2009 APA Conference Week Abstracts - Australian Physiotherapy ...

Abstracts FROM 

APA Conference Week 

1–5 October 2009 

Sydney Convention Centre, Australia 

Acupuncture and Dry Needling Group 

Animal Physiotherapy Group 

Aquatic Physiotherapy Group 

Cardiorespiratory Physiotherapy Australia 

Continence and Women’s Health Physiotherapy Australia 

Gerontology Physiotherapy Australia 

Joint Plenary Session: Get Off the Couch 

Musculoskeletal Physiotherapy Australia 

National Neurology Group 

National Paediatric Group 

Occupational Health Physiotherapy Australia 

Seven Years in Seven Minutes: 

short summaries of important recent research 

Sports Physiotherapy Australia

Abstracts 





Abstracts listed alphabetically by first author


2 

Western acupuncture supplements a biomechanical 

corrective model in knee pain 

Berg D 

Movehappy Health Care Clinic, ACT 

A sixty-two year old female presented with a sudden onset of 

left medial knee pain while walking. The pain was constant 

and had reduced her walking tolerance from one hour to 

five minutes. Physical examination excluded structural 

instability, and a diagnosis of medial patellofemoral and 

tibiofemoral joint stress due to poor biomechanics was 

made. Over four sessions various treatments were tried, 

aimed at reducing the loading of the medial knee. These 

consisted of both active and passive interventions, including 

dry needling of the quadriceps group. These treatments 

were all ineffective, and on some occasions exacerbated 

the patient’s pain. In an attempt to offer relief from the 

pain while the patient improved her biomechanics, western 

acupuncture was trialled. Six sessions of 20 minutes 

duration over a period of 3 weeks were used. Needles were 

placed adjacent to the L3 and L4 vertebrae bilaterally, 

and points SP6, SP9, SP10, GB34, LR3, and, ST36. The 

needles were stimulated intermittently. These points and 

the treatment time were chosen to facilitate pain relief via 

facilitation of local, segmental and extrasegmental effects. 

Using this treatment regime, the patient achieved excellent 

pain relief. Upon completion of the 3 weeks, the patient 

had intermittent pain and was able to walk for 30 minutes. 

She continued to work on her strengthening and resumed 

her normal walking routine after 3 additional weeks. This 

case study demonstrates that the analgesic effect of western 

acupuncture may facilitate a biomechanical corrective 

model for musculoskeletal pain. 

Needle manipulation and fascia: workshop with 

ultrasound analysis 

Langevin HM 

Departments of Neurology, Orthopaedics and Rehabilitation,University 

of Vermont 

Ultrasound imaging during acupuncture needle manipulation 

offers an opportunity to ‘see what is going on beneath the 

skin’ during acupuncture needling. This workshop will 

demonstrate how ultrasound can be used to visualise the 

interaction of acupuncture needles with connective tissues, 

including subcutaneous and perimuscular fascia, as well as 

elastography techniques allowing quantification of tissue 

displacement and strain induced by needle motion. 

The use of acupunctures in the management of complex 

regional pain syndrome type I: a pilot study 

Longbottom JE 

Acupuncture Association of Chartered Physiotherapists, 

Peterborough, UK 

The aim of this small pilot study was to develop a working 

protocol for the management of pain, anxiety and stress in 

the condition of complex regional pain syndrome type I. A 

single system research design comprising of 4 subjects (n 

= 4) diagnosed with complex regional pain syndrome type 

I, affecting the upper limb (n = 2) and lower limb (n = 2) 

was used. In addition to the usual rehabilitation program, 

subjects underwent acupuncture using auricular, segmental 

and distal acupuncture points as a means of modifying 

hyperalgesia within the sympathetic nervous system, 

anxiety and stress, before a formal exercise program. All 

4 subjects received the acupuncture protocol for 6 weeks 

whilst undergoing a home exercise program, pacing and 

relaxation training, prior to a formal 6-week intensive 

rehabilitation program. All participants demonstrated 

reduction in the Hospital Anxiety and Depression Scores, 

Visual Outcome Scale for pain, and Quality of Life Score. 

This study was designed to determine and test the protocol 

used as a precursor to future research using a single-blind, 

randomised controlled trial. 

Western acupuncture and dry needling 

in spinal regions 

McCutcheon LM 

Combined Health Acupuncture and Dry Needling Education, 

Research Fellow School of Medicine, Griffith University 

Physiotherapists in ‘western’ countries, including Australia, 

the UK, New Zealand, Canada, the US and South 

Africa are increasingly using dry needling and Western 

Acupuncture. Western Acupuncture has its foundations in 

neurophysiological clinical reasoning and combines local, 

segmental and extra-segmental needling points. Even 

though traditional acupuncture points are used with this 

style of needling Western Acupuncture is not viewed as 

Traditional Chinese Medicine (TCM) as no paradigms or 

traditional assessment methods are adopted from TCM. Dry 

needling in the spinal region will be discussed considering 

Travell and Simons, Gunn and Baldry approaches. Clinical 

reasoning combining both Western Acupuncture and dry 

needling will be presented along with relevant literature 

from the current evidence base for needling in spinal 

regions. 

Western acupuncture and dry needling for triathletes 

McCutcheon LM 

Combined Health Acupuncture and Dry Needling Education, Research 

Fellow School of Medicine, Griffith University 

The role of physiotherapy with the triathlete often 

includes sports screening, injury prevention, performance 

enhancement and treatment of musculoskeletal injuries. 

The sport of triathlon has a high incidence of injury ranging 

from 37% to 91%. Injuries are predominately due to overuse, 

however they may also be traumatic in origin. The most 

commonly reported sites of injury are the knee and lower 

leg regions, although the shoulder, back and neck have also 

been identified as commonly injured in triathletes. Western 

acupuncture has developed over the past 30–40 years having 

its foundations in neurophysiological clinical reasoning and 

combining local, segmental and extra-segmental needling 

points. Dry needling using a Travell and Simons style is an 

established form of needling therapy which addresses the 

aetiology and treatment of myofascial pain syndromes. Both 

dry needling and Western Acupuncture can be effective in 

the treatment of triathlete related injuries although there 

is only presently limited reference to the use of needling 

therapies in triathlete related injuries in the research 

literature. A review of various musculoskeletal conditions 

that triathletes commonly present with are discussed 

along with a presentation of dry needling and Western 

acupuncture techniques that may be employed in the overall 

management of the triathlete. 

The e-AJP Vol 55: 4, Supplement


The influence of educational background in health 

professionals on reporting adverse reactions to 

acupuncture 

McDowell J, 1 Johnson GM, 1 Hale L 1 , Gray A 2 

1 

Centre for Physiotherapy Research, School of Physiotherapy, 

University of Otago, Dunedin, New Zealand. 2 Department of 

Preventative and Social Medicine, University of Otago, Dunedin, 

New Zealand 

The aim of this study was to examine the influence that 

educational background has on decision making processes by 

health professionals in regard to reporting adverse reactions 

to acupuncture. A 101 item postal questionnaire purposely 

developed to examine the reporting patterns and opinion 

relating to adverse reactions to acupuncture was completed 

by 147 New Zealand health professionals. All were members 

of their respective professional acupuncture associations. 

Respondents were categorized as physiotherapists (n = 

123), physiotherapy experts (n = 12) or general practitioners 

(n = 12). The mean results for the time taken to report a 

mild adverse reaction to acupuncture showed a significant 

difference (p


Is differential assessment of temperomandibular 

related headache and cervicogenic headache required 

in preparation for dry needling? 

4 

Selvaratnam PJ 

The University of Melbourne and The Melbourne Spinal and Sports 

Physiotherapy Clinic 

Dry needling may benefit patients with headache. Prior to 

dry needling, it is important to diagnose the type of headache 

and potential structures contributing to the headache. The 

International Headache Society has classified headaches as 

primary and secondary. Some of these headaches can be 

sinister and others catastrophic. This paper discusses two 

of the secondary headaches, temperomandibular related 

headache and cervicogenic headache. Temperomandibular 

related headache is associated with temperomandibular 

disorders while cervicogenic headache is related to upper 

cervical dysfunction. Temperomandibular disorders refer 

to conditions involving the temperomandibular joints and 

associated muscles in the absence of visceral pathology 

(such as ear disorder, tooth abscess and pharyngeal 

tumour). Temperomandibular related headache is generally 

referred to the temple and frontal regions and needs to be 

differentiated from cervicogenic headache which can refer 

to the temple and retro-orbital regions. This paper evaluates 

the differential assessment of temperomandibular related 

headache and cervicogenic headache and the clinical 

decision making involved in the choice of the target region 

for dry needling. Dry needling of myofascial trigger points 

and dermatomal, myotomal and neural pathways will be 

discussed. 

Chronic musculoskeletal pain and sensitization: 

integrating pain mechanisms with objective physical 

findings and treatment strategies 

Shah JP 

Rehabilitation Medicine Department, Clinical Center, National 

Institutes of Health, USA 

Chronic pain states are characterised by profound changes 

in neuronal excitability and architecture in the pain 

matrix. These neuroplastic changes occur in the spinal 

cord, thalamic nuclei, cortical and limbic areas and may 

alter the threshold, intensity and affect of one’s pain 

experience. Moreover, the dynamic changes that occur 

during the initiation, amplification and perpetuation of 

chronic pain syndromes may provide explanations for 

some of the effects observed following dry needling and 

other physical medicine modalities. Spinal segmental 

sensitisation is a hyperactive state of the dorsal horn 

caused by bombardment of nociceptive impulses from 

sensitised and/or damaged tissue (somatic, visceral, etc). 

Manifestations in the sensitised spinal segment include 

dermatomal allodynia and hyperalgesia, sclerotomal 

tenderness and myofascial trigger points within the involved 

myotomes. This workshop integrates emerging knowledge 

from the pain sciences in a clinically accessible way. 

Attendees will learn important palpation skills to identify 

objective physical findings suggestive of spinal segmental 

sensitisation. These objective and quantitative examination 

techniques help clinicians identify the tissues and likely 

pain mechanisms involved in the patient with chronic 

musculoskeletal pain. These easy-to-learn examination 

skills are fundamental to the proper evaluation and 

management of chronic musculoskeletal pain. Participants 

will also learn needling techniques and physical modalities 

to desensitise the involved spinal segment, as well as how to 

objectively determine whether the physical manifestations 

of spinal segmental sensitisation were resolved following 

their treatment selection. Application of these examination 

techniques before and after treatment provides the clinician 

and patient meaningful and reproducible physical findings 

to guide treatment outcomes. 

Novel applications of ultrasound technology to visualise 

and characterise myofascial trigger points and 

surrounding soft tissue 

Shah JP 



There are currently no imaging criteria for the diagnosis 

of myofascial trigger points or for assessing the clinical 

outcome of treatments. Therefore, it remains a clinical 

diagnosis based exclusively on history and physical 

examination. Accordingly, there is a need to develop 

objective, repeatable and reliable diagnostic tests for 

evaluating the nature and natural history of trigger points 

and determining treatment outcome measures. Our 

laboratory recently began using three types of ultrasound 

diagnostic imaging techniques—grayscale (2D Ultrasound), 

vibration sonoelastography, and Doppler—to differentiate 

tissue characteristics of trigger points in the upper trapezius 

muscle compared to surrounding soft tissue. We found that 

trigger points appeared as focal, hypoechoic regions on 2D 

ultrasound, indicating local changes in tissue echogenicity, 

and as focal regions of reduced vibration amplitude on 

vibration sonoelastography, indicating a localised area of 

stiffer tissue. We have shown that ultrasound is feasible 

for imaging trigger points and that trigger points exhibit 

different echogenicity compared to surrounding muscle. 

Furthermore, vibration sonoelastography shows differences 

in relative stiffness between trigger points and normal 

(uninvolved) muscle. That is, sites containing trigger points 

have significantly greater relative stiffness compared to 

normal tissue. Doppler ultrasound was also able to show 

differences in the microcirculation in and around active 

trigger points compared to latent trigger points and normal 

tissue. For example, blood flow waveform characteristics 

can be used to differentiate active and latent trigger points. 

Retrograde flow on diastole was associated with active 

trigger points, indicating a very high resistance vascular 

bed and possible blood vessel compression. 

The unique neurobiology of myofascial pain: 

from peripheral to central sensitisation 

Shah JP 



Most of our scientific knowledge about pain mechanisms 

is derived from studies of cutaneous pain, and incorrectly 

applied to pain of muscular origin. In contrast to cutaneous 

pain, muscle pain causes an aching, cramping pain that is 

difficult to localise and often referred to deep and distant 

somatic tissues; muscle pain activates unique cortical 

structures in the central nervous system, particularly those 

which are associated with the emotional components of pain; 

muscle pain is inhibited more strongly by descending painmodulating 

pathways; and activation of muscle nociceptors 



is much more effective at inducing central sensitisation and 

maladaptive neuroplastic changes in dorsal horn neurons. 

Sensitisation is responsible for the transition from normal to 

aberrant pain perception; that is, when the central nervous 

system experience of pain outlasts the noxious stimulus 

coming from the periphery. There is a biochemical basis to 

the development of peripheral and central sensitisation in 

muscle pain. Continuous activation of muscle nociceptors 

leads to the co-release of substance P and glutamate at the 

pre-synaptic terminals of the dorsal horn and maximal 

opening of calcium-permeable ion channels. Moreover, 

prolonged noxious input may lead to long-term changes in 

gene expression, somatosensory processing and synaptic 

connections in the spinal cord and other higher structures. In 

addition, previously silent synapses may become effective. 

These mechanisms of sensitisation lower the activation 

threshold of afferent nerves and their central terminals, 

allowing them to fire even in response to daily innocuous 

stimuli. Consequently, even non-noxious stimuli such as 

light pressure and muscle movement can cause pain. 

Why are active myofascial trigger points painful 

and tender? In-vivo microdialysis suggests a 

biochemical component 

Shah JP 



This lecture summarises microdialysis studies that have 

surveyed the biochemical basis of myofascial trigger points, 

in order to help elucidate the mechanisms of myofascial 

pain and local tenderness. Though myofascial pain is a 

common type of non-articular pain, its pathophysiology 

is only beginning to be understood due to its enormous 

complexity. Myofascial pain is characterised by the 

presence of myofascial trigger points, which are defined 

as hyperirritable nodules located within a taut band of 

skeletal muscle. Myofascial trigger points may be active 

(spontaneously painful and symptomatic) or latent (nonspontaneously 

painful). Painful myofascial trigger points 

activate muscle nociceptors that, upon sustained noxious 

stimulation, initiate peripheral and central sensitisation. 

In order to investigate the peripheral factors that influence 

the sensitisation process, a microdialysis technique was 

developed to quantitatively measure the biochemical 

milieu of skeletal muscle. Concentrations of bradykinin, 

calcitonin gene-related peptide, substance P, tumor necrosis 

factor-α, interleukin-1β, serotonin, and norepinephrine 

were found to be significantly higher in subjects with an 

active trigger point compared to those with a latent one and 

those without trigger points in a standardised location in the 

upper trapezius muscle (p < 0.01). A subsequent study by 

our laboratory corroborated these findings and also found 

elevated levels of these and other biochemicals in a distant, 

unaffected muscle (the upper medial gastrocnemius muscle) 

in subjects with an active myofascial trigger point in the 

upper trapezius. This lecture relates the findings of elevated 

levels of sensitising and pain-producing substances within 

painful trigger points to the current theoretical framework 

of myofascial pain. 

Needling the carpal tunnel: neuroimaging effects 

Strudwick MW 

Centre For Magnetic Resonance, University of Queensland, Brisbane 

Carpal tunnel syndrome (CTS) is a common entrapment 

neuropathy often seen in acupuncture practice. Acupoint 

PC7, at the midpoint of the transverse crease of the wrist, 

is commonly listed as a treatment. The ability of magnetic 

resonance imaging (MRI) to evaluate early subtle changes 

within soft tissue could be exploited to determine the efficacy 

of this as a clinical treatment. With approval from ethics 

committees of UQ and The Wesley Hospital, after giving 

informed consent in writing, 10 participants (5 male; mean 

age 40.6 years) with CTS of the right wrist were enrolled 

in the study. Acupuncture was performed at PC7 using 

a sterile, single use 0.5 x 16mm Terumo IV needle. MR 

was performed on a Bruker Medspec 4T system equipped 

with a purpose-built transmit/receive coil. Measurements 

of signal intensity within the median nerve, flattening 

index calculated as the ratio of long to short axis and cross 

sectional area at each of three levels: the distal radio-ulnar 

joint, the pisiform and the hook of the hamate-were made 

on T2-weighted images before and after acupuncture. 

Paired samples t-tests demonstrated significantly reduced 

signal intensity after acupuncture. Acupuncture is reported 

to reduce swelling and oedema, but the timeframe for the 

effect has not been measured. The measurements recorded 

in this study were taken 4 hours apart, leading to the 

conclusion that acupuncture has a rapid onset of activity, at 

least in CTS. MR evaluation of clinical outcomes provides 

another link in the chain of validation of acupuncture as 

a successful treatment for conditions involving pain and 

swelling. 

Neuroimaging of acupuncture: 

an overview for clinicians 

Strudwick MW 

Centre For Magnetic Resonance, University of Queensland, Brisbane 

In 2001, a review by Shen of a series of neuroimaging 

studies demonstrated acupuncture effects appear to be 

mediated centrally in the brain. Cho et al. had initially 

demonstrated that functional magnetic resonance imaging 

was capable of revealing the expected actions of certain 

acupoints. This experiment showed a direct relationship 

between the stimulation of BL67 (clinically accepted 

for the treatment of eye-related disorders) and the visual 

centres of the cerebral cortex. One conclusion drawn is the 

possibility that acupuncture first stimulates or activates the 

corresponding cortex via the central nervous system, thereby 

controlling chemical or hormone release to the diseased or 

disordered organs. Any demonstration of regionally specific, 

quantifiable acupuncture effects on relevant structures of 

the human brain might facilitate acceptance and integration 

of acupuncture into the practice of Western medicine. A 

more recent review by Lewith et al, concluded that fMRI 

studies show specific and largely predictable areas brain 

activation and deactivation attributable to certain specific 

acupoints. In relation to pain, which involves a degree 

of expectation, acupuncture has both specific and nonspecific 

effects; but, in light of pharmacologic MR studies, 

central nervous system activity may be a line of evidence 

for analgesic effects. No publications to date have fully 

The e-AJP Vol 55: 4, Supplement 5


correlated clinical outcome in pathological conditions with 

definitively induced acupuncture changes in brain activation. 

This paper purposes an overview of imaging techniques and 

studies which shed light on the neurophysiological effects 

of acupuncture, from electroencephalography to functional 

magnetic resonance imaging. 

Comparison of the effects of manual acupuncture, 

electroacupuncture and TENS to acupoint LI4 on 

regional pressure pain thresholds 

Szabo S, Cobbin D, Zaslawski C, Choy B 

Faculty of Science, University of Technology, Sydney 

To compare the effects on regional pressure pain 

threshold (PPT) produced by manual acupuncture (MA) 

electroacupuncture (EA) and TENS to the acupoint Large 

Intestine 4 (LI4). Design a randomised and dual-blind 

(subject and assessor) study involving 24 healthy volunteers. 

The three 21 minute interventions to LI4 were TENS, EA 

and MA. Pressure pain threshold (PPT) was measured 

before and after each intervention at 10 sites (7 acupoints 

and 3 nonacupoints) across the body. In addition, subjects 

rated on a visual analogue scale (VAS) their subjective 

levels of pain, intervention needling sensation, tension 

experienced during, and anxiety prior to, the intervention. 

Among the 10 sites, statistically significant increases 

from pre-intervention PPT means were obtained at 9 sites 

following MA (mean PPT range 5.5%–10.5%), six sites 

following TENS (6.2%–12.4%), and all 10 sites following 

EA (6.8%–16.5%) to LI4. The effects on regional PPT 

following EA were statistically significantly greater than 

that produced by TENS at 5 sites; and than that of MA at 

2 sites. No significant difference was observed between 

the 3 interventions for the 5 subjective VAS ratings. All 

3 interventions elicited significant statistical increases in 

regional PPT. The effects were generalised across the body. 

The TENS intervention was the least effective and EA the 

most effective. The effects on regional PPT following MA 

were consistent with previous studies. 

The impact of site specificity and needle manipulation 

on pain pressure threshold: a controlled study 

Zaslawski C, Cobbin D, Petocz P, Lidums E 

Faculty of Science, University of Technology, Sydney 

To investigate the contribution of two principal features that 

underlie traditional Chinese acupuncture: site specificity 

and application of needle manipulation. Thirteen volunteers 

completed a randomised, dual blind (subject and assessor) 

repeated measures study involving 5 interventions. Pressure 

pain threshold (PPT) was measured with an algometer, 

before and after intervention at 10 sites (acupoints and 

nonacupoints) across the body. Interventions: deep needling, 

with or without manual needle rotation, applied to the 

acupoint Large Intestine 4 (LI4) or to a nonacupoint located 

on the medial side of the second metacarpal. Inactive 

laser to LI4 was used as a control. All interventions were 

administered for 21 minutes. Percentage change in PPT 

from pre-intervention baseline at the 10 sites during the 18 

minutes immediately following intervention. Statistically 

significant increases from pre-intervention PPT means 

were obtained at all 10 sites following needling of LI4 

with manipulation compared with one site after needling 

LI4 without manipulation. Needling the nonacupoint 

led to statistically significant increases at 6 sites when 

manipulation was present compared with none in the 

absence of manipulation. No significant changes in mean 

PPT followed inactive laser. Needling LI4 with manipulation 

produced mean increases that were statistically significantly 

greater than those for the other interventions with one 

exception: needling the nonacupoint with manipulation 

was as effective as needling LI4 with manipulation at 

one measurement site only. Both manipulation and site of 

needling contributed significantly to the elevation of PPT 

following acupuncture. Distribution of effects on PPT did 

not support either neural segmental or Traditional Chinese 

Medicine channel theories. Psychological and physiological 

nonspecific effects appeared to play a minimal role in 

changes to PPT. 

An energetics approach to plantar fasciitis 

Tan P 

Physiotherapy Dept, Casino Community Health, Casino 

Three separate case studies are discussed with emphasis on 

similarities and differences in presentation and intervention 

according to meridian theory as applied in meridian 

therapy. All three cases were referred with the diagnosis of 

plantar fasciitis. The first case is a 49 year old male with a 

history of bilateral plantar fasciitis of insidious onset over 

3–4 months. The second case is a 58 year old female with 

a history of bilateral plantar fasciitis for 12 months. Heel 

pain began gradually when she started a new job where 

she had to stand on her feet all day. The third case is a 42 

year old female with a history of an extreme rupture of the 

plantar fascia insertion while playing squash in February 

2009. This was diagnosed by an ultrasound scan. Common 

exercise prescriptions for plantar fasciitis are also discussed 

according to the energetics approach of meridian therapy. 

6 









2 

Acute canine idiopathic polyradiculoneuritis 

Connell L 

Animal physiotherapy solutions, Brisbane 

Acute canine idiopathic polyradiculoneuritis is an acute 

inflammatory condition that causes demyelination and 

axonal degeneration in ventral nerve roots and peripheral 

nerves, resulting in flaccid paralysis similar to Guillian- 

Barré syndrome in humans. Although the pathophysiology 

is not fully understood, it is thought to be due to an immune 

mediated response to antigens present in raccoon saliva, 

or following respiratory or gastrointestinal infections or 

vaccination. Initially, clinical signs present in the pelvic 

limbs with the onset of a stiff, stilted hind limb gait, this 

rapidly progresses to flaccid lower motor neuron tetraparesis 

or tetraplegia. In some cases facial and laryngeal paralysis 

may occur along with respiratory paralysis due to the 

phrenic and intercostal nerve involvement. In severe 

cases, reduced respiratory function can result in death, 

but generally prognosis is good with the majority of 

dogs making a full recovery. As there is no specific 

medical treatment for this condition, good nursing care 

and physiotherapy are essential in the animal’s recovery. 

Many dogs are recumbent for several weeks and suffer 

from severe muscle atrophy. Physiotherapy is essential in 

the prevention of joint and soft tissue contractures as well 

as assisting with correct movement patterning, increasing 

muscle strength and overall function. This presentation 

discusses the pathophysiology of the condition, its clinical 

presentation and physiotherapy management from onset to 

return of functional independence. 

Neospora caninum: a case study 

Connell L 

Animal physiotherapy solutions, Brisbane 

Neospora caninum is a protozoan parasite that 

causes neuromuscular conditions in the canine, including 

meningoencephalitis, myositis, and polyradiculoneuritis. 

It’s most common route of transmission is by transplacental 

infection from an asymptomatic bitch to her litter although 

other forms of transmission are by ingestion of infected 

tissues from the intermediate hosts such as cattle, sheep, 

goats and horses. Once infected the host may remain 

asymptomatic with clinical signs presenting more often 

in young or immuno-suppressed older dogs. The clinical 

presentation in older animals tends to be multifocal with 

variable central nervous system and muscular involvement. 

In puppies less than 6 months of age the infection is usually 

more focal, affecting the muscles and nerve roots of the hind 

limbs. This can result in progressive hind limb paralysis, 

muscle atrophy, and loss of patella reflexes. Depending on 

the severity of damage to these tissues, severe quadriceps 

muscle atrophy and fibrosis leading to rigid hyperextension 

of the hind limbs can occur. This case study presents a 

puppy with multifocal neurological and muscular signs 

due to infection from neospora caninum, and discusses the 

pathophysiological progression of the condition as well as 

the medical and physiotherapy management. 

Physiotherapy rehabilitation following a sacroiliac 

injury in a dressage horse 

Craig, LJM 

Auckland, New Zealand 

This single case study was designed to examine the 

effectiveness of a selection of physiotherapy techniques in the 

treatment of a 6-year old Warmblood stallion competitive at 

dressage with a sacroiliac joint injury. Treatment consisted 

of twice weekly physiotherapy including joint mobilisations 

described by Maitland, soft tissue massage, proprioceptive 

retraining, stretches, facilitated strengthening exercises on 

the lunge and under saddle. Subjective changes were noted 

from the treating veterinarian, the owner of the horse, and 

the rider of the horse. The main presenting complaint was 

the inability of the stallion to perform on the phantom for 

breeding purposes. Objective measurements consisted of 

muscle symmetry, pain on palpation, gait analysis, and 

stability of the shear force transmitted through the affected 

sacroiliac joint. Treatment continued over a 1-year period 

until the stallion was competing, and then a maintenance 

program was introduced with twice monthly followups 

which are still ongoing. Subjective and objective 

improvements were noted in all measurements taken 

deeming physiotherapy management to be effective in the 

rehabilitation of this stallion in that he can perform on the 

phantom without any perceivable difficulties, has no gait 

abnormalities or muscle asymmetry, and has progressed in 

his competitive dressage from Elementary to Prix St George 

in a 3-year period. 

The effects of an eleven week physiotherapy 

intervention on the mobility of the 

equine thoracic spine 

Craig LJM, Stubbs NC, McGowan CM 

The University of Queensland, Gatton 

The aim of this study was to determine the effects of an 11 

week physiotherapy intervention on flexibility and resting 

spinal flexion of the mid-thoracic spine in a group of 14 

asymptomatic horses by measuring the distance between 

vertebral dorsal spinous processes and subjective scores of 

flexibility. Fourteen horses of varying breeds and disciplines 

and asymptomatic for back pain, mean age 10 ± (4.81) years 

were selected. A non-blinded method was used to allocate 

the subject to a control and treatment group. Seven received 

twice weekly treatments consisting of deep soft tissue 

massage, spinal and intervertebral joint mobilisations to 

the thoracic spine at T10, T11 and T12, facilitated range of 

motion exercises and myofascial stretches. The remaining 

7 received no treatment. Significant increases in distance 

between vertebral spinous processes using real time 

ultrasonography at all levels (p < 0.05) were found in the 

treated horses compared to controls. Although the horses 

were asymptomatic for back pain, the owners had noticed 

positive changes in their riding following the treatment. 

There were gradable changes in all outcomes for all horses 

for range of motion for lateral and slump baited stretches, 

perceived amount of dorso-ventral glide with intersegmental 

joint mobilisations, and amount of spinal excursion seen 

with abdominal stimulation. This study has shown that 

resting spinal flexion, measured ultrasonographically as 

an increased distance between dorsal spinous processes, 

was increased following physiotherapy intervention. 

Physiotherapy treatment can increase the flexibility of 



the equine mid thoracic spine including over an 11 week 

period. 

Diffuse noxious inhibitory control uses a noxious 

stimulus to improve canine gait 

Davidson, PT 

All Animal Physio, Melbourne 

A major challenge for animal physiotherapists is to get 

injured dogs to weight bear on painful limbs. Otherwise, 

uneven weight bearing on 3 good limbs may result in 

spinal scoliosis, muscle atrophy and contracture of lame 

leg muscles, increased compression of alternate good limb 

joints and, possibly, injury to 1 of the 3 remaining good 

legs, a diabolical outcome. Heterotopic noxious stimulus is 

a stimulus occurring in an abnormal place. This could be the 

use of a bottle or syringe top under the paw, or a piece of silver 

foil under the pad. A noxious stimulus anywhere in the body 

can reduce the perceived intensity of pain of a concomitant 

noxious stimulus elsewhere. This study hypothesised that 

the use of a noxious stimulus to the contralateral good leg 

would encourage greater weight bearing on the lame leg of 

a dog. Four lame dogs were used in this study and 1 normal 

dog for comparison. Video analysis and Grade of Lameness 

pre-and post-noxious stimulus was established. This study 

showed that a noxious stimulus under the pad of the good 

leg did encourage the dogs to weight bear more evenly on 

the lame leg (p = 0.046). The neurophysiological reason 

for this may be Diffuse Noxious Inhibitory Control, Spinal 

Cord Inhibition, Opioid Mediated Analgesia or a simple 

Withdrawal Reflex. 

Labrador elbow dysplasia and anthropometric 

measurements of scapula, humerus, radius and ulna 

Davidson PT, 1 Bullock-SaxtonJ, 2 Lisle A 2 

1 

All Animal Physio, Melbourne, 2 The University of Queensland, Gatton 

The aim of this study was to determine if anthropometric 

measurements of Labrador scapula, humerus, ulna and 

radius, or their ratios, was related to the presence of 

elbow dysplasia. One hundred and three Labradors were 

volunteered for the study: 41 male dogs and 62 bitches. 

Digital caliper measurements of the lengths of the left 

scapula, humerus, radius and ulna, and their ratios, were 

analysed, by gender, against International Elbow Working 

Group derived Elbow Dysplasia radiological scores. The 

International Elbow Working Group score is an umbrella 

score used to classify for elbow dysplasia and includes 

Fragmented Coronoid Process, Osteochondritis Dissecans 

and Un-united Anconeal Process, the last of which occurs 

rarely in Labradors and was excluded in this study. Of the 

103 Labradors studied, 31 were diagnosed radiographically 

with elbow dysplasia (20 bitches (32%), 11 (27%) of the 

male dogs. Scapula length was significantly shorter for 

bitches with elbow dysplasia, p = 0.02, but not for male 

dogs. However, male dogs showed a trend for a difference 

in ulna:radius ratio, p = 0.06, but bitches did not. Although 

a greater percentage of bitches than male dogs had elbow 

dysplasia in this study, this difference was not statistically 

significant. This study demonstrated that a shorter scapula 

existed in bitches diagnosed with Labrador elbow dysplasia. 

This result is a new finding associated with this condition. 

The difference in presentation associated with gender is 

unexpected. Further research is recommended. 

A comparison of the sacroiliac joints of thoroughbred 

racehorses and Australian brumbies 

Goff LM 

The University of Queensland 

Morphological features of the thoroughbred sacroiliac joint 

have been previously documented post-mortem, and the 

presence of degenerative changes on the joint surfaces has 

been noted to be high. In this current study, the surface area, 

shape and morphological features of sacroiliac joints of 

thoroughbred racehorses were compared to sacroiliac joints 

of Australian brumbies. It is hoped that the information 

gleaned from this study in morphology assists in our 

understanding of pathologies that exist in the sacroiliac 

joint of the performance horse. 

The equine and canine temporo-mandibular joint 

Goff LM 


The aim of this presentation is to provide a contemporary 

review of the anatomy and biomechanics of the equine and 

canine temporo-mandibular joint. Physiotherapy assessment 

and treatment concepts will be discussed. 

Coxofemoral stability 

Grimaldi AM 

PhysioTec Physiotherapy, Brisbane 

Mechanisms for stability of the coxofemoral or hip joint 

include passive, active and neural control elements. The 

passive system includes bony structure, the acetabular 

labrum, and ligamentous and capsular structures. This 

system may be compromised by bony deviations such 

as acetabular dysplasia, labral damage, or generalised 

or focal ligamentous laxity. The acetabular labrum 

plays a critical role in minimisation of joint loading and 

protection of articular cartilage. Labral damage may occur 

in association with acetabular dysplasia or ligamentous 

laxity, but other bony deviations may also result in labral 

damage via femoroacetabular impingement. Assessment 

should involve close examination of radiographs and 

considerations of clinical signs of inadequate passive 

stability. The active subsystem in close association with 

the neural control subsystem also plays an integral role in 

joint protection and stability, particularly in the presence 

of structural deficiencies. Deep rotatory muscles around 

the hip are thought to provide an active rotator cuff for 

fine control and joint protection. Muscles around the hip 

joint in quadripedal animals such as cats and dogs closely 

mirror those of the human hip. Fibre typing studies in 

these animals has revealed high percentages of slow twitch 

fibres in muscles such as the quadratus femoris, reflecting 

a tonic, joint protection function. This presentation aims to 

promote consideration of the role of the deep hip rotators 

in joint protection, and highlight postural habits in humans 

and animals alike that may have negative consequences for 

optimal muscular protection. 



4 

The canine hip 

Marsh BE 

Holistic Animal Physiotherapy, Brisbane 

Canine hip dysplasia (CHD) is a condition of the coxofemoral 

joint with multifactorial genetic and environmental 

components. It is associated with joint instability, which 

can lead to degenerative changes and varying degrees of 

dysfunction and pain. There are several surgical options 

to treat canine hip dysplasia, most of which are considered 

salvage procedures. Physiotherapy, preventive therapies, 

and rehabilitation could have a large role to play in the 

management of nonsurgical CHD patients. Physiotherapy 

management has been shown widely in human literature to 

improve the alignment of the femoral head in the acetabulum, 

create the best possible musculoskeletal environment for 

pain-free hip function, and to delay or prevent the onset of 

degenerative joint disease. Conservative management for 

canine hip pathologies warrants further discussion. 

Western acupuncture and dry needling in canines 

McCutcheon LM, 1, 2 Marsh B 3 

1 

Combined Health Acupuncture and Dry Needling Education, 

2 

Research Fellow School of Medicine, Griffith University, 3 Holistic 

Animal Physiotherapy; North Coast Veterinary Specialists 

Western acupuncture has its foundations in 

neurophysiological clinical reasoning and combines local, 

segmental and extra-segmental needling points. Even though 

traditional acupuncture points are used with this style of 

needling Western acupuncture is not viewed as Traditional 

Chinese Medicine (TCM) as no paradigms or traditional 

assessment methods are adopted from TCM. The various 

dry needling approaches including Travell and Simons, 

Gunn and Baldry styles will be considered. Both animal 

and human research has established the aetiology of trigger 

points and forms the neurophysiological basis to these 

needling techniques. Clinical reasoning for the treatment 

of canine musculoskeletal conditions using both Western 

acupuncture and dry needling will be presented along with 

the present evidence base for needling in canines. Selected 

case studies will be drawn upon in order to illustrate the use 

of Western acupuncture and dry needling in canines. 

Clinical examination and palpation of the stifle joint: 

can it help with the detection of meniscal injuries 

in the dog? 

