRF should be routinely available as part of their package of care. Exercise Facilitators Taking into account the aforementioned barriers to exercise for patients with CRF, it is interesting, yet not surprising, that participants’ exercise facilitators were the polar opposite of their barriers. Participants felt strongly that an exercise program should be delivered by a specially trained health care professional and held within a hospital setting. These findings have been reported in previous studies3,28,31 and indicate that such requirements would assist participants with overcoming the barriers associated with the side effects of treatment, physical deconditioning, and environmental factors and allay fears surrounding safety issues. Furthermore, participants suggested these exercise programs should be tailored to the individual and gradually progressed. These factors may help avoid the negative side effects of exercise that many participants had experienced previously and would ensure fear-avoidance behaviors did not develop. Because participants felt that lack of motivation and the additional side effects of treatment such as lack of confidence and self-image issues were major barriers, they required a program to be conducted with other patients with cancer, of similar abilities and with whom they could share their experiences. Group support has been reported as an exercise facilitator, as it generates friendship, solidarity,26,30,33 and feelings of belonging and subjective norms.30 Overall, the facilitators of exercise described suggest that patients with CRF require much support and guidance when it comes to initiating exercise and changing behaviors. Physical therapists working in oncology and palliative care are ideally placed and have the core skills to design and deliver exercise programs to help patients manage their fatigue and thus improve their functional status and QoL. Donnelly et al50 recently conducted a survey of UK physical therapists working in oncology and palliative care to establish physical therapists’ knowledge and management of CRF. The authors found that although physical therapists recognize CRF as a major problem and many therapists are using exercise as a management strategy, physical therapists themselves face barriers in prescribing exercise. The main barriers reported were: a lack of exercise guidelines for patients with CRF, patients’ family and friends advising rest, poor exercise adherence among patients, limited time with patients, and a lack of patient referral for physical therapy. These findings suggest that both patients with CRF and physical therapists would benefit from the development of exercise guidelines. Motivators of Exercise The motivators of exercise that were identified by the participants were encouraging, as these were actually their perceived benefits of exercise. Realizing that exercise provides a means of escapism and induces feelings of physical and mental well-being that would assist them in achieving a sense of normality and progression from illness are important factors in the promotion of exercise among patients with CRF. Previous studies32,33 have shown that the perceived benefits of exercise, such as managing fatigue, were the main reasons for initiating exercise programs. As a result, we propose that although patients with CRF have many unique barriers to exercise, these barriers could be dispersed if their exercise facilitators were in place. Furthermore, such exercise facilitators could help patients achieve the benefits of exercise identified by the participants in this study, and knowledge of the benefits of exercise could act as an exercise motivator. Disease and Sex-Specific Issues Using a mixed sample of cancer diagnoses and staging proved beneficial within this study, as it highlighted variations in the side effects of treatment. This finding raises several issues regarding exercise programs for patients of mixed sexes and mixed diagnoses. First, research carried out by Adamsen et al33 detailed the benefits of sex-specific exercise groups among male patients, as they allow the development of comradeship, “male trust,” and action-oriented togetherness. The issues surrounding incontinence for survivors of prostate cancer in the current study support the findings of Adamsen and colleagues.33 The barrier of decreased range of movement, which was specific to the survivors of breast cancer, further supports the fact the barriers often may be disease specific. Second, patients who had received chemotherapy had additional barriers of immunosuppression; whereas those who had radiotherapy raised issues of skin sensitivities that they felt would place restrictions on the use of certain exercise modalities. The lack of confidence regarding self-image or identity reported by the survivors of breast cancer may further suggest the need for disease- or sex-specific exercise groups. Emslie and colleagues26 reported that setting up a specialized exercise program specifically for survivors of breast cancer helped to dismantle sex-related barriers and empowered patients to exercise without feeling self-conscious. Perhaps this is the only realistic option to obtain patient satisfaction and produce an effective exercise program that is, in the first instance, appealing to patient subgroups, and in the longer term, maintainable. Pragmatically, although this option creates major challenges, considering the spectrum of cancer diagnoses and those that are indiscriminate of sex. Further complicating the situation, group exercise is not suitable or appealing to every individual. Limitations Although this study addressed some of the methodological issues of previous qualitative studies, there are several limitations. First, the participants were a convenience sample of patients with CRF, and when the sample was separated into the trajectory subgroups, the sample sizes were relatively small. Second, the majority of the sample were patients with stage III or stage IV breast cancer, with minimal representation of other cancer diagnoses and staging. Furthermore, all participants were white, with no representation from other ethnic groups. As a result, the findings of this study may not be transferable to the general population with cancer. Future qualitative studies should aim to include a wide range of cancer diagnoses and stages and include participants with varied ethnic backgrounds. Finally, taking into account the aforementioned limitations, the sex-specific issues raised in this study should be handled tentatively. Participants did not state explicitly that they would prefer sex-specific exercise groups; this was more implied by the participants and is an interpretation on the part of the authors. However, these issues warrant further exploration with both sexes. Conclusions The findings of this study highlight the barriers that patients with CRF may face in initiating and maintaining exercise. These barriers are mainly attributed to the side effects of treatment, in particular fatigue; however, most barriers are not experienced in isolation, and many can cause a ripple effect, creating additional exercise barriers. On a positive note, however, the participants in this study could identify the benefits of exercise, which may well act as an exercise motivator. Furthermore, the participants offered solutions to their own barriers in the form of exercise facilitators. Physical therapists have the core skills required to deliver the exercise facilitators described by the participants, especially tailoring an exercise program to an individual's ability and level of functioning, graduating an exercise program according to the progress made, and setting short-term and long-term goals, thus giving patients structure, targets, and the sense of achievement and normality that many desired. When designing exercise programs for patients with CRF, physical therapists and researchers in this area should be mindful of variables such as stage of disease, treatment protocols, side effects of treatment, exercise tolerance, and physical abilities, as well as sex-specific issues, personal exercise barriers, facilitators, and motivators. The Bottom Line What do we already know about this topic? Despite evidence to suggest that participation in regular exercise can help manage cancer-related fatigue, few patients with cancer meet physical activity guidelines. The reasons behind this are not well understood. This study explored the barriers and facilitators of exercise participation among patients with cancer-related fatigue. What new information does this study offer? Barriers to exercise participation are interlinked and often stem from the side effects of cancer treatment. Fatigue and physical deconditioning were identified as major barriers that contributed to patients’ lack of interest in exercise and motivation to exercise, as well as their difficulties in exercise participation and in making exercise a routine. Facilitators of exercise included programs that were group-based, supervised, individualized, and gradually progressed. If you’re a patient, what might these findings mean for you? Identifying personal barriers and adopting practical strategies to overcome such barriers will aid exercise participation, which may ultimately decrease the experience of fatigue and physical deconditioning associated with a cancer diagnosis. " The authors thank the staff at all 3 sites for their assistance with recruitment and the participants for giving so freely of their time and experiences. " Ethical approval was granted by the Research Governance Office at the Regional Cancer Centre and the Office for Research Ethics, Northern Ireland (April 2007). " A poster presentation was given at the annual international symposium of the Multinational Association of Supportive Care in Cancer; June 26–28, 2008; Houston, Texas. " This study was supported by the Department for Employment and Learning, Northern Ireland. * " SPSS Inc, 233 S Wacker Dr, Chicago, IL 60606. References 1 National Comprehensive Cancer Network (NCCN) . NCCN clinical practice guidelines in oncology: cancer-related fatigue V.1; 2006 . Available at: http://www.nccn.org/professionals/physician_gls/PDF/fatigue.pdf/. Accessed October 12, 2006 . 2 Alberg K Ekman T Gaston-Johansson F Mock V . Assessment and management of cancer-related fatigue in adults . Lancet . 2003 ; 362 : 640 – 650 . Google Scholar Crossref Search ADS PubMed WorldCat 3 Coon SK Coleman EA . Keep moving: patients with myeloma talk about exercise and fatigue . Oncol Nurs Forum . 2004 ; 31 : 1127 – 1135 . Google Scholar Crossref Search ADS PubMed WorldCat 4 Ganz P . 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Google Scholar Crossref Search ADS PubMed WorldCat 36 Courneya KS McKenzie DC Reid RD , et al. . Barriers to supervised exercise training in a randomized controlled trial of breast cancer patients receiving chemotherapy . Ann Behav Med . 2008 ; 35 : 116 – 122 . Google Scholar Crossref Search ADS PubMed WorldCat 37 Rogers LQ Courneya KS Robbins KT , et al. . Physical activity correlates and barriers in head and neck cancer patients . Support Care Cancer . 2008 ; 16 : 19 – 27 . Google Scholar Crossref Search ADS PubMed WorldCat 38 Hwang SS Chang VT Rue M , et al. . Multidimensional independent predictors of cancer-related fatigue . J Pain Symptom Manage . 2003 ; 26 : 604 – 614 . Google Scholar Crossref Search ADS PubMed WorldCat 39 Blaney J Rankin J Lowe-Strong A , et al. . Cancer-related fatigue: the barriers and facilitators to exercise across the cancer trajectory . Support Care Cancer . 2008 ; 16 : 648 . OpenURL Placeholder Text WorldCat 40 Bandura A . Social Foundations of Thought and Action . Upper Saddle River, NJ : Prentice Hall Inc ; 1986 . Google Scholar Google Preview OpenURL Placeholder Text WorldCat COPAC 41 Glanz K Lewis FM Rimer BK . Health Behaviour and Health Education, Theory, Research and Practice . San Francisco, CA : Wiley ; 1997 . Google Scholar Google Preview OpenURL Placeholder Text WorldCat COPAC 42 Marcus B King TK Clark MM , et al. . Theories and techniques for promoting physical activity behaviours . Sports Med . 1996 ; 22 : 321 – 331 . Google Scholar Crossref Search ADS PubMed WorldCat 43 Strauss A Corbin J . Basics of Qualitative Research . London, United Kingdom : Sage Publications ; 1998 . Google Scholar Google Preview OpenURL Placeholder Text WorldCat COPAC 44 Lucia A Earnest C Perez M . Cancer-related fatigue: can exercise physiology assist oncologists? Lancet Oncol . 2003 ; 4 : 616 – 625 . Google Scholar Crossref Search ADS PubMed WorldCat 45 al-Majid S McCarthy DO . Cancer-induced fatigue and skeletal muscle wasting: the role of exercise . Biol Res Nurs . 2001 ; 2 : 186 – 197 . Google Scholar Crossref Search ADS PubMed WorldCat 46 Smets EM Garssen B Bonke B de Haes JC . The Multidimensional Fatigue Inventory (MFI): psychometric qualities of an instrument to assess fatigue . J Psychosom Res . 1995 ; 39 : 315 – 325 . Google Scholar Crossref Search ADS PubMed WorldCat 47 Cramp F Daniel J . Exercise for the management of cancer-related fatigue in adults . Cochrane Database Syst Rev . 2008 ; 2 : CD006145 . OpenURL Placeholder Text WorldCat 48 National Comprehensive Cancer Network (NCCN) . NCCN clinical practice guidelines in oncology: cancer-related fatigue V.1; 2009 . Available at: http://www.nccn.org/professionals/physician_gls/PDF/fatigue.pdf. Accessed June 1, 2009 . 49 Bennett JA Brown P Cameron L , et al. . Changes in employment and household income during the 24 months following a cancer diagnosis . Support Care Cancer . 2009 ; 17 : 1057 – 1064 . Google Scholar Crossref Search ADS PubMed WorldCat 50 Donnelly CM Lowe-Strong A Rankin JP , et al. . Physiotherapy management of cancer-related fatigue: a survey of UK current practice . Support Care Cancer . 2009 08 23 [Epub ahead of print] . OpenURL Placeholder Text WorldCat Author notes " Ms Blaney, Ms Rankin, and Dr Gracey provided concept/idea/research design. Ms Blaney, Dr Lowe-Strong, Ms Rankin, Dr Campbell, and Dr Gracey provided writing. Ms Blaney provided data collection. Ms Blaney and Dr Gracey provided data analysis. Ms Blaney, Dr Lowe-Strong, and Dr Gracey provided project management. Dr Lowe-Strong, Prof Allen, and Dr Gracey provided fund procurement. Ms Rankin provided participants. Ms Rankin and Dr Gracey provided facilities and equipment. Ms Rankin, Dr Campbell, and Dr Gracey provided institutional liaisons. All authors provided consultation (including review of manuscript before submission). © 2010 American Physical Therapy Association

