Low Back Pain Management: An Evidence-Based, Comprehensive Approach by Rose Clinic performance Physiotherapy

Author: Navid Zadeh, Senior Physiotherapist, MSc, BSc, MHCPC, MCSP, Physio First UK info@roseclinicphysio.co.uk

Introduction

Low back pain (LBP) is one of the most prevalent musculoskeletal conditions globally, affecting individuals across all age groups, occupations, and lifestyles. It is a leading cause of disability and reduced quality of life, with a significant impact on both individual well-being and public health systems. The condition can range from acute episodes to chronic, persistent pain, often resulting in decreased mobility, psychological distress, and long-term functional limitations.

Low back pain represents not only a major clinical challenge but also a substantial economic burden due to healthcare costs, lost productivity, and work absenteeism. Despite its widespread occurrence, effective management of LBP remains complex and multifaceted, requiring a comprehensive, evidence-based approach that integrates clinical expertise, patient-centred care, and the latest research in diagnosis, treatment, and prevention strategies.

At Rose Clinic Performance Physiotherapy, we are dedicated to providing structured, evidence-based care that comprehensively addresses low back pain through physical, psychological, social, and occupational perspectives.

This article aims to present Rose Clinic’s management strategy for low back pain, discuss the contributing factors, and outline our physiotherapy protocols for its prevention and evidence-based treatment.

Understanding the Complexity of Low Back Pain

Low back pain is a multifaceted condition influenced by a combination of physical, psychological, and social factors. It can result from issues such as muscle strain, disc problems, poor posture, or even stress and emotional well-being. Because its causes and symptoms vary widely between individuals, effective management requires a personalised, holistic approach that addresses both the physical and underlying contributing factors. Recognising this complexity is key to achieving long-term relief and improved function.

Low back pain can arise from a variety of causes, including:

• Discopathies and disc degeneration
• Radicular pain and nerve root involvement
• Sacroiliac joint dysfunction
• Muscle spasms and strains
• Ligament and tendon inflammation around the pelvis and hip
• Spinal stenosis
• Postural abnormalities and biomechanical dysfunction
• Inflammatory conditions
• Stress and psychological distress

Often, the cause is not singular but a combination of physical dysfunction, lifestyle habits, and emotional or behavioural factors. Unfortunately, LBP is sometimes mislabelled with vague terms like “lumbago” without a proper diagnostic process, leading to ineffective treatment.

Therefore, an accurate physiotherapy diagnosis is the foundation for successful rehabilitation. According to NICE guidelines (2020), effective management depends first on identifying the root cause, not merely treating the symptoms.

Initial Assessment and Diagnosis

The first and most vital step in managing low back pain is a thorough assessment and clinical examination during the initial consultation. This session is not only about diagnosing the issue but also about understanding the person behind the pain. A skilled physiotherapist evaluates:

• Physical findings: posture, mobility, strength, asymmetries
• Psychosocial factors: personality, lifestyle, work demands, stress
• Functional limitations: daily activities, sports participation, household responsibilities
• Emotional and cognitive aspects: fear of movement (kinesiophobia), pain behaviours, beliefs

In addition, our physiotherapists evaluate postural and biomechanical factors that may be contributing to the condition. This includes a thorough assessment of:

• Postural deviations
• Leg length discrepancies
• Foot arch structure
• Pelvic alignment
• Gait patterns

These components are essential, as they can significantly influence lumbar mechanics and contribute to LBP. Each element is assessed using personalised observation and clinical reasoning.

At this stage, the integration of the biopsychosocial model and a mind-body approach becomes essential to address the complex interplay between physical, psychological, and social factors in LBP. Research shows that fear, stress, and even loneliness can influence the perception and persistence of pain (Kamper et al., 2015).

Developing a Personalised Treatment Plan

Once the assessment is complete, the next step is to design a tailored physiotherapy treatment plan. This is never a copy-paste programme. Each treatment plan considers:

• Clinical findings
• Patient goals (returning to sport, work, or daily life)
• Psychosocial context
• Outcome measures (e.g., VAS and PSFS)

This physiotherapy treatment plan is explained in detail to ensure clarity, collaboration, and patient engagement.

Though treatment techniques vary depending on the root cause and the individual, key goals remain consistent:

• Reduce pain and inflammation
• Improve spinal and joint mobility
• Restore functional movement
• Prevent recurrence
• Support the patient’s mental and physical rehabilitation

Addressing Fear of Movement and Psychological Barriers

One of the most underestimated factors in LBP management is kinesiophobia, the fear of movement. Prolonged pain often leads patients to instinctively avoid movement, which can result in:

• Muscle atrophy
• Joint stiffness
• Increased disability
• Delayed recovery

This is where cognitive-behavioural techniques and the mind-body approach become crucial. Physiotherapists must not only reassure and educate but also progressively reintroduce movement in a safe, structured manner. Success comes from guiding patients through achievable, confidence-building steps, not just words of encouragement.

Manual Therapy and Early Interventions

For patients experiencing severe pain and limited mobility, immediate exercise therapy alone may not be feasible or effective. Therefore, applying manual therapy combined with some specific exercises would be most beneficial for the patient’s outcome. Early intervention must focus on pain reduction and restoring basic function, particularly in those who have been inactive for extended periods. Thus, manual therapy in the first phase of low back pain recovery, is vital.

At Rose Clinic Performance Physiotherapy, we prioritise Hands-On techniques/ Manual therapy alongside exercise in the early stages, including:

• Joint mobilisation and distraction
• Myofascial release
• Muscle energy techniques
• Trigger point therapy
• Spinal decompression
• Soft tissue mobilisation and stretching

These manual techniques reduce protective muscle tension and stiffness and prepare the body for active rehabilitation. Each intervention is carefully selected based on diagnosis, clinical presentation, and patient tolerance.

This approach aligns with NICE and international guidelines, which support manual therapy as part of a multimodal strategy, especially when combined with exercise and education.

Exercise Therapy and Clinical Reasoning

Once pain is controlled and mobility improved, attention shifts to exercise therapy. There is no one-size-fits-all protocol. The physiotherapist must:

• Prescribe the right exercises
• Apply appropriate load and intensity
• Adjust based on non-verbal cues and real-time performance
• Modify techniques using clinical reasoning
Clinical reasoning is the physiotherapist’s ability to alter their approach in real-time using knowledge, experience, and patient feedback for the best outcomes. Examples include:
• Reducing a 20-second plank to 15 seconds if the patient shows signs of strain
• Providing hands-On feedback for better muscle activation
• Modifying load based on tissue readiness

This real-time adaptability is a hallmark of expert physiotherapy and a critical component of successful outcomes.

Sport and Functional Rehabilitation: Return-to-Sport Considerations

As patients progress, we implement graded loading to restore strength, endurance, and neuromuscular control. Research (Searle et al., 2015) supports progressive loading and functional exercises as essential components in managing most types of LBP. These must be tailored to:

• The patient’s sport (e.g., weightlifting, running)
• Daily functional demands
• Previous injuries
• Current performance goals

We also examine posture, gait, foot biomechanics, and asymmetries (e.g., leg length discrepancy, flat feet), which influence spinal mechanics. Many LBP patients are active in sports such as running, martial arts, or team athletics. Each sport imposes different demands. Some continue activity despite pain, while others withdraw entirely. A nuanced approach is essential to manage these variations effectively.

Work and Lifestyle Factors

Work-related demands, sedentary or physically intensive, have a direct impact on spinal health. Important considerations include:

• Workplace posture
• Duration of sitting or lifting
• Daily movement patterns
• Ergonomic education and adjustments

Additionally, household activities such as cleaning, carrying groceries, or childcare are often overlooked but may be significant contributors to pain. Physiotherapists must account for the patient’s home environment, support system, and functional requirements to build a sustainable plan. Pain lives in context, and recovery depends not only on what happens in the clinic but also in everyday life.

Tracking Progress and Outcome Measurement

Progress must be consistently tracked using validated outcome measures, such as:

• VAS (Visual Analogue Scale) for pain
• PSFS (Patient-Specific Functional Scale) for function
• Disability questionnaires and physical performance tests

These tools offer objective feedback, helping patients stay motivated and allowing therapists to adjust interventions as needed.

The Rose Clinic Approach: Evidence-Based Excellence

At Rose Clinic Performance Physiotherapy, we have developed a comprehensive, structured method that integrates clinical reasoning, manual therapy, targeted specific exercise, and psychosocial support. All our interventions and health management strategies, particularly in cases of low back pain consistently address five key components: mobility, flexibility, strength, stability, and stamina/endurance. In addition to targeted tissue repair and rehabilitation, we ensure that each of these factors is carefully assessed and optimally managed. This comprehensive approach helps to minimise the risk of recurrence and supports long-term functional recovery and resilience.

Our protocol includes:

• Detailed assessment and diagnosis
• Hands-On/ Manual therapy techniques
• Tailored, progressive exercise plans
• General fitness
• Sport- and work-specific modifications
• Cognitive and behavioural coaching
• Ongoing progress evaluation

Our outcomes are supported by data and consistently demonstrate faster recovery with fewer sessions. As Approved and Certified Quality-Assured Practitioners, we use an impact-based methodology backed by research and real-world clinical results.

Conclusion

Managing low back pain is challenging—but not impossible. With the right knowledge, structured planning, and patient-centred care, physiotherapists can deliver life-changing outcomes.

At Rose Clinic, we are committed to helping individuals move freely, live confidently, and return to the activities they love.

We don’t just treat pain, we help people return to who they are.

References

Maher, C., Underwood, M. & Buchbinder, R., 2017. Non-specific low back pain. The Lancet, 389(10070), pp.736–747. https://doi.org/10.1016/S0140-6736(16)30970-9

Qaseem, A., Wilt, T.J., McLean, R.M. & Forciea, M.A., 2017. Noninvasive treatments for acute, subacute, and chronic low back pain: A clinical practice guideline from the American College of Physicians. Annals of Internal Medicine, 166(7), pp.514–530. https://doi.org/10.7326/M16-2367

Sharma, S., Traeger, A.C., Reed, B. & Maher, C.G., 2020. Physiotherapist-delivered education and advice for patients with low back pain: a systematic review and meta-analysis. BMJ Open, 10(6), e032669. https://doi.org/10.1136/bmjopen-2019-032669

Searle, A., Spink, M., Ho, A. & Chuter, V., 2015. Exercise interventions for the treatment of chronic low back pain: a systematic review and meta-analysis of randomised controlled trials. Clinical Rehabilitation, 29(12), pp.1155–1167. https://doi.org/10.1177/0269215515570379 van Middelkoop, M., Rubinstein, S.M., Verhagen, A.P., Ostelo, R., Koes, B.W. & van Tulder, M.W., 2011. Exercise therapy for chronic nonspecific low-back pain. Best Practice & Research Clinical Rheumatology, 25(2), pp.193–204. https://doi.org/10.1016/j.berh.2010.01.002

Bronfort, G., Haas, M., Evans, R.L., Leininger, B. & Triano, J., 2010. Effectiveness of manual therapies: The UK evidence report. Chiropractic & Manual Therapies, 18(3). https://doi.org/10.1186/1746-1340-18-3

Hayward, L.M. & Noonan, A.C., 2004. Manual therapy: evidence-based approach to spine disorders. Physical Therapy, 84(10), pp.1029–1031. https://doi.org/10.1093/ptj/84.10.1029

National Institute for Health and Care Excellence (NICE), 2016. Low back pain and sciatica in over 16s: assessment and management (NG59). London: NICE. Available at: https://www.nice.org.uk/guidance/ng59

World Health Organization (WHO), 2015. World report on ageing and health. Geneva: World Health Organization. Available at: https://www.who.int/publications/i/item/9789241565042

Mobility: An Overlooked Key to Healthy Ageing

Evidence-Based Physiotherapy Strategies and Recommendations from Rose Clinic

Author: Navid Zadeh, Senior Physiotherapist, MSc, BSc, MHCPC, NCSP, Physio First UK
Email: info@roseclinicphysio.co.uk

Introduction

Mobility is fundamentally defined as an individual’s capacity to move independently and safely from one place to another. This encompasses a wide range of physical functions, including walking, transferring between surfaces (such as sitting to standing), maintaining balance, and coordinating complex movements. Mobility is a crucial determinant of functional independence and overall quality of life, especially for older adults. It is influenced by a combination of musculoskeletal, neurological, cardiovascular, and psychosocial factors that work together to facilitate smooth, coordinated movement.

The importance of mobility cannot be overstated, it enables individuals to perform everyday activities, engage meaningfully with their communities, and maintain both physical and emotional wellbeing. Unfortunately, mobility impairments are highly prevalent among the elderly population and often begin subtly, sometimes as early as the age of 50. These impairments may progress silently over the years until they significantly impact daily functioning, independence, and social participation.

This article aims to raise awareness of the critical importance of maintaining mobility throughout the ageing process, to explore common factors contributing to mobility loss, and to present effective, evidence-based physiotherapy strategies employed at Rose Clinic to prevent and manage mobility decline in older adults.

Understanding Mobility and Its Role in Healthy Ageing

Mobility encompasses more than just movement, it is the coordinated function of the joints, muscles, and neurological systems working harmoniously to perform complex patterns such as walking, standing, transferring, and turning. The World Health Organization (WHO) recognises mobility decline as one of the earliest and most significant markers of functional deterioration in ageing adults. This decline often precedes loss of independence, increased risk of falls, institutionalisation, and even mortality (WHO, 2015).

Maintaining mobility is not simply about moving more. Mobility is just one of five core elements of musculoskeletal health that must be maintained throughout the lifespan:

1. Mobility: Adequate joint range of motion in all planes is necessary for fundamental movements. For instance, sufficient ankle dorsiflexion is critical for safe and effective walking, while cervical spine rotation enables tasks such as looking over one’s shoulder while driving.

2. Flexibility: The ability of muscles to elongate appropriately around joints facilitates smooth movement. Muscle tightness, such as a tight trapezius muscle, can restrict lateral neck movements and reduce overall mobility.

3. Power: Muscle strength and the ability to generate force quickly are vital for functional tasks like rising from a chair, climbing stairs, or recovering balance. Age-related muscle loss, or sarcopenia, significantly impacts this aspect and is exacerbated by inactivity (Cruz-Jentoft et al., 2010).

4. Stability: Stability refers to the structural integrity provided by ligaments, tendons, and proprioceptive feedback mechanisms that keep joints stable during movement and prevent injury.

5. Endurance: Cardiopulmonary fitness supports sustained physical activity, preventing early fatigue that limits participation in activities such as walking to the shop or playing with grandchildren.

Together, these elements form the foundation of healthy movement and functional independence.

