Physical Therapy- Journal of the APTA, Volume 90, Issue 3 (March 2010)

March 2010  Volume 90  Number 3

Research Reports 338

Balance Impairment in Older Adults

348

Improving Postnatal Well-Being

356

Effects of Resistance Training on Physical Activity

367

Pediatric Endurance and Limb Strengthening

382

Motor Skill Development in Infants With Down Syndrome

391

Rehabilitation Improves Function in Facial Paralysis

398

Interhemispheric Modulation Induced by Cortical Stimulation and Motor Training

Technical Report 411

Case Reports 420

Physical Therapy in the Emergency Department

427

Aerobic Exercise in Spinal Cord Injury Rehabilitation

Perspective 438

Increasing Muscle Extensibility

CARE V Conference Series 450

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Patellar Taping in Patients With Patellofemoral Pain

Patient-Centered Research

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Perturbation-Based BalanceTraining Program for Older Adults

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HRQOL and Robotic-Assisted Therapy for Hand Function

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Supervised Exercise Program for People With Bleeding Disorders and Hemophilic Arthritis

• Intensive Physical Training After Stroke •

Electromyographic Comparison of Exercises With Dumbbells and Elastic Tubing

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Assessment of Risk of Recurrent Falls in Elderly People

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Kinematics of Rising From a Chair

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Construct Validity of Muscle Force Tests

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Cold Modalities and Nerve Conduction

• Therapeutic Exercise Program for Patients Osteoarthritis of the Hip •

Physical Therapist Management of Chronic Fatigue Syndrome/ Myalgic Encephalomyelitis

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Ethics in Nonpharmacological Treatment Research

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Continuing Professional Development in Arthritis Management

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Physical Therapy Journal of the American Physical Therapy Association

Editorial Office Managing Editor / Associate Director of Publications: Jan P. Reynolds, [email protected] PTJ Online Editor / Assistant Managing Editor: Steven Glaros Associate Editor: Stephen Brooks, ELS Production Manager: Liz Haberkorn

Editor in Chief Rebecca L. Craik, PT, PhD, FAPTA, Philadelphia, PA [email protected]

Deputy Editor in Chief Daniel L. Riddle, PT, PhD, FAPTA, Richmond, VA

Editor in Chief Emeritus Jules M. Rothstein, PT, PhD, FAPTA (1947–2005)

Steering Committee

Permissions / Reprint Coordinator: Michele Tillson

Anthony Delitto, PT, PhD, FAPTA (Chair), Pittsburgh, PA; J. Haxby Abbott, PhD, MScPT, DipGrad, FNZCP, Dunedin, New Zealand; Joanell Bohmert, PT, MS, Mahtomedi, MN; Alan M. Jette, PT, PhD, FAPTA, Boston, MA; Charles Magistro, PT, FAPTA, Claremont, CA; Ruth B. Purtilo, PT, PhD, FAPTA, Boston, MA; Julie Whitman, PT, DSc, OCS, Westminster, CO

Advertising Manager: Julie Hilgenberg

Editorial Board

Manuscripts Coordinator: Karen Darley

Director of Publications: Lois Douthitt

APTA Executive Staff Senior Vice President for Communications: Felicity Feather Clancy Chief Financial Officer: Rob Batarla Chief Executive Officer: John D. Barnes

Advertising Sales Ad Marketing Group, Inc 2200 Wilson Blvd, Suite 102-333 Arlington, VA 22201 703/243-9046, ext 102 President / Advertising Account Manager: Jane Dees Richardson

Board of Directors President: R. Scott Ward, PT, PhD Vice President: Paul A. Rockar Jr, PT, DPT, MS Secretary: Babette S. Sanders, PT, MS Treasurer: Connie D. Hauser, PT, DPT, ATC Speaker of the House: Shawne E. Soper, PT, DPT, MBA Vice Speaker of the House: Laurita M. Hack, PT, DPT, MBA, PhD, FAPTA Directors: Sharon L. Dunn, PT, PhD, OCS; Kevin L. Hulsey, PT, DPT, MA; Dianne V. Jewell, PT, DPT, PhD, CCS, FAACVPR; Aimee B. Klein, PT, DPT, DSc, OCS; Kathleen K. Mairella, PT, DPT, MA; Stephen C.F. McDavitt, PT, DPT, MS, FAAOMPT; Lisa K. Saladin, PT, PhD; Mary C. Sinnott, PT, DPT, MEd; Nicole L. Stout, PT, MPT, CLT-LANA

Rachelle Buchbinder, MBBS(Hons), MSc, PhD, FRACP, Malvern, Victoria, Australia; W. Todd Cade, PT, PhD, St. Louis, MO; James Carey, PT, PhD, Minneapolis, MN; John Childs, PT, PhD, Schertz, TX; Charles Ciccone, PT, PhD, FAPTA (Continuing Education), Ithaca, NY; Joshua Cleland, PT, DPT, PhD, OCS, FAAOMPT, Concord, NH; Janice J. Eng, PT/OT, PhD, Vancouver, BC, Canada; James C. (Cole) Galloway, PT, PhD, Newark, DE; Steven Z. George, PT, PhD, Gainesville, FL; Kathleen Gill-Body, PT, DPT, NCS, Boston, MA; Paul J.M. Helders, PT, PhD, PCS, Utrecht, The Netherlands; Maura D. Iversen, PT, ScD, MPH, Boston, MA; Diane U. Jette, PT, DSc, Burlington, VT; Christopher Maher, PT, PhD, Lidcombe, NSW, Australia; Christopher J. Main, PhD, FBPsS, Keele, United Kingdom; Kathleen Kline Mangione, PT, PhD, GCS, Philadelphia, PA; Patricia Ohtake, PT, PhD, Buffalo, NY; Carolynn Patten, PT, PhD, Gainesville, FL; Linda Resnik, PT, PhD, OCS, Providence, RI; Kathleen Sluka, PT, PhD, Iowa City, IA; Patty Solomon, PT, PhD, Hamilton, Ont, Canada

Statistical Consultants Steven E. Hanna, PhD, Hamilton, Ont, Canada; John E. Hewett, PhD, Columbia, MO; Hang Lee, PhD, Boston, MA; Xiangrong Kong, PhD, Baltimore, MD; Paul Stratford, PT, MSc, Hamilton, Ont, Canada; Samuel Wu, PhD, Gainesville, FL

Committee on Health Policy and Ethics Linda Resnik, PT, PhD, OCS (Chair), Providence, RI; Janet Freburger, PT, PhD, Chapel Hill, NC; Alan Jette, PT, PhD, FAPTA, Boston, MA; Michael Johnson, PT, PhD, OCS, Philadelphia, PA; Justin Moore, PT, DPT, Alexandria, VA; Ruth Purtilo, PT, PhD, FAPTA, Boston, MA

Linking Evidence And Practice Advisory Group Rachelle Buchbinder, MBBS(Hons), MSc, PhD, FRACP, Malvern, Victoria, Australia (Co-Chair); Diane U. Jette, PT, DSc, Burlington, VT (Co-Chair); W. Todd Cade, PT, PhD, St. Louis, MO; Christopher Maher, PT, PhD, Lidcombe, NSW, Australia; Kathleen Kline Mangione, PT, PhD, GCS, Philadelphia, PA; David Scalzitti, PT, DPT, PhD, Alexandria, VA

The Bottom Line Committee Eric Robertson, PT, DPT, OCS; Joanell Bohmert, PT, MS; Lara Boyd, PT, PhD; James Cavanaugh IV, PT, PhD, NCS; Todd Davenport, PT, DPT, OCS; Ann Dennison, PT, DPT, OCS; William Egan, PT, DPT, OCS; Helen Host, PT, PhD; Evan Johnson, PT, DPT, MS, OCS, MTC; M. Kathleen Kelly, PT, PhD; Catherine Lang, PT, PhD; Tara Jo Manal, PT, MPT, OCS, SCS; Kristin Parlman, PT, DPT, NCS; Susan Perry, PT, DPT, NCS; Maj Nicole H. Raney, PT, DSc, OCS, FAAOMPT; Rick Ritter, PT; Kathleen Rockefeller, PT, MPH, ScD; Michael Ross, PT, DHS, OCS; Katherine Sullivan, PT, PhD; Mary Thigpen, PT, PhD; Jamie Tomlinson, PT, MS; Brian Tovin, DPT, MMSc, SCS, ATC, FAAOMPT; Nancy White, PT, MS, OCS; Julie Whitman, PT, DSc, OCS

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Subscriptions

Physical Therapy (PTJ) (ISSN 00319023) is published monthly by the American Physical Therapy Association (APTA), 1111 North Fairfax Street, Alexandria, VA 22314-1488, at an annual subscription rate of $12 for members, included in dues. Nonmember rates are as follows: Individual (inside USA)— $99; individual (outside USA)—$119 surface mail, $179 air mail. Institutional (inside USA)—$129; institutional (outside USA)—$149 surface mail, $209 air mail. Periodical postage is paid at Alexandria, VA, and at additional mailing offices. Postmaster: Send address changes to Physical Therapy, 1111 North Fairfax Street, Alexandria, VA 22314-1488. Single copies: $15 USA, $15 outside USA; with the exception of January 2001: $50 USA, $70 outside USA. All orders payable in US currency. No replacements for nonreceipt after a 3-month period has elapsed. Canada Post International Publications Mail Product Sales Agreement No. 0055832.

Members and Subscribers Send changes of address to: APTA, Attn: Membership Dept, 1111 North Fairfax St, Alexandria, VA 22314-1488. Subscription inquiries: 703/684-2782, ext 3124. PTJ is available in a special format for readers who are visually impaired. For information, contact APTA’s Membership Department at 703/684-2782, ext 3124.

Mission Statement

Physical Therapy (PTJ) engages and inspires an international readership on topics related to physical therapy. As the leading international journal for research in physical therapy and related fields, PTJ publishes innovative and highly relevant content for both clinicians and scientists and uses a variety of interactive approaches to communicate that content, with the expressed purpose of improving patient care.

Readers are invited to submit manuscripts to PTJ. PTJ’s content—including editorials, commentaries, letters, and book reviews—represents the opinions of the authors and should not be attributed to PTJ or its Editorial Board. Content does not reflect the official policy of APTA or the institution with which the author is affiliated, unless expressly stated.

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Full-text articles are available for free at ptjournal.apta.org 12 months after the publication date. Full text also is provided through DataStar, Dialog, EBSCOHost Academic Search, Factiva, InfoTrac, ProFound, and ProQuest.

Reprints

PTJ Online at ptjournal.apta.org PTJ Online is available via RSS feeds. PTJ posts articles ahead of print and rapid reader responses to articles. Articles, letters to the editor, and editorials are available in full text starting with Volume 79 (1999) and in searchable PDF format starting with Volume 60 (1980). Entire issues are available online beginning with Volume 86 (2006) and include additional data, video clips, and podcasts.

Indexing and Document Delivery

Readers should direct requests for reprints to the corresponding author of the article. Students and other academic customers may receive permission to reprint copyrighted material from this publication by contacting the Copyright Clearance Center Inc, 222 Rosewood Dr, Danvers, MA 01923. Authors who want reprints should contact June Billman, Cadmus Communications, at 800/4875625, or [email protected]. Nonacademic institutions needing reprint permission information should go to ptjournal.apta.org/misc/terms.dtl.

Advertising

PTJ is indexed and/or abstracted by Abridged Index Medicus, Abstracts of Health Care Management Studies, AgeLine, Allied and Complementary Medicine Database (AMED), Bibliography of Developmental Medicine and Child Neurology, Current Contents, Cumulative Index to Nursing and Allied Health Literature (CINAHL), EMBASE/Exerpta Medica, Exceptional Child Education Resources, Focus on: Sports Science and Medicine, General Science Index (GSI), Health Index, Hospital and Health Administration Index, Index Medicus, Inpharma Weekly, International Nursing Index, ISR, Medical & Surgical Dermatology, MEDLINE, Neuroscience Citation Index, Personal Alert: Automatic Subject Citation Alert (ASCA), Pharmacoeconomics and Outcomes News, Physical Education Index, Reactions Weekly, RECAL Bibliographic Database, Science Citation Index (SCI), Social Sciences Citation Index (SSCI), and SportsS. Article abstracts are available online at ptjournal.apta.org (1980 through present) and via DataStar, Dialog, FirstSearch, Information Access, Ovid

March 2010

Technologies. Ingenta provides online document delivery for articles published since September 1988.

Advertisements are accepted by PTJ when they conform to the ethical standards of the American Physical Therapy Association. PTJ does not verify the accuracy of claims made in advertisements, and acceptance does not imply endorsement by PTJ or the Association. Acceptance of advertisements for professional development courses addressing advanced-level competencies in clinical specialty areas does not imply review or endorsement by the American Board of Physical Therapy Specialties.

Statement of Nondiscrimination APTA prohibits preferential or adverse discrimination on the basis of race, creed, color, gender, age, national or ethnic origin, sexual orientation, disability, or health status in all areas including, but not limited to, its qualifications for membership, rights of members, policies, programs, activities, and employment practices. APTA is committed to promoting cultural diversity throughout the profession.

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Editorial Retaining Trust

W

e all are buried in paperwork and red tape, but we also live in an environment where trust is low and suspicion is high. To ensure even greater transparency in our published work, PTJ is presenting a new and improved conflictof-interest (COI) policy. We are adopting the COI policy and form developed by the International Journal of Medical Journal Editors (http://www.icmje.org/).1 Four types of disclosures are included in this policy: (1) Authors’ associations with commercial entities that provided support for the work reported in the submitted manuscript. (2) Authors’ associations with commercial entities that have an interest in the general area of the submitted manuscript. (3) Any financial associations involving the author or author’s spouse and children younger than 18 years of age. (4) Any nonfinancial associations that may be relevant to the submitted manuscript. Although PTJ has had a COI policy for many years, our adoption of this new policy will contribute to the standardization of a policy among many of the leading biomedical journals. A recent survey of 256 biomedical journals revealed that 89% had COI policies, but there was variation in the definition of COI and in the requirements for disclosure.2 The policy that PTJ has adopted provides standard definitions and disclosure requirements, and the electronic disclosure form (now available at http://ptjournal.apta.org/misc/coi_ disclosure.pdf) can be completed and uploaded to PTJ’s manuscript submission site. This approach should allow authors to save the form and update it as needed for future submissions. Our new policy goes one step further: we are asking Reviewers and Editorial Board members to identify potential conflicts with the topic of the manuscript. This is our attempt to recognize and address any potential bias that our review team may have. At this time, there is limited financial association between most of our authors and commercial entities, and, in those few cases where there is an association, that does not mean that the research has been “tainted.” It is important, however, that the reader is aware of a potential conflict and feels free to evaluate the meaningfulness of the results in the context of a financial association. More importantly, as physical therapists move to develop more interdisciplinary relationships to assist in the translation of basic science and engineering, opportunities to develop relationships with commercial entities are looming, and we want to be prepared. Thank you for helping PTJ to share all the relevant information so that our readers have increased confidence in the findings that authors report.

To comment, submit a Rapid Response to this editorial posted online at ptjournal.apta.org.

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Editorial

Special Thanks On another note, I would like to take this opportunity to thank an Editorial Board Member Extraordinaire. G. Kelley Fitzgerald, PT, PhD, OCS, has served on our Editorial Board for more than 5 years. During this time, he shepherded hundreds of manuscripts and worked with a committee to enhance our case reports. He called last year at this time to say that he had taken on additional responsibilities at the University of Pittsburgh and that he needed to preserve time to oversee his own, very exciting research endeavors. But we managed to hang on to him until he finally begged to leave his PTJ post. Kelley has been an insightful, and delightful, member of our team. He brought new authors to PTJ and was always in touch with our readers, often suggesting meaningful ways to improve the procedures that we use for review of manuscripts and dissemination of content. Never one afraid to express his opinion, Kelley always respected a sound rationale. Kelley, thank you for the endless hours you spent helping to improve the relevance of PTJ for our readers, and, in particular, for our readers who asked for more immediate clinical relevance. Rebecca L. Craik, PT, PhD, FAPTA Editor in Chief References 1 Drazen JM, Van Der Weyden MB, Sahni P, et al. Uniform format for disclosure of competing interests in ICMJE journals. JAMA. 2010;303:75–76. 2 Blum JA, Freeman K, Dart RC, et al. Requirements and definitions in conflict: conflict of interest policies of medical journals. JAMA. 2009;302:2230–2234. [DOI: 10.2522/ptj.2010.90.3.322]

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Editorial Improving the Evidence Base for Physical Therapy Disability Interventions

D

isability is an emerging global issue, as reflected by the first joint World Health Organization (WHO)–World Bank Report on Disability, Rehabilitation, and Inclusion, scheduled to be released by WHO in 2010. Some estimates suggest that 10% of the world’s population has some form of disability—but that figure excludes the families who are affected by a member’s disability.1 According to 2005 US Census Bureau statistics, 54 million (18.7%) people in the United States have some level of disability.2 That number will grow significantly over the next 20 years as the baby-boom generation enters late life, when the risk of disability is greatest. People with disabilities comprise the largest and arguably the most important health care consumer group in the United States; however, as the Institute of Medicine and others have warned,3,4 far too little progress has been made over the past 2 decades in removing obstacles that limit what many people with physical and cognitive impairments can achieve. Part of the challenge might be that disability is complex, multifactorial, and difficult to define. In addition, there is a persistent lack of evidence about strategies to reduce activity limitations and improve participation for people with disability, which hinders the development of sound policy and intervention options. Despite the challenges, this is a time of great innovation: many technological developments provide the opportunity for new strategies and interventions to enhance participation in people with disability. New technologies have the potential to reduce environmental barriers, such as “smarter” homes and buildings that allow tasks to be performed with minimal human input and mobility and communication equipment that minimizes the impact of underlying impairments on function. The usual delivery of therapy services is enhanced by telerehabilitation, which facilitates training via the Web, telephone, or other technology over great distances. New social media are allowing more people with disabilities to connect with one another and support each other in real time in a way that was impossible before. The field of physical therapy can be central to ensuring an optimal future for people with disability across the globe. As Jules Rothstein, Editor in Chief Emeritus, wrote in PTJ’s 1994 special issue on Physical Disability: We began, and I hope will always be seen as, professionals who seek to deal not just with pathologies and impairments, but also with the disabling consequences of diseases, trauma, and developmental anomalies. In essence we became an identifiable group not when we administered massages, heat, exercises, or electrical stimulation, but rather when we chose to collect a body of knowledge and clinical approaches that focused on eliminating disability, when we sought to bring meaningful function back into the lives of those who sought our services.5(p375)

To comment, submit a Rapid Response to this editorial posted online at ptjournal.apta.org.