Mitchell RAS, 1 Innes JF 2 

1 

North Coast Veterinary Specialists, Sunshine Coast 2 University of 

Liverpool, UK 

A prospective study was performed to evaluate whether 

joint line tenderness (JLT) and pain on stifle joint flexion are 

useful indicators for meniscal injury in cases of concurrent 

cranial cruciate ligament (CCL) rupture. The stifle joint of 

each case was examined clinically and radiographically and 

the following findings noted: presence of cranial drawer 

and cranial tibial thrust, pain on caudomedial joint capsule 

palpation, discomfort on joint flexion, pain on palpation 

over parapatellar and lateral joint capsule and the absence 

of other significant stifle disease. A positive response 

was noted when a painful response was elicited on direct 

pressure over the relevant joint capsule and also on joint 

flexion. The association between background variables and 

meniscal injury was tested using Mann Whitney U tests. 

Fisher’s exact test was used to test the associations between 

pain on caudomedial joint palpation or joint flexion and 

medial meniscal injury. There were 98 stifle joints in 90 

dogs. Seventy-eight of 98 stifles had complete rupture of the 

CCL, 8 had partial tears and 12 had a late meniscal injury. 

The overall incidence of meniscal injury was 66/98 (67%). A 

significant relationship (p = 0.0001) was found between JLT 

positive cases and meniscal injury. A significant relationship 

(p = 0.0021) was also found between pain on joint flexion 

and meniscal injury. Lateral joint capsule pain was not 

identified in any case of lateral meniscal injury. JLT and 

joint flexion appear to be useful tests for the preoperative 

detection of medial meniscal injury in the canine cruciate 

deficient stifle joint. 

Physiotherapy following joint arthroplasty 

in the canine 

Monk ML 1 , Preston CA 2 

1 

Dogs In Motion Canine Rehabilitation Centre, Melbourne 2 Animal 

Surgery Centre, Melbourne 

Just as in humans, joint arthroplastic surgery is available 

for the canine patient to alleviate pain and improve mobility 

in joints affected by degenerative joint disease. This 

presentation outlines current joint arthroplastic surgeries 

available for the canine patient in Australia including hip, 

knee and elbow. This will include common complications 

and outcomes in patients to date. Following this will be a 

discussion about post-operative physiotherapy protocols 

that are suitable for these patients. 

The use of whole body vibration in a paraplegic 

ridgeback 

Nicholson HL 

Animal Physiotherapy Services, Sydney 

A four-and-a-half-year-old male neutered ridgeback was hit 

by a vehicle on a 110 kph freeway on 02/01/09 and suffered 

an open fracture to the right radius and ulna, fracture 

luxation of T11–12 and numerous other injuries. He had 

surgery to stabilise his spine on 03/01/09, wound closure 

surgery on 17/01/09 and open reduction and internal fixation 

on 28/01/09. Conventional physiotherapy commenced on 

09/01/09 and slow progress was made. On 20/03/09, he 

had an initial session on a whole body vibration (WBV) 

machine and his thigh circumference was measured as 36.0 

cm on the right and 35.0 cm on the left. At his second WBV 

session on 27/03/09 his thighs measured 37.6 cm on the right 

and 36.4 cm on the left. On 02/04/09 his thighs measured 

37.6 cm on the right and 37.2 cm on the left. On 09/04/09 

his thighs measured 38.1 cm on the right and 38.1 cm on 

the left. Conventional physiotherapy continued throughout 

the time that the WBV was used, however the speed of 

increase in thigh circumference had not been achieved with 

conventional physiotherapy alone. 



Physiotherapy in the small animal intensive 

care setting 

Nicholson HL 

The University of Queensland, Brisbane and Animal Physiotherapy 

Services, Sydney 

This presentation will combine a summary of the PhD topic 

‘Physiotherapy in the canine intensive care setting’ with 

examples of the practical application of techniques on small 

animals, including a cat with laryngeal paralysis, a wombat 

with aspiration pneumonia, and a dog with tick (Ixodes 

holocyclus) poisoning. Topics discussed will include the 

causes, characteristics and risk factors for the survival of 

recumbency in dogs presenting to four veterinary referral 

hospitals in Sydney in a 12-month period, and a literature 

review of involuntary canine recumbency. The short-term 

effects of recumbency in dogs will be discussed and case 

studies of the administration of continuous positive airway 

pressure and manual chest physiotherapy will be presented. 

The session will conclude with recommendations for future 

research and an opportunity to ask questions. 

Advanced diagnostic imaging modalities in the horse: 

magnetic resonance imaging and nuclear scintigraphy 

Smith CL 

Veterinary Teaching Hospital Camden, University of Sydney, Camden 

Lameness in horses causes enormous economic losses 

within the equine industry and also has important animal 

welfare implications. New diagnostic imaging modalities 

including nuclear scintigraphy and magnetic resonance 

imaging can help identify the site and cause of difficult 

lameness problems in horses. Magnetic resonance imaging 

and nuclear scintigraphy has been a valuable diagnostic tool 

in human medicine for over 20 years and is now available 

in Australia in some equine veterinary clinics. Nuclear 

scintigraphy involves injecting a technetium-labeled 

radiopharmaceutical intravenously. A gamma camera then 

identifies sites of increased radioisotope uptake, which 

indicates active bone remodeling. It is of particular benefit 

in cases in which the lameness is difficult to localise, such as 

in the upper limb. MRI should be considered in horses that 

have a lameness that has been localised to a specific region 

but convention diagnostic techniques such as radiographs 

and ultrasound have failed to provide a definitive diagnosis. 

MR imaging is very sensitive and specific, and gives detailed 

information about both soft tissues and bones. Magnetic 

resonance imaging and nuclear scintigraphy can provide 

invaluable information in horses that have complicated 

lameness problems. A thorough clinical and lameness 

examination including diagnostic nerve blocks, radiographs 

and ultrasound is imperative to ensure case selection for 

MR Imaging or nuclear scintigraphy is optimal. Improving 

our ability to accurately pinpoint the cause of lameness will 

improve treatment and hopefully improve the prognosis for 

return to function in these horses. 

A randomised double-blind comparative study of 

the dorsal movement of the thorax relative to the 

scapula as achieved by four different 

physiotherapeutic techniques 

Steed C 

Topline Physiotherapy 

Horses frequently incur injury around the scapulothoracic 

and shoulder regions. Shoulder lameness resistant to standard 

treatment and causing a loss of performance, particularly in 

high intensity stretch-shortening cycles (such as collection 

and jumping) may benefit from active assisted physiological 

mobilisations (AAPMs) of the scapulothoracic joint. 

Physiotherapists have long implemented such techniques 

in the management of human musculoskeletal disorders. 

Animal physiotherapists have applied these principles and 

use a variety of AAPM techniques to evaluate dysfunction 

and provide treatment. Despite clinical practice in animal 

physiotherapy, little research evidence exists in the equine 

field to support the efficacy of these techniques. Therefore, 

this study aims to evaluate the effectiveness of four different 

AAPMs in their ability to influence the motion of structures 

of the scapulothoracic region. Changes in the equine wither 

height was considered to reflect alterations of mobility of 

the scapulorthoracic complex. The four AAPM techniques 

evaluated were: Thoracic lift, Thoracic Rounding, 

Cervicothoracic Dorsoventral Flexion and Thoracolumbar 

Sacral Rounding. Twelve thoroughbred geldings aged 

between 7 and 15 years, reportedly over 15’3hh (160 

cm), and currently in work for at least 3 hours per week 

were randomly allocated to one of 4 groups. Each group 

received the techniques in a different order to control for 

training or stretching responses. The horse owner ensured 

square stance in the crush during each measurement. Two 

assistants measured wither height. The researcher applied 

the AAPM and was blind to the measures collected by 

the recording assistant. Each AAPM was measured twice. 

Results demonstrated a significant increase in wither height 

associated with both the Thoracic Lift and the Thoracic 

Rounding techniques, p < 0.01. These findings reveal two 

effective techniques for mobilisation of the scapulothroacic 

complex resulting in significant changes to equine wither 

height. 

Rehabilitation following traumatic cauda equina 

transection and sacral displacement in a young puppy: 

a year in review 

Steinman L 

Four Foot Physiotherapy/Capital Animal Physiotherapy, Canberra 

Physiotherapy is regularly used in neurological cases with 

good outcomes. This retrospective case study presents 

a Rhodesian ridgeback puppy, referred by its treating 

veterinarian for physiotherapy evaluation and treatment for 

a severe spinal injury. The injury was sustained 2 hours after 

birth when the puppy was bitten by his mother who was 

recovering from anaesthetic post caesarean. He presented at 

8 weeks, with bilateral hind limb paresis and LMN damage 

to bladder, perineum and tail indicating some complete 

cauda equina transection with other parts incompletely 

transected. Significant neurological compromise included 

absent reflexes (deep pain, withdrawal, patellar) left hind 

leg and severely reduced reflexes in right hind (slight deep 

pain and withdrawal, no patellar reflex). Radiographs 

showed a sacroiliac fracture and separation with ventral 



displacement of sacrum with cauda equina transection. 

Specialist opinion at 3 weeks old was grim with euthanasia 

initially recommended, however the owner elected to pursue 

treatment to improve his quality of life and function. The 

challenges of addressing severe neurological dysfunction in 

a developing large breed puppy, the extensive physiotherapy 

treatment interventions and outcomes are presented. At 1 

year of age, the pup is fully ambulatory and independent. 

Although there are still some residual deficits, his high level 

of function has exceeded the expectations of the owner, 

veterinarians and physiotherapist. The effectiveness of 

combined techniques and owner dedication demonstrates 

that despite significant timeframe and cost, physiotherapy 

intervention can dramatically improve an animal’s function 

and quality of life, even in severe cases with very poor 

prognoses. 

Conservative management of canine cranial crucial 

ligament disease: a case study 

Vacher SD 

There are many different types of surgery described for the 

management of Cranial Cruciate Ligament (CCL) rupture 

in the canine. There is no good evidence to recommend 

any form type of surgery over another, but there are 

indications that postoperative rehabilitation is an important 

part of the management. There is nothing in the literature 

regarding conservative management. This case study 

describes a 2 year old female rottweiler with a left CCL 

rupture. The owners opted for conservative management 

against veterinary advice. Treatment consisted of cage 

rest for 6 weeks with a graduated walking program and 

strengthening and proprioceptive program. By 6 weeks she 

displayed only a mild lameness. The owners were advised 

to avoid fetching games and any twisting actions, and at 

follow-up 10 weeks they reported no noticeable lameness. 

A year later she had an injury of the contralateral limb. 

With the same management she is now sound. This case 

demonstrates that with owner compliance, canine CCL 

disease can be managed conservatively. Further research 

is indicated to compare conservative management with 

surgical management. 

Vaulting and trick riding: a role for physiotherapy 

Vacher SD 

Vaulting and trick riding are very demanding equestrian 

activities that require different skills than normal riding. 

Vaulting originally started as an Olympic sport similar 

to gymnastics on horse back, but in recent years has been 

modified with input from sports medicine specialists and 

physiotherapists to create an emphasis on neutral spine and 

core stability to prevent hyperextension of the spine. Vaulters 

have a higher rate of recurrent back pain compared to other 

disciplines, but have a higher level of balance control. 

Core stability is essential in vaulting to achieve the correct 

positions on a moving horse; upper limb strength and lower 

limb power and proprioception are also important aspects. 

Trick riding differs to vaulting in that the riding uses straps 

on the specially made saddle to hang off the side or back 

of a moving horse. There is considerable torsion and stress 

on the supporting leg in these positions, with knee injuries 

being quite common. Physiotherapy has an important role 

to play in treating injuries in vaulting and trick riding and 

providing appropriate sport specific rehabilitation, including 

proprioceptive re-education. Assessment of technique, 

core stability and muscle imbalances may be beneficial to 

address potential problems and improve technique. 

6 




Understanding Water 






2 

What’s different about my sport: 

swimming? 

Blanch P 

Australian Institute of Sport 

Swimming fast has come under intense public scrutiny in 

the last few months. There seems to be a public feeling that 

if we could all put on the ‘super suits’ we would all be able 

to move like a dolphin. Certainly the reduction of drag is an 

important concept in swimming fast but there is more to it 

than putting on a suit. The concepts of moving fast through 

water, the musculoskeletal requirements and costs will be 

discussed. 

Measuring the outcome of aquatic physiotherapy 

interventions with persistent pain patients 

Daly AE 

Persistent Pain Service, Austin Health, Melbourne. 

Aquatic physiotherapists and their persistent pain patients 

know that the aquatic environment impacts positively on 

pain, stiffness, function and exercise ability. Yet many studies 

fail to find a significant effect from aquatic interventions. 

This presentation will touch briefly on some of the possible 

reasons for this lack of demonstrated effect and suggest 

possible solutions. Various forms of outcome measurement 

will be presented and the benefits and drawbacks of each 

will be discussed. Delegates will gain knowledge about 

combining different types of outcome measurement and 

be able to access and utilise the majority in their clinical 

practice immediately. 

Successful management of the persistent pain patient 

in the aquatic environment 

Daly AE 

Persistent Pain Service, Austin Health, Melbourne. 

Persistent pain is a common problem encountered by 

aquatic physiotherapists. Many clinicians question their own 

abilities to manage this challenging condition optimally. 

This presentation will discuss the model of care within the 

interdisciplinary pain service at Austin Health, Melbourne, 

with particular consideration of our utilisation of the aquatic 

environment. The consequences of persistent pain for the 

patient will be discussed and an alternative to the common 

paradigm of acute pain management will be presented. 

The challenges faced by the aquatic physiotherapist will 

be presented as will solutions and management strategies. 

Delegates will gain knowledge about the management of 

persistent pain that can be put into practice immediately. 

Greater trochanteric pain syndrome: fat, female and 

over forty. Fact or fiction? 

Fearon AM, 1,2 Scarvell JM, 1,2 Cook JL, 3 Smith PN 1,2 

1 

The Australian National University, Canberra. 2 The Trauma 

and Orthopaedics Research Unit, Canberra. 3 Deakin University, 

Melbourne. 

The aim of this research was to clarify the demographic and 

body type profile, and the signs and symptoms of people with 

Greater Trochanteric Pain Syndrome (gluteal tendinopathy, 

Trochanteric bursitis). Thirty-two participants who fitted the 

inclusion criteria and 20 age and sex matched asymptomatic 

control participants were recruited. GTPS was diagnosed 

clinically and confirmed by imaging. Participants were 

assessed using the Oswestry Disability Index, the Harris 

Hip Score and a purpose built questionnaire. A battery of 

clinical tests including BMI, hip joint range of movement, 

hip muscle strength using a hand held dynamometer, 

Trendelenburg’s sign, step up and hip hitch tests, timed 

up and go, and ten metre walk test were undertaken. The 

demographic and body type results will be presented in the 

light of existing research. The sensitivity and specificity of 

the clinical tests will be presented. This presentation will 

provide clarification for clinical and differential diagnosis 

in complex cases. 

Hydrotherapy for osteoarthritis of the hip or knee: 

review of randomised clinical trials 

Fransen M 

The University of Sydney, Sydney 

Osteoarthritis of the hips or knees is associated with poor 

lower limb muscle strength and function. In addition, 

many older people with osteoarthritis of the hips or knees 

are overweight and sedentary, greatly increasing the risk 

of various serious co-morbidities. However, participating 

in regular land-based physical activity programs is often 

experienced as exacerbating joint pain, leading to poor 

adherence and therefore non-responsiveness in terms of 

symptomatic benefits. While there is a high level of evidence 

for the symptomatic effectiveness of land-based exercise 

programs for most people with osteoarthritis of the knee, 

there is very limited evidence for the benefits for people with 

osteoarthritis of the hips. The results of a recently conducted 

systematic review of randomised clinical trials evaluating 

hydrotherapy programs for people with osteoarthritis of 

the hips or knees will be presented. These results will be 

compared with results from systematic reviews evaluating 

land-based programs. The possible rationale for conflicting 

or contrasting findings will be discussed. 

Higher intensity aquatic physiotherapy for 

compensable patients with musculoskeletal injury and 

chronic pain: a study of two comparative cases 

Geytenbeek JM 

Roberts Physiotherapy, Adelaide 

Water-based exercise is intuitively regarded as a treatment 

of gentle intensity with low likelihood of aggravating 

patient pain for application in the management of chronic 

musculoskeletal injury. However, the greater volume 

of research evidence supporting the use of water-based 

exercise has investigated arthritic populations undergoing 

group-prescribed exercise. More recently, researchers 

have documented exercise intensity, aiding clinicians 

in transferring the measured results of researchers into 

repeatable clinical practice. The complexity of compensable 

injury with several issues potentially mitigating measurable 

outcome-effectiveness attributable to a discrete therapeutic 

approach among a multitude of co-interventions, has 

probably posed a disincentive to the investigation of this 

relevant, highly prevalent and costly, therapeutic population. 

Two clinical cases of patients with chronic musculoskeletal 

compensable injury are presented to demonstrate the 

reasoning behind and application of higher intensity 

aquatic physiotherapy in an environment of kinesiophobia 



and fear-avoidance, and physical deconditioning. Clinical 

measurement and video analysis are used to highlight this 

aquatic physiotherapy approach. 

Land-based versus pool-based exercise for people 

awaiting joint replacement surgery of the hip or knee: 

results of a randomised clinical trial 

Gill SD, 1,2 McBurney H, 1 Schulz DL 2 

1 

School of Physiotherapy, La Trobe University, Bendigo, 2 Barwon 

Health, Geelong 

The aim of this investigation was to compare the preoperative 

effects of multi-dimensional land-based and pool-based 

exercise programs for people awaiting joint replacement 

surgery of the hip or knee. A randomised single-blinded 

trial was conducted in a physiotherapy gymnasium or 

hydrotherapy pool. Eighty-two patients were allocated to 

either a land-based (n = 40) or pool-based exercise program 

(n = 42). Each six-week program included an education 

session, twice weekly exercise classes, and an occupational 

therapy home assessment. Participants were assessed 

immediately before and after the six-week intervention then 

8 weeks later. Primary outcomes were pain (WOMAC), 

self-reported function (WOMAC), and patient global 

assessment. Secondary outcomes were performance-based 

measures (timed walk and chair stand) and psychosocial 

status (SF36 MCS). Pain was also measured before and 

after each exercise class on a 7 point verbal rating scale. 

Although both groups demonstrated improvements in pain 

and function following the interventions, there were no 

post-intervention differences between the groups for the 

primary and secondary outcomes. The pool-based group 

had less pain immediately after the exercise classes. Multidimensional 

land-based or pool-based interventions appear 

to be beneficial in those awaiting joint replacement surgery 

of the hip or knee. Pool-based exercise might have a more 

favourable effect on pain immediately after the exercise 

classes. 

Aquatic physiotherapy in sport: considerations for 

measuring effectiveness, integrating evidence into 

practice and developing targeted programs 

Heywood SE 

The Melbourne Sports Medicine Centre, Melbourne, Carlton Football 

Club, Melbourne, Sunshine Hospital, Western Health, Melbourne 

A pragmatic pilot trial assessing the effectiveness of an 

aquatic physiotherapy program in a group of elite athletes 

was carried out. The content and focus of the intervention 

was varied and individualised with up to ten participants 

(18–28 years) in each session. The primary aim of the 

aquatic physiotherapy session was to address trunk control 

and pelvic stability. Secondary aims were individualised 

and included specific musculoskeletal or post-operative 

rehabilitation, stretching, plyometric exercise or deep water 

running. Once a week for 6 weeks measures including 

pain, strength and range of movement were taken poolside 

before and after the aquatic physiotherapy intervention. 

Aquatic exercise is commonly described as less loaded 

but the unstable properties of the environment are often 

underestimated particularly with regard to rotational forces. 

Consideration must be given to the starting position, base of 

support or points of fixation for each exercise in conjunction 

with hydrostatic and hydrodynamic factors including the 

plane of rotation, weight bearing, speed, surface area and 

direction of movement. Monitoring trends and changes in 

objective measures can assist with ensuring that the content 

of the aquatic physiotherapy session is more targeted. A 

combined format of group exercise and individualised 

exercise can be effective. The challenge in the area of 

aquatic physiotherapy in sport is to develop specific aims 

for the intervention, to consistently measure outcomes and 

to integrate land based and aquatic based evidence into 

practice. 

Considerations for discharge planning in aquatic 

physiotherapy-facilitating self-management and 

independent aquatic exercise in chronic disease: 

a pilot trial 

Heywood SE, 1 Cross EA, 1 Dodds KJ, 1 Logan AD, 1 

Bramley RE 2 

1 

Sunshine Hospital, Western Health, Melbourne 2 Eastern Health, 

Melbourne 

The aim of this project was to identify barriers to, 

and subsequently trial a structure that would facilitate 

independent aquatic exercise following discharge from 

aquatic physiotherapy in a community based rehabilitation 

setting. Preliminary data collection involved a phone 

survey post discharge from the standard 6-week aquatic 

physiotherapy intervention (n = 16). One month after 

discharge 62% of patients were still participating in some 

form of aquatic exercise. Insufficient access to transport was 

determined as the principle reason for non-attendance. A 

care plan was developed prompting aquatic physiotherapists 

to classify their patients early in the rehabilitation phase 

into one of three sub-groups: aquatic likely (AL): those 

with good resources, support and understanding of their 

condition; aquatic possible (AP): those with some issues 

regarding transport, support or understanding; and aquatic 

assist (AA): those who would require a trained carer either 

in the pool or poolside to assist with mobility or changing. 

Over a period of 8 weeks the care plan was trialled with 

a new group of patients (n = 20). The 6-week intervention 

was reduced to 5 weeks, with patients offered a bonus 

week of therapy only after they agreed to attend and trial 

a community pool independently. Outcomes measured 

during this trial include percentage of patients continuing 

independent aquatic exercise at 1 month post discharge. 

There is scope to monitor the impact of this project on rereferral 

rate to aquatic physiotherapy in the future. 

The business of aquatic physiotherapy 

Howell DH 

Ergogym, Phillip ACT 

This presentation will discuss some of the requirements to 

run a successful aquatic physiotherapy practice. The aquatic 

environment offers a physiotherapist a unique marketing 

opportunity, specifically it offers a point of difference in 

service delivery. The diversity of the environment also 

offers a range of challenges and special requirements. Topics 

included will be: how to optimise the aquatic environment 

without compromising safety and service delivery; working 

and communicating with third party payers including 

compliance with their requirements; communicating 

outcomes and other marketing opportunities; use of APA 

resources and mentors. 



4 

Pool design: the big and the small of it 

Larsen JA 

Hydrotherapy Consulting and Training, Brisbane. PhysioLogic, 

Brisbane. 

Pool design has come a long way. Textiles and lighting, 

automated dosing, measuring and more. Hotel finishes, 

glossy magazines, temperature controlled everything. But 

are we overreaching? Are we allowing design and guidelines 

to ultimately restrict access by limiting the number of 

pools being built? When a special school builds a pool and 

is emphatic that it is not a hydro pool, simply because of 

the expectation of the standard to which they must build 

it, have we overstepped the mark? When the expectations 

of patients and physiotherapists outweigh reality and cost 

recovery do we need to return to the drawing board? This 

will be a somewhat humorous journey to find out what 

makes a hydrotherapy pool and whether we can ever have 

consensus in any area. 

What to do when there is no evidence: the aquatic 

guidelines, principles and practice. Fact or fiction? 

Larsen JA 

Hydrotherapy Consulting and Training, Brisbane. PhysioLogic, 

Brisbane. 

There is no doubt that evidence must guide our practice, 

but equally there are areas where, with no evidence, we 

must be guided by clinical consensus and popular belief 

that is everyday practice. The clinical guidelines for aquatic 

physiotherapy practice were written in 2002, and although 

well overdue for revision it is still referred to as a source 

of information relating to the suitability of immersion of 

patients with specific screening issues. In practice these 

days we find ourselves impacted by the need to justify and 

quantify when in fact sometimes some things just are, simply 

because they happen. Where is the evidence to support 

taking an open wound into a hydrotherapy pool? Is it safe to 

take someone with unstable epilepsy into the pool? Should 

incontinence be an absolute contraindication to immersion? 

Explore some of the pathways to a commonsense approach 

to some of the myths and fallacies of aquatic physiotherapy. 

The question needs to be asked: if something commonly 

and repeatedly exists in practice can we justify its use, 

or alternately if there is no double blind, randomised, 

placebo controlled trial to support its use should we cease 

its practice? Does the glass half full or glass half empty 

scenario apply here? 

What; you’re still going to hydro? 

Lewington MA 

Private Practice, Brisbane 

Aquatic physiotherapy is a true modality, like any other that 

we have in physiotherapy. However, too often we still hear 

health professionals say to patients, ‘I’d like you to go to a 

pool and just do some walking and move around a bit’, or 

‘What, are you still going to hydro?’ Although it may be a 

wonderful environment to encourage self help at the right 

time just as any other home exercise program or self help 

techniques, it is much more than this. Great harm can arise 

from the wrong things, done the wrong way, at the wrong 

time. Physiotherapy guidance is essential. We have all seen 

our patients do amazing translations of our descriptions and 

demonstrations in land-based therapy, let alone what they 

might do in the water. An aquatic program may be a lifelong 

exercise choice, providing progression and meeting specific 

physical and emotional rehabilitation needs of clients. 

Aquatic physiotherapists assess, reassess, guide, correct, 

facilitate, inhibit, control, encourage, advise, just as any 

other physiotherapists may do. These points are expanded 

with reference to a specific case history of a patient shared 

with a land-based program. My aim is to challenge you to 

look wider, to let your patients get wet and maybe even to 

get wet yourself! 

Aquatic physiotherapy following gluteus medius 

tendon repairs: two case studies 

McIlveen BH 

East Brighton Physiotherapy Centre, East Brighton Melbourne 

The aim of these case studies is to describe aquatic 

physiotherapy treatment for 2 subjects with complex 

problems where their post-op rehabilitation was significantly 

improved by including aquatic physiotherapy as a treatment 

modality. Both patients subsequently progressed to good 

functional outcomes, resumed work and active family life. 

They continued unsupervised aquatic physiotherapy on 

discharge. Discussion will include co-morbidities, surgery 

performed, clinical reasoning for the choice of aquatic 

physiotherapy techniques, home exercises and functional 

retraining. 

Water-based exercise in people with chronic 

obstructive pulmonary disease with physical co-morbid 

conditions: a randomised controlled trial 

McNamara RJ, 1,2 Alison JA, 2,3 McKenzie DK, 1 McKeough 

ZJ 2 

1 

Prince of Wales Hospital, Sydney 2 The University of Sydney, Sydney 

3 

Royal Prince Alfred Hospital, Sydney 

The aim of this randomised controlled study was to determine 

whether a water-based exercise program was effective in 

improving exercise capacity and quality of life in people with 

chronic obstructive pulmonary disease (COPD) and physical 

co-morbidities compared to land-based exercise, and also to 

determine the acceptability of the aquatic environment for 

people with COPD. Participants were randomly allocated 

to one of three groups: land-based exercise, water-based 

exercise or a control group of no exercise. The two exercise 

groups trained for 8 weeks, 3 exercise sessions per week 

(2 supervised and 1 independent). Participants underwent 

measurements of respiratory function, exercise capacity 

and quality of life by a blinded investigator at baseline and 

following intervention. Acceptability and adverse events 

were recorded with a questionnaire at the completion of 

the program. Of 53 participants (mean (SD) age 72 (9) 

years, mean FEV 1 

% 62 (19) % predicted), 85% completed 

the study. Compared to control, water-based exercise 

significantly increased six-minute walk distance (mean 

difference 65m, 95% CI 42–88m), incremental-shuttle 

walk distance (mean difference 49m, 95% CI 29–69m) and 

endurance-shuttle walk distance (mean difference 371m, 

95% CI 124–618m). Only the water-based exercise group 

achieved the minimum clinically important difference of 4 

units change in the St George’s Respiratory Questionnaire. 

One hundred percent of participants reported acceptability 

with the water and air temperature, shower and change- 



room facilities, staff assistance and modes of pool entry. 

Water-based exercise is an effective alternative to landbased 

exercise and is well accepted in people with COPD 

and physical co-morbidities. 

Examining compliance, barriers and facilitators to 

ongoing aquatic exercise post discharge from hospital 

outpatient aquatic therapy 

Phillpotts W, 1,4 Cornwell P, 1,2 Haines T 1,2,3 

1 

Princess Alexandra Hospital, Brisbane 2 School of Health and 

Rehabilitation Sciences, the University of Queensland, Brisbane 

3 

Department of Physiotherapy, School of Primary Health Care, Monash 

University, Melbourne 4Sinnamon Village Day Therapy and Spa, 

Wesley Mission Brisbane 

The purpose of this study was to determine the level of 

compliance with a continued aquatic exercise program 

following discharge from a limited hospital outpatient 

aquatic service, and to discover patient perceptions of 

the barriers and facilitators to ongoing aquatic exercise 

in the community. A cross-sectional telephone survey 

comprising both closed and open-ended questions was 

conducted. Participants were 25 people who had attended 

a minimum of 6 outpatient aquatic physiotherapy sessions. 

Self-reported compliance with continued aquatic exercise, 

and descriptions of barriers and facilitators to this were 

recorded. Responses to open-ended questions were recorded 

verbatim and thematically analysed by investigators. Eight 

out of 25 participants were found to be continuing with a 

community-based aquatic exercise program as instructed 

(32%, 95% CI 17–52%). A range of barriers and facilitators 

were identified. Major themes for non-compliance included 

reduced perception of therapeutic outcome from aquatic 

physiotherapy and external constraints (for example 

transport difficulties and cost associated with access). The 

central theme for continued compliance was a perceived 

positive outcome of aquatic physiotherapy combined with 

ready access to a heated pool. Increasing compliance of 

ongoing aquatic exercise post discharge from an aquatic 

therapy program may require greater emphasis on educating 

patients as to the benefits of ongoing participation. 

Pregnancy-related pelvic girdle pain 

Pierce H 

Becoming a mother is one of the most significant 

and challenging events in the life of a woman. The 

musculoskeletal changes of pregnancy are secondary to 

the requirements of postural adaptations for increased 

anatomical space and increased pelvic joint mobility in 

preparation for parturition. Pregnancy-related low back 

pain and pelvic girdle pain is pain of musculoskeletal origin 

that is experienced in the lumbar and/or sacroiliac area 

during pregnancy or in the immediate postpartum period. 

Pain may also occur in conjunction with or separately in 

the symphysis pubis. At least 50% of women experience 

low back and/or pelvic girdle pain during pregnancy. The 

aetiology of pain remains unclear; although it is most likely 

to be biomechanical, arising from asymmetrical movement 

or positioning of the pelvic joints; and altered pelvic 

girdle biomechanics secondary to altered neuromuscular 

control. European guidelines recommend that the most 

effective form of management is exercise. Water exercise 

can be encouraged as safe during a healthy pregnancy with 

numerous physiological benefits when compared to land 

based exercise. A pregnant woman who has pelvic girdle 

pain, however, may experience exacerbation of symptoms 

because of the destabilising effects of immersion and the 

potential ‘pain masking’ that can occur. An understanding 

of the defining characteristics of pregnancy-related pelvic 

girdle pain will assist the therapist in aquatic management 

of this client population. 

Cardiovascular autonomic function during head-out 

water immersion 

Pöyhönen T, 1,2 Hautala A, 3 Keskinen K, 2 Kyröläinen H, 2 

Tulppo M 3 

1 

Kymenlaakso Central Hospital, Kotka, Finland; 2 University of 

Jyväskylä, Finland, 3 Rehabilitation and Research Centre Verve, Oulu, 

Finland 

The purpose of this study was to investigate the 

association between autonomic regulation (sympathetic/ 

parasympathetic) and head-out water immersion (WI). 

Sixteen healthy females (33 ± 9yr) were seated on the 

patient elevator chair on the poolside (27ºC) and immersed 

to the neck to thermo neutral water (35ºC). Cardiovascular 

autonomic function was assessed by measuring R-R intervals 

and analysing the heart rate (HR), low (LF, sympathetic) and 

high (HF, parasympathetic) frequency spectral components 

of HR variability at baseline on dry land (5min) and during 

WI (5min) were analysed. Participants were breathing at 

a constant rate of 25Hz. Blood pressure was measured for 

both conditions. The mean HR decreased from 72 ± 6 to 64 

± 7 bpm (p < 0.001) during WI. The HF power increased in 

all persons during WI from 5.4 ± 0.9 to 7.1 ± 0.9 lnms2 (p < 

0.001). LF power did not change during WI. Systolic blood 

pressure decreased from 108 ± 12 to 102 ± 10 and diastolic 

blood pressure from 66 ± 8 to 60 ± 9 mmHg during WI (p < 

0.05 for both). There were large inter-individual differences 

in HR response during WI (from +5 to-20 bpm). The change 

in HR was associated to the LF level of the R-R intervals 

on dry land (r = 0.54, p < 0.05). Persons with high LF level 

on land had larger decrease in HR than those with low LF. 

The change in HR was not associated to HR or HF power 

on land. Water immersion in thermo neutral water results in 

an increased parasympathetic (vagal nerve) activation. The 

most evident decrease in HR during WI occurs in persons 

with high sympathetic outflow. 

Neuromuscular function during therapeutic knee 

exercise in water and on land 

Pöyhönen T, 1,2 Keskinen K, 1 Kyröläinen H, 1 Hautala A, 3 

Savolainen,J 2 Mälkiä E 1 

1 

University of Jyväskylä, Finland; 2Kymenlaakso Central Hospital, 

Kotka, Finland; 3 Rehabilitation and Research Centre Verve, Oulu, 

Finland 

The aims of this study were to compare muscle activity and 

resistive drag forces during knee extension-flexion exercises 

while barefoot and while wearing a hydro-boot (increased 

frontal area) both in water and on dry land (isometric / 

isokinetic force production). Eighteen healthy persons (10 

women, 8 men) performed knee extension-flexion exercises 

while seated on an elevator chair in hydrotherapy pool. 

Isokinetic and isometric forces were measured with a 

dynamometer on dry land. The electromyographic (EMG) 

activity of the quadriceps and hamstring muscles was 

recorded. The underwater drag for the range of motion was 

calculated by using the general fluid equation. The underwater 



EMG patterns showed an early decrease in the concentric 

activity of the agonists with coincidental activation of the 

antagonists. In addition, the EMG amplitudes were similar 

between the two underwater conditions, but the hydro-boot 

produced a higher level (p < 0.001) of drag force than did 

the barefoot condition. As expected, in most cases the forces 

on dry land were higher (p < 0.001) than the drag forces in 

water. In flexion, however, the peak drag with hydro-boot 

and isokinetic torque did not differ. It can be concluded, 

that increasing the frontal area of the lower leg with hydroboot 

significantly increased the level of water resistance, 

thus providing flexion forces that approach those measured 

on dry land. This type of aquatic training offers stimulation 

to enhance the functional capacity and performance of 

the neuromuscular system. In addition, hydrodynamic 

principles and forces that influence the exercising limb must 

be considered to ensure appropriate progression. 

6 

Cost effectiveness of aquatic physiotherapy: 

the public health experience 

Rolls, G 

Royal North Shore Hospital. Sydney. 

In mid 2008 the Northern Sydney Central Coast Health 

Service established an expert panel under the chair of the 

Clinical Excellence Commission of NSW Health to provide 

advice regarding the clinical effectiveness, safety and 

cost effectiveness of hydrotherapy relative to alternative 

treatment modalities. The panel analysed evidence in 

relation to aquatic physiotherapy and hydrotherapy at Royal 

North Shore Hospital, Sydney and was also charged with 

including options for provision of hydrotherapy that provide 

good value for money. The panel analysed the available 

evidence-based literature, commissioned a systematic 

review in July 2008, and sought further evidence from 

referring clinical departments and consumers. The panel’s 

report including its approach, sources of evidence, findings, 

conclusions and recommendations are discussed with 

reference to implications for other health services and 

hydrotherapy provision. 

Two case studies demonstrating positive outcomes from 

specific primary aquatic techniques in the management 

of lumbar pelvic pain and dysfunction 

Shepherd JM 

It is widely accepted that immersion presents many 

advantages for treatment of the lumbar pelvic complex, 

however there is also a wide perception that the instability 

of the environment and potential body instability is a 

significant barrier to specificity. Movement of water on the 

body or body in water challenges body balance activating 

global postural reactions due in part to an unloaded base of 

support in vertical positions and unloading of the body in 

supine. The aim of the 2 clinical case studies was to evaluate 

the effectiveness of specific individual aquatic intervention 

as a primary treatment modality. Use of immersion of a 

body in water for therapeutic purposes is complex involving 

hydrodynamics, individual body characteristics including 

those of the presenting dysfunction and body movement. A 

clinical review of the environment highlighted the need to 

develop specific techniques to assist both body control and 

also to neutralise the negative elements of body immersion. 