Common Causes of Mobility Loss in Older Adults

Mobility decline typically occurs gradually and can be easy to overlook in its early stages until it begins to significantly limit daily activities. Several common factors contribute to this decline:

• Joint degeneration: Degenerative conditions such as osteoarthritis are highly prevalent in weight-bearing joints including knees, hips, and the spine. These conditions can cause pain, swelling, stiffness, and restricted joint movement, which directly impair mobility (Hunter & Bierma-Zeinstra, 2019).

• Muscle contracture and inactivity: A sedentary lifestyle and lack of regular movement lead to muscle shortening and tightening, often resulting in contractures. For example, Achilles tendon contracture can severely limit ankle dorsiflexion, disrupting gait and balance, and increasing fall risk.

• Chronic medical conditions: Conditions such as diabetes, hypertension, and gastrointestinal disorders contribute to generalised fatigue, muscle weakness, and reduced physical activity levels, further compounding mobility limitations.

• Neuromuscular deficits: Although less common, neurological impairments, sometimes undiagnosed can negatively affect motor control, proprioception, and balance, all of which are crucial for safe, efficient movement.

Kinetic Chain Considerations and the Importance of Mobility

The human body functions as an integrated kinetic chain, meaning that movement or restriction in one joint or region inevitably affects other parts of the body. Understanding this interconnectedness is fundamental in assessing and managing mobility issues effectively.

At Rose Clinic, physiotherapists conduct comprehensive full-body assessments, not only focusing on the patient’s presenting complaint but also evaluating mobility restrictions throughout the kinetic chain. This is especially important in older adults, where compensatory patterns often develop silently.

For example, an elderly patient presenting with hip pain may also exhibit limited ankle dorsiflexion or restricted thoracic spine rotation. Although these impairments may not be the primary concern, they can significantly alter biomechanics, leading to compensatory stress and overloading other regions such as the lower back or opposite hip.

Thoracic rotation is particularly vital for efficient, pain-free movement. When thoracic mobility is reduced, especially during dynamic activities like walking, twisting, or running, the hips and lower back often compensate by increasing their motion or loading. Over time, this compensatory loading can cause overuse injuries, strain, and pain development.

Restricted thoracic mobility can also disrupt spinal alignment and pelvic positioning, leading to altered gait mechanics. This often results in uneven loading of the hip joints, increasing the risk of discomfort, fatigue, and musculoskeletal injury.

Moreover, the thoracic spine plays a crucial role in distributing mechanical forces during movement. When its mobility is compromised, excessive stress is redirected to the hips or lumbar spine, which may provoke or exacerbate pain, particularly in individuals with pre-existing musculoskeletal conditions or age-related decline.

Within Rose Clinic’s physiotherapy practice, assessing thoracic spine mobility is an essential component of managing not only hip and lumbar complaints but also lower limb dysfunction. Targeted interventions to restore thoracic mobility enhance movement efficiency and reduce compensatory strain on other joints, improving overall functional outcomes.

While restricted thoracic mobility may not always be the primary cause of hip pain, it is often a significant contributing factor. Addressing these mobility restrictions through comprehensive, evidence-based physiotherapy approaches is critical for effective treatment, injury prevention, and sustainable functional improvement.

Implications for General Health and Economic Perspectives

Restricted mobility in older adults often leads to compensatory movement patterns that increase stress on other joints and soft tissues. These maladaptive patterns can accelerate joint degeneration, leading to conditions like osteoarthritis. Individuals may experience pain, reduced range of motion, and diminished walking capacity, severely limiting their independence and overall quality of life.

Poor mobility and physical inactivity also exacerbate chronic health conditions such as diabetes, cardiovascular disease, and obesity, all of which increase the risk of complications, hospitalisation, and mortality. This decline in health status impacts not only individuals but also places substantial strain on healthcare systems and government resources, due to increased demand for acute medical care, rehabilitation, and long-term support services.

Early identification and effective management of mobility limitations are therefore essential. Maintaining musculoskeletal health and mobility not only improves individual wellbeing but also reduces healthcare costs and lessens the burden on public resources, contributing to a more sustainable health economy.

Rose Clinic’s Approach to Managing Mobility

At Rose Clinic Performance Physiotherapy, we believe that early assessment and timely intervention are critical for preventing and reversing limited mobility. Our approach includes:

• Comprehensive biomechanical assessments: We evaluate joint range of motion, muscle tone, strength, balance, and functional capacity to identify specific deficits and areas requiring intervention.

• Tailored exercise prescriptions: Based on assessment findings, patients receive customised mobilising and stretching programmes to improve mobility and flexibility (e.g., calf stretches targeting ankle dorsiflexion), resistance training to enhance muscle power, and functional mobility exercises aimed at coordination and balance improvements (Sherrington et al., 2017).

• Manual therapy: Hands-On techniques such as joint mobilisation, gliding, distraction, decompression, Mulligan techniques, and soft tissue release are utilised to improve joint mobility and reduce pain.

• Education and self-management: We provide patients with guidance on safe movement patterns, posture correction, activity modifications, and self-management strategies essential for long-term success.

Our approach goes beyond treating the presenting complaint. We conduct full-body screenings assessing joint mobility, flexibility, strength, and general fitness. Many patients over 60 are unaware of early joint restrictions until assessed, which allows us to identify and address musculoskeletal decline proactively.

Physiotherapy mobility management at Rose Clinic is always tailored to the individual. Complementary interventions include structured home stretching programmes, exercises to improve gluteal activation during gait (such as hip bridges and clamshells), balance training through single-leg stands or wobble board exercises, general physical conditioning, and prescribed daily walking routines.

These strategies collectively reduce fall risk, a leading cause of injury and hospitalisation among older adults (WHO, 2021), and prevent related health issues like cardiovascular disease, diabetes, and obesity, which are often worsened by inactivity (NICE, 2014; CDC, 2020).

Promoting sustained mobility and fitness improves independence and quality of life while also easing the burden on healthcare services and lowering long-term healthcare costs nationwide (Public Health England, 2019).

Recommendations for Community Health and Policy

Rose Clinic Performance Physiotherapy strongly advocates for the following community health and policy measures:

• Biannual physiotherapy assessments: Regular mobility screenings for adults aged 55 and above to detect early restrictions. Funding should be supported via private insurers, local councils, or national health programmes to improve access.

• Community awareness campaigns: Public education initiatives to increase awareness about joint health, early mobility loss signs, and the benefits of physiotherapy-led interventions.

• Education programmes: Practical training targeted at older adults and their caregivers on mobility exercises, fall prevention strategies, and fostering independence.

• Referral pathways: Encourage general practitioners, specialists, and other healthcare providers to promptly refer patients for physiotherapy assessments and interventions.

• Policy support: Endorsement and promotion of these initiatives by professional organisations such as the Chartered Society of Physiotherapy and Physio First UK to ensure widespread implementation and adherence.

Implementing these strategies can significantly reduce the prevalence of mobility-related health issues, decrease healthcare costs associated with falls and chronic disease complications, and improve the overall quality of life for older adults.

Call to Action

Healthcare providers, local governments, policymakers, and community stakeholders are urged to collaborate in integrating these recommendations into existing health frameworks. By doing so, we can promote healthy ageing through accessible, cost-effective, and high-impact physiotherapy interventions that improve long-term musculoskeletal health outcomes.

Conclusion

Mobility loss in older adults is not an inevitable consequence of ageing but a preventable and manageable condition when identified and addressed early. Physiotherapy offers an effective, evidence-based approach to maintaining joint range, muscle flexibility, strength, and independence.

If you are aged 50 or above, or have concerns about your movement or joint health, a professional physiotherapy assessment may be one of the most valuable investments you can make in your long-term health and quality of life.

References

• Cruz-Jentoft, A.J., et al. (2010). Sarcopenia: European consensus on definition and diagnosis. Age and Ageing, 39(4), 412–423.
• Hunter, D.J., & Bierma-Zeinstra, S. (2019). Osteoarthritis. Lancet, 393(10182), 1745–1759.
• Sherrington, C., et al. (2017). Exercise for preventing falls in older people living in the community. Cochrane Database Syst Rev, 1:CD012424.
• World Health Organization. (2015). World Report on Ageing and Health. Geneva: WHO.
• World Health Organization (WHO). (2021). Falls. https://www.who.int/news-room/fact-sheets/detail/falls
• National Institute for Health and Care Excellence (NICE). (2014). Physical activity: exercise referral schemes. NICE guideline [PH54].
• Centers for Disease Control and Prevention (CDC). (2020). Benefits of Physical Activity. https://www.cdc.gov/physicalactivity/basics/pa-health/index.htm
• Sherrington, C., et al. (2017). Exercise to prevent falls in older adults: an updated systematic review and meta-analysis. British Journal of Sports Medicine, 51(24), 1750-1758.
• Public Health England. (2019). Falls and fractures: prevention and management. https://www.gov.uk/government/publications/falls-and-fractures-prevention-and-management.

Effectiveness of Different Ergonomic Approaches for Computer-Related Musculoskeletal Disorders in the Neck

Author: Navid Zadeh, Senior Physiotherapist, MSc, BSc, MHCPC, NCSP, Physio First UK
Email: info@roseclinicphysio.co.uk

Abstract

The effectiveness of different ergonomic approaches for computer related musculoskeletal disorders (MSDs) in the neck and arms: a systematic review. N M ZADEH, University of East London, School of Health and Sciences, May 2016. Supervisor: Dr Graham Copnell.

Background: In the last decade, the prevalence of upper extremity musculoskeletal disorders has significantly increased amongst computer users. Computer related injuries are causing MSDs with disabilities, absenteeism, and time/cost consuming to employers. The aetiology of musculoskeletal complaints of the arm, neck, and shoulder (CANS) is highly complex and has yet to be properly investigated.

Objective: To assess the quality of RCTs looking at the use of ergonomic interventions in the treatment of pain for CANS.

Method: A systematic search of English language literature was performed using six medical databases PubMed, EMBASE, EBSCO, DARE, Science Direct and Cochrane library and the reference lists of the retrieved articles, from 2000 to 2015.

This review included all RCTs that have studied the effectiveness of ergonomicapproaches on the neck and arm injuries linked to desktop computers, laptops and tablets aged 18 to 60 years, with pain as the primary outcome measure.

Results: From 1032 studies that were found during initial literature searches, only three RCTs met the eligibility criteria and were included in the final appraisal of this review. The reviewed literature indicates that computer related injuries in the neck and arms are linked to poor ergonomic designs of workplaces/ computer devices, the handling of too many repetitive tasks and static body postures. 

Conclusion: The balance of high to moderate quality of evidence has examined different types of ergonomic approaches to find an alternative method for reducing incidences of computer-related CANS. Their recommendations include a thoughtful consideration of the most adequate ergonomic workstations, computer devices and ergonomic training to provide appropriate work settings and postures for prolonged period of times.

Keywords: work-related injuries, repetitive strain injury (RSI), computer users, neck pain, arm pain, ergonomic and RCT.

Critical Analysis of Exercise Interventions Prescribed for Stroke Survivors

Author: Navid Zadeh, Senior Physiotherapist, MSc, BSc, MHCPC, NCSP, Physio First UK
Email: info@roseclinicphysio.co.uk

Introduction

Stroke is a major cause of death and dependency and it is the third common cause of mortality after cancer and cardiovascular disease in developed countries (Daviet et al, 2012). In addition, a third of stroke patients are developing considerable, permanent neurological impairment, which in turn are the number one cause of disability in older adults (Weiss et al, 2000).

The aim of this essay is to evaluate and analyse the effectiveness of progressive resistance training (PRT) on lower extremity of stroke survivors. In addition, the muscle strength, function, disability and gait pattern in stroke survivors will be discussed and finally based on the reviewed literature the effectiveness of PRE in stroke patients will be concluded. The inclusion criteria include both Ischemic and haemorrhagic stroke in adult. Yet, the efficacy of PRE on upper limbs has been excluded to enable in-depth review of PRE effectiveness in lower extremity.

Strokes can occur when the blood supply to an area of the brain is stopped by bold clot [Ischemic], or when a blood vessel ruptures and the blood leaks into the part of the brain [Hemorrhagic] (Daviet et al, 2012). In both cases, the effected part of the brain and the surrounding tissues can damage severely. Such disorder in the brain will limit the function of affected area and can be deadly (Stroke Association, 2013).

In an ischemic stroke, a clot or thrombus is formed by plaques on the walls of brain arteries. Usually, a high concentration of low-density lipoproteins (LDL) in blood cholesterol is creating plaque deposits, which decreases the diameter of the brain artery. Consequently, the artery becomes inflexible and can reduce blood flow to the brain. The hemorrhagic stroke happened, when a blood vessel ruptures and the blood leaks to the space between the brain and the skull. Brain cells beyond the hemorrhage area are also deprived of oxygen and glucose. Hemorrhagic stroke can be caused by hypertension, aneurysm or trauma. In both ischemic and hemorrhagic strokes, the effected brain cells become damaged or die because they do not receive oxygen and other nutrients which are usually received by red blood cells (Stroke Association, 2013).

Depending on the brain area that has been affected by stroke, the function will suffer either in its reaction, planning or execution (Ouellette et al., (2004). If the lesion has affected the motor control area of brain then instructions will not be sent correctly.

When the co-ordination area of brain is damaged then the movement will not be coordinated and when the somatosensory area of brain is injured then position sense is distorted, hence the sensory reception are affected which leads to alteration of movement patterns (Ouellette et al., (2004). In the United Kingdom 150,000 people are affected by stroke every year (Stroke association; 2007) and most of them are older adult age 65 and over. In addition, the stroke is the 3rd most common cause of death in the UK and 2nd most common cause of death worldwide (O’Donnell et al., 2010).

Stroke can happen at any time to anyone, yet there are few risk factors which are associated with stroke including hypertension, diabetes mellitus, overweight, physical activity, diet, alcohol intake, smoking and psychosocial factors such as stress and depression (O’Donnell et al., 2010). Stroke can have severe consequences including cognitive deficits, sensory and motor deficit, changes in aerobic capacity, visual problems, and muscle strength deficit (Daviet et al, 2012). In addition, stroke can affect the neuromuscular function by deconditioning the hemiparesis limbs in which the motor unit firing rates and recruitment are reduced and this is leading to muscle fibre composition changes and atrophy of type II muscle fibers (Oullette et al, 2004) and all of these factors can contribute to muscle weakness (Moreland et al, 2003).