There is a scarcity of available scientific evidence about the patterns of health conditions and the health care needs of people with disability and about effective interventions for prevention, treatment, and rehabilitation. In addition to the lack of evidence about what works to improve activity and participation of those with disabilities, there also is little evidence about the costs incurred. With the aim of helping to advance science and practice in these areas, PTJ invites original contributions to a special issue, to be published in late 2010/early 2011. Improving the Physical Therapy Evidence Base for Disability Interven-

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Editorial tion will capture the latest research, perspectives, and scholarship. We seek to aggregate and disseminate high-quality disability research on such topics as: • What are the patterns of need for physical therapy in people with disabilities? • What are the key physical therapy interventions that will improve levels of activity and participation for people with disabilities? • What new interventions or technological developments have preliminary evidence of efficacy in improving participation in people with disability? • What is the current state of understanding of the etiology, prevention, and treatment of secondary conditions for people with disability? • Are physical therapy services, technological aids, and universal design features that promote good health and that maximize societal participation accessible to people with disability? • Are there effective ways to reduce environmental barriers for people with disability? • Are there important breakthroughs and advances in the conceptualization, definition, and measurement of disability? • Are there special issues and needs for people aging with a disability compared to those who develop a disability as they age? • What rehabilitation approaches have some evidence of efficacy when used in developing countries? We encourage scientists conducting research relevant to the nexus of physical therapy and disability to contribute to building this crucial knowledge base. PTJ’s special issue will provide a global forum for presenting authoritative empirical research, theoretical development and perspectives, clinical case studies, and related innovative developments. Those interested in contributing to the special issue are asked to forward an outline of your proposed topic for consideration to [email protected]. Alan M. Jette, PT, PhD, FAPTA Nancy Latham, PT, PhD References 1 Mont D. Measuring disability prevalence. SP Discussion Paper No. 0706. Washington, DC: The World Bank; 2007. 2 Brault M. Americans with disabilities: 2005. Current Population Reports. Washington, DC: US Census Bureau; 2008:3. 3 Field M, Jette AM, eds; Committee on Disability in America. The Future of Disability in America. Washington, DC: The National Academies Press; 2007. 4 Disability: beyond the medical model [editorial]. The Lancet. 2009;374:1793. 5 Rothstein JM. Disability and our identity [editorial]. Phys Ther. 1994;74:375–378. [DOI: 10.2522/ptj.2010.90.3.324]

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In Tribute Geoffrey D. Maitland, 1924–2010 Geoffrey D. Maitland, a physical therapy visionary and innovator for more than 4 decades, died on January 22, 2010, in Australia. A pioneer in the use of mobilization for pain modulation, his models for practice and his descriptions of examination and treatment techniques are still used as methodological standards by manual therapy researchers. Maitland authored the classic texts Vertebral Manipulation, now in its 7th edition, and Peripheral Manipulation, now in its 4th edition, both of which have been translated into several languages, including Japanese, Spanish, and German. He wrote extensively for the Australian Journal of Physiotherapy and other journals worldwide. He promoted “research by physical therapists for physical therapists” at a time when prescribing physical therapy interventions was viewed as the role of the physician. In 1965, Maitland presented the first 3-month course on “Manipulation of the Spine,” based at the South Australian Institute of Technology. In 1974, this course developed into the 1-year postgraduate diploma in manipulative physiotherapy and subsequently became a master’s degree course. In addition to serving on various physical therapy committees and boards in Australia, Maitland contributed to the bigger, international picture. In 1974, he participated in founding the International Federation of Orthopaedic Manipulative Therapy (IFOMPT), a branch of the World Confederation for Physical Therapy (WCPT). The founders of IFOMPT wanted to establish a benchmark for the teaching of manual therapy internationally, and the 2008 IFOMPT Educational Standards Document is the culmination of those early efforts, forming the basis of manual therapy education program in member countries. Maitland also inspired the establishment of the International Maitland Teacher’s Association (IMTA). Maitland received numerous honors throughout his career. He was named a Member of the British Empire in 1981 and received the Mildred O. Elson Award from WCPT in 1995 for his life’s work. He was awarded honorary membership in the American Physical Therapy Association in 1992. Maitland’s legacy is reflected in the work of several researchers who have built on his decision-making process and developed it into a structured and evidence-based clinical reasoning framework and who have advanced knowledge, skills, and strategies that address neurogenic and other pain mechanisms. He highlighted the need for deep and broad theoretical knowledge to support and inform clinical practice. In addition to his foundational work in manipulation and mobilization, Maitland has been heralded for fostering patientcentered care and awareness of “the nature of the person” and its impact on treatment. He believed in “the body’s capacity to inform” both verbally and nonverbally and was said to detect the almost imperceptible nuances of the patient’s responses. Maitland died almost 1 year after the death of his wife Anne, who was often present at his lectures and gave him honest feedback. From the beginning, Maitland and his wife developed a robust internal moderation system to ensure quality control and quality assurance of his work. —Submitted by Kevin Banks, Chairman, and Members of The International Maitland Teacher’s Association

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Health Policy in Perspective Comparative Effectiveness Research: Opportunities and Challenges for Physical Therapy Janet K. Freburger, Timothy S. Carey

I

n February 2009, President Obama signed the American Recovery and Reinvestment Act of 2009, which, among other initiatives, appropriated $1.1 billion for comparative effectiveness research (CER). Of that $1.1 billion, $300 million was allocated to the Agency for Healthcare Research and Quality (AHRQ); $400 million to the National Institutes of Health (NIH); and $400 million to the Secretary of the Department of Health and Human Services. The purposes of the appropriations are to: (1) conduct, support, or synthesize research that compares the clinical outcomes, effectiveness, and appropriateness of items, services, and procedures that are used to prevent, diagnose, or treat diseases, disorders, and other health conditions; and (2) encourage the development and use of clinical registries, clinical data networks, and other forms of electronic health data that can be used to generate or obtain outcomes data.1

As applied to health care, CER is simply the evaluation of the impact of different options that are available for treating a given medical condition for a particular set of patients.2 Many believe that CER is a mechanism for decreasing health care costs and improving health care quality, the primary goals of health care reform.2,3 This belief is fueled by 2 major factors: (1) the limited evidence available to patients and providers about what treatments work best for which patients and (2) the fact that there are significant geographic

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differences in health care spending within the United States—but few apparent differences in healthrelated outcomes. The Institute of Medicine (IOM) estimates that less than half of all health care treatments delivered in our nation are supported by adequate evidence.4 Furthermore, many practice guidelines—even those thoughtfully conceived and developed by experts—are based on limited evidence.5 For example, of the 23 Osteoarthritis Research Society International (OARSI) guidelines for the treatment of hip and knee osteoarthritis, 6 are based on expert opinion, and several are based on only moderate evidence.6 Even if evidence is available on the effectiveness of a treatment, we often do not know whether the treatment is effective for all subgroups of patients.2,4,5 Nor do we typically know whether the added benefits of a more expensive treatment warrant the added costs. Sometimes effective treatments are underutilized in all patients or in specific subpopulations, such as minority populations or groups with a low socioeconomic status. For example, our study published in 2009 found that exercise, one of the moderately effective treatments for chronic low back pain, is underutilized and that individuals with less education are less likely to be prescribed exercise.7 Even after accounting for differences in health or “need,” wide geographic variation in the use of

various types of health care has been repeatedly documented in the literature.8–10 This variation in health care use is attributed to the uncertainty about the effectiveness of many types of care. Weinstein and colleagues11 illustrated this concept clearly in their study of lumbar spine surgery rates among Medicare beneficiaries. They found significant geographic variation in surgery rates and attributed this to the uncertainty regarding the effectiveness of lumbar spine surgeries. In contrast, rates for surgical repair of hip fracture, an intervention with strong evidence of effectiveness and minimal tradeoffs between risks and benefits, varied little across the United States. Use of procedures and treatments that have more uncertainty in terms of effectiveness or that have tradeoffs between risks and benefits may vary based on (1) patients’ values and attitudes toward risk and (2) providers’ attitudes, experiences, incentives, and judgments about the treatment. Although most physical therapy interventions carry little risk, the effectiveness of many of our interventions is far from certain. The aim of CER is to improve health care quality by providing patients, health care providers, and other stakeholders with better information about the risks and benefits of different treatment options. In addition to identifying effective treatments, CER should educate about tests and treatments of limited effectiveness. Because there is so much uncertainty about the effectiveness and relative effec-

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Health Policy in Perspective tiveness of medical treatments, many believe that CER could eventually alter the way in which medicine is practiced and lead to lower health care spending without having adverse effects on health.2

Defining Comparative Effectiveness Research As CER has come to the forefront as a mechanism to improve health care, several public and private agencies have created definitions for the term “comparative effectiveness research.”5 Although these definitions differ slightly in their wording, they all emphasize that CER involves the direct comparison of the effectiveness of 2 or more interventions in “real world settings” and that its purpose is to inform patients, providers, and decision makers about what interventions are most effective for what patients under what circumstances. The definition from the IOM states: Comparative effectiveness research is the generation and synthesis of evidence that compares the benefits and harms of alternative methods to prevent, diagnose, treat, and monitor a clinical condition or to improve the delivery of care. The purpose of CER is to assist consumers, clinicians, purchasers, and policy makers to make informed decisions that will improve health care at both the individual and population levels.5

What is lacking from the IOM definition is a specific mention of costs. There is disagreement as to whether costs should be incorporated into CER.3,12 Costs can be defined in different ways and from different perspectives (eg, patient, private insurer, society). Because costs can vary dramatically depending on the perspective, there is concern that results of cost analyses may be

used inappropriately to make decisions regarding pricing, coverage, and reimbursement. Opponents also argue that reducing uncertainty through clinical effectiveness research—rather than through cost effectiveness research—is a more valuable use of scarce research dollars. Proponents of including costs in CER argue that costs are already a part of the decision-making process regarding coverage and health care services and that not including costs does not adequately address the problem of rising health care costs.

Is Comparative Effectiveness Really Something Novel? In a broad sense, CER is nothing new. Scientists have been comparing the effectiveness of different interventions for decades. Relative to efficacy research, however, CER is lagging behind. Efficacy studies are randomized, controlled trials comparing an intervention to a control (often a placebo or a sham treatment) on a carefully selected group of subjects under controlled conditions. Although these types of studies are considered the “gold standard” for determining the effects of an intervention, their findings often are not generalizable to broader populations and settings or to certain subgroups that may have been excluded from the study. Subgroups often excluded from efficacy trials include the elderly and those with multiple coexisting conditions. Comparative effectiveness research utilizes a variety of data sources, including systematic reviews of existing literature and analysis of secondary data, such as claims data, patient registries, and electronic health records. Study designs include nonexperimental studies, such as prospective cohort studies and practical experimental clinical

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trials (eg, head-to-head pragmatic randomized trials, clustered randomized trials). The AHRQ has been supporting CER for many years through its Effective Health Care Program (EHC).13 The EHC program consists of Evidence Based Practice Centers (EPCs), the Developing Evidence to Inform Decisions about Effectiveness (DEcIDE) network, Centers for Education and Research on Therapeutics (CERTs), and the John M. Eisenberg Clinical Decisions and Communications Science Center. Each of these centers performs a variety of activities related to the various aspects of CER. The Eisenberg Center, in particular, focuses on distilling and disseminating the EHC reports for providers and the public. Although many of the activities of the EHC have not specifically focused on physical therapy–related issues or interventions, one EPC review currently underway is the Comparative Effectiveness of NonOperative and Operative Treatments for Rotator Cuff Repair. Several reports on methodologies for CER are also available and may be of use for physical therapy researchers interested in learning more about CER. In addition, 3 of the 14 CERTs focus on topics particularly relevant to physical therapists: musculoskeletal disorders, therapies for older adults and the effects of aging, and pediatric therapeutics. A final key aspect of the EHC program is that it seeks strong involvement of all stakeholders (eg, patients, clinicians, researchers, health care payers, professional organizations). Interested individuals can nominate topics to be researched and can submit comments on drafts of proposed research and reports through the EHC Web site (www.effective healthcare.ahrq.gov).

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Health Policy in Perspective • Compare the effectiveness of primary prevention methods, such as exercise and balance training, versus clinical treatments in preventing falls in older adults at varying degree of risk. • Establish a prospective registry to compare the effectiveness of treatment strategies for low back pain without neurological deficit or spinal deformity. • Compare the effectiveness of school-based interventions involving meal programs, vending machines, and physical education, at different levels of intensity, in preventing and treating overweight and obesity in children and adolescents. • Compare the effectiveness of various strategies (eg, clinical interventions, selected social interventions [such as improving the built environment in communities and making healthy foods more available], combined clinical and social interventions) to prevent obesity, hypertension, diabetes, and heart disease in at-risk populations such as the urban poor and American Indians. • Compare the effectiveness of interventions (eg, community-based multi-level interventions, simple health education, usual care) to reduce health disparities in cardiovascular disease, diabetes, cancer, musculoskeletal diseases, and birth outcomes.

Figure 1. Priorities in the Insititute of Medicine’s top quartile that are relevant to physical therapists.

What Does Comparative Effectiveness Research Mean for the Physical Therapy Profession? There is no question that CER is relevant to physical therapy. In reviewing the IOM’s list of initial national priorities for CER,5 we identified 5 topics in their upper quartile of priority that were particularly rel-

evant to physical therapy (Fig. 1). In addition, several of the remaining 75 topics were relevant. Many of the priority conditions and populations that are a focus of AHRQ’s CER projects also are of interest to physical therapy (Table). Priority conditions and populations are cross-cutting themes in the strategic framework of the Federal Coordinating Council

Table. Agency for Healthcare Research and Quality: Priority Conditions and Populations Priority conditions

Priority populations

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• Arthritis and nontraumatic joint disorders • Cancer • Cardiovascular disease, including stroke and hypertension • Dementia, including Alzheimer disease • Depression and other mental health disorders • Developmental delays, attention-deficit hyperactivity disorder, and autism • Diabetes mellitus • Functional limitations and disability • Infectious diseases, including HIV/AIDS • Obesity • Peptic ulcer disease and dyspepsia • Pregnancy, including preterm birth • Pulmonary disease/asthma • Substance abuse • Racial and ethnic minorities • Persons with disabilities • Children • Elderly • Patients with multiple and chronic conditions • Disadvantaged and/or under-represented populations for the specific condition being studied

for CER14 (Fig. 2). This framework groups investments and activities of CER into 4 major categories and serves as a useful point of departure for considering physical therapists’ efforts and roles in this area. Research Research is needed to better understand the comparative effectiveness of physical therapy interventions relative to other medical/surgical interventions and relative to other physical therapy interventions. To better understand the usefulness of physical therapy within the context of the larger health care system, the comparison of physical therapy interventions to other medical/ surgical interventions is important. Such research across disciplines is challenging, however, because it requires multidisciplinary, collaborative efforts that may take time to develop and that require understanding different disciplinary perspectives. Physical therapy also needs to look within its own practices to determine which interventions are most effective and for whom. Too often the term “physical therapy” has been used as a poorly described bundle of heterogeneous services, similar to the way the term “usual care” is applied. Physical therapist researchers also need to consider that certain interventions, although often delivered by physical therapists, are not necessarily specific to the profession. Interventions such as exercise and manipulation may be delivered by various health care providers. In addition to demonstrating the comparative effectiveness of such interventions, it would be useful to determine whether certain types of providers are more or less effective in delivering those interventions. The IOM report and AHRQ emphasize that CER can compare systems of care as well as specific treat-

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Health Policy in Perspective but will facilitate growth in this type of physical therapy researcher.