It was found that precise positioning of both body and 

equipment provided the required positional stability. It was 

further found that with the body stabilised it was possible 

to isolate those positive environmental elements useful for 

therapeutic purposes in this instance relating to neuromotor 

control, postural responses and pain management. It is 

hypothesised that the two clinical case studies presented 

demonstrate effectiveness of specific supine and vertical 

positioning and combined with specific uses of equipment 

and facilitation techniques assist primary intervention in 

the management of lumbar pelvic pain and dysfunction. 

Effects of intensive aquatic resistance training on 

mobility limitation and lower limb impairments after 

knee joint replacement 

Valtonen A, 1,2 Pöyhönen T, 2 Sipilä S, 3 Heinonen A 1 

1 

University of Jyväskylä, Jyväskylä, Finland; 2 Kymenlaakso Central 

Hospital, Kotka, Finland; 3 Finnish Centre for Interdisciplinary 

Gerontology, University of Jyväskylä, Jyväskylä, Finland. 

The aim was to study the effects of aquatic resistance training 

on mobility, muscle power and cross-sectional area in 

persons with knee replacement. Fifty 55–75-year-old women 

and men 4–18 months after unilateral knee replacement 

were randomly assigned to a 12-week progressive aquatic 

resistance training group (n = 26) or control group (n = 24). 

Physical functional and mobility difficulties were assessed 

by WOMAC questionnaire, and mobility limitation by 

walking speed and stair ascending time. Knee extensor 

(KEP) and flexor power (KFP) were assessed isokinetically, 

and thigh muscle cross-sectional area (MCSA) by computed 

tomography. Compared to the change in the control group, 

habitual walking speed increased by 9% (p = 0.005) and 

stair ascending time decreased by 15% (p = 0.006) after 

training. The WOMAC mobility difficulty score tended 

to decrease in the training group compared to the control 

group (12%, p = 0.088), suggesting improved mobility after 

training. Training increased KEP by 32% (p < 0.001) in 

the operated and 10% (p = 0.001) in the non-operated leg, 

and KFP by 48% (p = 0.003) in the operated and 8% (p = 

0.002) in the non-operated leg compared to controls. The 

mean increase in thigh MCSA of the operated leg was 3% 

(p = 0.018) and that of the non-operated leg 2%, (p = 0.019) 

after training compared to controls. Progressive aquatic 

resistance training had favourable effects on mobility by 

increasing walking speed and decreasing stair ascending 

time. In addition, training increased muscle power and 

muscle mass. Resistance training in water is a feasible mode 

of rehabilitation which has wide ranging positive effects on 

patients after knee replacement surgery. 




11th Biennial National 

Scientific Conference 






2 

Repeatability of six-minute walk test and relation to 

physical function in survivors of a critical illness 

Alison JA, 1 Elliott D, 2 McKinley S, 2 Aitken LM, 3 King 

MT, 4 Leslie GD, 5 Kenny P 6 

1 

Discipline of Physiotherapy, University of Sydney, 2 Faculty of 

Nursing, Midwifery and Health, University of Technology, Sydney, 

3 

School of Nursing & Midwifery, Griffith University, Nathan, 4 School 

of Psychology, University of Sydney, Sydney, 5 School of Nursing & 

Midwifery, Curtin University, Perth, 6 Centre for Health Economics 

Research and Evaluation, University of Technology, Sydney 

The six-minute walk test (6MWT) is widely used as an 

outcome measure. Previous research has shown a 7%–14% 

increase in distance walked in a second 6MWT in subjects 

with chronic obstructive pulmonary disease. The study 

aimed to evaluate the repeatability of the 6MWT performed 

at home in survivors of a critical illness and to determine 

the relationship between the 6MWT and the score of 

physical function from the Short Form 36 (SF-36) quality 

of life questionnaire. Participants were adult survivors of 

critical illness discharged from intensive care units who 

were: admitted for ≥ 48 hours, mechanically ventilated for 

≥ 24 hours. Blinded assessments for the 6MWT and SF-36 

were conducted 1, 8, and 26 weeks after hospital discharge. 

Two 6MWTs were performed at each time-point with 30 

minutes rest between tests. At all time-points the mean 

distance walked in the second test was significantly higher 

than in the first test (week 1: mean difference 8 metres (95% 

CI 2.4 to 13.7, n = 162); week 8: 11 metres (95% CI 5.8 to 

16.6, n = 140); week 26: 11.3 metres (95% CI 3.4 to 19, n 

= 128). The mean increase was 2% in weeks 1 and 8 and 

3% increase in week 26. There was a significant correlation 

between the better 6MWT and physical function at each 

time point (week 1: r = 0.59, p = 0.01, n = 176; week 8: r 

= 0.58, p = 0.01, n = 153; week 26: r = 0.48, p = 0.01, n 

= 145). In this cohort only a small increase was observed 

in the repeat 6MWT at each time-point. The 6MWT was 

reflective of self-reported physical function. 

Paediatric chronic respiratory conditions and 

physiotherapy care: where do domiciliary models fit? 

Baggio S, Wilson C, Wright S, Moller M 

Royal Children’s Hospital, Brisbane 

This presentation will discuss paediatric chronic respiratory 

conditions and the impacts of an increased burden to the 

health system and families with limited physiotherapy 

resources available. Medical advances have lead to 

earlier diagnosis of chronic respiratory conditions, and 

significantly improved survival rates. The Royal Children’s 

Hospital, Brisbane, has had progressive and significant 

increases in referrals for these conditions and subsequent 

increases in activity. In this presentation, we review current 

models of care; including quality measurements and patient 

health outcomes, and will offer potential solutions which 

include flexible but targeted services across the continuum 

and incorporate a variety of domiciliary care models and 

the indicators for success. Current literature shows that 

existing domiciliary programs demonstrate mixed results 

and primarily in the cystic fibrosis population group. 

However, domiciliary care across the continuum, inclusive 

of specialised allied health professionals, has shown to be 

cost- and clinically- effective, in the presence of appropriate 

referrals and resources. Unfortunately, in the Queensland 

experience, the quality and extent of domiciliary care 

is being adversely affected by limited community 

physiotherapy funding, decreased availability of specialist 

paediatric physiotherapy and limited accessibility of 

domiciliary services. Considerable rethinking is required to 

provide appropriate care to this patient group, which can be 

modified to support and adapt to individual, local and statewide 

needs to ensure a seamless approach to paediatric 

physiotherapy for chronic respiratory conditions. 

Tubing positive expiratory pressure: a simple, novel, 

cheap, and disposable method 

Boden I 

Launceston General Hospital, Launceston 

Positive expiratory pressure therapy is an essential 

evidence-based physiotherapy technique for cystic fibrosis, 

bronchiectasis, pneumonia, and post-operative pulmonary 

complication prophylaxis. Therapy can be performed via 

expensive autoclavable commercial devices. However, the 

most common devices used by inpatients in Australia are 

blow bottles made from water-filled reused milk or hospitalissue 

bottles. This device is simple and cheap. However, 

concerns have been raised about their potential for microbial 

growth and have been banned in some hospitals. A cheap, 

disposable, waterless alternative would be beneficial. The 

Hagen-Poiseuille law, ∆P = Q8ηL/πr4, states that during 

laminar gas flow through a tube, halving the radius has a 16- 

fold increase in pressure. Most positive expiratory pressure 

devices utilise this concept. However, this law also states 

tubing length is directly proportional to pressure. This 

phenomenon could be utilised to generate positive expiratory 

pressure. This study investigated the pressure generated 

with variable lengths of tubing with a fixed radius across a 

range of flow rates. Standard hospital-issue 2.5mm internal 

diameter oxygen tubing was connected to flow meter and 

manometer. Pressure generated whilst passing flow rates 

(4–11 L/min) through varying tubing lengths (10–120cm) 

was measured. A 40cm long, 2.5mm tube maintained a 

therapeutic pressure of 10cmH 2 O or greater with flow rates 

equal to or greater than 6L/min. The lower the flow rate the 

longer the tubing is needed to maintain a pressure greater 

than 10cmH 2 O. Oxygen tubing lengths can be utilised as a 

cheap, readily disposable alternative to water filled bottles 

for positive expiratory pressure therapy. 

A trial of a physiotherapy screening service in a lung 

transplant long-term follow-up clinic 

Brede FL, 1 Fuller LM, 1 Button BM, 1,2,3 Holland AE, 1,2 

Snell GI1 ,3 

1 

The Alfred Hospital, Melbourne, 2 La Trobe University, Melbourne, 

3 

Monash University, Melbourne 

The Alfred Hospital is a major international centre for 

lung transplantation. It has a well established inpatient 

physiotherapy service and outpatient rehabilitation service 

for the first three months post lung transplant, but not beyond 

this time. Many lung transplant patients have complications 

related to immunosuppressant medication, respiratory 

complications, musculoskeletal morbidity, and inpatient 

admissions with associated deconditioning, however there 

is no literature supporting physiotherapy services in this 

long-term outpatient setting. The aim of this study was 

to scope the demand and type of physiotherapy service 

required in a lung transplant long-term follow-up clinic. 

A four month trial was undertaken using a screening tool 



developed by senior lung transplant physiotherapists which 

addressed current exercise regime, musculoskeletal issues 

limiting function or exercise, unmet airway clearance needs, 

gastro-oesophageal reflux, and urinary incontinence. The 

physiotherapist attended a multidisciplinary team meeting 

after each clinic. Thirty four patients were screened. Of 

these, 44% reported insufficient exercise regimes, 15% had 

musculoskeletal issues limiting function or exercise; 3% had 

unmet airway clearance needs, 9% had gastro-oesophageal 

reflux symptoms, and 18% reported urinary incontinence. 

Of note, 21% reported pre-transplant urinary incontinence 

that resolved post lung transplant. Interventions included 

exercise advice and modification; referral to pulmonary 

rehabilitation programs or local gymnasiums; referral for 

musculoskeletal assessment; airway clearance advice and 

education; education and positioning advice for gastrooesophageal 

reflux; and pelvic floor exercise education. In 

conclusion, this study identified several areas in the longterm 

post lung transplant population where physiotherapy 

intervention is highly likely to provide clinical benefit. 

Qualitative findings of a clinical study of supervised 

exercise with the chronic disease self-management 

program for chronic obstructive pulmonary disease 

Cameron-Tucker HL, 1,3 Joseph L, 4 Wood-Baker R, 1 

Owen, C2 

1 

Menzies Research Institute and 2 Faculty of Education University of 

Tasmania, Hobart 3 Departments of Physiotherapy, 4 Nursing Royal 

Hobart Hospital, Hobart 

Supervised exercise is recommended as part of pulmonary 

rehabilitation, but the Stanford chronic disease selfmanagement 

program has no supervised exercise. This 

study aimed to explore the experience of group-based 

supervised exercise with the program for people with 

chronic obstructive pulmonary disease as part of a 

randomised controlled clinical trial using mixed methods. 

Qualitative data are reported. Qualitative data were 

collected by semi-structured interviews with a purposeful 

sample following the programme with or without supervised 

exercise. Data were subjected to thematic analysis. Of 84 

participants, 14 men and 6 women were interviewed over 

2 years about their experiences of chronic obstructive 

pulmonary disease, the program and supervised exercise. 

Major findings were: the meaning of chronic obstructive 

pulmonary disease was described in terms of its impact 

on participants’ lives; participants bring self-developed 

strategies for managing their condition (planning and 

pacing, acceptance of limitations) and a personal meaning 

of self-management (self-awareness and self-reliance, 

adopting health-behaviours) to healthcare interactions; 

social benefits (relief from social isolation, identification, 

social comparison) were benefits of the program for most 

people and provided motivation to exercise for some; 

and the importance of respecting exercise preferences, of 

acknowledging individual sources of motivation, of goalsetting 

and action-planning pointed to a participant-centred 

engagement. Effectiveness of healthcare interactions for 

chronic obstructive pulmonary disease may be enhanced 

by recognising the impact and personal meaning of the 

condition and the self-management strategies and meaning 

people bring to interactions. Exercise preference should 

be sought and motivational level identified. A participantcentred 

framework is proposed to underpin interactions. 

A mixed methods study of supervised exercise with the 

chronic disease self-management program for chronic 

obstructive pulmonary disease: quantitative results 

Cameron-Tucker HL, 1,2 Joseph L, 2 Owen C, 1 

Wood-Baker R 1,2 

1 

University of Tasmania, Hobart 2 Royal Hobart Hospital, Hobart 

Supervised exercise is recommended in pulmonary 

rehabilitation. The Stanford chronic disease selfmanagement 

program has no supervised exercise. The aim 

of the study was to investigate the effect of adding supervised 

exercise to the program compared to the program only, 

on physical capacity in people with chronic obstructive 

pulmonary disease. Quantitative results are reported. 

Eighty-four older adults were randomised to the program 

with or without 1 hour of group-based weekly supervised 

exercise over 6 weeks. The primary outcome was sixminute 

walk test distance. Secondary outcomes were selfreported 

exercise, exercise stage of change, exercise selfefficacy, 

breathlessness, quality of life and self-management 

behaviours. Between-groups differences and within-groups 

pre-and post-test differences were analysed on an intentionto-treat 

basis. There were 15 withdrawals. Six-minute walk 

test distance increased for both groups: intervention = 18.6 

± 46.2 m; control = 20.0 ± 46.2 m, p < 0.001. There were 

no statistically significant differences between groups for 

change in distance walked (p = 0.9) or secondary outcomes. 

Weekly exercise frequency (β =-0.257, p = 0.05) and 

exercise self-efficacy (β = 0.220, p = 0.09) contributed to 

the variance in six-minute walk test distance. Within-group 

changes showed supervised exercise conferred benefit for 

some secondary outcomes but statistical significance was 

not reached. Supervised exercise does not need to be integral 

to the program for small increases in six-minute walk test 

distance. However, 1 hour of weekly supervised exercise 

does not result in clinically significant changes. Ways to 

increase weekly exercise frequency and self-efficacy should 

be explored. 

A pilot study to test the validity of an outcome tool for 

predicting the outcomes of cardiac surgery 

Caruana LR, 1 Bellet, RN, 1 Mullany D, 1 Bartlett H, 1 Carter 

C, 2 Spencer S, 2 Paxman N, 2 Rash J, 2 Mair E 2 

1 

The Prince Charles Hospital, Critical Care Research Group, Brisbane, 

2 

Griffith University, Gold Coast 

This study aims to validate a new outcome measure (index) 

to predict outcomes post cardiac surgery. Eighty-seven 

charts of patients who underwent cardiac surgery were 

audited and given a score out of 60 at intervals during the 

first 24 hours after surgery. Twenty-four patients who died 

were compared to 32 survivors who didn’t require transfer 

to long-term intensive care (routine) and 31 survivors who 

required transfer to long-term intensive care (long-term). 

Patients were matched by age, sex, and surgery. The 63 

survivors and 24 deceased were analysed using logistic 

regression. A significant difference in index values between 

survivors and deceased appears at 4 hours post-operatively 

(p = 0.02). A 1 point increase in index improves the odds 

of survival (odds ratio 1.12 (95% CI 1.02 to 1.22)). At 12 

hours the index significantly predicts survival (p = 0.002), 

with an odds ratio of 1.09 per 1 point increase improving 

survival (95% CI 1.03 to 1.15). It also separated long-term 

survivors from routine survivors (p = 0.02) with decreased 

chance of transfer to long-term intensive care predicted per 



1 point increase (odds ratio 0.94 (95% CI 0.90 to 0.99)). The 

index distinguished between those who died and long-term 

survivors (p = 0.04) with an increased chance of survival 

albeit via intensive care (odds ratio 1.06 for a 1 point 

increase in index (95% CI 1.00 to 1.13)). The index could 

lead to decreased morbidity and mortality rates post cardiac 

surgery as it appears to detect possible complications as 

early as 4 hours after surgery. 

An investigation into the time taken for the regional 

distribution of ventilation to equilibrate using electrical 

impedance tomography 

Caruana LR 1,2 , Fraser JF 1,2 , Paratz JD 1,2 , Chang AT 1,2 , 

Barnett AG 3 

1 

The University of Queensland, Brisbane. 2 The Prince Charles 

Hospital: Critical Care Research Group, Brisbane. 3 Queensland 

University of Technology, Brisbane 

Electrical Impedance Tomography is a new technology 

capable of quantifying ventilation distribution in the 

lung during various therapeutic manoeuvres, however 

normative data needs to be gained. This within subject 

observational study aimed to determine the time taken for 

the regional distribution of ventilation to equilibrate after 

changing position. Eight healthy male volunteers were 

connected to the Draeger Medical Electrical Impedance 

Tomography Evaluation Kit 2 (Lubek, Germany) and a 

pneumotachometer (Ventrak 1550: Novametrix Medical 

Systems, Wallingford, USA). After 30 minutes stabilisation 

in supine, subjects were moved into 60 degrees upright 

sitting and then returned to supine. Thirty minutes was 

spent in each position. Concurrent readings of ventilation 

distribution and tidal volumes were taken every 5 minutes. 

A mixed model was used with a random intercept and 

position-time as a factor to perform a pair-wise comparison 

of the estimated means. Significant differences (p < 

0.05) occurred prior to equilibration in both positions 

demonstrating an appropriately powered study. These 

results are not presented as only non-significant differences 

equated to equilibration. The anterior-posterior distribution 

stabilised after 10 minutes of sitting (p = 0.15) and 10 

minutes of returning to supine (p = 0.06). After15 minutes 

left-right stabilisation in sitting (p = 0.09) and in supine (p = 

0.69) was achieved. Fifteen minutes of stabilisation should 

be allowed for spontaneously breathing individuals when 

assessing ventilation distribution to allow equilibration to 

occur in the anterior-posterior direction as well as the leftright 

direction. This data has important implications for 

future studies involving this technology. 

4 

A pilot study into the reproducibility of electrical 

impedance tomography 

Caruana,L 1,2 Barnett AG, 2,3 Tronstad O, 2 Fraser JF 1,2 

1 

The University of Queensland, Brisbane. 2 The Prince Charles 

Hospital: Critical Care Research Group, Brisbane. 3 Queensland 

University of Technology, Brisbane. 

This study aims to assess the reproducibility of electrical 

impedance tomography and is a within subject observational 

design. Five healthy male volunteers were placed in supine 

and connected to the Draeger Medical Electrical Impedance 

Tomography Evaluation Kit 2 (Lubek, Germany) which 

uses a 16 electrode array and a pneumotachometer (Ventrak 

Model No 1550: Novametrix Medical Systems, Wallingford, 

USA) and concurrent two minute recordings of tidal 

variations, ventilation distribution and tidal volumes were 

made in the morning and repeated in the afternoon. Every 

effort to ensure identical electrode placement was made. 

The Bland and Altman statistic was used to determine the 

limits of agreement for the tidal variations, tidal volumes, 

and ventilation distribution. A Pearson correlation between 

tidal variations and tidal volumes was used to judge the 

transferability of the limits of agreement. Descriptive 

statistics were used to compare actual and predicted tidal 

volumes, and for comparison to fractal ventilation. Results 

demonstrated significant correlation between tidal variations 

and tidal volumes (Pearson correlation = 0.72, p < 0.001), 

allowing for tidal variations to be judged as in agreement 

between readings. The tidal volumes showed a coefficient 

of variation similar to that of fractal ventilation at 26.7%. 

The ventilation distribution showed significant ‘clustering’ 

above or below the zero line indicating a lack of agreement. 

A number of possible causes for this lack of agreement 

existed including that regional distribution might be fractal. 

Electrical impedance tomography tidal variations are 

reproducible and could be useful in clinically assessing the 

effects of recruitment manoeuvres or positional changes. 

Pulmonary rehabilitation: moving forward 

Casaburi R 

Rehabilitation Clinical Trials Center, Los Angeles Biomedical Research 

Institute at Harbor-UCLA Medical Center, Torrance, California, USA 

Pulmonary rehabilitation can reasonably be called the 

standard of care for COPD patients debilitated by their 

disease. High-quality evidence based documents attest to 

its benefits. However, rehabilitation remains poorly funded 

and therefore poorly available. In the United States, changes 

in national policy may make pulmonary rehabilitation 

more generally available in coming years, but unanswered 

questions may yet stymie wider application of this therapy. 

Can rehabilitation be administered at home? What is the 

relative effectiveness of home vs. in-center programs? Is 

activity level increased by rehabilitation? This has important 

implications, as everyday activity level (and not exercise 

tolerance) may be the key factor mediating long-term 

benefits. Can the benefits of rehabilitation be maintained? 

Maintenance programs seem essential for assuring long-term 

benefits. Collaborative self-management concepts may offer 

a practical route to assure the prolongation of rehabilitation’s 

effects. How can we make rehabilitative exercise programs 

more effective? Optimal bronchodilation and judicious use 

of supplemental oxygen seem attractive adjuncts. Other 

additions, such as anabolic steroids, interval training, noninvasive 

ventilation, ventilatory pattern modification and 

ventilatory muscle training, require further study. Can we 

demonstrate a survival benefit? Interventions that prolong 

life have high priority. Whether pulmonary rehabilitation 

improves survival has never received an adequate test. A 

clinical trial to study this question is in the planning stage. 



Home intravenous antibiotic therapy improves lung 

function but not exercise capacity in children with 

cystic fibrosis: a pilot study 

Cox N, 1,2a,3 Alison J, 2a McKay K, 2b,3 Follett J 3 

1 

Monash Medical Centre, Melbourne, The University of Sydney 

2a 

Faculty of Health Sciences and 2b Discipline of Paediatric and Child 

Health, 3 The Children’s Hospital at Westmead. 

To decrease the impact of chronic illness on people with 

cystic fibrosis (CF), home intravenous (IV) antibiotic 

therapy use has increased recently. This pilot study aimed 

to evaluate the effects of home IV antibiotic therapy on lung 

function and exercise capacity, measured by the Modified 

Shuttle Test (MST), in children with CF. A prospective, nonrandomised, 

controlled study was undertaken. Inclusion 

criteria for the intervention group were children with CF 

prescribed a 14-day course of home IV antibiotic therapy for 

respiratory exacerbation. Control group were children with 

CF and stable lung function with no evidence of respiratory 

exacerbation. All participants performed spirometry and a 

MST within 48 hours of commencement and cessation of IV 

antibiotic therapy, or at the commencement and completion 

of 2 weeks usual care for the controls. Twenty children 

completed the study. At baseline the groups had equivalent 

ages, FEV 1 and MST distance. For the Intervention group 

(n = 10 [7 boys]) the mean (SE) increase in FEV 1 and MST 

distance from baseline was 11.7 (4.1 ) % (p < 0.05) and 30 

(39.2) m (p = 0.46) respectively. For the Control group (n 

= 10 [3 boys]) the mean decrease in FEV 1 and MST from 

baseline was 5.8 (2.8) % (p = 0.6) and 56m (70.1) (p = 0.45). 

This study demonstrates small, significant, improvement in 

lung function, and non-significant improvement in exercise 

capacity, following 14 days of home IV antibiotic therapy 

in children with CF. Over a 14-day period there was a nonsignificant 

decline in lung function and MST in the Control 

group. 

The relationship between six-minute walk test 

and peak and endurance cycle tests in people with 

dust-related lung disease 

Dale M, 1 Alison,J 1,2 McKeough Z, 1 Munoz P, 2 Bye P, 2 

Corte P 2 

1 

Discipline of Physiotherapy, The University of Sydney, Sydney, 

2 

Department of Respiratory Medicine, Royal Prince Alfred Hospital, 

Sydney 

Understanding the relationships between cycle tests and 

functional walk tests can aid exercise prescription in people 

with lung disease. The aim of this study was to investigate 

the relationship between exercise capacity measured by the 

incremental peak cycle and endurance cycle tests and by the 

six-minute walk test (6MWT) in people with dust-related 

lung disease. Ten male participants with asbestos related 

pleural disease, asbestosis and silicosis performed two 

6MWTs separated by 30 minutes with the better of the tests 

used for analysis. On a separate day, participants performed 

spirometry, lung volumes, DLCO, peak cycle test and an 

endurance cycle test at 80% peak work rate. Mean (SD) age 

of participants was 71 (5) years. As a percentage of predicted 

lung function, TLC was 82 (13) %, FRC was 79 (22)%, RV 

was 79 (24)%, FEV 1 /FVC was 73 (7)% and DLCO was 64 

(14)%. There was a non-significant increase of 15 m (4%) 

between the first and second 6MWT (p = 0.10). The mean of 

the better 6MWT was 450 m (76) and the mean peak work 

rate was 100 (37) watts. There was a significant correlation 

between the better 6MWT and peak watts (r = 0.8, p = 

0.005) but not with endurance cycle time. This preliminary 

finding suggests that 6MWT may be a useful measure of 

exercise capacity in people with dust-related lung disease. A 

larger sample size is required to confirm this finding. 

Physiological responses to perceptually regulated 

six-minute walk and six-minute cycle tests in young, 

healthy adults: a pilot study 

Dylke E, 1,2 Hirschhorn A, 2 Mungovan S 2 

1 

The University of Sydney, Sydney 2Westmead Private Physiotherapy 

Services, Sydney 

The aim of this study was to investigate physiological 

responses to perceptually regulated six-minute walk and 

six-minute cycle exercise tests in young healthy adults. 

Ten subjects completed 3 sub-maximal exercise tests; 

a modified-Astrand sub-maximal cycle test, followed 1 

week later by sequential six-minute walk and cycle tests, 

performed 1 hour apart. Subjects were encouraged to 

perform the latter two tests at a perceived ‘moderate’ to 

‘somewhat strong’ intensity of exertion. Outcomes were: 

six-minute walk distance, six-minute cycle work, estimated 

oxygen consumption, peak heart rate, and post-test rating of 

perceived exertion. Subjects had higher oxygen consumption 

(p < 0.001), a higher peak heart rate (p = 0.03) and reported 

higher perceived exertion (p = 0.005) during the six-minute 

cycle test when compared to the six-minute walk test. Sixminute 

walk distance and six-minute cycle work did not 

correlate with one another (r2 = 0.05), nor did they correlate 

with predicted maximal oxygen consumption as calculated 

from the modified Astrand sub-maximal cycle test (walk: r2 

= 0.13, cycle: r2 = 0.24). While subjects work harder during 

a perceptually regulated six-minute cycle test, neither the 

six-minute cycle test nor the six-minute walk test provides 

a valid indication of exercise capacity in young, healthy 

adults. 

Control of separation in sternal instability by 

supportive devices: a comparison of an adjustable 

fastening brace, compression garment and sports tape 

El-Ansary D, 1,2 Waddington G, 3 Adams R 1 

1 

The University of Sydney, 2 The University of Melbourne, 3 The 

University of Canberra 

The aim of this study was to examine the effectiveness of 

3 supportive devices for controlling sternal separation in 

patients with sternal instability following cardiac surgery. A 

cross-sectional, randomised intervention study was carried 

out in an outpatient cardiac rehabilitation facility. Fifteen 

patients with a diagnosis of sternal instability trialled 

sports tape, a compression garment and an adjustable 

fastening brace for amount of support. The control was no 

support to the chest wall. Outcomes were an ultrasoundbased 

measure of sternal separation during upper limb 

movements and a series of functional tasks; as well as selfreport 

measures of comfort, pain, feeling of support, ease of 

upper-limb movement, and ease of breathing. Having some 

chest support resulted in a significant reduction in sternal 

separation (F 1,14 = 30, p = 0.001) and improved self-report 

across the five dimensions (F 1,14 = 22.8, p = 0.001). In 

addition, wearing an adjustable fastening brace was best, 

and was significantly better than wearing a compression 

garment with respect to both sternal separation (F 1,14 = 

5.4, p = 0.041) and self report measures (F 1,14 = 31.1, p = 



0.001). Supportive devices may therefore be useful in the 

management of patients with sternal instability awaiting 

surgical repair, or those who are required to manage an 

ongoing deficit. 

Funding: Workers’ Compensation (Dust Diseases) Board of 

NSW 

Trunk stabilisation exercises reduce sternal separation 

in chronic sternal instability after cardiac surgery: 

a randomised cross-over trial 

El-Ansary D, 1,2 Waddington G, 3 Adams R 1 

1 

The University of Sydney, 2 The University of Melbourne, 3 The 

University of Canberra 

The aim of this study was to examine the impact of 

trunk stabilisation exercises on pain and functional task 

performance in individuals with chronic sternal instability. 

A randomised crossover study with concealed allocation and 

intention-to-treat analysis was conducted in an outpatient 

cardiac rehabilitation facility. Nine individuals with chronic 

sternal instability following a median sternotomy for 

cardiac surgery participated in the study. The experimental 

intervention consisted of 6 weeks of trunk stabilisation 

exercises; the control intervention was activities of daily 

living and included no exercises. Outcomes were sternal 

separation measured by ultrasound; participant ratings on a 

100mm scale for pain during the performance of 9 everyday 

tasks, and observer ratings for movement quality and motor 

control of sit-to-stand. Overall, sternal separation during 

the period of trunk stabilisation exercises decreased by 

6.2 mm (95% CI 3.5 to 8.9) more than during the control 

period. Pain decreased when performing everyday tasks 

by 14 mm (95% CI 5 to 23) more than during the control 

period. However, task performance during the period of 

trunk stabilisation exercises did not significantly improve 

(mean difference 10 mm, 95% CI–3 to 22) more than during 

the control period. Trunk stabilisation exercises should be 

included in the rehabilitation of individuals who experience 

sternal instability following cardiac surgery. A larger trial 

is warranted to determine if stabilisation exercises are 

beneficial in improving the quality and control of task 

performance. 

6 

New technologies in cardiorespiratory management 

Elkins M, 1 Harris B, 2 Seale P, 3 Jones A, 4 Caruana L 5 

1 

Royal Prince Alfred Hospital, Sydney, 2Royal North Shore Hospital, 

Sydney, 3 Woolcock Institute of Medical Research, Sydney, 4 The 

Hong Kong Polytechnic University, Hong Kong, 5 The Prince Charles 

Hospital, Brisbane 

This session will provide an overview of five new 

technologies that are emerging in the management of 

patients with cardiorespiratory disease. The technologies 

include measurement techniques, pharmacological agents, 

and other clinical interventions. Each presenter will include 

a description of the technique. Where possible, a summary 

of the diseases or scenarios in which it has been applied 

in clinical practice or research will also be presented. If 

relevant, any evidence of clinical efficacy or clinimetric 

properties will also be reviewed. The new technologies 

to be discussed include inhaled mannitol in respiratory 

disease, analysis of ventilation with hyperpolarised Helium 

magnetic resonance imaging, intrabronchial thermal therapy 

for asthma, Acu-TENS, and assessment of tidal ventilation 

using electronic impendence tomography. 

Repeatability of the SenseWear Pro3 Armband 

monitoring of healthy adults and adults with cystic 

fibrosis during a modified shuttle test 

Elkins MR, 1 Dentice RL, 1 McKeough ZJ, 2 Alison JA 1,2 

1 

Royal Prince Alfred Hospital, Sydney, 2 The University of Sydney, 

Sydney 

The SenseWear Pro3 Armband (BodyMedia, USA) is an 

activity monitor that estimates exercise parameters. This 

study aimed to determine the repeatability of the armband’s 

estimates of energy expenditure and step count during a 

modified shuttle test. The reliability and repeatability of 

the modified shuttle test are established, and we recently 

validated an extension of this test to 25 levels (MST-25) 

because 6% of adults in our cystic fibrosis clinic and 31% of 

age-matched healthy controls exceeded the test’s 15 levels. 

In this study, 10 healthy participants and 11 participants 

with clinically stable cystic fibrosis performed the MST-25 

on two occasions, an average of 7 days apart. Paired t-tests 

were used to confirm that heart rate, SpO 2 , and distance 

covered were comparable on the two tests. Pearson’s r was 

then used to assess the test-retest reliability of the monitor’s 

estimates of cumulative energy expenditure, peak energy 

expenditure, and total step count. Bland-Altman methods 

were used to assess repeatability, limits of agreement, and 

coefficients of repeatability for the same parameters. Heart 

rate, SpO 2 , and distance differed by 3% or less on the two 

tests. Between-trial correlations (r) were 0.98 for cumulative 

energy expenditure, 0.99 for peak energy expenditure, and 

0.96 for step count, all p < 0.001. Mean differences (limits 

of agreement, coefficient of repeatability) were 5 (-55 to 64, 

51) ml/kg for cumulative energy expenditure, 1 (-3 to 5, 3) 

ml/kg/min for peak energy expenditure, and 10 (-170 to 190, 

109) steps. SenseWear Pro3 Armband data are repeatable 

and reliable in this setting. 

Sensitivity of the SenseWear Pro3 Armband to change 

in exercise parameters following antibiotic therapy in 

adults with cystic fibrosis 


1 


Sydney 

The SenseWear Pro3 Armband (BodyMedia, USA) is 

an activity monitor that integrates accelerometry and 

physiological sensors to estimate exercise parameters. This 

study aimed to determine the sensitivity of this monitor in 

detecting changes in the cumulative energy expenditure, 

peak energy expenditure, and total step count achieved 

in a modified shuttle test performed by adults with cystic 

fibrosis receiving antibiotic therapy. Participants with 

cystic fibrosis performed a modified shuttle test twice: once 

before and once after a minimum of 7 days of antibiotic 

therapy for an acute respiratory exacerbation. Standardised 

response means were used to quantify the responsiveness of 

the three exercise parameters. Nine participants with cystic 

fibrosis (6 females, mean (SD) age 26 (5) years, baseline 

FEV 1 45 (19) % predicted, final FEV 1 55 (25) % predicted) 

were enrolled and all completed both tests. The duration 

of the test increased from 9.9 (2.2) minutes before the 

antibiotic course to 11.1 (2.2) minutes afterwards, and the 

distance covered during the test increased from 765 (286) 

to 932 (319) m. Similarly, cumulative energy expenditure 

increased from 72 (62) to 87 (71) ml/kg, peak energy 

expenditure increased from 10 (8) to 12 (10) ml/kg/min, 



and the step count increased from 1021 (352) to 1154 (372) 

steps. The standardised response means (1.26 for cumulative 

energy expenditure, 0.83 for peak energy expenditure, and 

0.91 for step count) all exceeded 0.80 and were therefore 

categorised as highly sensitive to change. The SenseWear 

Pro3 Armband is sensitive to changes in exercise capacity 

in adults with cystic fibrosis. 

Validation of the SenseWear Pro3 Armband during 

a modified shuttle test in healthy adults and adults 

with cystic fibrosis 


1 


Sydney 

The SenseWear Pro3 Armband (BodyMedia, USA) is 

an activity monitor that integrates accelerometry and 

physiological sensors to estimate step count and energy 

expenditure. This study aimed to validate the armband’s 

estimates of step count and energy expenditure against 

observed step count and predicted energy expenditure 

values from a normative equation, during a modified 

shuttle test. Thirteen healthy participants and 34 with cystic 

fibrosis (CF) performed the test. Correlations between the 

measurement methods were assessed with Pearson’s r, and 

differences were identified with Bland-Altman analysis. 

Within individual subjects, the two methods of step 

counting correlated strongly throughout the levels of the 

test: r values ranged from 0.77–1.0. Across all participants, 

total step counts correlated very strongly between the two 

methods, r = 0.98. Bland-Altman analysis showed that the 

armband underestimated the observer’s step count by only 

40 steps (around 2.5%) across the whole test, with greater 

error at higher step counts. Within individual participants, 

the two estimates of energy expenditure correlated strongly 

throughout the levels of the test: r values ranged from 

0.88 to 1.0. Across all participants, the two estimates of 

energy expenditure at the maximum level completed by 

the participant correlated weakly, r = 0.27. Bland-Altman 

analysis showed underestimation of energy expenditure 

by the armband compared to the predicted equation, with 

greater error at higher values. Validity was comparable 

in health and CF. This study supports use of the armband 

for activity monitoring in CF, especially for change within 

individuals, although not for identifying peak energy 

expenditure. 