Nevertheless, stroke reduces the capability to activate muscles which reduce the movement. (Burr et al, 2012). Reduction of muscle power in stroke patients is associated with physiological modification of muscle tissues and morphological changes in muscle fibre type, which decreases the functional ability (Ramasa et al., 2007). Limitation of mobility in stroke patients is increasing the risk of other preventable chronic disease including diabetes, cardiovascular condition, osteoporosis, depression and cancer which have impressive negative consequences on the overall quality of life and increases the sedentary lifestyle (Morris et al, 2004).

Therefore adequate exercise programs are required to manage wellbeing status and improve the overall quality of life for stroke patients (Burr et al, 2012). Current evidence suggests that stroke patient can tolerate moderate physical activities and PRE with few adverse side effects compared to other pharmacologic interventions (Morris et al, 2004). The main principles of PRE are (1) completing a small number of repetitions before fatigue, (2) having adequate rest between sets to allow recovery and (3) increasing the resistance as the muscle’s force generation ability increases (Morris et al, 2004). Traditionally, there have been many concerns regarding the safety and side effects of PRE for stroke patients (Taylor et al, 2005).

Many stroke survivors are barred from participating in different physical activity and exercise programs, while they could benefit significantly from such program. This is mainly because of wrong perceptions regarding their functional ability and undue concern about side effects including increased hypertonia (Taylor et al, 2005), exacerbation of contractures, spasticity, reduced joint range of motion, safety and a significant risk of falls (Burr et al, 2012). However, the idea that PRE may aggravate spasticity has now been disproved (Taylor et al, 2005) and the risk of side effects was (0.03%) only in aerobic training which was cardiovascular in nature such as stroke exacerbation or myocardial infarction (Borbonnais and Noven,1989).

There is no common PRE training protocol for stroke patient amongst different authors. However, the reviewed literature suggest that typical PRE for stroke patients consist of 4 to 8 exercises using isokinetic dynamometers, weight machines or free weights with the loads corresponding to an 8- to 12 Repetition Maximum (RM) be lifted in 1 to 3 sets and exercising 2 or 3 days per week (Taylor et al, 2005; Burr et al., 2012, Morris et al., 2004), The 8 to 12 RM is a maximal weight that a person can lift 8 to 12 times properly until fatigue (Burr et al., 2012).

Ouellette et al, (2004) have studied the effectiveness of PRE in a RCT in which, Forty-two subjects, were received a 12-week supervised high-intensity PRE consisting of bilateral leg press (LP), unilateral paretic and nonparetic knee extension (KE), ankle dorsiflexion (DF), and plantarflexion (PF) exercises. In this study the functional performance was measured by using the 6-minute walking test, stair-climb time, repeated chair-rise time and maximal gait velocities.

Their results indicate that a single-repetition maximum strength considerably increased in the PRT group for LP (16.2%), in paretic KE (31.4%) and nonparetic KE (38.2%), whereby there were no changes in the control group. In addition, the paretic ankle DF (66.7% versus 24.0%), paretic ankle PF (35.5% versus 20.3%), and in nonparetic ankle PF (14.7% versus 13.8%) have also improved greatly in the PRT group compared with the control group. Moreover, the PRT group also had important progress in selfreported function and disability, while there were no changes in the control. Based on these results, Ouellette et al, (2004) concluded that the high-intensity PRT improves both paretic and nonparetic lower extremity strength after stroke which has positive effects on reducing functional restrictions and disability.

Sharp and Brouwe (1997) carried out a pre-post test cohort study of 15 patients with stroke of more than 6 months, who did isokinetic strength training for 6 weeks. They showed that there were statistically major changes in peak torque of the knee flexors and the knee extensors, walking speed and the Human Activity Profile (a subjective measure of activity). The results of this study were significant because they did find that the muscle spasticity did not increase with muscle strengthening exercises. However, since there was no control group in this trial their explanation cannot be justified.

In another RCT (Moreland et al., 2003) examined the effectiveness of PRE on gross motor function and walking ability have been studied. In this study both experimental and control groups received conventional physiotherapy programs. In addition, the experimental group carried out, 9 lower-extremity progressive resistance exercises 3 times a week for the time being in the hospital, while the control group received the same exercises and for the same time but without any resistance. Interestingly their result showed that during the time in hospital, there were no significant changes in disability inventory, the between group difference was 0.02 points per day (95%) confidence interval. In addition, at discharge, the rate of change in the 2 Minute Walking Test (MWT) was 0.01m in the experimental group and 0 .15m in the control group; which indicate the between-group difference was 0.16m. Moreland et al., (2003) concluded that PRE as carried out in their study were not effective for stroke patient when compared with the same exercises program performed without resistance.

In study by Inaba et al, (1973), 176 participants were randomised in to into 3 groups: functional training and stretching; active exercise plus functional training and stretching; and progressive resistive exercise plus functional training and stretching. They have showed that PRE group improved considerably more in strength and gross motor function at 1 month, while at 2 months the differences were not significant. Since there was 56% loss in follow up of this study, there may have been significant biases that influenced the results. Therefore, the authors did not reach a definitive conclusion because of shortcomings in the study’s methodologic.

Weiss et al., (2000) in an uncontrolled study have examined the effects of PRE on both the affected and least affected sides in long-standing stroke patients. The result showed strength increased by 68% on the affected side and 48% on the least affected side. They measured the results by repeated chair to stands movement.

Though, it is difficult to justify their finding since these improvements may be resulted from the strengthening on the least affected side. In addition, the lack of a control group confines the explanation of this trial.

Engardt et al (1995) have studied the reactions of 20 hemiparesis subjects to concentric and eccentric isokinetic training for knee extension. The patients were divided to the 2 groups by matching their clinical characteristics. This study have proven that the eccentric group was superior (P0.05) to the concentric group in improvement toward symmetrical body weight distribution when performing sit to stand exercise. Again, the lack of a control group was a main limitation of this study.

Considering the above randomised trials, indicate that there are conflicting results regarding number of training sessions per week and the duration of such training programs. The Burr et al., (2012) suggest 8 to 12 RM, 1 or 3 sets, 2 or 3 times per week while Taylor et al, (2005) recommend 6 to 10 RM, 1 to 3 sets, 2 to 5 times per week, ranging from 4 to 12 weeks. Nevertheless, variety of the methods used in the above randomised control trials (Engardt et al, 1995; Inaba et al, 1973; Moreland et al, 2003, Sharp and Brouwe, 1997; Weiss et al., 2000,) and protocols used in other reviews (Morris et al., 2004, orbonnais and Noven, 1989) do not agree on general recommendations on this type of exercise for hemiplegic stroke patients.

Morris et al., (2004) in a meta-analysis of PRE programs, showed that muscles strength improve without increasing spasticity in stroke subjects. Yet, the muscle improvement varies between muscle groups and also between the plegic and healthy limb. The plegic limb improved 68% while the healthy limb gained 48% improvement. However, the effectiveness of PRE on activity of daily living depends on the training principle and the specificity of programs. Therefore, one should not necessarily expect that improvements in muscle force generation definitely lead to improvement in everyday activities (Morris et al., 2004).

Walking limitation and asymmetric gait pattern are the most common consequences of stroke which is caused by motor deficits in hemiplegic patients (Ramasa et al.,2007). In the gait cycle of stroke patients, the stance phase of plegic limb is shorter and swing phase take longer time, which decreases the step length on the plegic side and hence reducing the speed of walking (Ramasa et al., 2007). In this group of patients the ability for fast walking is significantly decreased due to failure of lengthening the step size (Ramasa et al., 2007). The important features for asymmetric gait and walking abnormality in stroke patient include lack of sufficient balance, spasticity, motor and sensory deficit, insufficient muscle strength of the healthy and plegic limb (Ramasa et al., 2007) and body mass composition (Teixera et al., 1999). Gait training and exercise programs aim to improve functional ambulation and gait pattern in stroke patient. The determining factors are walking speed, step length, endurance, cadence, balance and symmetry (Ramasa et al.,2007). Yet, Weiss et al (2000) indicate that the reduced walking speed and movement is associated to decreased strength in hip flexors and knee extensors when compared with healthy participants within the same age range.

It is very helpful if physical activity and exercises are promoted in the early stage of post stroke, which can avoid the survivors from entering the vicious cycle of deconditioning and prevent another stroke and another vascular complication which support social reintegration and improve quality of life (Daviet et al, 2012).

Conclusion

After reviewing the above articles about the effectiveness of PRE on stroke patients, it is clear that there is a mixed result in the current literature regarding this subject. Although ascertaining and comparing the outcomes of these studies are crucial for clinical interventions, yet it is difficult to recommend a general protocol from these studies regarding the effectiveness of PRE on stroke patients. Because there are many different confounding variables in each trial such as sample size, age, post stroke time, gender, type of stroke, severity of lesion, impairment level, functional limitation and different type of measurement tool used in each study. Therefore, a future study may try to set up a new methodology for studying large sample of stroke patient in deferent stage of disease with different impairment. Yet, there is sufficient evidence in the reviewed literature that PRE are increasing the muscle force generation, improving walking ability and reducing disability which improve the quality of life and functional performance after stroke.

Reference list:

Borbonnais D, Vanden Noven S. (1989) Weakness in patients with hemiparesis. Am J Occup Ther; 43:313-9.

Burr J. F., Shephard R. J. Zehr E. P, (2012), Physical activity after stroke and spinal cord injury, Evidence-based recommendations on clearance for physical activity and exercise Physical Activity Series

Daviet J. C., Bonan I., Caire J. M., Colle F., Damamme L., Froger J., Leblond C.,Leger A., Muller F., Simon O., Thiebaut M., Yelnik A.,(2012), Therapeutic patient education for stroke survivors: Non-pharmacological management. A literature review Annals of Physical and Rehabilitation Medicine 55 (2012) 641–656

Duncan, P., Richards, L., Wallace, D., Stoker-Yates, J., Pohl, P., Luchies, C., (1998) A randomized, controlled study of a home-based exercise program for individuals with mild and moderate stroke. Stroke; 29:2055–60.

Engardt M, Knutsson E, Jonsson M, Sternhag M. (1995) Dynamic muscle strength training in stroke patients: effects on knee extension torque electromyographic activity, and motor function. Arch Phys Med Rehabil; 76:419-25.

Inaba M. Edberg E, Montgomery J, Gillis M. K. (1973) Effectiveness of functional training, active exercise and resistive exercise for patients with hemiplegia. Phys Ther; 53:28-30

Moreland JD, Goldsmith CH, Huijbregts MP, Anderson RE, Prentice DM, Brunton KB, O’Brien MA, Torresin WD. (2003) Progressive resistance strengthening exercises after stroke: a single-blind randomized controlled trial. Arch Phys Med Rehabil; 84:1433-40.

Morris, S. L., Dodd, K. J., Morris, M. E., (2004) Outcomes of progressive resistance strength training following stroke: a systematic review. Clin Rehabil.; 18:27–39.

O'Donnell M. J., Xavier D., Liu L., Zhang H., Chin S. L., (2004) Risk factors for ischaemic and intracerebral haemorrhagic stroke in 22 countries (the INTERSTOKE study): a case-control study” The Lancet 376(9735); p112-123

Ouellette, M. M, Le Brasseur, N. K., Bean J. F., Phillips, E., Stein. J., Frontera W. R., (2004) High-intensity resistance training improves muscle strength, selfreported function, and disability in long-term stroke survivors. Stroke; 35(6):1404–9.

Ramasa J., Courbona A., Rocheb F., Bethouxc F., Calmelsa P. (2007) Effect of training programs and exercise in adult stroke patients: literature review Annales de réadaptation et de médecine physique 50 (2007) 438–444

Sharp SA, Brouwer BJ. (1997) Isokinetic strength training of the hemiparetic knee: effects on function and spasticity. Arch Phys Med Rehabil; 78:1231-6.
Stroke Association http://www.stroke.org.uk/information/index.html (accessed 02/03/2013)

Taylor, N. F., Dodd K. J and Damiano D. L., (2005) Progressive Resistance Exercise in Physical Therapy: A Summary of Systematic Reviews PHYS THER.; 85:1208-1223.

Teixera, S. L.., Olney S. J, Nadeau, S., Brouwer, B. (1999) Muscle strengthening and physical conditioning to reduce impairment and disability in chronic stroke survivors. Arch Phys Med Rehabil; 80:1211–8.

Weiss A, Suzuki T, Bean J, Fielding RA. (2000) High intensity strength training improves strength and functional performance after stroke. Am J Phys Med Rehabil; 79:369-76.

The Efficacy of Exercise Intervention on Knee Osteoarthritis in Old Adults Critical Review of Evidence

Author: Navid Zadeh, Senior Physiotherapist, MSc, BSc, MHCPC, NCSP, Physio First UK
Email: info@roseclinicphysio.co.uk

Foundations in Research 2009/10 PTM001 UEL 

Around 2.4% of people over 55 years are disabled by knee pain due to osteoarthritis (OA) knee and by the age of 65 years 30% of men and 40% of women have radiographic changes of knee osteoarthritis 3 which often limits the ability to rise from a chair, stand comfortably, walk, and use stairs (Deyle et al, 2000).

Many randomised controlled trials concluded that exercise reduces pain and improves function in patients with osteoarthritis of the knee, but the optimal exercise regimen has not been determined. Fitness walking, aerobic exercise, and strengthening training have all been reported to result in functional improvement in patients with osteoarthritis of the knee (Carter et al, 2002; McAlindon, et al, 1993).

The aim of this paper is to critically review the current literature in relation to knee osteoarthritis in older adults and evaluate the methodology of those studies, while assessing the robustness and benefits of their outcomes. Hence, the factors that determining the study’s’ results and implication of outcome for large population will be discussed.

In this study, different type of design, subjects of all age groups and of either gender were included. Studies were included if the subjects primary complaint was OA knee with or without disability. The exclusion criteria were joint replacement (total knee), infection, fracture, neoplasm and posture abnormality or biomechanics problems.

However, this study will not describe the different assessment tools that have been used in each study to measure different variables like health and disability of their subjects.

Method

Deyle et al, (2000) have carried out a RCT to evaluate the effectiveness of physical therapy for osteoarthritis of the knee, by combining the manual therapy and exercise. In this RCT study, 83 patients with OA knee who were randomly assigned to receive treatment (n = 42; 15 men and 27 women [mean age, 60 ± 11 years]) or placebo (n = 41; 19 men and 22 women [mean age, 62 ± 10 years]).

The treatment group received manual therapy, applied to the knee as well as to the lumbar spine, hip, ankle and performed a standardized knee exercise program in the clinic and at home. The placebo group had sub-therapeutic ultrasound to the knee at an intensity of 0.1 W/cm2 with a 10% pulsed mode. Both groups were treated at the clinic twice weekly for 4 weeks.