Figure 2. Strategic framework for Comparative Effectiveness Research (CER). Adapted with permission from Federal Council on Coordination of CER.14

ments. Comparing the effectiveness of treatments delivered by different providers is an example of comparing systems of care. Other systems analyses could include comparing the effectiveness of different combinations of treatments or of different numbers of provider visits. In addition to focusing CER on priority conditions and populations, some suggest targeting interventions that exhibit significant geographic variation in use.14 We know little about practice variation in physical therapy. Some of our research suggests that physician referral to physical therapy for the treatment of musculoskeletal conditions varies by census region,15,16 as does use of physical therapy by community-based Medicare beneficiaries.17 More research in this area would be useful to identify conditions and services to target for future research. Another area that will be particularly useful to target are the research gaps identified in newer systematic reviews. Planned CER

initiatives will endeavor to provide more rapid-turnaround research to fill these gaps and address policyrelevant research needs. Human and Scientific Capital Investing in the future of researchers and training individuals in CER is important to maintain the enterprise. Physical therapists are expanding beyond traditional PhD programs with more individuals pursuing degrees in health services research and epidemiology. This should continue to remain a priority for the profession. Because training in these areas opens the door to many career opportunities, one challenge will be keeping these individuals connected to the profession. Academic physical therapy program chairs need to recognize the value of having such individuals connected with their departments. Exposing professional students to the area of health services research, and to CER in particular, not only will increase their understanding of the value of this type of research

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The Foundation for Physical Therapy’s recent establishment of a new research funding opportunity— the New Investigator Fellowship Training Initiative in Health Services Research—is one avenue for training of physical therapists in CER and health services research. The AHRQ will also be increasing training opportunities in CER over the next several years through its T32 mechanism for predoctoral and postdoctoral fellowships and through K12 institutional career development awards. The latter awards will provide institutions with several 75%-supported positions for faculty start-up funds and career development. A final human capital path is through the 46 Clinical Science and Translational Award (CTSA) institutions that have been established throughout the country via NIH funding. Each CTSA institution supports several research career development positions. The physical therapy profession should help disseminate information about these different training opportunities, keep abreast of new opportunities, and encourage graduate students and junior faculty to take advantage of these opportunities. CER Data Infrastructure Data infrastructure is a key aspect of CER and includes the development of patient registries and distributed health data networks. Currently, research too often consists of a one-time effort in which the data-gathering infrastructure is not maintained over time. An enhanced infrastructure will allow ongoing analyses of care patterns and outcomes over time. A patient registry is “…an organized system that uses observational data methods to collect uniform

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Health Policy in Perspective data (clinical and other) to evaluate specified outcomes for a population defined by a particular disease, condition, or exposure and serves a predetermined scientific, clinical or policy purpose(s).”18 A distributed health data network, or federated data network, is a system that allows secure, remote analysis of a collection of geographically and organizationally separate databases that are treated as one entity and viewed through a single user interface.19 Such networks facilitate sharing and interchanges of data among autonomous databases, such as electronic health records located within different organizations. Distributed data networks are particularly appealing because they allow data holders to retain physical control over their data, thereby eliminating some of the barriers related to confidentiality and proprietary interests. The establishment of APTA Connect and APTA’s vision for a national outcomes database have been timely, strategic moves in the context of CER data infrastructure. The Focus on Therapeutic Outcomes (FOTO) database also has the potential to facilitate CER in physical therapy.20 Because electronic data collection serves as the basis for distributed health data networks and patient registries, the profession should strive to increase the adoption of electronic health records (EHRs). Health information technology is a rapidly moving field, and interoperability issues will be critical. In addition, the profession should keep abreast of the development of distributed data networks and registries that are relevant in regard to physical therapy populations and identify ways in which to partner with stakeholders involved in these networks and registries. Finally, the profession should consider how to partner with key stakeholder groups to develop a distributed data network or patient registry focused March 2010

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on issues and populations that are relevant to physical therapy. Dissemination and Translation of CER Research articles and federal reports are often lengthy, with substantial technical language. Providers need brief abstracts of the best available evidence. Professional societies can serve as one dissemination conduit, as can hospitals and outpatient practice administration. An as-yet underused but exciting dissemination tool will be the incorporation of CER findings into EHRs—for example, reminding providers of the most effective interventions for the patient’s condition. Although straightforward in concept, such dissemination tools will be challenging. We will need to keep information up-to-date, work with EHR vendors, and avoid overloading providers with prompts and reminders.

Conclusions A considerable amount of money and effort currently are being invested in building the foundation for a CER enterprise. Physical therapy will be well served by joining the effort. The time seems right for several reasons: • The evidence base for practice has grown enough that we can synthesize evidence across multiple studies for many physical treatments. Sometimes the evidence base will be sufficiently strong to arrive at conclusions regarding treatment effectiveness; in other cases, we will be able to arrive at much more specific recommendations for future research. • The movement for reform of the health care system is both an opportunity and a challenge to providers to demonstrate that their treatments are effective and provide value to the health care system.

• The rapid dissemination and interoperability of EHRs should speed both the conduct of comparative effectiveness research as well as its dissemination. Although the physical therapy profession has lagged somewhat behind other health professions in their use of EHRs, that will likely change in the very near future. • Patient-centered care has been and continues to be a primary focus of physical therapy. The physical therapist works with the patient to develop a plan of care and treatment goals that are consistent with the patient’s values and needs. This attribute of care will serve the profession well as we attempt to gain a better understanding of what works best, for whom, and when. We have seen many positive changes in the delivery of physical therapy in response to the evidence-based practice movement. CER has the potential to transform health care delivery even more dramatically. Getting in on the ground floor of the CER movement will accelerate advancement of the physical therapy profession, lead to the delivery of higher quality care, and ultimately improve the health of individuals with activity and functional limitations. J.K. Freburger, PT, PhD, is Research Associate and Fellow at the Cecil G. Sheps Center for Health Services Research, and Research Scientist at the Institute on Aging at the University of North Carolina, in Chapel Hill North Carolina. T.S. Carey, MD, MPH, is Director at the Cecil G. Sheps Center for Health Services Research, and Professor in the Departments of Medicine and Social Medicine. The authors would like to thank Kendra Heatwole Shank, MS, OTR/L for her assistance in the preparation of this manuscript. This work was partially supported through multiple task order contracts from the Agency for Healthcare Research and Quality to the RTIUNC Evidence-based Practice Center. DOI: 10.2522/ptj.2010.90.3.327

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Health Policy in Perspective References 1 American Recovery and Reinvestment Act of 2009, Pub L No. 111-5. 123 Stat. 115–521. 2 Congressional Budget Office. Research on the Comparative Effectiveness of Medical Treatments: Issues and Options for an Expanded Federal Role. December 2007. Available at: http://www.cbo.gov/ ftpdocs/88xx/doc8891/12-18-Compara tiveEffectiveness.pdf. Accessed on October 28, 2009. 3 Kaiser Permanente Foundation. Explaining Health Reform: What Is Comparative Effectiveness Research? Focus on Health Reform. October 2009. Available at: http:// www.kff.org/healthreform/upload/7946. pdf. Accessed October 28, 2009. 4 Olsen LA, Aisner D, McGinnis JM, eds. The Learning Healthcare System: Workshop Summary (IOM Roundtable on EvidenceBased Medicine). Washington, DC: National Academies Press; 2007. Available at: http://www.nap.edu/catalog.php?record_ id=11903#toc. Accessed October 28, 2009. 5 Committee on Comparative Effectiveness Research Prioritization, Board on Health Care Services, Institute of Medicine. Initial National Priorities for Comparative Effectiveness Research. Washington, DC: National Academies Press; 2009. Available at: http://books.nap.edu/openbook. php?record_id=12648. Accessed October 28, 2009. 6 Zhang W, Moskowitz RW, Nuki G, et al. OARSI recommendations for the management of hip and knee osteoarthritis, part II: OARSI evidence-based, expert consensus guidelines. Osteoarthritis Cartilage. 2008;16(2):137–162.

7 Freburger JK, Carey TS, Holmes GM, et al. Exercise prescription for chronic back or neck pain: who prescribes it? Who gets it? What is prescribed? Arthritis Rheum. 2009;61(2):192–200. 8 Wennberg JE, Fisher ES, Goodman DC, Skinner JS. Tracking the Care of Patients With Severe Chronic Illness: The Dartmouth Atlas of Health Care. Lebanon, NH: The Dartmouth Institute of Health Policy and Clinical Practice; 2008. Available at http://www.dartmouthatlas. org/atlases/2008_Chronic_Care_Atlas.pdf. Accessed October 28, 2009. 9 Fisher ES, Bynum JP, Skinner JS. Slowing the growth of health care costs—lessons from regional variation. N Engl J Med. 2009;360(9):849–852. 10 Fisher ES, Wennberg DE, Stukel TA, et al. The implications of regional variations in Medicare spending, part 2: health outcomes and satisfaction with care. Ann Intern Med. 2003;138(4):288–298. 11 Weinstein JN, Lurie JD, Olson PR, et al. United States’ trends and regional variations in lumbar spine surgery: 1992-2003. Spine. 2006;31(23):2707–2714. 12 Gluck ME. Research Insights: Incorporating Costs Into Comparative Effectiveness Research. Washington, DC: Academy Health; 2009. Available at: http://www. academyhealth.org/files/publications/ ResearchInsightsCER.pdf. Accessed October 28, 2009. 13 Agency for Healthcare Research and Quality. Effective Health Care Program. Available at: http://effectivehealthcare.ahrq. gov/. Accessed October 28, 2009.

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14 Federal Coordinating Council for Comparative Effectiveness Research. Report to the President and Congress. Washington, DC: Department of Health and Human Services; 2009. Available at http://www.hhs. gov/recovery/programs/cer/cerannualrpt. pdf. Accessed October 28, 2009. 15 Freburger JK, Carey TS, Holmes GM. Physician referrals to physical therapists for the treatment of spine disorders. Spine J. 2005;85(5):530–541. 16 Freburger JK, Holmes GM, Carey TS. Physical referrals to physical therapy for the treatment of musculoskeletal conditions. Arch Phys Med Rehabil. 2003;84(12):1839– 1849. 17 Freburger JK, Holmes GM. Physical therapy use by community-based older people. Phys Ther. 2005;85(1):19–33. 18 Gliklich RE, Dreyer NA, eds. Registries for Evaluating Patient Outcomes: A User’s Guide. Rockville, MD: Agency for Healthcare Research and Quality; April 2007. AHRQ Publication No. 07-EHC001-1. 19 Pace WD, West DR, Valuck RJ, et al. Distributed Ambulatory Research in Therapeutics Network (DARTNet): Summary Report. Rockville, MD: Agency for Healthcare Research and Quality; July 2009. Available at: http://effectivehealthcare.ahrq.gov/ ehc/products/53/151/2009_0728DEcIDE_ DARTNet.pdf. Accessed October 28, 2009. 20 Deutscher D, Hart DL, Dickstein R, et al. Implementing an integrated electronic outcomes and electronic health record process to create a foundation for clinical practice improvement. Phys Ther. 2008;88:270–285. Epub 2007 Nov 27.

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Special Communication The Added Value of Confidence Intervals Paul W. Stratford

S

ince its formal introduction in 1991, evidence-based medicine/practice has received considerable attention. Defined as “the conscientious, explicit, and judicious use of best evidence in making decisions about the care of individual patients,”1 evidence-based practice embraces the integration of best research evidence, clinical expertise, and patient values.2 Clinicians are active participants not only in applying their expertise, but also in seeking out and interpreting research evidence. To allow the optimal transfer of information from research report to clinical practice, researchers must present their findings in an easy-to-understand format that provides the maximum amount of information efficiently.

sonal beliefs, risk of an adverse event, cost, and the feasibility of providing the intervention, test, or measure in practice. Because clinicians—and researchers for that matter—are likely to have different opinions concerning the magnitude of a clinically important difference, it is essential that authors provide their results in a manner that informs the widest audience and that the audience is equipped to interpret the information. Confidence intervals (CIs) convey both statistical and clinical information to assist clinicians with their decision making. The following example is offered to illustrate the communicative advantage that CIs have over P values.

Clinical Illustration

When interpreting the results from studies investigating the merits of competing therapeutic interventions, the reliability or validity of clinical measurements, or the causal association of putative risk factors, clinicians and researchers are interested in the answers to 2 important questions: (1) Are the results likely due to chance? and (2) Are the findings clinically important? The former question considers statistical significance, and the latter question addresses clinical significance.

This illustration considers the results from 4 hypothetical randomized clinical trials. For each study, the research question was: In patients with low back pain of 8 to 12 weeks’ duration, is there a difference between interventions A and B in the proportion of successful outcomes following 2 weeks of treatment? A successful outcome was defined as a 2-point reduction in pain, as measured by an 11-point (0–10) numeric pain rating scale. The investigators formed the following hypotheses:

Statistical significance is dictated by tradition, with a critical P value of .05 typically being the requisite minimal value. Statistical significance is influenced by sample size, sample variability, and the magnitude of the observed effect. In contrast to the arbitrary standard for statistical significance, clinical importance is influenced by per-

Null hypothesis: There will be no difference in the proportion of successes (π) between groups A and B (Hnull: πA = πB).

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Alternate hypothesis: There will be a difference in the proportion of successes between groups A and B (Halternate: πA ≠ πB).

Consistent with the alternate hypothesis, a 2-tailed test of significance was applied, and the critical P value for rejecting the null hypothesis was set at P≤.05. The investigators reported P values and 95% CIs on the betweengroup difference in the proportion of patients with a successful outcome. To complete the vignette, suppose we are treating patients with intervention B; however, we would consider acquiring the skills necessary to implement treatment A if there is a good chance that it would truly increase the proportion of patients who would achieve a successful outcome by 0.15 (15%), which is considered, for the purposes of this example, to be the minimal clinically important difference (MCID). Two studies produced negative results (P>.05), and the other 2 studies yielded positive results (P.05). In addition, the difference in the observed success proportions of 0.05 was much less than the designated MCID value of 0.15. Armed with this information alone, as is the case when investigators present P values only, 2 questions arise: (1) Is the sample size sufficiently large to detect a difference if one truly exists? and

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The Added Value of Confidence Intervals Table 1.

Results From the Negative Studies Difference in Success (95% Confidence Interval)

Study No.

Sampe Size per Group

Treatment A (Successes/n)

Treatment B (Successes/n)

1

100

30/100=0.30

25/100=0.25

0.05 (−0.073, 0.173)

.428

2

200

60/200=0.30

50/200=0.25

0.05 (−0.037, 0.137)

.263

Study No.

Sampe Size per Group

Treatment A (Successes/n)

Treatment B (Successes/n)

3

30

18/30=0.60

9/30=0.30

0.30 (0.06, 0.54)

.037

4

100

60/100=0.60

30/100=0.30

0.30 (0.17, 0.43)

8 Weeks) and Chronic Stretching Programs The effect of longer-term stretching programs (⬎8 weeks) and rigorous chronic stretching regimens on passive torque/angle curves has not yet been evaluated.14

Conflicts in Research Conflicting Terminology Throughout the rehabilitation literature regarding the effects of stretching, confusion arises due to inconsistent use of terminology among studies. Some of the above-cited studies confirmed that increases in muscle extensibility occurred after stretching, whereas others claimed that muscle extensibility did not in-

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crease. On the surface, it appears that these studies had conflicting results, but the difference merely resides in the definition of muscle extensibility. The studies reporting increases in muscle extensibility used a sensory endpoint, which indicates that the selected sensation had onset later during stretch application, allowing increases in end-range joint angles.15,59 The studies reporting no increases in muscle extensibility used an endpoint of standardized torque, which gives some evidence that there was no shift of the torque/angle curves or change in muscle stiffness.61,62,65 Taken together, the findings of all of these studies support the sensory theory to explain increases in end-range joint angles. Conflicting Interpretations Although the results of many of the supporting studies were similar, not all of these studies attributed the findings to a change in sensory perception.43– 45,64 Some studies43– 45 suggest instead that because there is increased applied torque, a longer torque/angle curve, and increased end-range joint angles, the stretching program has induced structural changes within the muscle, such as increased sarcomeres in series and a mechanical increase in muscle length. If an increase in the number of serial sarcomeres is accompanied by an increase in length of the muscle, there should be an observable right shift in the entire passive torque/angle curve similar to the shift in passive length/tension curves shown in the animal studies (Fig. 1).39,40,67 Without a concurrent right shift in passive torque/angle curves, there is no evidence of an increase in muscle length. The theory of structural adaptation occurring after a short-term stretching program also does not explain similar increases seen immediately after a single stretching session that occur

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Increasing Muscle Extensibility without a regimented stretching program.14,25,59,60 Conflicting Results Although there is growing evidence to support the theory that increases in muscle extensibility observed after stretching are due to modified sensation only, there are a few conflicting reports. In a study of ankle plantar-flexor muscles, Guissard and Duchateau68 observed a right shift of torque/angle curves that occurred over a 6-week training period. This result may have been due to the vigorous design of the stretching program, which was performed 5 days per week and took 20 minutes to complete. This stretching dosage for a single muscle group on a single limb is well in excess of the 15 to 150 seconds29,44,64,69,70 of daily stretch typically used in sports and research but may be applicable in rehabilitation settings. Thirty days after the stretching program ended, increases in extensibility and muscle length were partially maintained. More research is needed to determine: (1) whether increases in muscle length are an appropriate and desirable outcome of treatment and (2) the most efficient therapeutic intervention and dosage to induce and maintain length increases.