Home-based physical rehabilitation had no effect 

on six-minute walk test distance for survivors of a 

critical illness 

Elliott, D. 

Faculty of Nursing, Midwifery & Health, University of Technology, 

Sydney 

Interventions to improve physical recovery after a critical 

illness are currently being explored, including rehabilitation 

and mobility programs in intensive care units (ICU), 

post-ICU discharge and outpatient settings. This tri-state 

multi-centre randomised controlled trial examined the 

impact of an 8-week, home-based, individually-tailored 

rehabilitation program on physical recovery. Participants 

were adult survivors of critical illness discharged from five 

Australian tertiary-level ICUs who were: admitted for ≥ 48 

hours, mechanically ventilated for ≥ 24 hours, discharged 

to self-care, not receiving organised rehabilitation, able 

to participate in physical activity, and residing locally to 

enable home visits. Blinded assessments for the six-minute 

walk test (6MWT) were conducted at weeks 1, 8 and 26 

post-hospital discharge. Training included 3 home visits, 

5 progress phone calls and a printed exercise manual, 

involving core, upper and lower exercises and a walking 

program. Participants (n = 180) were equivalent at baseline 

(median: 58 years old, hospital and ICU length of stay 18 and 

6 days respectively, ventilation hours 90, APACHE II score 

19, 59% male, 6MWT distance 310 metres). No significant 

treatment effect was evident; for the control and intervention 

groups respectively, the mean 6MWT distance metres 

(adjusted for week 1) were 396 and 402 at 8 weeks, and 431 

and 428 at 26 weeks. Both groups improved significantly 

over time; change scores respectively were 80 [SD: 124]m 

and 89 [114]m at 8t weeks, and 116 [134]m and 126 [111] 

m at 26 weeks. Future work should investigate increasing 

the treatment effect and identifying patient sub-groups who 

would benefit from such home-based interventions. 

Critical decision making in paediatric intensive care: 

benefit versus burden? 

Ferguson A, Woolley L 

Royal Children’s Hospital, Brisbane. 

Scientific advances in the diagnosis and treatment of 

children with neoplastic disease has led to increased 

survival rates. However, survival for these complex patients 

is challenged by malignancy-related critical complications 

causing increasing numbers to require admission to the 

Paediatric Intensive Care Unit (PICU). Limited literature 

on physiotherapy treatment for such children leads us to 

base decision making purely on clinical reasoning, thereby 

highlighting the crucial importance of the therapist’s 

ability to rationalise the costs and benefits of treatment. To 

facilitate this rationalisation, a new clinical decision making 

tool has been developed. This tool is valuable for assisting 

clinicians in decision making and education. It encompasses 

assessment parameters and treatments but also considers 

the potential for deterioration which may be associated with 

physiotherapy treatment. Longer term clinical improvements 

may outweigh initial deterioration, but potential for 

deleterious effects should be minimised when rationalising 

treatment techniques. Decision making should be based on 

current parameters, taking previous responses into account. 

Efficacy of the decision making tool is demonstrated in a 

case example which illustrates the multidimensional factors 

in the physiotherapy management of a 13 year-old patient 

in PICU with acute lymphoblastic leukaemia, disseminated 

fungal infection and associated sequelae. Haemodynamic 

instability, ventilatory requirements, coagulopathy, 

radiographic changes and behavioural intolerance were 

key considerations in the assessment and treatment of this 

patient. Use of the decision making tool in this case example 

demonstrates the importance of recognising the benefit/ 

burden balance and the limitations of physiotherapy in this 

setting; sometimes the benefits do not outweigh the cost. 



The International Physical Activity Questionnaire 

overestimates moderate and vigorous physical activity 

in individuals with human immunodeficiency virus 

compared with accelerometry 

8 

Fillipas S, 1,4 Ciccutini F, 1,4 Holland AE, 1,3 Cherry CL 1,2,4 

1 

The Alfred, Melbourne, 2Burnett Institute, Melbourne, 3 La Trobe 

University, Melbourne, 4 Department of Epidemiology and Preventive 

Medicine, Monash University, Melbourne 

The study aimed to evaluate the validity of the last 7-day, self 

administered version of the International Physical Activity 

Questionnaire Long Form in a human immunodeficiency 

virus-infected population, using accelerometry as the 

objective criterion. Thirty male participants (mean age 

53.2 (SD = 10.2)) took part in the study. The ActiGraph 

GT1M accelerometer was worn during all waking hours 

for seven days and the questionnaire was completed on 

day 7. Agreement between measures was assessed using 

correlations and modified Bland-Altman analysis. The 

total number of MET-minutes per week reported on the 

questionnaire correlated modestly with the main criterion 

measure of total weekly activity counts measured by the 

accelerometer (r = 0.41, p = 0.023). However, time spent 

in both moderate and vigorous physical activity was 

over reported on the questionnaire. The mean difference 

compared to accelerometer was 546.63 minutes per week 

(95% CI 217.1 to 871.2 minutes) for moderate and 295.33 

minutes per week (95% CI 88.08 to 502.6 minutes) for 

vigorous activity. The tool’s sensitivity to detect individuals 

with insufficient physical activity to derive a health benefit 

was low (9.5%), however specificity was high (100%). We 

conclude that self-reported physical activity measured by 

this questionnaire correlates with the objective criterion of 

accelerometry, but substantial over-reporting occurs. The 

tool may be useful in screening physical activity levels 

but should not be used to determine precise amounts of 

activity. 

Inspiratory muscle training 

Hill K, 1 Elkins MR, 2 Berlowitz D 3 

1 

School of Physiotherapy, Curtin University of Technology, Perth; 

2 

Respiratory Medicine, Royal Prince Alfred Hospital, Sydney; 3 Institute 

for Breathing and Sleep, Austin Health, Melbourne 

This session will provide an overview of the use of inspiratory 

muscle training (IMT) as part of pulmonary rehabilitation, 

in athletes, in patients with spinal cord injury, to assist 

weaning from mechanical ventilation and to prevent postoperative 

respiratory complications. Inspiratory muscle 

dysfunction contributes to impaired exercise capacity and 

the sensation of dyspnoea in people with chronic obstructive 

pulmonary disease (COPD). Although IMT applied at loads 

that exceed 30% of maximal inspiratory pressure (Pimax) 

improves task-specific measures and dyspnoea, it is unclear 

whether or not such training confers benefits in exercise 

capacity or quality of life. It is possible that individuals with 

marked inspiratory muscle weakness may benefit the most. 

People living with spinal cord injury (especially tetraplegia) 

have significantly impaired inspiratory muscle performance 

as a direct result of their injuries. Similarly, people receiving 

mechanical ventilation, particularly for prolonged periods, 

experience marked reductions in inspiratory strength and 

endurance. Unfortunately, as with COPD, although IMT 

has been shown to increase task-specific measures, data 

examining longer-term functional outcomes are sparse and 

conflicting. In patients undergoing coronary artery surgery, 

pre-operative IMT minimises the post-operative fall in 

Pimax, lung function and gas exchange. This significantly 

reduces post-operative pulmonary complications and length 

of stay in high-risk patients. Recent research suggests 

three mechanisms by which IMT could improve athletic 

performance in healthy people, especially elite athletes. 

Randomised trials in the area have conflicting results. 

Physical activity measurement monitors 

Hill K, 1 Holland AE 2 

1 

School of Physiotherapy, Curtin University of Technology, Perth, 2 La 

Trobe University, Melbourne and Alfred Health, Melbourne 

An inactive lifestyle has deleterious health consequences. 

In individuals with chronic disease, physical inactivity 

is associated with impaired quality of life, increased 

healthcare utilisation, the development of cardiovascular 

disease and poor survival. An important goal of many 

physiotherapy interventions is to optimise daily physical 

activity. Quantification of physical activity is most often 

achieved via self-report methods, structured questionnaires 

or the use of devices such as pedometers, accelerometers or 

metabolic monitors. Self-report methods and questionnaires, 

whilst inexpensive and simple to administer, often yield 

inaccurate results. This reflects recall and acquiescence 

(social desirability) bias inherent with such techniques. 

Pedometers may be useful for individuals with a normal 

gait pattern and minimal disability, however measurement 

error is common when used by individuals with very slow 

walking cadences and/or abdominal obesity. Accelerometers 

measure movement in one or more planes. Compared 

with pedometers, accelerometers are more accurate and 

may provide information regarding movement type and 

intensity as well as the distribution of activity relative to 

time. Metabolic monitors combine the technology of an 

accelerometer with sensors that evaluate skin responses 

to estimate energy expenditure. Preliminary data suggest 

that they yield accurate and responsive information in 

individuals with chronic disease. Both accelerometers and 

metabolic monitors are expensive and require technical 

expertise, factors which currently limit their utility in the 

clinical setting. It is likely that measurements of physical 

activity will increasingly be used to evaluate physiotherapy 

interventions, providing unique information that is not 

captured by measures of exercise capacity. 

Effects of repeated administration of a perceptually 

regulated six-minute walk test in patients awaiting 

coronary artery bypass graft surgery 

Hirschhorn A, 1,3 Richards D, 2 Mungovan S, 1 Morris N, 3 

Adams L 3 

1 

Westmead Private Hospital, Sydney 2 Westmead Private Cardiology, 

Sydney, 3 School of Physiotherapy and Exercise Science, Griffith 

University, Gold Coast 

The aim of this study was to assess the presence and 

magnitude of any training effects with repeated six-minute 

walk test administration in patients awaiting coronary 

artery bypass graft surgery. Thirty-six patients performed 

two six-minute walk tests, one hour apart, on hospital 

admission. Six-minute walk tests were perceptually 

regulated, with patients encouraged to walk at a perceived 

‘moderate’ or ‘somewhat strong’ level of exertion. The 

primary outcome measure was six-minute walk distance; 



secondary outcome measures were resting and post-test 

heart rate, blood pressure and oxygen saturation, peak 

heart rate, and perceived intensity of exertion. A training 

effect was observed, in that patients walked further on the 

second walk test (p < 0.001). Peak heart rate (p = 0.002) 

and perceived intensity of exertion (p = 0.003) were also 

higher for the second walk test. The mean improvement in 

distance (18 m) from first to second test was small relative 

to total six-minute walk distance (test one: 471 m, test two: 

489 m). It is recommended that a training effect be taken 

into consideration when comparing pre-operative to postoperative 

six-minute walk test performance in patients 

undergoing coronary artery bypass graft surgery. 

A randomised controlled trial of staircase recruitment 

manoeuvres, high PEEP and low airway pressure as a 

bundle of protective ventilation 

Hodgson CL, 1,2 Nichol A, 1,2 Tuxen DV, 1,2 Bailey M, 1,2 

Holland AE, 1,3 Keating J, 2 Pilcher D, 1 Davies A, 1,2 

Westbrook A, 2 Hilton A, 1 Cooper DJ 1,2 

1 

The Alfred Hospital, Melbourne, 2 Monash University, Melbourne, 3 La 

Trobe University, Melbourne 

The aim of this study was to examine the effectiveness of an 

‘optimal’ ventilatory strategy including staircase recruitment 

manoeuvres compared to current best practice in patients 

with acute respiratory distress syndrome (ARDS). The 

‘optimal’ ventilator strategy consisted of a novel open lung 

low airway pressure approach (Permissive Hypercapnia 

and Alveolar Recruitment with Limited Airway Pressures: 

PHARLAP ACTRN12607000465459) compared to the 

current ARDS net low tidal volume strategy. In this report, 

we describe the oxygenation results of our first interim 

analysis. Fifteen subjects (ten males) with ARDS and a 

mean age of 57.2 ± 15.3 years and baseline PaO2/FiO2 157 

± 54 were randomly allocated into experimental PHARLAP 

ventilation (n = 8) or control ventilation (n = 7). Outcomes 

were gas exchange and lung compliance at 1, 3, 6 and 24 

hours. At 24 hours PHARLAP ventilation improved PaO2/ 

FiO2 ratio (PHARLAP 223.06 ± 25.46, Control 130.9 ± 

13.06, p = 0.009) and lung compliance (PHARLAP 43.62 

± 3.85, Control 27.7 ± 2.33, p = 0.001). These preliminary 

results suggest that a package of ventilation including 

staircase recruitment manoeuvres and high PEEP are well 

tolerated and may be effective to improve oxygenation and 

lung compliance in patients with acute respiratory distress 

syndrome. 

The effects of a thoracic mobilisation exercise program 

following open heart surgery: a randomised 

controlled pilot study 

Hoggins TR, 1 Denehy L, 2 Tully EA, 2 El-Ansary D 2 

1 

Monash Medical Centre, Melbourne 2 The University of Melbourne, 

Melbourne 

The aims of this study were to investigate any trends in 

differences for thoracic and shoulder range of movement, 

pain and function, between participants provided with a 

thoracic mobilisation exercise program and those receiving 

standard care after open heart surgery. A single-blinded 

randomised controlled pilot study was carried out in a tertiary 

public hospital in Melbourne. Thirty-eight participants who 

underwent open heart surgery were randomly allocated 

using concealed allocation to a treatment (n = 23), or a 

control (n = 15) group. In addition to standard post-operative 

physiotherapy care, treatment group participants received an 

individualised, progressive thoracic mobilisation exercise 

program on discharge from the acute hospital. Control group 

participants received no thoracic mobilisation exercises. 

Baseline pre-operative outcome measures of shoulder and 

thoracic range of movement, pain, function and health 

related quality of life were repeated post-operatively prior 

to discharge, at 4 weeks and 3 months post-operatively. 

Reliability of measures of range of movement using ImageJ 

was established prior to use. At the conclusion of the followup 

period, participants completed a global rating of change. 

Treatment group participants reported less sternal pain at 4 

weeks post discharge (p = 0.029) and greater improvements 

on the global rating of change assessment (p = 0.04). There 

were no significant differences between groups for shoulder 

or thoracic range of movement, function, or health related 

quality of life. The role of thoracic mobilisation exercises 

following open heart surgery in reducing sternal pain 

warrants further investigation. 

The functional difficulties questionnaire: a new tool 

for measuring physical function in an open heart 

surgery population 

Hoggins TR, 1 Denehy L, 2 Tully EA, 2 El-Ansary D 2 

1 

Monash Medical Centre, Melbourne 2 The University of Melbourne, 

Melbourne 

A functional questionnaire suitable for a population following 

open heart surgery which addresses the thoracic region and 

has been validated currently does not exist. A new tool, the 

functional difficulties questionnaire, was developed for this 

purpose and comprises 13 functional tasks that are likely 

to cause difficulty following open heart surgery, as well 

as being tasks necessary in everyday life. The respondent 

marks the degree of difficulty they experience for each 

component task on a 10 cm visual analogue scale (VAS). 

Individual VAS scores are aggregated to form a total out of 

130, with higher scores representing greater difficulty. The 

aims of this study were to provide preliminary evidence as 

to the functional difficulties questionnaire’s validity and 

sensitivity to change. Thirty-eight participants undergoing 

open heart surgery completed the questionnaire preoperatively, 

post-operatively, 4 weeks post-operatively and 

3 months post-operatively. The questionnaire showed good 

internal consistency, with a Cronbach alpha coefficient of 

0.971. Results showed a significant increase in functional 

difficulties questionnaire scores from pre-operatively to 

post-operatively (p < 0.001) and a significant decrease in 

scores from post-operatively to 4r weeks post-operatively 

(p < 0.001) and from 4 weeks post-operatively to 3 months 

post-operatively (p = 0.006). There was a moderate to good 

correlation between the questionnaire’s scores and sternal 

pain (rho = 0.60, p < 0.001), shoulder pain (rho = 0.51, p 

= 0.001) and total pain (rho = 0.69, p < 0.001). Further 

investigation of the tool, particularly with regards to test 

re-test reliability, is required. 



10 

Predicting peak cycle work capacity from the sixminute 

walk test: differences between reference 

equations 

Holland AE, 1,2 Hill K, 3 Jenkins SC, 3,4,5 

1La Trobe University, Melbourne, 2 Alfred Hospital, Melbourne, 

3 

Curtin University, Perth, 4 Sir Charles Gairdner Hospital, Perth, 5 Lung 

Institute of Western Australia, Perth. 

Prescription of appropriate exercise intensity is critical 

to optimising the outcomes of pulmonary rehabilitation, 

however prescribing cycle workloads is challenging if peak 

work capacity is not known. Recently two studies reported 

regression equations which allow estimation of peak cycle 

workload from the six-minute walk distance in chronic 

obstructive pulmonary disease. The aim of this study was 

to compare estimates of peak work and target training 

workload (60% of peak) obtained from these equations. 

Sixty-four (38 male) subjects, mean (standard deviation) 

age 70 (8) years and FEV 1 49 (18) % predicted with chronic 

obstructive pulmonary disease performed the six-minute 

walk test according to a standardised protocol. Estimates of 

peak work were obtained using the published equations and 

agreement between equations was examined using the Bland 

and Altman method. Mean walk distance was 376 (86) m 

compared to 464 (110) m and 501 (83) m in samples used 

to derive the equations. There was substantial variation in 

estimates of peak workload between equations (range 1–75 

Watts difference). The Luxton equation tended to predict 

higher peak work than the Hill equation at workloads over 

50 Watts. Estimated training workload differed by more 

than 10 Watts in 32 subjects (50%) and more than 20 Watts 

in 18 subjects (28%). This comparison of reference equations 

for predicting peak cycle workload from six-minute walk 

distance indicates substantial variation between methods 

that differs systematically across the range of workloads. 

Further research is required to validate the equations and 

assess their utility for exercise prescription in patients with 

chronic obstructive pulmonary disease participating in 

pulmonary rehabilitation. 

Too many research questions, not enough time: models 

for improving the quantity and quality of research by 

combined clinician-researchers in physiotherapy 

Holland AE, 1,2 Elkins MR 3 

1 

La Trobe University, Melbourne; 2 Alfred Health, Melbourne; 3 Royal 

Prince Alfred Hospital, Sydney 

Many physiotherapists would like to undertake clinical 

research in order to answer important clinical questions 

and broaden their career options. However new clinical 

researchers face substantial barriers including insufficient 

time, inadequate funding and lack of a well-defined career 

path. A growing number of physiotherapists successfully 

combine research and clinical practice, giving rise to 

new models for physiotherapy career paths and better 

opportunities for clinicians to participate in research. Getting 

started as a clinician-researcher requires a good research 

question, a supportive and experienced team, persistence 

and outstanding time management. It is widely accepted 

that having a carefully selected mentor is important for 

beginning researchers, however to date these relationships 

have not been widespread in physiotherapy. Furthermore, 

the limited time, funding and mentorship available to most 

clinician-researchers can reduce the quality of the research 

they conduct. In particular, blinding is often not used. 

We must find innovative strategies to create the time and 

resources needed to conduct high quality research projects. 

Several models will be presented that illustrate novel and 

successful strategies used by clinician-researchers to deal 

with these limitations. For trial quality, novel approaches to 

blinding in clinical trials will be used as an example. 

Does supplemental oxygen worsen hypercapnia in 

patients with obesity-related respiratory failure 

(obesity hypoventilation syndrome)? 

Hollier C, 1,2 Harmer AR, 1 Maxwell LJ, 1 Piper AJ, 2,3 

Menadue C, 1,2 Willson GN 4 

1 

Faculty of Health Sciences, The University of Sydney, Sydney, 2 Royal 

Prince Alfred Hospital, Sydney, 3 Woolcock Institute of Medical 

Research, Sydney, 4Faculty of Health, University of Canberra, 

Canberra 

Breathing high concentration supplemental oxygen may 

worsen hypercapnia and pH in patients with chronic 

obstructive pulmonary disease. A similar effect has been 

proposed in patients with chronic hypercapnic respiratory 

failure secondary to obesity (obesity hypoventilation 

syndrome), however, this has not been substantiated. This 

study investigates the effects of supplemental oxygen in 

patients with obesity hypoventilation syndrome. Preliminary 

data are presented here. In this double-blinded randomised 

crossover study, responses to two concentrations of oxygen 

(FIO 2 = 0.28 and 0.50) were measured in patients with 

untreated obesity hypoventilation syndrome. After first 

breathing room air for 10 minutes via a closed breathing 

circuit, participants breathed each oxygen concentration 

for 20 minutes in random order, followed by a 10-minute 

recovery period breathing room air and a 45-minute 

washout period. Arterialised-venous PCO 2 and pH were 

assessed every 5 minutes. Respiratory variables were 

measured continuously; however, are not presented here. 

Four participants (FM = 1:3; age = 47.8 ± 13.8, mean ± SD; 

BMI = 56.6 ± 5.1 kg.m-2; PaCO 2 = 50.2 ± 3.9mmHg; PaO 2 

= 74.4 ± 12.1 mmHg) completed the protocol. PCO 2 rose 

by 2.7 ± 1.6 mmHg (from 51 ± 3.6 mmHg) and 4.1 ± 2.1 

mmHg (from 52.7 ± 2.9 mmHg) after 20-minute periods of 

breathing FIO 2 = 0.28 and 0.50, respectively. Changes in pH 

reflected the PCO 2 rise, decreasing by 0.011 ± 0.001 (from 

7.38 ± 0.033) during FIO 2 = 0.28, and by 0.033 ± 0.018 

(from 7.38 ± 0.029) during FIO 2 = 0.50. This novel study 

documents the effects of oxygen in patients with obesity 

hypoventilation syndrome. Participants are enrolled in a 

larger study investigating responses to oxygen before and 

after treatment with positive airway pressure. Results may 

help to guide clinical practice and improve health outcomes 

in this population. 

A narrative review on home-based exercise training for 

patients with chronic heart failure 

Hwang R, 1 Redfern J, 2 Alison JA 2,3 

1 

Princess Alexandra Hospital, Brisbane, 2 The University of Sydney, 

Sydney, 2,3 Royal Prince Alfred Hospital, Sydney 

In view of the growing incidence of chronic heart failure 

and its poor prognosis, there has been increasing interest 

in optimising management of people with this condition. 

Exercise has been widely accepted as part of the 

management plan for patients with chronic heart failure. 

Traditionally, exercise training for this group of patients has 

concentrated on supervised centre-based training programs. 



However, home-based training may offer an alternative to 

conventional training or as a means of maintaining physical 

fitness after graduating from the centre-based program. 

This review was undertaken to examine the literature for 

home-based exercise training in patients with chronic heart 

failure. Literature searches were performed initially using 

electronic databases. The obtained papers were crossreferenced 

and appropriate articles were ordered through 

interlibrary loans. A total of 21 relevant papers were 

identified for review. The majority of studies documented 

benefits with home-based training including increased 

exercise capacity, improved self-efficacy and increased 

muscle strength. Home-based exercise training has been 

shown to benefit people with chronic heart failure in the 

short term. Further research is required to investigate the 

long-term effects of home exercise and to determine the 

optimal strategies for improving exercise adherence in 

patients with chronic heart failure. 

Is pulmonary rehabilitation lost in translation? 

Johnston KN, Kumar S 

Centre for Allied Health Evidence, University of South Australia, 

Adelaide 

There is a strong evidence base recognising the importance 

of pulmonary rehabilitation for patients with chronic lung 

disease. However, to date it is unclear whether this has 

translated into national policy and clinical practice. This 

means it is likely that thousands of Australians are not 

receiving the health benefits of this intervention. The aim 

of the study was to report on pulmonary rehabilitation 

in the light of the main components of implementation 

research. This study involved: systematic literature review 

(2005 to present) and prospective observational study of 

local health system model of care development. Findings 

indicated that while evidence generation and synthesis 

were well established, there were serious gaps in mapping 

current patterns of health care and policy, and development 

and testing of implementation strategies. Barriers were 

identified in medical referral to pulmonary rehabilitation, 

patient adherence and program completion. Studies which 

aimed to improve implementation directed strategies to a 

single stakeholder only (clinicians or patients). Workforce 

and infrastructure modelling were a focus for model of care 

development, even though there were gaps in the evidence to 

accurately underpin this. Work has commenced to translate 

pulmonary rehabilitation evidence into health policy and 

practice. However, the evidence suggests a whole-of-system 

approach which involves mapping of current practice, 

barriers and enablers, and the relative influence of each, is 

incomplete. This information is required to then develop, 

implement and evaluate appropriate organisational and 

health care system level interventions to deliver quality 

pulmonary rehabilitation. 

The use of evidence-based practice in pulmonary 

rehabilitation in Australia 

Johnston CL, 1,2 Alison J, 2,3 Maxwell L 2 

1 

The University of Newcastle, Newcastle, 2 The University of Sydney, 

Sydney, 3 Royal Prince Alfred Hospital, Sydney 

Gaps between current evidence and clinical practice have 

been identified in many health care settings. Barriers to the 

use of evidence-based recommendations may exist at the 

level of the professional, the patient and/or the organisation 

and can also relate to resource constraints and wider social 

or economic contexts. Little is known about the issues that 

health professionals working in pulmonary rehabilitation 

perceive as important in relation to using evidence-based 

recommendations. The aim of this study was to undertake 

a preliminary exploration into knowledge of, and barriers 

to, using evidence-based recommendations in pulmonary 

rehabilitation. A custom designed questionnaire was sent 

to all pulmonary rehabilitation programs listed on the 

Australian Lung Foundation national database (n = 193, 

response rate 83%). Respondents were primarily from 

physiotherapy (70%) and nursing (28%) backgrounds. 

While most respondents (70%) were aware of the 

Pulmonary Rehabilitation Toolkit (Australian evidencebased 

recommendations), 30% were not aware of any 

published major international pulmonary rehabilitation 

statements/guidelines. Most respondents (80%) reported 

that they had the authority to make changes in the exercise 

training component of their program. The main barriers to 

implementing change in practice were reported to be lack 

of staffing and limited resources. A perceived gap between 

evidence and current practice in their program was reported 

by 63% of respondents, with a further 12% stating they 

were not sure of current evidence. These results suggest 

that knowledge of evidence-based practice in pulmonary 

rehabilitation is variable. Further research into the barriers 

to the use of evidence-based recommendations in pulmonary 

rehabilitation is recommended. 

Comparison of peak expiratory flow between 

Mapleson-C and Magill circuits: a benchtop study 

Jones AM, 1 Thomas PJ, 2,3 Paratz J 2 

1 

School of Physiotherapy, University of Queensland, 2 Burns, Trauma 

& critical Care Research Centre, University of Queensland, 3 Dept of 

Physiotherapy, Royal Brisbane & Women’s Hospital, Brisbane 

Manual hyperinflation (MHI) is a treatment technique 

commonly used by physiotherapists in order to reverse/ 

prevent atelectasis and mobilise airway secretions in 

intubated patients. Previous research has determined that the 

Mapleson-C circuit produces a faster peak expiratory flow 

and smaller inspiratory:expiratory ratio than the Laerdal 

and Air Viva 2 circuits resulting in an increased yield of 

secretions. However, little research has been performed 

evaluating the flow rates produced by the Magill circuit and 

this study aimed to compare peak expiratory flow between 

the Magill and Mapleson-C manual hyperinflation circuit. 

A semi-blinded crossover study of 12 physiotherapists 

experienced in tertiary level intensive care was conducted 

on a lung model (Lung Simulator SMS, Essex, UK) and 

respiratory mechanics monitor (Model 1550 Novametrix 

Medical Systems Inc. Connecticut, USA) with data 

downloaded to a laptop computer. The order of circuit and 

compliance low (0.02), medium (0.05) or high (0.75) L/cm 

H2O were randomised. The Mapleson-C circuit produced 

a significantly higher peak expiratory flow (p = 0.006) and 

smaller inspiratory to expiratory flow ratio (p = 0.004) 

than the Magill circuit regardless of compliance settings. 

The results of this study suggest that the Mapleson-C 

circuit may be theoretically more effective at mobilising 

secretions. However, both the Mapleson-C and Magill 

circuits generated an inspiratory to expiratory flow ratio 

theoretically capable of mobilising secretions. 



12 

Aerobic exercise training improves lung function in 

children with intellectual disability: a randomised, 

controlled trial 

Khalili MA, 1 Elkins MR 2 

1 

Semnan University, Semnan, Iran, 2 Royal Prince Alfred Hospital, Sydney 

Respiratory infections are common in children with Down 

syndrome and other intellectual disabilities. Their increased 

risk may relate to poor underlying lung function, although 

only limited evidence exists about their lung function 

when they are well. This study aimed to compare the lung 

function of these children when they are well to normative 

data, and to determine whether their lung function can be 

improved with exercise training. Children with intellectual 

disability underwent a week of coaching in spirometric tests, 

followed by measurement of their lung function. They were 

randomly allocated to an exercise group (aerobic walking, 

running and cycling for 30 minutes, 5 days per week, for 8 

weeks) or a control group (usual daily activities only). The 

exercise was supervised, with a target of moderate intensity. 

Lung function was measured again at 8 weeks. Of the 44 

participants enrolled (mean age 12 (1.5) years and IQ 42 (8) 

points), randomisation allocated 24 participants to exercise 

and 20 participants to control. For the full cohort after 

coaching, FEV1 was a mean of 87% (95% CI, 84 to 91) and 

FVC was 93% (95% CI, 90 to 96) of normative values. Both 

FEV1 and FVC improved significantly more in the exercise 

group than in the control group. For change in FEV1, the 

mean between-group difference was 160mL (95% CI, 

30 to 290). For change in FVC, the mean between-group 

difference was 330mL (95% CI, 200 to 460). Lung function 

is reduced, but improves with exercise training, in children 

with intellectual disability. 

Does a self management driven exercise program 

improve long-term adherence to physical activity post 

cardiac rehabilitation? 

Kirwan G, 1 Hibberd Y, 1 Morris N, 2 Duncan L, 1 Bourke F, 1 

Forward B, 1 Hollis-Novak F 1 

1 

Lifestyle Management and Cardiac Rehabilitation Team Metro South 

Health Service District Brisbane, 2 Griffith University Gold Coast 

Insufficient physical activity has been well supported as a 

fundamental risk factor for the development of cardiovascular 

disease. Many clients who have cardiovascular disease are 

aware that exercise is beneficial however recent studies 

have reported adherence levels post phase two cardiac 

rehabilitation at less than 50%. A single-blind randomised 

controlled trial within the cardiac rehabilitation team is 

currently investigating the effects of a self management 

driven exercise program (goal program) on client adherence to 

exercise. Clients are randomised into cardiac rehabilitation 

(control group) or cardiac rehabilitation and goal program 

(intervention group). Data are collected pre cardiac 

rehabilitation, post cardiac rehabilitation, 6 months and 

12 months post program. Based on current literature 

physical activity levels expressed in the form of METS 

are measured using a Sensewear® Pro3 Physical Activity 

Monitor. Furthermore waist, weight, BMI, dietary habits 

and six-minute walk test data are also collected at the 

above mentioned timeframes. It is hypothesised that clients 

attending the GOAL program post cardiac rehabilitation 

will demonstrate higher levels of physical activity 12 months 

post cardiac rehabilitation completion when compared to 

the control group. 

An on-line device for tracking survival determinants 

and educating individuals with breast cancer 

Laakso E-L, 1 Somerset S, 2 Usher W, 3 Ravenscroft A 4 

1 

School of Physiotherapy and Exercise Science; 2 School of Public 

Health; 3 School of Education and Professional Studies; 4 School of 

Information and Communication Technology; Griffith University, Gold 

Coast. 

The Australian Institute of Health and Welfare calculates 

that chronic disease accounts for nearly 43% of the total 

disease burden in Australia. Diet and exercise (together 

with smoking cessation) are acknowledged as the most 

important factors in achieving and maintaining desired 

BMI for the prevention of chronic diseases such as breast 

cancer. Despite the evidence, community attitudes to diet 

and exercise have been difficult to transform; geographic 

and socioeconomic barriers to health care and advice are 

difficult to overcome; and sustainable long-term change in 

health behaviours has been elusive. Attempts at delivering 

health education via the internet have been encouraging 

although long-term follow-up results are scarce, and 

issues of adherence remain unknown. We describe the 

development of a secure on-line interactive device for breast 

cancer patients to: educate individuals regarding evidencebased 

guidelines for exercise, physical activity and diet; and 

assess self-monitoring of physical and psychosocial health 

outcomes. The Healthy Outcomes web site was constructed 

with a central framework incorporating interactive user 

personal profiles; personal exercise, physical activity, 

diet and medications diaries; and a bank of self-report 

questionnaires which can be utilised by practitioners 

and researchers for tracking user outcomes. The Healthy 

Outcomes web site will eventually include health enablers 

such as blogging and personal reminders. This model of 

service delivery has the potential for application in a wide 

range of important health priority areas. 

Gastro-oesophageal reflux in bronchiectasis and 

COPD: clinical implications and the effects of 

physiotherapy 

Lee AL, 1,2 Button BM, 2,3 Denehy L, 1 Roberts S2, ,3 Ellis S, 2 

Heine R, 4 Stirling R, 2,3 Wilson JW 2,3 

1 

School of Physiotherapy, The University of Melbourne, Melbourne, 

2 

The Alfred, Melbourne, 3 Monash University, Melbourne, 4 Royal 

Children’s Hospital, Melbourne 

The prevalence of gastro-oesophageal reflux (GOR) and 

its clinical implications in bronchiectasis and COPD are 

not well described. It is unknown whether physiotherapy 

interventions in these patients provoke GOR. The aims 

of this study were to determine the prevalence of GOR in 

bronchiectasis and COPD and its effect on lung function 

and quality of life (QOL) and to identify the impact of a 

commonly prescribed airway clearance technique and 

exercise on gastro-oesophageal function. Patients and 

controls completed dual-probe 24-hour oesophageal pH 

monitoring. Disease severity (spirometry and HRCT 

scoring) and QOL were measured. All patients completed 

a session of upright positive expiratory pressure (PEP) 

therapy, measures of exercise capacity (Six-minute walk 

test [6MWT]) and upper limb function (Grocery Shelving 

Task [GST]). The number of reflux episodes (NRE) and 

reflux time (RI) were recorded during each intervention and 

compared to background time (BGT). Thirty patients with 

bronchiectasis (mean [SD] FEV 1 73.9% [23.4]), 27 with 

COPD (FEV 1 47.2% [17.4]) and 17 controls were recruited. 



The prevalence of GOR in bronchiectasis was 40%; 37% 

in COPD; 18% in controls. A diagnosis of GOR was not 

associated with increased disease severity or a poorer QOL 

in bronchiectasis or COPD (all p > 0.05). PEP therapy 

did not increase distal NRE (p = 0.71) or RI (p = 0.642) 

compared to BGT. Fewer distal NRE occurred during the 

6MWT (p < 0.001) and GST (p < 0.001) compared to BGT. 

GOR was a co-morbidity in bronchiectasis and COPD 

across the disease spectrum but aspects of physiotherapy 

performed in this study did not provoke GOR. 

The impact of musculoskeletal pain on adults 

with cystic fibrosis 

Lee AL, 1,2 Kelemen L, 3 Button BM, 2,4 Wilson JW, 2,4 

Presnell S, 2,3 Holland AE2 ,3 

1 


2 

The Alfred, Melbourne, 3 La Trobe University, Melbourne, 4 Monash 

University, Melbourne 

Musculoskeletal pain is recognised as a complication 

in cystic fibrosis (CF) but the prevalence and clinical 

significance of this co-morbidity in adults with stable 

lung disease has not been well described. The aim of 

this study was to determine the location, intensity and 

experience of musculoskeletal pain and its impact on 

quality of life in individuals with CF. Participants with 

clinically stable CF from an outpatient clinic completed 

three questionnaires measuring the location, severity and 

degree of interference in daily activities of musculoskeletal 

pain (Brief Pain Inventory), the psychological impact 

of pain (Pain Catastrophising Scale) and quality of life 

(Cystic Fibrosis Quality of Life questionnaire). Seventyseven 

participants with mean age 29 years (SD 8 years), 

FEV 1 60 (25) % predicted were included. The prevalence 

of musculoskeletal pain was 89% and was not influenced 

by lung disease severity. Pain was commonly located in the 

back, buttocks and hips (70%), head and neck (52%) and 

lower limbs (29%). Although pain intensity was generally 

mild, participants with musculoskeletal pain reported poorer 

physical functioning (p = 0.01) and increased interference 

with treatment aspects of CF (p = 0.03) compared to 

those with no pain. Participants with symptoms of CF 

arthropathy reported greater intensity and impact of pain. 