Dependent variables measured consisted distance walking in 6 minutes and sum of the function, pain, stiffness, sub scores of the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC). A tester who was blinded to group assignment made group comparisons at the initial visit, 4 weeks, 8 weeks and 1 year. After controlling for potential confounding variables, the average distance walked in 6 minutes at 8 weeks among patients in the treatment group was 170 m (95% CI, 71 to 270 m) more than that in the placebo group and the average WOMAC scores were 599 mm higher (95% CI, 197 to 1002 mm).

At 1 year, patients in the treatment group had clinically and statistically significant gains over baseline WOMAC scores and walking distance. Interestingly Deyle et al, (2000) proved that 20% of patients in the placebo group and only 5% of patients in the treatment group had undergone knee replacement (arthroplasty).

Deyle et al, (2000) conclude that a combination of manual physical therapy and exercise programme have functional benefits for patients with osteoarthritis of the knee and may delay or avoid the need for knee replacement. Although Deyle et al, (2000) have used reliable measurement tool like 6-minute walk distances and WOMAC scores, yet there is a significant weak points in their methodology, which they have not explained. Because the treatment group was receiving manual therapy and knee exercise, therefore it is not clear that the outcomes are linked to manual therapy or the knee exercise. Hence, a second treatment group, with performing only knee exercise could be a good alternative for this confounding variable.

In addition, Deyle et al, (2000) had relatively small sample size for RCTs, did not used regression module and they have not adequately measured the accuracy and intensity of home exercises, especially between the 8th sessions and 1-year.

Although Deyle et al, (2000) have found sufficient evidence for their realistic hypothesis, yet the reliability of these outcomes needs to be clarified in future studies, before generalizing.

Jinks et al, (2007) carried out a cohort study, to determine the incidence of knee pain over a 3-yr period and to assess its impact on general health status and physical function, in people aged 50 and over.

In this study, four groups of responders were defined according to change in knee pain over the 3 yrs by using knee pain question (KNEST) and SF-36 scores: (i) no knee pain group, (ii) new knee pain group, (iii) resolved knee pain group, (iv) Foundations in Research 2009/10 PTM001 UEL continuing knee pain group. At baseline, 8995 subjects were sent a questionnaire to which 6792 responded. Finally 3907, (91%) responded to the follow-up questionnaire by answering the KNEST knee pain question at both baseline and follow-up. In total, 43% of the original population sent the baseline questionnaire (53% adjusted for deaths and departures from the GP list) and were followed up at 3 yrs.

They (Jinks et al, 2007) carried out all adjusted analyses by using multiple linear regression unlike Deyle et al, (2000), with all independent variables entered simultaneously and checks performed on the residuals for departure from normality, homogeneity of variance and multicollinearity between the independent variables. After controlling the data, overall, mean SF-36 scores in their study are similar to the UK norm-based SF-36 data (Jinks et al, 2007). However, using the SF-36 scores and KNEST as main assessment tools without any practical examination of the knee joint, reduce the robustness of methodology in this study.

Nevertheless, SF-36 scores in 3-yr showed the no knee pain, resolved and continuing groups remained relatively stable in SF-36 scores at follow up, with generally only small falls in the no knee pain and continuing groups. In contrast, the new knee pain group (i.e. those who developed knee pain between baseline and follow-up) showed a mean fall of more than 10 points for Physical Functioning.

The main weak point of this cohort study is that they have not measured other variables related to general health and physical function decline like psychological aspects, illness perceptions, health beliefs and optimism and pessimism. In addition, this study could not explain why the resolved group did not return to full function.

Their results emphasize the importance of knee pain as a likely risk factor of physical decline in aged persons. Almost a quarter of adults over 50 yrs who suffer from knee pain will experience resolution of pain at 3 yrs however; their general health status and physical functioning will not gain full recovery. Because there were no any obvious methodological weak point in this study, hence, their results are likely to be generalized to the wider population. However, the results (Jinks et al, 2007) are not useful to apply in physiotherapy practice directly. These results are more suitable for NHS and other government bodies to manage and prevent the elderly disabilities on time.

The purpose of McAlindon, et al (1993) research was to assess the influences of radiographic severity, quadriceps strength, knee pain, age, and gender on functional ability in patients with osteoarthritis of the knee.

Equal numbers of knee pain positive and negative respondents to a survey of registrants aged more than 55 years at a general practice were invited to attend for knee radiographs and quadriceps femoris isometric strength estimations. Disability was measured using the Stanford Health Assessment Questionnaire (SHAQ).

Respondents with knee pain and an equal number of controls were contacted in random order by telephone and invited to participate in the study. Cases and controls were matched by gender and were born within 12 months of each other.

Full data were obtained on the first 159 from 513 subjects who attended. These 159 patients were younger (mean age 70-2 years v 72-4; p<005) and less disabled (X2=l1-2; one degree of freedom; p<005) than the remainder. They used the following methods to measure the studied variables: knee pain, was assessed verbatim by Health and Nutrition Examination Survey, disability was measured by SHAQ, quadriceps isometric strength was tested by Edwards test and radiography was assessed with weight bearing in anteroposterior position and standardised technique. However, early research using the Kellgren and Lawrence (1957) radiographic osteoarthritis score showed relatively poor reproducibility.

The relations between variables were investigated first using simple linear regression for continuous variables (age and quadriceps strength) and Spearman rank correlation for discontinuous measures McAlindon, et al (1993).

In this study logistic regression was undertaken because of the non-normal distribution of the Health Assessment Questionnaire score, while Jinks (2007) used linear regression which might favour a continuous dependent variable in favour of a discontinuous measure like (McAlindon, et al (1993) quadriceps strength may favour radiographic score.

McAlindon, et al (1993) conclude that of the variables studied, quadriceps strength, knee pain, and age are essential determinant of functional disability in older people than the severity of knee osteoarthritis as assessed radiographically. Therefore, an adequate intervention can optimise muscle strength that has the potential to reduce a vast burden of disability, dependency, and cost. However, they did not explain, what is the optimise muscle strength for older adults.

The critiques to this study are the reliability of the measurement tools and examine many variables at same time. Selection of relatively young patient with less disability is another issue, which may increases biases and reduce the validity of their outcomes. However, the result of this study seems be more realistic and rigorous than Jinks et al, (2007).

McAlindon, et al (1993) have acknowledged their limitation and biases that may affect the applicability of the outcomes while (Jinks, 2007 and Deyle et al, 2000) have not considered any possible biases. Generally, the methodology of this study seems to be rigorous and therefore the outcomes of this study could be generalised to wider population.

Penninx et al (2001) have studied the relation between an exercise programme and prevention of disability in activities of daily living (ADL) in patients with OA knee. Their method consisted of a 2-center, randomized, single blind, controlled trial, in which participants were assigned to an aerobic exercise program, a resistance exercise program, or an attention control group.

Of the 439 person aged 60 years or older with OA knee, the 250 participants free of ADL disability were used for this study. They defined ADL disability, as difficulty in transferring from a bed to a chair, eating, dressing, using the toilet, or bathing, and they assessed ADL disability, quarterly during 18 months of follow-up.

Although they had a long list of inclusion/ exclusion criteria, nevertheless it is not clear on what ground they have set up these criteria list. In addition, there are some contraindication in their exclusion criteria and their conclusion. For instance, subjects with heart condition, lung disease and inflammatory arthritis were excluded, though they acknowledged, “Many of the older participants with knee osteoarthritis in our study (41%) had other disabling comorbid conditions, such as cardiovascular disease, diabetes mellitus, lung disease, or cancer” (Penninx et al, 2001, P2315).

Interestingly, Penninx et al (2001) had monthly group sessions for control group, including time for discussions and social gathering, to educate participants and give them adequate study attention, while other studies (McAlindon et al, 1993; Deyle et al, 2000) had not such educational meetings. Hence, the benefits of these monthly group sessions have not been explained or measured by Penninx et al (2001).

The aerobic group and resistance group exercise programme was scheduled as 3 times per week for 1 hour. They do not explain the grounds for this hypothesis, which may be intensive training for this group of patient. Their results have showed that the cumulative incidence of ADL disability was lower in the exercise groups (37.1%) than in the attention control group (52.5%) (P=.02). After adjustment for demographics and baseline physical function, the relative risk of incident ADL disability for assignment to exercise was 0.57 (95% confidence interval, 0.38-0.85; P=.006). Both exercise programs prevented ADL disability; the relative risks were 0.60 (95% confidence interval, 0.38-0.97; P=.04) for resistance exercise and 0.53 (95% confidence interval, 0.33-0.85; P=.009) for aerobic exercise. The lowest ADL disability risks were found for participants with the highest compliance to exercise.

Penninx et al (2001) have proven that persons participating in either a resistance or an aerobic exercise program had a significantly higher probability of remaining free of ADL disability for 18 months. In addition, Penninx et al (2001) relayed on subjects self-reporting assessment method and Cox proportional hazards analyses, to measure disability and pain, while in similar situation Deyle et al, (2000) used WOMAC health questionnaire assessment tool and Jinks et al, (2007) used Short Form-36 and knee pain screening tool (KNEST). Therefore, it is obvious that different studies come up with different results even if they research the same topic.

However, it appears that the differential study loss due to unavailability might have biased (Penninx et al, 2001) results. Overall, 129 (8.6%) of the total 1500 ADL disability assessments were missing.

Penninx et al (2001) concluded that aerobic and resistance exercise may be an effective strategy for preventing ADL disability and consequently, may prolong older persons’ autonomy. Although the methodology of this study have few weak points as mentioned above, since, their results are not contradicting any of the above studies, therefore, their outcome can be generalised to a large population of OA knee.

Carter et al (2002) conducted a randomized controlled trial of specific exercise programs designed specifically for women with OA to prevent falls. Their RCT’s methods consisted of 93 women 65 to 75 years diagnosed with OA knee by dual-energy X-ray absorptiometry in Vancouver and BC Women’s hospital between 1996 and 2000. The subjects were selected if they had not engaged in regular weekly programs of moderate or hard exercise. The subjects were randomly assigned to participate in a twice-weekly exercise class or to not participate in the class. Whereas Penninx et al (2001) exercise programme was scheduled as 3 times per week for 1 hour for similar age group.

Carter et al (2002) had emphasised on improving posture and balance, which differentiate their program from other exercise programs (Penninx et al, 2001 and Deyle et al, (2000)) of which include an aerobic exercise and strengthening component. Carter et al (2002) have used static and dynamic balance to measure risk factors for falls and strength. They used the Equitest computerized posturography platform (Neurocom International, Clackamas) for static balance and speed traversing a 10-m figure-eight circuit for dynamic balance.

In this study both the experimental and control subjects were invited to bimonthly social seminars to encourage the control group to stay involved in the study, similar to Penninx et al (2001). They assessed general health of the subjects by Canadian Multicentre Osteoporosis questionnaire, evaluated total physical activity by questionnaire of Blair and colleagues and measured quality of life by questionnaire of the European Foundation. Although the assessment tools of variables in this study are different from above studies, yet they are reliable tools.

Before adjustment for covariates, the intervention group tended to have greater, although non-significant, improvements in static balance (mean difference 4.8%, 95% confidence interval [CI] –1.3% to 11.0%), dynamic balance (mean difference 3.3%, 95% CI –1.7% to 8.4%) and knee extension strength (mean difference 7.8%, 95% CI –5.4% to 21.0%). The intervention group also had a 6.3% greater improvement in static balance after adjustment for rheumatoid arthritis and osteoarthritis, but this difference was not significant (p = 0.06). Compared with the control group, the intervention group experienced no improvement in quality of life.

This study had few limitations for instance, their participants were more healthy and motivated individuals and the subjects’ age was limited to 65-70 years, which limits the generalizability of their findings. However, Carter et al (2002) indicated that participants in the exercise program experienced improvements in dynamic balance and strength, both important determinants of risk for falls, particularly in older women with osteoarthritis. This focused review has highlighted the benefits of exercise and physical activity for older adults. It was part of the study guide on geriatric rehabilitation in the Self-Directed Physiatric Education Program for practitioners and trainees in physical medicine and rehabilitation. This article specifically focused on the benefits of physical activity and exercise for older adults with regard to morbidity, mortality, and disability. 

Campbell et al, (2001) carried out a mixed method design to understand reasons for compliance and non-compliance with a physiotherapy home based exercise intervention by patients with osteoarthritis of the knee. This qualitative study was nested within a RCT, to investigate the effectiveness of physiotherapy intervention in reducing knee pain and mobility restriction associated with OA knee. In total, they have recruited 87 people, of whom 43 were randomised to the treatment arm. In the intervention arm, patients undertook nine half hour exercises sessions over eight weeks to strengthen the quadriceps muscle and taping of the patella. In depth, interviews were conducted with 20 patients in the intervention arm using open ended questions, guided by a topic schedule, to encourage patients to describe their experiences and reflect on why they did or did not comply with the physiotherapy exercises. Interviews were audio taped, fully transcribed and analyzed thematically according to the method of constant comparison.

Those in the control group received only general advice about weight reduction and exercise at a single baseline visit. However, the control group in this study may have been affected by external variables such as age and lack of radiographic result, and the advices, while the authors have not mentioned these issues. The trial results showed that five months after the start of treatment there was a small decrease in pain and a significant increase in the strength of the quadriceps muscle of the knee. After one year, however, there were no significant differences in the outcome measures, most of which had returned to pre-treatment levels.

Initial compliance was high because of loyalty to the physiotherapist. A necessary precondition for continued compliance was the perception that the physiotherapy was effective in ameliorating unpleasant symptoms. Campbell et al, (2001) study have few weak points like (1) recruiting young participants (age 45 and over), (2) three quarters of participants had previously Knee treatment and (3) a single session exercise with some advice to control group. In addition, their methodology have no sufficient measurement tool for RCT design and they have not explained for instance how they measured the strength of quadriceps muscles and the reason of taping patella.

However, Campbell et al, (2001) mixed methods provided us with relevant and rigorous evidence, from the patient’s perspective which may help practitioners to make adequate decision about home exercise and whether we should judge effectiveness according to whether an intervention works when compliance is optimal or taking into account variable levels of compliance.

Dawson et al (2003) have carried out a matched case-control study to explore the risk factors for knee osteoarthritis in women, which included wearing high heeled shoes. Their methodology, in which exposure information was obtained by interview in women, aged 50 to 70 included occupational activities, past shoe wearing, participation in competitive sports, height, body weight, smoking and use of contraceptive pills at three different stages of life.

In total, 111 eligible women were interviewed (29 cases, 82 controls) and the information was entered on a life grid. Dawson et al (2003) measured past exposure by focusing on specific risk factors in their interviews and unlike Campbell et al, (2001) they did not used only, open ended question. For instance, they showed the pictures of 38 different styles of shoes, with both front and side view to the participants to find out the heights of their shoes in the past.