A Multidimensional Approach to Evaluating Muscle Length The sensory theory of increasing muscle extensibility demonstrates how multidimensional muscle length testing can enhance basic knowledge about muscle adaptation. Evaluation techniques that include multiple dimensions of muscle length (eg, extensibility measurements, torque and cross-sectional area) provide tools to better assess muscle status and the effect of therapeutic interventions.

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Muscle Extensibility Muscle extensibility is a critical dimension of muscle length. Tests of extensibility (traditionally called “muscle length tests”) were developed with the idea that there is a “normal” or ideal range of muscle extensibility that promotes optimal kinematics, resulting in efficient motion, enhancing the ability to adapt to imposed stresses, and potentially decreasing the risk of injury.71,72 It is suggested that when a particular muscle or muscle group demonstrates insufficient extensibility (appearing to be “short”), motion between joint surfaces that the muscle crosses may be limited, resulting in restricted joint motion. When the muscle or muscle group demonstrates excessive extensibility (appearing to be “long”), motion between the joint surfaces also may be excessive, resulting in excessive joint motion. Whether insufficient or excessive, a deviation from optimal extensibility is thought to precipitate unusual wear patterns on capsular structures and articular surfaces of involved joints. It is suggested that deviations from optimal extensibility contribute to muscle imbalances, faulty posture, and dysfunctional movement.71,73 Although guidelines for what constitutes insufficient, optimal, and excessive extensibility measurements are based on the science of kinematics, their clinical validity has rarely been studied. Although kinematic analysis is concerned with the motion that occurs at the joint and can identify the clinical extensibility measurements that are theoretically optimal, it is not concerned with analyzing the forces causing the motion.1,72 Except in cases where bony approximation is the limiting factor, this type of analysis does not clearly define what should constitute the endpoint of stretch application. Perhaps this is

the reason that stretch endpoints often are poorly defined and inconsistent among texts and research studies and in clinical practice. An endpoint of the examiner’s perception of “(firm) resistance” is suggested in some texts72,74 and often is used in research, although many studies did not measure the amount of applied torque required to reach this point.35,49,53,69,70 The validity and reliability of this endpoint are highly questionable because without quantitative measurement, there is no way to be certain that torque is being applied consistently.75 There also is evidence that the amount of torque applied by trained therapists can vary markedly—as much as 40fold for a single subject.76 Even if torque were standardized, how would the most clinically relevant torque be determined? The importance of subject sensation as an endpoint has largely been overlooked. To date, endpoints of subject sensation are widely used in research, but basic texts describing muscle extensibility assessment have not clearly and unequivocally made this recommendation. Is passive muscle stiffness necessary to stop joint motion, or is it possible that just the subject’s sensory perception of stiffness or perception of moderate stretch can be a limiting factor? Studies evaluating the biomechanical effects of stretching reveal that in controlled clinical settings under the condition of slowly applied passive stretch, it is subject sensation—not the degree of stiffness—that limits joint motion. Researchers have been able to apply passive torque up to the sensory endpoint of pain25,58 or stretch tolerance15,59 without being limited by stiffness. It seems reasonable that subject sensation could both alter and reflect the way the tested muscle is routinely used in function. Further research is needed to determine whether subject sensa-

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Increasing Muscle Extensibility tion is a significant factor in limiting joint motion during functional motion and whether muscle extensibility measurements are truly a reflection of the way muscles are used during function. Although subject sensation is the most frequently used endpoint in human stretching research, there is little consensus regarding which sensation is most relevant clinically. A wide range of sensations has been used in research, from the subject’s perception of a “pull,”47 to varying degrees of: • • • • • •

“resistance”16,37 “stretch”15,17,19,20,22,42,44,45,59,63 “discomfort”7,29,33,69 –71 “tightness”25,26,28,58,69,70,77 “stiffness”78 “pain”7,15,18,25,26,58,60,64,79

A change in endpoints from detection of the “first sensation of pain” to pain or stretch tolerance can result in a change in end-range joint angles that varies markedly among subjects.15 This has been demonstrated in the hamstring musculature of otherwise “normal” subjects assessed with “short” hamstring muscles to range anywhere from no change at all to a 20-degree increase in endrange joint angle values.15 Further research is needed to assess which sensation is most clinically relevant. Subject sensation is—at the very least—an important endpoint of the torque/angle curve and may give information regarding how the muscle is routinely used during functional activity. However, extensibility measurements alone are only one dimension of muscle length and may not accurately reflect the actual length of the muscle. This has been demonstrated repeatedly in studies that included evaluation of torque80 and cross-sectional area.81,82 Torque and cross-sectional area measurements provide critical information that allows a more precise muscle length assessment. 446

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Torque When the dimension of tension is included in muscle length evaluation, a passive torque/angle curve can be constructed. This curve shows the relationship between individual extensibility measurements and the torque required to attain each measurement (the torque/angle relationship). Using this curve, important biomechanical properties such as stiffness, compliance, energy, and hysteresis can be assessed.2 This information allows evaluation of an individual’s muscle for comparison before and after an intervention, thus showing the effect of the intervention on the tested muscle’s biomechanical properties. Use of this type of testing led to the development of the sensory theory.15,25,58,59 Torque/angle curves, however, may not fully reflect actual muscle length. Torque measurements quantify a muscle’s resistance to passive stretch, and this resistance is partly determined by thickness of the muscle. Other factors being equal, a thicker muscle demonstrates increased stiffness at a given joint angle, which causes the muscle to appear shorter on a torque/angle curve. A thinner muscle, other factors being equal, demonstrates decreased stiffness at a given joint angle, causing the muscle to appear longer on a torque/angle curve. In order to evaluate the contribution of muscle thickness to passive resistance, measurement of crosssectional area is required. Cross-Sectional Area Measurement of cross-sectional area is, by itself, valuable. Changes in cross-sectional area indicate an intervention effect of muscle hypertrophy (when increased) and atrophy (when decreased). When assessment of muscle crosssectional area is combined with

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torque and joint angle, the biomechanical properties of muscles of different thicknesses can be compared.1,81,82 Measurements of stress (tension/cross-sectional area), as well as normalized stiffness, compliance, energy, and hysteresis values, can be derived. These normalized values allow researchers to determine to what degree muscle crosssectional area contributes to observed passive resistance and biomechanical properties.

Implications for Research and Clinical Practice Despite its fundamental role in rehabilitation, as well as sports and fitness, very little is actually known about muscle length: what constitutes optimal extensibility, torque/ angle parameters, and crosssectional area. Future research is needed to address which biomechanical properties and measures (or combination thereof) reflect an optimal muscle length. An optimal muscle length would allow not only an optimal range of muscle extensibility and joint motion but also optimal tendon length, overlap of contractile tissue filaments, and overall muscle thickness so that the muscle can generate the amount of passive and active tension required during function. Further research could address the extensibility, torque/angle relationship, and cross-sectional area considered optimal and how these parameters vary among individuals, between the sexes, over the lifespan, and for various muscles and subject groups. With continued research, muscle length disorders may someday be more precisely assessed, allowing selection of the intervention that will best address the specific disorder. This research also has relevance in developing general fitness guidelines. For example, a muscle that is too short is operating in a range that is left of optimal torque/angle curves. March 2010

Increasing Muscle Extensibility Clinically, this would be considered to be a “contracture.” Whether a muscle exhibits decreased extensibility or if it is truly shortened cannot be determined by extensibility measures alone. Two studies on ankle plantar-flexor muscles compared different subject groups (elderly women7 and subjects diagnosed with diabetes mellitus and peripheral neuropathies80) with control subjects and found that the test groups exhibited decreased extensibility but that torque/angle curves, besides being shorter, were not significantly different. These findings would suggest that the test subjects’ muscles were not actually shortened (torque/angle curves were not shifted left) but were lacking in extensibility. The commonly prescribed treatment of stretching would address this clinical problem by increasing extensibility without shifting torque/angle curves. Neither of these studies assessed cross-sectional area of the tested muscles, however, so it is not known to what extent muscle thickness contributed to passive resistance. For example, it is possible that shortened muscles combined with decreased cross-sectional area could have confounded the results.80 Another study involving male endurance athletes found that subjects whose hamstring muscles were classified as “tight” did have passive torque/angle curves that were shifted left compared with control subjects’ hamstring muscles.82 Both groups were similar in age, height, weight, training history, and hamstring muscle cross-sectional area. Decreased hamstring muscle extensibility also has been associated with a left shift in active torque/angle curves.83 Does this left shift in torque/angle curves predispose the subjects to be less efficient in functional motion or more prone to musculoskeletal pain syndromes and injury? Does the change in biomeMarch 2010

chanical properties that accompanied the shorter muscles enhance or detract from functional performance? It appears that standard dosage stretching regimens do not change the torque/angle relationship in the short term, and 8 of 10 of the athletes with “tight” hamstring muscles were already performing regular stretching exercises. If the left shifted position was found to be detrimental, the challenge would be to find a therapeutic intervention that would induce a lasting right shift of these subjects’ torque/angle curves. A study involving subjects diagnosed with benign joint hypermobility syndrome (BJHS) suggests that hamstring muscles attaining greater than “normal” extensibility may not actually be longer than those of “normal” control subjects.81 Both groups were matched for age and sex and were similar in hamstring muscle crosssectional area. The biomechanical properties (VESR and passive energy absorption [area under the stress/angle curve] at mutual joint angles) of the subjects with BJHS were not significantly different from those of “normal” controls.1,81 The excessive range of muscle extensibility in the subjects diagnosed with BJHS was attributed to altered sensation and not to mechanically longer muscles.81 Using just the end-range joint angles as a guide, the typical treatment recommendation would be strengthening of the muscles and avoiding stretched positions.71 In this case, the biomechanical analysis suggests that the primary problem is sensory in nature—a late onset of sensation in response to stretch. Strengthening has been shown to affect torque/angle curves by increasing passive stiffness84 but would not address the sensory problem. Instead, perhaps treatment should focus primarily on avoidance of overstretching the muscle. It is not known whether the sensory perception of stretch could return to an

optimal range over time with appropriate treatment and adherence to kinematic guidelines. These examples suggest 3 different potential muscle length disorders and how treatment can be specifically directed to address them. As research continues, there are likely to be more disorders of muscle length (involving different combinations of altered extensibility, torque/ angle curves, and cross-sectional area) discovered that may be able to explain clinical anomalies. One possible example could be an athletic subject with a history of recurrent hamstring muscle strains who stretches regularly and demonstrates an optimal range of extensibility. Perhaps the root of the problem is a torque/angle curve that is left of optimal. The challenge, once again, would be to find an intervention that can induce a lasting shift in the torque/angle curve toward an optimal range. Multidimensional muscle length testing also can be important in developing fitness guidelines. There is a growing popularity of various exercise regimens that encourage stretching to a degree considered excessive by kinematic analysis. Little is known about the short- and long-term effects of this type of stretching and what accounts for the increased extensibility it induces. Are the adaptations sensory in nature, as was suggested by the study of subjects diagnosed with BJHS, or is there a long-term increase in muscle length or a change in other biomechanical properties? Are these adaptations reversible once this type of stretching is stopped? Are these adaptations desirable, despite kinematic evidence to the contrary?

Conclusion Traditionally, rehabilitation literature has attributed increases in muscle extensibility observed after stretching to a mechanical increase in muscle length. A growing body of re-

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Increasing Muscle Extensibility search refutes these mechanical theories, suggesting instead that in subjects who are asymptomatic, increases in muscle extensibility observed immediately after a single stretching session and after shortterm (3- to 8-week) stretching regimens are predominantly due to modification in subjects’ sensation. This research brings to light the importance of using sensory endpoints when assessing muscle extensibility, the value of multidimensional muscle length assessment, and the need for basic research in this field. Multidimensional evaluation of muscle length can lead to a more comprehensive and effective approach to addressing disorders of muscle length and has application in developing fitness guidelines. Both authors provided concept/idea/project design and writing. Ms Weppler collected and analyzed information. Dr Magnusson provided consultation (including review of manuscript before submission). This article was received January 15, 2009, and was accepted October 12, 2009. DOI: 10.2522/ptj.20090012

References ¨ zkaya N, Nordin M. Fundamentals of 1 O Biomechanics: Equilibrium, Motion, and Deformation. 2nd ed. New York, NY: Springer; 1999. 2 Enoka RM. Neuromechanics of Human Movement. 3rd ed. Champaign, IL: Human Kinetics Publishers; 2002. 3 Hollinshead WH, Rosse CM. Textbook of Anatomy. 4th ed. Baltimore, MD: Lippincott Williams & Wilkins; 1985. 4 Magnusson SP, Narici MV, Maganaris CN, Kjaer M. Human tendon behaviour and adaptation, in vivo. J Physiol (Lond). 2008; 586:71– 81. 5 Gajdosik RL, Rieck MA, Sullivan DK, Wightman SE. Comparison of four clinical tests for assessing hamstring muscle length. J Orthop Sports Phys Ther. 1993; 18:614 – 618. 6 Gajdosik RL, Lusin G. Hamstring muscle tightness: reliability of an active-kneeextension test. Phys Ther. 1983;63: 1085–1090. 7 Gajdosik RL, Vander Linden DW, Williams AK. Influence of age on length and passive elastic stiffness characteristics of the calf muscle-tendon unit of women. Phys Ther. 1999;79:827– 838.

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8 Johnson EK, Chiarello CM. The slump test: the effects of head and lower extremity position on knee extension. J Orthop Sports Phys Ther. 1997;26:310 –317. 9 Kornberg C, Lew P. The effect of stretching neural structures on grade one hamstring injuries. J Orthop Sports Phys Ther. 1989;10:481– 487. 10 Turl SE, George KP. Adverse neural tension: a factor in repetitive hamstring strain? J Orthop Sports Phys Ther. 1998; 27:16 –21. 11 Webright WG, Randolph BJ, Perrin DH. Comparison of nonballistic active knee extension in neural slump position and static stretch techniques on hamstring flexibility. J Orthop Sports Phys Ther. 1997;26: 7–13. 12 Gajdosik RL. Passive extensibility of skeletal muscle: review of the literature with clinical implications. Clin Biomech (Bristol, Avon). 2001;16:87–101. 13 Liebesman J, Cafarelli E. Physiology of range of motion in human joints: a critical review. Crit Rev Phys Rehabil Med. 1994; 6:131–160. 14 Magnusson SP. Passive properties of human skeletal muscle during stretch maneuvers: a review. Scand J Med Sci Sports. 1998;8:65–77. 15 Halbertsma JP, Go ¨ eken LN. Stretching exercises: effect on passive extensibility and stiffness in short hamstrings of healthy subjects. Arch Phys Med Rehabil. 1994; 75:976 –981. 16 de Weijer VC, Gorniak GC, Shamus E. The effect of static stretch and warm-up exercise on hamstring length over the course of 24 hours. J Orthop Sports Phys Ther. 2003;33:727–733. 17 Chan SP, Hong Y, Robinson PD. Flexibility and passive resistance of the hamstrings of young adults using two different static stretching protocols. Scand J Med Sci Sports. 2001;11:81– 86. 18 Willy RW, Kyle BA, Moore SA, Chleboun GS. Effect of cessation and resumption of static hamstring muscle stretching on joint range of motion. J Orthop Sports Phys Ther. 2001;31:138 –144. 19 Magnusson SP, Simonsen EB, Aagaard P, et al. Viscoelastic response to repeated static stretching in the human hamstring muscle. Scand J Med Sci Sports. 1995;5: 342–347. 20 Magnusson SP, Simonsen EB, Aagaard P, Kjaer M. Biomechanical responses to repeated stretches in human hamstring muscle in vivo. Am J Sports Med. 1996;24: 622– 628. 21 McNair PJ, Dombroski EW, Hewson DJ, Stanley SN. Stretching at the ankle joint: viscoelastic responses to holds and continuous passive motion. Med Sci Sports Exerc. 2001;33:354 –358. 22 Duong B, Low M, Moseley AM, et al. Time course of stress relaxation and recovery in human ankles. Clin Biomech (Bristol, Avon). 2001;16:601– 607.