Pain catastrophising and FEV 1 were independent predictors 

of quality of life in adults with CF. Musculoskeletal pain 

is a significant complication which negatively influences 

quality of life in adults with stable CF. These results lend 

support to the inclusion of musculoskeletal pain screening 

as part of CF management. 

Pepsin, a measure of pulmonary microaspiration in 

COPD and bronchiectasis 

Lee AL, 1,2 Button BM, 2,3 Denehy L, 1 Roberts S, 2,3 Bamford 

TL, 3 Mifsud N, 3 Tjen F, 3 Stirling R, 2,3 Wilson J 2,3 

1 


2 

The Alfred, Melbourne, 3 Monash University, Melbourne 

Gastro-oesophageal reflux (GOR) in COPD and 

bronchiectasis is a potential contributor to lung disease 

severity. Pepsin in airways samples is a probable non-invasive 

marker of pulmonary microaspiration. The aim of this study 

was to determine the presence of pepsin in airway samples 

in COPD and bronchiectasis and its association with GOR 

and lung function. Patients with COPD and bronchiectasis 

completed dual-probe 24-hour oesophageal pH monitoring, 

measuring number of reflux episodes (NRE), % reflux time 

(RI) and a DeMeester score (DMS). Lung disease severity 

was assessed using spirometry. Four samples of sputum 

and saliva were collected over the 24-hour study period, 

with the concentration of pepsin measured by an ELISA. 

Thirty patients with bronchiectasis (mean [SD] FEV 1 73.9% 

[23.4]) and 27 with COPD (mean [SD] FEV 1 47.2% [17.4]) 

were recruited. A total of 36 sputum saliva and 71 saliva 

samples were positive for pepsin (concentration > 1.953 ng/ 

ml). NRE, RI and DMS were not associated with pepsin 

in sputum or saliva in COPD or bronchiectasis (all p > 

0.05). There was a trend towards lower FEV 1 % in those 

with positive sputum (pepsin present) in COPD (p = 0.079) 

but not bronchiectasis (p = 0.411). In COPD, patients with 

positive sputum only (not diagnosed with GOR) had a lower 

FEV 1 % (p = 0.005) compared to those with GOR only 

(sputum negative for pepsin). Pepsin in airways samples in 

COPD and bronchiectasis is not reliant on a diagnosis of 

GOR. Pulmonary microaspiration of GOR may contribute 

to airway damage in COPD. 

Communication with general practitioners enhances 

the early intervention of exacerbations in people with 

chronic obstructive pulmonary disease 

Leung RWM, 1 Greer T 2 

1 

Department of Physiotherapy, Concord Repatriation General Hospital 

(CRGH), Sydney, 2 The COPD program, CRGH, Sydney 

An action plan is recommended for the management 

of acute exacerbations of COPD (AECOPD) but the 

completion rate by general practitioners is low. This study 

aimed to investigate the completion rate of the COPD action 

plan after written communication with GPs was initiated. 

Those patients who consecutively attended pulmonary 

rehabilitation between January and June 2009 were given 

a letter addressed to their GP with a blank action plan 

in addition to a self-management education pack. Each 

participant was contacted 4 weeks after the letter was 

issued in order to review the response from the GP. People 

were excluded if they could not follow instructions in 

English. The participants (n = 54, mean (SD) FEV 1 = 47 

(18) % predicted) were interviewed and the results were 

compared to a study conducted in 2007. Thirty-two percent 

of participants had a completed action plan compared to 

22% in the previous study. Seventy percent of participants 

(including those without an action plan) had prescriptions 

for prednisone and antibiotics for early intervention of 

AECOPD compared to 60% in the last study. For those 

who did not have an action plan, the majority (81%) were 

advised to contact the GP at the onset of AECOPD. The 

completion rate of the action plan has increased through 

written communication to the GP. This improvement is 

vital as early detection and prompt intervention reduces the 

severity and recovery time of exacerbations. 



14 

Overground walk training improves endurance 

walking capacity and quality of life in people with 

COPD: a randomised controlled trial 

Leung RWM, 1,2 Alison JA, 2 McKeough ZJ, 2 Peters MJ 3 

1 

Department of Physiotherapy, Concord Repatriation General Hospital 

(CRGH), Sydney, 2 Discipline of Physiotherapy, University of Sydney, 

Sydney, 3 Department of Respiratory Medicine, CRGH, Sydney 

Walking is often recommended as one of the training 

modalities in pulmonary rehabilitation but there is no 

rigorous scientific evidence to support the use of supervised, 

overground walk training as a sole training modality 

in people with chronic obstructive pulmonary disease 

(COPD). The aim of this study was to investigate the effect 

of overground walk training, compared to cycle training, 

on exercise capacity and health-related quality of life in 

people with COPD. Thirty-six participants with stable 

COPD were randomised into either walk or cycle training. 

Both groups trained 3 times weekly for 8 weeks with target 

intensity individualised. Testing at baseline and at 8 weeks 

included peak and endurance cycle tests, incremental and 

endurance shuttle walk tests and the Chronic Respiratory 

Disease Questionnaire (CRQ). Thirty-two participants 

completed the study (walk training n = 17, mean (SD) FEV 1 

= 56 (17) % predicted; cycle training n = 15, FEV 1 = 48 (13) 

% predicted). There was a significantly greater increase in 

endurance walk time in the walk training than the cycle 

training group (mean difference 279 seconds, 95% CI 70 to 

483). CRQ following training was significantly improved in 

both groups but the increase was not significantly different 

between the two groups (mean difference 4 points 95% 

CI-2 to 10).This study provides evidence for prescribing 

individualised overground walk training as a training 

modality in pulmonary rehabilitation to improve endurance 

walking capacity and quality of life. 

Active cycle of breathing technique: a systematic review 

Lewis LK, Williams MT, Olds T 

University of South Australia, School of Health Sciences, Adelaide 

This study aimed to identify the current research evidence 

underpinning the active cycle of breathing technique. A 

systematic search of six databases was undertaken using 

terms synonymous with the active cycle of breathing 

technique. Hand searching of reference lists was conducted 

and experts contacted. Two assessors independently 

allocated each reference to an evidence hierarchy and 

assessed methodological bias. One hundred and five 

articles were identified. Twenty-four studies reporting 

primary data on the technique were included (1970–2007), 

including several high level, low risk of bias studies. 

Ten comparators were identified with the most common 

including conventional chest physiotherapy (n = 5), positive 

expiratory pressure (n = 5) and a control (n = 4). A total of 

36 outcome measures were identified in the included studies. 

The most commonly assessed outcomes were sputum wet 

weight (n = 17), forced vital capacity (n = 13) and forced 

expiratory volume in one second (n =13). Meta-analysis was 

completed on the primary outcome measure of sputum wet 

weight. Preliminary results indicate that the standardised 

mean difference (SMD) across studies showed an increase 

in sputum weight during and up to one hour post treatment 

(SMD 0.29, 95% CI 0.20 to 0.37), but no difference in the 

during and up to 24 hour post treatment weight (SMD 0.15, 

-0.03 to 0.34). The majority of studies (92%) demonstrated 

excellent generalisability to the target population. Assessing 

the body of evidence was problematic due to the diversity of 

research designs, comparators and outcomes used. 

Educational processes for teaching the research 

evidence component of evidence-based practice in 

physiotherapy education 



The inclusion of evidence-based practice training in 

physiotherapy programs is relatively recent. Little is known 

about the methods used to teach evidence-based practice. 

The aim of this study was to describe the educational 

processes used to facilitate learning of the research evidence 

component of evidence-based practice in Australian 

entry-level physiotherapy programs. A purpose designed 

cross sectional survey was developed and achieved the 

psychometric properties for reliability and validity. All 

institutions offering entry-level training were invited to 

participate. Program directors and course coordinators 

provided detail concerning the competencies that were 

included and assessed. Ten institutions with 16 programs 

(11 undergraduate, five graduate entry) were involved in the 

study. Twelve programs had a stand-alone evidence-based 

practice course. The percentage of total programs that 

contained courses identified as including research evidence 

competencies ranged from 4–38% (undergraduate), and 

6– 51% (graduate-entry). The most commonly taught and 

assessed competency was knowledge of quantitative research 

design (included in 82% and assessed in 61% of identified 

courses). In the graduate entry programs, knowledge of 

critical appraisal tools (83%) was the most commonly 

included and formulation of an answerable question, 

search strategy, critical appraisal application and hierarchy 

of evidence knowledge (67%) were the most commonly 

assessed. A didactic lecture was the most frequent mode 

of disseminating information for all competencies except 

search strategy (tutorials). Given that physiotherapists 

predominantly use techniques acquired during entry level 

training, it is important to determine which educational 

processes are currently in place to facilitate evidence-based 

practice learning. 

Knowledge of final year physiotherapy students of 

the research evidence component of evidence-based 

practice 



The physiotherapist who can not critically read a study is 

as unprepared as one who can not undertake a muscle test. 

Research evidence skills should be taught with the same 

rigour as the objective examination. The aim of this study 

was to describe the knowledge of final year entry-level 

physiotherapy students of the research evidence component 

of evidence-based practice. A cross-sectional questionnaire 

was developed, assessed and achieved the psychometric 

properties for reliability and validity. The questionnaire 

consisted of a clinical scenario and 9 items related to 

research evidence competencies (maximum possible score 

12). These included: formulation of an answerable question 

and search strategy, knowledge of research design, hierarchy 

of evidence systems and research evidence statistics, 



knowledge and application of critical appraisal tools. All 

programs currently providing entry-level training were 

invited to participate. The questionnaire was disseminated 

by academics and completed by students at a face to face 

class. Eight institutions were involved (response rate: 

60 per cent, n = 313 students). The individual institution 

response rates ranged from 19–93% with 6 institutions 

achieving 55% or above. The total score for the individual 

institutions ranged from 6.7 (1.7) to 8.0 (1.6). The highest 

scoring competencies were: critical appraisal application, 

knowledge of research design and hierarchy of evidence 

ranking systems. The two lowest scoring items assessed 

knowledge of research evidence statistics. Final year 

students have a good understanding of research design, 

hierarchy of evidence and critical appraisal application. 

The ability to understand and interpret research evidence 

statistics requires more attention. 

Indigenous lung health: current issues and strategies 

to improve lung health 

Maguire G, Barker R, Alison J 

James Cook University 

Indigenous Australians die from COPD at a rate 5 times 

the national average and the incidence of bronchiectasis 

is high compared to that in non-indigenous Australians. 

‘Closing the gap’ in lung health has a long way to go. Assoc 

Professor Graeme Maguire, a respiratory physician with 

extensive experience in aboriginal health, will present what 

is currently known about indigenous lung health. Dr Ruth 

Barker will outline the development of the ‘Nose Blowing 

Program’, from its humble beginnings in remote Aboriginal 

communities of central Australia in the early 1990s, to 

widespread use around Australia today. The purpose of 

the ‘Nose Blowing Program’ was to improve ear and lung 

health in school-aged children. Unlike previous strategies 

designed for this purpose, this program used a population 

strategy that was directed towards all school-aged children, 

was quick, easy and fun and so could gain acceptance as a 

social norm. Assoc Professor Jenny Alison will talk about 

the development of the ‘Breath Easy, Walk Easy’ program 

which is aimed to enhance the capacity of allied health 

professionals and primary health care workers to identify 

COPD, assess exercise capacity and implement exercise 

training programs in rural and remote communities. The 

‘Breath Easy, Walk Easy’ program has been developed 

and evaluated with the support of the Australian Lung 

Foundation and is in the evaluation of implementation 

phase. 

A randomised controlled trial of the effects of a novel 

exercise program for young people with cystic fibrosis 

Mandrusiak A,1 MacDonald J, 1 Paratz J, 1 Wilson C, 2 

Moller M, 2 Wright S, 2 Watter P 1 

1 

The University of Queensland, Brisbane, 2 Royal Children’s Hospital, 

Brisbane 

The important role of exercise for young people with cystic 

fibrosis is recognised, and the development of innovative 

physiotherapy exercise programs is a focus of current 

clinical research. This randomised controlled trial with 

blinded assessor aimed to investigate the effectiveness 

of a novel inpatient physiotherapy exercise program (the 

Cystic Fibrosis: Fitness Challenge, and accompanying 

FitKit TM ) (n = 15) compared to the current physiotherapy 

exercise practice provided at a tertiary hospital (n = 16), 

for young people with cystic fibrosis experiencing an 

acute exacerbation of respiratory symptoms. Performance 

on study measures (scoped within the framework of the 

International Classification of Functioning, Disability 

and Health model) was assessed at admission, and after 

completion of a 10–14 day inpatient program, and betweengroup 

changes compared. Repeated measures analysis 

of variance demonstrated that both inpatient programs 

contributed to significant improvements for participants 

for a range of measures, including respiratory function (p = 

0.04), hip extensor muscle strength (p = 0.01) and perception 

of physical status (p = 0.003). Additionally, participants 

in the intervention group showed significantly greater 

improvements for some measures, for example: ankle 

dorsiflexor strength (p = 0.01), six-minute walk distance 

(p = 0.001) and the parent’s perception of their child’s 

respiratory status (p = 0.03). However, teenage participants 

in the intervention group reported greater treatment burden 

following the program (p = 0.009). This study expands the 

horizons of physiotherapy practice by strengthening the 

evidence-base for inclusion of tailored exercise programs in 

the management of young people with cystic fibrosis during 

the inpatient phase. 

Does the language of breathlessness change over time 

in people with chronic obstructive pulmonary disease? 

McEvoy C, 1 Williams MT, 1 Petkov J, 1 Cafarella P, 2 Frith P 2 

1 

University of South Australia, Adelaide, 2 Repatriation General 

Hospital, Adelaide 

The aim of this study was to determine whether the language 

used to describe the sensation of breathlessness reflected 

changes in impairment over a 2-year period in people 

with chronic pulmonary disease. Using a prospective, 

observational design, people who participated in a 2006 

study on the language of breathlessness (n = 107) were 

invited to participate in a follow-up study in 2008. The 

main outcome measures were a structured interview on 

the language of breathlessness (volunteered and endorsed 

statements) and the body-mass index, airflow obstruction, 

dyspnoea and exercise capacity (BODE) index which is 

a composite measure of global impairment. Differences 

between 2006 and 2008 were analysed using McNemars 

test (language categories) and t-tests (BODE scores). Forty 

subjects (37%) participated in this study (72 ± 8years, 18 

males, FEV 1 percent predicted 57 ± 19). With the exception 

of the volunteered language category (depressed, regret, 

helpless: 17 people in 2006 versus five in 2008) no other 

volunteered or endorsed language category demonstrated 

significant differences. Contrary to expectation, several 

impairment measures improved between 2006 and 2008 

(six-minute walk tests 378 ± 124m versus 427 ± 127m and 

Medical Research Council scale grade 3 versus grade 2) 

resulting in no significant difference in BODE index score 

(3 ± 2 for both 2006 and 2008). A positive self selection bias 

was evident with predominantly those people with moderate 

airways obstruction who were effectively managing their 

health taking part in the follow-up study. In this sample 

the sensation of breathlessness was unchanged or improved 

with respect to depression over time. 



16 

The influence of demographic characteristics on 

attitudes, knowledge, behaviours, confidence and 

antipathy to evidence-based practice 

McEvoy MP, Williams MT, Olds T 

The University of South Australia, Adelaide 

Surveys of evidence-based practice knowledge, attitudes 

and behaviours are common in specific health professions 

but comparisons across professions are made less frequently. 

This study aimed to investigate factors influencing domains 

of evidence based practice within and between professions. 

Academics and students (n = 515) in various disciplines 

within the University of South Australia (physiotherapy, 

human movement, occupational therapy, podiatry, medical 

radiation, nursing, psychology and commerce), were surveyed 

using a valid and reliable trans-professional evidence-based 

practice profile questionnaire which collected information 

across 5 domains (relevance, terminology, confidence, 

practice, antipathy). Using ANOVA and post hoc t-tests, 

significant professional differences were calculated for 

terminology, relevance, practice (p < 0.001), confidence (p = 

0.003), antipathy (p = 0.018), with a pattern of more positive 

self-report scores for all domains in the physiotherapy and 

podiatry respondents. Increasing age was associated with 

higher self-report scores for all domains with the exception 

of confidence. Females reported greater relevance (p < 

0.001) and least antipathy (p = 0.005) compared to males. 

In student respondents (n = 474), the type of degree program 

(bachelor, honours, masters and PhD) was associated with 

significant differences (p < 0.001 to 0.002) for all domains. 

Respondents currently completing a PhD scored more 

positively for 4 domains while respondents completing 

bachelor degrees scored more negatively for 4 domains. 

Significant differences (p = 0.05) for the antipathy domain 

were evident between respondents for whom English was or 

was not a first language. Recognition of the demographic 

characteristics which influence an individuals evidence 

based practice profile should allow the development of 

targeted educational interventions cognisant of professional, 

program and personal factors. 

Development and psychometric testing of a 

trans-professional evidence-based practice profile 

questionnaire 

McEvoy MP, Williams MT, Olds T 


A number of survey tools addressing a range of evidencebased 

practice domains have been developed with varying 

rigour for specific medical and allied health professions. The 

aim of this study was to develop and psychometrically test 

a trans-professional questionnaire to describe the evidencebased 

practice profile of health professionals. Successive 

drafts were developed from a 4 stage procedure (literature 

review, expert panel, pilot-testing, validity and reliability). 

Ninety-five items relating to evidence-based characteristics 

were pooled from existing questionnaires. The draft 

questionnaire was disseminated to 547 academics and 

students in the Schools of Health Sciences (physiotherapy, 

human movement, occupational therapy, podiatry, medical 

radiation), nursing and midwifery, psychology and 

commerce. Principal component factor analysis revealed 

the presence of 5 factors. Based on this analysis, a panel 

with expertise in EBP questionnaire development, analysis, 

education and research reviewed and revised items within 

the questionnaire. Pilot–testing with 23 subjects from 

a range of health science backgrounds contributed to 

wording, layout and structural changes. Reliability (testretest) 

and validity-testing (convergent and discriminant) 

was undertaken with 106 subjects from health science, and 

for discriminant validity, from non-health backgrounds. 

The final questionnaire consisted of 5 factors (relevance, 

terminology, confidence, practice, antipathy) and 

demonstrated good to very good test-retest reliability (ICCs 

for factor scores range 0.70–0.94) and convergent validity 

(Spearman’s rho for factor scores range 0.50–0.74) Three 

factors (relevance, terminology, confidence) distinguished 

groups with different levels of exposure to EBP (factorial 

AVOVA p < 0.001–0.019)). 

Acceptability of the SenseWear Pro3 Armband in 

measurement of free-living physical activity in people 

with chronic obstructive pulmonary disease 

McNamara RJ, 1,2 Alison JA, 2,3 McKenzie DK, 1 

McKeough ZJ 2 

1 

Prince of Wales Hospital, Sydney, 2 The University of Sydney, Sydney, 

3 


The SenseWear Pro3 Armband is a multi-sensor physical 

activity monitor designed for extended periods of wear 

on the upper arm. While the validity and reproducibility 

of the monitor for estimating energy expenditure in 

chronic obstructive pulmonary disease (COPD) has been 

established, patient acceptability in wearing the device is 

currently unknown. This study aimed to determine whether 

wearing the armband was acceptable over a 7-day period in 

people with COPD. Participants were provided with written 

instructions for use. Acceptability and adverse reactions 

were recorded with a questionnaire at the completion of the 

7-day period. Twenty-five participants with COPD (mean 

(SD) age 73 (10) years; FEV 1 % 53 (15) % predicted) referred 

to pulmonary rehabilitation were recruited. All participants 

completed the questionnaire. Twenty-two (88%) participants 

were compliant in wearing the armband for 5 or more days. 

Three participants discontinued wearing the armband after 

1 to 3 days. Comfort level during the day was rated as: 

‘comfortable’ or ‘very comfortable’ (76%); ‘neutral’ (8%); 

‘uncomfortable’ or ‘very uncomfortable’ (16%). Comfort 

level during the night was rated as: ‘comfortable’ or ‘very 

comfortable’ (64%); ‘neutral’ (24%); ‘uncomfortable’ or 

‘very uncomfortable’ (12%). Adverse side effects were 

reported by 56% of participants, the most common being 

itchiness (40%) and rash (16%). Ease of applying and 

removing the armband was rated as ‘easy’ or ‘very easy’ by 

92% of participants. Wearing the SenseWear Pro3 Armband 

for 7 days is tolerable in people with COPD despite a high 

occurrence of minor adverse side effects. 



Acceptability of the aquatic environment for exercise 

training in people with chronic obstructive pulmonary 

disease with physical co-morbid conditions 

McNamara R,J 1,2 Alison JA, 2,3 McKenzie DK, 1 

McKeough ZJ 2 

1 


3 


Only recently has the physiological response to exercise 

training in water been shown to be safe in people with 

chronic obstructive pulmonary disease (COPD). Waterbased 

exercise may be an alternative to land-based exercise, 

especially for patients with physical co-morbid conditions. 

However, no studies have evaluated the acceptability of 

warm water and the humid aquatic environment as a medium 

for exercise in this population. The aim of this study was to 

determine whether the aquatic environment was acceptable 

for people with COPD and physical co-morbidities enrolled 

in an 8-week water-based exercise program. Acceptability 

and adverse events were recorded with a questionnaire at 

the completion of the program. Eighteen participants (mean 

(SD) age 72 (10) years; FEV 1 % 61 (14) % predicted) were 

recruited. All participants completed the questionnaire. One 

hundred percent of participants reported acceptability with 

the water and air temperature, shower and change-room 

facilities, staff assistance and modes of pool entry. Fifteen 

participants achieved at least 65% training adherence and 

identified 6 factors enabling successful completion of the 

program: support from staff (93%), enjoyment (80%), a 

sense of achievement (80%), noticeable improvements 

(73%), personal motivation (73%) and support from other 

participants (53%). Of the 3 participants who withdrew 

from training, 1 suffered a lower limb skin tear following 

an accident in the water, whilst 2 withdrew due to general 

body pain and fatigue unrelated to the water-based training. 

Eighty-nine percent of participants indicated they would 

continue with water-based exercise. Water-based exercise 

was well accepted by people with COPD and physical comorbidities. 

Assessment of free-living physical activity using 

a multi-sensor armband in people with chronic 

obstructive pulmonary disease with physical 

co-morbid conditions 

McNamara RJ, 1,2 Alison JA, 2,3 McKenzie DK, 1 

McKeough ZJ 2 

1 


3 


The impact of physical co-morbid conditions such as obesity, 

orthopaedic and musculoskeletal conditions on exercise 

capacity and physical activity in people with chronic 

obstructive pulmonary disease (COPD) is unknown. The aim 

of this study was to compare the amount of physical activity 

performed by people with COPD with and without physical 

co-morbidities. Twenty-five participants with COPD (mean 

(SD) age = 73 (10) years; FEV 1 % 53 (15) % predicted) 

referred to pulmonary rehabilitation were recruited. 

Participants underwent measurement of respiratory 

function, quality of life, functional performance and sixminute 

walk distance prior to wearing the SenseWear Pro3 

Armband (a multi-sensor monitor that estimates physical 

activity) for a period of 7 days. Participants with the 

physical co-morbid conditions had a significantly reduced 

six-minute walk distance (mean difference 240m, 95% CI 

161 to 319m) and reduced quality of life (mean difference = 

14 units on St George’s Respiratory Questionnaire, 95% CI 

3–25 units) compared to those with no physical co-morbid 

condition. There was a significant lower daily average 

energy expenditure and daily average number of steps (both 

p < 0.001) in the physical co-morbid condition group. The 

presence of physical co-morbid conditions in people with 

COPD leads to a more sedentary lifestyle, reduced exercise 

capacity and poorer quality of life. 

Water-based exercise in people with chronic 

obstructive pulmonary disease with physical co-morbid 

conditions: a randomised controlled trial 

McNamara R,J 1,2 Alison JA, 2,3 McKenzie DK, 1 

McKeough ZJ 2 

1 


3 


The aim of this randomised controlled study was to determine 

whether a water-based exercise program was effective in 

improving exercise capacity and quality of life in people with 

chronic obstructive pulmonary disease (COPD) and physical 

co-morbidities compared to land-based exercise and also to 

determine the acceptability of the aquatic environment for 

people with COPD. Participants were randomly allocated 

to one of three groups: land-based exercise, water-based 

exercise or a control group of no exercise. The two exercise 

groups trained for 8 weeks, 3 exercise sessions per week 

(2 supervised and 1 independent). Participants underwent 

measurements of respiratory function, exercise capacity 

and quality of life by a blinded investigator at baseline and 

following intervention. Acceptability and adverse events 

were recorded with a questionnaire at the completion of 

the program. Of 53 participants (mean (SD) age 72 (9) 

years, mean FEV 1 % 62 (19) % predicted), 85% completed 

the study. Compared to control, water-based exercise 

significantly increased six-minute walk distance (mean 

difference 65m, 95% CI 42–88m), incremental-shuttle 

walk distance (mean difference 49m, 95% CI 29–69m) and 

endurance-shuttle walk distance (mean difference 371m, 

95% CI 124–618m). Only the water-based exercise group 

achieved the minimum clinically important difference of 4 

units change in the St George’s Respiratory Questionnaire. 

One hundred percent of participants reported acceptability 

with the water and air temperature, shower and changeroom 

facilities, staff assistance and modes of pool entry. 

Water-based exercise is an effective alternative to landbased 

exercise and is well accepted in people with COPD 

and physical co-morbidities. 

High and low level pressure support during exercise 

in people with severe kyphoscoliosis: a double blind 

randomised crossover trial 

Menadue C, 1,2 Ellis ER, 2 Piper AJ, 1,3 Hollier C, 1 

Alison JA 1,2 

1 

Department of Respiratory & Sleep Medicine, Royal Prince Alfred 

Hospital, Sydney, 2 Discipline of Physiotherapy, The University of 

Sydney, Sydney, 3 Woolcock Institute of Medical Research, Sydney 

Reports on the effect of non-invasive ventilation during 

exercise in people with severe kyphoscoliosis are conflicting. 

To determine whether the level of pressure support provided 

during exercise influences exercise endurance time, a 

randomised crossover study with repeated measures was 

performed. We hypothesised that only high level pressure 

support would increase exercise endurance time. Thirteen 



participants with severe kyphoscoliosis performed 4 

endurance treadmill tests in random order: unassisted; 

with sham pressure support; low level pressure support (10 

cm H 2 O); and high level pressure support (20 cm H 2 O). 

Participants and assessors were blinded to the level of 

pressure support delivered during exercise. A linear mixed 

model analysis revealed a difference between conditions 

with respect to endurance time (p < 0.001). Pairwise 

comparisons demonstrated that endurance time was greater 

with high level pressure support [median 217 s; interquartile 

range (IQR) (168–424)] compared to unassisted exercise 

[median 139 s, IQR (111–189), p = 0.039)], sham pressure 

support [median 103 s, IQR (88–155), p < 0.001] and low 

level pressure support [median 159 s, IQR (131–206), p = 

0.012]. Isotime respiratory rate was a mean 8 breaths/minute 

lower (95% CI-11.0 to-4.8, p < 0.001) and oxygen saturation 

a mean 4% higher (95% CI 1 to 7, p = 0.021) with high level 

pressure support compared to unassisted exercise. High 

level pressure support during walking improves exercise 

performance in people with severe kyphoscoliosis. The 

role of high level pressure support as an adjunct to exercise 

training or to assist the performance of daily activities 

warrants investigation. 

18 

Double blind randomised controlled trial of 

domiciliary ambulatory oxygen versus air in chronic 

obstructive pulmonary disease 

Moore RP, 1,2,3,4 Berlowitz DJ, 1,2,3,4 Denehy L, 4 Sharpe K, 5 

Pretto, JJ, 6 Brazzale DJ, 1,2 Jackson B, 7 McDonald CF 1,2 

1 

Department of Respiratory and Sleep Medicine, 2 Institute for 

Breathing and Sleep, Austin Hospital, Heidelberg; 3 Northern Clinical 

Research Centre, Northern Hospital, Epping; 4 School of Physiotherapy 

and 5 Department of Mathematics and Statistics, The University of 

Melbourne; 6 Department of Respiratory and Sleep Medicine, John 

Hunter Hospital, Newcastle; 7 Vascular Medicine Unit, Dandenong 

Hospital, Dandenong. 

Patients with chronic obstructive pulmonary disease, who 

are not severely hypoxaemic at rest and do not qualify to 

receive long-term, continuous oxygen therapy, often exhibit 

significant dyspnoea. Despite of lack of supportive evidence, 

ambulatory oxygen is prescribed in this circumstance, 

usually for those who also exhibit exertional desaturation. 

This study aimed to determine the effects of long-term, 

domiciliary ambulatory oxygen for such patients and 

factors predictive of benefit. This was a 12-week, parallel, 

double-blinded, randomised, placebo-controlled trial 

of ambulatory cylinder air or oxygen. Study gases were 

provided at 6 L/min intranasally, for use during any activity 

provoking breathlessness. Outcome measures assessed 

dyspnoea, quality of life, mood alteration, functional status 

and gas utilisation. Data were analysed on an intention-totreat 

basis, p ≤ 0.05. One hundred and forty-three subjects, 

mean age 71.8 SD ± 9.8 yrs, FEV 1 1.16 ± 0.51 L, PaO 2 71.4 

± 8.5 mmHg were randomised, 64 with desaturation to ≤ 

88% during exercise testing. No significant differences were 

found between air and oxygen for any outcome. Subgroup 

analyses found no factors predictive of benefit from 

oxygen. Participants overall (both air and oxygen groups) 

demonstrated statistically significant but clinically trivial 

improvements in dyspnoea, depression and six-minute walk 

distance. This group of patients with chronic obstructive 

pulmonary disease derived no benefit from domiciliary 

ambulatory oxygen in terms of dyspnoea, quality of life 

or function. Exertional desaturation was not predictive of 

long-term improvement in function but intranasal gas (both 

air and oxygen) may provide a placebo benefit. 

The long term effect of inhaled hypertonic saline in 

non-cystic fibrosis bronchiectasis 

Nicolson C, 1,2 Stirling R, 1,3 Button B, 1,3 Wilson J, 1,3 

Holland A 1,4 

1 

The Alfred Hospital, Melbourne, 2 The University of Melbourne, 

Melbourne, 3 Monash University, Melbourne, 4 La Trobe University, 

Melbourne. 

Patients with bronchiectasis have chronic cough and sputum 

production, frequent exacerbations and progressive decline 

in lung function. The aim of this double-blind randomised 

controlled trial was to determine if the long term inhalation 

of hypertonic saline (6%) improved lung function in patients 

with non-cystic fibrosis bronchiectasis. Forty subjects with 

demonstrated bronchiectasis were randomised to receive 

either hypertonic saline (6%) or normal saline (0.9%) which 

they were instructed to inhale through an AeronebGo 

nebuliser twice a day for 12 months while performing the 

active cycle of breathing technique. Participants and assessors 

were blinded to the treatment allocation. Spirometry was 

performed at baseline, 3, 6 and 12 months. Participants had 

a mean age (standard deviation) of 57.0 (14.8) years, BMI 

28.0 (5.2) kg.m-2, and FEV 1 82.6 (20.7) % predicted. There 

were no differences between groups at baseline for age, 

gender, BMI or respiratory function. After 6 months, both 

groups demonstrated significant improvements in FEV 1 

(mean 94ml, 95% CI 17–177ml) and FEF (mean 252ml, CI 

107–396ml), however there were no differences between 

groups for any respiratory function variable. We conclude 

that hypertonic saline did not improve respiratory function 

more than normal saline over 6 months however clinically 

significant improvements in small airways function were 

evident in both groups. Data collection is continuing to 

assess the effects on exacerbation frequency and quality of 

life over 12 months. 

The effects of outpatient pulmonary rehabilitation 

in adult patients with bronchiectasis. a retrospective 

study 

Ong HK, 1 Lee A, 1,4 Hill C 2 , Holland A, 3,4 Denehy L 1 

1 

The University of Melbourne, Melbourne, 2 The Austin Hospital, 

Melbourne, 3 LaTrobe University, Melbourne, 4 The Alfred, Melbourne 

At present few publications support the claim that the 

benefits of pulmonary rehabilitation (PR) in COPD may 

be applicable to patients with bronchiectasis. This study 

aimed to evaluate the six-minute walk distance (6MWD) 

and Chronic Respiratory Questionnaire (CRQ) outcomes of 

patients with bronchiectasis who completed an out-patient 

PR program, and to compare these outcomes to a matched 

group of patients with COPD. The study population was 

identified retrospectively from two PR databases from May 

2000 to Nov 2008. Outcome results from baseline and 

post PR assessments in patients with bronchiectasis were 

compared using paired t-tests. In total, 96 patients completed 

the program: 48 male, mean age 67 (10) years and mean 

FEV 1 62.8 (24.0) % predicted. Significant improvements 

in 6MWD (mean change 53.4 m, 95% CI 45.0–61.7, p < 

0.001) and all CRQ domain summary scores (mean change 

2.3 to 4.8 units, all p < 0.001) were observed immediately 

after the PR. The longitudinal trends in 6MWD and CRQ 

in patients with bronchiectasis were compared with a 

matched group of 69 patients with COPD using repeated 

measures ANOVA. Improvements in 6MWD and CRQ 

were comparable between patients with bronchiectasis 



and those with COPD with no significant between group 

differences for either outcome. In conclusion, the results of 

this retrospective review support the role of PR in patients 

with bronchiectasis. 

‘Protective’ manual hyperinflation is safer and as 

effective as current techniques 

Paratz JD, 1 Thomas PJ 1,2 

1 

Burns, Trauma & Critical Care Research Centre, University of 

Queensland, 2 Dept of Physiotherapy, Royal Brisbane & Women’s 

Hospital 

Current evidence in mechanical ventilation supports a 

‘protective lung strategy’ that is, smaller tidal volumes 

and preventing derecruitment via maintenance of positive 

end expiratory pressure. There is concern that manual 

hyperinflation may conflict with this strategy and cause 

atelectrauma potentially leading to biotrauma. This semiblinded 

randomised study aimed to compare two methods 

of manual hyperinflation (protective-[Vt 8ml/kg and 

maintenance of positive end expiratory pressure] and nonprotective 

[Vt 12ml/kg and zero end expiratory pressure]) 

for 10 minutes. Outcomes included inflammatory mediators 

(TNFα, IL-1b, IL-6, IL-8), static lung compliance, PaO 2 / 

FIO 2 , mean arterial pressure and sputum weight (g). Twentytwo 

patients were included and completed the study on day 

one of their intensive care admission (14 male, age 18–63 

years, synchronised intermittent mechanical ventilation 

mode). A between within repeated measures ANOVA found 

a significant increase in IL6 (p = 0.002, δ = 0.8) and TNFα 

(p = 0.006 δ= 0.65) at 60 minutes post non protective manual 

hyperinflation technique. Regression analysis indicated that 

subjects with high baseline levels of inflammatory mediators 

demonstrated a larger increase (R2 = 0.55, p < 0.02). Mean 

arterial pressure decreased during (p = 0.04, δ=0.56) 

and increased (p = 0.009, δ = 0.6) at 1 minute post non 

protective manual hyperinflation. There was no difference 

between techniques for static compliance, PaO 2 /FiO 2 , or 

sputum weight, but an improvement over time in static 

compliance (p = 0.03, δ = 0.5) for both techniques. Results 

indicate that current techniques of manual hyperinflation 

may potentially cause lung injury particularly those patients 

with a high baseline inflammatory status. 

Early exercise in sepsis attenuates inflammation and 

loss of muscle mass 

Paratz JD, 1 Thomas PJ, 2 Chang AT, 2 Boots RJ 1 

1 

Burns, Trauma & critical Care Research Centre, University of 

Queensland, 2 Dept of Physiotherapy, Royal Brisbane & Women’s 

Hospital, 3 School of Physiotherapy, University of Queensland 

Patients with severe sepsis and septic shock in intensive 

care can lose large amounts of muscle mass attributed to a 

proteolysis or protein degradation process closely linked to 

the inflammatory cascade associated with sepsis. This can 

often result in profound debilitation and weakness. There is 

some preliminary evidence that early exercise may attenuate 

this response. This semi blinded, randomised controlled 

study compared early exercise (including passive, active/ 

assisted and active including stretch facilitation) with a 

control group who received no early movements. Outcome 

measures included cytokines (Interleukin 6 and tumour 

necrosis factor α, Interleukin 10) and percentage of fat 

free mass by bioelectrical impedance analysis (IMP SFB7, 

Impedimed, Brisbane Qld). Measurement was performed 

at a specific time of day to account for diurnal variation. 