In addition, Dawson et al (2003) used few self-developed assessment tools like lifegrid, which may not meet the standard criteria for such study. Hence, for the statistical analysis, Dawson et al (2003) used conditional logistic regression to compare cases and controls in relation to the frequency of risk factors, while Campbell et al, (2001) did not used any regression models in for analysing their interview results.

One of the studied variables in this research was socioeconomic status. While their results suggested that control subjects were generally of higher socioeconomic, than cases, interestingly, Dawson et al (2003) found no significant differences in any of the measures of socioeconomic status between cases and controls; nevertheless, socioeconomic was not the main objective of this pilot study.

However, several variables showed a significant relation with OA Knee, in particular occupational activities like lifting and bending. All respondents reported wearing shoes with heels at least one inch high at some time in their lives, while 8 of 111 (7%) said that they had never worn heels as high as two inches and 40 of 111 (36%) reported never wearing three inch heels.

Interestingly, none of the measures of high heel wearing was significantly associated with OA Knee and in most cases the odds ratios indicated a protective effect rather than the hypothesised increase in risk. Dawson et al (2003) concluded that it is very unlikely that prolonged wearing of high heeled shoes represents a risk factor for symptomatic osteoarthritis of the knee in women. Furthermore, they confirmed that being overweight before the age of 40 considerably increases the risk of subsequent OA in women. Hence, small sample size in this research (Dawson et al, 2003) coupled with a large number of risk factors is the main weak point of this study that may increases the risk of obtaining false positive results and the findings should therefore be treated with due caution. However, based on the topic of this study, RCT would be an appropriate design to obtain accurate outcomes.

CONCLUSION

Reviewing the above studies has revealed that most of them have a few weak points in their methodology in producing clinical evidence and recommendations. Based on the current literature, especially the above reviewed studies, exercise intervention generally have been proven to reduce the symptoms and disability in patients with OA knee. Based on different methodology and different measurement tools that have been used in each of the above study, it is not possible to compare the outcomes.

In addition, most of the above studies have not produced robust and valid evidence. Therefore, the results of this paper cannot be applied to a large group of OA patient. However, the result of individual study (Campbell et al, 2001; Penninx et al 2001; McAlindon, et al, 1993) revealed, that applying exercise interventions are effective approaches in reducing pain and disability in patients with OA knee therefore their outcomes could be generalised to large population of osteoarthritis. Based on the above facts, the future studies have to be more accurate in their methods and measurement tools to produce robust outcomes for large population of OA knee.

Reference

Bean J. F., Vora A., Frontera W. R. (2004) ‘Benefits of exercise for communitydwelling older adults’ FOCUSED REVIEW, Arch Phys Med Rehabil; 85 (Suppl 3):S31-42.

Campbell R., Evans M., Tucker M., Quilty B., Dieppe P., Donovan J L., (2001) ‘Why don't patients do their exercises? Understanding non-compliance with physiotherapy in patients with osteoarthritis of the knee Public health policy and practice’ Epidemiol Community Health; 55:132-138

Carter N. D., Khan K. M., McKay H. A., Petit, M. A., Waterman C., Heinonen A., Patti

Juszczak J., M., Marks S-A., Dodd C., Fitzpatrick R., (2003) ‘An investigation of risk factors for symptomatic osteoarthritis of the knee in women using a life course approach’ J Epidemiol Community Health; 57:823–830

Deyle G. D., Henderson, Nancy ., Matekel L Robert ., Michael R.G G; Garber B. and Allison S. (2000) ‘Effectiveness of Manual Physical Therapy and Exercise in Osteoarthritis of the Knee’ a Randomized, Controlled Trial, Annals of Internal Volume 132 Issue 3 Pages 173-181

Janssen, M. G., Mallinson D., Riddell L., Kruse K., Jerilynn C. Prior, Flicker L. (2002) ‘Community- based exercise program reduces risk factors for falls in 65- to 75-year-old women with osteoarthritis’ randomized controlled trial, Canadian Medical Association, CMAJ; 167(9):997-1004 Foundations in Research 2009/10 PTM001 UEL

Jinks C., K. Jordan and P. Croft (2007) ‘Osteoarthritis as a public health problem: the impact of developing knee pain on physical function in adults living in the community’ Rheumatology; 46:877–881

Kellgren J. H, Lawrence J S. (1957) ‘Radiological assessment of osteo-arthrosis’ Ann Rheum Dis 1957; 16: 494-501.

McAlindon T E., C Cooper, J R Kirwan and P A Dieppe (1993) ‘Determinants of disability in osteoarthritis of the knee’ Ann Rheum Dis, 52;258-262

Penninx .B. J. H.; Stephen P. Messier; W. Jack Rejeski; Jeff D. Williamson, MD; Mauro DiBari; Chiara Cavazzini; William B. Applegate; Marco Pahor, (2001) ‘Physical Exercise and the Prevention of Disability in Activities of Daily Living in Older Persons With Osteoarthritis’ Arch Intern Med.;161:2309-2316

Roddy, E., Zhang, W., Doherty M., N. K. Arden, J. Barlow, F. Birrell A. Carr, K. Chakravarty, J. Dickson, E. Hay, G. Hosie, M. Hurley K. M. Jordan, C. McCarthy, M. McMurdo, S. Mockett, S. O’Reilly, G. Peat, A. Pendleton and S. Richards, (2005) `Evidence-based recommendations for the role of exercise in the management of osteoarthritis of the hip or knee` Rheumatology; 44:67–73

The Role of Eccentric Training in the Management of Achilles Tendinopathy

Author: Navid Zadeh, Senior Physiotherapist, MSc, BSc, MHCPC, NCSP, Physio First UK
Email: info@roseclinicphysio.co.uk

Sports injuries can be caused by intrinsic or extrinsic factors, either alone or in combination (Paavola, et al, 2002). In chronic tendon disorders, an interaction between these two types of factors is common. Achilles tendon injury is a common sequel to sporting participation. Similar to other tendons, pain classically appears with an increase in training load, or in elite athletes, sustained high training loads (Cook et al, 2002). Achilles tendinopathy appears more prevalent in sports that have a large running component, but occurs in all sports and at all levels of participation.

Prevalent occurrence of Achilles tendinopathy amongst the athletes, slow rehabilitation progress and reoccurrence of the injury in some occasion has made Achilles tendinopathy an appropriate subject for this essay.

The aim of this essay is to critically evaluate and analyse a few key points of the above study in depth and scrutinize the implications of the outcomes within practice in relation to sport injuries rehabilitation to optimal performance. In addition, the robustness and benefits of the study’s outcomes for athletes will be analysed. The key features that will be discussed include pathology of Achilles tendon, eccentric training and ultrasound application. Finally, the implication of the study’s outcome in practice will be evaluated and some relevant features for further research will be recommended.

Achilles tendon problems are very common among athletes as well as the general population. The terminology used to describe the painful condition of the Achilles tendon is superfluous, confusing and most often does not reflect the underlying abnormality (Paavola, et al, 2002). Additional terms such as Achilles tendinopathy, tenopathy, tendinosis, partial rupture and paratenonitis, have been used to describe the problems of noninsertional pain associated with this tendon (Paavola, et al,2002). Two-thirds of Achilles tendon injuries in competitive athletes are paratenonitis and one-fifth are insertional complaints (bursitis and insertion tendinitis). The remaining afflictions consist of pain syndromes of the myotendineal junction and tendinopathies (Kvist, 1994). Occasionally, Achilles tendon pain is found in inactive individuals (Paavola, et al, 2002) and interestingly aging is not specifically associated with tendinopathy. However, active older individuals may also present Sport Rehabilitation with Achilles tendon problems, often with symptoms for the first time. Occasionally, they can recall a previous episode or previous symptoms, or report asymptomatic tendon swelling for an extended period (Cook et al, 2002). Achilles tendon overuse injuries are thought to account for 11% of all running injuries (Kvist, 1994).

In addition, Kvist (1994) have demonstrated that limited mobility of the subtalar joint and limited range of motion of the ankle joint were more frequent in athletes with Achilles tendinopathy than in those with other symptoms. In addition to hyperpronation of foot and varus deformity of the forefoot (Paavola et al, 2002), leglength discrepancy is one of the more controversial potential contributing factors to Achilles tendinopathy (Kvist, 1994, Cook et al, 2002).

The Achilles tendon is the single tendon of the soleus and gastrocnemius muscles, inserting into the calcaneum. It has a highly structured peritendinous tissue with no synovial membrane and is hypovascular. The blood supply to the tendon enters on the deep (anterior) surface, and appears to be similar in volume throughout its length (Cook et al, 2002). However, the chronic form of Achilles tendinopathy is not an inflammatory condition (Paavola, et al, 2002) which is an important aspect in rehabilitation. The evidence confirms that the histopathological findings in athletes with overuse tendinopathies are consistent with those in tendinosis - a degenerative condition of unknown aetiology. This may have implications for the prognosis and timing of a return to sport after experiencing tendon symptoms. The literature indicates that healthy tendons appear glistening white to the naked eye and microscopy reveals a hierarchical arrangement of tightly packed, parallel bundles of collagen fibers that have a characteristic reflectivity under polarized light. Stainable ground substance (extracellular matrix) is absent and vasculature is inconspicuous.

Tenocytes are generally inconspicuous and fibroblasts and myofibroblasts absent (Khan et al, 1999). In stark contrast, symptomatic tendons in athletes appear grey and amorphous to the naked eye and microscopy reveals discontinuous and disorganised collagen fibers that lack reflectivity under polarized light (Khan et al, 1999). However, Khan et al, (1999) conclude that effective treatment of athletes with tendinopathies must target the most common underlying histopathology, tendinosis, a non-inflammatory condition.

Alfredson et al, (1998) indicate that conservative treatment should be applied prior to surgical approach. “Nevertheless, the management of Achilles tendinopathy is varied. Traditionally conservative treatment is often passive with little emphasis placed on activities to modify the tendons’ structure and its ability to withstand the stresses placed on it, often leading to a recurrence of the problem” (Herrington & McCullochb, 2007; Croisier et al, 2001). As Achilles tendinopathy may cause disability (Kader et al., 2002), therefore an adequate management is essential to return the athlete to the desired level of performance. Herrington & McCullochb, (2007) confirm that all subjects returned to full functional ability based on VISA-A questionnaire tool, yet the robustness and validity of their outcomes for a large population and beyond one year is unknown. Herrington & McCulloch (2007) have carried out a pilot study in which their repeated measures trial compared two interventions outcome. “The objective of their study was to investigate the effect of different types of treatment on Achilles tendinopathy. One proposed to increase tensile strength of the tendon by eccentric training, the other a more traditional treatment used in a clinical setting using Ultra Sound (US) and Deep Frictional Massage (DFM)” (Herrington & McCulloch, 2007, p191). They had randomly allocated twenty-five participants to the eccentric group (n ¼ 13) or the control group (n ¼ 12). Herrington & McCullochb, (2007) had measured the outcomes by using the VISA-A questionnaire (Robinson et al., 2001). They assessed overall functional changes of the participants after 12 weeks and the changes occurring in function at four-weekly intervals throughout the study. They used the VISA-A questionnaire to measure the functional improvement of the participants. The VISAA questionnaire has been previously established by Robinson et al., (2001), which measure the functional improvement in patients with Achilles tendinopathy.

Although the authors back up the reliability and validity of this tool, yet none of the other studies that have been reviewed for this essay had used the VISA-A questionnaire.

Conventional interventions especially ultrasound application have been used regularly for treatment of Achilles tendinopathy. Herrington & McCulloch (2007) have applied ultrasound in combination with DFM in both control group and experimental group. In this review, only the US application that has been used will be evaluated. They applied six sessions of ultrasound with 1-week interval, while using the same machine (EMS Combination 850; Model 90) for all applicants. The ultrasound frequency, which they applied over painful part of the Achilles tendon, was 1 MHz, on a continuous setting at 1.0W/cm² for a period of 5 minutes (Enwemeka, 1989). However, they did not explain why they used this particular US setting or why they had not tried a different modality for instance lower or higher intensity. There is strong supporting evidence from literature on the positive effects of ultrasound on tendon healing. In a similar study Chestera et al, (2007) have compared the effectiveness of eccentric loading exercises with therapeutic ultrasound in the management of chronic Achilles tendon pain whereby they used 3MHz at 0.5w/cm² for 2 minutes. The results of Chestera et al, (2007) study demonstrated that there was no statistically significant difference in the effectiveness of both procedures. This was the only study that examined the effect of two applications, which have been discussed in this essay, nevertheless because their subjects were not athletes; it made it difficult to compare their result with Herrington & McCulloch (2007) study. In addition, Enwemeka et al (1990) has proven that the effect of 1 MHz therapeutic ultrasound with intensity of 1W/cm² for 5 minutes, on the healing strength of rabbit tendons induced a significant increase in both the tensile strength and the energy absorption capacity of the tendons. In another study, Chukuka et al, (1990) have indicated that the effect of low-intensity ultrasound on the healing strength of tendons in continuous waves at a intensity of 0.5 W/cm² for 5 minutes every day increases tensile stress and energy absorption capacity. They appeared to demonstrate that the same effect is not produced when sonication intensity is raised to 1.5 W/cm². Enwemeka (1989) showed that sonication at 0.5 W/cm² augments both tensile strength and tensile stress without increasing the relative sizes of the tendons. Hence, all of the above studies suggest that the beneficial effects of ultrasound may be enhanced by sonicating at continuous and lower intensities rather than high intensity. Therefore, It has been suggested that, high-intensity ultrasound may hinder fibroplasia and collagen synthesis and hence impair the healing process of tendons Enwemeka (1989).

Accordingly, the US setting 1.0W/cm² continuous intensity with one-week intervals used by Herrington & McCulloch (2007) may not be the best option. However, this does not undermine their results. In addition, because the authors have applied the US to both control and eccentric group, it is difficult to conclude that the improvements of the subjects in the eccentric group was related only to the exercise, and this is one of the possible biases of this study.

A number of studies have indicated that eccentric calf muscle training has beneficial effects in the management of Achilles tendon pain for recreational athletes (Chestera et al, 2007). Remarkable study by Stanish et al (1986) led to the proposed theory of eccentric loading and since then this method become a popular choice for managing Achilles tendinopathy. Calf muscle strength has been measured after rehabilitation in patients with surgically treated complete Achilles tendon ruptures and in patients with complete Achilles tendon ruptures treated either surgically or nonsurgically (Alfredson et al, 1998). “Although there is evidence that eccentric, exercise shows beneficial short-term effects in treating Achilles tendinopathy, the literature is still limited” (Herrington & McCullochb, 2007; Mafi et al, 2001).