Verschuren,, Olaf;Bloemen,, Manon;Kruitwagen,, Cas;Takken,, Tim

doi: 10.2522/ptj.20090318pmid: 20558568

Background Very few objective data exist regarding aerobic performance in young people with cerebral palsy (CP). The characterization of aerobic fitness could provide baseline and outcome measures for the rehabilitation of young people with CP. Objective The objective of this study was to provide reference values for aerobic fitness in a group of children, adolescents, and young adults who had CP and who were classified at Gross Motor Function Classification System (GMFCS) level I or II. Data were collected with 10-m shuttle run tests. Design This investigation was a cross-sectional observational study conducted between August 2008 and June 2009. Methods Reference values were established using data from a total of 306 children, adolescents, and young adults who had CP, who were 6 to 20 years old, and who were recruited from 26 rehabilitation centers in the Netherlands, Switzerland, Australia, Canada, and the United States. A total of 211 participants were classified at GMFCS level I (mean age=12.2 years, SD=3.0), and 95 were classified at GMFCS level II (mean age=12.4 years, SD=3.2); 181 were male, and 125 were female. Aerobic fitness was reflected by the level achieved on the 10-m shuttle run tests. Results On the basis of a total of 306 assessments from the 10-m shuttle run tests, 4 reference curves were created. Limitations The limitation of this study is the cross-sectional nature of the design. Conclusions This study provided height-related reference values for aerobic fitness in children, adolescents, and young adults who had CP, who were 6 to 20 years old, and who were classified at GMFCS level I or II. Generalized additive models for location, scale, and shape were used to construct centile curves. These curves are clinically relevant and provide a user-friendly method for the prediction of aerobic fitness in young people with CP. Aerobic fitness may be defined as the ability to deliver oxygen to the muscles and to utilize it to generate energy during exercise; it often is presented as peak oxygen uptake (V̇o2peak).1 Peak oxygen uptake is strongly associated with health and disease in adulthood.2,3 Moreover, it is a strong indicator of functional capacity and mortality in adulthood.4 Maintaining an appropriate level of aerobic fitness reduces the risk of disease and injury and increases the ability to work efficiently and to participate in and enjoy physical activity (sports, recreation, and leisure).5,6 A high aerobic fitness level has a positive impact on optimum health and prevents the onset of problems associated with inactivity at all ages.2,5–7 Research consistently has shown that people with cerebral palsy (CP) have low V̇o2peak values.8,9 These low levels of V̇o2peak affect both daily and recreational activities and could have significant implications for health in people with CP.10 An appropriate method for assessing aerobic fitness is a test of progressive exercise to exhaustion, in which the highest exercise intensity achieved (eg, peak work load, endurance time) is a parameter of aerobic fitness.11,12 The gold standard for determining aerobic fitness is a direct measurement of V̇o2peak during such a test.13 However, a direct measurement of V̇o2peak usually is not feasible because it requires specialized respiratory gas analysis equipment, which typically is not available in clinical, rehabilitation, or field settings and often is not tolerated by younger children with CP. Shuttle run tests are useful measures of aerobic fitness. These field tests, in which participants walk or run between 2 markers, can easily be administered in a clinical setting. For young people who have CP and who are able to walk independently, 2 reliable and valid 10-m shuttle run test protocols are available: shuttle run test I (SRT-I) and shuttle run test II (SRT-II) for young people classified at Gross Motor Function Classification System (GMFCS)14,15 levels I and II, respectively. Both shuttle run tests have several characteristics that are similar to those of the accepted gold standard.16 Aerobic fitness measured with shuttle run tests reflects the overall capacity of the cardiovascular, respiratory, and muscular systems and the ability to carry out prolonged, strenuous exercise.17 The progression of aerobic fitness has been well established in people who are healthy and have no disabilities from childhood through adolescence.18 Aerobic fitness increases with age and is at its peak in childhood and late adolescence.18 The literature fails to provide objective data regarding aerobic fitness in young people with CP. The characterization of aerobic fitness of young people with CP could provide baseline and outcome measures for their rehabilitation. Therefore, the aim of this study was to provide reference data for aerobic fitness in 306 children, adolescents, and young adults who had CP, who were from various geographic regions, and who were classified at GMFCS level I or II. Data were collected with the SRT-I and the SRT-II. Method Procedure and Participants The SRT-I and the SRT-II were implemented in 17 rehabilitation centers and schools for special education in the Netherlands between August 2008 and June 2009. The tests also were implemented in rehabilitation centers in Switzerland (n=3), Australia (n=3), Canada (n=2), and the United States (n=1). During the implementation process, the pediatric physical therapists and exercise physiologists were trained both theoretically and practically in executing the shuttle run tests. All therapists or exercise physiologists at the participating centers performed the shuttle run tests under the supervision of the developers of the tests and were instructed to follow the guidelines described in the Appendix throughout the data collection period. Trained therapists or exercise physiologists were asked to return the data obtained from testing of young people with CP in their clinics by using a standardized Microsoft Word or Excel data sheet.* Data included in this study were from children, adolescents, and young adults who were 6 to 20 years old, were diagnosed with spastic CP, and were classified at GMFCS level I or II. All participants were receiving physical therapy or were assessed during an examination at a clinic follow-up visit. Cognitively, they had to be able to follow simple commands. Young people were excluded if they had had orthopedic surgery or neurosurgery within 6 months before study entry or cardiac or respiratory conditions that could be adversely affected by exercise. Young people with CP who were considered to be athletes (completing more than 10 hours of formal exercise training per week) also were excluded. Besides data on test performance, information regarding the assessment dates, diagnosis, GMFCS level, date of birth, height, weight, and sex was collected. Measurements Anthropometry Participants’ body mass and height were measured in a standardized manner. Before testing, each child was weighed in underwear to the nearest 100 g on the digital scales available in the participating clinics. Height measurements were taken on the same day while each child was standing against a wall. Height was measured to the nearest 0.5 cm with a stadiometer or wall-mounted measuring stick. Body mass index was calculated as weight in kilograms divided by height in meters squared. GMFCS The GMFCS was used by a pediatric physical therapist who was experienced with this classification system to classify the young people with CP on the basis of their functional mobility. Because of the characteristics of the shuttle run tests, only children, adolescents, and young adults who were classified at GMFCS level I (able to walk indoors and outdoors and climb stairs without limitations) or level II (able to walk indoors and outdoors and climb stairs holding onto a railing but experiencing limitations in walking on uneven or inclined surfaces and in walking in crowds or confined spaces) were included. The original GMFCS has been reported to yield reliable and valid data for children who are 6 to 12 years old.14 Participants who were older than 12 years were classified with the expanded and revised version of the GMFCS.19 The physical characteristics of the participants (according to GMFCS level) are summarized in the Table. Table Participant Characteristicsa Participants . Variable . GMFCS Level Ib . GMFCS Level IIc . X̅ . SD . Median . Range . X̅ . SD . Median . Range . Male Age (y) 12.1 2.7 11.6 6–19 12.6 3.5 12.5 7–19 Height (cm) 151.1 15.8 151.0 118–187 150.7 19.9 149.3 122–190 Body mass (kg) 44.0 14.5 41.0 20–92 43.4 15.8 41.0 23–88 BMI (kg/m2) 18.7 3.6 18.1 12.7–29.7 18.5 3.3 18.1 14.2–26.5 Female Age (y) 12.3 3.2 12.3 7–19 12.2 2.7 12.6 6–17 Height (cm) 149.2 17.8 150.0 117–181 140.8 14 142 115–178 Body mass (kg) 45.6 17.2 44.0 19–85 38.3 13.0 34.0 20–90 BMI (kg/m2) 19.7 4.0 19.2 13–30.5 19.0 4.2 17.6 13.0–30.5 Participants . Variable . GMFCS Level Ib . GMFCS Level IIc . X̅ . SD . Median . Range . X̅ . SD . Median . Range . Male Age (y) 12.1 2.7 11.6 6–19 12.6 3.5 12.5 7–19 Height (cm) 151.1 15.8 151.0 118–187 150.7 19.9 149.3 122–190 Body mass (kg) 44.0 14.5 41.0 20–92 43.4 15.8 41.0 23–88 BMI (kg/m2) 18.7 3.6 18.1 12.7–29.7 18.5 3.3 18.1 14.2–26.5 Female Age (y) 12.3 3.2 12.3 7–19 12.2 2.7 12.6 6–17 Height (cm) 149.2 17.8 150.0 117–181 140.8 14 142 115–178 Body mass (kg) 45.6 17.2 44.0 19–85 38.3 13.0 34.0 20–90 BMI (kg/m2) 19.7 4.0 19.2 13–30.5 19.0 4.2 17.6 13.0–30.5 a GMFCS=Gross Motor Function Classification System, BMI=body mass index. b n=133 male participants and 78 female participants. c n=48 male participants and 47 female participants. Open in new tab Table Participant Characteristicsa Participants . Variable . GMFCS Level Ib . GMFCS Level IIc . X̅ . SD . Median . Range . X̅ . SD . Median . Range . Male Age (y) 12.1 2.7 11.6 6–19 12.6 3.5 12.5 7–19 Height (cm) 151.1 15.8 151.0 118–187 150.7 19.9 149.3 122–190 Body mass (kg) 44.0 14.5 41.0 20–92 43.4 15.8 41.0 23–88 BMI (kg/m2) 18.7 3.6 18.1 12.7–29.7 18.5 3.3 18.1 14.2–26.5 Female Age (y) 12.3 3.2 12.3 7–19 12.2 2.7 12.6 6–17 Height (cm) 149.2 17.8 150.0 117–181 140.8 14 142 115–178 Body mass (kg) 45.6 17.2 44.0 19–85 38.3 13.0 34.0 20–90 BMI (kg/m2) 19.7 4.0 19.2 13–30.5 19.0 4.2 17.6 13.0–30.5 Participants . Variable . GMFCS Level Ib . GMFCS Level IIc . X̅ . SD . Median . Range . X̅ . SD . Median . Range . Male Age (y) 12.1 2.7 11.6 6–19 12.6 3.5 12.5 7–19 Height (cm) 151.1 15.8 151.0 118–187 150.7 19.9 149.3 122–190 Body mass (kg) 44.0 14.5 41.0 20–92 43.4 15.8 41.0 23–88 BMI (kg/m2) 18.7 3.6 18.1 12.7–29.7 18.5 3.3 18.1 14.2–26.5 Female Age (y) 12.3 3.2 12.3 7–19 12.2 2.7 12.6 6–17 Height (cm) 149.2 17.8 150.0 117–181 140.8 14 142 115–178 Body mass (kg) 45.6 17.2 44.0 19–85 38.3 13.0 34.0 20–90 BMI (kg/m2) 19.7 4.0 19.2 13–30.5 19.0 4.2 17.6 13.0–30.5 a GMFCS=Gross Motor Function Classification System, BMI=body mass index. b n=133 male participants and 78 female participants. c n=48 male participants and 47 female participants. Open in new tab Aerobic fitness Aerobic fitness was reflected by the level achieved on the 10-m shuttle run tests.16 In these tests, participants walk or run between 2 markers delineating the respective course of 10 m at a set incremental speed determined by a signal (every minute). The starting speeds for the tests are 5 and 2 km/h for participants who are classified at GMFCS levels I and II, respectively, and the speeds are increased by 0.25 km/h every minute. The last completed level (accurate to a half shuttle) was recorded and used for analysis. These tests have been shown to be reliable, valid, and sensitive to change in children with CP.16,20 Each participant's heart rate was measured continuously with a portable heart rate monitor. All participants were instructed to walk or run until exhaustion. One physiological objective criterion and 2 physiological subjective criteria were used to determine whether the tests were maximal. Each child had to meet the objective criterion and 1 of the 2 subjective criteria at the end of the tests. The physiological objective criterion was a heart rate of ≥180 bpm.21 The subjective criteria were signs of intense effort, such as an unsteady walking or running pattern, sweating, facial flushing, and a clear unwillingness to continue walking or running despite repeated strong verbal encouragement. Further details on the preparation of the participants and procedures were published previously.16 Data Analysis Cross-sectional data analyses were performed with SPSS version 15.0† and the R statistical program.‡,22 Data for male and female participants are presented separately. Data from all participants, GMFCS levels I and II and male and female participants together, were analyzed with generalized additive models for location, scale, and shape (GAMLSS).23 This method is similar to those used for the growth standard recently published by the World Health Organization.24 The GAMLSS method extends the least mean square method25 in several ways.26 Generalized additive models for location, scale, and shape are parametric or semiparametric regression-type models in which various distribution functions can be compared to find the best distribution for the data.26 They offer a choice of error distributions (rather than just one), can process general linear predictors for each moment parameter (rather than being limited to a single covariate), and offer a choice of links between predictors and outcomes. In preliminary analyses, height showed the best correlation with shuttle run test performance. As possible predictors, therefore, we included GMFCS level, sex, height, and their interactions. Next, model building was performed for each test (dependent variable) to determine the significant predictor variables and their effect sizes, and formulas were constructed from these models. All data were used for model building. The larger number of participants classified at GMFCS level I increased the stability for the curves created for GMFCS level II. Separate graphs of the resulting models were made according to GMFCS level and sex. Role of the Funding Source This research was supported by the Dr W.M. Phelps Foundation, Bussum, the Netherlands. The funding body did not participate in the design or execution of the study; in the collection, management, analysis, or interpretation of the data; or in the preparation, review, or approval of the article. Results Data from 306 participants in the Netherlands (n=170), Switzerland (n=41), Australia (n=68), Canada (n=13), and the United States (n=14) were used to establish reference values. A total of 211 participants were classified at GMFCS level I, and 95 were classified at GMFCS level II; 181 were male, and 125 were female. The physical characteristics of the male and female participants classified at GMFCS level I (Table) were not significantly different. The physical characteristics of the male and female participants classified at GMFCS level II (Table) were comparable, except for height; the male participants were significantly taller than the female participants. The mean (±SD) heart rate of the participants at peak level of exercise was 194±10 bpm, indicating good effort during exercise. No injuries, complaints of pain, or other medical problems occurred in the participants who completed the shuttle run tests. Figures 1 and 2 show the height-related centile curves (P3, P25, P50, P75, and P97) for both sexes and GMFCS levels; these centile curves were calculated by use of a gamma distribution. Figure 1 Open in new tabDownload slide Reference centile curves for 10-m shuttle run test I for male participants (left) and female participants (right) classified at Gross Motor Function Classification System level I. The test started at 5 km/h. Height was measured in centimeters. Figure 1 Open in new tabDownload slide Reference centile curves for 10-m shuttle run test I for male participants (left) and female participants (right) classified at Gross Motor Function Classification System level I. The test started at 5 km/h. Height was measured in centimeters. Figure 2 Open in new tabDownload slide Reference centile curves for 10-m shuttle run test II for male participants (left) and female participants (right) classified at Gross Motor Function Classification System level II. The test started at 2 km/h. Height was measured in centimeters. Figure 2 Open in new tabDownload slide Reference centile curves for 10-m shuttle run test II for male participants (left) and female participants (right) classified at Gross Motor Function Classification System level II. The test started at 2 km/h. Height was measured in centimeters. Discussion This study provided an objective characterization of aerobic fitness in relation to the height of children, adolescents, and young adults who had CP and who were from various geographic regions. Generalized additive models for location, scale, and shape were used to construct centile curves. These curves are clinically relevant and provide a user-friendly method for the prediction of aerobic fitness. The results of this study showed that with increasing height, children, adolescents, and young adults achieved a larger number of shuttles on the SRT-I and the SRT-II. These findings are comparable to those of their peers who are developing typically, in whom performance on shuttle run tests increases with age and height.27 Aerobic performance values have been shown to be consistently higher in boys who are developing typically than in girls, and the sex difference becomes more pronounced as children progress through adolescence.27 The results of the present study showed that male and female participants with CP had increases in their shuttle run performance during development that were similar to those of their peers who are developing typically. Male participants were found to accomplish more shuttles than female participants. These results may have been attributable to their greater muscle mass and cardiac output and the ability to achieve higher levels of physical activity during development.13 Because these differences between the sexes were consistent across the countries, they were probably biological rather than social in origin. Both shuttle run tests typically involve speed being increased systematically as a function of time until the participants are unable to continue. Theoretically, at the limit of tolerance, well-motivated participants will have achieved their maximal (exercise mode–specific) heart rates. A continuous, progressive exercise test should ideally result in exhaustion after 6 to 12 minutes.28 For the SRT-I, the median (±SD) exercise time was 7 (±3.4) minutes, and for the SRT-II, the median (±SD) was 10 (±4.0) minutes. These data indicate that both shuttle run tests are suitable, efficient, and within current recommendations.28 Moreover, both tests also have been shown to be sensitive to change in children with CP.20 In clinical practice, the safety of running-based maximal exercise testing for children with CP is a concern. As a result, less intense exercise testing, such as the Six-Minute Walk Test, has been used routinely for children with CP. Despite evidence supporting the usefulness of the Six-Minute Walk Test, the information gathered from the test remains limited because the only measurements obtained are related to distance walked.29,30 In contrast, maximal exercise testing, such as 10-m shuttle run testing, provides more information related to aerobic fitness.17 Four studies that described data regarding maximal aerobic fitness in children and adolescents with CP reported no adverse effects.9,16,31,32 These data indicate that maximal exercise testing for children and adolescents with CP is suitable and safe. Height was used instead of age for the construction of the standard reference curves because, among all of the anthropometric factors that were proven to have a significant correlation with the shuttle run tests, height was the most discriminative variable; it showed the highest correlation with shuttle run test performance. Height is an anthropometric parameter that is routinely documented in all medical records in pediatric clinics. In addition, height is a more robust parameter than age, because people of the same age but with different backgrounds can have substantial differences in height.33 In the present study, no information regarding ethnicity was gathered. Reference values for aspects of fitness in children who are developing typically vary in different countries.34 The use of height-specific curves might lessen such variations, but further studies that include the ethnicity of the participants in the analyses are needed for a formal comparison.35 The limitation of the present study is the cross-sectional nature of the design. Given the difficulty of recruiting special populations, it would be quite difficult to conduct a similar study with a longitudinal design. Certainly, this is an area for future research; future longitudinal research with a smaller cohort should confirm the height-related increase in performance reported here. The shuttle run test that often is used for children who are developing typically is the 20-m shuttle run test described by Leger et al.36 For most children with CP, this test is not suitable, because the starting speed (8 km/h) and the increase (0.5 km/h) every minute are beyond their capabilities. In a randomized controlled trial by Verschuren and colleagues,20,37 only 2 of the 68 participants who had CP (classified at GMFCS level I or II) and who participated in an exercise training program had a peak running speed of greater than 8 km/h on the SRT-I or the SRT-II at baseline. Because the running speed of children with CP is different from that of children who are developing typically, it is not possible to compare the performance of both groups of children on the same shuttle run test. Although all therapists from the participating centers were instructed to follow the guidelines described in the Appendix, we are not aware of the interrater and intrarater reliability across sites and testers. This limitation of the present study needs to be investigated in future research. Moreover, the data used in the present study were from an “open-source” convenience sample of children, adolescents, and young adults who had CP and who were receiving physical therapy or were assessed during an examination. Most of the physical therapy took place in rehabilitation centers or schools for special education because most of the therapists who received the training for conducting the tests were working either in a rehabilitation center or in a school for special education. This situation may have led to selection bias, as data from young people who were not receiving treatment in a rehabilitation center or school for special education may have been missed. In addition, children, adolescents, and young adults who have CP and who do not attend a school for special education or a rehabilitation facility may be the young people with the highest exercise performance. This situation affects the generalizability of the reference values reported here to the clinical CP population. For future research, measuring physical activity with a physical activity questionnaire or an objective measure such as an activity monitor would provide important baseline information that would be useful for interpreting exercise testing results. Caution also should be taken when our centile curves are applied to people who fall outside the characteristics of our cohort, such as those younger than 6 years and older than 19 years. The performance of people older than 19 years on shuttle run tests has not been investigated yet. In conclusion, we used state-of-the-art statistical modeling techniques to provide reference values for aerobic fitness in relation to height for children, adolescents, and young adults who have CP, who are 6 to 20 years old, and who are classified at GMFCS levels I and II. The centile curves are clinically relevant and provide a user-friendly method for the prediction of aerobic fitness in young people with CP. The Bottom Line What do we already know about this topic? The progression of aerobic performance, using a shuttle run test, has been well established in individuals without disabilities. What new information does this study offer? This study provides data regarding aerobic performance in children and adolescents with cerebral palsy using a reliable and valid field test that is easy to administer: the 10-meter shuttle run test. If you’re a patient or a caregiver, what might these findings mean for you? Comparing the result from the 10-m shuttle run test with the reference values can be used to: (1) indicate relative weaknesses; (2) determine improvement over time with adjustment for natural development; (3) enable the patient to assess the success of the training program; (4) place the patient in the appropriate training group; and (5) motivate the patient. " This study was approved by the local ethics committees of the participating rehabilitation centers. " This research was supported by the Dr W.M. Phelps Foundation, Bussum, the Netherlands. * " Microsoft BV, Evert van de Beekstraat 354 1118 CZ Schiphol, Amsterdam, the Netherlands. † " SPSS Inc, 233 S Wacker Dr, Chicago, IL 60606. ‡ " R Foundation for Statistical Computing, Vienna, Austria, www.r-project.org/foundation/. References 1 Armstrong N Welsman JR . Aerobic fitness: what are we measuring? Med Sport Sci . 2007 ; 50 : 5 – 25 . Google Scholar Crossref Search ADS PubMed WorldCat 2 Myers J Prakash M Froelicher VF , et al. . 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OpenURL Placeholder Text WorldCat Appendix Guidelines for 10-m Shuttle Run Tests Measurement: aerobic capacity Population: children, adolescents, and young adults who had cerebral palsy and who were classified at Gross Motor Function Classification System (GMFCS) levels I and II Equipment Required: flat, nonslip surface; marking cones; measuring tape; 2 shuttle run test CDs; CD player; recording sheets; heart rate monitor Preparations and Conditions The course is 10 m long. Mark each end of the course with the marking cones and measuring tape. Participants should wear sports clothing and shoes (and orthoses, if applicable). Each participant also should wear a heart rate monitor. Shuttle Run Test Protocol Participants walk or run between 2 markers at a set incremental speed. GMFCS Protocols There are 2 CDs for the shuttle run tests. Shuttle run test I (SRT-I) is for children, adolescents, and young adults classified at GMFCS level I. The SRT-I starts at a speed of 5 km/h. Shuttle run test II (SRT-II) is for children, adolescents, and young adults classified at GMFCS level II. The SRT-II starts at 2 km/h. Speed is increased by 0.25 km/h every minute in each test. Each CD begins with a brief introduction to the test. The introduction is followed by a 5-second countdown to the start of the test. Thereafter, the CD emits a single beep at regular intervals. The walking or running pace is determined by a series of beeps on the accompanying CD. The participant should walk or run to the opposite end of the course when the first beep sounds. The participant should then continue walking or running at this speed, aiming at the opposite end of the course each time there is a beep. The participant should always place 1 foot either on or behind the 10-m mark at the end of each shuttle. If the participant arrives at the end of the shuttle before the beep sounds, then he or she should turn around, wait for the beep, and resume an adjusted walking or running speed. The walking or running speeds at the start of the test are very slow. On the SRT-I and the SRT-II, the participant has 7.2 and 18 seconds, respectively, to walk or run the 10-m shuttle. The walking or running speed is gradually increased. After each minute, the time interval between beeps decreases. The first speed is referred to as “level 1,” the second speed is referred to as “level 2,” and so on. Each level lasts approximately 1 minute, and each CD continues up to level 23. The end of each shuttle is denoted by a single beep; the end of each half level is denoted by a double beep; and the end of each level is denoted by a double beep and by the commentator on the CD. The test is finished when the participant is more than approximately 1.5 m (no markers necessary) away from the marker 2 consecutive paced signals within 1 level. The participant is instructed to walk or run for as long as possible, until he or she can no longer keep up with the speed set by the CD, at which point he or she should voluntarily withdraw from the test. In some cases, the person conducting the test may need to withdraw the participant when it becomes apparent that he or she is dropping behind the required pace and is unable to reach the marker on 2 consecutive shuttles. The test result is measured in units of a “level” (eg, 13) and a “half level” (eg, 14.5). The final level that a participant has completed is recorded on a recording sheet. The heart rate is read from the wrist monitor at the end of the test and recorded on a recording sheet. This heart rate can be used to determine whether a participant has performed maximally (a heart rate of >180 bpm). Some participants find it difficult to coordinate their walking or running speed with the pace of the audio signal. Therefore, it is recommended that someone assist participants during the first stages of the test. Once participants understand the instructions, they can continue the test without assistance. Participants who continue to experience difficulty pacing themselves should be accompanied throughout the test. In this situation, an additional person is required to accompany a participant to ensure the reliability and validity of the test. Measurement: aerobic capacity Population: children, adolescents, and young adults who had cerebral palsy and who were classified at Gross Motor Function Classification System (GMFCS) levels I and II Equipment Required: flat, nonslip surface; marking cones; measuring tape; 2 shuttle run test CDs; CD player; recording sheets; heart rate monitor Preparations and Conditions The course is 10 m long. Mark each end of the course with the marking cones and measuring tape. Participants should wear sports clothing and shoes (and orthoses, if applicable). Each participant also should wear a heart rate monitor. Shuttle Run Test Protocol Participants walk or run between 2 markers at a set incremental speed. GMFCS Protocols There are 2 CDs for the shuttle run tests. Shuttle run test I (SRT-I) is for children, adolescents, and young adults classified at GMFCS level I. The SRT-I starts at a speed of 5 km/h. Shuttle run test II (SRT-II) is for children, adolescents, and young adults classified at GMFCS level II. The SRT-II starts at 2 km/h. Speed is increased by 0.25 km/h every minute in each test. Each CD begins with a brief introduction to the test. The introduction is followed by a 5-second countdown to the start of the test. Thereafter, the CD emits a single beep at regular intervals. The walking or running pace is determined by a series of beeps on the accompanying CD. The participant should walk or run to the opposite end of the course when the first beep sounds. The participant should then continue walking or running at this speed, aiming at the opposite end of the course each time there is a beep. The participant should always place 1 foot either on or behind the 10-m mark at the end of each shuttle. If the participant arrives at the end of the shuttle before the beep sounds, then he or she should turn around, wait for the beep, and resume an adjusted walking or running speed. The walking or running speeds at the start of the test are very slow. On the SRT-I and the SRT-II, the participant has 7.2 and 18 seconds, respectively, to walk or run the 10-m shuttle. The walking or running speed is gradually increased. After each minute, the time interval between beeps decreases. The first speed is referred to as “level 1,” the second speed is referred to as “level 2,” and so on. Each level lasts approximately 1 minute, and each CD continues up to level 23. The end of each shuttle is denoted by a single beep; the end of each half level is denoted by a double beep; and the end of each level is denoted by a double beep and by the commentator on the CD. The test is finished when the participant is more than approximately 1.5 m (no markers necessary) away from the marker 2 consecutive paced signals within 1 level. The participant is instructed to walk or run for as long as possible, until he or she can no longer keep up with the speed set by the CD, at which point he or she should voluntarily withdraw from the test. In some cases, the person conducting the test may need to withdraw the participant when it becomes apparent that he or she is dropping behind the required pace and is unable to reach the marker on 2 consecutive shuttles. The test result is measured in units of a “level” (eg, 13) and a “half level” (eg, 14.5). The final level that a participant has completed is recorded on a recording sheet. The heart rate is read from the wrist monitor at the end of the test and recorded on a recording sheet. This heart rate can be used to determine whether a participant has performed maximally (a heart rate of >180 bpm). Some participants find it difficult to coordinate their walking or running speed with the pace of the audio signal. Therefore, it is recommended that someone assist participants during the first stages of the test. Once participants understand the instructions, they can continue the test without assistance. Participants who continue to experience difficulty pacing themselves should be accompanied throughout the test. In this situation, an additional person is required to accompany a participant to ensure the reliability and validity of the test. Open in new tab Guidelines for 10-m Shuttle Run Tests Measurement: aerobic capacity Population: children, adolescents, and young adults who had cerebral palsy and who were classified at Gross Motor Function Classification System (GMFCS) levels I and II Equipment Required: flat, nonslip surface; marking cones; measuring tape; 2 shuttle run test CDs; CD player; recording sheets; heart rate monitor Preparations and Conditions The course is 10 m long. Mark each end of the course with the marking cones and measuring tape. Participants should wear sports clothing and shoes (and orthoses, if applicable). Each participant also should wear a heart rate monitor. Shuttle Run Test Protocol Participants walk or run between 2 markers at a set incremental speed. GMFCS Protocols There are 2 CDs for the shuttle run tests. Shuttle run test I (SRT-I) is for children, adolescents, and young adults classified at GMFCS level I. The SRT-I starts at a speed of 5 km/h. Shuttle run test II (SRT-II) is for children, adolescents, and young adults classified at GMFCS level II. The SRT-II starts at 2 km/h. Speed is increased by 0.25 km/h every minute in each test. Each CD begins with a brief introduction to the test. The introduction is followed by a 5-second countdown to the start of the test. Thereafter, the CD emits a single beep at regular intervals. The walking or running pace is determined by a series of beeps on the accompanying CD. The participant should walk or run to the opposite end of the course when the first beep sounds. The participant should then continue walking or running at this speed, aiming at the opposite end of the course each time there is a beep. The participant should always place 1 foot either on or behind the 10-m mark at the end of each shuttle. If the participant arrives at the end of the shuttle before the beep sounds, then he or she should turn around, wait for the beep, and resume an adjusted walking or running speed. The walking or running speeds at the start of the test are very slow. On the SRT-I and the SRT-II, the participant has 7.2 and 18 seconds, respectively, to walk or run the 10-m shuttle. The walking or running speed is gradually increased. After each minute, the time interval between beeps decreases. The first speed is referred to as “level 1,” the second speed is referred to as “level 2,” and so on. Each level lasts approximately 1 minute, and each CD continues up to level 23. The end of each shuttle is denoted by a single beep; the end of each half level is denoted by a double beep; and the end of each level is denoted by a double beep and by the commentator on the CD. The test is finished when the participant is more than approximately 1.5 m (no markers necessary) away from the marker 2 consecutive paced signals within 1 level. The participant is instructed to walk or run for as long as possible, until he or she can no longer keep up with the speed set by the CD, at which point he or she should voluntarily withdraw from the test. In some cases, the person conducting the test may need to withdraw the participant when it becomes apparent that he or she is dropping behind the required pace and is unable to reach the marker on 2 consecutive shuttles. The test result is measured in units of a “level” (eg, 13) and a “half level” (eg, 14.5). The final level that a participant has completed is recorded on a recording sheet. The heart rate is read from the wrist monitor at the end of the test and recorded on a recording sheet. This heart rate can be used to determine whether a participant has performed maximally (a heart rate of >180 bpm). Some participants find it difficult to coordinate their walking or running speed with the pace of the audio signal. Therefore, it is recommended that someone assist participants during the first stages of the test. Once participants understand the instructions, they can continue the test without assistance. Participants who continue to experience difficulty pacing themselves should be accompanied throughout the test. In this situation, an additional person is required to accompany a participant to ensure the reliability and validity of the test. Measurement: aerobic capacity Population: children, adolescents, and young adults who had cerebral palsy and who were classified at Gross Motor Function Classification System (GMFCS) levels I and II Equipment Required: flat, nonslip surface; marking cones; measuring tape; 2 shuttle run test CDs; CD player; recording sheets; heart rate monitor Preparations and Conditions The course is 10 m long. Mark each end of the course with the marking cones and measuring tape. Participants should wear sports clothing and shoes (and orthoses, if applicable). Each participant also should wear a heart rate monitor. Shuttle Run Test Protocol Participants walk or run between 2 markers at a set incremental speed. GMFCS Protocols There are 2 CDs for the shuttle run tests. Shuttle run test I (SRT-I) is for children, adolescents, and young adults classified at GMFCS level I. The SRT-I starts at a speed of 5 km/h. Shuttle run test II (SRT-II) is for children, adolescents, and young adults classified at GMFCS level II. The SRT-II starts at 2 km/h. Speed is increased by 0.25 km/h every minute in each test. Each CD begins with a brief introduction to the test. The introduction is followed by a 5-second countdown to the start of the test. Thereafter, the CD emits a single beep at regular intervals. The walking or running pace is determined by a series of beeps on the accompanying CD. The participant should walk or run to the opposite end of the course when the first beep sounds. The participant should then continue walking or running at this speed, aiming at the opposite end of the course each time there is a beep. The participant should always place 1 foot either on or behind the 10-m mark at the end of each shuttle. If the participant arrives at the end of the shuttle before the beep sounds, then he or she should turn around, wait for the beep, and resume an adjusted walking or running speed. The walking or running speeds at the start of the test are very slow. On the SRT-I and the SRT-II, the participant has 7.2 and 18 seconds, respectively, to walk or run the 10-m shuttle. The walking or running speed is gradually increased. After each minute, the time interval between beeps decreases. The first speed is referred to as “level 1,” the second speed is referred to as “level 2,” and so on. Each level lasts approximately 1 minute, and each CD continues up to level 23. The end of each shuttle is denoted by a single beep; the end of each half level is denoted by a double beep; and the end of each level is denoted by a double beep and by the commentator on the CD. The test is finished when the participant is more than approximately 1.5 m (no markers necessary) away from the marker 2 consecutive paced signals within 1 level. The participant is instructed to walk or run for as long as possible, until he or she can no longer keep up with the speed set by the CD, at which point he or she should voluntarily withdraw from the test. In some cases, the person conducting the test may need to withdraw the participant when it becomes apparent that he or she is dropping behind the required pace and is unable to reach the marker on 2 consecutive shuttles. The test result is measured in units of a “level” (eg, 13) and a “half level” (eg, 14.5). The final level that a participant has completed is recorded on a recording sheet. The heart rate is read from the wrist monitor at the end of the test and recorded on a recording sheet. This heart rate can be used to determine whether a participant has performed maximally (a heart rate of >180 bpm). Some participants find it difficult to coordinate their walking or running speed with the pace of the audio signal. Therefore, it is recommended that someone assist participants during the first stages of the test. Once participants understand the instructions, they can continue the test without assistance. Participants who continue to experience difficulty pacing themselves should be accompanied throughout the test. In this situation, an additional person is required to accompany a participant to ensure the reliability and validity of the test. Open in new tab Author notes " Dr Verschuren, Ms Bloemen, and Dr Takken provided concept/idea/research design. All authors provided writing, data analysis, and consultation (including review of manuscript before submission). Dr Verschuren and Ms Bloemen provided data collection. Dr Verschuren provided project management and fund procurement. The authors thank all of the therapists who participated in the data collection. © 2010 American Physical Therapy Association

Cagnie,, Barbara;Dolphens,, Mieke;Peeters,, Ian;Achten,, Eric;Cambier,, Dirk;Danneels,, Lieven