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23 Taylor DC, Dalton JD, Seaber AV, Garrett WE. Viscoelastic properties of muscletendon units: the biomechanical effects of stretching. Am J Sports Med. 1990;18: 300 –309. 24 Ryan ED, Beck TW, Herda TJ, et al. The time course of musculotendinous stiffness responses following different durations of passive stretching. J Orthop Sports Phys Ther. 2008;38:632– 639. 25 Magnusson SP, Simonsen EB, Aagaard P, et al. Mechanical and physical responses to stretching with and without preisometric contraction in human skeletal muscle. Arch Phys Med Rehabil. 1996;77: 373–378. 26 Magnusson SP, Aagard P, Simonsen E, Bojsen-Møller F. A biomechanical evaluation of cyclic and static stretch in human skeletal muscle. Int J Sports Med. 1998;19: 310 –316. 27 De Deyne PG. Application of passive stretch and its implications for muscle fibers. Phys Ther. 2001;81:819 – 827. 28 Magnusson SP, Aagaard P, Nielson JJ. Passive energy return after repeated stretches of the hamstring muscle-tendon unit. Med Sci Sports Exerc. 2000;32:1160 –1164. 29 Feland JB, Myrer JW, Schulthies SS, et al. The effect of duration of stretching of the hamstring muscle group for increasing range of motion in people aged 65 years or older. Phys Ther. 2001;81:1110 –1107. 30 Draper DO, Castro JL, Feland B, et al. Shortwave diathermy and prolonged stretching increase hamstring flexibility more than prolonged stretching alone. J Orthop Sports Phys Ther. 2004;34: 13–20. 31 Wessling KC, DeVane DA, Hylton CR. Effects of static stretch versus static stretch and ultrasound combined on triceps surae muscle extensibility in healthy women. Phys Ther. 1987;67:674 – 679. 32 Sapega AA, Quedenfeld TC, Moyer RA, Butler RA. Biophysical factors in range-ofmotion exercise. Phys Sportsmed. 1981;9: 57– 65. 33 Zito M, Driver D, Parker C, Bohannon RL. Lasting effects of one bout of two 15second passive stretches on ankle dorsiflexion range of motion. J Orthop Sports Phys Ther. 1997;26:214 –221. 34 Hortoba´gyi T, Faludi J, Tihanyi J, Merkely B. Effects of intense “stretching”-flexibility training on the mechanical profile of the knee extensors and on the range of motion of the hip joint. Int J Sports Med. 1985;6:3173–3121. 35 Knight CA, Rutledge CR, Cox ME, et al. Effect of superficial heat, deep heat, and active exercise warm-up on the extensibility of the plantar flexors. Phys Ther. 2001; 81:1206 –1214. 36 Smith CA. The warm-up procedure: to stretch or not to stretch: a brief review. J Orthop Sports Phys Ther. 1994;19: 12–17. 37 Taylor BF, Waring CA, Brashear TA. The effects of therapeutic application of heat or cold followed by static stretch on hamstring muscle length. J Orthop Sports Phys Ther. 1995;21:283–286.

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Increasing Muscle Extensibility 38 Warren CG, Lehmann JF, Koblanski JN. Elongation of rat tail tendon: effect of load and temperature. Arch Phys Med Rehabil. 1971;52:465– 474. 39 Tabary JC, Tabary C, Tardieu C, et al. Physiological and structural changes in the cat’s soleus muscle due to immobilization at different lengths by plaster casts. J Physiol. 1972;224:231–244. 40 Goldspink G, Tabary C, Tabary JC, et al. Effect of denervation on the adaptation of sarcomere number and muscle extensibility to the functional length of the muscle. J Physiol. 1974;236:733–742. 41 Williams PE, Goldspink G. Changes in sarcomere length and physiological properties in immobilized muscle. J Anat. 1978; 127(pt 3):459 – 468. 42 Folpp H, Deall S, Harvey LA, Gwinn T. Can apparent increases in muscle extensibility with regular stretch be explained by changes in tolerance to stretch? Aust J Physiother. 2006;52:45–50. 43 Gajdosik RL. Effects of static stretching on the maximal length and resistance to passive stretch of short hamstring muscles. J Orthop Sports Phys Ther. 1991;14: 250 –255. 44 Gajdosik RL, Vander Linden DW, McNair PJ, et al. Effects of an eight-week stretching program on the passive-elastic properties and function of the calf muscles of older women. Clin Biomech (Bristol, Avon). 2005;20:973–983. 45 Reid DA, McNair PJ. Passive force, angle, and stiffness changes after stretching of hamstring muscles. Med Sci Sports Exerc. 2004;36:1944 –1918. 46 Spernoga SG, Uhl TL, Arnold BL, Gansneder BM. Duration of maintained hamstring flexibility after a one-time, modified hold-relax stretching protocol. J Athl Train. 2001;36:44 – 48. 47 Tanigawa MC. Comparison of the holdrelax procedure and passive mobilization on increasing muscle length. Phys Ther. 1972;52:725–735. 48 Alter MJ. Science of Flexibility. 3rd ed. Champaign, IL: Human Kinetics Publishers; 2004. 49 Bandy WD, Irion JM, Briggler M. The effect of static stretch and dynamic range of motion training on the flexibility of the hamstring muscles. J Orthop Sports Phys Ther. 1998;27:295–300. 50 Etnyre BR, Lee EJ. Comments on proprioceptive neuromuscular facilitation stretching techniques. Res Q Exerc Sport. 1987; 58:184 –188. 51 Depino GM, Webright WG, Arnold BL. Duration of maintained hamstring flexibility after cessation of an acute static stretching protocol. J Athl Train. 2000;35:56 –59. 52 Winters MV, Blake CG, Trost JS, et al. Passive versus active stretching of hip flexor muscles in subjects with limited hip extension: a randomized clinical trial. Phys Ther. 2004;84:800 – 807. 53 Nelson RT, Bandy WD. Eccentric Training and static stretching improve hamstring flexibility of high school males. J Athl Train. 2004;39:254 –258.

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54 Chalmers G. Re-examination of the possible role of Golgi tendon organ and muscle spindle reflexes in proprioceptive neuromuscular facilitation muscle stretching. Sports Biomech. 2004;3:159 –183. 55 Sharman MJ, Cresswell AG, Riek S. Proprioceptive neuromuscular facilitation stretching : mechanisms and clinical implications. Sports Med. 2006;36:929 –939. 56 Moore MA, Hutton RS. Electromyographic investigation of muscle stretching techniques. Med Sci Sports Exerc. 1980;12: 322–329. 57 McHugh MP, Kremenic IJ, Fox MB, Gleim GW. The role of mechanical and neural restraints to joint range of motion during passive stretch. Med Sci Sports Exerc. 1998;30:928 –932. 58 Magnusson SP, Simonsen EB, Aagaard P, et al. A mechanism for altered flexibility in human skeletal muscle. J Physiol. 1996; 497(pt 1):291–298. 59 Halbertsma JP, van Bolhuis AI, Go ¨ eken LN. Sport stretching: effect on passive muscle stiffness of short hamstrings. Arch Phys Med Rehabil. 1996;77:688 – 692. 60 Laessøe U, Voigt M. Modification of stretch tolerance in a stooping position. Scand J Med Sci Sports. 2004;14:239 –244. 61 Ben M, Harvey LA. Regular stretch does not increase muscle extensibility: a randomized controlled trial. Scand J Med Sci Sports. 2009 May 28. [Epub ahead of print] 62 Law RYW, Harvey LA, Nicholas MK, et al. Stretch exercises increase tolerance to stretch in patients with chronic musculoskeletal pain: a randomized controlled trial. Phys Ther. 2009;89:1016 –1026. 63 Bjo ¨ rklund M, Hamberg J, Crenshaw AG. Sensory adaptation after a 2-week stretching regimen of the rectus femoris muscle. Arch Phys Med Rehabil. 2001;82: 1245–1250. 64 Gajdosik RL, Allred JD, Gabbert HL, Sonsteng BA. A stretching program increases the dynamic passive length and passive resistive properties of the calf muscletendon unit of unconditioned younger women. Eur J Appl Physiol. 2007;99: 449 – 454. 65 Harvey LA, Byak AJ, Ostrovskaya M, et al. Randomised trial of the effects of four weeks of daily stretch on extensibility of hamstring muscles in people with spinal cord injuries. Aust J Physiother. 2003;49: 176 –181. 66 Harvey LA, Batty J, Crosbie J, et al. A randomized trial assessing the effects of 4 weeks of daily stretching on ankle mobility in patients with spinal cord injuries. Arch Phys Med Rehabil. 2000;81: 1340 –1347. 67 Williams P, Simpson H, Kyberd P, et al. Effect of rate of distraction on loss of range of joint movement, muscle stiffness, and intramuscular connective tissue content during surgical limb-lengthening: a study in the rabbit. Anat Rec. 1999;255:78 – 83. 68 Guissard N, Duchateau J. Effect of static stretch training on neural and mechanical properties of the human plantar-flexor muscles. Muscle Nerve. 2004;29:248 –255.

69 Bandy WD, Irion JM. The effect of time on static stretch on the flexibility of the hamstring muscles. Phys Ther. 1994;74:845– 580; discussion 850 – 852. 70 Bandy WD, Irion JM, Briggler M. The effect of time and frequency of static stretching on flexibility of the hamstring muscles. Phys Ther. 1997;77:1090 –1096. 71 McCreary EK, Provance PG, Rodgers MM, Romani WA. Muscles: Testing and Function, With Posture and Pain. 5th ed. Baltimore, MD: Lippincott Williams & Wilkins; 2005. 72 Reese NB, Bandy WD. Joint Range of Motion and Muscle Length Test. Philadelphia, PA: Saunders; 2002. 73 Sahrmann S. Diagnosis and Treatment of Movement Impairment Syndromes. St Louis, MO: Mosby; 2002. 74 Norkin CC, White DJ. Measurement of Joint Motion: A Guide to Goniometry. 3rd ed. Philadelphia, PA: FA Davis Co; 2003. 75 Bohannon RL. Commentary on “Hamstring Muscle Tightness.” Phys Ther. 1983; 63:1088 –1089. 76 Harvey LA, McQuade L, Hawthorne S, Byak A. Quantifying the magnitude of torque physiotherapists apply when stretching the hamstring muscles of people with spinal cord injury. Arch Phys Med Rehabil. 2003;84:1072–1075. 77 Magnusson SP, Simonsen EB, Aagaard P, et al. Contraction specific changes in passive torque in human skeletal muscle. Acta Physiol Scand. 1995;155:377–386. 78 Stephens J, Davidson J, Derosa J, et al. Lengthening the hamstring muscles without stretching using “awareness through movement”. Phys Ther. 2006; 86:1641–1650. 79 Halbertsma JP, Go ¨ eken LN, Hof AL, et al. Extensibility and stiffness of the hamstrings in patients with nonspecific low back pain. Arch Phys Med Rehabil. 2001; 82:232–238. 80 Salsich GB, Mueller MJ, Sahrmann SA. Passive ankle stiffness in subjects with diabetes and peripheral neuropathy versus an age-matched comparison group. Phys Ther. 2000;80:352–362. 81 Magnusson SP, Julsgaard C, Aagaard P, et al. Viscoelastic properties and flexibility of the human muscle-tendon unit in benign joint hypermobility syndrome. J Rheumatol. 2001;28:2720 –2725. 82 Magnusson SP, Simonsen EB, Aagaard P, et al. Determinants of musculoskeletal flexibility: viscoelastic properties, crosssectional area, EMG and stretch tolerance. Scand J Med Sci Sports. 1997;7:195–202. 83 Alonso J, McHugh MP, Mullaney MJ, Tyler TF. Effect of hamstring flexibility on isometric knee flexion angle-torque relationship. Scand J Med Sci Sports. 2009;19: 252–256. 84 Klinge K, Magnusson SP, Simonsen EB, et al. The effect of strength and flexibility training on skeletal muscle electromyographic activity, stiffness, and viscoelastic stress relaxation response. Am J Sports Med. 1997;25:710 –716.

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CARE V Conference Series I. Kjeken, OT, PhD, is Senior Researcher, National Resource Centre for Rehabilitation in Rheumatology, Diakonhjemmet Hospital, Oslo, Norway. Address all correspondence to Dr Kjeken at: [email protected]. C. Ziegler, Bachelor in German and Danish, is Project Manager, Danish Rheumatism Association, Gentofte, Denmark. J. Skrolsvik, Bachelor in Marketing Management, is General Secretary, Norwegian Rheumatism Association, Oslo, Norway. J. Bagge, Master of Social Science, is Research Executive, Swedish Rheumatism Association, Stockholm, Sweden. G. Smedslund, PhD, is Senior Researcher, National Resource Centre for Rehabilitation in Rheumatology, Diakonhjemmet Hospital. A. Tøvik, Bachelor in Social Work, is Social Worker, National Resource Centre for Rehabilitation in Rheumatology, Diakonhjemmet Hospital.

How to Develop Patient-Centered Research: Some Perspectives Based on Surveys Among People With Rheumatic Diseases in Scandinavia Ingvild Kjeken, Connie Ziegler, Jack Skrolsvik, Jan Bagge, Geir Smedslund, Anne Tøvik, Hanne S. Dagfinrud, Ingemar F. Petersson, Kåre Birger Hagen Patient-centered research addresses the research agenda of patients and captures aspects of health and functioning that they consider important. Yet, those who live with a disease or condition have limited influence when it comes to setting the research agenda, and we know little about how they experience being participants in research studies. Furthermore, knowledge is limited concerning factors enhancing or hindering patients’ participation in trials and the format that people with rheumatic diseases and their families prefer for dissemination of the results from clinical research. This perspective article describes the research priorities of people with rheumatic diseases in Scandinavia, their experiences and attitudes concerning participation in research projects, and which format for research information they prefer. Based on results from 3 surveys organized by the Scandinavian Rheumatism Associations and on related research literature, the possible implications for future research also are discussed.

H.S. Dagfinrud, PT, PhD, is Senior Researcher, National Resource Centre for Rehabilitation in Rheumatology, Diakonhjemmet Hospital. I.F. Petersson, MD, PhD, is Associate Professor, Departments of Orthopaedics and Rheumatology, Lund University and Lund University Hospital, Lund, Sweden. KB Hagen, PhD, is Senior Researcher, National Resource Centre for Rehabilitation in Rheumatology, Diakonhjemmet Hospital. [Kjeken I, Ziegler C, Skrolsvik J, et al. How to develop patientcentered research: some perspectives based on surveys among people with rheumatic diseases in Scandinavia. Phys Ther. 2010;90: 450 – 460.] © 2010 American Physical Therapy Association

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here is a growing consensus among health care providers and researchers that patients should be involved as partners in clinical practice and research. On an individual level, patients participate in medical decisions and take increased responsibility for managing their disease.1,2 On a broader system level, patients’ feedback on the content and provision of health care is used to develop services that correspond to patients’ needs.3 Moreover, patients identify and assess important outcomes, and they evaluate the effect of interventions and programs.4,5 From the very beginning, research has depended upon the willingness of patients to volunteer as participants in studies. Recently, patients also have been involved as working partners in research projects.6 –10 Yet, we know little about how they experience being subjects in research studies, and those who live with a disease or condition still have limited influence when it comes to setting the research agenda.11,12 According to Bem et al,13 patientcentered research designs address the research agenda of patients and capture aspects of health and functioning that they consider to be important. However, knowledge concerning patients’ research priorities is still scarce. Researchers in 3 studies involving participants with cancer,14 chronic obstructive pulmonary disease (COPD),15 and ulcerative colitis16 all concluded that there is a need to broaden the research agenda in order to capture issues that are important to patients but poorly covered by current research. In all 3 studies, patients and researchers highly agreed that research on biological and treatment-related aspects such as causes, risk factors, early detection and prevention, and development of effective treatment is important. However, the top priority among people with cancer was reMarch 2010

search on the management of practical, social, and emotional issues, whereas the participants with COPD prioritized research on comorbidity, side effects of and interaction between medications, and psychosocial aspects.14,15 Participants with ulcerous colitis called for research on topics such as the effect of complementary therapies and how their colitis affected other family members.16 In a project involving people with low back pain, discussions with participants yielded 3 research themes: diagnosis and causality, understanding and proving the pain, and the impact of low back pain on quality of life.17 Within rheumatology, a study of people with knee osteoarthritis (OA) concluded that although the participants favored conservative treatments such as physical therapy and complementary medicine, the research was concentrated on studies on drugs and surgical treatment.18 Participants also wanted more research on psychological impact, education, and self-help strategies.

Research Priorities Among People With Arthritis in Scandinavia Within rheumatology, there have been several initiatives to strengthen the collaboration between patients and researchers. The CARE conferences were initiated in 2002 as an international forum where patient representatives and researchers meet and discuss issues related to care and research within rheumatology.19 Close collaboration with consumers has been central to the CARE conferences,20,21 and at the fifth CARE conference, consumers’ research agenda and experiences were specifically addressed. Preceding the conference, surveys addressing these issues had been administered on the Web site of the Danish Rheu-

matism Association and to a sample of members of the Norwegian Rheumatism Association, and members of the Swedish Rheumatism Association had been asked to evaluate a 10-year program within the association to facilitate transference of research results to people with arthritis and their families (for more detailed information regarding the 3 surveys, see Appendix 1). The results from the surveys indicate a general consensus across diagnoses regarding priorities for research. As in the other diagnostic groups,14 –16 etiology, prevention, and early diagnosis of disease were the most frequently chosen research topics among the Danish participants, and even if these topics were not listed as options in the Norwegian survey, they often were raised in the comments from the participants (Fig. 1). This finding probably reflects the understanding that increased knowledge of disease causes is essential to be able to prevent diseases and develop effective medications. In general, there seems to be consensus between consumers and researchers on the importance of biomedical research. Regarding research on treatments, the participants in the Danish and Norwegian surveys most frequently prioritized new medications and exercises as important issues (Figs. 1 and 2). However, there were interesting differences among diagnostic groups with regard to treatment options. In both surveys, participants

Available With This Article at ptjournal.apta.org • Audio Abstracts Podcast This article was published ahead of print on January 28, 2010, at ptjournal.apta.org.