Twenty patients were recruited (11 intervention, 9 controls), 

(14 males) age range 27–72 years, acute physiological and 

chronic health evaluation II scores mean 25.2 ± SD5.1, 

mortality in intensive care 30%. Result indicate that the 

anti-inflammatory cytokine Interleukin 10 was significantly 

higher (p = 0.008, δ = 0.6) at day 4 post onset of severe 

sepsis in the intervention group. There were no significant 

changes in Interleukin 6 or tumour necrosis factor α. 

Percentage of fat free mass maintained was greater in the 

intervention group at day 7 (p = 0.008, δ = 0.55). These 

results indicate short term beneficial effects of exercise 

which may attenuate proteolysis. This study is part of a 

larger project to investigate whether these changes lead to 

improved functional outcome. 

Non-invasive ventilation as an adjunct to 

cardiopulmonary physiotherapy 

Piper AJ 

Dept of Respiratory and Sleep Medicine, Royal Prince Alfred Hospital, 

Camperdown, Woolcock Institute of Medical Research, University of 

Sydney, Glebe 

Non-invasive ventilation is widely used to reduce the work 

of breathing, improve gas exchange, normalise breathing 

pattern, and prevent respiratory complications associated 

with respiratory failure. The goals of cardiopulmonary 

physiotherapy are similar, and consequently the two 

interventions can be used synergistically in selected patients 

to achieve the greatest benefits from clinical intervention. 

While most physiotherapists currently have little input into 

setting up non-invasive ventilation, those working in acute 

care areas frequently encounter patients using this therapy 

and therefore need to know how to treat such individuals. 

Physiotherapists may also utilise the benefits of non-invasive 

ventilation to assist in promoting greater tolerance and 

gain from standard respiratory techniques. Accumulating 

evidence suggests that non-invasive may be advantageous in 

assisting airway clearance in patients with severe respiratory 

disease and as an adjunct to early mobilisation and exercise 

training in those with severe shortness of breath and limited 

exercise capacity. However, an understanding of how noninvasive 

works is crucial in selecting those individuals most 

likely to respond to intervention. Non-invasive ventilation 

is now seen as standard care in patients with respiratory 

muscle weakness and chronic respiratory failure. Although 

the technique assists inspiratory efforts, it does not address 

the problem of expiratory muscle weakness and poor cough. 

Physiotherapists have a key role in assessing and treating 

these individuals not only during an acute respiratory 

illness, but also in the community setting. This includes 

training carers in skills such as manual inflation and cough 

assist techniques to minimise the consequences of chronic 

hypoventilation and secretion retention. 

The role of non-invasive ventilation in the management 

of acute respiratory failure 

Piper AJ 

Dept of Respiratory and Sleep Medicine, Royal Prince Alfred Hospital, 

Camperdown, Woolcock Institute of Medical Research, University of 

Sydney, Glebe 

Non-invasive ventilation is an effective and widely used 

therapy to stabilise and reverse hypercapnic respiratory 

failure, avoid the need for intubation and improve clinical 



outcomes in patients with acute exacerbations of chronic 

obstructive pulmonary disease. More recently the technique 

has been proposed for several other applications including 

facilitation of weaning, management of post-extubation 

respiratory failure, acute lung injury and as a ceiling 

intervention for those deemed unsuitable for intubation. 

Key aspects of using non-invasive ventilation effectively 

include identifying candidates who are most likely to 

derive benefit from this technique and minimising delays 

in implementing alternative approaches to care should 

the patient fail to respond to therapy. A major reason for 

non-invasive ventilation failure is an impaired ability to 

clear secretions effectively. Physiotherapists therefore 

have an important role to play in the management of 

these patients, identifying early those individuals not 

responding appropriately to treatment. Current evidence 

suggests that clinicians generally have a limited knowledge 

of the published evidence regarding indications for and 

outcomes with non-invasive ventilation. Low utilisation of 

this technique in the acute setting for patients appearing 

to meet the criteria for non-invasive ventilation has been 

attributed to this lack of knowledge. Consequently, health 

professionals involved in the respiratory care of patients 

using non-invasive ventilation need to appreciate the 

benefits, risks and consequences associated with this noninvasive 

approach to managing acute respiratory failure. 

20 

Cardiac rehabilitation: moving forward 

Redfern J 

NHMRC NICS-Heart Foundation Fellow, ANZAC Research Institute, 

Concord Hospital, Sydney. 

Coronary patients who favourably modify their risk factors, 

take cardioprotective pharmacotherapy and attend cardiac 

rehabilitation substantially lower the risk of a recurrent 

event or death. However, traditional cardiac rehabilitation 

programs are not utilised by the majority of eligible patients 

and the potential benefits are not maintained in the longterm. 

Contemporary secondary prevention programs 

involving new approaches have emerged as researchers 

and clinicians aim to narrow the evidence-practice gap. 

These programs incorporate combinations of clinic/home 

visitations, community services, and home programs 

often accompanied by phone support offer flexible and 

individualised approaches to managing the underlying 

disease long term. Recent systematic reviews of ongoing 

prevention measures in coronary patients have found 

significant reduction in mortality for all models (exerciseonly, 

exercise and education, education-only), and that 

shorter duration programs (< 10 hours) and those delivered 

in general practice were as effective as those delivered 

through cardiac rehabilitation programs. Accordingly, 

there is resounding evidence to support a change in 

managing coronary disease risk. Therefore, best practice is 

evolving toward a model of care which is selected based on 

appropriateness for each patient considering their clinical 

history, personal preferences/circumstances, cultural 

values and the available resources. A generic framework 

is currently being developed for translation into Australian 

clinical practice to provide health professionals, managers 

and policy makers with practical information about how 

secondary prevention evidence can be integrated into a 

unified yet flexible framework based on contemporary 

evidence. 

Implementing scientific evidence into clinical practice 

Redfern J, 1 Kumar S 2 

1 

NHMRC NICS-Heart Foundation Fellow, ANZAC Research Institute, 

Concord Hospital Sydney, 2 NHMRC NICS-MAC Fellow, Centre for 

Allied Health Evidence, University of South Australia, Adelaide 

The workshop will be conducted by two physiotherapists, 

both of whom are NHMRC-NICS Fellows. This workshop 

will focus on key principles underpinning evidencebased 

practice and its application into clinical practice. 

Participants will gain an understanding and overview of 

evidence-based practice and consequently the increasing 

drivers for implementing evidence into clinical practice. 

The workshop will introduce the ‘science’ underpinning 

evidence implementation and achieving change in health 

care. This workshop will also focus on barriers and 

enablers commonly encountered in clinical settings when 

implementing evidence into clinical practice. Participants 

will be provided with opportunities to reflect on evidence 

implementation issues in their own practice settings and 

embrace practical strategies to embed research evidence into 

clinical practice and achieve successful knowledge transfer. 

The workshop will also highlight free, widely available 

tools which can be utilised by health care practitioners in 

their efforts to implement evidence into clinical practice. 

Does physiotherapy reduce the incidence of 

postoperative pulmonary complications in patients 

following pulmonary resection via thoracotomy? 

A randomised controlled trial 

Reeve JC, 1,4 Nicol K, 2 Stiller K, 3 McPherson KM, 1 

Birch,P 2 Denehy L 4 

1 

AUT University, Auckland, New Zealand, 2 Auckland City Hospital, 

Auckland, New Zealand, 3 Royal Adelaide Hospital, Adelaide, 

4 

University of Melbourne, Melbourne 

Postoperative pulmonary complications are an 

important cause of morbidity following thoracotomy and 

physiotherapy interventions are commonly provided with 

the aim of preventing and treating these. This study aimed 

to determine if prophylactic postoperative respiratory 

physiotherapy reduced the incidence of postoperative 

pulmonary complications and decreased length of stay in 

patients following open pulmonary resection. Seventy-six 

patients undergoing elective thoracotomy were randomised 

to a treatment group (n = 42) or a control group (n = 34). 

Treatment group participants received daily respiratory 

physiotherapy interventions until discharge. Control group 

participants received no physiotherapy interventions. Both 

groups received standard medical/nursing care involving 

a clinical pathway. Postoperative pulmonary complication 

data were recorded daily throughout hospitalisation by a 

physiotherapist blinded to group allocation using a diagnostic 

tool previously described. There was no significant 

difference between groups in baseline demographic data or 

in surgical interventions. Overall incidence of postoperative 

pulmonary complications was 3.9% (n = 3) and there 

was no significant difference between the incidence of 

postoperative pulmonary complications in the Treatment 

and Control group (p = 1.00, absolute risk reduction -0.02, 

95% CI-0.13 to 0.11). No significant difference was found 

between groups for LOS (p = 0.87), with the median 

(interquartile range) length of stay for the Treatment group 

6.0 (4.0) and the Control group 6.0 (1.0) days. Given the low 

incidence of postoperative pulmonary complications, these 



results suggest that prophylactic postoperative respiratory 

physiotherapy may not be required in addition to standard 

care involving a clinical pathway following open pulmonary 

resection. 

Recent developments in respiratory physiotherapy 

management of children with neuromuscular disease 

at Sydney Children’s Hospital 

Reid NG 

Sydney Children’s Hospital, Sydney 

Respiratory complications are a common cause of morbidity 

and mortality in children with neuromuscular disease. 

They have weakness of the muscles of respiration causing 

them to breathe at reduced lung volumes. This places them 

at risk of developing atelectasis and retaining secretions 

making them vulnerable to developing pneumonia. In 2008 

respiratory physiotherapy management of this patient group 

at Sydney Children’s Hospital was identified as a service 

lacking in resources and needing development. Following 

a literature review, including recommendations by the 

American Thoracic Society and clinical experts in this 

field, a working party within Sydney Children’s Hospital 

physiotherapy department was established to develop 

respiratory physiotherapy services. This working party has 

successfully introduced a number of new resources and 

therapies. Now, in addition to a neurology physiotherapist, 

a respiratory physiotherapist also reviews children who 

attend outpatient neuromuscular clinics on a needs basis. 

A cough assist machine was purchased and is used to 

treat inpatients and outpatients who present with an acute 

respiratory illness. During neuromuscular clinics, children 

are educated about, and practice using, the cough assist 

machine so they are familiar with it. The deep breathing 

bag was introduced into neuromuscular clinics and is given 

out to children to be used as part of their home management 

program. Information handouts about the deep breathing 

bag and manual assisted coughing have been published and 

are distributed to patients. Future plans are to evaluate the 

efficacy of introducing these new resources and therapies. 

Via the process of evaluating service delivery and instituting 

recommended changes, Sydney Children’s Hospital aims to 

offer an improved quality of patient care, which is closer 

to current best practice, to children with neuromuscular 

disease. 

Evaluation of a phase one cardiac rehabilitation 

exercise program 

Ryan D, 1 Hoggins TR, 1 Keating J, 2, Haines T 2 

1 

Monash Medical Centre, Melbourne, 2 Monash University, Melbourne 

Phase two cardiac rehabilitation has been shown to reduce 

mortality rates in attendees, however program uptake has 

been consistently low. This pilot study evaluated the effect 

of a new phase one cardiac rehabilitation exercise program 

titled ‘First Steps on physical function, quality of life and 

attendance at phase two cardiac rehabilitation’. The First 

Steps program was a single session exercise and education 

class conducted by a multidisciplinary team within an acute 

cardiac care unit. Thirty-one participants were randomised 

to an intervention (n = 19) or a control group (n = 12). 

All participants received standard ward care, comprising 

education about cardiovascular disease and cardiac risk 

factors. The intervention group also attended First Steps. 

Outcome measures the SF12 and MacNew quality of life 

questionnaires, the self administered physical activity 

questionnaire, the DeMorton Mobility Index and the cardiac 

two minute walk test, a novel test used as an indicator of sub 

maximal endurance in gait were taken at baseline and three 

week follow up by a blinded assessor. Attendance at phase 

two cardiac rehabilitation was recorded at four weeks. A 

higher proportion of intervention group participants (79%) 

attended phase two cardiac rehabilitation than control 

group participants (25%: p = 0.006). Physical function and 

general health domains of the SF12 (p = 0.004 and 0.05 

respectively) also increased significantly in favour of the 

intervention group. First Steps may have an important role 

to play in acute cardiac rehabilitation and should be the 

subject of larger investigation in future. 

Functional outcomes after pulmonary endarterectomy 

Seale H, 1 Davis R, 1 Hall K, 1 Harris J, 1 Walsh J, 1 Tuppin 

M, 1 Franks C, 1 McNeil K, 1 Hopkins P, 1 Dunning J, 2 

Kermeen F 1 

1 

Queensland Centre for Pulmonary Transplantation and Vascular 

Disease, The Prince Charles Hospital, Brisbane, 2 Papworth Institute, 

Cambridge, UK 

Chronic thrombo-embolic pulmonary hypertension 

(CTEPH) is caused by unresolved or recurrent pulmonary 

embolism. Pulmonary endarterectomy (PEA) offers 

potential surgical cure and long-term survival. The aim 

was to evaluate outcomes of patients following PEA at a 

tertiary referral hospital.: Patients received a standard 

physiotherapy directed inpatient rehabilitation program 

following PEA surgery. At discharge patients were given 

a home-based exercise program which was escalated 

according to clinical progress during outpatient follow-up. 

Outcome measurements of New York Heart Association 

functional class (NYHA-FC), six-minute walk test distance 

(6MWD), echocardiography parameters and mortality 

from June 2004 to April 2007 were analysed. Twenty-six 

patients (17 females) of mean age 55 ± 15 years (range 20– 

77) underwent PEA. Pre-operatively, 27% were NYHA-FC 

II, 46% class III and 27% class IV. Three month mortality 

was 3% and 1-year survival 96%. By 3 months, all patients 

improved one or more NYHA-FC to 82% class I, 14% 

class II and 4% class III. At 3 and 6 months respectively, 

there was significant improvement compared to baseline in 

6MWD-mean 390 ± 126m vs 555 ± 102m (p < 0.001) vs 

520 ± 90m (p < 0.001). Furthermore there was a reduction 

in right ventricular systolic pressure from 80 ± 30mmHg 

to 37 ± 21mmHg (p < 0.001), 44 ± 19mmHg (p = 0.001). 

After PEA, cardiopulmonary function recovery is excellent 

in most patients. This study demonstrates that 6MWT and 

echocardiogram are useful tools in the functional evaluation 

of patients affected by CTEPH and submitted to PEA. 

Development of objective physiotherapy assessment 

domains for intensive care unit electronic charts 

Seller DR 

St Vincent’s Hospital, Melbourne 

The Intensive Care Unit at St Vincent’s Hospital, Melbourne, 

adopted a comprehensive electronic medical record in 

1994; the first unit in Victoria to do so. Physiotherapy 

involvement in such systems has been limited to date, due 

to system limitations and difficulty accurately adapting 

physiotherapy assessment and treatment documentation to 



an electronic database format. Electronic charts generally 

store information as text (such as progress notes), or data 

fields in flowsheet or observation chart forms. Physiotherapy 

documentation in our original system, CareVue, was limited 

to progress notes; apart from a few basic assessment and 

treatment fields. In April 2009, CareVue was superseded 

by a new system: Intellivue Clinical Information Portfolio 

(ICIP). Specific physiotherapy admission and progress notes 

were developed including pre-morbid mobility and social 

history. Objective physiotherapy domains, such as muscle 

strength and mobility assessment, were incorporated into 

the flowsheet. The recently developed, intensive carespecific 

physiotherapy assessment; Physical Function in ICU 

Test (PFIT) is currently being added to the flowsheet. As 

well as allowing more detailed documentation of objective 

physiotherapy assessment findings than previously, these 

physiotherapy-specific flowsheet fields allow rapid, simple 

data retrieval for quality improvement and research 

purposes. For instance, the database will enable comparison 

of physiotherapy data with other fields (e.g. correlating 

strength with trache-shielding time). Also, the system can 

be configured to send alerts when certain criteria are met 

(e.g. a patient with a tracheostomy, Glasgow Coma Scale 

greater than 8, mean arterial pressure greater than 65, 

and not on inotropes), as indicators for specific clinical or 

research interventions. 

Measurement of maximal inspiratory pressure in 

normal subjects: a systematic review of the literature 

Sia M, 1 Hardy F, 1 Harris B 2 

1 

University of South Australia Adelaide, 2 Flinders Medical Centre 

Adelaide 

The wide range of reported normal values for maximal 

inspiratory pressure (Pimax) makes it difficult to interpret 

results of studies using this outcome measure. The aim of 

this systematic review was to collate the literature of normal 

values for Pimax in healthy adult subjects. Observational 

normative studies on Pimax, published after 1966 in healthy 

adults were included. CINAHL, SPORTDiscus, AMED, 

EMBASE, MEDLINE, OVID and Scopus databases were 

searched. A modified ‘Critical Appraisal Skill Program 

(CASP): Cohort Study’ was used to assess methodological 

quality of the studies. Thirteen studies were included 

with majority of the studies showing moderate to good 

methodological quality scores. There were considerable 

variations in the methods of Pimax testing between studies 

limiting the ability to compare results. Some consistencies 

in factors affecting Pimax were observed with age and sex 

being the strongest predictors of Pimax. 

Evaluating health outcomes in critical illness: a 

comparison of three health-related quality of life 

measures 

Skinner EH, 1,2 Hawthorne G, 2 Warrillow S, 1 Denehy L 2 

1 

Austin Health, Melbourne, 2 The University of Melbourne, Melbourne 

analyses respectively. The Assessment of Quality of Life 

(AQoL) provides both domain and utility scores. This aim 

of this study was to compare and report the correlation 

between the AQoL, the SF-36 and the SF-6D in patients 

admitted to an Australian mixed medical-surgical tertiary 

ICU. A prospective cohort of 100 patients admitted to ICU 

for longer than 48 hours was recruited. Patients completed 

both instruments on two occasions; preadmission health 

status on admission and current health status 6 months 

after discharge from the ICU. Data were analysed using 

Spearman’s rho. Four out of five domains of the AQoL had 

good correlation with related domains of the SF-36 (r > 

0.55) with the exception of the Physical Senses domain (r < 

0.5). Independent living (AQoL) and the physical function 

domain of the SF-36 showed the highest correlation (r 

=-0.733). Correlations were consistent with data from the 

2008 South Australian Health Omnibus Survey (SAHOS). 

The AQoL utility scores correlated with utility scores of 

the SF-6D (r = 0.703). The AQoL correlates with SF-36 

domain scores and SF-6D utility scores and can therefore 

be recommended for use in patients with critical illness. 

Health-related quality of life in Australian survivors 

of critical illness 

Skinner EH, 1,2 Hawthorne G, 2 Warrillow S, 1 Denehy L 2 

1 

Austin Health, Melbourne, 2 The University of Melbourne, Melbourne 

Patients admitted to an intensive care unit (ICU) suffer 

worse health-related quality of life (HR-QOL) than the 

general population. The aim of this study was to compare 

preadmission and 6-month HR-QOL of patients admitted 

to an Australian ICU. A prospective cohort of 100 patients 

completed the Short Form-36 (SF-36) and the Assessment 

of Quality of Life (AQoL) after admission to ICU and 6 

months following ICU discharge. Data from the SF-36, 

Short-Form 6D (SF-6D) and the AQoL were compared to 

the age and sex-matched Australian population. Survivors 

reported significant improvements in bodily pain (p < 0.001), 

social functioning (p < 0.05), role emotional (p < 0.05) and 

mental health (p < 0.05) domains of the SF-36 at 6 months, 

while physical functioning, role physical and general health 

domains did not differ significantly from preadmission (p > 

0.05). At follow-up, the physical functioning and role physical 

domains compared worst with Australian population norms. 

A significant improvement in SF-6D utility was noted at 6 

months compared to preadmission (p < 0.05); however the 

mean AQoL utility score was unchanged (p > 0.05). The SF- 

36 and AQoL domain scores, and SF-6D and AQoL utilities 

remained worse for survivors of critical illness than both 

healthy and recent inpatient admission population norms. 

Six months following ICU discharge, patients had returned 

to preadmission HR-QOL and reported improved pain 

and mental health levels. The HR-QOL of critical illness 

survivors remained less than population norms six months 

after discharge from ICU with physical function being most 

affected. 

Measurement of health and quality of life outcomes after 

critical illness is an important goal yet little attention has 

been given to comparison of quality of life instruments. 

The Short Form-36 (SF-36) and Short Form-6D (SF-6D) 

are commonly described instruments in intensive care 

unit (ICU) populations, measuring both health domains 

and preference-based utility scores for use in economic 

22 



Static and dynamic changes in thoracic function 

following bariatric surgery for patients with morbid 

obesity 

Skinner MA, 1 Sutherland TJT, 2 Cowan JO, 2 Taylor DR 2 

1 

School of Physiotherapy and 2 Dunedin School of Medicine, University 

of Otago, Dunedin 

Our aim was to examine the effect of weight-loss following 

bariatric surgery on thoracic mobility and respiratory 

function. A before–after study was carried out on 14 

subjects with morbid obesity (mean body mass index 

61.4kg/m 2 ) immediately prior to and six months following 

surgery. Outcomes included thoracic circumference at 

three standardised levels taken at rest, on full inspiration, 

and full expiration, as a measure of dynamic function of 

the thorax; measurement of the global thoracic angle in 

the upright, fully flexed and fully extended positions using 

an external electronic device, to record thoracic spine 

mobility; and forced expiratory volume in one second and 

forced vital capacity, as a measure of respiratory function. 

Mean body mass index reduced to 40.3kg/m2 and results 

for all repeated measures were highly significant (p < 0.01). 

Mean maximum respiratory excursion at the sternal angle 

improved from 0.45cm to 3.25cm (n = 10). The mean global 

thoracic angle in upright standing reduced from 64.70 to 

57.10, with the change in kyphosis being greater in the 

upper thoracic spine (n = 8). Mean forced expiratory volume 

in one second improved from 3.0L to 3.5L and forced vital 

capacity from 3.8L to 4.4L (n = 11). Improvements in the 

dynamic and static function of the thorax and thoracic 

posture occur along with improvement in respiratory 

function and other benefits of surgically achieved weight 

loss in morbidly obese subjects. 

Ventilatory, metabolic and symptom responses to 

maximal treadmill and cycle exercise tests in people 

with chronic obstructive pulmonary disease (COPD) 

Smith KF, 1,2,3 Jenkins SC, 1,2, Williamson J, 3 Cecins N, 1,2 

Hillman D, 3 Eastwood P 1,3,4 

1 


Departments of 2 Physiotherapy & 3 Pulmonary Physiology, Sir Charles 

Gairdner Hospital, Perth; 4 School of Anatomy & Human Biology, 

University of Western Australia, Perth 

Cycling and walking tests are used to measure exercise 

capacity in people with COPD. Different responses have 

been reported between these modalities. The aim of this 

study was to characterise the ventilatory, metabolic and 

symptom responses to maximal cycling and supported 

treadmill walking tests in subjects with COPD. Sixteen 

subjects (three females) aged 66–67 years with COPD, 

(forced expiratory volume in one second 42–14% predicted), 

exercised to a symptom-limited maximum during a 

treadmill (TMT) and cycle ergometry (CET) test. Dyspnoea, 

heart rate, oxygen saturation (SpO2) and breath-by-breath 

metabolic and ventilatory variables were collected. Blood 

lactate concentration and inspiratory capacity (IC) were 

measured before and at test end. Compared to the CET, the 

TMT resulted in significantly (p < 0.001) higher oxygen 

uptake (VO2peak) (17.8–3.4 vs 15.83.4 ml/kg/min) and 

dyspnoea (5.7–1.6 vs 4.41.0 Borg score), and lower SpO2 

(86.3–5.5 vs 90.2–4.9%) and blood lactate (2.8–1.5 vs 4.7– 

1.9 mmol/L). Inspiratory capacity decreased at the end of 

both tests (p < 0.001), but the magnitude of change was 

not significantly different between modalities. The higher 

blood lactate and lower VO2peak at the end of the cycle 

test is most likely a consequence of the smaller muscle 

mass recruited during cycling than walking. The lack of 

significant difference in the change in IC indicates that 

degree of dynamic hyperinflation is likely to have been 

similar with both exercise modalities. Testing exercise 

capacity on a cycle ergometer may underestimate the extent 

of oxygen desaturation occurring in COPD subjects during 

activities of daily living that include walking. 

Maintaining exercise capacity and quality of life twelve 

months following pulmonary rehabilitation in chronic 

obstructive pulmonary disease: a randomised trial 

Spencer LM, 1, 2 Alison JA, 1, 2 McKeough ZJ 2 

1 

Royal Prince Alfred Hospital, Sydney, 2 The University of Sydney 

Pulmonary rehabilitation programs of eight weeks have 

been shown to increase functional exercise capacity and 

quality of life in chronic obstructive pulmonary disease 

(COPD) patients, however benefits begin to decline unless 

patients participate in ongoing maintenance exercise. The 

aim of this study was to determine if weekly-supervised, 

outpatient based exercise maintained functional exercise 

capacity and quality of life twelve months following 

pulmonary rehabilitation compared to unsupervised, 

home exercise. COPD participants were recruited after 

completing an eight-week pulmonary rehabilitation program 

and were randomised to an intervention group of weeklysupervised 

outpatient based exercise plus home exercise 

or to a control group of unsupervised home exercise. 

Outcome measurements immediately following pulmonary 

rehabilitation and 3, 6 and 12 months later included the 

six-minute walk test (6MWT) and St George’s Respiratory 

Questionnaire (SGRQ). Of 59 participants, 48 completed 

the study (24 in each group). Twelve months following 

pulmonary rehabilitation, there was no significant decline 

in either group for the 6MWT [intervention: -11m (-21 to 

10); control: -6 m (-34 to 11)] or the SGRQ [intervention: 3 

(0.8 to 7); control: -3 (0.7 to 3)]. Twelve months following 

pulmonary rehabilitation, both weekly-supervised 

outpatient based exercise and unsupervised home exercise 

maintained six-minute walk distance and quality of life in 

COPD participants. 

Efficacy and safety of instillation of normal saline in 

intubated patients: a systematic review 

Stockton K, Paratz JD 

Burns, Trauma & Critical Care Research Centre, The University of 

Queensland, Brisbane 

Instillation of normal saline in patients with artificial airways 

is a controversial technique. This systematic review aimed 

to critically analyse the current evidence. Using keywords 

‘saline instillation,’ ‘tracheal toilet’ and related synonyms, 

randomised controlled trials, crossover trials, within patient 

studies, quasi and full systematic reviews were identified 

through electronic database searches and citation tracking. 

From 66 articles screened, 17 articles (two quasi systematic 

reviews and 15 empiric studies) met the eligibility criteria 

and were included for data extraction. The outcomes in the 

reviewed studies included oxygenation, lung mechanics, 

sputum yield, dyspnoea, tube patency and ventilator 

associated pneumonia (VAP). Data from identified studies 

were extracted and assessed by two independent reviewers. 



Standardised mean differences (effect sizes) with 95% 

confidence intervals were determined, and overall effects 

calculated using meta-analysis where possible. Studies 

were mainly of low methodological quality due to factors 

such as lack of assessor blinding and within group only 

statistics. Overall there was a positive effect favouring the 

use of saline to increase sputum yield (d = 0.50 95% CI 

0.10 to 0.90). One well conducted study found a relative risk 

reduction in VAP of 54% (95% confidence interval, 18% to 

74%). While a decrease was found in SpO 2 post instillation 

of normal saline compared to no saline, this was of limited 

clinical significance. There is little evidence for benefit but 

also minimal evidence of safety risks. Controlled trials of 

better quality and more clinically relevant outcomes need 

to be performed before this technique is either accepted or 

rejected. 

24 

Exercise and metabolism post burn injury 

Stockton K, 1 Plaza A, 1 Paratz J, 1 Davis M, 2 Brown M, 2 

Boots R, 1 Muller M 1 

1 

Burns, Trauma & Critical Care Research Centre, RB&WH, UQ, 

2 

Thoracic Medicine, RB&WH, UQ 

Following severe burns to large body surface areas, patients 

often have major problems with decreased functional 

outcome and poor quality of life. The hypermetabolic and 

catabolic responses to large burns also result in decreased 

muscle mass and muscle weakness. Aerobic and resistance 

exercise has been strongly recommended to assist the 

recovery of muscle mass and to improve overall outcomes, 

but there is currently almost no evidence in adults with 

burn injuries to indicate whether early exercise is safe and 

effective. Two studies investigating exercise responses and 

training following burn injury to greater than 20% body 

surface area are currently being conducted at the RB&WH 

Burns Unit. An RCT investigating whether exercise training 

can improve exercise capacity, strength, quality of life and 

metabolic profile in adults post burn injury. In addition 

an observational study investigating maximal exercise 

response following burn injury has commenced. Twenty 

patients with burns to greater than 20% of their body will 

undergo a maximal exercise test on cycle ergometry within 

6 weeks of discharge. To date 10 patients have completed the 

study (nine males), age 29.6 (11.7) The results demonstrate 

a trend towards normal maximal exercise results in the 

population studied -predicted maximal heart rate 98% (5.5), 

VO2 max 36.2 ml/min/kg (7.8). As the studies are currently 

still in progress preliminary data will be presented. The 

knowledge of specific physiologic responses induced by 

specific exercise testing protocols in burns patients will 

enable the clinician to prescribe and evaluate appropriate 

individualised exercise programs. 

Therapeutic exercise 

Taylor NF, Dodd KJ 

La Trobe University, Melbourne 

Therapeutic exercise is one of the main interventions 

employed by physiotherapists and there is increasing 

evidence of its efficacy. Our summary of 38 systematic 

reviews concluded that there is high quality evidence that 

therapeutic exercise can reduce pain and improve activity in 

many health conditions, and reduce mortality rates in some 

conditions such as coronary heart disease. Exercise programs 

appear to be relatively safe, and more effective if they are 

intensive and individualised rather than standardised. Apart 

from therapeutic exercise, physiotherapists are increasingly 

involved in prescribing physical activity. Physical activity 

is an umbrella term that includes therapeutic exercise, 

purposeful exercise and activities of daily living. National 

guidelines recommend at least 30 minutes of moderateintensity 

physical activity on most, preferably all, days. 

Activity prescription has an important role in the prevention 

of disease, and the management of chronic diseases. 

However, just meeting physical activity guidelines may not 

be enough if people are sedentary for the rest of each day. 

Recent evidence has found that the total amount of sedentary 

time is associated with risk factors for cardiovascular 

disease and type 2 diabetes. Breaking up sedentary time 

with frequent light movements has been associated with 

improved health outcomes. Physiotherapists with their 

skills and knowledge as educators, motivators, prescribers, 

problem solvers and contributors to public health policy have 

important roles in prescribing therapeutic exercise to help 

manage health conditions, and prescribing and promoting 

increased physical activity and reduced sedentary time to 

help prevent disease and promote good health. 

A survey into the use of non-invasive ventilation by 

Australian physiotherapists 

Tooth AM, 1 Kuys SS 1, 2 

1 

Princess Alexandra Hospital, Brisbane, 2 University of Queensland, 

Brisbane 

Physiotherapists use positive pressure devices such as IPPB 

for the treatment of atelectasis, lobar collapse and sputum 

retention. The last decade has seen the advent of many 

more sophisticated bi-level positive pressure ventilators 

and their application has expanded to exercise training 

as well as airway clearance. In the United Kingdom and 

Europe, physiotherapists appear to have embraced this 

new technology but it is unclear whether Australian 

physiotherapists are as confident in their use or whether 

they have as large a role in assessing and initiating noninvasive 

ventilation for respiratory failure as their overseas 

colleagues. In an attempt to benchmark Australian 

physiotherapists’ current use of positive pressure devices 

(IPPB, BiPAP), a survey was piloted on 21 tertiary hospitals 

in all states and territories. A follow up survey aimed to 

expand on issues raised by the pilot survey responses, such 

as staff training and use of outcome measures. Of the 14/21 

(67%) surveys returned, three centres stated they did not use 

any positive pressure devices for physiotherapy, 4/11 (36%) 

departments owned at least one IPPB and 5/11 (45%) owned 

at least one BiPAP. Other centres reported treating patients 

on BiPAP but the ownership of equipment and initiation 

of this therapy was by medical and nursing staff. No 

consensus in the form of a protocol or treatment guidelines 

was reported for any patient groups where positive pressure 

devices were used for physiotherapy. 

Management of chronic cough 

Vertigan A 

Area Director Speech Pathology, Hunter New England Health 

Chronic cough is a common condition defined as a cough 

lasting longer than eight weeks. Chronic cough is associated 

with vocal cord dysfunction, a condition whereby the vocal 



folds adduct involuntarily and episodically during phonation 

leading to symptoms of dyspnoea, stridor, cough and 

dysphonia. This presentation will describe chronic cough 

in terms of associated medical conditions, symptomatology, 

differential diagnosis and traditional treatment methods. It 

will outline the approaches used by speech pathologists in 

the management of these conditions and the evidence behind 

these approaches. Finally the presentation will explore 

multidisciplinary management of chronic cough and vocal 

cord dysfunction including some practical suggestions for 

patients with severe respiratory conditions. 

The effect of an abdominal binder on respiratory 

function and voice in people with acute tetraplegia 

Wadsworth BM, 1,2 Haines TP, 3 Cornwell PL, 2,4 Paratz JD 5 

1 

Princess Alexandra Hospital, Brisbane, 2 The University of 

Queensland, 3 Monash University, Melbourne, 4 Princess Alexandra 

Hospital, Brisbane, 5 The University of Queensland 

A recent systematic review found low evidence for wearing 

an abdominal binder to improve respiratory function or 

voice quality in people who had suffered a spinal cord injury. 

The aim of this study was to determine the short term effect 

of an abdominal binder on respiratory function and voice 

in acute tetraplegia. A randomised cross over study design 

was employed with each subject tested with and without 

the abdominal binder seated in a wheelchair. The twelve 

subjects (11 males, 1 female) who had recently sustained 

a tetraplegic level spinal cord injury (C4–T1) underwent 

testing of forced vital capacity, forced expiratory volume 

in one second and peak expiratory flow using a SpiroPro 

Spirometer at the point of six weeks upright sitting in a 

wheelchair. Sustained phonation and voice loudness were 

recorded using an Edirol sound recorder. Paired t-tests 

analyses indicated that the forced vital capacity was greater 

when wearing the abdominal binder [mean difference 

0.32 litres (95% CI 0.47 to 0.18) p < 0.001] as was forced 

expiratory volume in one second [mean difference 0.22 

litres (95% CI 0.37 to 0.07), p = 0.007]. Peak expiratory 

flow also appeared to be higher when wearing the binder 

[mean difference 0.48 litres/second (95% CI 1.03 to 0.08), p 

= 0.09] though this was not significantly different. Sustained 

phonation and voice loudness were also increased when 

wearing the abdominal binder. This study has provided 

evidence that an abdominal binder aids in respiration and 

speech in acute tetraplegic spinal cord injuries. These initial 

findings form part of a larger longitudinal study. 

Identifying responders to pulmonary rehabilitation 

Walsh JR, 1, 2 Paratz J, 2 Chang AT, 2 McKeough Z, 3 

Seale H, 1 Morris N 4 

1 

The Prince Charles Hospital, Brisbane, 2 The University of 

Queensland, 3 The University of Sydney, 4 Griffith University, Gold Coast 

Pulmonary rehabilitation has emerged as recommended 

standard care for people with Chronic Obstructive Pulmonary 

Disease (COPD). However potential demand to access these 

services far exceeds the available resources. This study’s 

aim was to determine if baseline measures of the BODE 

Index, dyspnoea (Modified Medical Research Council 

questionnaire), six minute walk distance (6MWD), physical 

activity, Taunton Respiratory quality of life questionnaire 

(TRQ), smoking status, and frequency of hospitalisations 

can predict responders to pulmonary rehabilitation. A 

participant was considered a responder to pulmonary 

rehabilitation if benefit was achieved in exercise capacity 

(≥ 20% increase in 6MWD) and/or quality of life (≥ 0.5 

SD decrease in TRQ as described by Cohen’s Effect Size). 