doi: 10.2522/ptj.20090351pmid: 20522674

Background Chronic whiplash-associated disorders (WAD) have been shown to be associated with motor dysfunction. Increased electromyographic (EMG) activity in neck and shoulder girdle muscles has been demonstrated during different tasks in participants with persistent WAD. Muscle functional magnetic resonance imaging (mfMRI) is an innovative technique to evaluate muscle activity and differential recruitment of deep and superficial muscles following exercise. Objective The purpose of this study was to compare the recruitment pattern of deep and superficial neck flexors between patients with WAD and controls using mfMRI. Design A cross-sectional design was used. Method The study was conducted in a physical and rehabilitation medicine department. The participants were 19 controls who were healthy (10 men, 9 women; mean [±SD] age=22.2±0.6 years) and 16 patients with WAD (5 men, 11 women; mean [±SD] age=32.9±12.7 years). The T2 values were calculated for the longus colli (Lco), longus capitis (Lca), and sternocleidomastoid (SCM) muscles at rest and following cranio-cervical flexion (CCF). Results In the overall statistical model for T2 shift, there was a significant main effect for muscle (F=3.906, P=.033) but not for group (F=2.855, P=.101). The muscle × group interaction effect was significant (F=3.618, P=.041). Although not significant, there was a strong trend for lesser Lco (P=.061) and Lca (P=.060) activity for the WAD group compared with the control group. Although the SCM showed higher T2 shifts, this difference was not significant (P=.291). Limitations Although mfMRI is an innovative and useful technique for the evaluation of deep cervical muscles, consideration is required, as this method encompasses a postexercise evaluation and is limited to resistance types of exercises. Conclusions Muscle functional magnetic resonance imaging demonstrated a difference in muscle recruitment between the Lco, Lca, and SCM during CCF in the control group, but failed to demonstrate a changed activity pattern in the WAD group compared with the control group. The mild symptoms in the WAD group and the wide variability in T2 values may explain the lack of significance. Chronic whiplash-associated disorders (WAD) have been shown to be associated with motor dysfunction, which occurs soon after injury and persists into the period of chronicity in some patients.1,2 Changes observed include reduced cervical spine movements, disturbances in cervical kinesthesia as reflected by errors in head and neck repositioning, and increased electromyographic (EMG) activity in neck and shoulder girdle muscles during tasks of functional low-load activities, as well as during a task of supported cranio-cervical flexion (CCF).2–11 The task of CCF aims to address the deep cervical muscles and was developed by Jull and coworkers12 in response to research indicating the importance of the deep cervical flexors in support of the cervical lordosis and motion segments and clinical observations of their impairment with neck pain.12–16 More specifically, CCF is the primary action of the longus capitis (Lca) muscle that attaches to the cranium and the superior portion of the longus colli (Lco) that attaches to the first cervical vertebra.12,17,18 In contrast, superficial cervical flexor muscles such as the sternocleidomastoid (SCM) muscle are not prime movers of CCF and are structurally more suited to assist in flexing the lower cervical spine on the thorax. Previous studies have demonstrated higher EMG signal amplitudes in the SCM in both patients with WAD and patients with insidious-onset neck pain compared with people who are healthy.2,8,10,16 Inferences were made that the increased activation of the superficial cervical flexors was likely to be a compensation for reduced deep cervical flexor activation, but there was no direct evidence for this assumption. This evidence was provided in a subsequent study that directly measured activity in the deep cervical flexors with a novel surface EMG technique.16,19 It was demonstrated that individuals with chronic neck pain exhibited reduced activity of the deep cervical flexors during this test, which was, in combination with an increased activity in the SCM, an indication of an altered neuromotor control strategy.16 Although this novel EMG technique allows direct measurement of deep cervical flexor activity, it has some limitations. This technique is quite invasive, as electrodes are inserted via the nose with a nasopharygeal suction catheter and suctioned onto the posterior oropharyngeal wall. This method also does not differentiate between the Lco and Lca, and muscle cross-talk cannot be ruled out.20,21 In contrast, muscle functional magnetic resonance imaging (mfMRI) has gained popularity in studies evaluating muscle function to overcome the problems with surface EMG. It has been demonstrated to be a noninvasive method to observe the differential activation of deep and superficial cervical flexor muscle layers and to allow differentiation between the Lco and Lca, as both muscles may have a different anatomical action based on their attachments.22–25 The technique is based on an acute enhancement of the T2 relaxation time (T2) of muscle water due to activity.26 Increased T2 of muscle water is reflected in a significant augmentation of the signal intensity of the activated muscles and provides information regarding the pattern and the intensity of the muscle activation. Previous studies in which the sensitivity of the T2 value for changes in exercise intensity was investigated provided evidence of a linear association between the T2 value and exercise intensity.27,28 Although there is enough evidence of an association between chronic neck pain and impaired cervical flexor muscle performance, mfMRI may provide additional information regarding the recruitment of the cervical flexor muscles in patients with WAD. The purpose of the present study was to compare the recruitment pattern of Lco, Lca, and SCM during CCF between patients with WAD and people who are healthy by use of mfMRI. Materials and Method Setting and Participants Nineteen participants who were healthy (10 men and 9 women), with a mean (±SD) age of 22.2±0.6 years, comprised the control group. Exclusion criteria were recent neck pain, back pain, or headache of cervical origin (<3 months) and contraindications to magnetic resonance imaging (MRI), such as a cardiac pacemaker, claustrophobia, implanted metals, unremovable piercings, aneurysm clips, carotid artery vascular clamp, neurostimulator, cochlear or ear implants, and (possible) pregnancy within the first 3 months. Patients in the WAD group were 5 men and 11 women with a mean (±SD) age of 32.9±12.7 years. Patients were selected via the Flemish Whiplash Association, and criteria for inclusion in the study consisted of a period of at least 6 months since the accident (mean=6.4 years, SD=4.7), ongoing pain and disability in the neck region, severity of injury classified as Québec Task Force grade 2 or 3,29 and no other injury relating to a previous motor vehicle accident. Patients were excluded if they had either undergone cervical spine surgery or reported any neurologic signs. On the test day prior to MRI, patients were asked to complete the Neck Disability Index (NDI)30 and to indicate their average intensity of neck pain on a 10-cm numerical rating scale (NRS) anchored with “no pain” and “the worst possible pain imaginable.” The NDI (score out of 50) was used to measure the perceived impairments of the patients resulting from their neck pain. The mean (±SD) for average intensity of pain (NRS) and perceived disability (NDI) were 3.9±2.6 and 17.2±7.4, respectively. Written informed consent was obtained from all participants. General Design The protocol was designed to compare the recruitment pattern of deep and superficial neck flexors between patients with WAD and controls by use of mfMRI. Therefore, magnetic resonance images were obtained under 2 conditions. They first were obtained at rest. Participants then performed the CCF exercise outside the scanner room. Immediately after the CCF exercise, a second magnetic resonance image was obtained. Exercise Protocol At least 1 week prior to the test day, participants were instructed in the action of CCF. In a supine position, participants first were carefully instructed in this action by performing a gentle nodding action without lifting the head off the surface until full CCF range of motion was reached. Analysis of the performance was based on the clinical protocol, as described by Jull et al.12 Once the correct movement pattern was achieved, a pressure cuff (Stabilizer)* was placed suboccipitally behind the participant's cervical spine and inflated until a stable pressure of 20 mm Hg was achieved in order to monitor the slight flattening of the cervical lordosis and register the muscular effort as an increase in pressure. Participants practiced progressive targeting of 5 incremental levels (2-mm-Hg increments) between 22 and 30 mm Hg by steadily maintaining the pressure on each target for 10 seconds, guided by visual feedback of the pressure cuff and controlled by an examiner. As 26 mm Hg was the pressure level that was used on the test day, 10-second holds of this target were repeated 10 times. On the test day, participants were asked to maintain the pressure level at 26 mm Hg and to execute an isometric hold until fatigue prevented them from sustaining the contraction any longer. The exercise was performed 3 times, with 1 minute of rest between the sets. Participants were instructed to discontinue the test when they perceived an inability to sustain the contraction at the indicated intensity. The mean (±SD) time CCF was held (CCF time) was 107.7±46.7 seconds in the control group compared with 58.7±31.4 seconds in the WAD group. MRI Magnetic resonance imaging was performed using a 3-T magnet (MAGNETOM Trio, Tim system, syngo MR VB13 software).† A flexible surface coil, 20 × 50 cm, fixed over the anterior aspect of the participants' neck was combined with the phased-array spine coil as a receiver coil combination. The participants were placed in a comfortable and relaxed supine position, with their hips flexed to 45 degrees and their legs supported by foam wedges. Their head was positioned in neutral, without rotation, lateral flexion, or exaggerated lordosis. Axial images of the cervical spine were obtained at rest and after the exercise. As the half-life of exercise-induced changes in muscle T2 has been shown to be 7 minutes, participants were placed in the scanner immediately following the exercise.28 The mean (±SD) time between the end of the exercise and the start of scanning was 117±13 seconds. A sagittal localizing sequence first was performed to identify cervical disk space intervals. Axial images parallel to the consecutive intervertebral disks with a slice thickness of 5 mm were obtained at 5 different cervical levels (C0–C1, C2–C3, C3–C4, C4–C5, and C5–C6). For T2 calculation, a multi-spinecho sequence was used: repetition time=2,500 milliseconds; echo times=10 to 161.6 milliseconds, with steps of 10.1 milliseconds (16 echoes); field of view=256 mm; matrix=128 × 128; and voxel size=2 × 2 × 5 mm. Total acquisition time for 1 scan was 5:12 minutes. Imaging procedures were identical for the resting scan and the exercise scan. Data Analysis After scanning, the images were transferred to a computer for calculation of muscle T2 using ImageJ, a Java-based version of the public domain NIH Image software.§ In order to calculate T2 values, regions of interest were identified on the T2 images. On the base of its clearest visualization, the Lca was analyzed at the C0-C1 level, whereas the SCM and Lco were analyzed at the C5–C6 level (Fig. 1). Figure 1 Open in new tabDownload slide Axial T2-weighted scan at (a) the C0–C1 level, showing the longus capitis muscle (Lca) surrounded by the oropharynx (OP), the anterior arch of the atlas (AAA), and the spinal cord (SC), and (b) the C5–C6 level, showing the sternocleidomastoid muscle (SCM) and the longus colli muscle (Lco) surrounded by the vertebral body of C5, the common carotid artery (CCA), and the larynx (L). A=anterior, P=posterior, TR=repetition time, and TE=echo time Figure 1 Open in new tabDownload slide Axial T2-weighted scan at (a) the C0–C1 level, showing the longus capitis muscle (Lca) surrounded by the oropharynx (OP), the anterior arch of the atlas (AAA), and the spinal cord (SC), and (b) the C5–C6 level, showing the sternocleidomastoid muscle (SCM) and the longus colli muscle (Lco) surrounded by the vertebral body of C5, the common carotid artery (CCA), and the larynx (L). A=anterior, P=posterior, TR=repetition time, and TE=echo time A region of interest was defined as the greatest outline of the muscle with avoidance of nonmuscular tissue, such as fat, fascia, and vessels. Sixteen echoes were used in T2 calculation, using a Simplex algorithm to fit the values from the specific slice in a T2 image volume to the exponential Sn=S0 exp(−TEn/T2) (n=1:16), where Sn is a signal intensity of n-th echo, S0 is the initial signal intensity, and TEn is the echo interval. The mean T2 value and its standard deviation were derived for each region of interest. The T2 measurements for the Lca, Lco, and SCM have been shown to be highly reliable in our laboratory, with intraclass correlation coefficients ranging from .87 to .94, depending on the muscles evaluated.23 Analysis of the data was performed using SPSS statistical software, version 16.‡ Descriptive statistics (mean±SD) were calculated for T2 values (millisecond) at rest and after exercise for each muscle group. The T2 shifts, which are defined as T2 values after exercise minus T2 values at rest, were used for statistical analysis. The T2 shifts were evaluated using a repeated-measures analysis of variance with the within-participant factor being muscle (Lca, Lco, and SCM) and the between-participant factor being group (WAD and control). Participant's sex was used as covariate in this analysis. Post hoc comparisons were made when required, and adjustments were used to correct for multiple tests (Holm-Bonferroni method). Pearson correlation coefficients were used to evaluate correlations between T2 shifts and the following parameters: NDI, NRS, CCF time, and time since injury. Statistical significance was accepted at the .05 alpha level. Results The T2 values at rest and after exercise calculated for all muscles in the control and WAD groups are shown in the Table. There were no significant differences in the T2 values at rest for all muscles between the control and WAD groups. Table Mean (±SD) T2 Values (in Milliseconds) for the Longus Capitis (Lca), Longus Colli (Lco), and Sternocleidomastoid (SCM) Muscles at Rest and Following Cranio-Cervical Flexion (CCF), With Mean Differences and 95% Confidence Intervals (CI) and P Values for Comparisons of T2 Shifts Between Control Participants and Patients With Chronic Whiplash-Associated Disorder (WAD) Muscle . . Control Group . WAD Group . Mean Difference (95% CI) . P . Lca Rest 44.1±3.3 45.2±4.7 CCF 49.1±5.1 47.2±5.9 T2 shift 5.0±5.3 2.0±3.7 −3.0 (−6.1 to 0.1) .060 Lco Rest 44.5±2.8 43.2±5.1 CCF 46.7±3.2 43.7±5.4 T2 shift 2.2±2.9 0.5±2.0 −1.7 (−3.4 to 0.1) .061 SCM Rest 43.6±3.4 43.4±2.2 CCF 44.7±2.1 45.6±3.8 T2 shift 1.3±2.3 2.2±2.8 0.9 (−0.9 to 2.7) .291 Muscle . . Control Group . WAD Group . Mean Difference (95% CI) . P . Lca Rest 44.1±3.3 45.2±4.7 CCF 49.1±5.1 47.2±5.9 T2 shift 5.0±5.3 2.0±3.7 −3.0 (−6.1 to 0.1) .060 Lco Rest 44.5±2.8 43.2±5.1 CCF 46.7±3.2 43.7±5.4 T2 shift 2.2±2.9 0.5±2.0 −1.7 (−3.4 to 0.1) .061 SCM Rest 43.6±3.4 43.4±2.2 CCF 44.7±2.1 45.6±3.8 T2 shift 1.3±2.3 2.2±2.8 0.9 (−0.9 to 2.7) .291 Open in new tab Table Mean (±SD) T2 Values (in Milliseconds) for the Longus Capitis (Lca), Longus Colli (Lco), and Sternocleidomastoid (SCM) Muscles at Rest and Following Cranio-Cervical Flexion (CCF), With Mean Differences and 95% Confidence Intervals (CI) and P Values for Comparisons of T2 Shifts Between Control Participants and Patients With Chronic Whiplash-Associated Disorder (WAD) Muscle . . Control Group . WAD Group . Mean Difference (95% CI) . P . Lca Rest 44.1±3.3 45.2±4.7 CCF 49.1±5.1 47.2±5.9 T2 shift 5.0±5.3 2.0±3.7 −3.0 (−6.1 to 0.1) .060 Lco Rest 44.5±2.8 43.2±5.1 CCF 46.7±3.2 43.7±5.4 T2 shift 2.2±2.9 0.5±2.0 −1.7 (−3.4 to 0.1) .061 SCM Rest 43.6±3.4 43.4±2.2 CCF 44.7±2.1 45.6±3.8 T2 shift 1.3±2.3 2.2±2.8 0.9 (−0.9 to 2.7) .291 Muscle . . Control Group . WAD Group . Mean Difference (95% CI) . P . Lca Rest 44.1±3.3 45.2±4.7 CCF 49.1±5.1 47.2±5.9 T2 shift 5.0±5.3 2.0±3.7 −3.0 (−6.1 to 0.1) .060 Lco Rest 44.5±2.8 43.2±5.1 CCF 46.7±3.2 43.7±5.4 T2 shift 2.2±2.9 0.5±2.0 −1.7 (−3.4 to 0.1) .061 SCM Rest 43.6±3.4 43.4±2.2 CCF 44.7±2.1 45.6±3.8 T2 shift 1.3±2.3 2.2±2.8 0.9 (−0.9 to 2.7) .291 Open in new tab Mean T2 shifts plotted by muscle and group are shown in Figure 2. In the overall statistical model for T2 shift, there was a significant main effect for muscle (F=3.906, P=.033) but not for group (F=2.855, P=.101). The muscle × group interaction effect was significant (F=3.618, P=.041). There was no effect of participant's sex (P=.404). Figure 2 Open in new tabDownload slide T2 shifts in milliseconds (mean±SD) of the longus capitis (Lca), longus colli (Lco), and sternocleidomastoid (SCM) muscles for the group with chronic whiplash-associated disorders (WAD) and the control group. *P<.05. Figure 2 Open in new tabDownload slide T2 shifts in milliseconds (mean±SD) of the longus capitis (Lca), longus colli (Lco), and sternocleidomastoid (SCM) muscles for the group with chronic whiplash-associated disorders (WAD) and the control group. *P<.05. In the control group, there was a significantly higher T2 shift in the Lca compared with the SCM (P=.010), whereas no differences among muscles were found in the WAD group (Fig. 2). The patients with WAD demonstrated a trend for lower T2 shifts in both the Lco (P=.061) and the Lca (P=.060) compared with the control group. Although the SCM showed higher T2 shifts, this difference was not significant (P=.291). There were no significant correlations between the observed T2 shifts and NDI, NRS, and time since injury (r=−.319 to .562). Although there was a significant difference in CCF time between the control and WAD groups (P≤.001), no correlation was found between CCF time and observed T2 shifts in all muscles (r=−.244 to .132). Discussion The results of this study indicate that mfMRI demonstrated a difference in muscle recruitment between the Lca and SCM during CCF in the control group, but failed to demonstrate a changed activity pattern in the WAD group compared with the control group. In the control group, the Lca displayed a significant higher T2 increase than the Lco and SCM. This finding is in accordance with previous studies that demonstrated that the CCF method is more specific to the anatomical action of the deep cervical flexor muscles and less specific to the anatomical action of the superficial cervical flexors.20,21 However, in these studies, the Lca and Lco were taken together as the deep cervical flexors, and no distinction was made between the muscles.14,19,25 As the results demonstrate that the Lca is more activated than the Lco during the CCF, this study highlights that the action of these muscles can be distinguished using mfMRI. When comparing the WAD and control groups, the results lacked significance, although the patients with WAD demonstrated a trend for lower T2 shifts in both the Lco and Lca. To the best of our knowledge, Falla et al16 are the only researchers who also investigated the deep cervical flexors during CCF between patients with chronic neck pain and asymptomatic controls by use of surface EMG. They demonstrated a trend for lower deep cervical flexor activity at all stages of the CCF in participants with neck pain, but this difference was statistically significant only at the higher stages of the test (28 and 30 mm Hg). As the pressure level in the present study was fixed at 26 mm Hg, it is plausible and in accordance with the data of Falla et al16 that only a trend for lower muscle activation was found. It could be questioned why 26 mm Hg was used in this study, as Falla et al16 previously had demonstrated significant differences only at the 2 highest levels of the test. The reason for choosing this level was based on the results of Jull et al,10 who demonstrated large shortfalls in pressure in the latter 2 stages of the test, indicating that many of the participants would fail to execute these stages of the test. Although the SCM showed higher T2 shifts in the WAD group, this difference was not significant compared with the control group (P=.291). Different studies have demonstrated higher measures of EMG signal amplitude in the SCM in patients with WAD, as well as in patients with cervicogenic headache and idiopathic neck pain and office workers with neck pain, compared with control participants who were healthy.2,8,10,16,31–33 Except for the study of Falla et al,16 who only found a trend for greater SCM activity for participants with mild neck pain (NDI=12.4±9.5), a common finding in these studies was a significant increase in EMG amplitude of the SCM for the final 2 stages of the test (28 and 30 mm Hg).2,8,10,31,33 The results for the other stages of the test differed among the previous studies. Jull et al33 found significantly greater SCM activity in individuals with cervicogenic headache for the final 3 stages of the test (P<.001), and Johnston et al32 also found a significant difference at the 24-mm Hg level. Sterling et al31 only found higher levels of EMG activity with CCF in individuals with WAD and persistent moderate to severe symptoms (NDI=37.1±8), whereas there was no difference between individuals with mild pain and disability (NDI=16.7±6) and a control group. Based on these results, we hypothesize that the impairment in CCF is not dependent on the etiology of neck pain, but rather on the severity of the neck pain. As the mean (±SD) NDI score of the patients with WAD in this study was 17.2±7.4, which is quite similar to the patient characteristics in the studies by Falla et al16 and Sterling et al,31 it could be argued that this reflects a mild pain and disability group, resulting in no significant differences between groups. Further research in patients with WAD with moderate to severe symptoms is needed to evaluate whether mfMRI can distinguish between patients with neck pain and controls. There are different hypotheses as to why there is a differential muscle recruitment in patients with WAD. The current evidence suggests that an altered control strategy may be induced by pain, which, in turn may contribute to muscle overload or disuse.34 These changes in motor control may lead to additional adaptations at the muscle level. Elliott et al35 recently demonstrated a significantly greater muscle fat infiltration and cross-sectional area in the anterior neck muscles, especially in the deeper Lca and Lco, in participants with chronic WAD compared with a control group. It is assumed that larger intracellular fat stores would increase the T2 values, because fat has a high T2 value relative to muscle.36 However, the current study could not demonstrate a significant difference in T2 values at rest between the control and WAD groups. The present results must be viewed within the limitations of the study. The male/female ratio was not similar in both groups, which may have affected the results. However, there was no effect of participant's sex (P=.404), which is in accordance with previous studies.10,31 As mfMRI is very sensitive to the intensity of the exercise, a fixed pressure level (26 mm Hg) with an isometric hold until exhaustion was used for all participants.28,37 This is not a real reflection of clinical practice, in which the baseline assessment is documented as the pressure level that the patient can achieve and hold for 2 to 3 seconds with the correct CCF action, with minimal superficial muscle activity and in the absence of any other substitution strategy.12 This pressure level differs between patients and people who are healthy; individuals who are asymptomatic normally attain 26 to 28 mm Hg, and the baseline assessment in patients with neck pain is only 22 to 24 mm Hg. Higher T2 values were found in this study compared with previous studies.25,38–40 The most acceptable reason for this discrepancy is the fact that different imaging sequences were used, which may have given a systematic deviation of 10% to 20%. The current T2 values, however, are comparable to the values found by Dickx and colleagues,24,41 who evaluated the lumbar muscles with the same apparatus and the same imaging sequences. Besides the discussion of methodological limitations, a perspective on the state of the art of mfMRI is warranted. It is important to recognize that mfMRI may not be seen as a superior method compared with EMG but rather as a complementary evaluation technique. The underlying mechanisms and physiological representation differ between the 2 methods. Electromyography monitors electrical activity of activated muscles, whereas the mfMRI method is based on registering changes in metabolic activity and water content. Both MRI and EMG measurement techniques have intrinsic advantages and disadvantages. Electromyography has the advantage of evaluating real time, which permits the investigation of timing of muscles and changes over time. However, due to the problem of cross-talk, it often is difficult to obtain an EMG signal representing isolated activity of the target muscle.26 In addition, deep muscles are not accessible with surface electrodes.42 Another technical problem is the variability in myoelectrical signal attributed to subcutaneous tissue and electrode type and placement. The mfMRI technique has the advantage, especially in the case of the spinal muscles, of easily evaluating deep muscles, adjacent muscles, and even overlying muscles without the problem of cross-talk. However, some careful considerations about the mfMRI technique need to be made. First, mfMRI is a postexercise evaluation of muscle recruitment, which enables only evaluation of spatial characteristics, whereas no temporal characteristics such as changes in timing of muscle activity can be assessed. Second, mfMRI is limited to resistance exercises. Although a linear relationship has been demonstrated among exercise intensity, EMG activity, and T2 times, the lowest activity threshold to induce a significant shift in signal intensity is still not known.27,37,43 However, most studies agree that changes in T2 times can be detected with as few as 2 repetitions of a task.25,44,45 The validity of this method has been demonstrated in different muscles, but studies are lacking defining the sensitivity of this method in the assessment of cervical muscles.27,37,43,46,47 As the muscles evaluated in this study are rather small compared with larger muscles of the limbs, which have been investigated in previous studies using mfMRI, the small muscle size may partly explain the wide variability observed in the T2 values and the lack of significant results. Finally, it is clear that changes in T2 values with exercise are multifactorial, including fiber type distribution, differences in regional perfusion, and aerobic capacity.44 The time course and the persistence of the changes in T2 times recently were modeled by Damon and Gore.48 However, the precise mechanism of how individual physiological and biochemical variables contribute to the changes in T2 remains unclear and warrants further research. As a consequence of the advantages and disadvantages of both techniques, it is clear that mfMRI and EMG can be used independently to assess muscle activity, depending on the purpose of research. However, combining both techniques provides additional information and adds value to answering research questions. Conclusions The results of this study confirm the findings of earlier experiments on cervical muscle recruitment by using a novel technique of mfMRI to evaluate muscle function and dysfunction of the cervical flexors. The mfMRI technique demonstrated differences in muscle recruitment among the Lco, Lca, and SCM during CCF in the control group, but failed to demonstrate a changed activity pattern in the WAD group compared with the control group. The mild symptoms in the WAD group and the wide variability in T2 values may explain the lack of significance. " This study was approved by the local ethics committees (Ghent University). " This research was presented at the XVII Congress of the International Society of Electrophysiology and Kinesiology; June 16–19, 2010; Aalborg, Denmark. " This study was supported by the Research Foundation–Flanders (FWO). * " Chattanooga Group, 4717 Adams Rd, Hixson, TN 37343. † " Siemens AG, Erlangen, Germany. § " Office of Research Services, National Institutes of Health, 31 Center Dr, MSC 2324, Building 31, Room 4B30, Bethesda, MD 20892-2324. ‡ " SPSS Inc, 233 S Wacker Dr, Chicago, IL 60606. References 1 Sterling M . 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Dizziness and unsteadiness following whiplash injury: characteristic features and relationship with cervical joint position error . J Rehabil Med . 2003 ; 35 : 36 – 43 . Google Scholar Crossref Search ADS PubMed WorldCat 6 Treleaven J Jull GA Lowchoy N . The relationship of cervical joint position error to balance and eye movement disturbances in persistent whiplash . Man Ther . 2006 ; 11 : 99 – 106 . Google Scholar Crossref Search ADS PubMed WorldCat 7 Heikkila H Astrom PG . Cervicocephalic kinesthetic sensibility in patients with whiplash injury . Scand J Rehabil Med . 1996 ; 28 : 133 – 138 . Google Scholar PubMed OpenURL Placeholder Text WorldCat 8 Sterling M Jull GA Vicenzino B , et al. . Development of motor system dysfunction following whiplash injury . Pain . 2003 ; 103 : 65 – 73 . Google Scholar Crossref Search ADS PubMed WorldCat 9 Nederhand MJ Ijzerman MJ Hermens HJ , et al. . Cervical muscle dysfunction in the chronic whiplash-associated disorder grade II (WAD-II) . 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Cranio-cervical flexor muscle impairment at maximal, moderate, and low loads is a feature of neck pain . Man Ther . 2007 ; 12 : 34 – 39 . Google Scholar Crossref Search ADS PubMed WorldCat 15 Falla DL Jull GA Rainoldi A Merletti R . Neck flexor muscle fatigue is side specific in patients with unilateral neck pain . Eur J Pain . 2004 ; 8 : 71 – 77 . Google Scholar Crossref Search ADS PubMed WorldCat 16 Falla DL Jull GA Hodges PW . Patients with neck pain demonstrate reduced electromyographic activity of the deep cervical flexor muscles during performance of the craniocervical flexion test . Spine . 2004 ; 29 : 2108 – 2114 . Google Scholar Crossref Search ADS PubMed WorldCat 17 Vasavada AN Li S Delp SL . Influence of muscle morphometry and moment arms on the moment-generating capacity of human neck muscles . Spine . 1998 ; 23 : 412 – 422 . Google Scholar Crossref Search ADS PubMed WorldCat 18 Mayoux-Benhamou MA Revel M Vallee C , et al. . Longus colli has a postural function on cervical curvature . Surg Radiol Anat . 1994 ; 16 : 367 – 371 . Google Scholar Crossref Search ADS PubMed WorldCat 19 Falla DL Jull GA Dall'Alba PT , et al. . An electromyographic analysis of the deep cervical flexor muscles in performance of craniocervical flexion . Phys Ther . 2003 ; 83 : 899 – 906 . Google Scholar PubMed OpenURL Placeholder Text WorldCat 20 Falla DL Jull GA O'Leary S Dall'Alba PT . Further evaluation of an EMG technique for assessment of the deep cervical flexor muscles . J Electromyogr Kinesiol . 2006 ; 16 : 621 – 628 . Google Scholar Crossref Search ADS PubMed WorldCat 21 O'Leary S Falla DL Jull GA Vicenzino B . Muscle specificity in tests of cervical flexor muscle performance . J Electromyogr Kinesiol . 2007 ; 17 : 35 – 40 . Google Scholar Crossref Search ADS PubMed WorldCat 22 Mayer JM Graves JE Clark BC , et al. . The use of magnetic resonance imaging to evaluate lumbar muscle activity during trunk extension exercise at varying intensities . Spine . 2005 ; 30 : 2556 – 2563 . Google Scholar Crossref Search ADS PubMed WorldCat 23 Cagnie B Dickx N Peeters I , et al. . The use of functional MRI to evaluate cervical flexor activity during different cervical flexion exercises . J Appl Physiol . 2008 ; 104 : 230 – 235 . Google Scholar Crossref Search ADS PubMed WorldCat 24 Dickx N Cagnie B Achten E , et al. . Changes in lumbar muscle activity because of induced muscle pain evaluated by muscle functional magnetic resonance imaging . Spine . 2008 ; 33 : E983 – E989 . Google Scholar Crossref Search ADS PubMed WorldCat 25 Conley MS Meyer RA Bloomberg JJ , et al. . Noninvasive analysis of human neck muscle function . Spine . 1995 ; 20 : 2505 – 2512 . Google Scholar Crossref Search ADS PubMed WorldCat 26 Patten C Meyer RA Fleckenstein JL . T2 mapping of muscle . 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Google Scholar Google Preview OpenURL Placeholder Text WorldCat COPAC 35 Elliott JM O'Leary S Sterling M , et al. . Magnetic resonance imaging findings of fatty infiltrate in the cervical flexors in chronic whiplash . Spine (Phila Pa 1976) . 2010 01 28 [Epub ahead of print] . OpenURL Placeholder Text WorldCat 36 Ploutz-Snyder LL Yackel-Giamis EL Rosenbaum AE Formikell M . Use of muscle functional magnetic resonance imaging with older individuals . J Gerontol A Biol Sci Med Sci . 2000 ; 55 : B504 – B511 . Google Scholar Crossref Search ADS PubMed WorldCat 37 Jenner G Foley JM Cooper TG , et al. . Changes in magnetic resonance images of muscle depend on exercise intensity and duration, not work . J Appl Physiol . 1994 ; 76 : 2119 – 2124 . Google Scholar Crossref Search ADS PubMed WorldCat 38 Adams GR Harris RT Woodard D Dudley GA . Mapping of electrical muscle stimulation using MRI . J Appl Physiol . 1993 ; 74 : 532 – 537 . Google Scholar Crossref Search ADS PubMed WorldCat 39 Fleckenstein JL Canby RC Parkey RW Peshock RM . Acute effects of exercise on MR imaging of skeletal muscle in normal volunteers . AJR Am J Roentgenol . 1988 ; 151 : 231 – 237 . Google Scholar Crossref Search ADS PubMed WorldCat 40 Meyer RA Prior BM . Functional magnetic resonance imaging of muscle . Exerc Sport Sci Rev . 2000 ; 28 : 89 – 92 . Google Scholar PubMed OpenURL Placeholder Text WorldCat 41 Dickx N Cagnie B Achten E , et al. . Differentiation between deep and superficial fibers of the lumbar multifidus by magnetic resonance imaging . Eur Spine J . 2010 ; 19 : 122 – 128 . Google Scholar Crossref Search ADS PubMed WorldCat 42 Stokes IA Henry SM Single RM . Surface EMG electrodes do not accurately record from lumbar multifidus muscles . Clin Biomech . 2003 ; 18 : 9 – 13 . Google Scholar Crossref Search ADS WorldCat 43 Fleckenstein JL Watumull D McIntire DD , et al. . Muscle proton T2 relaxation times and work during repetitive maximal voluntary exercise . J Appl Physiol . 1993 ; 74 : 2855 – 2859 . Google Scholar Crossref Search ADS PubMed WorldCat 44 Segal RL . Use of imaging to assess normal and adaptive muscle function . Phys Ther . 2007 ; 87 : 704 – 718 . Google Scholar Crossref Search ADS PubMed WorldCat 45 Yue G Alexander AL Laidlaw DH , et al. . Sensitivity of muscle proton spin-spin relaxation time as an index of muscle activation . J Appl Physiol . 1994 ; 77 : 84 – 92 . Google Scholar Crossref Search ADS PubMed WorldCat 46 Kinugasa R Akima H . Neuromuscular activation of triceps surae using muscle functional MRI and EMG . Med Sci Sports Exerc . 2005 ; 37 : 593 – 598 . Google Scholar Crossref Search ADS PubMed WorldCat 47 O'Connor KM Price TB Hamill J . Examination of extrinsic foot muscles during running using mfMRI and EMG . J Electromyogr Kinesiol . 2006 ; 16 : 522 – 530 . Google Scholar Crossref Search ADS PubMed WorldCat 48 Damon BM Gore JC . Physiological basis of muscle functional MRI: predictions using a computer model . J Appl Physiol . 2005 ; 98 : 264 – 273 . Google Scholar Crossref Search ADS PubMed WorldCat Author notes " Dr Cagnie, Mr Peeters, Dr Achten, and Dr Danneels provided concept/idea/research design. Dr Cagnie provided writing. Dr Cagnie, Ms Dolphens, and Mr Peeters provided data collection and analysis. Dr Cagnie, Dr Cambier, and Dr Danneels provided project management. Ms Dolphens provided participants. Dr Achten, Dr Cambier, and Dr Danneels provided facilities/equipment. Dr Achten and Dr Cambier provided institutional liaisons. Dr Cagnie, Dr Achten, Dr Cambier, and Dr Danneels provided consultation (including review of manuscript before submission). The authors thank the staff of the Ghent Institute for Functional and Metabolic Imaging for their technical assistance and Nick Vandekeybus, Martijn Schouten, and Robert Dirks for their assistance with data collection. © 2010 American Physical Therapy Association