However, a few studies indicate that the eccentric training of ruptured Achilles tendon show promising results and benefits (Mafi et al, 2001; Vertommen et al, 1992; Silbernagel et al, 2001). Nevertheless, the specific results of eccentric exercise at tendon properties are yet unknown. In addition, Vertommen et al, (1992) found that the subjective pain measure favours the use of eccentric exercise for the rehabilitation of Achilles tendonitis. In another study, Chestera et al, (2007) indicate that the eccentric exercise increases the muscle-tendon length, which gradually enhance the tendon’s tensile strength.

In (Herrington & McCulloch, 2007) study, both the experimental group and the control group participants have received the similar DFM, US, and stretches. In addition, the experimental group received a 12-week eccentric training, including the DFM and US in the first 6 weeks of the study. The authors did not explain why the eccentric group also received the conventional treatment (US and DFM). In addition, all participants were performing an exercise programme twice a day, 7 days a week, based on their exercise sheet. Furthermore, a report by Alfredson et al (1998), later supported by randomised controlled trials (Mafi et al, 2001; Silbernageletal, 2001) have identified heavy-load eccentric calf muscle training as an effective treatment in the management of Achilles tendon pain. Alfredson et al (1998) carried out a 12-week eccentric training period; all 15 patients were back at their preinjury levels with full running activity. They (Alfredson et al, 1998) indicate that there was a significant decrease in pain during activity and the calf muscle strength on the injured side had increased significantly. Whereas, a 12-week eccentric exercise programme by Herrington & McCulloch (2007) appears to produce a superior functional outcome when used in addition to US and DTF rather than US and DTF alone, with none of the control group returning to their previous activity levels. Vertommen et al, (1992) compared the eccentric and concentric exercise and found no significant differences between the eccentric and concentric groups with respect to the return-to-activity measures. They concluded that the eccentric group had a significantly greater decrease in pain and the subjective pain measure favours the use of eccentric exercise for the rehabilitation of Achilles tendonitis. A randomised controlled trial (Silbernagel et al, 2001) indicated that eccentric overload training for patients with chronic Achilles tendon have significant improvements in plantar flexion and pain reduction even in the long-term and the participants were satisfied with their present physical activity level. They considered themselves fully recovered and had no pain during or after physical activity. Mafi et al, (2001) have demonstrated that after the eccentric training regimen 82% of the patients were satisfied and had resumed their previous activity level, compared to 36% of the patients (8/22) who were treated with the concentric training regimen. The results of eccentric training was significantly better (P<0.002) than concentric training.

There is sufficient evidence in support of heavy loading eccentric training and the recovery of Achilles tendinopathy (Herringtona & McCullochb, 2007, Alfredson et al, 1998). For instance, Alfredson et al, (1998) has demonstrated that after a 12-week eccentric training, all 15 patients with chronic Achilles tendinosis (degenerative changes) were back to their pre-injury levels with full running activity. There was a great decrease in pain during activity, and the calf muscle strength on the injured side had increased substantially and did not differ particularly from that of the noninjured side. Finally, isokinetic eccentric exercises (Croisier et al, 2001) have also presented a very satisfactory short-term effect for treatment of recurrent Achilles tendinitis. After comparing the above evidence with Herrington & McCulloch (2007) study the robustness of eccentric exercise, appears even more reliable than before. The result of the eccentric group is in consensus with all above reviewed studies, which indicates that eccentric exercise is an efficient intervention for treatment of Achilles tendinopathy amongst athletes, especially in addition to passive treatments.

However, since Herrington & McCulloch (2007) had no eccentric exercise only group in their research, and no other evidence was found in the reviewed literature with this specific modality, which compares the effectiveness of eccentric exercise and conventional treatment in athletes with Achilles tendinopathy, therefore it is not possible to have an unambiguous conclusion to this issue. Although (Chestera et al, 2007) have compared the effectiveness of US with eccentric exercise, their subjects were non-athletes, and therefore the question remains unanswered. Patients selected in this study (Chestera et al, 2007) were characterized by a long duration of symptoms and ineffectiveness of conventional treatment. It shows that eccentric training programmes proposed with the intention to adapt tendons to increased loads, had a positive effect on the painful Achilles tendon condition. It appears that the nature of this strength programme should be strongly biased towards eccentric muscle contraction. Most forms of treatment remain "passive" as to tissue structure adaptations and there is only limited evidence yet to support satisfactory results with these classical techniques. Ideally, future studies should undertake a prospective randomised trial to investigate the effectiveness of eccentric loading exercises, compared with therapeutic ultrasound in the management of Achilles tendon pain in athletes.

By analysing the methodology of Herrington & McCulloch (2007) and comparing their results with other similar study, the following features have considerable implications for their evidence in practice. Foremost, their study has not carried out a new hypothesis; they have combined and examined existing methods for conventional ultrasound settings (Enwemeka, 1989) and eccentric exercise (Alfredson et al, 1998; Mafi et al, 2001) treatment. In addition, their prescribed exercises included combined aspect of Alfredson et al (1998) and Stanish et al (1986) programmes. However, since the eccentric group (experimental group) was receiving the conventional treatment (US and DFM) and eccentric training and there was no group with eccentric exercise only, the outcome of the above study is not reliable enough to be applied in practice unless carried out as combination of those interventions. Yet there is no evidence in literature, which confirms the use of conventional and eccentric exercise independently. In addition, the eccentric exercises were performed every day, which is extremely time-consuming for most patients considering the busy lifestyles of many of the athletes. 

The results show that the eccentric group demonstrated considerably higher (F ¼ 5.21, p ¼ 0.014) VISA-A scores in their function than the control group over the 12-week period. “In addition, the main effect of the type of treatment (eccentric or DFM/US) was also significant (F ¼ 7.57, p ¼ 0.022)” Herrington & McCulloch (2007).

Nine participants in the eccentric group scored the highest number on the VISA-A questionnaire tool at 12 weeks and 4 of them achieved this score at 8 weeks. However, the maximum score that the control group achieved was 84/100. It appears that the eccentric group achieved the greatest overall increase in mean VISA-A score over the 12 weeks (51.8%). The best recovery in eccentric group was from 0 to 4 weeks (30.4%) with less improvement between 8 and 12 weeks (5.6%). Whereas the control group had an overall 31.9% raise in mean VISA-A scores over the 12 weeks, with the best improvement from 4 to 8 weeks (12.8%). In addition, the Post-hoc paired t-tests showed that the eccentric group had considerable increases in VISA-A scores between 0 and 4 weeks and 4–8 weeks (p ¼ 0.01) but no improve was found between 8 and 12 weeks. Therefore, no major progress founded between each time interval for the control group. This study has no relevancy for acute Achilles tendinopathy, because all participants were involved in different activities and Achilles-loading sports. In addition, participants had a long duration of symptoms (mean ¼ 24.5 months) and were vigorous in their Activity of Daily Living.

(ADL). The outcomes of this study indicate that the conservative management has to be tried first with Achilles tendinopathy (Alfredson & Lorentzon, 2000) as both eccentric and control groups improved significantly (p ¼ 0.001) after a 12-week treatment programme. However, the eccentric group scored much higher (p ¼ 0.014) than the control group, which is in consensus with previous evidence (Alfredson et al., 1998; Mafi et al., 2001). Since the eccentric group had received additional DFM, US and stretching, therefore it is difficult to relate the improvement in experimental group only to eccentric exercise training. It appears that two of the eight participants in the eccentric group did not return to the full activity; however, their performance had increased over the 12 weeks. The results indicate that none of the participants in the control group returned to their previous activity levels.

Consequently, returning to functional activities and preinjury running level is in accordance with all of the above studies, yet most of those studies used different types of measurement tools for the functional ability of their participant. Khan et al (1999) indicate that Achilles tendon recover slowly and therefore a prognosis of 3–6 months is relatively normal. Hence, any rehabilitation programmes should be as long as possible to allow for full structural repair of the tendon and reduce the risk of reoccurrence. Herrington & McCulloch (2007) suggested that the management of Achilles tendinopathy have to be long enough with a minimum 12-weeks treatment programme. “Herrington & McCulloch (2007) study suggests that the addition of a 12-week eccentric exercise programme to conventional treatment of ultrasound and deep transverse frictions is more effective in treating Achilles tendinopathy than conventional treatment alone”.

The study reviewed and other evidence suggests that Achilles tendinopathy should be treated first by conservative methods like US, DFM and eccentric exercise prior to any surgical approach. In addition, this study demonstrated that an additional 12-weeks eccentric training to DFM and US significantly improved (p ¼ 0.001) the functional ability of all participants. This study demonstrated that there are some indications as to the positive effects of eccentric exercise on Achilles tendinopathy; yet, their results are not sufficient to implement in practice as single modality because they had not an eccentric only group. Therefore, further research is required to investigate whether eccentric exercise alone will make such significant functional improvement in athletes with Achilles tendinopathy. In addition, the future studies may investigate how the full recovery of Achilles tendinopathy can be achieved in short period rather than the proposed 3-month prognosis. In conclusion, physiotherapists apply a wide variety of modalities in treating Achilles tendinopathy.

The final goal is a safe and painless return to sports or occupational activity with the maximal restoration of physical fitness components affected by the injury. Thus, further studies have to explore the effects of varying treatment parameters and clinical aspects, to develop therapeutic protocols that may optimize the healing process of repaired tendons in athletes.

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Reference list

Alfredson,H., Pietila, T., Jonsson, P., & Lorentzon, R. (1998). “Heavy load eccentric calf muscle training for the treatment of chronic Achilles tendinosis”. American Journal of Sports Medicine, 26, 360–366

Chestera R., Costac M. L., Shepstoned L, AdeleCooperc, Donellc S. T.(2007). “Eccentric calf muscle training compared with therapeutic ultrasound for chronic Achilles tendon pain” A pilot study, Manual Therapy 13, 484–491

Chukuka S. Enwemeka , Oscar Rodriguez and Sonia Mendosa (1990). “The biomechanical effects of Low intensity ultrasound on healing tendons”. Ultrasound in Medicine and Biology Volume 16, Number 8, 1990

Cook J. L., Khan K. M., Purdam C. (2002) “Achilles tendinopathy” Manual Therapy 7(3), 121–130

Croisier,J, Forthomme, B., Foidart-Dessalle, M., Godon, B., & Crielaard, J. (2001).”Treatment of recurrent tendinitis by isokinetic eccentric exercises”.
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Enwemeka, C. (1989). “The effects of therapeutic ultrasound on tendonhealing: A biomechanical study”. American Journal of Physical Medicine and Rehabilitation, 68, 283–287.

Khan, K,Cook, J., Bonar, F., Harcourt, P., & Astrom, M. (1999). “Histopathology of common tendinopathies update and implications for clinical management”. Sports Medicine, 27, 393–408.

Kvist,M. (1994). “Achilles tendon injuries in athletes”. Sports Medicine18, 173–201.

Mafi N. Lorentzon,R. & Alfredson, H. (2001). “Superior short-term results with eccentric calf muscle training in a randomised prospective multicenter study on patients with chronic AchillesTendinosis”. Knee Surgery Sports Trauma and Arthroscopy, 9, 42–47.

Paavola M., Pekka K., Järvinen T. A.H., Khan K., Józsa L. and Järvinen M. (2002) “Achilles tendinopathy”. J Bone Joint Surg Am; 84:2062-2076.

Robinson, J., Cook, J., Purdam, C., Visentini, P., Ross, J., Maffulli,N., (2001). “The VISA-A questionnaire: A valid and reliable index of the clinical severity of Achilles tendinopathy”. British Journal of Sports Medicine, 35, 335–34

Silbernagel, K., Thomee, R., Thomee, P., Karlsson, J. (2001). “Eccentric overload training for patients with chronic Achilles tendon pain” a randomised controlled. Scandinavian Journal of Medicine Science and Sports, 11, 197–206.

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Advantages and Disadvantages of Quantitative and Mixed Methods When Researching the Effects of Knee Osteoarthritis on Activities of Daily Living in Older Adults.

Author: Navid Zadeh, Senior Physiotherapist, MSc, BSc, MHCPC, NCSP, Physio First UK
Email: info@roseclinicphysio.co.uk

Osteoarthritis (OA) is the most common cause of musculoskeletal pain and disability in older adults. The disease is characterized by joint pain, tenderness, limitation of movement (ROM), crepitus, occasional effusion, and inflammation (Kenneth et al, 2008).

The disease processes not only affect the articular cartilage, but also involve the entire joint, including the subchondral bone, ligaments, capsule, synovial membrane, and periarticular muscles (Kenneth et al, 2008; Deyle et al, 2000). This paper discusses the advantages and disadvantages of quantitative, qualitative and mix methods when researching the effects of knee osteoarthritis in Activities of Daily Living (ADL). The paper will conclude by summarising the key features of each approach and by giving recommendations for the design of the study to be undertaken.

Quantitative designs 

Questions focused on the cause, prognosis, diagnosis, treatment and cost of diseases is best answered by quantitative designs (Roberts and Dicenso, 1999; Neill, 2007; DePoy and Gitlin, 1994). The positivist approach of quantitative or experimental research designs measures “causal relationships between variables” (Howitt and Cramer, 2005, pp.117) in an objective and unbiased manner. For example, this paper aims to measure the relationship between osteoarthritis of knee and functional ability in older adults. The quantitative research is the most rigorous design to determine whether some factor (exposure) causes an outcome and can identify variables of interest in advance. In addition, quantitative methods are more appropriate if we have a specific hypothesis; and we can operationalise the variables and coping strategies (Howit and Cramer, 2005). The causal relationships between the variables in quantitative designs can be measured by experimental hypothesis (Neill, 2007). For instance, (Penninx et al.,2001) measured the causal relationship between physical exercise and prevention of disability in older adults with OA knee. Wherein the authors conclude that extensive exercise programme reduce disability in patients with OA knee and this, improve their activity of daily living (ADL).

Quantitative designs are objective and study precise measurement (DePoy and Gitlin, 1994). For instance, Penninx et al, (2001) have studied the efficacy of exercise on prevention of ADL in patients with OA knee however; this method may miss contextual details (Neill, 2007). In addition, internal validity, external validity can have effects on reliability of evidence produced, for instance, in a RCT, (Deyle et al, 2000) lack of a second treatment group for applying only knee exercise have affected the outcomes, and this can be another disadvantage of quantitative designs (Campbell and Kerlinger 2007; DePoy and Gitlin, 1994). Furthermore, (Roberts and Dicenso, 1999) state that quantitative design can be costly and time consuming projects and may, therefore not be appropriate unless funding can be secured.