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Patient-Centered Research with rheumatoid arthritis (RA) most frequently chose research on medications, whereas participants with OA most often chose exercises. Over the last decades, new medical treatments have improved prognosis and quality of life in people with RA, and the priorities of the participants with this diagnosis may reflect a hope for even more progress in this area. Concerning exercises, there is an increasing body of evidence supporting the effectiveness of this intervention in the management of RA, ankylosing spondylitis (AS), and knee OA, although the research on hip and hand OA is still scarce. In general, there is currently little evidence for what types of exercises or doses are the most effective for which patients.22–24 Thus, there is a need for further research in this area, and the consensus among consumers regarding the importance of this research topic should be a strong encouragement for researchers within this field. Regarding research on symptoms and consequences, pain was the most frequently prioritized topic in all diagnostic groups in both the Danish and Norwegian surveys. Pain has been reported previously as the area of highest priority for improvement among people with RA25 and knee OA.18 Apparently, development of effective strategies aimed at pain relief and coping should have a high priority among health care professionals and researchers. In the Norwegian survey, fatigue and economy were the second and third most frequently listed topics for research on disease consequences. Accessibility to buildings and products was chosen as an important research topic by a substantial number of the participants in the Danish survey. In previous studies, people with RA have described fatigue as overwhelming, uncontrollable, and ignored by health care professionals,26 452

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and they rated decreased fatigue as an extremely important outcome.27 A few studies have addressed societal strategies to reduce barriers such as limited personal economic resources, inaccessible buildings, and poorly designed devices and technology.28 Thus, the priorities of consumers timely reflect important research gaps and contradict a notion held by some researchers that consumers are incapable of adequate research prioritization due to a lack of relevant knowledge, a failure to look beyond their own individual problems, or an inability to consider long-term targets.15 However, to close this gap, there is a need for funding resources and processes where patients can significantly influence strategic decisions. It should be noted that study participants frequently chose research topics where the evidence is scarce or conflicting, such as nutrition and alternative therapy.29 People with arthritis are frequent users of such therapies.30 Still, the evidence for these interventions is not always reviewed when guidelines for treatment of different rheumatic diseases are developed,31 and when the evidence is reviewed, the lack of highquality studies on effect is striking.32–35 More studies, therefore, are needed to allow for informed choices regarding the use of these therapies. Whereas level of education had little influence on the Norwegian survey participants’ research priorities, those still working chose research on workability 3 times more frequently than those who were out of work (P⬍.001), and a greater proportion also prioritized research on exercise (P⬍.001). These results indicate that people with rheumatic diseases have a strong motivation to stay in the workforce and may be interpreted as a call for strategies to enable them to do so. Recent studies

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indicate that early and aggressive treatment, including use of antitumor necrosis factor agents, increase ability to work among people with shorter RA duration.36,37 However, current vocational rehabilitation programs have not proven effective to increase work capacity among patients with rheumatic diseases at risk for job loss.38 – 40 More attention, therefore, should be directed to development and testing of the effect of evidence-based vocational rehabilitation programs to enable people with rheumatic diseases to remain working or return to work. Even if there seems to be high agreement among consumers regarding the research agenda, the rationale behind research priorities probably varies across people and diagnoses. Studies using qualitative methods, therefore, are needed to gain more insight into the reasoning behind participants’ priorities.

Factors Influencing Participation in Clinical Studies Studies reveal that there are numerous reasons why people agree to enroll in studies. Some common reasons are an altruistic hope that the research will benefit future patients or a wish to gain personal profit by learning more about one’s own health, having extra health checkups, and getting access to better treatment.41– 44 A general trust in health care researchers or in specific researchers and the ability of the researcher to establish a friendly relationship with the patient are further underscored as important factors enhancing participation.42,45– 49 However, studies indicate that trust also may easily be broken due to misunderstandings or erroneous descriptions of the extent, time, and inconvenience of research-based tasks; feelings of being treated as an object rather than a study participant; or a

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Figure 1. Danish consumers’ priorities for research within rheumatology (%) (n⫽451). RA⫽rheumatoid arthritis, OA⫽osteoarthritis.

Figure 2. Priorities for research on treatments and consequences of rheumatic diseases among 516 members of the Norwegian Rheumatism Association (%). RA⫽rheumatoid arthritis, AS⫽ankylosing spondylitis, OA⫽osteoarthritis, FM⫽fibromyalgia, ADL⫽activities of daily living.

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Patient-Centered Research Table. Summary of Research Attitudes Among 319 Members of the Norwegian Rheumatism Association Who Would Like to Participate in Research Projects Yes

No

Do Not Know

Ability to contribute with useful information

80

10

10

Economy

45

41

14

Time consumption

63

28

9

Travel distance

77

16

7

Availability of personal computer/e-mail

56

36

8

Aspects of Research (% of Respondents) My participation in research projects depends on:

I may be interested in contributing by: Answering questionnaires

96

2

2

Participating in individual interviews

78

12

10

Participating in focus groups

70

16

14

Donating blood samples

93

2

5

Medication

52

29

19

Surgery

27

50

23

Psychological interventions

55

27

18

Alternative treatment

82

8

10

Physical activities and exercising

95

2

3

Diets

91

3

6

I am interested in participating in research projects on the following treatments:

Physical therapy

90

5

5

Assistive technology and environmental adaptations

75

13

12

Patient education

76

10

14

Designing and planning a project

47

29

24

Analyzing the results

52

25

23

Disseminating the results

49

26

25

As co-worker in a research project, I would like to participate in:

general experience that the research did not bring forward any important knowledge.42,46,47 Concerning barriers for entering trials, painful procedures, time consumption, travel distance and expenses, and problems taking time off from work are frequently listed as de-motivating factors.42 Furthermore, personal embarrassment caused by a need to reveal intimate information or to expose body parts may be an important barrier against entering the trial.42,45,46 Ethnicity also may play a role, as people from ethnic minorities may lack fluency in 454

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the language used in the trial setting.42 Again, the results from the Scandinavian surveys, to a large degree, are in line with research within other medical areas. A total of 69% and 62% of the Danish and Norwegian survey respondents, respectively, were positive toward participating in research projects. The most frequently cited reason for participation among the Norwegian survey participants was a feeling that they could contribute important information, whereas time consumption and travel distance were the 2 most important

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practical barriers to participation (Table). Some suggestions for improving recruitment to studies were providing more information about the study aims and what participation would comprise and making study information available at drugstores and in the waiting areas of rheumatologists’ offices and rheumatology departments. However, the results of the Scandinavian surveys indicate that willingness to participate depends to a large degree on the aim of the study. Although more than 90% of the survey participants indicated they would participate in studies concerning physical activities and exercising, diets, and physical therapy, approximately half were willing to enroll in studies on medications or psychological interventions, and only one fourth were willing to enroll in studies on surgery. One reason for these findings could be that patients know that an operation often is followed by a period of pain and limited function and prefer interventions where they can contribute more actively and have more control. The high willingness to participate in research on exercises and diets supports this hypothesis. It also is interesting to note that even though research on new medications was one of the most frequently listed important research topics, only half of the Norwegian survey participants were willing to participate in pharmacological studies. In a recent study, findings indicated a general lack of trust in pharmaceutical companies among potential trial participants, which was based on an image that such institutions are driven by the pursuit of profit more than a pursuit of knowledge and the best interests of the participants.47 This finding underscores that trust is a dynamic concept, which is built and negotiated within the specific research setting.

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Patient-Centered Research Level of education and working status, to some degree, did influence people’s willingness to enroll in research projects, as 82% of the Norwegian survey participants with higher education levels were positive toward such participation compared with 59% of those with lower education levels (P⬍.001), and working participants were more likely than those who were out of work to report time consumption as a barrier to participation (73% versus 50%, P⫽.001). Both the Danish and Norwegian survey participants frequently commented that participation would depend on coverage of travel expenses and that good communication skills and a relaxed atmosphere would enhance their willingness to participate in future studies. Many respondents also emphasized that researchers and clinicians should understand that living with a disease is an individual experience, that the patient is the one with the most reliable knowledge about his or her situation and symptoms, and that patients develop a variety of strategies to cope with their disease. The comments indicate that participants want to be regarded as individuals with expertise rather than as study objects in a trial. It seems vital, therefore, that researchers establish workable relationships with participants by giving clear and concise information about the trial and what kind of performance participation requires. Furthermore, researchers should discuss mutual expectations and be willing to adapt time schedules and procedures to participants’ needs as much as possible.46 Great effort also should be taken to minimize the number of tests and questionnaires that patients need to complete and to optimize patient flow to avoid unnecessary waiting. From our own experience, we know that the possibility of performing tests and interviews on afternoons or on Saturdays March 2010

made it easier for working participants to attend a study, and a modest coverage of travel expenses was highly appreciated by the participants.50 To enhance participation from ethnic minorities, researchers should provide translated information sheets and use trained translators to inform potential participants. Concerning embarrassing procedures, care should be taken to minimize both the amount of time and parts of the body exposed and to ensure that the examination takes part in a shielded environment. Furthermore, some people may prefer to have the examination performed by a person of the same sex. In the Danish and Norwegian surveys, participants frequently commented that routinely providing feedback on study results would increase their willingness to participate in future studies, thereby underscoring the importance of research dissemination.

Dissemination of Study Results Study results may be disseminated to participants at 3 levels: (1) by reporting of individual results to each participant in a study; (2) by providing information of the aggregated results to study participants after study completion; and (3) by making results from new research available to those with the disease or condition, their families, and the general population. The International Ethical Guidelines for Biomedical Research Involving Human Subjects (Guideline 5: Obtaining Informed Consent: Essential Information for Prospective Research Subjects)51 states that before requesting an individual’s consent to participate in research, the investigator must provide information “that, after the completion of the study, subjects will be informed of the findings of the research in general, and individual subjects will be informed of any finding that relates to their particular health status.” In Appendix 1 in the guidelines, it is

further written that the following items, among others, should be included in the protocol: (1) plans and procedures, and the people responsible, for communicating to subjects information arising from the study (on harm or benefit, for example), or from other research on the same topic, that could affect subjects’ willingness to continue in the study; and (2) plans to inform subjects about the results of the study. Still, there is an ongoing discussion within the research community as to whether individual information should be disclosed to study participants.52,53 Results from a qualitative study, however, indicate that many participants are interested in receiving personal rather than, or in addition to, summary results.54 It also is argued that providing individual results will make the process of research more transparent and increase participants’ willingness to enroll in future studies.55 Some of the participants in the Danish and Norwegian surveys specifically commented that study participants should receive individual feedback on the results of their tests and assessments routinely. Such practice, however, raises both practical and ethical dilemmas. Producing valid, reliable, and comprehensible individual reports may be timeconsuming for researchers. Researchers should be careful not to force unwanted results on participants and should be aware that sharing the results has the potential to harm recipients by causing distress and anxiety.53,54 An invitation in the patient information sheet to request individual trial results, followed by a contact telephone number, may be a method to ensure disclosure to those participants who want such information. Obviously, researchers and ethical committees should consider carefully when and how participants should be informed of individual research results and include proce-

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Patient-Centered Research dures addressing this issue in the study protocol. Studies indicate that offering a summary of aggregate research results to participants after study completion has numerous benefits, including having a positive impact on the future health of the participants. Providing a summary affirms appreciation to the participants of their important contribution and may improve the perception of research in the public sphere by allowing the participants to directly see the impact of their contribution to scientific knowledge.56,57 Findings from a study involving survivors of cancer or their parents also indicate that research participants want feedback even when the information is upsetting.58 Furthermore, only 5% of these study participants called one of the investigators listed in the result leaflet. The results indicate that additional work related to returning results may be overestimated. However, studies demonstrate that even if many researchers support the practice of providing research results to participants, very few actually do so.57,59 – 62 Reasons for not providing results to participants include anticipation of potential follow-up or contact difficulties and anticipation of participant difficulty understanding the results.60 An inconsistent practice also was demonstrated in the Danish survey, as only half of those who had participated in a study (42 out of 83 respondents) reported having received any feedback of the study results. However, both the Norwegian and Danish survey participants frequently commented that the final study results should be communicated to the participants, the patient population, and the public in general. The method preferred by participants to receive study results seems to be a posted letter in which the main results are summarized in lay language, to456

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gether with contact telephone numbers.50,54,58 Additionally, planned, submitted, and published research articles could be listed in the leaflet, allowing those who want full-text versions of the articles to request them when they are published.58 It is further suggested that participants should have access to psychological support following dissemination of results and to medical follow-up if health risks are identified.60

and the patient population that is specific for the genre of research conducted.

Involving consumers in the development of patient information material has proven to be an effective method to ensure that the text is relevant, readable, and understandable to patients, without affecting participants’ anxiety.3 A recent article reporting communication of study results to participants in a trial for Huntington disease used modern technology in the dissemination process.63 The communication strategy included a media release that was posted on the Huntington Study Group’s public Web site and e-mailed to members of the Huntington disease community; a telephone call from the site staff to research participants providing results and next steps for their participation; and a joint telephone conference for the investigators, sponsor, and study participants to discuss study results.63

To reach a wider audience, relevant research could be summarized and discussed in open meetings announced in the local media. Publishing short reports in local and national patient magazines and on the Web sites of the patient associations may be an effective method for dissemination of study results. The power of these media to reach people with arthritis is confirmed by the results from the Swedish survey, as almost all respondents (93%) reported that they read about research in the Swedish Rheumatism Magazine and more than half of the respondents read the annual research supplement, whereas only 17% read about rheumatological research in journals and the popular press. The Swedish Rheumatism Magazine also was the most important source for research information, followed by the Internet and physicians. Nearly 40% of the Swedish consumers had participated at a lecture with popular presentations of rheumatological research, but even though more than one third had visited the Swedish Rheumatism Association’s Web page, only half of them had read research results published on the association’s Web site.

To improve future practice, existing guidelines for provision of study results should be followed. These guidelines include: (1) offering research results at the time of study enrollment; (2) disclosure following peer review but prior to public disclosure; (3) presenting participants with the harms and benefits of receiving the results; and (4) budgeting for the costs, including maintaining contact with research participants.56 All research projects also should include a communication plan for dissemination of the results to the participants and their families

Building on these experiences, the Norwegian Rheumatism Association recently published a report summarizing new research within rheumatology.64 The report is richly illustrated and consists of short summaries written by journalists based on interviews with researchers. Furthermore, a consumer and 2 researchers participated in the drafting committee, giving advice concerning content and language. The report was published on the association’s Web site, and printed copies have been available for free through the local branches of the association,

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Patient-Centered Research as well as in the waiting areas of rheumatology departments and rehabilitation institutions. However, researchers should recognize that the majority of people with chronic diseases are not members of a patient association. Researchers, therefore, need to emphasize other channels for research dissemination, such as open conferences, newspapers, magazines, television, and radio. Suggestions for new strategies to inform current and coming generations of people with chronic conditions include use of movies, animation, and online technology.65,66 Rheumatic diseases are chronic conditions primarily affecting middleaged or elderly women. The fact that research regarding acute and lifethreatening diseases usually has a greater potential to reach public media indicates that researchers need to ally with professional information providers such as journalists and lobbyists to reach policy makers and the general population with new and important research results and information.