Prediction of responders was assessed using chi square cross 

tabulations and t-tests with significant measures analysed 

using a binary logistic regression model. One hundred and 

forty-two consecutive COPD participants (76 males, mean 

age 68.6 (8.7 SD) years, mean FEV1 50.4 (20.3) %) who 

completed pulmonary rehabilitation were analysed. Sixtyfive 

(47.8%) people were categorised as responders using 

the above criteria. Significant mean differences were: TRQ 

40.9 (25.2 SD) for responders versus 18.5 (16.3) for nonresponders 

p < 0.001; BODE Index 3.4 (2.4) versus 2.5 (1.7) 

p = 0.021; 6MWD 367.5m (123.3m) versus 422.2m (95.9m) 

p = 0.004. The binary logistic regression model showed 

a higher TRQ score was the only factor that predicted a 

responder to pulmonary rehabilitation. No other measure 

added to the predictive power of the model. Further study is 

required to investigate other factors that may improve these 

findings. 

Who’s researching and how? An audit of Australian 

professional journal publications in 2007 across 

medicine, nursing and allied health 

Wiles L, Olds T, Williams M 


Bibliometrics are commonly used to map content and 

contributors in textual information. The aim of this study 

was to describe and compare research approaches and 

processes across health professions. A cross-sectional 

bibliometric audit was conducted of original research 

published in ten Australian journals representing health 

professional associations during 2007. The professions 

included dietetics, human movement, medicine, nursing, 

occupational therapy, pharmacy, physiotherapy, podiatry, 

pyschology and speech pathology. An audit tool was 

developed to collect information on article content and 

authorship. Inter-rater reliability of the tool was confirmed, 

prior to a single assessor auditing all volumes of each 

professional journal for 2007 (corrected for publication 

frequency). Study design (reported as a percentage of 

total publications for each profession) varied for crosssectional 

surveys (minimum 11% podiatry, maximum 

52% nursing), randomised controlled trials (0% dietetics/ 

occupational therapy/pharmacy/podiatry/psychology/ 

speech pathology, 43% physiotherapy) and personal opinion 

(0% nursing/physiotherapy/psychology/speech pathology, 

29% medicine). Per article, considerable variation existed 

between professions for the average number of pages 

(minimum 3 medicine, maximum 10 speech pathology), 

tables (1 podiatry, 3 speech pathology), figures (0.4 

occupational therapy, 3 speech pathology), references (21 

medicine, 38 speech pathology), and authors (2 podiatry, 4 

physiotherapy). In addition, inter-profession variation was 

noted in the percentage of articles reporting international 

author contribution (minimum 5% dietetics, maximum 88% 

speech pathology) and receipt of funding assistance (5% 

psychology, 39% physiotherapy). The distinct bibliometric 

differences observed between journals representing 

Australian health professional associations may reflect the 

nature of the profession, function of the journal, formatting 

restrictions or the prevailing research paradigm. 



26 

A pilot study of cognitive behavioural therapy for the 

sensation of breathlessness in people with chronic 

obstructive pulmonary disease 

Williams MT, 1 Cafarella P, 2 Petkov J, 1 Frith P 2 

1 



The aim of this study was to determine whether a program 

of cognitive behavioural therapy for the sensation of 

breathlessness altered descriptors of dyspnoea and improved 

health outcomes in people with chronic respiratory disease. 

Using a test-retest approach, 11 participants (10 males, 76 ± 

6 years, % predicted FEV1 55 ± 37) attended the cognitive 

behavioural therapy program (one hour session per week) 

facilitated by a psychologist in addition to completing an 

eight week pulmonary rehabilitation program (one hour 

education and three supervised exercise sessions per 

week). Outcomes were descriptors of breathlessness, six 

minute walk test, respiratory related impairment (Medical 

Research Council scale) and intensity of breathlessness (10 

cm visual analogue scale). On completion of the pulmonary 

rehabilitation/cognitive behavioural therapy program there 

was a consistent reduction in the number of participants 

volunteering adverse descriptors (frightening/worried: 5 

people pre versus 1 person post; annoying/uncomfortable: 

8 pre versus 4 post; depressed/helpless 3 pre versus 0 post). 

Compared to outcomes for past cohorts undertaking the same 

pulmonary rehabilitation program, participants completing 

the combined program had greater mean increases in 

functional exercise tolerance (six minute walk test 74 m effect 

size 0.23 versus 21 m after pulmonary rehabilitation alone), 

respiratory related impairment (one grade change effect 

size 2.1 versus no change after pulmonary rehabilitation 

alone), breathlessness intensity (mean change of 2 cm effect 

size 0.82 versus no change after pulmonary rehabilitation 

alone). These preliminary findings suggest that addressing 

cognitive aspects of the sensation of breathlessness may 

facilitate greater improvements in health outcomes. 

Supported by the University of South Australia precompetitive 

grant 

The language of pain and breathlessness in people with 

lung cancer 

Williams MT, 1 Quast E, 1 Cafarella P, 2 Petkov P, 1 , Frith P 2 

1 



Pain and dyspnoea are evolutionary mechanisms which 

alert the brain to threat and motivate a change in behaviour. 

While both sensations have been studied in people with 

persistent pain or chronic breathlessness, little is known 

about these sensations in people where these symptoms 

co-exist. This study explored the language used to describe 

pain and breathlessness in people with lung cancer. Using 

a cross sectional descriptive design, people with a definite 

diagnosis of lung cancer under the care of a respiratory 

physician completed two structured interviews for pain 

and breathlessness. Participants were invited to volunteer 

descriptors of each symptom, endorse descriptors from preexisting 

inventories for breathlessness and pain (McGill 

Pain Questionnaire) and nominate which symptom was 

more distressing. Thirty people (19 males, 68 ±12 years) 

with predominantly later stage non small cell lung cancer 

participated in this study. The most common descriptors for 

breathlessness were short of breath/frightening/strategies 

(volunteered) and out of breath/cannot get enough air in/ 

tight (endorsed). The most common descriptors for pain 

were uncomfortable/stabbing/annoying (volunteered) 

and stabbing/pricking/cramping/annoying/throbbing/ 

tight/tiring (endorsed). The number of people nominating 

breathlessness as the worse symptom (n= 13) was similar to 

the number who reported that the more distressing symptom 

varied with situation (n=12) with the minority nominating 

pain as the more distressing symptom (n= 5). The findings 

suggest that palliative management of breathlessness may 

not be as effective as the management of pain. 

A prospective multicentre study: physiotherapy during 

wellness and illness in children under five years with 

cystic fibrosis 

Wilson CJ, Wright SE, Wainwright CE, on behalf of the 

Australasian Cystic Fibrosis Bronchoalveolar Lavage 

(ACFBAL) study 


Despite most infants being asymptomatic, physiotherapy is 

recommended from diagnosis of cystic fibrosis (CF), with 

many variations internationally in actual interventions. The 

ACFBAL study physiotherapy protocol used positioning 

and chest percussion as the initial approach taught to 

parents, with further progressions or modifications made 

at physiotherapist discretion, selecting from many options 

including positive expiratory pressure. As part of the 

ACFBAL study, 168 children diagnosed by newborn screen 

were randomised to BAL directed therapy or standard care. 

Analysis of three-monthly reviews included physiotherapy 

interventions used, respiratory symptoms, and clinical 

assessments for the first 5 years of life. Additional final 

outcomes (5 years) included BAL, chest CT, and lung 

function. One-hundred participants have completed final 

outcomes, 159 have complete data to three years of age. 

Age-appropriate physical activity was reported to be 

used at all ages. Analysis included combined manual and 

other techniques (75%); PEP (52%); exercise alone; and no 

physiotherapy. Postural drainage (PD) incorporating headdown 

tipping was infrequently used in all ages (3%). No 

cough is reported by parents and health professionals 60% 

of the time, whereas 92% of children have cough symptoms 

at hospital admission. Increased cough is the most sensitive 

parent-reported exacerbation indicator. Multivariate 

analysis examining associations between physiotherapy 

interventions and clinical findings in the first five years of 

life demonstrates the expanded horizon of physiotherapy 

practice in CF, including many interventions comprising 

chest physiotherapy. A clearer picture is emerging of clinical 

features at baseline, exacerbation, admission, and the range 

of physiotherapy interventions at times of wellness and 

illness in CF. 



Why is positive expiratory pressure physiotherapy 

used in children with cystic fibrosis under three years 

of age? 





Positive Expiratory Pressure (PEP) physiotherapy is an 

option for airway clearance in cystic fibrosis (CF). PEP 

theory suggests volume change via collateral ventilation, 

and a secondary mechanism of airway stabilisation. PEP is 

typically introduced in CF around school commencement. 

The ACFBAL study physiotherapy protocol utilised 

positioning, chest percussion, and age-appropriate activity 

from infant diagnosis, with subsequent treatment changes 

made at the discretion of the physiotherapist. This 

prospective investigation reports PEP and clinical records 

when physiotherapy techniques were changed. Baseline, 

exacerbation, admission and routine reviews were analysed 

separately. PEP alone or used as an adjunct was compared 

to other techniques. 159 of 168 enrolled children (Mean 

age 3.6mths, SD 1.6) from 8 Australasian sites have three 

year data. 32 of 159 children (20%) used PEP before three 

years of age; three of these (9%) were diagnosed with 

significant tracheomalacia prior to commencing PEP. In 

PEP users, there was no association between barking or 

croupy coughs typically associated with tracheomalacia. 

Fort percent of the cohort had a cough (any description) 

compared with 72% of PEP users. The implications of this 

will be discussed Reasons for early initiation of PEP may 

include physiotherapist familiarity with PEP, the presence 

of persistent cough or unexpected bronchoscopy findings 

indicating a need to change the regimen. Our expectation 

that early use of PEP would be associated with barking or 

croupy cough; nocturnal cough, and/or malacia was not 

supported. Further systematic study of this emerging trend 

is warranted, particularly where airway malacia is identified 

in young children. 

The effects of pulmonary rehabilitation in the 

treatment of advanced cancer patients 

Zafiropoulos B, Jongs W, Glare P 

Sydney Cancer Centre Royal Prince Alfred Hospital, Sydney 

This study aimed to assess the effects of a multidisciplinary 

pulmonary rehabilitation approach in the treatment of 

advanced cancer patients. Patients were assessed by 

physician, dietician and physiotherapist and provided with 

symptom management, dietary intervention, and home 

or gym based exercise programs. Fifty-three patients 

(median age 62 years, mainly stage III and IV lung or 

gastrointestinal cancers) were referred to the program 

with 79% of these patients receiving anticancer therapies 

concomitantly. Baseline median and interquartile range 

(IQR) values for Karnofsky Performance Scores were 

70 (60–80), six-minute walk test distances were 442 m 

(382–521 m), and handgrip strengths were 69% (left) and 

74% (right) of predicted normal values. At baseline, 78% 

of the sample was moderately or severely malnourished as 

per the Patient Generated Subjective Global Assessment. 

Following 3 months in the program, six-minute walk test 

distance increased from baseline by 147 m (33%) to 589 

m (585 to 600 m) and handgrip strengths increased to 

82% (left) and 85% (right) of predicted values. Karnofsky 

Performance Scores remained stable with Edmonton 

Symptom Assessment System scores decreasing over time. 

Weight was observed to stabilise with decreases in Patient 

Generated Subjective Global Assessment scores indicating 

improvements in nutritional status. Although drop out 

rates were high, patients who remained in the program 

demonstrated improvements in nutritional status, endurance 

and strength, with decreases in cancer related symptoms. 

This multidisciplinary pulmonary rehabilitation approach 

is innovative and successful in providing supportive care 

for patients with advanced cancer. 

Prescribing walking training intensity from the sixminute 

walk test for people with chronic obstructive 

pulmonary disease 

Zainuldin R, 1 Mackey MG, 1 Alison JA 1,2 

1 

The University of Sydney, 2 Royal Prince Alfred Hospital, Sydney 

The six-minute walk test (6MWT) is often used to 

prescribe walking training intensity for people with chronic 

obstructive pulmonary disease (COPD). However, no 

research has investigated this training intensity in terms 

of oxygen consumption (VO2). The aim of this study was 

to examine whether the intensity of walking exercise 

prescribed from a 6MWT was within the recommended 

training range of 50–85% peak VO2. A prospective repeated 

measures study was conducted. Participants performed an 

incremental cycle test, and on a separate day two 6MWTs, 

each followed by 30 minutes rest and then 10 minutes of 

walking training at 80% of the average speed achieved in 

the better 6MWT. Each participant wore a rubber facemask 

connected to a lightweight portable gas analyser (Cosmed 

K4b2) worn on the chest with a harness. Breath-by-breath 

values of metabolic parameters were measured during each 

test and during walking training. Six participants walked 

a mean (SD) distance of 520(33)m and 694(44)m in the 

6MWT and the 10-minute walking training respectively. 

There was no significant difference between the peak VO2 

achieved in the cycle test and 6MWT (1356(255) ml/min 

and 1362(226) ml/min respectively). The VO2 from the 

10-minute walk training was 76(13)% of the peak VO2 

determined by the cycle test. Walking at 80% of the average 

speed of the 6MWT resulted in a training intensity within 

the recommended training range. 



National Paediatric Group joint session 

with Cardiorespiratory Physiotherapy 

Australia 






conditions and the impacts of an increased burden to the health 

system and families with limited physiotherapy resources 

available. Medical advances have lead to earlier diagnosis of 

chronic respiratory conditions, and significantly improved 

survival rates. The Royal Children’s Hospital, Brisbane, 

has had progressive and significant increases in referrals for 

these conditions and subsequent increases in activity. In this 

presentation, we review current models of care; including 

quality measurements and patient health outcomes, and 

will offer potential solutions which include flexible but 

targeted services across the continuum and incorporate a 

variety of domiciliary care models and the indicators for 

success. Current literature shows that existing domiciliary 

programs, demonstrate mixed results and primarily in the 

cystic fibrosis population group. However, domiciliary care 

across the continuum, inclusive of specialised allied health 

professionals, has shown to be cost- and clinically- effective, 

in the presence of appropriate referrals and resources. 

Unfortunately, in the Queensland experience, the quality 

and extent of domiciliary care is being adversely affected 

by limited community physiotherapy funding, decreased 

availability of specialist paediatric physiotherapy and 

limited accessibility of domiciliary services. Considerable 

re-thinking is required to provide appropriate care to 

this patient group, which can be modified to support and 

adapt to individual, local and state-wide needs to ensure a 

seamless approach to paediatric physiotherapy for chronic 

respiratory conditions. 

28 


children with intellectual disability: a randomised 



1 

Semnan University, Semnan, Iran, 2 Royal Prince Alfred Hospital, 

Sydney 












running and cycling for 30 minutes, 5 days per week, for 

8 weeks) or a control group (usual daily activities only). 

The exercise was supervised, with a target of moderate 

intensity. Lung function was measured again at 8 weeks. 

Of the 44 participants enrolled (mean age 12 (1.5) years and 

IQ 42 (8) points), randomisation allocated 24 participants to 

exercise and 20 participants to control. For the full cohort 

after coaching, FEV 1 was a mean of 87% (95% CI, 84–91) 

and FVC was 93% (95% CI, 90–96) of normative values. 

Both FEV 1 and FVC improved significantly more in the 

exercise group than in the control group. For change in 

FEV 1 , the mean between-group difference was 160ml (95% 

CI, 30–290). For change in FVC, the mean between-group 

difference was 330ml (95% CI, 200–460). Lung function 








systematic search of 6 databases was undertaken using terms 

synonymous with the active cycle of breathing technique. 

Hand searching of reference lists was conducted and 

experts contacted. Two assessors independently allocated 

each reference to an evidence hierarchy and assessed 

methodological bias. One-hundred and five articles were 

identified. Twenty-four studies reporting primary data on 

the technique were included (1970–2007), including several 

high level, low risk of bias studies. Ten comparators were 

identified with the most common including conventional 

chest physiotherapy (n = 5), positive expiratory pressure (n 

= 5) and a control (n = 4). A total of 36 outcome measures 

were identified in the included studies. The most commonly 

assessed outcomes were sputum wet weight (n = 17), forced 

vital capacity (n = 13) and forced expiratory volume in one 

second (n = 13). Meta-analysis was completed on the primary 

outcome measure of sputum wet weight. Preliminary results 

indicate that the standardised mean difference (SMD) across 

studies showed an increase in sputum weight during and up 

to 1 hour post treatment (SMD 0.29, 95% CI 0.20–0.37), but 

no difference in the during and up to 24 hour post treatment 

weight (SMD 0.15, -0.03–0.34). The majority of studies 

(92%) demonstrated excellent generalisability to the target 

population. Assessing the body of evidence was problematic 

due to the diversity of research designs, comparators and 

outcomes used. 



Mandrusiak A, 1 MacDonald J, 1 Paratz J, 1 Wilson C, 2 


1 


Brisbane 








FitKit) (n = 15) compared to the current physiotherapy 












contributed to significant improvements for participants for 

a range of measures, including respiratory function (p = 














A prospective multi-centre study: physiotherapy during 











and chest percussion initially taught to parents, with further 

progressions or modifications made at physiotherapist 

discretion. In the ACFBAL study 168 children diagnosed 

by newborn screen were randomised to BAL directed 

therapy or standard care. Three-monthly reviews included 

physiotherapy interventions used, respiratory symptoms, 

and clinical assessments for the first 5 years of life. Final 

outcomes (5 years, n = 100) included lung function. One 

hundred and fifty-nine have complete data to three years 

of age. Analysis included combined manual and other 

techniques (75%); PEP (52%); physical activity(100%). 

Postural drainage (PD) incorporating head-down tipping 

was infrequently used in all ages (3%). No cough is reported 

60% of the time, whereas 92% of children have cough 

symptoms at hospital admission. Cough is the most frequent 

indicator of clinical change; secretions, night cough, 

wheeze, and decreased activity levels occur less frequently 

during exacerbation. Eighty-six percent of participants 

had normal FEV 1 (> 85% predicted) at final outcome, 

with no participants below 60% predicted. Multivariate 


interventions and clinical findings in the first 5 years of 


practice in CF, including more interventions comprising 

chest physiotherapy. Although wellness is expected 

most of the time, the burden of treatment can be high. A 

clearer picture is emerging of clinical features at baseline, 

exacerbation, admission, and the range of physiotherapy 

interventions during wellness and illness in CF. 



of age? 













made at physiotherapist discretion. This prospective 

investigation reports PEP and clinical records when 

physiotherapy techniques were changed. Baseline, 



to other techniques. One hundred and fifty-nine of 168 

enrolled children (mean age 3.6 mths, SD 1.6) from 8 

Australasian sites have three year data. Thirty-two of 159 

children (20%) used PEP before 3 years of age; 3 of these 

(9%) were diagnosed with significant tracheomalacia prior 

to commencing PEP. In PEP users, there was no association 

between barking or croupy coughs typically associated with 

tracheomalacia. Forty percent of the cohort had a cough (any 

description) compared with 72% of PEP users. This report 

is limited by data collection methodology which does not 

record physiotherapy clinical reasoning. Reasons for early 

initiation of PEP may include physiotherapist familiarity 

with PEP, presence of persistent cough or unexpected 

bronchoscopy findings indicating need for changed therapy 

regimen. Our expectation that early use of PEP would be 

associated with barking or croupy cough; nocturnal cough, 

and/or malacia was not supported. Further systematic study 

of this emerging trend is warranted, particularly where 

airway malacia is identified in young children. 



Continence and Women’s Health 

Physiotherapy Australia 






2 

The prevalence of urinary incontinence among 

Omani women 

Al Busaidi K, 1 Briffa NK, 1 Center JR 2 

1 

School of Physiotherapy, Curtin University of Technology, Perth, 2 Bone 

and Mineral Research Program, Garvan Institute of Medical Research, 

St Vincent’s Hospital, University of New South Wales, Sydney 

The aim of this study was to investigate the prevalence and 

risk factors for UI in Omani women, as they are currently 

unknown. One hundred and twenty women aged ≥ 18 years 

from randomly selected households in the Muscat region of 

Oman were invited to participate. One hundred and eighteen 

women (mean age 39.1) agreed. Data were collected ‘doorto-door’ 

using a valid and reliable questionnaire developed 

for the study. Data were analysed using logistic regression 

analysis. 52.5% had urinary incontinence (UI); 28% stress 

UI, 11.9% urge UI and 12.7% mixed UI. Factors significantly 

associated with UI in bivariate analyses were sneezing 

related to allergy (OR 7.1; 95% CI 2.2–22.4), obesity (2.2; 

1.05–4.7), lower urinary tract symptoms (2.3; 1.02–5.2), 

and chronic cough (3.8; 1.005–14.4). Age, menopausal 

status, parity, diabetes, circumcision, diuretic use, and 

coffee consumption were not associated with UI. In forward 

stepwise logistic regression analysis with all significant risk 

factors included as independent variable, only sneezing was 

a significant predictor of UI. There was a high prevalence of 

UI among Omani women in Muscat. The strong relationship 

between allergy with sneezing and urinary incontinence is 

a novel finding that has not previously been documented 

as a risk factor for UI in population based studies. The risk 

factors associated with UI were generally amenable to health 

education and treatment suggesting excellent potential for 

the burden of UI to be reduced in this group of women. 

Pelvic floor muscle activity during abdominal 

hollowing and bracing manoeuvres in women with and 

without stress urinary incontinence 

Arab AM, Chehrehrazi M 

University of Social Welfare and Rehabilitation Sciences, Iran 

The aim of this study was to investigate the effect of 

abdominal hollowing and bracing manoeuvres on the pelvic 

floor muscle activity in women with and without stress 

urinary incontinence. A total of 40 non-pregnant females 

participated in the study. Subjects were categorised into two 

groups: continent females and stress incontinent females. 

An equal number of women (n = 20) were allocated to 

each group. Transabdominal ultrasound measurement 

of pelvic floor muscle activity was performed when they 

activated alone or during abdominal hollowing and bracing 

manoeuvres. The amount of bladder base movement on 

ultrasound (mm) was measured as an indicator of muscle 

activity and normalised to body mass index. The normalised 

value was used for data analysis. A two-way mixed-design 

ANOVA was used for statistical analysis. The abdominal 

manoeuvres had significant effect on pelvic floor muscle 

activity (p < 0.0001). There was no significant interaction 

between health status of subjects and abdominal manoeuvres 

(p = 0.81). Finally, there was significant main effect of heath 

status on pelvic floor muscle function (p = 0.04). The post 

hoc analysis showed that continent women had significantly 

higher pelvic floor muscle contraction compared to 

incontinent women when contraction was performed alone 

(p = 0.02). However, there was no significant difference 

in pelvic floor muscle activity between two groups when 

contraction was recorded during abdominal hollowing (p 

= 0.17) or bracing (p = 0.07). In conclusion, the results of 

this study indicate higher pelvic floor elevation, measured 

by transabdominal ultrasound, when pelvic floor muscle 

contraction was performed alone than in combination with 

abdominal muscle contraction. 

Effects of a physiotherapy program on impairments, 

function and quality-of-life in people with osteoporotic 

vertebral fracture: randomised controlled pilot trial 

Bennell K, 1 Matthews B, 1 Greig A, 2 Kelly A, 1 Briggs A, 3 

Sherburn M, 1 Larsen J, 4 Wark JD 1 

1 

University of Melbourne, Melbourne, 2 University of British Columbia, 

Vancouver, Canada, 3 Curtin University of Technology, Perth, 

4 

Hydrotherapy Consulting and Training, Brisbane 

This randomised, single-blind controlled pilot trial aimed 

to determine the efficacy of a physiotherapy program in 

improving physical impairments, physical function and 

health-related quality of life in people with an osteoporotic 

vertebral fracture sustained 3 months to 2 years 

previously. Twenty participants were randomly allocated 

to a physiotherapy (n = 11) or control (n = 9) group. The 

physiotherapy group attended individual sessions once 

weekly for 10 weeks and performed daily home exercises. 

The treatment program was standardised and aimed to: 

decrease back pain; improve posture; improve thoracic 

mobility; strengthen trunk extensor and lower limb muscles; 

improve trunk control; and provide education. It comprised 

soft tissue massage, postural taping, gentle vertebral 

mobilisation and exercises. The control group received no 

treatment. Blinded assessment was conducted at baseline 

and 11 weeks. Questionnaires assessed self-reported 

changes in back pain, physical function and health-related 

quality of life. Objective measures of thoracic kyphosis, 

back and shoulder muscle endurance and function were 

also taken. The physiotherapy group showed significantly 

greater improvements in pain (mean = 2.3 (95% CI to 

4.2 to-0.4), Qualeffo scores (Total Qualeffo-8.4 (-16.7 

to-0.1)) and the Timed loaded standing test (49.3 (18.8 to 

79.8)) compared with the control group (all p < 0.05). A 

successful outcome was reported by 9/11 (82%) participants 

in the physiotherapy group compared with 1/9 (11%) in the 

control group (p = 0.005). The results support the benefits of 

physiotherapy in the clinical management of patients with 

osteoporotic vertebral fractures but need to be confirmed in 

a larger sample. 

Physiotherapy interventions to reduce symptoms and 

slow disease progression in knee osteoarthritis 

Bennell K 


Knee osteoarthritis (OA), particularly of the medial 

tibiofemoral compartment, is a common chronic joint disease 

in women leading to pain, loss of functional independence 

and reduced quality-of-life. In the absence of a cure for 

knee OA, alleviating symptoms and improving function 

has been the primary aim of interventions. However, there 

is increasing attention being paid to identifying treatments 

that can also slow disease progression in those at risk. There 

is evidence that mechanical loading at the knee joint plays 

an important role in predisposing to both symptoms and 

structural change. Thus, it is feasible that interventions 

could also influence structural disease if they can reduce 



knee load. Interventions with this potential include specific 

exercise, lateral wedge insoles, shoe modifications, knee 

braces and gait retraining. Biomechanical studies support 

a reduction in knee load with many of these therapies but 

whether this translates into long-term structural benefit 

needs to be further evaluated. It is also apparent that effects 

are likely to differ according to the type of intervention and the 

local mechanical environment operating within each individual. 

The not-so-sexy business of marketing pelvic floor 

physiotherapy 

Bouvier AL 

Phsiocise 

Physiotherapists have traditionally had difficulty marketing 

their services to the general public. Part of the problem has 

been that our services are so diverse, that specific target 

markets become blurred. Pelvic floor physiotherapy is one 

of the few areas that is totally unique to our profession 

and therefore provides an ideal opportunity to niche 

market a specific professional and highly skilled service 

to a potentially huge audience. To do this we need to ask 

ourselves these questions. How do we start a dialogue about 

the issues so that we increase public awareness? How do we 

link the issues with our service? How do we ‘sell’ our skills 

and their benefits? 

Challenges and rewards in the extended scope of 

physiotherapy in oncology and lymphoedema 

Box RC 

QLD Lymphoedema and Breast Oncology Physiotherapy, Brisbane 

One in three Australians will be diagnosed with cancer 

by the age of 75, and 1 in 2 by 85 years (2005 data) but 

survival rates for many cancers are increasing. Treatment 

of primary or secondary cancer may result in physical 

impairments amenable to physiotherapy intervention. 

Physiotherapists are qualified to optimise health and wellbeing 

while minimising potential sequelae and impairments 

following a cancer diagnosis. Traditional paradigms and 

clinical practice suggest that the physiotherapy profession 

has not fully embraced its role in this area. As first contact 

practitioners in Australia’s health system, physiotherapists 

in the private sector are provided with unique challenges 

in differential diagnosis, treatment planning and health 

care team networking. Evidence based practice requires 

that physiotherapists working in oncology have broad 

knowledge, advanced clinical skills and a strong analytical 

framework to meet the challenges of extended scope across 

a broad spectrum of clinical presentations which often elude 

research evidence due to the complexity and chronic nature 

of some patients’ conditions. The challenge of appropriate 

activity and exercise prescription during treatment with 

subsequent reconditioning and retraining is largely unmet 

at present. Physiotherapists should be addressing a broad 

number of health and well-being issues in the presence of 

treatment sequelae such as fatigue, de-conditioned states, 

lymphoedema, weight gain, osteoporosis, incontinence, 

sexual dysfunction, neurological, cardiovascular and/or 

respiratory impairments. Management must address psychosocial 

distress which may impact on physical recovery. 

Making a difference by empowering individuals on their 

cancer journey to achieve maximum personal participation 

by embracing life is the immeasurable reward. 

Women’s health across the lifespan: differences 

and diversity 

Byles JE 

Research Centre for Gender, Health and Ageing, The University of 

Newcastle, NSW 

This presentation looks at some major differences in trends 

in health and social circumstances between three cohorts of 

women in the Australian Longitudinal Study on Women’s 

Health. The three cohorts include women born in 1921–26 

(aged 70–75 years when the study began in 1996), women 

born in 1946–51, and women born in 1973–78. The women 

have now been surveyed at least four times over the past 

12 years providing a large amount of data on the women’s 

lifestyles, use of health services and health outcomes. The 

data provide a unique opportunity to explore health and 

health behaviours at three critical stages in women’s lives, 

and to compare the differences between cohorts. Both age 

and cohort effects are apparent in the results. Older women 

have the highest prevalence of chronic conditions and health 

care needs, however there are also differences in the risk 

factor profile, lifestyle factors, and disease incidence of the 

younger cohorts that foreshadow that these women may have 

different health needs as they age. One of the most striking 

differences is the increasing incidence of overweight and 

obesity among women in the youngest cohort. This impact 

of this problem for women in the study can already be seen 

in the strong associations between overweight and obesity 

and chronic disease, poorer mental and physical health, and 

higher health care costs. The implications of these changes, 

and opportunities for prevention at different points in the 

lifespan will be discussed. 

Continence status of ageing Australian women: 

a fluid situation 

Chiarelli P 

The University of Newcastle 

Urinary incontinence – the accidental leaking of urine – is 

a major problem in Australia and has a significant impact 

on quality of life, affecting the social, psychological, 

physical and financial aspects of life. The prevalence of 

urinary incontinence is significantly higher in women 

than in men. The Australian longitudinal women’s health 

study provides a the opportunity to focus on a cohort of 

older women representative of a population group which 

is growing in size as the population as a whole ages 

and which is at high risk of falls and fractured bones. 

Overactive bladder symptoms associated with ageing have 

also been shown to be significantly associated with falls. 

The use of longitudinal data allows for the determination 

of new cases of incontinence (incidence) and also allows 

for the identification of temporal relationships between 

incontinence and associated disability. The Australian 

longitudinal women’s health study provided longitudinal 

data on the prevalence and incidence of incontinence from 

a large cohort of older women, over nine years of follow-up. 

Over this time, 14.6% (95% CI: 13.9–15.3) of the women in 

the study who had previously reported ‘rarely’ or ‘never’ 

leaking urine, developed incontinence. Women participating 

in the latest survey were twice as likely to report incontinence 

as they had been six years earlier. Longitudinal models 

demonstrated significant associations between incontinence 

and a number of health issues including dementia, falls to 



the ground, Body Mass Index, constipation, urinary tract 

infection, history of prolapse and prolapse repair. These 

associations will be discussed further. 

Resting thickness of transversus abdominis and 

lumbar multifidus and their changes on contraction in 

women with stress urinary incontinence 

Chih SY, 1 Wang S,F 2,3 Lin HH, 4 Wang TG, 1 Tsauo JY 1,2 

1 

Physical Therapy Center, National Taiwan University Hospital, Taipei, 

Taiwan, 2 School and Graduate Institute of Physical Therapy, College 

of Medicine, National Taiwan University, Taipei, Taiwan, 3 Department 

of Physical Medicine and Rehabilitation, National Taiwan University 

Hospital, Taipei, Taiwan, 4 Department of Obstetrics and Gynecology, 

National Taiwan University Hospital, Taipei, Taiwan 

The aims of the study are to assess the difference in resting 

thickness and change on contraction of transversus abdominis 

and lumbar multifidus in women with or without stress 

urinary incontinence through real-time ultrasonography. 

Further, to compare the differences among the women with 

different severities of stress urinary incontinence. Fifteen 

women with stress urinary incontinence were recruited 

as Group 1, and 10 age-matched asymptomatic women 

were recruited as Group 2. The changes of thickness 

of transversus abdominis and lumbar multifidus were 

recorded. Each muscle in both sides was assessed 3 times. 

Order of evaluation of muscles and sides was randomised. 

T-test and Mann-Whitney U test were used to compare 

the differences. There was no significant difference in 

resting muscle thickness of these two muscles between two 

groups. However, changes in muscle thickness of these two 

muscles in women with stress urinary incontinence were 

significantly less than asymptomatic controls. (transversus 

abdominis: Group 1, 0.14 cm, SD = 0.06 versus Group 

2, 0.22 cm, SD = 0.06, p = 0.001; multifidus: Group 1, 

0.29cm, SD = 0.17 versus Group 2, 0.51cm, SD = 0.20, p 

= 0.006). Measured variables were not different between 

women with different severities. Findings suggested that 

the morphometric change on contraction of transversus 

abdominis and lumbar multifidus is smaller in women with 

stress urinary incontinence comparing to asymptomatic 

controls by ultrasonography. Integrating transversus 

abdominis and lumbar multifidus with pelvic floor muscles 

training is suggested in treatment for women with stress 

urinary incontinence. 

Physiotherapy management of obstetric anal sphincter 

tears at Flinders Medical Centre: outcomes of a twelve 

month audit 

Cooper SJ, Ayoub J 

Flinders Medical Centre, Adelaide 

One third of all postnatal women with sphincter disruption 

develop symptoms of faecal incontinence despite primary 

repair. Physiotherapy intervention is included in best 

practice guidelines for this patient group. Morkved reported 

on several studies on the effect of physiotherapy treatment 

for faecal incontinence and found that all demonstrated a 

significant clinical improvement after intervention. Best 

practice was determined to be that the woman received 

at least one inpatient and one outpatient physiotherapy 

intervention postnatal. In a study conducted (in 2007 Flinders 

Medical Centre) to assess the management of women who 

suffer obstetric anal sphincter trauma, of the 53 postnatal 

women identified with anal sphincter tears, only 62% 

4 

received physiotherapy as per this best practice guideline. 

Of those seen by a non women’s health physiotherapist 

78% did not attend their outpatient physiotherapy followup 

appointments. This resulted in the creation of combined 

perineal trauma clinic; with obstetric consultant and 

women’s health physiotherapist, and a women’s health 

physiotherapist now sees all these women on the ward. 

Following these changes an audit was conducted between 

January 2008 and January 2009.The numbers of women 

identified with a 3rd or 4th degree tear increased from 53 to 

71, and the percentage receiving best practice has increased 

to 82 %. Demand has increased such that this clinic is now 

run on a weekly basis. 

Osteoporosis in the elderly: a new approach to an 

old geriatric syndrome 

Duque G 

Aging Bone Research Program and Discipline of Geriatric Medicine, 

Nepean Clinical School, University of Sydney, Penrith 

In addition to the socioeconomic costs, osteoporotic fractures 

often cause significant morbidity and disability mostly in the 

older population. The classic model to prevent fractures is to 

screen for osteoporosis by bone densitometry and then treat 

people with low bone density with antiresorptive or other 

bone-specific drugs. However, recent studies have shown 

that, in a significant number of cases, bone densitometry 

does not give reliable estimates of a person’s true bone 

mineral density. Partly because of the limitations of bone 

densitometry, the World Health Organisation is devising a 

new model to calculate absolute fracture risk: the FRAX 

tool. The model combines, age specifically, 6 clinical risk 

factors (previous fracture, glucocorticoid use, family history 

of fracture, current cigarette smoking, excessive alcohol 

consumption, and rheumatoid arthritis) with bone mineral 

density to estimate the 10-year probability of hip and other 

fractures. In addition to the identification of fracture risk, 

and considering that falls, and not osteoporosis, are the 

strongest single risk factor for fracture, identification of risk 

of falls, as well as interventions to prevent falls constitute 

a logical approach to preventing fracture. In fact, risk of 

falling is also completely overlooked in many important 

publications on preventing fractures. Considering that there 

is a progressive shift of the focus in fracture prevention 

from osteoporosis to falls, the role of geriatric medicine 

in this focus shifting is pivotal. This session will review 

the principles of a combined risk assessment for falls and 

fractures. In addition, the optimal structure and general 

recommendations for implementing a Falls and Fractures 

Clinic will be discussed. 