Webber, Sandra, C.;Porter, Michelle, M.

doi: 10.2522/ptj.20090394pmid: 20488976

Background Ankle strength (force-generating capacity) and power (work produced per unit of time or product of strength and speed) capabilities influence physical function (eg, walking, balance) in older adults. Although strength and power parameters frequently are measured with dynamometers, few studies have examined the reliability of measurements of different types of contractions. Objective The purpose of this study was to examine relative and absolute intrarater reliability of isometric, isotonic, and isokinetic ankle measures in older women. Design This was a prospective, descriptive methodological study. Methods The following dorsiflexion (DF) and plantar-flexion (PF) measures were assessed twice (7 days apart) by the same examiner in 30 older women (mean age=73.3 years, SD=4.7): isometric peak torque and rate of torque development (RTD), isotonic peak velocity, average acceleration and peak power, and isokinetic peak torque and peak power (30°/s and 90°/s). Several statistical methods were used to examine relative and absolute reliability. Results Intraclass correlation coefficients (ICCs) for the DF tests (ICC=.76–.97) were generally higher than ICCs for matched PF tests (ICC=.58–.93). Measures of absolute reliability (eg, coefficient of variation of the typical error [CVTE]) also demonstrated more reliable values for DF tests (5%–18%) compared with PF tests (7%–37%). Isotonic peak velocity tests at minimal loads were associated with the lowest CVTE and ratio limits of agreement values for both DF (5% and 14%, respectively) and PF (7% and 18%, respectively). Isometric RTD variables were the least reliable (CVTE=16%–37%). Limitations This study was limited to a relatively homogeneous sample of older women. Conclusions Test-retest reliability was adequate for determining changes at the group level for all strength and power variables except isometric RTD. Minimal detectable change scores were determined to assist clinicians in assessing meaningful change over time in ankle strength and power measurements within individuals. Loss of neuromuscular mass, strength (force-generating capacity), and power (work produced per unit of time or product of strength and speed) are closely associated with functional decline, loss of independence, and mortality in older adults.1 Some studies suggest that the rate of loss of neuromuscular power exceeds the rate of loss of strength with age.2,3 Cross-sectional studies also have demonstrated that functional capabilities such as the ability to get up and down from a chair, climb stairs, and walk quickly may be more closely associated with power than strength4–6 and that loss of power may be more related to the etiology of falls.7 In order to determine the true nature of the relationships among changes in strength and power with age and changes in function, reliable testing techniques are required. Isokinetic dynamometers frequently are used to assess neuromuscular function because they provide detailed torque, velocity, and position data with high mechanical reliability.8 Although researchers have investigated the reliability of dynamometer strength assessment in older adults, the focus has largely been on the knee.9–14 However, the distal leg muscles exhibit reductions in strength and power with aging15,16 and are important for walking,17,18 maintaining balance, avoiding falls,7,19 and braking a vehicle. Greater limitations in ankle strength (as opposed to knee strength) have been associated with falls in nursing home residents.20,21 Dorsiflexion (DF) power has been found to be closely associated with function in community-dwelling older women in terms of their ability to get up and down from a chair and climb stairs.4 Plantar-flexion (PF) strength has been shown to be positively related to both habitual gait speed and fast gait speed.4,18 Despite the important role that ankle function plays in mobility, there have been only a few evaluations of the reliability of ankle strength protocols11,12,22 and only one assessment concerned with reliability associated with measures of ankle power in this population.11 Because power is defined as work (force × distance) divided by time, it is influenced by both strength and speed. Peak or average power (watts=newton-meters × radians/s) can be measured using either the isokinetic or isotonic mode on a dynamometer. Other indirect measures that may be associated with the ability of the neuromuscular system to generate force or torque rapidly can be evaluated using either the isometric mode (rate of torque development [RTD]) or the isotonic mode (velocity, acceleration).2,16,23,24 Hartmann et al11 reported reliability scores for ankle average isokinetic power tests, but reliability of isotonic and isometric measures related to power has not been investigated previously in older adults. Preliminary findings suggest that isokinetic evaluations of power may not be as reliable as strength measures9,11 and that RTD averaged over a specified range (eg, from 30% to 60% of peak torque) may yield more consistent results compared with peak RTD.24 Further research is needed to compare reliability of strength and power measures and to determine which measures are associated with lower levels of measurement error for use in research and clinical situations. Physical therapists and other health care providers need to be able to properly interpret measurement change to determine the relative effectiveness of different interventions. Test-retest studies provide information about relative reliability, that is, the degree to which repeated measurements reveal consistent ranking of individuals' scores within a group. Measures of absolute reliability describe individual variability and measurement error and, therefore, are important in determining levels for clinically significant change. Although the literature suggests that power may be more important than strength in terms of function in older adults, very little is known about the reliability of different measures of power or power-related variables (eg, velocity during isotonic movements). The objective of this study was to determine the relative and absolute intrarater reliability for ankle strength and power measurements obtained using isometric, isotonic, and isokinetic tests on a dynamometer in older women. Method Participants Thirty older women (mean age= 73.3 years, SD=4.7) were recruited to take part in this study. This sample size was consistent with those traditionally chosen for studying dynamometer measures in older adults.9–12,14,25 A convenience sample consisting of women who had expressed an interest or participated in previous research in our laboratory was used. However, none of the women had been tested previously on an isokinetic dynamometer or participated in an exercise-related study. Exclusion criteria included acute or unstable chronic disease and neurological or musculoskeletal impairment that would interfere with testing. In addition to the 30 women who participated, another 22 women were approached to be involved in the study but either did not meet the inclusion and exclusion criteria or were not interested in participating. Participant characteristics are presented in Table 1. A physician's signed Physical Activity Readiness Medical Examination (PARmed-X) form was required when potential contraindications to exercise (eg, history of cardiac disease, uncontrolled hypertension, hernia, detached retina) were identified. All testing took place in a university research laboratory over the summer of 2008. At the initial evaluation session, participants provided their written informed consent. Table 1 Participant Characteristics Characteristic . Mean (SD) . Age (y) 73.3 (4.7) Body mass (kg) 73.8 (11.9) Height (cm) 159.9 (4.8) Body mass index (kg/m2) 28.8 (4.1) Active dorsiflexion range of motion (°) 11 (5) Active plantar-flexion range of motion (°) 53 (6) Characteristic . Mean (SD) . Age (y) 73.3 (4.7) Body mass (kg) 73.8 (11.9) Height (cm) 159.9 (4.8) Body mass index (kg/m2) 28.8 (4.1) Active dorsiflexion range of motion (°) 11 (5) Active plantar-flexion range of motion (°) 53 (6) Open in new tab Table 1 Participant Characteristics Characteristic . Mean (SD) . Age (y) 73.3 (4.7) Body mass (kg) 73.8 (11.9) Height (cm) 159.9 (4.8) Body mass index (kg/m2) 28.8 (4.1) Active dorsiflexion range of motion (°) 11 (5) Active plantar-flexion range of motion (°) 53 (6) Characteristic . Mean (SD) . Age (y) 73.3 (4.7) Body mass (kg) 73.8 (11.9) Height (cm) 159.9 (4.8) Body mass index (kg/m2) 28.8 (4.1) Active dorsiflexion range of motion (°) 11 (5) Active plantar-flexion range of motion (°) 53 (6) Open in new tab The median number of comorbidities reported by participants was 2 (range=0–3). Arthritis (18), hypertension (14), previous cancer diagnosis (5), and diabetes (4) were most commonly reported. Seven participants reported that they had fallen in the past year, and 1 participant regularly used a cane. The median number of medications prescribed was 1 (range=0–3). None of the participants changed their medications during their testing week. Procedure Upon admission to the study, participants completed a health/demographic questionnaire. All other tests were conducted twice, by the same physical therapist, exactly 1 week apart, at the same time of day. Information on the isokinetic dynamometer setup from session 1 was used for session 2, but the examiner was blinded to the results from session 1 until after session 2 was conducted. Resting blood pressure, heart rate, body mass, and height were measured using standard procedures. Active range of motion was measured for both DF and PF (right ankle) with the participant in a seated position with the knee supported in extension. Two measurements were taken in each direction and then averaged to determine active range of motion. A universal goniometer was used for the measurements, with the axis of the goniometer aligned with the lateral malleolus of the ankle, the proximal arm aligned with the head of the fibula, and the distal arm parallel to the lateral border of the fifth metatarsal. Ankle range of motion was measured to ensure that participants had adequate range of motion to tolerate the starting positions used for dynamometer testing. No participants were excluded because they lacked sufficient range of motion. Dynamometer Tests Dorsiflexion and PF torque, position, and velocity were measured using a Biodex System 3 Pro dynamometer.* The mechanical reliability of this dynamometer has been shown to be excellent.8 Calibration of the dynamometer was verified each day prior to testing. Participants warmed up by walking for 4 minutes on a treadmill before being seated on the Biodex dynamometer (right lateral malleolus aligned with the axis of rotation, right knee flexed 45°–55°, trunk reclined 5° from vertical). Only the dominant leg (defined as the leg that would be used to kick a ball) was tested. All participants reported right leg dominance. Each participant kept her arms folded across her chest during testing, and belts provided stabilization around the waist and over the right thigh. The end limits of range of motion were set at 10 degrees of DF and 30 degrees of PF for all tests. Participants performed isometric tests, concentric isotonic tests, and concentric isokinetic tests, always in that order, with DF contractions preceding PF contractions. Standardized, consistent verbal encouragement was provided for all tests using a script. Isometric Tests Following 3 practice trials, 3 maximal voluntary isometric contractions were performed for DF (at 25° of PF) and then for PF (at 0°). Test angles were chosen based on previous literature2,12,16,26 to correspond approximately to the angles at which maximum isometric torques can be produced. Participants were strongly encouraged to contract “fast” and to hold each contraction for 3 to 5 seconds. They were given 90 seconds of rest between trials. Isotonic Tests The dynamometer then was switched to the isotonic mode. The DF and PF movements were each performed against 2 set resistance levels: (1) a minimal resistance level (DF=1 N·m, PF=15 N·m) and (2) a load equal to 50% of isometric peak torque. These resistance levels represent the boundaries of those previously published for the dorsiflexors.2 Isotonic DF trials were initiated from 30 degrees of PF, and PF trials were initiated from 10 degrees of DF. Again, participants were strongly encouraged to move “fast.” Two practice trials preceded 5 test trials for each of the 4 conditions (DF and PF, 2 loads each). Thirty seconds of rest was provided between all repetitions. Isokinetic Tests Maximal-effort isokinetic concentric DF and PF tests were performed at 30°/s and 90°/s (in that order). These velocities were chosen because they are within the range of velocities typically studied for measurements about the ankle in older adults.4,25,27,28 In addition, restricting the highest velocity to 90°/s allowed for constant velocity to be maintained over approximately one third (12°) of the total 40-degree range of motion excursion (once acceleration and deceleration were accounted for). The passive mode on the dynamometer was used for these constant velocity tests because it provided a passive return to the start position after each concentric contraction; therefore, all concentric DF contractions were completed before PF testing began (ie, DF and PF contractions were not performed immediately back-to-back). Furthermore, many participants would not be able to generate enough DF torque to overcome the torque related to the combined mass of the foot and footplate to initiate DF movement. Matching concentric contractions with the onset of passive movement avoided this difficulty. Participants were given 3 to 5 submaximal practice trials for familiarization before 5 test trials were conducted for each movement, at each velocity. A 2-minute rest period was provided between velocities. One participant was unable to generate torque in the DF direction at the higher velocity; therefore, DF peak torque and peak power values were recorded at 90°/s for 29 participants. Data Analysis Biodex data were collected at a frequency of 100 Hz and exported for analyses in SigmaPlot (version 11.0).† All variables used in the analyses were means of the repetitions performed (isometric measures=mean of 3 repetitions, isotonic and isokinetic measures=mean of 5 repetitions). Because all scores inherently include some random error (which either adds to or subtracts from the true score), using mean scores may reduce the magnitude of the error component contributing to the total score.29 For each isometric contraction, peak torque (in newton-meters) was identified and RTD (in newton-meters per second) was calculated by 2 methods. Change in newton-meters/time was first determined from 0% to 50% of peak torque and then from 40% to 80% of peak torque (Fig. 1). Calculating RTD over a specified range has been shown to be more reliable than determining peak RTD.24 These specific ranges were chosen to allow comparison of RTD reliability between relatively steep sections of the isometric torque curve (0%–50% of peak torque) and less steep sections (40%–80% of peak torque). Figure 1 Open in new tabDownload slide Torque recorded during one repetition of isometric dorsiflexion for one representative participant. Rate of torque development was calculated as the change in newton-meters/change in time from 0% to 50% of peak torque and from 40% to 80% of peak torque. Torque is designated as negative in the dorsiflexion direction. Figure 1 Open in new tabDownload slide Torque recorded during one repetition of isometric dorsiflexion for one representative participant. Rate of torque development was calculated as the change in newton-meters/change in time from 0% to 50% of peak torque and from 40% to 80% of peak torque. Torque is designated as negative in the dorsiflexion direction. For each isotonic contraction, peak velocity (in degrees per second), average acceleration (peak velocity/time to reach peak velocity, measured in degrees per second squared), and peak power (watts= newton-meters × radians/s) were determined (Fig. 2). Although the dynamometer was set to the isotonic mode for these tests, torque is not held absolutely constant throughout the range of motion on this setting (Fig. 2). As has been noted previously,30,31 the sampling rate (100 Hz) of the dynamometer does not permit adjustments in speed to occur fast enough to result in a continuous torque level. For each isokinetic contraction, peak torque (in newton-meters) and peak power (watts=N·m × radians/s) were analyzed. Figure 2 Open in new tabDownload slide Torque, angle, velocity, and power measurements during one repetition of isotonic plantar flexion (against 50% of isometric peak torque) for one representative participant. Figure 2 Open in new tabDownload slide Torque, angle, velocity, and power measurements during one repetition of isotonic plantar flexion (against 50% of isometric peak torque) for one representative participant. Statistical analyses were conducted using SPSS (version 15.0)‡ and SigmaPlot. Means and standard deviations were calculated for each variable tested at time 1 and time 2. Paired t tests were conducted to look for significant bias between test sessions (P<.05). The intraclass correlation coefficient (ICC [2,k]) was used to evaluate both systematic and random errors that may affect relative test-retest reliability.32 Specifically, ICC [2,3] was used for all isometric measures because they were based on the mean of 3 repetitions, and ICC [2,5] was used for all isokinetic and isotonic measures that were scored as the mean of 5 repetitions. Normality of the difference scores was assessed using the Shapiro-Wilk test. Data were checked visually with Bland-Altman plots for the presence of heteroscedasticity, and Pearson correlation coefficients were calculated between absolute differences and the means of the 2 tests. Measures of absolute reliability were expressed using standard error of the measurement (SEM), coefficients of variation of the typical error (CVTE), limits of agreement (LOA), ratio limits of agreement (RLOA), and the minimal detectable change (MDC). Absolute reliability describes within-subject variation and the degree to which observed scores will vary with repeated measurements.33 Generally, CVTE and RLOA are used to describe heteroscedastic data, and SEM and LOA are used to describe homoscedastic data.34 The majority of the strength and power variables studied did not demonstrate heteroscedasticity (greater measurement error when measured values were larger) and, therefore, could be adequately described using SEM and LOA.34 However, because a few variables demonstrated a positive relationship between the degree of measurement error and the magnitude of the measured value, CVTE and RLOA statistics also are included. The SEM was determined as the square root of the residual mean square error term from the analysis of variance table.35 The SEM describes (in units of the actual measure) the limits for change required to indicate a real increase or decrease for a group of individuals following some sort of intervention.25 Whereas SEM values express typical error in original units, CVTE expresses typical error as a percentage, making it useful for comparing reliability among different measures and across different studies. Typical error was calculated as the standard deviation of the differences scores between sessions, divided by |$\sqrt 2$|⁠.33 Coefficient of variation of the typical error is defined as typical error divided by the mean of all trials from both sessions, multiplied by 100.36 The LOA was calculated as the systematic bias: (mean difference between 2 test sessions) ± the random error component (1.96 × standard deviation of the difference between the 2 test sessions), which is identical to systematic bias ± MDC9534 (MDC95=1.96 × |$\sqrt 2$| × SEM37,38). The MDC95 values provide information about the confidence limits associated with measurement error so that, for example, it can be stated with 95% confidence that an individual's change score that exceeds the LOA represents a true change. The MDC95 values also were expressed as a percentage in order to allow for comparisons among measures and across studies (RLOA=MDC95/mean of all observations × 100). Role of the Funding Source Ms Webber was supported by a Canadian Institutes of Health Research, Institute of Aging fellowship. Results Means and standard deviations for the isometric, isotonic, and isokinetic strength and power variables are presented in Table 2. There were no significant differences between session 1 and session 2 for almost all of the variables; however, PF isometric torque and RTD increased (P<.05). In addition, changes in DF isotonic average acceleration (1-N·m load) and PF isokinetic peak power at 30°/s were very close to being statistically significant (P=.05 and P=.06, respectively). Table 2 Means and Standard Deviations for Isometric, Isotonic, and Isokinetic Tests Measure . Test 1 . Test 2 . Pa . Dorsiflexion  Isometric results   Peak torque (N·m) 21.6 (5.1) 21.2 (5.5) .28   RTDb (to 50% of peak torque, N·m/s) 97.8 (28.6) 95.3 (34.9) .55   RTD (40%–80% of peak torque, N·m/s) 62.3 (18.6) 59.3 (23.1) .30  Isotonic results   Peak velocity (1-N·m load, °/s) 160.9 (31.0) 158.5 (28.9) .24   Average acceleration (1-N·m load, °/s2) 685.5 (183.0) 662.0 (176.7) .05   Peak power (1-N·m load, W) 14.7 (6.1) 13.8 (5.6) .18   Peak velocity (50% of maximum isometric load, °/s) 78.2 (18.5) 80.0 (15.0) .53   Average acceleration (50% of maximum isometric load, °/s2) 345.2 (95.3) 350.9 (81.9) .57   Peak power (50% of maximum isometric load, W) 15.7 (6.3) 15.5 (6.2) .64  Isokinetic results   Peak torque (30°/s, N·m) 14.0 (4.6) 13.9 (4.8) .68   Peak torque (90°/s, N·m) 10.5 (4.2) 10.6 (4.1) .68   Peak power (30°/s, N·m) 7.2 (2.3) 7.1 (2.5) .76   Peak power (90°/s, N·m) 11.2 (4.5) 10.9 (4.4) .35 Plantar flexion  Isometric results   Peak torque (N·m) 71.0 (21.5) 77.5 (24.0) .03   RTD (to 50% of peak torque, N·m/s) 113.5 (60.1) 142.0 (65.3) .02   RTD (40%–80% of peak torque, N·m/s) 68.9 (30.1) 90.3 (48.8) .02  Isotonic results   Peak velocity (15-N·m load, °/s) 275.2 (47.8) 274.8 (50.1) .93   Average acceleration (15-N·m load, °/s2) 1,686.4 (477.2) 1,698.3 (460.5) .79   Peak power (15-N·m load, W) 171.3 (73.0) 180.0 (71.2) .24   Peak velocity (50% of maximum isometric load, °/s) 224.6 (44.2) 217.9 (43.6) .34   Average acceleration (50% of maximum isometric load, °/s2) 1,304.7 (334.8) 1,235.6 (318.5) .17   Peak power (50% of maximum isometric load, W) 158.9 (59.1) 162.7 (57.0) .51  Isokinetic results   Peak torque (30°/s, N·m) 66.7 (20.0) 69.7 (20.2) .11   Peak torque (90°/s, N·m) 61.4 (15.8) 62.0 (18.5) .82   Peak power (30°/s, N·m) 35.0 (10.3) 37.1 (10.6) .06   Peak power (90°/s, N·m) 76.2 (18.0) 77.8 (21.2) .54 Measure . Test 1 . Test 2 . Pa . Dorsiflexion  Isometric results   Peak torque (N·m) 21.6 (5.1) 21.2 (5.5) .28   RTDb (to 50% of peak torque, N·m/s) 97.8 (28.6) 95.3 (34.9) .55   RTD (40%–80% of peak torque, N·m/s) 62.3 (18.6) 59.3 (23.1) .30  Isotonic results   Peak velocity (1-N·m load, °/s) 160.9 (31.0) 158.5 (28.9) .24   Average acceleration (1-N·m load, °/s2) 685.5 (183.0) 662.0 (176.7) .05   Peak power (1-N·m load, W) 14.7 (6.1) 13.8 (5.6) .18   Peak velocity (50% of maximum isometric load, °/s) 78.2 (18.5) 80.0 (15.0) .53   Average acceleration (50% of maximum isometric load, °/s2) 345.2 (95.3) 350.9 (81.9) .57   Peak power (50% of maximum isometric load, W) 15.7 (6.3) 15.5 (6.2) .64  Isokinetic results   Peak torque (30°/s, N·m) 14.0 (4.6) 13.9 (4.8) .68   Peak torque (90°/s, N·m) 10.5 (4.2) 10.6 (4.1) .68   Peak power (30°/s, N·m) 7.2 (2.3) 7.1 (2.5) .76   Peak power (90°/s, N·m) 11.2 (4.5) 10.9 (4.4) .35 Plantar flexion  Isometric results   Peak torque (N·m) 71.0 (21.5) 77.5 (24.0) .03   RTD (to 50% of peak torque, N·m/s) 113.5 (60.1) 142.0 (65.3) .02   RTD (40%–80% of peak torque, N·m/s) 68.9 (30.1) 90.3 (48.8) .02  Isotonic results   Peak velocity (15-N·m load, °/s) 275.2 (47.8) 274.8 (50.1) .93   Average acceleration (15-N·m load, °/s2) 1,686.4 (477.2) 1,698.3 (460.5) .79   Peak power (15-N·m load, W) 171.3 (73.0) 180.0 (71.2) .24   Peak velocity (50% of maximum isometric load, °/s) 224.6 (44.2) 217.9 (43.6) .34   Average acceleration (50% of maximum isometric load, °/s2) 1,304.7 (334.8) 1,235.6 (318.5) .17   Peak power (50% of maximum isometric load, W) 158.9 (59.1) 162.7 (57.0) .51  Isokinetic results   Peak torque (30°/s, N·m) 66.7 (20.0) 69.7 (20.2) .11   Peak torque (90°/s, N·m) 61.4 (15.8) 62.0 (18.5) .82   Peak power (30°/s, N·m) 35.0 (10.3) 37.1 (10.6) .06   Peak power (90°/s, N·m) 76.2 (18.0) 77.8 (21.2) .54 a P values from paired t tests, except dorsiflexion isotonic peak power (1-N·m load) and plantar-flexion isometric peak torque, which were analyzed with the signed rank test. b RTD=rate of torque development. Open in new tab Table 2 Means and Standard Deviations for Isometric, Isotonic, and Isokinetic Tests Measure . Test 1 . Test 2 . Pa . Dorsiflexion  Isometric results   Peak torque (N·m) 21.6 (5.1) 21.2 (5.5) .28   RTDb (to 50% of peak torque, N·m/s) 97.8 (28.6) 95.3 (34.9) .55   RTD (40%–80% of peak torque, N·m/s) 62.3 (18.6) 59.3 (23.1) .30  Isotonic results   Peak velocity (1-N·m load, °/s) 160.9 (31.0) 158.5 (28.9) .24   Average acceleration (1-N·m load, °/s2) 685.5 (183.0) 662.0 (176.7) .05   Peak power (1-N·m load, W) 14.7 (6.1) 13.8 (5.6) .18   Peak velocity (50% of maximum isometric load, °/s) 78.2 (18.5) 80.0 (15.0) .53   