Participatory Research Involvement of patients as working partners in research projects has proven to be an effective method to ensure patient-centered research.6 –10 In close collaboration with researchers, partners can contribute throughout the whole research process, from identification and prioritizing of research topics to dissemination of results and decisions about which research is funded (for a more detailed description, see Appendix 2).5,6,26,67–70 To ensure active involvement of patients, researchers should follow published recommendations, principles, and indicators of successful consumer involvement.6,67,69 –72 Some central principles are time and climate for role negotiation; an approMarch 2010

priate budget for covering the costs of consumer involvement; a mutual respect for the differing skills, knowledge, and experience of consumers and researchers; appropriate training of consumers and researchers; involving consumers throughout the whole research process and acknowledging such involvement in the research reports; and making the findings available to consumers in formats and languages they can easily understand.71 There is an increasing body of experience concerning participatory research. Some of the challenges described are that patient research partners may feel uncertain concerning their ability to contribute or doubt if they will really have any significant influence in the research process. Furthermore, they may have a tendency to look up to experts and question their own experiential knowledge.70 Research partners have emphasized how important it is to create a safe and respectful environment, especially in the beginning, and that researchers take time to share a cup of coffee, listen to the concerns of the research partners, provide reassurance, adjust time schedules, and help them with difficult tasks.6,67,70 Care should be taken not to overburden the research partners by expecting them to read large number of documents or participate in long meetings with little time for breaks.70 Researchers also should be alert to improper reasons and inappropriate forms for collaboration, such as involving patient research partners for external or “aesthetic” reasons, or to enhance the adherence of patients in a trial.6,70 One indicator of successful consumer involvement in research is that the roles of consumers are agreed on between the researchers and consumers involved in research.6,69,72 The Scandinavian sur-

veys involved rheumatism associations, consumers, and researchers in 3 countries. One lesson learned from this experience is that the roles and responsibilities of the participants concerning coordination of the work among the 3 associations, as well as within each of the countries, should have been discussed and clarified from the beginning. Furthermore, reporting and dissemination of the results beyond the CARE conference should have been included in the project plan. These actions would have saved us much time spent sorting out these matters along the way, and probably would have increased the scientific rigor of the surveys. However, our experiences are also in line with those of other researchers and research partners, who report that collaboration generates substantial benefits for the research process.6,67,70 Most important is the notion that research that reflects the needs and experiences of patients is more likely to produce knowledge that can be used to improve clinical practice. Other examples of benefits are revealing prejudices, translating complex and abstract language, gaining access to networks and organizations, establishing trust among study participants, minimizing the risk of misinterpretations, and developing new perspectives and friendships thorough dialogues and mutual processes within the research team.6,70

Conclusions The Scandinavian surveys demonstrate that people with rheumatic diseases respond positively to participating in research and are highly competent at identifying important research issues. In general, participants had similar priorities for research. New pharmacological treatments, physical exercise, and management of pain and fatigue were rated as the most important issues for research on treatment and disease consequences. There were,

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Patient-Centered Research however, some differences among diagnostic groups, as participants with RA gave highest priority to research on medications, whereas participants with OA gave highest priority to research on physical exercise. Research on surgery generally had low priority among participants with RA and OA. The results also indicate that willingness to participate varies, depending upon the aim of the study. Fewer than half of those enrolled in studies had received any information on the final results. To enhance future participation, researchers should develop a patientfriendly study design, including routines to ensure that participants receive feedback on the study results. Patients’ preferences for communication and dissemination of research also should be taken into account in future research projects. Involving consumers as research partners is an effective way to enhance patient-centered research. To ensure good practice, existing principles and recommendations for successful consumer involvement should be used to guide researchers who are new to participatory research. All authors provided concept/idea/project design and writing. Dr Kjeken, Ms Ziegler, Mr Bagge, Dr Smedslund, Ms Tøvik, and Dr Hagen provided data collection. Dr Kjeken, Ms Ziegler, Mr Skrolsvik, Mr Bagge, Ms Tøvik, Dr Dagfinrud, and Dr Petersson provided data analysis. Dr Kjeken, Ms Ziegler, Mr Bagge, Ms Tøvik, Dr Petersson, and Dr Hagen provided project management. Dr Kjeken and Dr Hagen provided fund procurement and institutional liaisons. Mr Skrolsvik and Mr Bagge provided patients. Dr Kjeken, Ms Ziegler, Mr Bagge, Dr Petersson, and Dr Hagen provided facilities/equipment. Dr Kjeken, Ms Ziegler, Mr Skrolsvik, and Mr Bagge provided clerical support. Dr Kjeken, Dr Smedslund, Dr Dagfinrud, Dr Petersson, and Dr Hagen provided consultation (including review of manuscript before submission).

23–25, 2008; Oslo, Norway. The results also were presented orally at the European League Against Rheumatism (EULAR) Congress; June 10 –13, 2009; Copenhagen, Denmark. This article was received December 1, 2008, and was accepted November 12, 2009. DOI: 10.2522/ptj.20080381

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42 Hussain-Gambles M. South Asian patients’ views and experiences of clinical trial participation. Fam Pract. 2004;21:636 – 642. 43 Heaven B, Murtagh M, Rapley T, et al. Patients or research subjects? A qualitative study of participation in a randomised controlled trial of a complex intervention. Patient Educ Couns. 2006;62:260 –270. 44 Verheggen FW, Nieman F, Jonkers R. Determinants of patient participation in clinical studies requiring informed consent: why patients enter a clinical trial. Patient Educ Couns. 1998;35:111–125. 45 Morris N, Balmer B. Are you sitting comfortably? Perspectives of the researchers and the researched on “being comfortable.” Account Res. 2006;13:111–133. 46 Morris N, Balmer B. Volunteer human subjects’ understandings of their participation in a biomedical research experiment. Soc Sci Med. 2006;62:998 –1008. 47 McDonald M, Townsend A, Cox SM, et al. Trust in health research relationships: accounts of human subjects. J Empir Res Hum Res Ethics. 2008;3:35– 47. 48 Dixon-Woods M, Tarrant C. Why do people cooperate with medical research? Findings from three studies. Soc Sci Med. 2009;68:2215–2222. 49 Kass NE, Sugarman J, Faden R, SchochSpana M. Trust: the fragile foundation of contemporary biomedical research. Hastings Cent Rep. 1996;26:25–29. 50 Kjeken I. Participation, Involvement and Functional Assessment in Rheumatology Care [thesis]. Oslo, Norway: University of Oslo; 2006. 51 International Ethical Guidelines for Biomedical Research Involving Human Subjects. Council for International Organizations of Medical Sciences. Available at: www.cioms.ch / frame_guidelines_nov_ 2002.htm. Accessed September 17, 2009. 52 Banks TM. Misusing informed consent: a critique of limitations on research subjects’ access to genetic research results. Sask Law Rev. 2000;63:539 –580. 53 Shalowitz DI, Miller FG. The search for clarity in communicating research results to study participants. J Med Ethics. 2008; 34:e17. 54 Dixon-Woods M, Jackson C, Windridge KC, Kenyon S. Receiving a summary of the results of a trial: qualitative study of participants’ views. BMJ. 2006;332:206 –210. 55 Shalowitz DI, Miller FG. Disclosing individual results of clinical research: implications of respect for participants. JAMA. 2005;294:737–740. 56 Fernandez CV, Kodish E, Weijer C. Informing study participants of research results: an ethical imperative. IRB. 2003;25:12–19. 57 Partridge AH, Winer EP. Informing clinical trial participants about study results. JAMA. 2002;288:363–365. 58 Schulz CJ, Riddle MP, Valdimirsdottir HB, et al. Impact on survivors of retinoblastoma when informed of study results on risk of second cancers. Med Pediatr Oncol. 2003;41:36 – 43.

59 Macneil SD, Fernandez CV. Informing research participants of research results: analysis of Canadian university based research ethics board policies. J Med Ethics. 2006;32:49 –54. 60 Rigby H, Fernandez CV. Providing research results to study participants: support versus practice of researchers presenting at the American Society of Hematology annual meeting. Blood. 2005; 106:1199 –1202. 61 Patridge AH, Hackett N, Blood E, et al. Oncology physician and nurse practices and attitudes regarding offering clinical trial results to study participants. J Natl Cancer Inst. 2004;96:629 – 632. 62 Fernandez CV, Kodish E, Taweel S, et al. Disclosure of the right of research participants to receive research results: an analysis of consent forms in the Children’s Oncology Group. Cancer. 2003;97: 2904 –2909. 63 Dorsey ER, Beck CA, Adams M, et al. Communicating clinical trial results to research participants. Arch Neurol. 2008;65: 1590 –1595. 64 Revmarapporten 2008: Om revmatiske leddsykdommer (The Rheuma Report 2008). Norwegian Rheumatism Association; 2009. Available at: www.revmatiker. no/Plager/Revmarapporten. Accessed September 17, 2009. 65 Fullilove MT, Green LL, HernandezCordero LJ, Fullilove RE. Obvious and notso-obvious strategies to disseminate research. Health Promot Pract. 2006;7: 306 –311. 66 Li LC, Adam P, Townsend AF, et al. Improving healthcare consumer effectiveness: an Animated, Self-serve, Web-based Research Tool (ANSWER) for people with early rheumatoid arthritis. BMC Med Inform Decis Mak. 2009;9:40. 67 Oliver S, Clarke-Jones L, Rees R, et al. Involving consumers in research and development agenda setting for the NHS: developing an evidence-based approach. Health Technol Assess. 2004;8:1–148, III– IV. 68 O’Donnell M, Entwistle V. Consumer involvement in decisions about what healthrelated research is funded. Health Policy. 2004;70:281–290. 69 Royle J, Steel R, Hanley B, Bradburn J. Getting Involved in Research: A Guide for Consumers. London, United Kingom: Consumers in NHS Research Support Unit; 2001. 70 Abma TA, Nierse CJ, Widdershoven GAM. Patients as partners in responsive research: methodological notions for collaborations in mixed research teams. Qual Health Res. 2009;19:401– 415. 71 Boote J, Barber R, Cooper C. Principles and indicators of successful consumer involvement in NHS research: results of a Delphi study and subgroup analysis. Health Policy. 2006;75:280 –297. 72 Telford R, Boote JD, Cooper CL. What does it mean to involve consumers successfully in NHS research? A consensus study. Health Expect. 2004;7:209 –220.

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Patient-Centered Research Appendix 1. Outline of Surveys Administered by the 3 Scandinavian Rheumatism Associations All 3 questionnaires contained questions regarding participants’ diagnosis, sex, and disease duration. The Norwegian questionnaire also included 2 questions regarding education and work status. In the Danish and Norwegian samples, statistical comparisons between groups were made concerning diagnoses (including diagnoses representing ⱖ10% of the total sample), using chi-square analyses. Comparisons concerning level of education and work status were conducted in the Norwegian sample. Denmark Three employees of the Danish Rheumatism Association developed the questionnaire. Topics were listed according to their experience of what members thought were important areas to research, based on questions raised by members in telephone calls and meetings. In the first part of the questionnaire, the participants were asked to indicate the 3 out of 17 listed topics they prioritized as the most important areas for future research, followed by an open question where the participants could suggest other topics. The second part of the questionnaire concerned participants’ experiences with and willingness to participate in research and contained an open question asking for suggestions on how to improve patients’ involvement in research. The questionnaire was available at the Danish Rheumatism Association’s Web site over a period of 8 months in 2007. A total of 451 people with a mean age of 61 years answered the questionnaire, of which 83% were women. Norway The Norwegian questionnaire was a revised version of the Danish questionnaire and was developed by a group of 2 researchers, 1 clinician, and 1 consumer with rheumatoid arthritis. In the questionnaire, participants first were asked to check the 3 out of 9 listed disease consequences they thought were the most important areas for future research, and then they were asked to indicate the 3 out of 9 treatments they would prioritize as the most important research areas. Some questions were added concerning members’ willingness to participate in research projects, and each section in the questionnaire had open-ended questions, allowing the participants to comment on the different issues. The questionnaire was mailed to 1,000 randomly selected members of the Norwegian Rheumatism Association in the autumn of 2007. A total of 516 people with a mean age of 56.9 years returned the questionnaire, of which 75% were women. Sweden The Swedish questionnaire was developed by 2 employees of the Swedish Rheumatism Association with the help of a researcher and contained questions concerning respondents’ use of the association’s Web site, magazine, and yearly supplement with summaries of relevant research and their participation in open meetings for members and families. In a last question, respondents were asked to list their 3 favorite sources for updating their knowledge about relevant research. The questionnaire was mailed to 300 randomly selected members of the Swedish Rheumatism Association in the spring of 2008, of which 158 completed the survey. The participants had a median age of 61 years, and 83% were women.

Appendix 2. Ways Patient Research Partners Can Contribute in Research Projects3,5,6,66 – 69 Patient research partners can contribute in research by: • identifying and prioritizing research topics • reviewing research protocols • developing specific research questions • identifying important outcomes • developing interview guides • choosing feasible tests and instruments • discussing inclusion and exclusion criteria • deciding appropriate time intervals from baseline to control • giving input concerning factors that can facilitate or hamper participation • writing or commenting on patient information sheets • serving as “pilot” participants • recruiting participants • conducting interviews with study participants • preparing or leading a focus group • asking people to complete questionnaires or surveys • monitoring research • analyzing and interpreting results • disseminating results • evaluating research • participating in decisions about research funding • providing training for professionals about involving consumers in research

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Letters to the Editor On “Exposure to low amounts of ultrasound energy…” Alexander LD, Gilman DRD, Brown DR, et al. Phys Ther. 2010;90:14–25. I must protest the title of this systematic review.1 A review of this systematic review reveals that there is nothing in the review that indicates whether or not low amounts of ultrasound energy improve soft tissue shoulder pathology. In fact, the authors clearly state, “Our results suggest that the effectiveness of ultrasound on soft tissue pathologies has not yet been evaluated using optimal treatment parameters, and, therefore, it is premature to conclude through systematic review of existing literature that this treatment dose ‘is not effective.’” Given that, the reader has to wonder how and why this title came about. Why didn’t the title reflect the finding that there were some beneficial effects from higher exposure to ultrasound energy? Why didn’t the title reflect that the current research was not sufficient to tell clinicians anything worthwhile regarding the use of ultrasound? Truthfully, the article told us far more about the inefficacy of the research than it did about the inefficacy of ultrasound. Why was this article even published, given what little clinical benefit it offers? Why were most of the studies the authors reviewed ever published? They may tell future researchers other ways not to do research, but they tell clinicians very little, if anything, about how to treat patients who have shoulder pathology. I am concerned that the use of this title is irresponsible. As third-party payers review the literature, not having the requisite

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knowledge and ability to truly analyze the content, they will rely on a title like that of this article to deny coverage. We cannot afford to give these people such ammunition. My biggest concern, though, is the negative effect that this title and the article in general may have on the evidence-based practice movement. We hear many complaints from researchers and academicians bemoaning the fact that so many clinicians do not embrace evidence-based practice. I suggest that it is, at least in part, because so many studies and articles like this one are published. Because they lack credibility and defy some of the conventional wisdom that is gained in introspective clinical practice, they shed a bad light on the evidence-based practice movement. Clinicians subsequently become suspicious of all of the “evidence” and either disregard it or stop reviewing it altogether. That is a terrible injustice, as it sets us backward rather than moves us forward. Understand that I am not writing in support of ultrasound. I am writing in support of responsible evidence-based practice. The jury is still out as to the efficacy of ultrasound. Clinically, use of ultrasound seems to help make mobilization easier. Is that a good clinical observation, or merely a “We’ve always done it that way, so don’t tell us it doesn’t work” lament? So far, the research has not been able to answer that question, so it is still up to clinicians to try to decide whether it works for them or not. The fact that so many clinicians still choose to use ultrasound for pain modulation and for mobilization preparation—whereas they

abandoned many other modalities through the years—probably tells us a lot. It might be the best available evidence we have right now. Maybe someday the research will prove them right, and maybe it will prove them wrong. In the meantime, we have to be very careful not to misinterpret or misrepresent what evidence we do have. We have to use our research just as responsibly as we are supposed to use all of our other practice tools. Philip P. Tygiel P.P. Tygiel, PT, is Physical Therapist, Tygiel Physical Therapy, 6606 E Carondelet, Tucson, AZ 85710. Address all correspondence to Mr Tygiel at: [email protected]. This letter was posted as a Rapid Response on January 7, 2010, at ptjournal.apta.org.

Reference 1 Alexander LD, Gilman DRD, Brown DR, et al. Exposure to low amounts of ultrasound energy does not improve soft tissue shoulder pathology: a systematic review. Phys Ther. 2010;90:14–25. [DOI: 10.2522/ptj.2010.90.3.461.1]

Author Response I thank the responder for his comments1 on our article.2 I believe this commentary helps to highlight a key point made in the article and perhaps challenges the editorial process associated with PTJ. I regret that Tygiel feels this article will have little clinical benefit to others. It represents a culmination of a tremendous amount of work, and obviously we believe that it makes an important contribution to the physical therapy profession. It supports a change in practice, which is to reduce the use of short treatments of low-intensity pulsed ultrasound that deliver extremely low amounts of ultrasound energy. In addition to changing clini-

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Letters to the Editor On “Exposure to low amounts of ultrasound energy…” Alexander LD, Gilman DRD, Brown DR, et al. Phys Ther. 2010;90:14–25. I must protest the title of this systematic review.1 A review of this systematic review reveals that there is nothing in the review that indicates whether or not low amounts of ultrasound energy improve soft tissue shoulder pathology. In fact, the authors clearly state, “Our results suggest that the effectiveness of ultrasound on soft tissue pathologies has not yet been evaluated using optimal treatment parameters, and, therefore, it is premature to conclude through systematic review of existing literature that this treatment dose ‘is not effective.’” Given that, the reader has to wonder how and why this title came about. Why didn’t the title reflect the finding that there were some beneficial effects from higher exposure to ultrasound energy? Why didn’t the title reflect that the current research was not sufficient to tell clinicians anything worthwhile regarding the use of ultrasound? Truthfully, the article told us far more about the inefficacy of the research than it did about the inefficacy of ultrasound. Why was this article even published, given what little clinical benefit it offers? Why were most of the studies the authors reviewed ever published? They may tell future researchers other ways not to do research, but they tell clinicians very little, if anything, about how to treat patients who have shoulder pathology. I am concerned that the use of this title is irresponsible. As third-party payers review the literature, not having the requisite

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knowledge and ability to truly analyze the content, they will rely on a title like that of this article to deny coverage. We cannot afford to give these people such ammunition. My biggest concern, though, is the negative effect that this title and the article in general may have on the evidence-based practice movement. We hear many complaints from researchers and academicians bemoaning the fact that so many clinicians do not embrace evidence-based practice. I suggest that it is, at least in part, because so many studies and articles like this one are published. Because they lack credibility and defy some of the conventional wisdom that is gained in introspective clinical practice, they shed a bad light on the evidence-based practice movement. Clinicians subsequently become suspicious of all of the “evidence” and either disregard it or stop reviewing it altogether. That is a terrible injustice, as it sets us backward rather than moves us forward. Understand that I am not writing in support of ultrasound. I am writing in support of responsible evidence-based practice. The jury is still out as to the efficacy of ultrasound. Clinically, use of ultrasound seems to help make mobilization easier. Is that a good clinical observation, or merely a “We’ve always done it that way, so don’t tell us it doesn’t work” lament? So far, the research has not been able to answer that question, so it is still up to clinicians to try to decide whether it works for them or not. The fact that so many clinicians still choose to use ultrasound for pain modulation and for mobilization preparation—whereas they

abandoned many other modalities through the years—probably tells us a lot. It might be the best available evidence we have right now. Maybe someday the research will prove them right, and maybe it will prove them wrong. In the meantime, we have to be very careful not to misinterpret or misrepresent what evidence we do have. We have to use our research just as responsibly as we are supposed to use all of our other practice tools. Philip P. Tygiel P.P. Tygiel, PT, is Physical Therapist, Tygiel Physical Therapy, 6606 E Carondelet, Tucson, AZ 85710. Address all correspondence to Mr Tygiel at: [email protected]. This letter was posted as a Rapid Response on January 7, 2010, at ptjournal.apta.org.