The Randomised Controlled Trial (RCT) is the strongest quantitative design for questions of whether healthcare interventions are beneficial (ie, do more good than harm (Roberts and Dicenso, 1999; DePoy and Gitlin, 1994). An RCT is a true experiment in which people are randomly allocated to receive a new intervention (experimental group) or to receive a conventional intervention or no intervention at all (control group) (Roberts and Dicenso, 1999). Because it is, the play of chance alone that determines the allocation the only systematic difference between the groups should be the intervention, which increases the validity of the study by removing likely bias (Roberts and Dicenso, 1999; DePoy and Gitlin, 1994).

Investigators follow participants forward in time (follow up) by measuring the dependant variables and then assess whether they have experienced a specific outcome (Roberts and Dicenso, 1999). For example, the baseline knee extensor strength as dependant variable was significantly lower among women who had no radiographic evidence of knee OA at the initial examination but who had developed OA changes some 30 months later than in women who did not develop radiographic changes of OA (Roberts and Dicenso, 1999).

Standardised questionnaires have been used to measure pain and functional ability (Brandt, 1997; DePoy and Gitlin, 1994). The Western Ontario McMaster Osteoarthritis index (WOMAC) is a validate questionnaire, producing nominal data, which can be analysed statically using non-parametric tests. WOMAC produce measurements for pain, stiffness and difficulty in subjects with OA and has been consistently used in each of the RCT’s mentioned above. For instance, Deyle et al, (2000) have used WOMAC to measure the pain and disability variables in patients with OA knee and used 6- minute walking test to measure the effect of manual therapy and exercise. There are occasions, however, when the evaluation of an intervention using an RCT is not ethical or feasible. In this case, we must rely on a less rigorous design such as the cohort analytic study (also known as a controlled trial).

This study design is similar to the RCT in which there are comparison groups who receive and do not receive an intervention and they are followed up to determine who experiences the outcome of interest (Roberts and Dicenso, 1999). When the outcome of interest is rare or takes a long time to develop, neither RCTs nor cohort analytic studies may be feasible (Roberts and Dicenso, 1999; Howitt and Cramer, 2005). In these circumstances, a case control design is more suitable to study the OA knee.

In a case control design, patients with the outcome of interest (cases) and patients without the outcome of interest (controls) are identified and then the investigator determines whether they have had previous exposure to the causative agent. For instance, investigating the risk factors for OA knee in women, including wearing of high-heeled shoes, can best be studied by case control design. The investigator is able to match the case (OA knee patients) and control group on important variables that may influence the outcome (e.g., age, sex, and other health conditions).

Qualitative designs

Since much of physiotherapy is concerned with understanding and affecting the function and roles of persons in their communities, the possible contributions of qualitative research to care and policy are significant (Morse and Field, 1995). Qualitative research is a useful approach to explore perplexing or complicated clinical situations (Beaton and Clark, 2009). For example, (Pendleton et al, 2005) indicate that an effective, exercise programmes should include advice and education to promote a positive lifestyle change for patient with OA knee. Qualitative research is generally based on non-probability and purposive sampling rather than probability or random approaches (Ploeg, 1999). Questions about the meaning or experience of OA knee are best answered using qualitative designs (DePoy and Gitlin, 1994; Beaton and Clark, 2009). The purpose of qualitative research is to describe, explore, and explain phenomena being studied. For example in this study qualitative research questions can take the form of how evidence based exercise programmes, can affect the social life of patients with OA knee?

Many data collection techniques are used in qualitative research, but the most common are interviewing and participant observation (Beaton and Clark, 2009) and journals, newspapers, letters, books, photographs, and video tapes (Morse and Field, 1995). In addition, unstructured interviews are used when the researcher knows little about the topic, whereas semi-structured interviews are used when the researcher has an idea of the questions to ask about a topic (Campbell, Kerlinger, 2007).

Although the qualitative research is a valuable source of knowledge but because of its unique focus and methodological approach, it cannot be evaluated according to the rules of levels of evidence or meta-analysis developed for quantitative studies. As a result, there is the potential for qualitative research to be undervalued or inappropriately relegated to a ‘lesser’ status of research if these evaluation methods are practised inappropriately or exclusively (Gibson and Douglas, 2002). The most commonly used approaches to qualitative research are phenomenology, ethnography, and grounded theory (Ploeg, 1999; Field, 1995).

The aim of a phenomenological approach to qualitative research is to describe accurately, the lived experiences of older adults with OA knee and not to generate theories or models of the phenomenon being studied (Morse and Field, 1995). Ethnography is another approach to qualitative design. The goal of ethnography is to learn about a culture from the people who actually live in that culture (DePoy and Gitlin, 1994; Morse and Field, 1995). In addition, ethnography is characterized by intensive, ongoing, face-to-face involvement with participants of the culture being studied and by participating in their settings and social worlds during a period of fieldwork (Ploeg, 1999). For example, when researching the life experience of a white OA patient living in Africans country amongst black population, ethnography can be appropriate methodology.

In addition, grounded theory can be used when researcher like to discover socialpsychological processes (DePoy and Gitlin, 1994; Chenitz, and Swanson, 1986) and develop a theory from a body of evidence, rather than verifying theories. For instance, Gignac and Cott, (1998) have used grounded theory to explore the meaning of dependence and in-dependence for older adults with disability. Their indepth analysis of the nature of independence and dependence informs physiotherapists by providing a comprehensive description of the ways that patient interpret and cope with the condition (Gignac and Cott, 1998).

Finally, by integrating qualitative research results such as Gignac and Cott, (1998) into practice, physiotherapists are more likely to understand what matters most to individuals and will be better equipped to work collaboratively with their patients, when formulating policy, or in establishing best practices.

Mix methods designs

Combining qualitative and quantitative approaches can result in a rich data set that provides multiple sources of information to address the research question (Campbell and Kerlinger, 2007; DePoy and Gitlin, 1994; Ploeg, 1999). In addition, by combining quantitative and qualitative methods we can answer multiple research questions, elaborate our findings and confirm the results (triangulation). However, mixed methods may have some disadvantages like contradictory of results, conflict between epistemological paradigms, cost and time consuming. Gibson et al., (2002) have combined quantitative survey, qualitative interviews and philosophical methods (examining competing arguments for logical validity and internal consistency) to examine practice and draw normative conclusions. The survey provided a summary of national practices and attitudes, while the interviews allowed for in-depth exploration of the meaning of terms such as ‘quality of life’ and ‘futility’ that would be otherwise difficult to capture, but were critical to the philosophical exploration (Gibson et al., 2002). In addition, in mix method, qualitative studies complement the limits of quantitative work because they can explicate deeper meaning and complexity associated with questions such as why OA patients decline joint replacement surgery, why they do not adhere to pain and exercise regimens, and why providers do not always provide evidence-based care (Beaton and Clark, 2009). Furthermore, conducting qualitative studies (interviews or focus group) prior or alongside the experimental study will add depth of understanding to the patient experience.

Nevertheless it is obvious that the needs for qualitative and mix method approach is essential to explore the meanings and experiences of subjects living with OA knee. Furthermore combining the experiences of qualitative designs with the experimental research can address many questions about OA that not have been answered adequately.

Conclusion

It is obvious that each research method have its strengths and weaknesses in producing clinical evidence, recommendations and guidelines. To date, the most commonly used forms of research regarding osteoarthritis and its effects on ADL have arisen from quantitative or experimental design. Although, RCTs are the most robust and reliable form of experimental research design, which can measure the effects of OA knee on the ADL, however this approach may not be sufficient to identify the specific needs of the range of client group physiotherapy encounters. Therefore, a more balanced design of research is encouraged where qualitative and quantitative designs are used to complement each other.

Surprisingly, none of the above studies has researched the long-term effect of osteoarthritis on ADL in older adults. Therefore, the author suggests that the future studies may investigate the effects of OA knee on patient’s ADL beyond 1-year. Since the quantitative method in long term is time and cost consuming, therefore the qualitative method would be appropriate design to find the answerer of many unsolved question about the effects of osteoarthritis on patient’s feeling, social and leisure activities in long term.

References

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DePoy E. and Gitlin L.N. (1994) ‘Introduction to research, multiple strategies for health and human services’. Mosby. St Louis. 12009-2316

Deyle, G. D., Henderson N. E., Matekel R. L., Ryder M. G., Garber B. and Allison S. C. (2000) ‘effectiveness of manual physical therapy and exercise in osteoarthritis of the knee’ a randomized controlled trial, Annals of Internal, Volume 132 Issue 3 | Pages 173-181

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Chenitz, W.C., Swanson, J.M. (1986) ‘From practice to grounded theory: qualitative research in nursing’ Addison Wesley Publishing

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Howitt, D. and Cramer, D. (2005) ‘Introduction to research methods in psychology’. Pearson Education Ltd.Essex

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Manual Handling Policy - Load Management, Ergonomics, Patient Handling & Positioning

Author: Navid Zadeh, Senior Physiotherapist, MSc, BSc, MHCPC, NCSP, Physio First UK
Email: info@roseclinicphysio.co.uk

Literature indicates that manual handling injuries are the most common type of work related conditions in the UK (Ariëns et al., 2001, Huang, Feuerstein and Sauter, 2002). According to the Health and Safety Executive (HSE, 2013/14), manual handling is a broad category of work-related injuries, which includes: harms due to carrying, lifting, pushing or pulling loads; sprains, strains; trapped fingers, fractures, falls and cuts from sharp objects. The HSE statistics (2013/14), reveal that 1.3 million of working people are suffering from a work-related illness, and overall 30% of the all injuries in the UK, are caused by manual handling. The National Patient Safety Agency (NPSA) (2012) statics shows that musculoskeletal conditions are accounting approximately 40% of all sickness absences and causing NHS almost £1 billion a year. Based on these statics in In 2015/16, an estimated 25.9 million working days were lost due to absenteeism linked to manual handling incidents, which was downward trend to around 2011/12, and recently the rate has been generally flat.

According to NHS manual handling guidelines work related accidents for some members of staff can result in long periods of sick leave, while for others it may even lead to the end of their career. There are different regulations that enforce all employers to commit to their legal responsibilities and ensure the health and safety of their staff at work as indicated by World Health Organization (WHO) (1999). The Health and Safety at Work Act, which was introduced in 1974, placed general obligations on employers and others to reduce the rate of manual handling incidents.

Since then, a few other regulations have been introduced to manage the manual handling incidents (e.g. the Management of Health and Safety at Work Regulations 1999, Manual Handling Operations Regulations199), which have been reasonably effective according to HSE.

Although there were existing regulations and legislations regarding manual handling incidents in the UK, there was no specific manual handling policy for the NHS staff, except NHS manual handling guidelines. Therefore, the Yeovil District Hospital NHS Foundation Trust recognised the need for an internal robust manual handling policy, specifically developed to manage the work related injuries of their staff more efficiently. Yeovil District Hospital NHS Foundation Trust, runs Yeovil District Hospital in Yeovil, Somerset England, and provides acute care for a about 180,000 people. Each year the hospital admits around 30,000 inpatients and treats more than 90,000 people in the outpatient departments.

Based on the Health and Safety Policy’s statement of intent, the Manual Handling Operations Regulations (2002) and the Risk Management Strategy as recommended by several authors including Hignett, (2003) and Baggott, (2011), who emphesised the correct management of manual handling injuries, Yeovil District Hospital had a legal responsibility to identify requirements concerning the risk managements of their staff for manual handling. This includes all aspects of moving and handling activities, ergonomics, patient handling and positioning (Smedley et al., 1997). Hence, to fulfil the required obligation, the policy group provided a comprehensive action plan for manual handling, load management and the high rate of manual handling incidents, Yeovil District Hospital NHS Trust, introduced the local health services manual handling policy.

The aim of this policy was to establish a detailed risk management strategy to be implemented within the Trust, in order to reduce the risk of injury to both staff and patients, and keep those risks at the lowest level so far as is realistically achievable. The manual handling policy intended to apply to all Yeovil District Hospital NHS Foundation Trust staff, both clinical and non-clinical, including bank/ temporary posts, volunteers and students working within the Trust. The policy had established well-defined and achievable objectives, however it dose not provide sufficient evidence and data on a few subjects (e.g. the prevalence of manual handling incidents in Yeovil District Hospital NHS Trust, prior to implementation of this policy, type of workplace injuries due to manual handling and ergonomics in Yeovil District Hospital). In addition, the policy did not provide appropriate information regarding the initial thoughts and how exactly they came up with this idea to develop this manual handling policy, while a few other regulations and legislations were already introduced. Alternatively, they could just implement the existing regulations or NHS manual handling guidelines and follow the HSE guidelines. Although no information has been provided, but apparently there have been some short falls and gaps in those guidelines, which led to developing this policy and achieving, desired goals, regarding common Occupational and handling injuries (Chaffin and Andersson, 2006).

This policy was proposed by the director of nursing and clinical governance and authored by academy manager. The first provision of the policy was approved on July 2007 and it was reviewed on September 2009, and October 2011. The policy group was responsible to consult and discuss the entire planning process to obtain appropriate data. The policy group consisted of: the trust risk manager, trust health and safety manager, head of operations, head of workforce and HR, Yeovil academy senior team, facilities manager, occupational health lead, resuscitation officer, matrons, etc.

The policy had Equality Impact Assessment (Bambra et al., 2010) on 29th September 2009, followed by reviews on 03/10/11 and 05/06/2014 accordingly. Finally, the policy was audited on 5th June 2014 and was approved by the policy group to be implemented. According to Adult Social Care Outcomes Framework (2014), which shared complementary measures in the health and social care, the fowling factors have to be considered when auditing health policies: comparison of the outcomes, effectiveness of cooperation, intelligible and reflective, safety, cost effectiveness, and equalities. Yet, the effectiveness of these measures needs to be revealed on the next review, on June 2017. The policy had not provided clear information regarding proponents and opponents, as it was an internal policy, preceded by the policy group. Considering the literature statics (HSE, 2015/16; Dellve, Lagerstrom, and Hagberg, 2003), which revealed a high rate of work related injuries amongst NHS staff, an alternative would be a national manual handling policy that could be proposed and applied for all NHS hospitals rather than in Yeovil District Hospital.

The policy considered all measures sufficiently well to prove the feasibility of objectives. This is due to adequate approaches such as vigorous audit and reviews, whereby the appropriate amendments were proposed and applied. In addition, this policy was developed by considering 15 existing legislations and regulations including: Health and Safety at Work Act 1974, Management of Health and Safety at Work Regulations 1999, Manual Handling Operations Regulations 2002, Reporting of Injuries, Diseases and Dangerous Occurrences Regulations (RIDDOR) 1995, Human Rights Act 1998, Equality Act 2010, Safeguarding Vulnerable Groups Act 2006, etc.