Average acceleration (50% of maximum isometric load, °/s2) 345.2 (95.3) 350.9 (81.9) .57   Peak power (50% of maximum isometric load, W) 15.7 (6.3) 15.5 (6.2) .64  Isokinetic results   Peak torque (30°/s, N·m) 14.0 (4.6) 13.9 (4.8) .68   Peak torque (90°/s, N·m) 10.5 (4.2) 10.6 (4.1) .68   Peak power (30°/s, N·m) 7.2 (2.3) 7.1 (2.5) .76   Peak power (90°/s, N·m) 11.2 (4.5) 10.9 (4.4) .35 Plantar flexion  Isometric results   Peak torque (N·m) 71.0 (21.5) 77.5 (24.0) .03   RTD (to 50% of peak torque, N·m/s) 113.5 (60.1) 142.0 (65.3) .02   RTD (40%–80% of peak torque, N·m/s) 68.9 (30.1) 90.3 (48.8) .02  Isotonic results   Peak velocity (15-N·m load, °/s) 275.2 (47.8) 274.8 (50.1) .93   Average acceleration (15-N·m load, °/s2) 1,686.4 (477.2) 1,698.3 (460.5) .79   Peak power (15-N·m load, W) 171.3 (73.0) 180.0 (71.2) .24   Peak velocity (50% of maximum isometric load, °/s) 224.6 (44.2) 217.9 (43.6) .34   Average acceleration (50% of maximum isometric load, °/s2) 1,304.7 (334.8) 1,235.6 (318.5) .17   Peak power (50% of maximum isometric load, W) 158.9 (59.1) 162.7 (57.0) .51  Isokinetic results   Peak torque (30°/s, N·m) 66.7 (20.0) 69.7 (20.2) .11   Peak torque (90°/s, N·m) 61.4 (15.8) 62.0 (18.5) .82   Peak power (30°/s, N·m) 35.0 (10.3) 37.1 (10.6) .06   Peak power (90°/s, N·m) 76.2 (18.0) 77.8 (21.2) .54 Measure . Test 1 . Test 2 . Pa . Dorsiflexion  Isometric results   Peak torque (N·m) 21.6 (5.1) 21.2 (5.5) .28   RTDb (to 50% of peak torque, N·m/s) 97.8 (28.6) 95.3 (34.9) .55   RTD (40%–80% of peak torque, N·m/s) 62.3 (18.6) 59.3 (23.1) .30  Isotonic results   Peak velocity (1-N·m load, °/s) 160.9 (31.0) 158.5 (28.9) .24   Average acceleration (1-N·m load, °/s2) 685.5 (183.0) 662.0 (176.7) .05   Peak power (1-N·m load, W) 14.7 (6.1) 13.8 (5.6) .18   Peak velocity (50% of maximum isometric load, °/s) 78.2 (18.5) 80.0 (15.0) .53   Average acceleration (50% of maximum isometric load, °/s2) 345.2 (95.3) 350.9 (81.9) .57   Peak power (50% of maximum isometric load, W) 15.7 (6.3) 15.5 (6.2) .64  Isokinetic results   Peak torque (30°/s, N·m) 14.0 (4.6) 13.9 (4.8) .68   Peak torque (90°/s, N·m) 10.5 (4.2) 10.6 (4.1) .68   Peak power (30°/s, N·m) 7.2 (2.3) 7.1 (2.5) .76   Peak power (90°/s, N·m) 11.2 (4.5) 10.9 (4.4) .35 Plantar flexion  Isometric results   Peak torque (N·m) 71.0 (21.5) 77.5 (24.0) .03   RTD (to 50% of peak torque, N·m/s) 113.5 (60.1) 142.0 (65.3) .02   RTD (40%–80% of peak torque, N·m/s) 68.9 (30.1) 90.3 (48.8) .02  Isotonic results   Peak velocity (15-N·m load, °/s) 275.2 (47.8) 274.8 (50.1) .93   Average acceleration (15-N·m load, °/s2) 1,686.4 (477.2) 1,698.3 (460.5) .79   Peak power (15-N·m load, W) 171.3 (73.0) 180.0 (71.2) .24   Peak velocity (50% of maximum isometric load, °/s) 224.6 (44.2) 217.9 (43.6) .34   Average acceleration (50% of maximum isometric load, °/s2) 1,304.7 (334.8) 1,235.6 (318.5) .17   Peak power (50% of maximum isometric load, W) 158.9 (59.1) 162.7 (57.0) .51  Isokinetic results   Peak torque (30°/s, N·m) 66.7 (20.0) 69.7 (20.2) .11   Peak torque (90°/s, N·m) 61.4 (15.8) 62.0 (18.5) .82   Peak power (30°/s, N·m) 35.0 (10.3) 37.1 (10.6) .06   Peak power (90°/s, N·m) 76.2 (18.0) 77.8 (21.2) .54 a P values from paired t tests, except dorsiflexion isotonic peak power (1-N·m load) and plantar-flexion isometric peak torque, which were analyzed with the signed rank test. b RTD=rate of torque development. Open in new tab Table 3 reports the reliability data for all DF and PF tests. The ICC values for DF tests (ICC=.76–.97) were higher (signed rank test, P<.001) than ICC values for matched PF tests (ICC=.58–.93), with the exception of 2 isotonic values (peak power against minimal load and peak velocity against 50% of maximum isometric load). Measures of absolute reliability (CVTE) also demonstrated more reliable values for all DF tests (5%–18%) compared with PF tests (7%–37%), except for the same 2 isotonic measures (signed rank test, P<.001). Isotonic peak velocity tests at minimal loads were associated with the lowest CVTE and RLOA values for both DF (5% and 14%, respectively) and PF (7% and 18%, respectively). Isometric RTD0%–50% and RTD40%–80% demonstrated the highest levels of variability between test sessions for both DF (CVTE=16% and 18%, respectively, and RLOA=45% and 50%, respectively) and PF (CVTE=35% and 37%, respectively, and RLOA=97% and 104%, respectively). The MDC values, considered to be the minimal amount of change in an outcome measure that can be measured for an individual that is not due to systematic or chance variation in measurement,37,39 are included for all variables. Specifically, MDC95 values indicate that a person can be 95% confident in the true nature of changes that exceed these levels. The LOA were equal to the systematic bias ± the MDC95 value. Table 3 Relative and Absolute Reliability Scores for Isometric, Isotonic, and Isokinetic Testsa Measure . ICCb . 95% CI for ICC . SEM (Units) . 95% CI for SEM (Units) . CVTE (%) . Systematic Biasc± MDC95 (Units) . Ratio LOA (% of Mean) . Dorsiflexion  Isometric results   Peak torque (N·m) .97 0.94–0.99 1.3 ±2.4 6 0.4±3.5 16   RTD (0%–50%, N·m/s) .86 0.71–0.94 15.8 ±31.0 16 2.5±43.8 45   RTD (40%–80%, N·m/s) .84 0.67–0.92 11.0 ±21.5 18 3.0±30.4 50  Isotonic results   Peak velocity (1-N·m load, °/s) .96 0.92–0.98 8.0 ±15.8 5 2.5±22.3 14   Average acceleration (1-N·m load, °/s2) .97 0.93–0.98 43.7 ±85.6 6 23.5±121.1 18   Peak power (1-N·m load, W) .90 0.79–0.95 2.5 ±4.9 17 0.9±6.9 48   Peak velocity (50%,°/s) .76 0.50–0.89 10.6 ±20.7 13 −1.7±29.2 37   Average acceleration (50%, °/s2) .90 0.79–0.95 37.9 ±74.3 11 −5.7±105.1 30   Peak power (50%, W) .95 0.90–0.98 1.9 ±3.7 12 0.2±5.3 34  Isokinetic results   Peak torque (30°/s, N·m) .95 0.89–0.98 1.5 ±3.0 11 0.2±4.2 30   Peak torque (90°/s, N·m) .96 0.92–0.98 1.2 ±2.3 11 −0.1±3.2 31   Peak power (30°/s, N·m) .94 0.88–0.97 0.8 ±1.6 11 0.1±2.3 32   Peak power (90°/s, N·m) .97 0.94–0.99 1.0 ±2.0 9 0.3±2.9 26 Plantar flexion  Isometric results   Peak torque (N·m) .90 0.74–0.95 9.2 ±18.0 12 −6.5±25.4 34   RTD (0–50%, N·m/s) .63 0.20–0.82 44.7 ±87.6 35 −28.4±123.8 97   RTD (40–80%, N·m/s) .58 0.12–0.80 29.9 ±58.6 37 −19.5±82.9 104  Isotonic results   Peak velocity (15-N·m load, °/s) .93 0.85–0.97 18.2 ±35.6 7 0.4±50.4 18   Average acceleration (15-N·m load, °/s2) .93 0.86–0.97 168.2 ±329.6 10 −11.9±466.1 28   Peak power (15-N·m load, W) .92 0.83–0.96 27.6 ±54.1 16 −8.6±76.5 44   Peak velocity (50%, °/s) .77 0.51–0.89 27.0 ±53.0 12 6.7±74.9 34   Average acceleration (50%, °/s2) .79 0.56–0.90 192.0 ±376.2 15 69.1±532.1 42   Peak power (50%, W) .92 0.68–0.93 22.2 ±43.5 14 −13.8±61.5 40  Isokinetic results   Peak torque (30°/s, N·m) .89 0.77–0.95 8.7 ±17.1 13 −3.8±24.2 36   Peak torque (90°/s, N·m) .85 0.68–0.93 8.9 ±17.5 14 −0.5±24.7 40   Peak power (30°/s, N·m) .88 0.75–0.95 4.6 ±9.0 13 −2.4±12.8 35   Peak power (90°/s, N·m) .86 0.71–0.93 9.8 ±19.2 13 −1.6±27.1 35 Measure . ICCb . 95% CI for ICC . SEM (Units) . 95% CI for SEM (Units) . CVTE (%) . Systematic Biasc± MDC95 (Units) . Ratio LOA (% of Mean) . Dorsiflexion  Isometric results   Peak torque (N·m) .97 0.94–0.99 1.3 ±2.4 6 0.4±3.5 16   RTD (0%–50%, N·m/s) .86 0.71–0.94 15.8 ±31.0 16 2.5±43.8 45   RTD (40%–80%, N·m/s) .84 0.67–0.92 11.0 ±21.5 18 3.0±30.4 50  Isotonic results   Peak velocity (1-N·m load, °/s) .96 0.92–0.98 8.0 ±15.8 5 2.5±22.3 14   Average acceleration (1-N·m load, °/s2) .97 0.93–0.98 43.7 ±85.6 6 23.5±121.1 18   Peak power (1-N·m load, W) .90 0.79–0.95 2.5 ±4.9 17 0.9±6.9 48   Peak velocity (50%,°/s) .76 0.50–0.89 10.6 ±20.7 13 −1.7±29.2 37   Average acceleration (50%, °/s2) .90 0.79–0.95 37.9 ±74.3 11 −5.7±105.1 30   Peak power (50%, W) .95 0.90–0.98 1.9 ±3.7 12 0.2±5.3 34  Isokinetic results   Peak torque (30°/s, N·m) .95 0.89–0.98 1.5 ±3.0 11 0.2±4.2 30   Peak torque (90°/s, N·m) .96 0.92–0.98 1.2 ±2.3 11 −0.1±3.2 31   Peak power (30°/s, N·m) .94 0.88–0.97 0.8 ±1.6 11 0.1±2.3 32   Peak power (90°/s, N·m) .97 0.94–0.99 1.0 ±2.0 9 0.3±2.9 26 Plantar flexion  Isometric results   Peak torque (N·m) .90 0.74–0.95 9.2 ±18.0 12 −6.5±25.4 34   RTD (0–50%, N·m/s) .63 0.20–0.82 44.7 ±87.6 35 −28.4±123.8 97   RTD (40–80%, N·m/s) .58 0.12–0.80 29.9 ±58.6 37 −19.5±82.9 104  Isotonic results   Peak velocity (15-N·m load, °/s) .93 0.85–0.97 18.2 ±35.6 7 0.4±50.4 18   Average acceleration (15-N·m load, °/s2) .93 0.86–0.97 168.2 ±329.6 10 −11.9±466.1 28   Peak power (15-N·m load, W) .92 0.83–0.96 27.6 ±54.1 16 −8.6±76.5 44   Peak velocity (50%, °/s) .77 0.51–0.89 27.0 ±53.0 12 6.7±74.9 34   Average acceleration (50%, °/s2) .79 0.56–0.90 192.0 ±376.2 15 69.1±532.1 42   Peak power (50%, W) .92 0.68–0.93 22.2 ±43.5 14 −13.8±61.5 40  Isokinetic results   Peak torque (30°/s, N·m) .89 0.77–0.95 8.7 ±17.1 13 −3.8±24.2 36   Peak torque (90°/s, N·m) .85 0.68–0.93 8.9 ±17.5 14 −0.5±24.7 40   Peak power (30°/s, N·m) .88 0.75–0.95 4.6 ±9.0 13 −2.4±12.8 35   Peak power (90°/s, N·m) .86 0.71–0.93 9.8 ±19.2 13 −1.6±27.1 35 a ICC=intraclass correlation coefficient, CI=confidence interval, SEM=standard error of measurement, CVTE=coefficient of variation of typical error, MDC95=minimal detectable change with 95% confidence. b ICC (2,3) for isometric results and ICC (2,5) for isotonic and isokinetic results. c Systematic bias=average difference between the 2 tests (time1−time2). Open in new tab Table 3 Relative and Absolute Reliability Scores for Isometric, Isotonic, and Isokinetic Testsa Measure . ICCb . 95% CI for ICC . SEM (Units) . 95% CI for SEM (Units) . CVTE (%) . Systematic Biasc± MDC95 (Units) . Ratio LOA (% of Mean) . Dorsiflexion  Isometric results   Peak torque (N·m) .97 0.94–0.99 1.3 ±2.4 6 0.4±3.5 16   RTD (0%–50%, N·m/s) .86 0.71–0.94 15.8 ±31.0 16 2.5±43.8 45   RTD (40%–80%, N·m/s) .84 0.67–0.92 11.0 ±21.5 18 3.0±30.4 50  Isotonic results   Peak velocity (1-N·m load, °/s) .96 0.92–0.98 8.0 ±15.8 5 2.5±22.3 14   Average acceleration (1-N·m load, °/s2) .97 0.93–0.98 43.7 ±85.6 6 23.5±121.1 18   Peak power (1-N·m load, W) .90 0.79–0.95 2.5 ±4.9 17 0.9±6.9 48   Peak velocity (50%,°/s) .76 0.50–0.89 10.6 ±20.7 13 −1.7±29.2 37   Average acceleration (50%, °/s2) .90 0.79–0.95 37.9 ±74.3 11 −5.7±105.1 30   Peak power (50%, W) .95 0.90–0.98 1.9 ±3.7 12 0.2±5.3 34  Isokinetic results   Peak torque (30°/s, N·m) .95 0.89–0.98 1.5 ±3.0 11 0.2±4.2 30   Peak torque (90°/s, N·m) .96 0.92–0.98 1.2 ±2.3 11 −0.1±3.2 31   Peak power (30°/s, N·m) .94 0.88–0.97 0.8 ±1.6 11 0.1±2.3 32   Peak power (90°/s, N·m) .97 0.94–0.99 1.0 ±2.0 9 0.3±2.9 26 Plantar flexion  Isometric results   Peak torque (N·m) .90 0.74–0.95 9.2 ±18.0 12 −6.5±25.4 34   RTD (0–50%, N·m/s) .63 0.20–0.82 44.7 ±87.6 35 −28.4±123.8 97   RTD (40–80%, N·m/s) .58 0.12–0.80 29.9 ±58.6 37 −19.5±82.9 104  Isotonic results   Peak velocity (15-N·m load, °/s) .93 0.85–0.97 18.2 ±35.6 7 0.4±50.4 18   Average acceleration (15-N·m load, °/s2) .93 0.86–0.97 168.2 ±329.6 10 −11.9±466.1 28   Peak power (15-N·m load, W) .92 0.83–0.96 27.6 ±54.1 16 −8.6±76.5 44   Peak velocity (50%, °/s) .77 0.51–0.89 27.0 ±53.0 12 6.7±74.9 34   Average acceleration (50%, °/s2) .79 0.56–0.90 192.0 ±376.2 15 69.1±532.1 42   Peak power (50%, W) .92 0.68–0.93 22.2 ±43.5 14 −13.8±61.5 40  Isokinetic results   Peak torque (30°/s, N·m) .89 0.77–0.95 8.7 ±17.1 13 −3.8±24.2 36   Peak torque (90°/s, N·m) .85 0.68–0.93 8.9 ±17.5 14 −0.5±24.7 40   Peak power (30°/s, N·m) .88 0.75–0.95 4.6 ±9.0 13 −2.4±12.8 35   Peak power (90°/s, N·m) .86 0.71–0.93 9.8 ±19.2 13 −1.6±27.1 35 Measure . ICCb . 95% CI for ICC . SEM (Units) . 95% CI for SEM (Units) . CVTE (%) . Systematic Biasc± MDC95 (Units) . Ratio LOA (% of Mean) . Dorsiflexion  Isometric results   Peak torque (N·m) .97 0.94–0.99 1.3 ±2.4 6 0.4±3.5 16   RTD (0%–50%, N·m/s) .86 0.71–0.94 15.8 ±31.0 16 2.5±43.8 45   RTD (40%–80%, N·m/s) .84 0.67–0.92 11.0 ±21.5 18 3.0±30.4 50  Isotonic results   Peak velocity (1-N·m load, °/s) .96 0.92–0.98 8.0 ±15.8 5 2.5±22.3 14   Average acceleration (1-N·m load, °/s2) .97 0.93–0.98 43.7 ±85.6 6 23.5±121.1 18   Peak power (1-N·m load, W) .90 0.79–0.95 2.5 ±4.9 17 0.9±6.9 48   Peak velocity (50%,°/s) .76 0.50–0.89 10.6 ±20.7 13 −1.7±29.2 37   Average acceleration (50%, °/s2) .90 0.79–0.95 37.9 ±74.3 11 −5.7±105.1 30   Peak power (50%, W) .95 0.90–0.98 1.9 ±3.7 12 0.2±5.3 34  Isokinetic results   Peak torque (30°/s, N·m) .95 0.89–0.98 1.5 ±3.0 11 0.2±4.2 30   Peak torque (90°/s, N·m) .96 0.92–0.98 1.2 ±2.3 11 −0.1±3.2 31   Peak power (30°/s, N·m) .94 0.88–0.97 0.8 ±1.6 11 0.1±2.3 32   Peak power (90°/s, N·m) .97 0.94–0.99 1.0 ±2.0 9 0.3±2.9 26 Plantar flexion  Isometric results   Peak torque (N·m) .90 0.74–0.95 9.2 ±18.0 12 −6.5±25.4 34   RTD (0–50%, N·m/s) .63 0.20–0.82 44.7 ±87.6 35 −28.4±123.8 97   RTD (40–80%, N·m/s) .58 0.12–0.80 29.9 ±58.6 37 −19.5±82.9 104  Isotonic results   Peak velocity (15-N·m load, °/s) .93 0.85–0.97 18.2 ±35.6 7 0.4±50.4 18   Average acceleration (15-N·m load, °/s2) .93 0.86–0.97 168.2 ±329.6 10 −11.9±466.1 28   Peak power (15-N·m load, W) .92 0.83–0.96 27.6 ±54.1 16 −8.6±76.5 44   Peak velocity (50%, °/s) .77 0.51–0.89 27.0 ±53.0 12 6.7±74.9 34   Average acceleration (50%, °/s2) .79 0.56–0.90 192.0 ±376.2 15 69.1±532.1 42   Peak power (50%, W) .92 0.68–0.93 22.2 ±43.5 14 −13.8±61.5 40  Isokinetic results   Peak torque (30°/s, N·m) .89 0.77–0.95 8.7 ±17.1 13 −3.8±24.2 36   Peak torque (90°/s, N·m) .85 0.68–0.93 8.9 ±17.5 14 −0.5±24.7 40   Peak power (30°/s, N·m) .88 0.75–0.95 4.6 ±9.0 13 −2.4±12.8 35   Peak power (90°/s, N·m) .86 0.71–0.93 9.8 ±19.2 13 −1.6±27.1 35 a ICC=intraclass correlation coefficient, CI=confidence interval, SEM=standard error of measurement, CVTE=coefficient of variation of typical error, MDC95=minimal detectable change with 95% confidence. b ICC (2,3) for isometric results and ICC (2,5) for isotonic and isokinetic results. c Systematic bias=average difference between the 2 tests (time1−time2). Open in new tab Bland-Altman plots (individual participant differences plotted against the mean for both test sessions) were created for all outcome variables to look for systematic bias, outliers, and the presence of heteroscedasticity. Pearson correlation coefficients were not significant for heteroscedasticity for 23 of the 26 tests, but isotonic PF peak velocity (against 50% of isometric peak torque), PF RTD0%–50%, and PF RTD40%–80% did demonstrate significant positive correlations (r=.45–.65, P≤.01). Reliability statistics associated with the RTD and peak isotonic velocity (against 50% of isometric peak torque) variables were relatively poor; therefore, other strength or power variables should be chosen in test-retest situations. No data transformations were conducted. Discussion This study was conducted to establish relative and absolute reliability scores for isometric, isotonic, and isokinetic strength- and power-related measures about the ankle in older women. Although the reliability of some of these measures (eg, isokinetic tests) has been investigated previously, other parameters (eg, isotonic values) have been reported infrequently in the literature with no associated reliability information provided. Results demonstrated that isometric, isotonic, and isokinetic measures of strength and power were associated with good relative reliability (all ICCs>.75, with the exception of PF RTD)29 and measures of absolute reliability were similar to previously published results involving both younger and older individuals.11,24,25,36 Virtually all isometric, isotonic, and isokinetic DF and PF measures demonstrated good relative reliability, indicating that these measures generally exhibited consistency for repeated measurements at the group level. With the exception of PF RTD0%–50% (ICC [2,k]=.63) and PF RTD40%–80% (ICC [2,k]=.58), all ICC values exceeded .75, and more than half of the values reached .90 or greater. The 95% confidence intervals associated with the ICCs (Tab. 3) provide a more thorough understanding of the reliability of these measurements. In the majority of cases (18/26), the lower confidence interval did not fall below 0.70; however, at the worst extreme, PF RTD measurements demonstrated lower confidence limits of 0.20 and 0.12, indicating very poor test-retest reliability. In terms of strength, women in this study obtained DF and PF isokinetic peak torque values similar to those previously reported.11,12,16,40 The ICC values associated with isokinetic DF and PF peak torque and peak power (ICC=.85–.97) also were very similar to those reported in a previous study (ICC=.92–.98) of older women and men tested at 60°/s.11 The current study is the first to report reliability statistics associated with isometric and isotonic tests about the ankle in older women; therefore, no comparisons of these variables could be made. Clinically, SEM values (expressed in absolute units) and CVTE values (expressed as a percentage) can be used to determine whether significant change has occurred in a group over time. The SEM and CVTE results were similar to those reported in other ankle strength and power studies for isokinetic parameters11,25,36 and isometric RTD.24 The CVTE values for DF and PF isometric peak torque were relatively low in this study (6% and 12%, respectively), whereas CVTE results were slightly higher for isokinetic peak torque and peak power results, ranging from 9% to 14%. Clinicians can use MDC95 and RLOA values to determine whether true change has occurred over time in individual patients. Based on our results, changes in isokinetic peak torques in individual patients would need to exceed the following thresholds to exceed measurement error: 4.2 N·m (DF=30°/s), 3.2 N·m (DF=90°/s), 24.2 N·m (PF=30°/s), and 24.7 N·m (PF=90°/s). Isometric peak torques would need to exceed 3.5 N·m (DF) and 25.4 N·m (PF). The MDC95, LOA (systematic bias ± MDC95), and RLOA results in this study were similar to those previously reported.11,12,25 Small differences among study results may be attributed to differences in the participants (eg, sex, age), the raters, or the test protocol itself (eg, test velocities, measurement of peak versus average power, and participant positioning). The older women in our study reached peak isotonic velocities of 275°/s for PF and 161°/s for DF when testing was conducted against minimal loads. Only one previous study has reported peak isotonic velocities about the ankle in older adults.2 The current study adds to the literature by providing detailed information about relative and absolute reliability associated with different isotonic parameters that have been measured infrequently to date. In the present study, isotonic peak velocity and average acceleration were associated with low CVTE values when the load was minimal (CVTE for DF=5% and 6% for peak velocity and average acceleration, respectively, CVTE for PF=7% and 10%, respectively) and slightly higher CVTE values (DF=13% and 11%, respectively, and PF=12% and 15%, respectively) when the load was equal to 50% of isometric peak torque. Isotonic peak velocity measured against low loads was associated with less variation compared with other isotonic and isokinetic variables. Further research involving other joint movements and different populations is needed to determine whether peak velocity is consistently more reliable than other more traditionally measured parameters. This information may be important clinically, as the isotonic setting allows for evaluation of contractions in which velocity is not constrained, and results, therefore, may be more functionally relevant compared with isokinetic tests. In all but 2 instances (isotonic peak power against minimal load and isotonic peak velocity against 50% of maximum isometric load), DF scores demonstrated better reliability compared with PF scores. This result is in agreement with the findings reported by Hartmann et al.11 In both studies, participants were positioned with the knee flexed for PF tests. Although the upper body and thigh were well stabilized with straps, it is conceivable that attempts to extend the knee or hip may have occurred during PF movements, adding variability to these PF measurements that did not occur with DF movements. Reliability of ankle PF measures may be improved with different positioning during testing (eg, hip in neutral and knee extended with the individual in a prone position). It has been suggested that from a functional perspective, increases in RTD may represent one of the most important adaptations that occurs in response to resistance training in older adults.41 That is, the ability to generate moderate forces quickly may be more important than being able to generate high forces, especially when quick action is required (eg, to regain balance and avoid a fall). Improvements in RTD are likely associated with a greater capacity to generate power. Although RTD may be a functionally important variable, our study demonstrated that it had the lowest absolute reliability of all the power-related variables studied about the ankle. The PF results were especially variable. Positioning used in this study (sitting with the hip and knee partially flexed) and the longer duration associated with isometric testing (3 seconds) likely contributed to some of this variability (greater potential contributions of hip or knee extension accompanying isometric PF attempts). It should be noted that isokinetic dynamometers may not be as reliable for isometric tests as other devices that are inherently more stable (eg, custom-made isometric rigs). It is recommended that the reliability of measurements of RTD about the ankle be examined in future studies using different joint and body positions and possibly using different types of strength testing equipment. In this study, a familiarization session on the dynamometer was not provided before the 2 test sessions. This lack of a familiarization session may represent a limitation of the study if learning had an effect on the scores during the second testing session. However, familiarization sessions are rarely provided in clinical situations and may not always be feasible in research circumstances because of time constraints, associated costs, and availability of equipment. For these reasons, we elected to omit a familiarization session. Measured levels of systematic bias were minimal for most variables, indicating that there was no substantial learning effect. This study involved a relatively homogeneous sample of community-dwelling older women. Future studies should continue to investigate the reliability of strength and power measurements attained using different modes on the dynamometer about different joints and in other segments of the older population (eg, older men, individuals who are more frail). Conclusions Interpreting and setting threshold levels for acceptable reliability results depends on the particular testing circumstance.29 In this study, many variables demonstrated good ICC results and CVTE values in the range of 6% to 13%, which are comparable to previous strength and power assessments in younger and older people.9,10,25,36 These levels are likely adequate to determine gross changes in strength- and power-related parameters among groups over the course of a training period; but ideally, more reliable measures would provide greater confidence in interpreting clinically meaningful change within individuals. Further research is needed to examine the reliability of isotonic variables that have been studied infrequently using dynamometers. These measures may prove to be more reliable and relevant to function in older adults than the more commonly reported isometric and isokinetic strength and power parameters. In the meantime, MDC95 scores have been presented for all DF and PF isometric, isotonic, and isokinetic variables to provide meaningful thresholds for clinicians and researchers to identify changes in individuals beyond those expected by measurement error. " Ethical approval for this study was granted by the Education/Nursing Research Ethics Board of the University of Manitoba. " Some of the results specific to isotonic tests were presented orally at the Canadian Society for Exercise Physiology meeting; November 11–14, 2009; Vancouver, British Columbia, Canada. " Ms Webber was supported by a Canadian Institutes of Health Research, Institute of Aging fellowship. * " Biodex Medical Systems Inc, 20 Ramsey Rd, Shirley, NY 11967. † " Systat Software Inc, 1735 Technology Dr, Ste 430, San Jose, CA 95110. ‡ " SPSS Inc, 233 S Wacker Dr, Chicago, IL 60606. References 1 Roubenoff R . Sarcopenia: effects on body composition and function . J Gerontol A Biol Sci Med Sci . 2003 ; 58 : 1012 – 1017 . 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Google Scholar Crossref Search ADS PubMed WorldCat 39 Haley SM Fragala-Pinkham MA . Interpreting change scores of tests and measures used in physical therapy . Phys Ther . 2006 ; 86 : 735 – 743 . Google Scholar PubMed OpenURL Placeholder Text WorldCat 40 Ferri A Scaglioni G Pousson M , et al. . Strength and power changes of the human plantar flexors and knee extensors in response to resistance training in old age . Acta Physiol Scand . 2003 ; 177 : 69 – 78 . Google Scholar Crossref Search ADS PubMed WorldCat 41 Aagaard P Simonsen EB Andersen JL , et al. . Increased rate of force development and neural drive of human skeletal muscle following resistance training . J Appl Physiol . 2002 ; 93 : 1318 – 1326 . Google Scholar Crossref Search ADS PubMed WorldCat Author notes " Both authors provided concept/idea/research design, data collection, and project management. Ms Webber provided writing and data analysis. Dr Porter provided fund procurement, facilities/equipment, and consultation (including review of manuscript before submission). © 2010 American Physical Therapy Association