Reference 1 Alexander LD, Gilman DRD, Brown DR, et al. Exposure to low amounts of ultrasound energy does not improve soft tissue shoulder pathology: a systematic review. Phys Ther. 2010;90:14–25. [DOI: 10.2522/ptj.2010.90.3.461.1]

Author Response I thank the responder for his comments1 on our article.2 I believe this commentary helps to highlight a key point made in the article and perhaps challenges the editorial process associated with PTJ. I regret that Tygiel feels this article will have little clinical benefit to others. It represents a culmination of a tremendous amount of work, and obviously we believe that it makes an important contribution to the physical therapy profession. It supports a change in practice, which is to reduce the use of short treatments of low-intensity pulsed ultrasound that deliver extremely low amounts of ultrasound energy. In addition to changing clini-

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Letters to the Editor cal practice, we must change how clinical trials are conducted and what is considered when conducting systematic reviews. If readers read the full text of our article, they will see that we agree with Tygiel’s point that current research is not helping us determine whether ultrasound will aid the treatment of people with shoulder disorders. In particular, the amount of energy delivered in the treatment arm of clinical trials must be “adequate” if we are to evaluate the effectiveness of any physical therapy intervention. With the popularity of systematic reviews and meta-analyses used to evaluate clinical treatments, the appropriateness of treatment parameters (not just methodological quality) must be considered when drawing conclusions about the treatment outcomes. Although the title may not have been best, I do believe the conclusions in the abstract and the results and discussion sections of the article accurately reflect the current literature. Unfortunately, there is not enough evidence to support

a suggestion that higher doses of ultrasound are effective in treating people with shoulder disorders. My hope is that third-party payers will venture beyond the title and at least read the conclusion section of the abstract. The title used in this article was not one submitted by the authors of this article and was not considered by the manuscript reviewers. It was in the final stages of editorial production that the title was changed to the current version so that it would be consistent with PTJ’s move to promote the use of active, more informative article titles. In fact, a revised title suggested by the editor in chief was “There is not strong evidence to support the use of therapeutic ultrasound for soft tissue shoulder pathology: a systematic review.” I suspect this title would have fueled to an even greater extent the valid concerns raised about the negative impact on the evidence-based practice movement. Perhaps this discussion will stimulate a review of this editorial practice of PTJ.

Pamela E. Houghton P.E. Houghton, HBSc, BScPT, PhD, is Associate Professor, School of Physical Therapy, University of Western Ontario, Room 1458, Elborn College, London, Ontario, Canada N6G 1H1. Address all correspondence to Dr Houghton at: [email protected]. This letter was posted as a Rapid Response on January 11, 2010, at ptjournal.apta.org.

References 1 Tygiel PP. Letter to the editor on “Exposure to low amounts of ultrasound energy does not improve soft tissue shoulder pathology: a systematic review. Phys Ther. 2010;90:461. 2 Alexander LD, Gilman DRD, Brown DR, et al. Exposure to low amounts of ultrasound energy does not improve soft tissue shoulder pathology: a systematic review. Phys Ther. 2010;90:14–25. [DOI: 10.2522/ptj.2010.90.3.461.2]

Correction Steffen T, et al. “Test-retest reliability and minimal detectable change on balance and ambulation tests...” Phys Ther. 2008;88:733–746. In the article titled “Test-Retest Reliability and Minimal Detectable Change on Balance and Ambulation Tests, the 36-Item Short-Form Health Survey, and the Unified Parkinson Disease Rating Scale in People With Parkinsonism” by Teresa Steffen and Megan Seney in the June 2008 issue of PTJ, the authors report an error in the literature review on page 737 (column 1, second paragraph). The sentences in that paragraph should have read (changes in bold): “The MDC95 values for comfortable and fast gait speeds were 0.20 and 0.30 m/s, respectively, for people with osteoporosis60 and 0.12 and 0.22 m/s for people with hip fracture.21 Overall, the MDC95 values for both comfortable and fast gait speeds appeared to be about 0.25 m/s or less for populations tested to date.” The latter sentence originally included the phrase “except for patients with hip fracture, with an MDC95 value of approximately 0.50 m/s,” which was an error. DOI: 10.2522/ptj.20070214.cx

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Letters to the Editor cal practice, we must change how clinical trials are conducted and what is considered when conducting systematic reviews. If readers read the full text of our article, they will see that we agree with Tygiel’s point that current research is not helping us determine whether ultrasound will aid the treatment of people with shoulder disorders. In particular, the amount of energy delivered in the treatment arm of clinical trials must be “adequate” if we are to evaluate the effectiveness of any physical therapy intervention. With the popularity of systematic reviews and meta-analyses used to evaluate clinical treatments, the appropriateness of treatment parameters (not just methodological quality) must be considered when drawing conclusions about the treatment outcomes. Although the title may not have been best, I do believe the conclusions in the abstract and the results and discussion sections of the article accurately reflect the current literature. Unfortunately, there is not enough evidence to support

a suggestion that higher doses of ultrasound are effective in treating people with shoulder disorders. My hope is that third-party payers will venture beyond the title and at least read the conclusion section of the abstract. The title used in this article was not one submitted by the authors of this article and was not considered by the manuscript reviewers. It was in the final stages of editorial production that the title was changed to the current version so that it would be consistent with PTJ’s move to promote the use of active, more informative article titles. In fact, a revised title suggested by the editor in chief was “There is not strong evidence to support the use of therapeutic ultrasound for soft tissue shoulder pathology: a systematic review.” I suspect this title would have fueled to an even greater extent the valid concerns raised about the negative impact on the evidence-based practice movement. Perhaps this discussion will stimulate a review of this editorial practice of PTJ.

Pamela E. Houghton P.E. Houghton, HBSc, BScPT, PhD, is Associate Professor, School of Physical Therapy, University of Western Ontario, Room 1458, Elborn College, London, Ontario, Canada N6G 1H1. Address all correspondence to Dr Houghton at: [email protected]. This letter was posted as a Rapid Response on January 11, 2010, at ptjournal.apta.org.

References 1 Tygiel PP. Letter to the editor on “Exposure to low amounts of ultrasound energy does not improve soft tissue shoulder pathology: a systematic review. Phys Ther. 2010;90:461. 2 Alexander LD, Gilman DRD, Brown DR, et al. Exposure to low amounts of ultrasound energy does not improve soft tissue shoulder pathology: a systematic review. Phys Ther. 2010;90:14–25. [DOI: 10.2522/ptj.2010.90.3.461.2]

Correction Steffen T, et al. “Test-retest reliability and minimal detectable change on balance and ambulation tests...” Phys Ther. 2008;88:733–746. In the article titled “Test-Retest Reliability and Minimal Detectable Change on Balance and Ambulation Tests, the 36-Item Short-Form Health Survey, and the Unified Parkinson Disease Rating Scale in People With Parkinsonism” by Teresa Steffen and Megan Seney in the June 2008 issue of PTJ, the authors report an error in the literature review on page 737 (column 1, second paragraph). The sentences in that paragraph should have read (changes in bold): “The MDC95 values for comfortable and fast gait speeds were 0.20 and 0.30 m/s, respectively, for people with osteoporosis60 and 0.12 and 0.22 m/s for people with hip fracture.21 Overall, the MDC95 values for both comfortable and fast gait speeds appeared to be about 0.25 m/s or less for populations tested to date.” The latter sentence originally included the phrase “except for patients with hip fracture, with an MDC95 value of approximately 0.50 m/s,” which was an error. DOI: 10.2522/ptj.20070214.cx

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Association Business In Memoriam The deaths of these members were reported to APTA between January 1, 2009, and December 31, 2009. Robert P. Albright Eunice W. Badoux Carol Bankson William T. Bell Jody R. Billingsley Cynthia T. Blanton Eugene H. Bodnar Lulu Boerner Gloria M. Brawley Lester Brower Robert I. Burks Catherine Dalcourt Julia A. Dazen Anne C. Debbaillion Carolyn L. Dieffenbach Dennis F. Driver Lucy S. Driver Walter Dworschak Helen L. Emerson Richard Erhard Martin Feldman

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Barbara L. Glasow Lenora V. Grizzell Elizabeth A. Hamilton Ina Helweg Joseph Henson Irja R. Hofschire Leonard Hultgren, Jr Daniel Winn Humphrey Wayne E. Kirker Faith MacLennan Alice L. McCleary Trevor Blake McCrory Wayne McKinney Max E. Mickey Jane Murdock Mary C. Noble Donna E. Peddicord Kathryn E. Phillips Pamela M. Pope I. Elayne Resignola Martine K. Rini

William Russell Sarah H. Seybold Scott T. Shuey Gerald W. Shumway Louise M. Shute Hazel C. Siegel M. Irene Snider Edward P. Taylor Mary Took Cheryl L. Turoff Martin R. Vassallo Beverly G. Villwock Dorothy F. Waldo Lynn A. Wallace William M. Wilde R. Lorraine Willer Elizabeth Winn John D. Workman, III Cherie A. Yadao

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Scholarships, Fellowships, and Grants News from the Foundation for Physical Therapy Recent Publications by Foundation-Funded Researchers “Endurance Time is Joint-Specific: A Modelling and Meta-Analysis Investigation,” by Frey Law LA and Avin KG, is featured in Ergonomics (2010;53[1]:109–129). Laura Frey Law, PT, PhD, received a McMillan Doctoral Scholarship in 2000, a Promotion of Doctoral Studies (PODS) I scholarship in 2001, and a PODS II in 2002. Keith Avin, PT, DPT is a 2008 recipient of a Kendall Scholarship as well as a current 2009 PODS I awardee.

Win a Trip to Hawaii! The Foundation is sponsoring the “Aloha Getaway” Sweepstakes, where you could win a trip for 2 to Hawaii! Every $10 donation to the Foundation will receive 1 entry into the drawing, or 5 entries will be placed for a $40 donation. If you missed your chance to enter at our booth at CSM, enter online at the Foundation’s Web site, www. FoundationforPhysicalTherapy. org. No Purchase Necessary to Enter or Win: The “Aloha Getaway” Sweepstakes is open to all legal residents of the United States, age 18 years or older as of January 22, 2010. Sweepstakes entry begins January 22, 2010 and ends June 25, 2010. The staffs of the Foundation and APTA are not eligible to participate. View the complete Official Rules at the Foundation’s Web site, which govern the Sweepstakes. Void where prohibited.

“Low Back Pain in Adolescents: A Comparison of Clinical Outcomes in Sports Participants and Nonparticipants,” by Fritz JM and Clifford SN, was published in the Journal of Athletic Training (2010; 45[1]:61–66). Julie Fritz, PT, PhD, ATC, won a 2002 Research Grant, and Shannon Clifford, PT, PhD, was a 2002 McMillan Doctoral Scholarship winner. “An Expanding Delivery Model Helps Clinicians Access the Literature,” by Guy Simoneau, PT, DPT, ATC, was featured in Journal of Orthopaedic & Sports Physical Therapy (2010;40[1]:1–3). Simoneau won a Foundation Research Grant in 1996. “6-Hz Primed Low-Frequency rTMS to Contralesional M1 in Two Cases with Middle Cerebral Artery Stroke,” by Carey JR, Anderson DC, Gillick BT, Whitford M, and Pascual-Leone A, was published online in Neuroscience Letters on December 16, 2009. James Carey, PT, PhD, received a Foundation award in 1986; Maureen Whitford, PT, received a 2004 McMillan Doctoral Scholarship; and Bernadette Gillick is a 2009 PODS II awardee. “Lower Energy Cost of Skeletal Muscle Contractions in Older Humans,” by Tevald MA, Foulis SA, Lanza IR, and Kent-Braun JA, was published online in American Journal of Physiology—Regulatory, Integrative and Comparative Physiology on December 23, 2009. Michael Tevald, PT, PhD, was awarded a New Investigator Fellowship Training Initiative (NIFTI) in 2007.

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“Neurophysiologic and Rehabilitation Insights from the Split-Belt and Other Locomotor Adaptation Paradigms,” by Reisman DS, Bastian AJ, and Morton SM, was published online ahead of print in Physical Therapy on December 18, 2009, and appears in the February 2010 issue (2010;90[2]:187–195). Darcy Reisman, PT, PhD, is a 1999 McMillan Doctoral Scholarship recipient. Amy Bastian, PT, PhD, received Foundation awards in 1994 and 1995. Susanne Morton, PT, PhD, was the winner of a 2001 PODS I, a 2002 PODS II, and a 2009 Research Grant.

Now Accepting Nominations to Join SRC The Foundation for Physical Therapy is currently accepting nominations to serve on the Scientific Review Committee. This all-volunteer committee is vital to awarding more than 25 scholarships, fellowships, and grants each year. If you know of someone who could serve as an application reviewer, or if you have an interest in volunteering yourself, please visit the Foundation’s Web site under “Grants, Fellowships, and Scholarships” to review the criteria for membership. If you qualify and have the desire to make an impact on the future of physical therapy education and research, submit your full CV to the Scientific Program Administrator. [DOI: 10.2522/ptj.2010.90.3.464]

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Scholarships, Fellowships, and Grants

Thank You for a Great CSM 2010! Thank you to all who stopped by the Foundation’s booth at CSM 2010 or participated in events that benefited the Foundation. The staff enjoyed meeting new faces and catching up with familiar ones. Special thanks to the Home Health Section for hosting the Coffee, along with event sponsor and Foundation Partner in Research Gentiva Health Services. What a way to wake up and start off Friday at CSM—with a nice, fresh cup of joe! Thank you also to

the Sports Physical Therapy Section for hosting the Beach Party Redux & Silent Auction again this year. Attendees enjoyed this evening of entertainment and look forward to next year’s Sports Section Gala. Both of these exciting events benefited the Foundation and will help the Foundation continue to fund outstanding future physical therapist researchers. The Foundation thanks all who attended the forum “Foundation Funding for Post-Professional Doctoral Study: Options and

Guidelines.” The participants were highly motivated to learn tips and advice from Scientific Review Committee (SRC) volunteers. It is no surprise that the quality of applications being submitted to the Foundation continues to rise. Heartfelt thanks are due to the SRC volunteers leading the roundtable discussions. Finally, the Foundation thanks the Section on Research, especially Section Chair Carole Tucker, for sponsoring this session once again.

New in Open Door: Medcom Video Training Programs Collection ProQuest now provides access to Medcom’s video training collection of 75 health care topics important to practitioners. Topics include: safe lifts, falls prevention, wound care, body mechanics, pressure ulcers, documentation, patient safety, HIPAA, medical errors, and more. Each topic contains a series of short presentations (1-5 minutes). View one part of the series, or all, as your time allows. Watch the videos inside the ProQuest interface, or download the files into QuickTime or .mp4 formats.

How do you access the Medcom Video Training Programs Collection? Go to Open Door, access ProQuest, click on the “Browse” tab (third from the left), and select “Video Training Programs” under the “Competency and Training Resources” section. A list of the available video topics appears. Access videos from this page. Bookmark www.apta.org/opendoor for online access to vital clinical research, whenever and wherever you need it. Visit often for full-text access to research and articles from more than a thousand leading clinical and academic publications on topics critical to clinical practice.

Questions? E-mail [email protected] or call 800/999-2782 (ext 8534). Open Door is an APTA members–only benefit.

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