Furthermore, the policy had vigorously specified the responsibility of all staff who were involved in the implementation process (Burton, 1997) including: Chief Executive, Chief Finance and Commercial Officer, Senior Managers, Line Managers and Professional Leads, Moving Handling and Ergonomics Advisor, Fire, Health & Safety Advisor, Specialist Handling Personnel and all Staff. This policy had formed a type pyramid system, a simple strategy of monitoring and conducting of tasks, to ensure the appropriate implementation process, as following.

The Chief Executive was the responsible officer for all aspects of health and safety within the Trust. The Chief Finance and Commercial Officer was the director who was responsible for Health and Safety, while ensuring that proper measures were succeeded across the Trust to protect staff and patients from injury. Senior managers, line managers and professional leads, were responsible to manage and co-ordinate all health and safety issues. In addition, they were accountable for making sure that manual handling risk management measures were implemented as specified in this policy. Line managers had an important role to play in the delivery of a safe work setting for staff and were accountable to ensure that their staff follow safe manual handling techniques and conduct safe practices. The Moving Handling and Ergonomics Advisor (MHA) were responsible to act as the Nominated Manual Handling Competent Person (NMHCP) for the Trust and ensure that manual handling risks are successfully accomplished and monitored, with assistance from the Academy Manager. The Fire, Health and Safety Advisor (FHSA) were responsible to provide support and advice to managers, the MHA and local trainers on legal and technical compliance. This support included training and assessments to related staff groups as required assisting management in accomplishing the requirements of this policy. In addition, Specialist Personnel (e.g. physiotherapists, occupational therapists, and Critical Care staff) were required to be frequently updated in their specialist manual handling techniques as considered appropriate by their individual governing bodies to provide essential manual handling principles.

Finally, all staff was responsible to comply with this policy in order to manage their own personal safety and the safety of patients. The policy has provided robust task specification and monitoring process of risk assessments (a method by which harmful hazards were identified and categorized to different risk levels, so that appropriate controls and actions could be taken to reduce the risks). Buehler, W., (1998) indicated that In order to improve the health of the population, a policy has to identify a health problem with continuous and systematic processes of data collection, analysis, and interpretation of descriptive information by linking data from more than one system. Although, this policy had strong links with other previously implemented regulations and legislations, there is not sufficient data regarding its effectiveness and outcomes, as it is a relatively new policy. The next review (2017), will reveal sufficient data and will indicate if the objectives of the policy have been achieved and to what extent. The next review will also identify, if the policy has benefited NHS employees and if it has been recognised as a success or failure by the staff.

Risk management strategy is one the most important tools for implementing an evidence based policy (Jacobs et al., 2012). This policy had developed a robust risk management strategy for several measures, that was based on a “minimal and safer lifting” policy that enabled the Trust to adopt an ergonomic approach and endeavour to work. This means that although manual lifting is part of everyday life and cannot always be totally eliminated or be made perfectly safe, yet unavoidable and hazardous manual handling had to be kept to an absolute minimum, while a sufficient risk assessment was carried out to avoid harms (Burton, 1997). In addition, safer handling methods, based on reliable evidence-based practices, had to be used, whenever possible. In the case of unpredicted imminent life threatening circumstances, a dynamic assessment approach had to be adopted to reduce the
risk of harms.

To adhere to the pre-planned risk management strategy and aid safer clinical handling, moving and ergonomics, the Trust ensured that employees were avoiding any hazardous manual handling tasks whenever possible, assessing clinical and non-clinical manual handling tasks prior to moving, assessing the risk of prolonged working postures that were unavoidable and reducing the level of risk to minimum so far as is practicable. To achieve these goals the policy had clear strategy in respect of risk assessments (Orme et al., 2007). All of the risk assessments comprised action plans, which were to be implemented by the risk assessors. In addition, risk assessments and implementation steps had to be documented and if actions could not be implemented, the line manager had to be informed and an incident report completed.

This policy had a strong reviewing strategy of tasks to reduce the risk of harms and avoid repeating incidents. Based on this review plans, any risk assessment should be carefully considered and reviewed within the appropriate time frame or at least annually, and all changes documented and implemented as required. Other review causes included: following an actual or near miss adverse incident that lead to substantial harm, changes in legislations, changes in employees, change of equipment, procedures/ processes and location. The review outcomes were clearly documented and actions were implemented accordingly.

The policy had set up clear manual handling and ergonomic risk assessment plans to identify any potential harmful (clinical and non-clinical) manual handling or working posture (Dellve, Lagerstrom and Hagberg, 2003). These manual handling and ergonomic risk assessments were conducted by managers and were available for staff to read and refer to them when needed. They had to be kept within the departments for compliance monitoring, reference and audit. To ensure that all assessments were suitable and sufficient, and to measure the risk of moving/handling tasks, the policy had set up the following two criteria and components: individual capability of staff undertaking the task and load (both for object and person), and environment and equipment.

As this is a relatively new policy (2014), and there is not enough data to evaluate the effectiveness or analyze the outcomes. Therefore, this policy will be evaluated based on its benefit and advantages for NHS staff and the prevention of manual handling injuries. Ariëns et al., (2001) indicates that the prevalence of work related injuries, linked to manual handling and ergonomics such as arms, neck, shoulders and back, are at a high level. The high rate of manual handling incidents has been confirmed by other evidence and statics including World Health Organization Statistical Information System (WHOSIS), HSE and NHS data. Therefore, this manual handling policy would certainly be a useful approach to reduce the workplace incidents and prevent many work related injuries, if implemented successfully (Kohatsu, Robinson and Torner, 2004).

Baggott R., (2011) indicated that there are many challenges to an evidence based policy including: a lack of communication between researchers and policy makers, policy makers are not informed about ongoing research, and researchers are not often aware of the policy questions in order to make their research more relevant (Bambra et al. 2010, Jansen et al. 2010). To ensure that this policy overcome these challenges and achieve its objectives, the Trust had four types of vigorous and foreseeable manual handling risk assessments including: equipment risk assessment, patient specific handling profile, general manual handling risk assessment and ergonomic job task analysis. These risk assessments were based upon ergonomic working principles, the execution of safe load management, safe positioning of patients, appropriate handling techniques with provision plan, maintenance and regular inspections of equipment.

The policy had planned some arrangements for ensuring that all actions are carried out appropriately. Therefore, all actions related to executing the risk assessment had to be documented in the risk assessment. In circumstances when actions could not be executed, the line manager had to be informed and an incident report prepared. The incident report had to identify why the risk assessment actions could not be completed and if this was related to the patient, a record had to be included in the patient’s health record too. To ensure that these risk assessments and their outcomes were followed rigorously; the policy has provided a comprehensive safer load management and ergonomic working procedures for managers as attachment.

In addition, staffs were required to conduct safer moving and handling principles, and they had to be educated through compulsory training in line with manufacturer’s recommendations, in conjunction with risk assessments to decrease the risk of incidents. The Trust recognised that the emergency and imminently life threatening situations may not be foreseen and may occur at any time (The NICE Guidelines, 2013). Therefore, the Trust advocated that in these situations, safer handling techniques and equipment should be used to reduce the risk of harm.

Jacobs et al (2012) indicated that training and preparation is an essential role in achieving the objectives of a health policy. Therefore, the Trust had proper strategy to inform, instruct, train and supervise all staff in the observance of the requirements of this policy according to the Corporate and Local Induction for Permanent and Temporary Staff Policy (2007), and the Mandatory Training Policy set out the arrangements for training. In addition, manual-handling training was included in the Trust’s Training Needs Analysis (TNA). All staff (substantive, bank/temporary, voluntary, clinical or non-clinical) including students, had to undertake the proper manual handling training. To ensure that the training and monitoring have been undertaken accordingly, managers had to be informed on staff attendance at training.

Generally implementation of policies are complicated processes and hardly linear or analytical (Jacobs et al., 2012). Simply providing evidence to policy makers and assuming them to take action upon it is not realistic idea. (Jansen et al. 2010). There are several feedback loops concerning basic and applied research, public health activities, monitoring, surveillance, and public opinions in the media (Macintyre S.,2012). Researchers usually promote scientific (objective) evidence, which has been supported empirically and theoretically, even if it required a long period of time (Hunter D., 2003). Conversely, policy makers need evidence, which is colloquial, relevant to context, practical, and timely with clear messages (Baggott, 2011). For instance, in chaotic situations and accidents, policy makers certainly do not gather all the relevant evidence, do not often explore and identify problems and results vigorously. They usually choose the best available alternative, create the policy and implement it, while monitoring and evaluating (Bambra et al. 2010).

The MHA was responsible to monitor the use of agreed manual handling techniques including appropriate risk assessments, equipment, training provision and content by undertaking unexpected compliance spot checks of staff and by trends found in incident reports in all working areas. The Incident reporting system were reviewed by the Health and Safety Committee with data presented by the Health and Safety Manager to review incidents raised as a result of failed actions based on risk assessment. In addition, all risk assessments were supervised through the Trust risk register and local ad hoc compliance checks made by the MHA. Finally, any decision necessary following these checks were sent to the line manager for further action and the Health and Safety Committee were responsible to overview this monitoring actions.

This policy had given clear statement regarding applicability strategy (Buse, Mays and Walt, 2012), which stated, “this applies to all staff both clinical and non-clinical, including substantive and bank/temporary posts, volunteers and students working within Yeovil District Hospital NHS Foundation Trust. Failure to follow this policy may result in disciplinary procedures being taken against individuals who do not follow safe handling practices. The policy had confirmed that it has been assessed and implemented in line with the policy on procedural documents and an equality impact assessment has been carried out to ensure the policy is fair and does not discriminate any staff groups (White Paper, equity and excellence, 2010).

This policy has two attachments (Annex A and B), with a full description of manual handling guidance for managers (A), and equality impact assessment tools (B). ANNEX (A), provided responsibilities of managers in every level, and described details of all task and risk assessments including: safer load management and ergonomic working procedure, patient handling techniques, and equipment provision/ maintenance and inspection procedure. ANNEX B, provided a predesigned tool to assess the equality impact of this policy by evaluating different variable such as ethnic origins, nationality, gender, sexual orientation, age, disability, discrimination, exceptions, legality, justifiably etc. which needs to be completed and forwarded to the relevant committee for consideration and approval with any procedural document.

According to NHS statics (2014), the lack of knowledge and misunderstanding in correct moving and handling is costing the Trust millions every year. In addition, musculoskeletal conditions link to manual handling have been shown to cause a reduction in overall productivity and absenteeism from work (Ariëns et al., 2001). Therefore, both employee and employer need to work together to help implementing this type of health policy to reduce work related injuries. A range of policy initiatives has supported the government’s responsibility in relation to public health since 1997 (Baggott, R., 2004). The concerns in public health are not linked to the lack of comprehensive policies (Brownson, Chriqui and Stamatakis, 2009), but it is associated with the planning process and implementation, where progress has been less inspiring (Crinson I., 2008). Improving public health problems have to be a consistent tendency in all health care systems and all the effort has to be focused on appropriate implementation processes (Lee, Buse and Fustukian, 2001). However, this depends largely on the government strategy on health inequalities, funding and how prioritises the heath care alternatives (Bambra et al.2010).

In addition, WHO (2010) statics indicate that governments lack systematic measures, concerning which research institutions to turn to, and when and how to create contact with academic researches. Consequently, governments are regularly not informed about current research. Literature indicate that there are several factors and unanswered questions (Brownson, Chriqui and Stamatakis, 2009) that affect the outcomes of policy including: policy-oriented research, policy makers pursuit mainly for evidence that supports their position (Palfrey C., 2000), researchers or research institutions have their own plan (e.g. restriction to particular research subjects), limiting related research projects by focusing on trade and growth (Lee, Buse and Fustukian, 2001), political economy considerations, non-existent or inaccessible data, and researchers supply information that policy-makers demand (Jacobs et al.,2012).

Considering public health as a complex adaptive system (Ham C., 2009), an effective health policy would require a new government approach, which facilitates new management systems and skills for the public health staff (Brownson, Chriqui and Stamatakis, 2009). Nonetheless it is not just a case of promoting a set of skills devoid of context (Abel-Smith et al., 1995). Since, context is an important factor, particularly in a subject like public health inequalities (Bambra et al., 2010), which transcends so many groups and professionals, yet there is a long way from achieving such results, unless the capacity for public health practice is enhanced, otherwise the policy in this topic may remain symbolic forever (Baggott R., 2007)

According to NHS statics (2014), the lack of knowledge and misunderstanding in correct moving and handling is costing the Trust millions every year. In addition, musculoskeletal conditions link to manual handling have been shown to cause a reduction in overall productivity and absenteeism from work (Ariëns et al., 2001). Therefore, both employee and employer need to work together to help implementing this type of health policy to reduce work related injuries. A range of policy initiatives has supported the government’s responsibility in relation to public health since 1997 (Baggott, R., 2004). The concerns in public health are not linked to the lack of comprehensive policies (Brownson, Chriqui and Stamatakis, 2009), but it is associated with the planning process and implementation, where progress has been less inspiring (Crinson I., 2008). Improving public health problems have to be a consistent tendency in all health care systems and all the effort has to be focused on appropriate implementation processes (Lee, Buse and Fustukian, 2001). However, this depends largely on the government strategy on health inequalities, funding and how prioritises the heath care alternatives (Bambra et al.2010).

In addition, WHO (2010) statics indicate that governments lack systematic measures, concerning which research institutions to turn to, and when and how to create contact with academic researches. Consequently, governments are regularly not informed about current research. Literature indicate that there are several factors and unanswered questions (Brownson, Chriqui and Stamatakis, 2009) that affect the outcomes of policy including: policy-oriented research, policy makers pursuit mainly for evidence that supports their position (Palfrey C., 2000), researchers or research institutions have their own plan (e.g. restriction to particular research subjects), limiting related research projects by focusing on trade and growth (Lee, Buse and Fustukian, 2001), political economy considerations, non-existent or inaccessible data, and researchers supply information that policy-makers demand (Jacobs et al.,2012).

Considering public health as a complex adaptive system (Ham C., 2009), an effective health policy would require a new government approach, which facilitates new management systems and skills for the public health staff (Brownson, Chriqui and Stamatakis, 2009). Nonetheless it is not just a case of promoting a set of skills devoid of context (Abel-Smith et al., 1995). Since, context is an important factor, particularly in a subject like public health inequalities (Bambra et al., 2010), which transcends so many groups and professionals, yet there is a long way from achieving such results, unless the capacity for public health practice is enhanced, otherwise the policy in this topic may remain symbolic forever (Baggott R., 2007)

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