Goble, Daniel, J.

doi: 10.2522/ptj.20090399pmid: 20522675

Over the past several decades, studies of use-dependent plasticity have demonstrated a critical role for proprioceptive feedback in the reorganization, and subsequent recovery, of neuromotor systems. As such, an increasing emphasis has been placed on tests of proprioceptive acuity in both the clinic and the laboratory. One test that has garnered particular interest is joint position matching, whereby individuals must replicate a reference joint angle in the absence of vision (ie, using proprioceptive information). On the surface, this test might seem straightforward in nature. However, the present perspective article informs therapists and researchers alike of multiple insights gained from a recent series of position matching studies by the author and colleagues. In particular, 5 factors are outlined that can assist clinicians in developing well-informed opinions regarding the outcomes of tests of position matching abilities. This information should allow for enhanced diagnosis of proprioceptive deficits within clinical settings in the future. Over the past several decades, a relative shift has occurred in the field of physical therapy and rehabilitation medicine. In contrast to traditional assessments of physical well-being, which have focused largely on the ability of individuals to generate motor output, a greater emphasis is now being placed on sensory feedback acuity. This fundamental change is likely the result of our growing understanding regarding the role sensory information plays in promoting neural plasticity through use-dependent mechanisms. Indeed, it is now well accepted that a clear relationship exists between massed physical practice and the expression of neural representations in primary sensorimotor regions of the brain.1,2 Arguably the most important source of feedback for promoting neural plasticity is our sense of proprioception.3–6Proprioception can be defined as the ability of an individual to determine body segment positions and movements in space and is based on sensory signals provided to the brain from muscle,7–9 joint,10 and skin11,12 receptors. Studies of individuals who lack proprioceptive sense (due mainly to large fiber neuropathy) have taught us important lessons regarding the role of proprioceptive feedback during sensorimotor performance. Indeed, despite the fact that these individuals have motor systems that remain fully intact,13 “deafferented” people show profound deficits in motor control. These deficits include, but are not limited to, poor endpoint accuracy,14 reduced control of multisegmental dynamics,15,16 and an inability to perform extended movement sequences.13 Although other methods (eg, identification of imposed movement direction or measurement of movement detection threshold) are available, an increasingly utilized tool for the assessment of proprioceptive acuity in clinical situations is the joint position matching task.17–33 In this test, a patient is asked to re-create (ie, match) a reference joint angle (ie, position) in the absence of vision. The accuracy of matching is subsequently determined in a variety of ways, ranging from the use of specialized biomechanical equipment to more qualitative visual inspection by a trained observer. Although the validity and reliability of position matching tests have rarely been evaluated,17,34,35 it is generally well accepted that the magnitude of matching errors can be a useful indicator of proprioceptive acuity. More specifically, those individuals who are prone to making large position matching errors are thought to be, at least in some way, proprioceptively deficient. The purpose of this perspective article is to express to clinicians and clinical researchers alike that, despite their relative efficacy, some caution is necessary when designing and interpreting the results of position matching studies. The foundation for this assertion lies in a recent series of studies conducted by me and my colleagues that assessed, in detail, the position matching abilities of individuals with and without disabilities.36–42 Taken together, the results of these studies emphasize that position matching tasks are not as straightforward as they might appear initially and that matching errors are significantly influenced by a number of experimental factors. In this article, a summary of 5 of these factors and their clinical relevance is provided. It is hoped that this information will aid therapists in future assessments of proprioceptive acuity, both in the clinic and in the laboratory. An Overview of the Basic Experimental Setup The experimental factors described in this perspective article were elucidated through numerous studies conducted in the same laboratory (see acknowledgments) over the past 5 years. For each experiment, an elbow position matching paradigm was used involving a custom-made motorized manipulanda system (Fig. 1; see video available online at ptjournal.apta.org). Participants were blindfolded (to prevent the use of vision) and seated with head supported and forearms resting on 2 aluminum levers. The levers were attached below the pivot point of the elbow to a ball bearing system that allowed near-frictionless movement of the forearm about the elbow joint in the horizontal plane. Reference elbow positions were established either by a torque motor system or through movement of the lever by the experimenter via a handle attached to its distal end. Figure 1 Open in new tabDownload slide Animated version of the basic setup used for determining the experimental factors influencing proprioceptive position matching (see video available online at ptjournal.apta.org). Figure 1 Open in new tabDownload slide Animated version of the basic setup used for determining the experimental factors influencing proprioceptive position matching (see video available online at ptjournal.apta.org). Elbow position (ie, angle) data were continuously transduced into a voltage signal via potentiometers located below the ball bearing system (ie, elbow joint). This analog signal was digitally sampled by a laptop computer and displayed on the computer's screen in real time. The online display gave the experimenter a continuous estimate of joint position throughout the experimental session. Testing sessions consisted of 30 to 75 matching trials presented in a pseudo-randomized order for the condition of interest. Data were saved to the computer's hard drive, which allowed for more precise calculation of matching error using computer algorithms off-line. The preferred measure of matching accuracy was absolute error, defined as the absolute difference between the reference and matching elbow joint angles in degrees. Factor 1: Type of Position Matching Task There are 2 types of position matching tasks that have commonly been used for the assessment of proprioceptive acuity in clinical and research situations. In the first task type, a reference joint angle initially is provided to the participant for a short period of time (usually several seconds). Then, the joint is brought back to the “start” angle, and the participant is asked to replicate the previously experienced reference position using the same (ie, ipsilateral) arm. This so-called “ipsilateral matching” task is contrasted by the second commonly used task type, known as “contralateral matching.” Contralateral matching involves matching of a reference joint angle with the opposite (ie, contralateral) limb. In this case, the previously established target joint angle remains at the reference position throughout matching and can serve as an “on-line” reference to aid in participant matching. Although the choice between ipsilateral and contralateral limb matching tasks may seem trivial, this is most certainly not the case. For example, in ipsilateral matching tasks, where the same arm serves to establish both the reference and matching locations, it is inherently necessary for participants to use memory in order to accurately match the target position. This reliance on memory is due to the fact that no single limb can concurrently provide a reference joint angle while performing matching of that angle. Given the memory component to this type of task, clinicians should exercise caution when ipsilateral matching is used to assess proprioceptive acuity in individuals who are prone to having memory issues. Indeed, it is likely that, in this situation, some portion of the matching error measured actually reflects cognitive or memory deficits, rather than any decrease in proprioception itself. The use of contralateral matching tasks eliminates the need for memory-based matching because the reference joint angle is available throughout the task from the opposing limb. Despite this advantage, however, contralateral position matching tasks are subject to limitations of their own. First, due to the involvement of both arms in the task, it is difficult to ascertain whether the measured error arises from the reference arm, the matching arm, or both. Additionally, based on the anatomical pathways involved in the transmission of peripheral proprioceptive input to the brain, it is almost certain that matching using the opposite limb requires greater interhemispheric communication (or transfer) compared with ipsilateral matching. Specifically, proprioceptive information from the reference limb is directed initially to the primary somatosensory region of the cerebral cortex in the contralateral hemisphere (eg, right arm reference information first received by the left hemisphere).43,44 Before this information can be used to direct action of the opposite limb, which also is controlled by the opposing hemisphere, it must cross the hemispheric divide. This crossing likely occurs via the transcallosal pathways of the corpus callosum.45 The enhanced need for interhemispheric transfer in contralateral matching tasks, therefore, represents another significant cognitive factor that may influence position matching performance in certain clinical populations. Indeed, individuals with asymmetric brain injuries or individuals with transcallosal degeneration would seem to be particularly disadvantaged for contralateral matching tasks. The influence of task type on position matching has been tested directly by the author and colleagues in several groups of young individuals who were healthy.37,39–41 These studies compared both the ipsilateral and contralateral position matching tasks described above, as well as a third type of matching task that combines elements of ipsilateral and contralateral matching. In the third task, participants are given a reference (elbow) joint angle on one side of the body and required to memorize this position over the course of several seconds. The reference joint position then is taken away from the participants by changing the joint angle just prior to their making a mirror image match of the reference angle with the opposite arm (ie, requiring interhemispheric transfer). Compared with the ipsilateral and contralateral tasks, which involve only memory or interhemispheric communication demands, respectively, the third task (also known as “contralateral remembered” matching) is considered to be more challenging, as it requires both memory and interhemispheric transfer components. Figure 2 shows exemplary data from previously unpublished work demonstrating the effects of task type on absolute elbow position matching errors in 10 individuals who were healthy. Overall, clear differences in matching error are evident among all 3 task conditions, with the smallest errors evident in the ipsilateral matching task involving memory demand. In contrast, absolute matching errors in the contralateral task, requiring more interhemispheric interaction, are greater than those in the ipsilateral case, despite not having a memory component. In the contralateral remembered condition, where cognitive demands included both memory and interhemispheric communication, absolute errors are approximately twice as large as in the ipsilateral condition and about one third greater than in the contralateral matching task. Taken together, these results provide strong evidence that tests of position matching are not simple measures of proprioceptive acuity alone. Rather, they also reflect the cognitive demands of the particular type of matching task being performed. Figure 2 Open in new tabDownload slide Average (SE) absolute errors for various types of position matching tasks. IHT=interhemispheric transfer. Figure 2 Open in new tabDownload slide Average (SE) absolute errors for various types of position matching tasks. IHT=interhemispheric transfer. Factor 2: Limb Preference Handedness is the tendency to prefer one arm versus the other arm for performing various activities of daily living and is one of the most obvious examples of lateralized brain function in humans.46 Based largely on questionnaires such as the Edinburgh Handedness Inventory of Oldfield,47 it has been estimated that 90% of the population is right-handed for tasks such as handwriting, throwing a ball, or eating with a spoon.48–50 Given the robust and enduring nature of this phenomenon, a logical prediction might be that the preferred right arm of right-handed people would demonstrate a position matching advantage over the nonpreferred left arm. Contrary to the above hypothesis, however, one of the more intriguing and consistent findings to arise from the work of my colleagues and me is a nonpreferred arm advantage for proprioceptive position matching tasks. Inspired by previous research within the realm of psychology,51–54 my colleagues and I have explored in some depth the extent to which elbow position matching errors differ for the left and right arms of left-handed42 and right-handed37–40,55 individuals. In initial studies,37–39 the 3 matching tasks described in the previous section (ie, ipsilateral, contralateral, and contralateral remembered) were used to manipulate the proprioceptive demands (ie, the need for memory or interhemispheric transfer of proprioceptive information) placed on the participants. The results of this work showed that not only was matching more accurate by the nonpreferred arm across all task types but the magnitude of arm asymmetry favoring the nonpreferred arm also was relatively increased with greater cognitive demands. Specifically, although preferred arm errors were progressively larger when comparing the contralateral condition with the ipsilateral and contralateral remembered conditions, nonpreferred arm matching errors were similar in magnitude across all tasks. To ensure that the handedness effects seen in initial studies of position matching truly were due to proprioceptive processing, rather than a generally greater ability of the nonpreferred arm to match elbow positions, a follow-up experiment was conducted. In this study,40 young participants who were healthy were asked to match 15- and 30-degree elbow extension positions according to both the ipsilateral and contralateral remembered task types. In one set of conditions, target elbow angles were matched visually by having participants point with a laser on a projection screen to targets that required the target amount of elbow extension. In another set of conditions, matching relied solely on proprioceptive information. Based on this design, it was shown that nonpreferred arm position matching advantages were evident only in the proprioceptive version of the matching experiment. Indeed, in the visual version, the reverse trend was identified (ie, a preferred arm advantage was seen for matching). These results suggest that the preferred and nonpreferred arms rely to a different extent on visual versus proprioceptive information, as might be beneficial for performing activities of daily living requiring both hands. Typically, the preferred arm requires visual information for the fine manipulation of objects. In contrast, the nonpreferred arm more often is held outside of visual attention, where it must rely on proprioceptive feedback to perform tasks such as holding objects in a particular position.56 The nonpreferred arm position matching advantages seen in adults who are healthy also appear to have meaning for position matching assessments of proprioceptive acuity in clinical populations. There is currently evidence in the literature that enhanced nonpreferred left arm matching is linked to a right-hemisphere specialization for the processing of proprioceptive inputs. The most convincing work done in this area to date is that of Naito and colleagues,44,57 who used a tendon vibration paradigm in combination with neuroimaging to map regions of the brain responsible for processing input from key proprioceptors—the muscle spindles. Given that the basis for proprioceptive performance lies more directly within the right hemisphere, it may be expected that individuals with right-hemisphere damage would be more prone to proprioceptive deficits than individuals with left-hemisphere injury. My colleagues and I36 recently tested this hypothesis for the ipsilateral elbow matching abilities of children with hemiplegic cerebral palsy. In agreement with our hypothesis, we found that, compared with children who were developing typically, only those individuals with right-hemisphere injuries showed increased position matching errors of the affected arm and, to a lesser extent, the unaffected arm. These preliminary results suggest the need for differential treatment of lateralized brain injuries in the clinic, with a greater emphasis placed on proprioception in those individuals with right-hemisphere damage. Factor 3: Reference Position Establishment The means by which the reference joint angle is established also is an important factor to consider in tests of position matching ability. This consideration includes not only the magnitude of the reference joint angle but also the characteristics of how the joint was displaced to produce that angle. Studies by me and my colleagues have regularly made comparisons of matching errors at different reference joint angles.38–40,42 Based on this work, we found that a clear relationship exists between the target amplitude and the magnitude of matching error, with further targets inducing greater matching errors (ie, poor performance). For example, in one study,38 20 young adults who were healthy were asked to match targets that were either 20 or 40 degrees from the start elbow joint position. Regardless of whether the preferred or nonpreferred arm served as the reference, absolute errors were found to be, on average, 66% greater for the larger target amplitude. One hypothesis that has been put forth to explain this finding is that the increased errors seen with larger target amplitudes reflect increased sensorimotor noise when movement requires an increased neural control signal.58 Nevertheless, clinicians and researchers are encouraged to take great care when conducting position matching studies, ensuring that target amplitudes are matched across all populations of individuals tested and within each particular experimental condition. Beyond the influence of target amplitude on position matching performance, experiments from as early as the 1960s demonstrated that participants make smaller errors when matching a reference position that is established through their own active movement, rather than the same target position determined passively by the experimenter.59–61 This effect is thought to be the consequence of 2 movement-related features. First, the sensitivity of muscle spindles (key proprioceptors) is enhanced during active movements via the gamma motor system.62 Second, an “efferent copy” of the motor command used to get to the target position may be called upon to inform subsequent matching movements.63,64 In addition to improvements in matching error with actively determined targets, work by Goble and Brown37 suggests that matching strategy also is altered based on the means by which the reference angle is established (ie, active versus passive). Indeed, regardless of matching task (ie, ipsilateral, contralateral, or contralateral remembered), elbow joint reference positions determined actively by movement of the participant (rather than passively by the experimenter) appear to lead to target movements that are faster and smoother. Although these increases in speed and smoothness did not result in fewer errors in their study, it seems likely that this change in strategy reflected the higher confidence participants had in their ability to match actively determined reference positions. Given that most position matching assessments conducted in clinical environments use passive displacement of the joint to the target angle (usually by the experimenter), another point of concern for clinical researchers is the “tau effect.” The tau effect, initially described in studies of movement extent estimation,65,66 manifests as a strong interdependence between time and space, such that movements of longer duration are perceived as traveling farther than those of shorter duration. For position matching experiments, this finding implies that, if during the establishment of the target joint angle an experimenter takes a long versus a short amount of time, the participants will perceive the target as being further from the starting joint angle than it actually is. The tau effect was confirmed recently in a set of elbow position matching trials conducted with young participants who were healthy.67 Using a motorized system, each participant's elbow joint was displaced to the same reference position, but at speeds that were faster or slower than or the same as the speed at which the elbow was subsequently moved back to the target location for matching. It was shown that matching error was systematically biased by the speed at which the reference position was established. Taken together, the results described in this section underscore the need for clinicians to take great care when establishing reference joint positions. Keeping potential experimental biases in mind when performing proprioceptive assessments via position matching will improve proprioceptive sensibility estimates. Factor 4: Participant Age Age-related changes in the peripheral and central nervous system are a natural consequence of human growth and development. Peripheral alterations of proprioceptor size and number vary across the life span and affect the quality of the limb position signal provided to the brain. On the other hand, central feedback processing of limb position signals is refined throughout a lifetime of experience. Given that clinical populations often occupy certain spectra of the life span (eg, cerebral palsy in children, stroke in older people), it is important for clinicians to take into account natural shifts in acuity with age when determining the existence of any proprioceptive deficit. In light of the task-related factors influencing position matching error described in the previous sections, the true relationship between proprioceptive matching ability and age is difficult to ascertain from a simple meta-analysis of the existing literature. Rather, comparisons of position matching performance among various age groups must be made under experimental conditions that are very closely matched. In this case, a compilation of the data collected by Goble and colleagues39,40,68 provides an ideal opportunity to explore the relationship between normal aging and proprioceptive ability. In Figure 3, the average absolute matching errors are displayed for different cross-sections of the age spectrum that were tested using very similar task parameters (ie, ipsilateral matching with the preferred arm of a 30° target). As shown in Figure 3, the relationship between age and position matching error is nonmonotonic, with an overall refinement of position matching ability (ie, decrease in absolute error) from childhood (ie, age 8–10 years) through adolescence to young adulthood. Absolute matching errors then increase into middle age and continue to rise with old age. Figure 3 Open in new tabDownload slide Average (SE) absolute errors in the ipsilateral matching of 30-degree targets for different cross sections of the human life span. Figure 3 Open in new tabDownload slide Average (SE) absolute errors in the ipsilateral matching of 30-degree targets for different cross sections of the human life span. Although the data provided in Figure 3 clearly demonstrate the pattern of proprioceptive performance across the life span, it must be emphasized the absolute magnitude of the errors provided in this (or any) particular position matching study should not be considered “norms.” Unless very similar task parameters (eg, elbow joint, ipsilateral matching, preferred arm) are used, it is recommended that therapists make use of study-specific normative databases when making any determination of what represents pathological performance. Indeed, failure to compare data under similar task conditions may result in a relative underestimation or overestimation of a patient's matching ability and a subsequent misdiagnosis of proprioceptive sensibility. Factor 5: Task Workspace Task workspace is the relative area wherein most individuals perform a given activity of daily living. For most visually guided upper-limb tasks (eg, writing, opening a jar, cutting food) the “common” workspace used by right-handed individuals is located at the front of the body at approximately chest height with the hands centered to the right of body midline. In light of this seeming “right shift” of workspace preference for visual tasks, a question of interest for me was whether a similar or different dependence on workspace existed for tests of positions matching. Figure 4 presents previously unpublished data from a study of 10 young adults who were healthy and who performed 20-degree elbow joint position matching tasks in various locations of the workspace relative to body midline. Workspace was divided into far left, near left, near right, and far right of body midline. The elbow on the same side of the body as the workspace tested performed matching in either an ipsilateral or contralateral fashion. In contrast to what typically is seen for visually guided tasks, proprioceptive position matching showed greater performance to the left of body midline, with the smallest errors seen in the far left workspace. These results, although subtle in absolute magnitude (∼1°), are in good agreement with those of a previous study69 in which a similar far-left advantage was found for reaching to proprioceptive targets (ie, the unseen finger of a participant located under a tabletop). In this case, a left workspace bias in position matching performance also should be accounted for in the design and interpretation of position matching studies by clinicians and researchers alike. Figure 4 Open in new tabDownload slide Demonstration of bias in average (SE) absolute error when position matching occurs in different locations of the task workspace. Figure 4 Open in new tabDownload slide Demonstration of bias in average (SE) absolute error when position matching occurs in different locations of the task workspace. Summary and Conclusions Based on studies of elbow position matching, this article sought to inform clinicians and clinician researchers of various insights gained from studies conducted by my colleagues and me over the past half decade. Although these insights may not be fully generalizable to all joints in the upper and lower extremities, it remains possible to offer several “best practice” suggestions regarding how clinically based assessments of proprioceptive function should be performed. First, it has been demonstrated that the choice of ipsilateral versus contralateral matching task (factor 1) is not trivial, as these tasks have very different requirements for memory and interhemispheric communication, respectively. In this case, prudent selection of matching task, based on the cognitive abilities of the individual being tested, will reduce cognition-based confounds and provide more accurate assessments of proprioceptive ability. Second, there appears to be a left-arm advantage for position matching (factor 2) that likely stems from an enhanced role for the right hemisphere in proprioceptive feedback processing. The implication of this finding for clinicians and researchers is that individuals with right- versus left-hemisphere injury may be expected to exhibit greater proprioceptive deficits. Third, the position matching studies of the author and colleagues have shown that the manner by which target positions are established (factor 3) can have significant effects on position matching performance. In this case, clinician researchers are advised to take care in ensuring that tested target amplitudes are of the same magnitude and established in the same manner (active versus passive) and at the same speed across all participants and experimental conditions. Fourth, clinicians and researchers must be sure to account for natural shifts in proprioceptive acuity with age (factor 4), as clinical populations often fall nearer to one end of the spectrum compared with other populations (eg, people with stroke, older people). Fifth, there appears to be an effect of task workspace on position matching (factor 5), such that matching movements are enhanced when made to the far left of body midline. Clinicians and researchers, therefore, should perform tests of position matching ability within a common workspace. Despite the many factors presented, it was not the intent of this perspective article to call into question, or advise against the use of, position matching tasks in clinical research. Rather, it is hoped that the information provided will help enhance future studies within the field of physical therapy and allow for more substantive breakthroughs to be made. Indeed, it is more apparent than ever that proprioceptive information is a key component of the plastic reorganization of central nervous system following injury.1,2 Adequate assessment of proprioceptive acuity, therefore, will be a critical indicator of treatment outcomes in future assessments of many disease conditions. " The studies forming the basis for this article were conducted in the Motor Control Laboratory of Dr Susan Brown at the University of Michigan. The author gives special thanks to Dr Brown and all of his former colleagues in the Motor Control Laboratory for their contributions to this work. 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Greenfield, Bruce, H.;Jensen, Gail, M.

doi: 10.2522/ptj.20090348pmid: 20539020

This perspective article provides a justification, with an overview, of the use of phenomenological inquiry and the interpretation into the everyday ethical concerns of patients with disabilities. Disability is explored as a transformative process that involves physical, cognitive, and moral changes. This perspective article discusses the advantages of phenomenology to supplement and enhance the principlist process of ethical decision making that guides much of contemporary medical practice, including physical therapy. A phenomenological approach provides a more contextual approach to ethical decision making through probing, uncovering, and interpreting the meanings of “stories” of patients. This approach, in turn, provides for a more coherent and genuine application of ethical principles within the “textured life-world” of patients and their evolving values as they grapple with disability to make ethical and clinical decisions. The article begins with an in-depth discussion of the current literature about the phenomenology of people with disability. This literature review is followed by a discussion of the traditional principlist approach to making ethical decisions, which, in turn, is followed by a discussion of phenomenology and its tools for use in clinical inquiry and interpretation of the experiences of patients with disabilities. A specific case is presented that illustrates specific tools of phenomenology to uncover the moral context of disability from the perspective of patients. The article concludes with a discussion of clinical, educational, and research implications of a phenomenological approach to ethics and clinical decision making. Physical therapy continues to emerge as a health care profession whose central role is the ethical commitment to caring for patients with significant disabilities.1 As greater numbers of people survive life-threatening disease and injury, greater interest has developed about the ethical meaning of long-term rehabilitation, the nature of clinical caring, and the healing qualities of physical therapy around the notion of disability.2,3 Yet, caring for patients with disabilities presents several ethical challenges for physical therapists. Patients with significant disabilities due to spinal cord injuries, stroke, or closed head injuries experience both physical and psychic discontinuities.4–9 As a result of life-changing diseases and injuries, many patients with disabilities undergo transformations in their physical abilities and personal identity. These patients face changes in their social roles, including their family roles. Husbands may no longer assume their traditional role as “breadwinners” in the family. Patients with severe closed head injuries may exhibit childish outbursts of inappropriate behaviors, making it difficult for them to serve as proper role models for their children. Patients with long-term disabilities also may experience significant social stigma.2 The burgeoning field of rehabilitation and disability studies has raised some interesting questions regarding how we view disability. Some authors argue that people with disabilities have the misfortune of being a minority living among an insensitive majority. Therefore, it is the civil right of people with disabilities for society to accommodate to their particular conditions.5 Yet, the need for physical therapists to move, as Purtilo1 advocated in her Mary McMillan address, to acting on meeting society's health care needs makes it particularly relevant for physical therapists to understand the moral concerns of patients with disabilities as they assimilate back into their communities. As a result of these challenges, we believe that caring for patients with disabilities calls for a unique type of ethical reflection and decision making. The traditional approach to clinical ethics is to apply principles such as autonomy, beneficence, nonmaleficence, and justice using an ethical framework such as deontology or consequentialism to solve an ethical problem involving patient care.10 This type of ethical decision making tends to be rationalistic, detached, and fact oriented. For the most part, the principlist approach has been the accepted norm for hospital ethics committees addressing significant end-of-life issues.11 Critics, though, point out that this type of approach is not as useful to uncover the changing moral concerns and ethical issues associated with long-term disability.10,12–17 Purtilo18 defined ethics as a systemic reflection of a person's morality (values and beliefs about right and wrong and good and bad behaviors). She argued that, in the presence of moral conflict, ethical reflection uses special methods and approaches to examine moral situations. This type of ethical reflection necessitates exploring and uncovering the values and value conflicts embedded in the daily experiences of individuals living with disability. We agree with Purtilo, and, as argued below, we advocate for an ethical reflection that focuses on uncovering and understanding the everyday moral concerns of patients living with disability who are undergoing rehabilitation. Understanding the everyday moral concerns of patients living with disability opens up potentialities for caring that most closely relates to the transforming values, concerns, and self-identity of those for whom care is provided. Ethics, in these instances, is, as Moules wrote, “a pause to wonder, to question, to step back and to notice.”19(p3) This type of ethical reflection should include the changing ethical concerns and needs of all stakeholders who are affected, including the patient's family and the local community members, if possible. The intent is to uncover the manifold meanings of a patient's illness experience from the perspectives of all relevant stakeholders, including the patient living with the disability. How we do this type of reflection is the concern of this perspective article. The purpose of this article is to provide a framework for a type of ethical reflection based on phenomenology. We argue that a phenomenological approach to ethics can be used as a process of reflective inquiry that is fundamental in a human caring profession such as physical therapy. This type of approach will help us understand the experiences and ethical concerns of patients living with disabilities that are critical components of patient care. This understanding, in turn, is imperative to aid a patient adjusting to disablement and discovering a new self-identity. Reflective inquiry using the tools of phenomenology also has the potential to help us uncover or construct “clinical knowledge” that includes consideration and action directly linked to understanding the patient's experience and meanings. Therefore, the tools of phenomenology, as argued in this article, help us understand the patient more fully and potentially are part of our clinical knowledge that is now either tacit or implicit. The Nature of Disability In the current World Health Organization model of disability (International Classification of Functioning, Disability and Health [ICF]), disability is defined as a limitation in or loss of a person's ability to participate in a social role.20 The limitation in or loss of a person's social role includes the ability to participate in his or her vocation, hobbies, sports activities, or family role. Some authors argue that limitation in social role functioning due to disability results partly from what society and its formal institutions consider socially important and willing to support.5 For example, legislation such as the Americans With Disabilities Act21 recognizes that potential discrimination directed toward patients with disabilities for future employment and access to facilities should be addressed proactively and encoded in law. The legislation underscores the social responsibility that members of society have to not discriminate against otherwise capable individuals based on their disabilities. Notwithstanding society's roles in reducing potential discrimination for individuals with disabilities, changes in social roles that result from significant impairments in body function and structure and activity levels have a profound effect on a patient's moral understanding of his or her own identity and roles in society. People with disabilities, for example, are confronted with issues of re-identification and value transformation related to the people they were, who they are currently, and what they might become as they and their families come to terms with the nature and scope of their disabilities.9 Charon15 referred to patients with life-changing disabilities as caught between stable states. Undoubtedly, rehabilitation for many patients and their families is characterized by periods of emotional and moral turmoil as they confront the meaning of their disabilities. Boylstein et al underscored this point, writing that a “chronic illness, such as a stroke, can lead to biographical disruption, about which people use narrative to reconstruct their self-identity.”22(p279) Many patients undergo an existential loss of self and an existential awareness of loss, distortion, fear, and entrapment.23 Entrapment can take many forms, including emotional and physical (eg, consider the previously active patient with a severe spinal cord injury who uses a wheelchair). This type of entrapment is illustrated in the following comments from 3 patients with spinal cord injuries who are in wheelchairs: I didn't know what I was supposed to look like sitting in this chair…. I started buying clothes that were really big on me. I was trying to hide and get lost in the chair so that nobody would notice me.6(p276) It's not the freedom of being able to jump into the car and go wherever you want to go; you have to rely on public transportation. Also, I just don't have the freedom of doing a lot of spur-of-the-moment, spontaneous things.6(p279) I felt like I was looking into a mirror. I hated what I saw. I tried to pretend that I wasn't in a wheelchair and I wasn't disabled. In my heart, I didn't feel I was, but if I saw someone else in a wheelchair, it reminded me, like a big slap in the face.6(p277) Other authors describe the ontological assault on a person's sense of space and time that occurs in the presence of severe disability. In a qualitative study exploring the phenomenology of patients with strokes, one participant described her lived experience with changed mobility: I wanted to get to the chair by the window. I just couldn't go to see the garden. It was always the same place that I stopped. I just do not seem to go any further. I thought I had been doing well.4(p305) Gadow8 described the dehumanizing effects that life-changing injuries can have in a person in terms of dissolution of the individual's embodied self. Her qualitative exploration of patients with severe stroke indicates that many of these patients experience an initial and often long-term feeling that their bodies are separated from their minds. She describes that, for most of us, the body is experienced normally as an aspect of self. More precisely, for most of us, in our normal daily activities, we experience no distinction between body and self. The result is that our embodied self has an immediacy of being in the world, “the feeling of being able to affect one's world and be affected by it as a unified whole.”8(p88) In patients with stroke, an inversion of the embodied self occurs. Instead of the self and body acting together, the self is felt acted upon by part of itself. The primary unity between body and self is disrupted, and the body obtains a new and often strange distinctness, in many cases as a force that needs to be governed or an object that needs to be overcome. Gadow described the dissolution of the embodied self as a disrupted immediacy experienced by patients with strokes. As she describes this relationship, patients with stroke often perceive their bodies in the same way that they experience the immediate world around them—as an objective and external reality apart from themselves. For these patients, the body often becomes a source of impediment to normal function. Instead of the body and self working as one, the patient with stroke often feels encumbered by his or her body. This dichotomy between self and body has a profound impact on an individual's self-identity. How many of us have awakened from a deep sleep frightened because we have slept on a numb and useless arm. Thankfully, we shake it out, blood flow returns, and the arm starts to work under our control once again. Imagine, though, the patient with a massive spinal cord injury, for whom no amount of shaking (if possible) would restore a sense of feeling to a limb. The sense of loss of control in cognitive and physical function can be overwhelming, as uniquely explored in an autobiography written by Claudia Osborn.24 Osborn, who is a physician, wrote about her loss of control over her cognitive and physical functions after a closed head injury. Attempting to return to clinical care, she wrote about her existential angst as she realized she was a different person than before her injury. The rules had changed, and everyone but I was privy to key information. I alternated between moments of anger and despair because I could not will myself to improve, then I quickly forgot both emotions until the next mishap, when I would relive the emotional cycle.24(p38) In summary, the quotes provided above illustrate ontological changes that occur within individuals who are forced to live with disability. These changes invariably will result in different ethical concerns that these individuals did not face in their daily life. By giving voice to patients' lived experiences, clinicians have the opportunities to uncover the changing ethical framework of patients in order to apply ethical principles that are consistent with the ethical concerns of these patients. The next section provides an overview of principlism, as it is currently understood in medical ethics. Foundational Ethics: Principlism Principlism is an approach to making ethical decisions that involves the application of ethical principles to solve ethical dilemmas. Table 1 provides a summary of definitions for the concepts described herein. Beauchamp and Childress25 argued for the existence of a common morality that contains basic moral norms that bind all serious moral people. According to Beauchamp and Childress, the common morality contains moral norms that include 4 major principles: beneficence, nonmaleficence, justice, and autonomy. These principles are basic to biomedical ethics. Table 1 Definition of Concepts Related to Phenomenology and Principlism Concept . Definition . Phenomenology The study of the meaning of experiences from an individual’s own subjective perspective. Consciousness The subjective understanding of phenomena from an individual perspective. Inter-subjective understanding A broader interpretation of an understanding of a particular phenomenon from the perspectives of several individuals. In phenomenological research, inter-subjective understanding often is presented as unifying themes. Epistemology The study of how we know things. Intentionality Intentionality refers to the human condition that we are always conscious of our external world and always trying to make sense of our experiences. Natural attitude The natural attitude reflects our default position of our lack of attending to and making meaning of our daily experiences. Phenomenologists often point out that many of us function at a preconscious level of understanding. In other words, we take things for granted without reflecting about their meaning. Phenomenological attitude The phenomenological attitude refers to a conscious effort to recount and understand our lived experiences. Bracketing Bracketing is a component of our attitude in which we consciously identify our values and biases that influence our assumptions about patient care. Respect for autonomy Respect for autonomy “encompasses, at a minimum, self rule that is free from both controlling interference by others and certain limitations such as inadequate understanding that prevents meaningful choice.”25(p99) Beneficence The principle of beneficence refers to our moral obligation to act for the benefit of others. This obligation may include protecting and defending the rights of others, preventing harm, removing conditions that will cause harm to others, helping people with disabilities, and rescuing people in danger.25 Nonmaleficence The principle of nonmaleficence imposes an obligation not to inflict harm on others. Rules specifying the principle of nonmaleficence include: do not kill, do not cause pain or suffering, do not incapacitate, do not cause offense, and do not deprive others of the good life.25(p153) Justice The principle of justice obligates us to treat like cases alike; distribute benefits and burdens fairly. Deontology Ethics based on one’s duty. Consequentialism Ethics based on weighing the best or most optimal outcomes for all parties involved. Categorical imperative The Kantian philosophy that enjoins us to act in such as way that we can also will our act to become a universal law. Principle of utility The principle that requires one to balance benefits and drawbacks to produce the best overall results. Concept . Definition . Phenomenology The study of the meaning of experiences from an individual’s own subjective perspective. Consciousness The subjective understanding of phenomena from an individual perspective. Inter-subjective understanding A broader interpretation of an understanding of a particular phenomenon from the perspectives of several individuals. In phenomenological research, inter-subjective understanding often is presented as unifying themes. Epistemology The study of how we know things. Intentionality Intentionality refers to the human condition that we are always conscious of our external world and always trying to make sense of our experiences. Natural attitude The natural attitude reflects our default position of our lack of attending to and making meaning of our daily experiences. Phenomenologists often point out that many of us function at a preconscious level of understanding. In other words, we take things for granted without reflecting about their meaning. Phenomenological attitude The phenomenological attitude refers to a conscious effort to recount and understand our lived experiences. Bracketing Bracketing is a component of our attitude in which we consciously identify our values and biases that influence our assumptions about patient care. Respect for autonomy Respect for autonomy “encompasses, at a minimum, self rule that is free from both controlling interference by others and certain limitations such as inadequate understanding that prevents meaningful choice.”25(p99) Beneficence The principle of beneficence refers to our moral obligation to act for the benefit of others. This obligation may include protecting and defending the rights of others, preventing harm, removing conditions that will cause harm to others, helping people with disabilities, and rescuing people in danger.25 Nonmaleficence The principle of nonmaleficence imposes an obligation not to inflict harm on others. Rules specifying the principle of nonmaleficence include: do not kill, do not cause pain or suffering, do not incapacitate, do not cause offense, and do not deprive others of the good life.25(p153) Justice The principle of justice obligates us to treat like cases alike; distribute benefits and burdens fairly. Deontology Ethics based on one’s duty. Consequentialism Ethics based on weighing the best or most optimal outcomes for all parties involved. Categorical imperative The Kantian philosophy that enjoins us to act in such as way that we can also will our act to become a universal law. Principle of utility The principle that requires one to balance benefits and drawbacks to produce the best overall results. Open in new tab Table 1 Definition of Concepts Related to Phenomenology and Principlism Concept . Definition . Phenomenology The study of the meaning of experiences from an individual’s own subjective perspective. Consciousness The subjective understanding of phenomena from an individual perspective. Inter-subjective understanding A broader interpretation of an understanding of a particular phenomenon from the perspectives of several individuals. In phenomenological research, inter-subjective understanding often is presented as unifying themes. Epistemology The study of how we know things. Intentionality Intentionality refers to the human condition that we are always conscious of our external world and always trying to make sense of our experiences. Natural attitude The natural attitude reflects our default position of our lack of attending to and making meaning of our daily experiences. Phenomenologists often point out that many of us function at a preconscious level of understanding. In other words, we take things for granted without reflecting about their meaning. Phenomenological attitude The phenomenological attitude refers to a conscious effort to recount and understand our lived experiences. Bracketing Bracketing is a component of our attitude in which we consciously identify our values and biases that influence our assumptions about patient care. Respect for autonomy Respect for autonomy “encompasses, at a minimum, self rule that is free from both controlling interference by others and certain limitations such as inadequate understanding that prevents meaningful choice.”25(p99) Beneficence The principle of beneficence refers to our moral obligation to act for the benefit of others. This obligation may include protecting and defending the rights of others, preventing harm, removing conditions that will cause harm to others, helping people with disabilities, and rescuing people in danger.25 Nonmaleficence The principle of nonmaleficence imposes an obligation not to inflict harm on others. Rules specifying the principle of nonmaleficence include: do not kill, do not cause pain or suffering, do not incapacitate, do not cause offense, and do not deprive others of the good life.25(p153) Justice The principle of justice obligates us to treat like cases alike; distribute benefits and burdens fairly. Deontology Ethics based on one’s duty. Consequentialism Ethics based on weighing the best or most optimal outcomes for all parties involved. Categorical imperative The Kantian philosophy that enjoins us to act in such as way that we can also will our act to become a universal law. Principle of utility The principle that requires one to balance benefits and drawbacks to produce the best overall results. Concept . Definition . Phenomenology The study of the meaning of experiences from an individual’s own subjective perspective. Consciousness The subjective understanding of phenomena from an individual perspective. Inter-subjective understanding A broader interpretation of an understanding of a particular phenomenon from the perspectives of several individuals. In phenomenological research, inter-subjective understanding often is presented as unifying themes. Epistemology The study of how we know things. Intentionality Intentionality refers to the human condition that we are always conscious of our external world and always trying to make sense of our experiences. Natural attitude The natural attitude reflects our default position of our lack of attending to and making meaning of our daily experiences. Phenomenologists often point out that many of us function at a preconscious level of understanding. In other words, we take things for granted without reflecting about their meaning. Phenomenological attitude The phenomenological attitude refers to a conscious effort to recount and understand our lived experiences. Bracketing Bracketing is a component of our attitude in which we consciously identify our values and biases that influence our assumptions about patient care. Respect for autonomy Respect for autonomy “encompasses, at a minimum, self rule that is free from both controlling interference by others and certain limitations such as inadequate understanding that prevents meaningful choice.”25(p99) Beneficence The principle of beneficence refers to our moral obligation to act for the benefit of others. This obligation may include protecting and defending the rights of others, preventing harm, removing conditions that will cause harm to others, helping people with disabilities, and rescuing people in danger.25 Nonmaleficence The principle of nonmaleficence imposes an obligation not to inflict harm on others. Rules specifying the principle of nonmaleficence include: do not kill, do not cause pain or suffering, do not incapacitate, do not cause offense, and do not deprive others of the good life.25(p153) Justice The principle of justice obligates us to treat like cases alike; distribute benefits and burdens fairly. Deontology Ethics based on one’s duty. Consequentialism Ethics based on weighing the best or most optimal outcomes for all parties involved. Categorical imperative The Kantian philosophy that enjoins us to act in such as way that we can also will our act to become a universal law. Principle of utility The principle that requires one to balance benefits and drawbacks to produce the best overall results. Open in new tab The 4 principles identified by Beauchamp and Childress25 are role specific—they are duties that health care professionals owe to patients. They are sometimes called “mid-level principles” because they occupy a level of generality and abstraction below universal, foundational principles such as the principle of utility, or the categorical imperative.26 According to the usual framework of the 4-principle approach, there is no intrinsic priority to any of the principles—they are all of equal weight or are prima facie duties that are considered always to be in effect.25 Critics of principlism argue that the original principlist approach did not provide a framework of moral deliberation to help health care professionals choose one principle over another to solve an ethical dilemma.27 In some cases, the principle of respect for autonomy (respecting the patient's right to refuse treatment) may conflict with the principle of beneficence (the treatment is medically imperative for an individual to recover function). In response to this criticism, Beauchamp and Childress25 added several justificatory conditions for infringing on prima facie norms, including choosing a principle-based approach that must be realistic, an approach that minimizes infringement of patient rights, or an approach that offers no other morally alternative action possible that would fulfill both conflicting principles. Critics point out, despite the justifications, that the locus of certitude in applying principles is embedded in the particularities of a case. That is, although the 4 principles of Beauchamp and Childress' approach25 apply in most cases, the particularities of the cases should influence their application and justification. Interestingly, Beauchamp and Childress agree that principles provide only an abstract starting point for making ethical decisions and argue for a process of specifying the particularities of conditions and context in the application of principles. The evolution of medical ethics toward case-based decision making, casuistry, narrative, ethics of care, and phenomenology underscores the recognition from many medical ethicists of the limitations of a pure principle-based approach, and the importance of the context and story to shape the ethical concerns and application of principles.4,8,12–16 The question for many ethicists is how (and how much of) the case story should unfold. Should the case simply reveal the major facts and issues, or do we need more telling of the story through the voices and perspectives of the major stakeholders? For phenomenologists, it is clearly the latter case. We agree with the position of Wiggins and Schwartz28 and Zaner,29 who argued that clinical ethics takes on reality in the concrete and actual human relationships that exist among patients and their families, friends, physicians, and other caretakers. They see the application of principles, as we do, as simply the starting point for a much fuller set of moral considerations that remain particular to the patient's past, present, and future being. Phenomenological Ethics The experiences of patients living with their disabilities described above were revealed through phenomenological conversations. Phenomenology, as argued here, is predicated on understanding the experiences and the “everyday ethics” of how a person lives with disability from that individual's own viewpoint. This type of perspectival understanding, we believe, will best determine lived experience with disabilities. The following section provides a brief overview of phenomenology. Phenomenology began with the writings of Husserl30 as a philosophical movement in the early 20th century. An in-depth description of his philosophy is well beyond the scope of this article. There are, however, certain concepts of his phenomenology that have relevance for our discussion. Husserl's philosophical quest was to explore how individual consciousness is formed. His epistemology can best be described as skepticism of inter-subjective understanding of external reality. Put more simply, he doubted that we all experience external things and events in the same way. Instead, Husserl believed that the ideas and meaning we develop come from our experiences and our reflection about things in the world. That is, we are highly intentional beings. Husserl was not alluding to the ordinary usage of “practical intending to do something.” Rather, he was alluding to phenomenological intending—the belief that we have a conscious relationship with an object, either external or in our memory, which we interpret and develop meaning about. The basis of intentionality indicates that every act of consciousness we perform, every experience that we are conscious of having, is an experience of something or other. Sokolowski wrote about intentionality: All our awareness is directed toward objects. If I see some visual object, such as a tree or a lake; if I imagine, my imagining presents an imaginary object, such as a car, that I visualize coming down a road; if I am involved in remembering, I remember a past object; if I am engaged in judging, I intend to a state of affairs.31(p8) What is particularly important about intentionality is that it elevates experience of things to the forefront of knowing. Phenomenology raises the questions: What is my patient's daily experience like? How does my patient's lived world present itself? How does my patient reconceive his or her values in light of his or her disability? What do those reconceived values mean for caring for this patient ethically? More simply put, phenomenology helps us to understand what an individual is experiencing and how. From an ethical standpoint, the goal is to uncover the moral predicaments and everyday moral concerns inherent to the patient's illness experience. It is at that point of understanding that we can more fully and accurately assess which principles may apply to a particular situation and how. Like Dewey,32 Husserl30 believed that consciousness and meaning about things are made through and in experience. We are constantly in a reciprocal relationship with our experiences of external reality. Subjective knowing cannot exist without objective experiences. Husserl referred to our subjective-objective life as part of our life-world (Lebensweld). Therefore, to understand our subjective meaning of things, we have to explore our experiences (our intentionality). Part of how we do that, according to Husserl, is to disengage temporarily from our natural, everyday attitude about things and move toward a phenomenological attitude of self-reflection. Similarly, Dewey would argue that we do not learn from experience alone, but from thinking about our experience. Natural attitude is the viewpoint we assume of everyday life. Some may call this the default position, others the nonreflective position. Heidegger,33 a protégé of Husserl, talked about a prereflective attitude. What he meant by this attitude is that often we do things so automatically that we fail to reflect on them, or we do things when we are not particularly conscious of what we are doing. In this attitude, experiences sift through our subconsciousness, influencing, unawares, our behaviors. The goal of phenomenology is to shift our and our patients' viewpoint from the everyday, natural attitude to refocus in a reflective way. We want to help our patients (and ourselves) to examine and describe our internationalities associated with their everyday experiences and their subjective correlates. The importance of phenomenological exploration of the illness experiences lies in its ability to increase our broad understanding of boundaries, limits, and responsibilities as health care professionals. Jaeger,13 for example, argued that phenomenological reflection opens up the possibility of understanding the contextual and embodied understanding of one's particular predicament. Eventually, understanding multiple patient perspectives may open up the possibilities of broader understanding of patient experiences with particular disabilities. Benner et al34 saw the goal of interpretive phenomenology as to uncover and understand the meaning of one's experience in his or her own terms by being critically reflective and engaging in a dialogue between practical concerns and the lived experience of the patient. Kestenbaum35 asserted that phenomenology captures the humanness that is central to the illness experience. Phenomenology, he argued, seeks to suspend the habits of mind inculcated through medical training based on a rational and detached process of decision making from the medical viewpoint. For example, attending to a patient's discourse about her changing experiences during her process of disablement enables us to understand her shifting values, her transforming identity of herself and her place in the world, her changing moral and ethical concerns, and her own relationship between her dimensions of human suffering and the cultural and structural contexts in which they occur. That is, as Benner et al pointed out, it is within her own terms (and not ours) that we reconstruct meaning about her illness experiences. It is, necessarily, within the context of these changes that we are able to uncover everyday ethical concerns that may remain hidden with a more rationalistic and detached process of decision making. Phenomenological Attitude The question for health care professionals is: How do we shift into a phenomenological attitude with our patients? The following case taken from Kuczewski and Pinkus36 provides a useful example to compare the traditional principlist approach and the phenomenological approach to the moral concerns of a patient with spinal cord injury. Table 2 provides the key constructs of phenomenology applied to this clinical case. Table 2 Applying a Phenomenological Approach to Ethics Cases: Key Concepts Key Concept . Application/Sample Questions . Phenomenological attitude Explore the meaning of the patient’s circumstances from the patient’s perspective. What do I believe about this patient’s experiences with his or her injury or disability is motivating his or her behaviors? Identify own biases (bracketing) What do I believe are the experience of patients with this injury in general? Thick description of patient’s experiences Facilitate the patient’s description of his or her experience with his injury or disability. What is it like to live in a wheelchair? Describe your daily experience. Identify key themes of meaning for this patient What are the main ideas that my patient is expressing? What are the “meanings” about self that are emerging? How do these meanings of self fit with ethical principles that are embedded in the care of this patient? Key Concept . Application/Sample Questions . Phenomenological attitude Explore the meaning of the patient’s circumstances from the patient’s perspective. What do I believe about this patient’s experiences with his or her injury or disability is motivating his or her behaviors? Identify own biases (bracketing) What do I believe are the experience of patients with this injury in general? Thick description of patient’s experiences Facilitate the patient’s description of his or her experience with his injury or disability. What is it like to live in a wheelchair? Describe your daily experience. Identify key themes of meaning for this patient What are the main ideas that my patient is expressing? What are the “meanings” about self that are emerging? How do these meanings of self fit with ethical principles that are embedded in the care of this patient? Open in new tab Table 2 Applying a Phenomenological Approach to Ethics Cases: Key Concepts Key Concept . Application/Sample Questions . Phenomenological attitude Explore the meaning of the patient’s circumstances from the patient’s perspective. What do I believe about this patient’s experiences with his or her injury or disability is motivating his or her behaviors? Identify own biases (bracketing) What do I believe are the experience of patients with this injury in general? Thick description of patient’s experiences Facilitate the patient’s description of his or her experience with his injury or disability. What is it like to live in a wheelchair? Describe your daily experience. Identify key themes of meaning for this patient What are the main ideas that my patient is expressing? What are the “meanings” about self that are emerging? How do these meanings of self fit with ethical principles that are embedded in the care of this patient? Key Concept . Application/Sample Questions . Phenomenological attitude Explore the meaning of the patient’s circumstances from the patient’s perspective. What do I believe about this patient’s experiences with his or her injury or disability is motivating his or her behaviors? Identify own biases (bracketing) What do I believe are the experience of patients with this injury in general? Thick description of patient’s experiences Facilitate the patient’s description of his or her experience with his injury or disability. What is it like to live in a wheelchair? Describe your daily experience. Identify key themes of meaning for this patient What are the main ideas that my patient is expressing? What are the “meanings” about self that are emerging? How do these meanings of self fit with ethical principles that are embedded in the care of this patient? Open in new tab Mr X is an inpatient in a rehabilitation hospital. He is a 70-year-old man with a history of an L5 spinal cord injury that occurred 1 month ago due to a motor vehicle accident, which has left him as a lower-extremity paraplegic confined to a wheelchair. Mr X was formerly a proud steelworker. A history of chronic pain contributed to his decision to take to an early retirement buyout from a local company about 10 years ago. Since his retirement, Mr X has gained a great deal of weight, although 2 attempts to control it resulted in significant weight losses. Mr X's lifestyle includes occasional alcohol consumption, and he smokes a pack of cigarettes each day. His medical history also is significant for rheumatoid arthritis and chronic obstructive pulmonary disease. Mr X's mood is quite variable. It is observed that when he goes to his various therapies, he participates well and seems to makes some progress. Unfortunately, Mr X sometimes refuses therapy, stating that it is “[expletive deleted] awful that he had to be taken care of like a little baby” or that his pain is too much that day. When asked by the nursing staff why he is not going to therapy, he sometimes says, “What's the use?” Mr X has a 33-year-old son, Skip, who is a banker. Skip is married with 2 children, He says that his father was always a fighter. Skip says that he believes his father can be so again. If Mr X can get to the point where he can take care of most of his daily living functions (“If he just doesn't stay in bed all day,” says Skip), Skip and his wife would like Mr X to live with them. If not, Mr X will have to find some sort of a structured living situation. As it stands based on principlism, the case concerns the scope of a patient's autonomy to refuse treatment, which conflicts with the obligation of the medical staff to act in the patient's best interests. Approaching this problem, a principlist would consider which principles apply, how we might specify those principles based on the issues in this case, and how we might apply moral theories to those principles. In this particular instance, from the viewpoint of a detached and rational process of decision making, the medical team might draw upon a mixture of deontologism and consquentialism to arrive at a solution. For example, the medical team may frame their discussion with Mr X based on their preconceived notion that their duty, in the best interests of the patient, is to encourage him to attend therapy. To the extent that the medical team views their duty of beneficence as more important than their obligation to honor patient autonomy and the right to refuse treatment, the medical team can justify acting paternalistically toward this patient. The rationale for this approach is that this patient has not had sufficient time to adjust to his disability and is unable to make a proper value judgment about his choices. In any event, the medical team may be making assumptions about what ethical concerns are important for this patient, when, in fact, the medical team, the patient, and the patient's family have not had opportunities to explore the meaning of their circumstances. Let us now propose a different way of reflecting or deconstructing about this case. Based on the shift to a phenomenological attitude, the health care team prepares to see the world differently. That is, the rehabilitation team members must be willing to explore the experiences and their meanings from the perspective of the patient.37 To do this, the health care team must first address their own biases or preconceived ideas about what is occurring and what course of action is most appropriate, based on their obligations. A process of bracketing or a filtering process occurs.31 In this process, originally identified by Husserl30 as phenomenological epoche, the health care team members should discuss their beliefs and assumptions about this case and try to hold them in abeyance in order to be open to phenomena of the lived experiences of this particular patient as he recounts and explores those experiences. In effect, the process of bracketing requires that we set aside our own personal values and beliefs to focus on the values and beliefs of another individual. This process requires a commitment of ongoing self-reflection about our own personal and professional values. Part of this self-reflection can take the form of an internal dialogue with oneself or, as mentioned, an external dialogue with colleagues about each other's values and beliefs pertaining to patient care and practice. Either circumstance, we believe, is critical to phenomenological understanding of another individual. In phenomenological ethics, we must be open and willing to set aside time to engage in dialogue with ourselves and then with our patients in an ethics of reflection and listening. This course involves respect, a certain humility, sensitivity, and flexibility. Simply put, we must be able and willing to step out of our professional role. Stepping out of our professional role requires some explanation toward our understanding of the clinical encounter based on phenomenology. Physical therapists, like most health care professionals, are trained to develop clinical judgments based on a medical framework of patient diagnosis (whether that is a medical or impairment-based diagnosis) that is expressed in the patient's own everyday language. Zaner29 suggested that most physicians mistakenly listen to a patient to identify a locational index that frames the patient's story within his or her medical framework. Misunderstanding results when the patient's interpretation of experiences is displaced by the health care professional's interpretation. Rather, phenomenological discourse offers an authentic understanding of the patient's existential predicament of his or her disability that is grounded in his or her own life experience, shaped through his or her own voice, tempered by his or her own emotions and feelings, and embedded in his or her own values. Stepping out of one's professional role, then, depends upon the willingness of the clinician to hold in abeyance his or her own biases about a patient and be willing to listen to the patient's whole story in his or her own voice to allow his or her own life-world to reveal itself. Finally, Zaner29 reminded us that ethical issues often are deeply buried and rarely recognized as such within the experiences of patients. It often is the case that we can best uncover these ethical issues by not directly talking about them. That is, indirect discourse, and allowing the patient to talk about whatever is important to himself or herself—regardless of however seemingly trivial you may think it is—may be the best way to go about understanding things human, especially in the matter of ethics. In the case of Mr X, what would fit the idea of indirect discourse is not to directly talk about the ethical issues involved, or rather talk about them by never talking about them. The therapist would just give him a chance to talk, to come to what was bothering him in his way, in his own voice, and at his own pace. Phenomenological ethics reminds us about the potential of our relationship with our patients as human beings. Daly wrote: Morally speaking, the caregiver is neither superior nor better nor even necessarily at an advantage. As a matter of fact, the caregiver not only must understand himself or herself as equal to the care receiver, but…the act of caregiving ought to be as perfective and changing of the caregiver.38(p34) In this case, the caregiver should take some time to reflect on his or her assumptions and beliefs about this case and the patient's motives, the issues involved, and possible methods of resolution. The caregiver may ask himself or herself: What is it I believe about this patient's experiences with spinal cord injury and paraplegia that is motivating his behaviors? What do I believe are the experiences of patients with paraplegia and with disabilities in general? What do I believe are the experiences of a patient with spinal cord injury and paraplegia undergoing rehabilitation? What is it that I believe is the proper course of action in this case? In the case of Mr X, a once proud and independent man, a phenomenological exploration of these questions might have revealed his terror about the loss of control of his life, his uncertainty of whether a future without independence held any meaning, and his belief in the limits of a medical cure to reverse his condition. Further exploration might reveal what Gadow8 termed the “disrupted immediacy” of his body from his self. Many patients with spinal cord injuries face the existential angst of the incapability of the self to control the body, the sense of a changed spatial reality that confinement to a wheelchair presents (eg, “I must look up to everyone like a child”), and the vulnerability of relying on others for basic human needs. In such a case, the primacy of autonomy often is trumped by fear of humiliation and the need for reaffirmation of respect. In the next step, the health care team and caregiver make a conscious effort to uncover the experiences of the patient in his own words and with little prompting. The initial goal is to develop “thick description” of the patient's experiences. As much as possible in an initial interview, the caregiver wants to determine the way things present themselves to Mr X and through his own experiences. To do this, the caregiver should begin with very broad and open-ended questions (eg, “Mr X, describe your lived experiences of your spinal cord injury?” “What is it like to live in a wheelchair?” “Describe your daily experiences in rehabilitation?”). This manner of dialogue places greater value on embedding understanding in concrete experiences over asking more general, abstract questions that lend themselves little to uncovering the subjective understanding of Mr X's illness experiences. The process should be iterative. The caregiver should explore ideas and examples in as much concrete detail as possible. The importance of language becomes paramount. The caregiver should listen for particular uses of metaphors to describe experiences that may represent complex thought processes that reflect the patient's understanding of embodied concepts and his or her reality of daily life.39 Changes in the use of language and metaphor over time can help the caregiver determine changes in a person's recovery experiences and self-identity. As the narrative emerges, the caregiver should probe emerging ideas for clarification. The goal at this point is to identify dimensions and aspects of indented experiences. For example, the caregiver may question Mr X about how he views his current experiences in rehabilitation in view of his past life and future expectations. The final stage of phenomenological understanding involves developing some thematic understanding of the patient's experiences. The caregiver should ask himself or herself: What are the main ideas Mr X is expressing? How do these ideas reflect his lived experiences? In this stage, it is important for the caregiver and the patient to continue to move back and forth between interpretation and his lived experiences and their meanings. Further questions to clarify include: What are the philosophical assumptions about self that are emerging from Mr X's stories? and How do these assumptions of self as “changing from what was” reflect my own perceptions of caring for this patient? Finally, how do the caregiver's philosophical assumptions of self stand behind most of the central ethical principles we use to direct ends and procedures of health care? In summary, a phenomenological approach may result in a deeper understanding of Mr X's and Skip's world, which, in turn, could facilitate the development of a mutual plan of action that is embedded in the values and goals of the patient and his son. In contrast to the principlist approach based on deduction, the phenomenological approach provides an alternative approach that is inductive, contextually based, and involves an iterative process of decision making. Most importantly, the tools of a phenomenological approach are particularly sensitive to uncovering the transformative nature of disability. Implications The importance of phenomenology to a human caring profession such as physical therapy underscores the importance of the connection between caring and exploring the lived experiences of patients with disabilities. To care for patients with disabilities, for example, the physical therapist combines cognitive decision-making processes to correctly identify and prioritize relevant impairments and functional losses to be treated. Treatment interventions, in turn, are influenced by clinical judgments, experience, values, and the best current evidence. In addition, many authors have pointed out that the nature of the moral relationship that is built between the therapist and patient40,41 fosters the emotional climate of trust and respect that has a direct impact on patient care and outcomes.42–44 Research that has explored the nature of caring demonstrates that experienced and expert physical therapists have embraced a broadly construed vision of caring.45,46 For many physical therapists, an ethic of caring defines their approach to patient care. This type of ethical commitment to caring values the human experience associated with the patient's suffering. An ethics of caring opens up the possibility of making an empathetic connection with patients in order to make ethical decisions that reflect the totality of their emotional and physical needs. Empathy, in turn, disposes individuals to ongoing communication with patients and reflection about their changing conditions and needs. Rogers47 described empathy as being sensitive to the changing felt meanings of another person. Davis48 described a phenomenological empathy that involves a unique moment of shared meaning between 2 people that is based on a deep, committed form of listening. Peloquin44 described empathy as an expression of connecting deeply with another person by entering into his or her own experiences. Both empathy and caring, like phenomenology, acknowledge the importance of being other directed, accepting feelings as part of practice, acknowledging the different contextual factors that influence illness experiences, and being willing to take time to listen deeply and openly to the meaning of others. What we believe sets phenomenology apart from caring and empathy is it's recognition that phenomena occur everywhere within a person's experience. As a result, from a phenomenological approach, we are careful not to assume that any experience as we care for our patients is too trivial. An ethics of caring reminds us of the importance of context in caring. The tools of phenomenology provide an iterative process of embedding meaning in an individual's unique experiences. An ethics of caring provides the moral impulse to connect with our patients as fellow human beings in need. The tools of phenomenology, as described below, allow us methods to do so as one person caring for another person. In physical therapy, we acknowledge that there are aspects of our work as physical therapists where understanding the patient's experience, the belief and value system of the patient, or the context of the care delivery is important in patient care, but as a profession, we remain too comfortable with and committed to analytical reasoning and knowledge creation through that analytical process. We are not alone in this struggle. Sullivan49(p250) argued that this strong emphasis in professional education on formal analytic reasoning leaves out one of the most essential elements of expertise: the act of inquiry in the context of the relationship in practice (reflection). What should we do in our educational programs and clinic practices to integrate core elements of a phenomenological approach as part of practice? In this article, we focus on the role of phenomenological framework for ethical reflection. Exploration of the lived experience of the patient is a core component, but it is more than asking the right questions and listening to the patient's responses. Although procedures and skills are important, interpretative phenomenology is guided by an ethic of understanding and responsiveness to the needs and goals of patients. In this way, phenomenology has similarities to an ethics that is based on caring. The connection to an ethics of caring is particularly important for best practice based on previous research that has examined the characteristics of experienced and expert physicians,50 nurses,51 and physical therapists.46 These studies have universally demonstrated the importance of contextual understanding of patients' experiences with illness in ethical and clinical decision making. This discussion leads us to the question of the impact phenomenology has on clinical reasoning. Edwards and colleagues52–54 described 2 clinical reasoning strategies in physical therapy. One strategy is diagnostic reasoning, which is the formation of a diagnosis related to a patient's physical disability or functional limitation and associated impairments. This hypothetic-deductive process of diagnostic reasoning has a strong presence in physical therapy. The second strategy is narrative reasoning, which maps out the landscape between the patient's actions and motivations. Narrative reasoning involves understanding the patient's story—his or her illness experience and its context and his or her beliefs and values. This strategy involves an interpretive paradigm, similar to phenomenology, focusing on context-dependent and subjectively constructed knowledge (about phenomena). Like a phenomenological approach, this reasoning strategy is consistent with the therapist's ability to listen to the patient and to fully understand the patient's lived experience. Embedded in narrative reasoning are aspects of caring and empathy, as the therapist must be open to a committed form of listening and acknowledging and accepting feelings (patient's and therapist's) as part of practice. It is the making of a history through patients telling their story that represents their interpretation of their experiences and events over time. The tools of phenomenology offer strategies for developing students' narrative reasoning skills. As previously indicated, we believe that these skills have to begin with a focus on self (one's own phenomenological attitude). This belief follows the logic that one cannot fully connect with patients and engage in a process of reflection without the ability to engage in critical self-reflection.55,56 Phenomenological bracketing (Tab. 1), as a way of filtering one's own perspective and prior experiences to control bias, provides a tool for educators to use with students to facilitate self-awareness critical to reflective practice and understanding of the patient's perspectives. Reflective inquiry is an important meta-cognitive skill that needs nurturing and development in professional education. The phenomenological practice of soliciting “thick descriptions” of experiences, both one's own and of others, is an important tool to embed reflective practice in concrete experiences. Students are taught that meaning is embedded in experiences and that to fully understand meaning is to uncover experiences. This process facilitates habits of reflective practice that pay great dividends for the future development of reflective skills.57 These processes of self-reflection can be facilitated by reflecting together between a student and clinical instructor at the moment of a clinical encounter or small-group discussion. Part of this reflection includes the identification and understanding of emotions as steps in strengthening novices' capacity to hold on to and name their own emotional experiences and having students uncover the emotions they are feeling rather than telling them what they should feel or should have felt when interacting with patients or others (eg, empathy, compassion). Simulations or standardized patients provide learning opportunities for novices to interact with simulated patients or real patients in a clinical situation, experience emotions in a safe environment and then reflect on their experiences in their own words.58,59 Reflection on emotions emphasizes the relationship between a student's behaviors or words that begin or trigger an emotional response. By openly acknowledging that different emotions are evoked in different circumstances, novices have an opportunity to reflect on their emotional repertoire in a way that is encouraging and safe. Although some people may argue that emotions are a somewhat fragile platform upon which to build heavy obligations such as moral duty or care, it is by attending to emotions we can see that they highlight certain aspects of a situation. The reflection on this experience can serve as a mode of communication, lead to deeper self-knowledge, and provide insight into motivation.59 Grounding and naming emotions in specific examples from novices' and experts' experiences in clinical practice begins to create a framework that legitimizes this component of the self in one's professional role. Novices then can examine, question, and develop their skills in emotional sensitivity—an important part of ethical comportment and caring for others.59 Another educational strategy related to phenomenological approaches also acknowledges the importance of language and metaphoric descriptions of illness and disability. Phenomenology opens up the possibility of exploring metaphors with students as they begin to engage in patient interaction. Students can be taught to identify patterns of metaphors that patients use to impart meaning to their experiences. Students and professors can review previously described studies that explore the metaphoric understanding of disability from the perspectives of patients with strokes or spinal cord injuries. The tools of phenomenology also provide a link between ethical and clinical reasoning that is embedded in everyday practice. Clinical education is instrumental in training professional health care workers to foster the practical application of knowledge, including practical reasoning. Benner and colleagues34 used observations and narrative accounts of actual clinical examples as primary tools for understanding everyday clinical and caring knowledge and practical reasoning that occur in nursing practice. Finally, Benner and colleagues argued that it is not possible to separate clinical and ethical reasoning, because good clinical judgments reflect good clinical practice. Although biomedical ethical principles and procedures such as ensuring the autonomy of the patient, informed consent, justice, beneficence, and nonmaleficence are important, they must be translated into good practice. Expert practitioners are motivated to do excellent work along with their moral obligation to help other human beings. According to Benner et al: Learning to make good clinical judgments and be a good practitioner requires ongoing experiential learning, reflection, and dialogue with patients and their families…. Nursing, like teaching, medicine and social work, and other helping professions, depends on solidarity with one's fellow human beings and on professional standards of beneficence and nonmaleficence for helping people during periods of vulnerability and distress—this is what it means to be “good” at one's work.34(p17) Just as we have advocated that the tools of phenomenology have great relevance in education, they also have significant implications for research in physical therapy. Although expert clinicians may have great insight and skill in understanding the lived experience of their patients, little of that “narrative understanding” has been uncovered and codified in our literature. Much of that rich clinical knowledge remains tacit. In daily practice, skilled therapists engage in a situation, take action, and through reflection in action, continue to build their tacit knowledge.59 There is great need for applying a phenomenological approach and crafting questions that would uncover the “narrative understandings” that emerge from the exchange and collaboration between patient and therapist. Imagine what we may find out about the work of physical therapists if we developed clinical case knowledge that is based on understanding the patient's voice? How could we better hear that voice? Although the analysis of clinical cases is an essential structure and tool in ethics, there are many ethical considerations that are woven into the context of practice that remain implicit. It is only by expanding our set of research tools beyond the “traditional hammer” that we will be able to uncover this important practical knowledge. Conclusion Physical therapists are health care professionals who have a central role in rehabilitation and working with people with disabilities. As such, physical therapists need skills that will help them develop a rich understanding of the physical, cognitive, emotional, and moral changes and challenges that arise with individuals who have disabilities. We are not well served by a rational, principlist approach to ethical issues that excludes the possibility of contextual understanding from the perspectives of our patients. At the very least, a starting point to apply principles to navigate ethical decisions should be the story of the individual. Phenomenology uncovers the patient's values and goals embedded in that story as they pertain to his or her direct experiences. Through these stories, we are reminded that disability is not an illness that is cured by medical intervention or rehabilitation, but it is the social and context issues that are paramount. Through our patients' stories, we also are made aware of the transformative nature of disabling conditions that challenges us to be sensitive to the changing web of values accompanying the changing physical conditions of our patients. We believe that the physical therapy profession would benefit by increased exposure to and dialogue about the role of phenomenological inquiry and interpretation in the everyday life and concerns of people with disabilities. Phenomenology opens up the possibility to capture the transformative nature of disability better than other approaches. As a result, phenomenology opens up unique possibilities for student education and research that reflect a patient-centered approach to, and an ethics of, caring. References 1 Purtilo RB . Thirty-first Mary McMillan Lecture. A time to harvest, a time to sow: ethics for a shifting landscape . Phys Ther . 2000 ; 80 : 1112 – 1119 . Google Scholar Crossref Search ADS PubMed WorldCat 2 Kuczewski MG Fiedler I . 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Swisher, Laura, Lee

doi: 10.2522/ptj.20090348.icpmid: 20675296

It is a privilege to provide commentary on the article by Greenfield and Jensen.1 There has been extensive debate within medicine about the dominance and adequacy of principlism,2–9 but there is limited discussion of its strengths and weaknesses in the physical therapy literature. Indeed, one could argue that animated discussion about appropriate ethical decision-making models and their philosophical underpinnings is long overdue within physical therapy. The authors undoubtedly have initiated an important dialogue regarding ethical decision making within physical therapy. In this commentary, I will address specific issues raised by the article within the context of the following broader concerns in physical therapy ethics raised by this important contribution by Greenfield and Jensen: the importance of expanding scholarship in physical therapy ethics, the moral import of disability, evaluating the value of the dominant Western principlist model of ethics for physical therapy, and hearing the patient's voice through dialogue and partnership. Expanding Scholarship in Physical Therapy Ethics Greenfield and Jensen point to the need not only for additional scholarship in physical therapy ethics, but also for a different focus for this scholarship. Pellegrino defined ethics as “a branch of philosophy; it is not a set of visceral sensations arising somewhere in the solar plexus and suffusing the frontal lobes with ‘good' or ‘bad' feelings. Ethics is a formal, rational, systematic examination of the rightness and wrongness of human actions.”10(p65) Although the majority of the physical therapy ethics literature has focused on applying ethical principles to specific cases or problems, Greenfield and Jensen invite us to broaden the worldview of physical therapy ethics and address the adequacy of philosophical frameworks that undergird our ethical decisions. By focusing on the possible contributions of the philosophical perspective of phenomenology, the authors indicate that philosophical debate is an appropriate and necessary topic for physical therapy ethics scholarship. For example, their argument might suggest that the very definition of ethics provided by Pellegrino, with its rigid segregation of feeling or emotion from the determination of right versus wrong, may not be adequate. In effect, they suggest that philosophy should have a role in physical therapy, just as anatomy, physiology, biomechanics, and other fields inform the theory and practice of physical therapy. The Moral Import of Disability and Rehabilitation The authors also point the way toward a type of ethics scholarship that currently is under-represented in the physical therapy literature: phenomenological analysis of the lived experiences of patients and clients. Greenfield and Jensen note that people with disabilities undergo a transformation of their bodies, self-concept, life experience, and social systems. These transformations of the socially situated self11,12 have moral import; listening and perspective-taking, therefore, are essential to being a reflective, ethical, caring physical therapist. Research into the nature of these perspectives and of the rehabilitation setting would be helpful in grounding ethical decisions. For example, Martone's13 description of her own experience with her daughter's traumatic brain injury provides a powerful example of the kind of rich experiential narrative to which Greenfield and Jensen refer. As a medical ethicist, Martone was dissatisfied with the rehabilitation process because she felt that the family was not included in decision making. She provided a number of suggestions for rehabilitation professionals, including a call for the kind of listening and dialogue described by Greenfield and Jensen. Listening to families and involving them in the decisionmaking throughout the rehabilitation process not only honors their dignity and helps them better prepare for the long recovery road that lies ahead of them, it also does much for the medical profession…. Joint, cooperative decisionmaking leads to bonds of trust between the professionals and families. Without these bonds, health care personnel are no longer professionals but only employees of an impersonal health care system.13(p41) It is interesting to note that Martone's comments are consistent with Delany's qualitative grounded theory study of informed consent among physical therapists in Australia.14 Delany found that, among physical therapists, informed consent was “interpreted as providing explanations rather than offering choices.”14(p175) Does Principlism Have Value for Physical Therapy? Greenfield and Jensen link their proposal for an ethics based in phenomenology to a critique of principlism. (Principlism also is referred to as the “four principles approach” to ethical analysis because Beauchamp and Childress identified 4 major categories or “clusters” of prima facie principles: autonomy, beneficence, nonmaleficence, and justice.2(p13)). Greenfield and Jensen argue that, even though it is the dominant paradigm in physical therapy ethics, principlism is too rationalistic, detached, and abstract to be useful in clarifying the experience of patients: “We are not well served by a rational, principlist approach to ethical issues that excludes the possibility of contextual understanding from the perspectives of our patients.” The critique of principlism offered by Greenfield and Jensen poses the question as to whether the use of principles is an adequate basis for ethical decision making in physical therapy, and, if it is not, what alternative approaches might be considered. Although the use of ethical principles was widespread during the early years of medical ethics (1970s),4(p181) it is most associated with the work of Beauchamp and Childress due to the longevity and success of Principles of Biomedical Ethics.2 Beauchamp and Childress stated that the 4 “clusters” of principles were derived from “common morality” and selected based on their historic role or current relevance to biomedical ethics.2(pp12–13) Beginning in the mid-1980s, the use of principles was criticized from a number of perspectives.4(p182) From a philosophical perspective, Clouser and Gert3 were critical of what they called “principlism” because they believed that the principles lacked a true underlying moral theory (such as deontology or utilitarianism), were not systematically related to each other, failed to provide guidance for ethical action, and frequently conflicted with each other. Consistent with criticisms of the dominant Western philosophical tradition, others found the use of principles individualistic, unidimensional, abstract, deductivist, and overly rational. Principlism was criticized by proponents of virtue ethics, feminist ethics, casuistry, the ethics of care, and narrative ethics. As Greenfield and Jensen describe, another common theme is that principlism is inattentive to specific context or individual experience: “The evolution of medical ethics toward case-based decision making, casuistry, narrative, ethics of care, and phenomenology underscores the recognition from many medical ethicists of the limitation of a pure principle-based approach, and the importance of the context and story to shape the ethical concerns and application of principles.” In response to these concerns, Beauchamp and Childress have constantly refined their arguments. In addition, Beauchamp4 observed that principlism is not incompatible with casuistry, narrative ethics, or virtue ethics. Likewise, Campbell argued that principles and virtues complement each other: Despite tendencies to compete for a prime place in moral theory, neither virtue ethics nor the four principles approach should claim to be superior to, or logically prior to, the other. Together they provide a more adequate account of the moral life than either can offer on its own. The virtues of principlism are clarity, simplicity and (to some extent) universality.… But the vices of this approach are the converse of its virtues: neglect of emotional and personal factors, oversimplification of the issues, and excessive claims to universality. Virtue ethics offers a complementary approach, providing insights into moral character, offering a blend of reason and emotion, and paying attention to the context of decisions. The cases provided can be more adequately understood if we combine the approaches.5(p292) Although Greenfield and Jensen suggest that an ethics of care is most compatible with phenomenological ethics, it is not clear whether they would agree with Beauchamp,4 Campbell,5 and McCarthy15 that principlism is complementary to or compatible with casuistry, narrative, and virtue ethics. Given the numerous concerns about the limitations of principlism in medicine and nursing, it is surprising that there has been relatively little critical examination of this model within physical therapy. In describing the early development of the Code of Ethics, Linker16 observed that, unlike many other female-dominated professions that endorsed an ethic of care, the early physical therapists in the United States self-consciously turned away from an ethic of care in the interest of professional self-preservation. In light of the fact that the 4 principles were derived from the historic and contextual concerns of medicine, it is especially important for scholarship to evaluate the strengths and weaknesses of the principlist model for responding to ethical issues encountered in physical therapy. McCarthy17 addressed this situation within nursing, arguing for a pluralist approach. In her view, simply adopting the medical principlist framework does not address the unique nature of the nursing profession, and developing a unique nursing framework proves inadequate to the diverse ethical issues in nursing. To what extent is the framework developed by Beauchamp and Childress appropriate for physical therapy? In a similar vein, the strengths and weaknesses of other models (including phenomenology and ethic of care) should be evaluated. Hearing the Patient's Voice Through Dialogue and Partnership Whether one views the principlist paradigm as totally inadequate or complementary to other models, there can be no doubt that hearing the patient's voice, creating a true dialogue, and developing a partnership with the patient are fundamental to physical therapy. Although Greenfield and Jensen provide valuable strategies for engaging in dialogue with many patients, these strategies may not be appropriate or effective with patients who present unique challenges to communication, such as patients with traumatic brain injury or dementia.18 Regardless of the challenges, as Zaner11(p104) notes, the clinician must resist the temptation to displace the patient's experience with the clinician's “objective” experience. This requires physical therapist practitioners to free themselves from the “natural attitude,” that is, “the clinical mind-set” whereby patients within the life world are reduced to a “total hip that is difficult and needs to be treated by 11:30.” By bringing forward the issues of the philosophical underpinnings for ethical frameworks, the moral implications of disability, and the limitations of the dominant principlist ethics model, Greenfield and Jensen encourage us individually and collectively to broaden our ethics worldview. I commend the authors for initiating this dialogue within physical therapy. References 1 Greenfield BH Jensen GM . Understanding the lived experiences of patients: application of a phenomenological approach to ethics . Phys Ther . 2010 ; 90 : 1185 – 1197 . Google Scholar Crossref Search ADS PubMed WorldCat 2 Beauchamp TL Childress JF . Principles of Biomedical Ethics . 6th ed. New York, NY : Oxford University Press ; 2009 . 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Casuistry and principlism: the convergence of method in biomedical ethics . Theor Med Bioeth . 1998 ; 19 : 509 – 524 . Google Scholar Crossref Search ADS PubMed WorldCat 10 Pellegrino ED . Toward a reconstruction of medical morality . American Journal of Bioethics . 2006 ; 6 : 65 – 71 . Google Scholar Crossref Search ADS PubMed WorldCat 11 Zaner RM . Ethics and the Clinical Encounter . Englewood Cliffs, NJ : Prentice Hall ; 1988 . Google Scholar Google Preview OpenURL Placeholder Text WorldCat COPAC 12 Jaeger SM . Ethical reasoning and the embodied, socially situated subject . Theor Med Bioeth . 2005 ; 26 : 55 – 72 . Google Scholar Crossref Search ADS PubMed WorldCat 13 Martone M . Decisionmaking issues in the rehabilitation process . Hastings Cent Rep . 2001 ; 31 : 36 – 41 . Google Scholar Crossref Search ADS PubMed WorldCat 14 Delany CM . In private practice, informed consent is interpreted as providing explanations rather than offering choices: a qualitative study . Aust J Physiother . 2007 ; 53 : 171 – 177 Google Scholar Crossref Search ADS PubMed WorldCat 15 McCarthy J . Principlism or narrative ethics: must we choose between them? Med Humanit . 2003 ; 29 : 65 – 71 . Google Scholar Crossref Search ADS PubMed WorldCat 16 Linker B . The business of ethics: gender, medicine, and the professional codification of the American Physiotherapy Association, 1918–1935 . J Hist Med Allied Sci . 2005 ; 60 : 320 – 354 . Google Scholar Crossref Search ADS PubMed WorldCat 17 McCarthy J . A pluralist view of nursing ethics . Nurs Philos . 2006 ; 7 : 157 – 164 . Google Scholar Crossref Search ADS PubMed WorldCat 18 Jennings B . Traumatic brain injury and the goals of care: the ordeal of reminding . Hastings Cent Rep . 2006 ; 36 : 29 – 37 . Google Scholar Crossref Search ADS PubMed WorldCat © 2010 American Physical Therapy Association