Osteoarthritis 

Fransen M 

The University of Sydney 

The prevalence of osteoarthritis increases markedly with 

age. Osteoarthritis is mainly a disease of the articular 

cartilage and subchondral bone. There is no cure for 

osteoarthritis, nor treatments proven to slow structural 

disease progression. While ageing cartilage is considered 

to be more vulnerable to mechanical insults, changes to the 

cartilage considered to typify osteoarthritis are not universal 

in older people. In addition, there are many older people 

with clear radiographic evidence of osteoarthritis who are 



not experiencing joint pain or physical limitations. For 

osteoarthritis, the greatest disability burden is attributable 

to lower limb joint involvement. Given osteoarthritis 

involving the lower limb joints has mainly a biomechanical 

pathogenesis, various non-pharmacology interventions 

should have great potential as effective treatment strategies 

for this chronic musculoskeletal condition. An overview 

of the current level of evidence for the symptomatic 

effectiveness of various non-pharmacological strategies 

frequently used by physiotherapists for older people with 

painful osteoarthritis of the hips or knees will be outlined 

in this presentation. 

Physiotherapy management of obstetric anal sphincter 

tears at Flinders Medical Centre: outcomes of a twelve 

month audit 

Cooper SJ, Ayoub J 


One-third of all postnatal women with sphincter disruption 

develop symptoms of faecal incontinence despite primary 

repair. Physiotherapy intervention is included in best 

practice guidelines for this patient group. Morkved reported 

on several studies on the effect of physiotherapy treatment 

for faecal incontinence and found that all demonstrated a 

significant clinical improvement after intervention. Best 

practice was determined to be: the woman received at least 

one inpatient and one outpatient physiotherapy intervention 

postnatally. In a study conducted in 2007 at Flinders 

Medical Centre to assess the management of women who 

suffer obstetric anal sphincter trauma, of the 53 postnatal 

women identified with anal sphincter tears, only 62% 

received physiotherapy as per this best practice guideline. 

Of those seen by a non women’s health physiotherapist 

78% did not attend their outpatient physiotherapy followup 

appointments. This resulted in the creation of combined 

perineal trauma clinic – with obstetric consultant and 

women’s health physiotherapist, and a women’s health 

physiotherapist now sees all these women on the ward. 

Following these changes an audit was conducted between 

January 2008 and January 2009.The numbers of women 

identified with a 3 rd or 4 th degree tear increased from 53 to 

71, and the percentage receiving best practice increased to 

82 %. Demand has increased such that this clinic is now run 

on a weekly basis. 

A novel electrode to record activity of the external 

urethral sphincter in men 

Hodges PW, Stafford R, Sapsford R 

NHMRC Centre of Clinical Research Excellence in Spinal Pain, Injury 

and Health, The University of Queensland, Brisbane 

Recordings of electromyographic (EMG) activity from 

striated muscle fibres of the external urethral sphincter 

(EUS) in males are generally made using concentric needle 

electrodes inserted via the perineum. With this technique, 

it is difficult to make recordings during dynamic or upright 

tasks. Here we aimed to design an electrode to enable 

transurethral EUS recordings in males and to investigate 

the quality of these recordings. A novel electrode was 

fabricated from a 6 Fr urinary catheter with recording 

surfaces made from 4 strands of Teflon-coated stainless 

steel wires threaded through small pinholes ~15 and 25 mm 

from the end of the catheter. Wires were threaded down 

the lumen of the catheter. Suctioning the catheter to the 

mucosa stabilised the electrode position. The electrode was 

inserted using a conventional aseptic technique for selfcatheterisation. 

Recordings have been made from 5 healthy 

male subjects (25–38 years). Recordings were well-tolerated 

with minimal evidence of urethral trauma and only mild 

discomfort on urination for ~24 hr. Stable EMG recordings 

have been made during voluntary efforts, coughing, and 

trunk/limb movements in standing and sitting. Good 

signal to noise ratio has been achieved and only small 

amplitude movement artefacts are observed, even during 

dynamic tasks. The quality of EMG was confirmed by the 

power spectral density of the EMG signal. High quality 

recordings of EMG activity of the EUS can be made in men 

with a urethral electrode. The stabilisation of the electrode 

placement by suction to urethral mucosa enables recordings 

during dynamic tasks. 

Comparing the effect of utilising trunk muscle 

synergists with intensive pelvic floor muscle training in 

treating urinary incontinence 

Hung HC, 1 Chih SY, 2 Lin HH, 3 Tsauo JY 1,2 

1 

School and Graduate Institute of Physical Therapy, College of 

Medicine, National Taiwan University, Taipei, Taiwan, 2 Physical 

Therapy Center, National Taiwan University Hospital, Taipei, Taiwan, 

3 

Department of Obstetrics and Gynecology, National Taiwan University 

Hospital, Taipei, Taiwan 

The purpose of this study was to investigate the effect 

of treating urinary incontinence utilising trunk muscle 

synergists comparing with pelvic floor muscle training. 

Fifty-nine women with stress urinary leakage symptom 

were recruited in this trial. Thirty-one women (age: 48.6 

years old, SD = 6.4) were allocated to Group 1, and twentyeight 

women (age: 51.0 years old, SD = 5.8) were allocated 

to Group 2. Every participant received 8 individual visits 

during the 4-month intervention period. The women in 

Group 1 followed specially designed exercises utilizing 

trunk synergists including diaphragm, deep abdominal 

muscles, and pelvic floor muscles. The women in Group 2 

received intensive pelvic floor muscle training. Evaluations 

before and after the intervention period included 

demographic data, urogynaecological history, self-reported 

cure/improved rate, leaking frequency during 3-days 

diary, leaking amount during 20-mins pad test, maximal 

vaginal squeeze pressure and holding time by manometer, 

and quality of life by Symptom Impact Index. All basic 

characteristics and outcome measures were comparable 

between groups except the number of women with urge 

incontinence was more in Group 1 at baseline. The selfreported 

cure/improved rate were 96.8% and 92.9% in 

Group 1 and Group 2 respectively. There was no significant 

difference between groups after intervention. The leaking 

frequency, leaking amount, quality of life, and vaginal 

squeeze holding time were significantly improved in both 

groups. However, the maximal vaginal squeeze pressure 

was only improved in Group 2. Findings suggested that 

the effect of treating urinary incontinence utilising trunk 

muscle synergists was comparable with intensive pelvic 

floor muscle training. 



6 

Sacroiliac joint dysfunction, coccydinia, and altered 

pelvic floor muscle function: is there a link? 

Hungerford B 

Sydney Spine & Pelvis Centre 

Low back pain and sacroiliac joint dysfunction have 

both been shown to affect normal muscle recruitment 

patterns in the lumbo-pelvic region. The normal pattern 

of tonic activation of transversus abdominus (TrA), lumbar 

multifidus (LM) and pelvic floor muscles prior to and 

during movement has been shown to be altered in patients 

with low back pain. The delay in recruitment of local 

muscles decreases segmental stability of the lumbar spine, 

and is often associated with increased substitution of global 

muscle activity such as external and internal oblique, and 

erector spinae during loading tasks. Similarly, sacroiliac 

joint dysfunction and pelvic girdle pain have been shown 

to be linked to altered local muscle recruitment, including 

changes to pelvic floor function. Clinically we see 

decreased activation of pubococcygeus and iliococcygeus, 

with subsequent effects on bladder support and urinary 

continence. A common substitution pattern is increased 

activity of ischiococcygeus and piriformis. Ischiococcygeus 

muscle is regularly described as part of levator ani, however 

it is anatomically ineffective in lifting the levator plate. 

Conversely, tonic over activity of ischiococcygeus may 

create irritation of the pudendal nerve and sacrospinous 

ligament, and inflammation of the coccyx and inferior 

surface of the sacrum where it attaches. Current research 

linking sacroiliac joint dysfunction, coccygeus over activity, 

and coccydinia will be discussed, including suggestions for 

assessment and treatment. 

Does self-reported urinary incontinence at two days 

post-partum predict longer term urinary incontinence? 

Járos E, 1,2 Hirschhorn A, 1 Mungovan S 1 

1 

Westmead Private Physiotherapy Services, Sydney, 2 School of Public 

Health and Family Medicine, University of Cape Town, South Africa 

The aims of the study were to determine whether selfreported 

urinary incontinence in the acute post-partum 

period predicted longer term urinary incontinence, and 

to determine which birth-related factors contributed to an 

increased risk of post-partum urinary incontinence. All 

75 women who gave birth at Westmead Private Hospital, 

Sydney over a 2-week period were recruited to participate 

in the study. Participants completed the International 

Consultation on Incontinence Questionnaire – Short Form 

at 2 days, 6 weeks and 6 months post-partum. Birth-related 

data and history of pre-partum incontinence were collected 

from the medical record and patient interview. The primary 

outcome measure was presence or absence of self-reported 

urinary incontinence symptoms. Twenty-four percent of 

participants reported urinary incontinence at 2 days postpartum, 

40% at 6 weeks and 23% at 6 months. Univariate 

analysis found that those women who reported urinary 

incontinence at 2 days post-partum were more likely to 

report urinary incontinence at 6 weeks (67% versus 30%, 

p = 0.006). History of incontinence prior to pregnancy (p 

= 0.001) was associated with incontinence at 2 days postpartum, 

however incontinence during pregnancy was not 

(p = 0.21). Traditionally proposed risk factors for postpartum 

incontinence, specifically increased birth-weight, 

duration of second-stage labour and parity, did not predict 

longer term post-partum incontinence. The International 

Consultation on Incontinence Questionnaire: Short Form, 

administered 2 days post-partum, is a useful adjunct to 

identify women who may be at risk of longer-term postpartum 

incontinence. 

Rehabilitation during and following treatment for 

breast cancer 

Kilbreath SL 


Breast cancer is common in older women, with 1 in 11 

women diagnosed with the disease by the age of 75 years. 

However, the 5-year survival is high, with 87.7% alive at 5 

years following diagnosis, in part due to early detection and 

aggressive treatment. The treatments that successfully treat 

the cancer include surgery, radiotherapy, chemotherapy and 

hormones. However, they can also cause chronic problems: 

localised to the arm and chest on the side of surgery, eg, 

shoulder stiffness, weakness, pain, and swelling (i.e. 

lymphoedema) and/or systemic problems such as fatigue, 

osteoporosis, and sarcopenia. These problems can interfere 

with activities of daily living, affect quality of life and are 

likely to be associated with increased levels of psychological 

distress. Exercise during and following treatments may 

reduce the impact of these side-effects. For example, postoperative 

exercises directed at muscles of the scapula, spine 

and upper limb, and aiming to increase range, strength 

and motor control in the upper quadrant, are likely to 

alleviate these chronic upper limb symptoms. Adoption of 

an exercise regimen that includes aerobic exercise and high 

impact exercises may also reduce osteoporosis and fatigue. 

One chronic side-effect, lymphoedema, is uncommon 

but is feared by many, and is still not well-understood. 

Nevertheless, at least some of the beliefs, such as exercise 

exacerbating lymphoedema, are not supported by recent 

studies. In conclusion, exercise has a substantial role in 

rehabilitation during and following treatment for breast 

cancer. 

High rate of untreated incontinence in women 

presenting for major gynaecological surgery 

Liacos A, 1 Evans,J 1 Khera A, 2 Langford J,P 3 Wills V, 1 

Finlayson J, 1 Winter A, 1 Coburn P, 1 Pertich L, 1 

Holland AE4 ,5 

1 

Physiotherapy Department, Sandringham Hospital, 2 Caulfield 

Continence Service, Caulfield Hospital, 3 Southern Health, 4 La Trobe 

University, 5 Alfred Health, Melbourne. 

Urinary incontinence occurs in up to 40% of women and 

many will benefit from pelvic floor training. The aim of 

this study was to assess the prevalence of incontinence 

in women presenting for major gynaecological surgery at 

Sandringham Hospital; to determine the proportion who 

had previously received pelvic floor physiotherapy; and 

to document the uptake and outcomes of postoperative 

referral to continence services. All women admitted for 

major gynaecological surgery were eligible for inclusion. 

Pre-existing incontinence was assessed according to a 

standardised protocol and previous management was 

recorded; those with incontinence were offered continence 

clinic referral. Outcomes of continence clinic treatment 

were obtained from referral centres. Fifty-one women 

were included with mean age 52 years (range 33–88 years). 

Thirty-four women (67%) reported incontinence prior to 

surgery whilst 24% were admitted for surgical management 



of incontinence. Incontinence was also prevalent amongst 

those admitted with prolapse (54%) and uterine disorders 

(58%). Incontinence was documented in preadmission notes 

in only 56% of women and 3 women (9%) had previous 

contact with a continence clinic. Thirty-five participants 

accepted referral to a continence clinic and 67% of these 

attended. Seventy-five percent of attendees completed 

their treatment and had good outcomes (asymptomatic 

or improved). We conclude that incontinence is prevalent 

amongst women presenting for gynaecological surgery 

and most have not attended a continence clinic. Uptake of 

continence services is high post-operatively although not 

all complete treatment. Assessment of continence should 

be performed routinely in women presenting for major 

gynaecological surgery. 

After prostate cancer surgery: 

rehabilitation versus retraining 

Nahon I 

ACT Health, Community Health 

Post-operative pelvic floor muscle training is still a poorly 

researched area in males. The value of PFMT has been 

shown, but there is no research into the type of exercise, 

the dose or intensity. Before we can explore how to treat 

PF dysfunction in men, it is necessary to know how the 

muscles work within the male continence mechanism. The 

orientation of the smooth muscle fibres and the extent to 

which they track down the urethra, differs between the male 

and the female. The existence of the urogenital diaphragm 

in the male is being debated. The levator ani around the 

male urethra are not circular as previously thought but more 

of a horseshoe shape. Surgery for prostate cancer causes 

changes to the male continence mechanism. The prostatic 

urethra, which plays a large role in maintaining continence, 

is removed. The PF must learn to function in a more active 

role. As there usually is no direct damage to the levator 

muscle by surgery, learning when and how to activate the 

pelvic floor is important. Pelvic floor muscles need to be 

retrained rather than rehabilitated. Functional exercises are 

needed as the PF needs to be activated at lower levels of 

rises in abdominal pressure. This means that PFMT needs 

to be incorporated into other activities such as sport, lifting 

and sudden changes in position. The ‘knack’ has become 

an important part of retaining the male pelvic floor after 

prostate surgery as a way to reduce the leaks men are faced 

with post prostatectomy. 

Male continence promotion: men have a pelvic floor too 

Nahon I 

ACT Health, Community Health 

As more men are screened for and diagnosed with, prostate 

cancer, the pelvic floor physiotherapist is faced with a 

growing population of male patients. Treatment of men, 

whilst at times similar to managing continence in women, 

brings new challenges and problems. The male pelvic floor 

is not well understood, the male continence mechanism is 

still being explored and the psychosocial impact of male 

incontinence is wholly unresearched. There are also issues 

within the profession that have not yet been resolved. How 

does a female therapist assess a male pelvic floor? How 

valid is the assumption that we can take what we know 

about women and apply it to men? PPI requires careful 

assessment before it can be managed. Pre-existing LUTS 

need to be identified and managed. Careful quantification 

of leakage can assist with making a management plan 

and communicating with other team members. Teaching 

a man how to find and activate the pelvic floor prior to 

surgery will assist in retraining his pelvic floor after the 

continence mechanism has been altered. Functional pelvic 

floor exercises and the ‘knack’ need to be incorporated into 

other activities such as sport, lifting and sudden changes 

in position. The role of the pelvic floor physiotherapist is 

to educate and support the man through his journey. The 

psychosocial support that can be provided will improve 

the overall experience of the surgery and the recovery of 

continence. This workshop will give the experienced pelvic 

floor physiotherapist some basic knowledge to start treating 

men with post-prostatectomy incontinence. 

Pre-activation of transversus abdominis protects the 

rectus abdominis diastasis of post-partum women 

doing a head lift 

Ng Hung Shin PB, Osmotherly PG, Chiarelli P 

The University of Newcastle, Newcastle 

The aim of this study was to investigate the effect of a headlift 

on the rectus abdominis diastasis of the immediate 

post-partum women with and without pre-contraction of 

pelvic floor and transversus abdominis muscles. The impact 

of collagen deficiency on postpartum rectus abdominis 

diastasis was also explored. A within-patient, repeated 

measures study was conducted with 66 post-partum women 

in the postnatal ward of a large, non-urban, teaching hospital. 

The size of rectus abdominis diastasis was measured in mm 

using a digital calliper. Markers of collagen deficiency were 

taken as presence of benign joint hypermobility syndrome, 

assessed using the Beighton scale. Type I collagen deficiency 

was determined through the presence of marked abdominal 

striae. Women doing a head-lift without a pelvic floor and 

transversus abdominis muscles pre-contraction had a 15% 

increase in the size of their rectus abdominis diastasis as 

compared to no measured change when the same women 

pre-activated the muscles. The presence of benign joint 

hypermobility syndrome appeared to have no association 

with rectus abdominis diastasis (p = 0.97). When measured 

during head-lift with pre-contraction, women with Type I 

collagen deficiency, showed less reduction in their rectus 

abdominis diastasis (mean -3.58, 95% CI -0.03 to -7.11) when 

compared to women without collagen deficiency. The results 

indicate that it may be worthwhile for physiotherapists to 

teach post-partum women to activate their core muscles to 

protect their rectus abdominis diastasis. Moreover, the data 

also suggest that it may be sensible to prioritise treatment 

time to women with marked abdominal striae. 

Pregnancy-related low back and pelvic girdle pain: 

a practical approach 

Pierce H 

Pregnancy-related low back and pelvic girdle pain is pain of 

musculoskeletal origin that is experienced in the lumbar and/ 

or sacroiliac and/or symphysis pubis area during pregnancy 

or in the immediate postpartum period. At least half of 

all pregnant women experience low back and/or pelvic 

girdle pain which may significantly affect their mobility, 

daily functioning and psychological health. There has 



been a plethora of research and clinical observations in the 

management of pelvic-girdle pain in recent years however 

the assimilation and application of this new knowledge into 

clinical practice remains challenging. This workshop aims 

to introduce the novice clinician to assessment methods and 

treatment choices for pregnant and postnatal women who 

present with low back and/or pelvic girdle pain. Common 

clinical presentations will be discussed and various 

management options explored. 

8 

From muscles to midwifery 

Pierce H 

Midwifery is an ancient profession, yet in Australia is it only 

in recent years that midwifery has begun establishing itself 

as an autonomous profession. Some would say that it is more 

than a profession – it is a calling. ‘Catching’ babies would 

have to be one of the most wonderful and yet potentially 

terrifying jobs that you could ever have. As a physiotherapist 

of many years experience, the last 15 in women’s health and 

the last 10 in a tertiary referral hospital that delivers ~ 4500 

babies a year, I found myself frustrated with the system, 

realising that I could no longer continue to just pick up the 

pieces of a woman’s pregnancy and birth trauma. I was also 

discouraged and saddened by many women’s experiences 

of birth and the rates of medical intervention. I was tired 

of repeating over and over again: ‘No, back pain is not a 

normal part of pregnancy, it is common, but it is definitely 

not normal’. I decided that I needed to be where the action 

was; to cross over the professional line and work in the birth 

unit so that I could visualise again and again this amazing 

biomechanical, physiological and spiritual process called 

birth. The experience of becoming a midwife has been the 

most challenging and yet the most rewarding of my life. 

I am thankful for this opportunity to share my journey 

and future professional path, with the goal of improving 

outcomes for the childbearing women. 

The development of an incontinence treatment 

motivation questionnaire for patients undergoing 

pelvic floor physiotherapy in the treatment of stress 

incontinence 

Sarma S, Thakkar K, Hayes W, Karantanis E, Hawthorne 

G, Moore KH 

At present there are no validated questionnaires to assess 

a person’s motivation with pelvic floor muscle training. 

The purpose of this study was to design and validate a 

questionnaire for those women undergoing this treatment 

for stress urinary incontinence. Some studies have noted 

that motivation to comply with pelvic floor muscle training 

is an important predictor of a positive outcome, increasing 

the cure rate. No research has been conducted to assess the 

role of motivation as a prognostic indicator. This was the 

initial development of the test instrument and was conducted 

in collaboration with the Department of Psychiatry. Five 

broad domains relating to motivation to persist with pelvic 

floor muscle training, were developed by personal interview 

with women who had previously undertaken pelvic floor 

muscle training. Fifteen common themes emerged. After 

culling, there were 73 questions in the pilot questionnaire. 

Each question was linked to a 5-point Likert scale (strongly 

agree to strongly disagree). The initial questionnaire was 

completed by 101 women with stress urinary incontinence 

and who had had at least one episode of pelvic floor muscle 

training. After factor analysis, the final version, comprised 

21 items, gives sufficient internal consistency with each 

domain scale accounting for a reasonable proportion of 

variance. The final version gives a good representation of 

the clinically important factors that affect motivation for 

pelvic floor muscle training. A prospective observational 

study is underway. 

The effect of sitting posture and breathing patterns 

on pelvic floor and abdominal muscle activity during 

coughing 

Sapsford RR, Hodges PW 

Centre of Clinical Research Excellence in Spinal Pain, Injury and 

Health, Department of Health and Rehabilitation Sciences, The 

University of Queensland, Brisbane 

This study investigated the effect of sitting posture 

and breathing patterns on pelvic floor and abdominal 

muscle activity during coughing. In 8 healthy women 

mouth pressure, intra-abdominal pressure, surface 

electromyographic activity of left and right superficial and 

deep pelvic floor muscles and fine wire electromyographic 

activity of 4 abdominal muscles were monitored during 

cough in slump supported and upright unsupported sitting 

with self-selected, diaphragmatic and thoracic breathing 

patterns. During coughing, mouth pressure was not 

affected by posture or breathing but the cough-related 

increase in intra-abdominal pressure was less in slumped 

(p = 0.02). Activity in all pelvic floor muscles increased 

above baseline during coughing (p < 0.001). Although 

deep pelvic floor activity was not affected by posture or 

breathing; superficial pelvic floor activity was greater in 

slumped than upright (left p < 0.001, right p < 0.01). During 

coughing, activity in all abdominal muscles increased (p 

< 0.001). Transversus abdominis activity was affected by 

posture (p < 0.01) (greater in upright) and by breathing 

(p < 0.007) (greatest with thoracic breathing), obliquus 

internus abdominis activity was affected by breathing (p 

< 0.03) (greater during self-selected breathing in slumped), 

obliquus externus abdominis activity was affected by 

posture (p < 0.02) (greater in upright) and by breathing 

(p < 0.02) (greatest with thoracic breathing), and rectus 

abdominis activity was not affected by posture or breathing 

pattern. Activity in both pelvic floor and abdominal muscle 

groups is affected by sitting posture during coughing, but 

the changes are variable. Breathing patterns only influence 

abdominal muscle activity. 

Evaluation of outcome measures for stress urinary 

incontinence in older women 

Sherburn M, 1 Bø K, 2 Galea MP 1 

1 

Melbourne Physiotherapy School, The University of Melbourne, 

2 

Norwegian School of Sports Sciences, Oslo, Norway 

The aim of this study was to determine valid and responsive 

outcome measures for assessing treatment outcomes in an 

elderly female sample with stress urinary incontinence. 

The analyses were performed using data from a previously 

reported RCT (n = 76). Concurrent and predictive validity, 

responsiveness, and minimal clinically important difference 

needed to detect a treatment effect, were evaluated for cough 

stress tests with and without a pre-contraction of the pelvic 

floor muscles, the ICIQ-UI SF (International Consultation 

on Incontinence Questionnaire-Urinary Incontinence Short 

Form), leakage episodes in a seven-day Accident Diary, 



Bother 10cm VAS (visual analogue scale), and participant 

perceived global rating of change of symptoms (global 

change) at the primary end-point (20 weeks intervention). 

Results indicated that the ICIQ-UI SF and Accident Diary 

were the most valid and responsive outcome measures for 

assessing stress urinary incontinence outcomes in older 

women, and showed moderate effect sizes (0.51 and 0.39). 

The scores needed to detect a minimal clinically significant 

difference between the two intervention groups were two 

points on the 21-point ICIQ-UI SF, and six leakage episodes 

per week on the Accident Diary. Poor predictive validity 

was demonstrated for all measures with global change (r < 

0.1), but for all measures other than the stress tests, moderate 

concurrent validity was demonstrated (r = 0.36 to 0.43, p 

< 0.001). Global change scores significantly discriminated 

between participants who improved and those who did 

not, for all outcome measures other than the stress tests, 

indicating significant responsiveness (p < 0.001). This 

information can be used for planning future trials in older 

populations. 

Postgraduate physiotherapy students’ perceptions of 

learning pelvic floor assessment through peer physical 

examination (PPE): a questionnaire 

Tan JS, Delany C, Frawley HC 

The University of Melbourne, Melbourne Physiotherapy School, 

Melbourne 

This paper examined via a questionnaire, the perceptions 

of physiotherapists who participated in peer physical 

examination (PPE) during a 4-week postgraduate pelvic 

floor course. During the course, PPE involved using 

students as human subjects for each other when conducting 

internal pelvic examinations performed via vaginal or 

rectal palpation. All participants (n = 21) attending the 

course completed the questionnaire that examined their 

experience of learning pelvic floor physiotherapy skills 

using PPE, and the adequacy of the informed consent 

process for participation. Ninety percent of participants 

agreed that PPE is an important way to learn techniques 

of pelvic floor examination and treatment. However, the 

majority disagreed that PPE was the only way to learn these 

techniques. Suggestions for alternative methods included 

using paid models or volunteer patients; teaching videos; 

observation of experienced practitioners and using cadaver 

specimens. Less than half (47%) felt comfortable being a 

patient during the course. Almost all participants agreed that 

they were given adequate information and a clear choice to 

participate in the PPE component of this course. However 

their discomfort in participating and their suggestions for 

alternative teaching methods highlights a need for wider 

discussion and debate about the use of PPE as a learning 

technique and further identification of associated ethical 

issues. Although this survey was confined to a specific area 

of physiotherapy practice, discussion about the value of and 

ethical issues arising from using PPE for learning practical 

physiotherapy skills is relevant to all physiotherapy students 

and educators. 

Do women with incontinence need to learn to relax the 

pelvic floor muscles? 

Thompson J, Bogoias N, Boucher E, Briffa K 

Curtin University of Technology, Perth, WA 

Digital palpation is used to assess the pelvic floor muscles 

for signs of dysfunction at rest, during contraction and 

relaxation. In women presenting with symptoms of urinary 

incontinence the proportion of women that have difficulty 

relaxing the pelvic floor muscles has not previously 

been reported. The aim of this study was first to assess 

the proportion of women presenting with symptoms of 

urinary incontinence who have difficulty relaxing after 

performing voluntary pelvic floor muscle contractions and 

second to assess in each of the symptomatic groups: stress, 

urge and mixed urinary incontinence if the proportion of 

women differed between groups. Using an observational 

study design a retrospective audit of women attending a 

private physiotherapy clinic with symptoms of urinary 

incontinence over a 12-month period were reviewed. Three 

continence and women’s health physiotherapists (JT, NB, 

EB) had assessed 137 women by vaginal examination and 

direct palpation of pelvic floor muscles. On analysis 79.6% 

(109/137) had some difficulty fully relaxing after voluntary 

pelvic floor muscle contractions. The proportion of women 

with difficulty relaxing the pelvic floor differed between 

groups (χ2 (2 ) = 10.6; p = 0.005), with a higher proportion 

in the urge incontinence group (97%) compared with stress 

incontinence (78%; χ2 (1) = 6.2; p = 0.013), or mixed 

incontinence (69% χ2 (1) = 10.7; p = 0.001). These data 

suggest pelvic floor rehabilitation programs should include 

training to fully relax the pelvic floor muscles in addition to 

strength and conditioning components. 

Intra-rater reliability of transabdominal ultrasound, 

transverse and sagittal, in measuring bladder base 

movement during pelvic floor muscle contractions and 

functional manoeuvres 

Thompson JA, Carroll S 

Curtin University of Technology, Perth, WA 

Transabdominal ultrasound has been used to assess 

voluntary pelvic floor muscle contractions and pelvic 

floor activation during functional manoeuvres. To date a 

comprehensive analysis of the reliability of transabdominal 

ultrasound measurements of bladder base movement 

during functional manoeuvres has not previously been 

undertaken. Thus the aims of this study were to assess the 

intra-rater reliability of transabdominal ultrasound using 

the transverse and sagittal views during pelvic floor muscle 

contractions, Valsalva and abdominal curl manoeuvres. 

Twenty female volunteers with a mean (SD) age of 43 (8) 

yrs, BMI 23 (3) kg m 2 and a median parity of 1 (range 0–4) 

were assessed on two occasions one week apart by the same 

experienced continence and women’s health physiotherapist. 

Transabdominal ultrasound assessment was performed with 

the subjects in the crook lying position using a curved linear 

array probe (3.5 MHz). A previously described standardised 

protocol was used. Measurements were taken at rest and 

at the peak of each contraction or manoeuvre using both 

views. Intraclass correlations and 95% confidence intervals 

showed very good reliability for measurements for both 

views during the voluntary contractions (Transverse 0.89 

[0.57–0.93], Sagittal 0.86 [0.68–0.95]). Better reliability 

however was found in the transverse view compared to the 



sagittal view for the functional manoeuvres (abdominal curl: 

Transverse 0.84 [0.62–0.94] versus Sagittal 0.72 [0.39–0.88] 

and Valsalva: Transverse 0.82 [0.58–0.92] versus Sagittal 

0.76 [0.47–0.90]). These results indicate that transverse 

and sagittal views can be recommended for assessment of 

voluntary pelvic floor muscle contractions but the transverse 

view is more reliable during functional manoeuvres. 

10 









2 

Support-group based exercise to address risk factors 

for falls in people with Parkinson’s disease: 

a randomised controlled trial 

Allen NE, 1 Canning CG, 1 Sherrington C, 2 Fung VSC, 3 

Murray SM, 1 ,O’Rourke SD 1 

1 

The University of Sydney, Sydney, 2 The George Institute for 

International Health, The University of Sydney, Sydney, 3 Westmead 

Hospital, Sydney 

Leg muscle weakness, reduced balance and freezing are 

potentially remediable risk factors for falling in people 

with Parkinson’s disease. This randomised controlled trial 

with blinded assessment aimed to determine the effect of 

a 6-month support-group based exercise program on these 

risk factors. Forty-eight participants with Parkinson’s 

disease who had fallen or were at risk of falling were 

randomised into an exercise (n = 24) or control (n = 24) 

group. The exercise group attended one exercise class each 

month which included progressive leg strengthening and 

balance exercises as well as techniques to reduce freezing. 

Participants also exercised three times a week at home. 

Risk of falling was assessed with tests of: knee extensor 

muscle strength (kg); balanced standing (coordinated 

stability test) and freezing (Freezing of Gait Questionnaire). 

Physical abilities (fast walking speed and time to complete 

5 repetitions of sit to stand), fear of falling and quality of 

life were also measured. The exercise group had greater 

improvements in freezing (mean = -2.8, 95% CI -5.4 to 

-0.3) and sit to stand time (mean = -1.9 s 95% CI -3.6 to 

-0.2) compared to the control group. The exercise group 

also showed trends toward improvement in knee extensor 

strength (p = 0.08), fast walking speed (p = 0.21) and fear of 

falling (p = 0.10) when compared to the control group. There 

were no between-group differences in balanced standing 

or quality of life. The exercise program improved two risk 

factors for falling in people with Parkinson’s disease. 

Improved mobility can mean increased fall and 

fracture risk: understanding the mobility, fall and 

fracture relationship in residential aged care 

Barker A, 1,2 Nitz J, 1 Low Choy N, 3 Haines T 4 

1 

Division of Physiotherapy, School of Health & Rehabilitation Sciences, 

The University of Queensland, Brisbane, 2 The Northern Clinical 

Research Centre, Melbourne, 3 Faculty of Health Sciences and Medicine, 

Bond University, Robina, 4 Southern Physiotherapy School, Monash 

University 

The aim of this study was to explore the relationship between 

mobility and fall and fracture risk using the Physical 

Mobility Scale (PMS). A development-external validation 

study was carried out in nine residential aged care (RAC) 

facilities. There were 99 residents in the development 

cohort and 87 in the validation. PMS assessments and fall 

and fracture data were obtained by retrospective audit for 

the development analysis. Validation data were obtained 

through a prospective study with assessments completed 

at baseline, two and four months after baseline. Survival 

analysis was used to explore the relationship between 

fall and fracture risk and PMS total and item scores. 

Data on 423 falls and 23 fractures were analysed. A nonlinear 

relationship between risk of falling and sustaining 

a fracture and mobility was found, with mild to moderate 

mobility impairment (PMS total score 28–36) the highest 

risk category (Fall:Hazard Ratio [HR]:2.18, 95% CI:1.65– 

2.87, p = 0.000). Univariate analysis found that the risk of 

falling increased as mobility improved between the item 

score of 0 to 4 for bed and chair mobility items and 0 to 3 

for standing mobility items. There is a complex relationship 

between falls and fracture risk and mobility. Residents with 

mild to moderate mobility impairment are at greater risk of 

falling and sustaining a fracture than residents who are nonambulant 

or independent. Falls prevention strategies in RAC 

that focus on increasing resident mobility may increase risk 

of falling and sustaining a fracture in some residents. 

Reliability and validity of a ‘low-tech’ choice stepping 

reaction time test 

Barraclough E, 1, , Sherrington C, 2,1 Delbaere K, 1,3 Lord SR 1 

1 

Prince of Wales Medical Research Institute, The University of New 

South Wales, Sydney, 2 The George Institute for International Health, 

The University of Sydney, Sydney, 3 Ghent University, Ghent, Belgium 

Choice stepping reaction time (CSRT) has been found to be 

a composite measure of falls risk in older people. We have 

developed a portable ‘low-tech’ CSRT procedure which 

involves a thin flexible rubber mat marked with 6 rectangles 

and a set of 20 verbal cues. The person is asked to step as 

quickly as possible to the given position whilst maintaining 

balance. The total time to complete the last 10 steps is 

recorded. This study aimed to establish the test re-test 

reliability of the CSRT mat and compare measures taken on 

the mat to measures taken on the original electronic CSRT 

device in older people. Forty-five people participated in this 

study: 15 rehabilitation inpatients (mean age = 81.6, SD = 

6.2, 11 women), 15 older community dwellers (mean age = 

80.53, SD = 5.9, 7 women) and 15 younger people (mean 

age = 28.5, SD = 4.4, 8 women). Participants were tested 

on the mat on two consecutive days. The older community 

dwellers and rehabilitation inpatients were also tested on 

the original CSRT device on the first study day. Test-retest 

reliability for the CSRT mat was good (ICC (3,1) = 0.70, 

95% CI 0.51 to 0.83, p < 0.001) and there was a strong 

correlation between the performance on the original CSRT 

device and on the mat (r = 0.84, p < 0.001). Our current 

studies are investigating whether the low-tech CSRT device 

can predict falls and whether it is a useful outcome measure 

in clinical trials. 

Stroke rehabilitation in the 21st Century 

Bernhardt J 

National Stroke Research Institute (part of the Florey Neuroscience 

Institutes), Melbourne, La Trobe University, Melbourne 

Our understanding of stroke and its management has changed 

markedly in the last 20 years. ‘Time is brain’ is the new 

catch cry and estimates that patients experiencing a typical 

large vessel acute ischemic stroke lose 120 million neurons, 

830 billion synapses, and 714 km of myelinated fibres 

each hour have prompted a new approach to acute stroke 

management. Rehabilitation models are also changing, 

with greater emphasis on commencing rehabilitation 

within hours (not days) of stroke within dedicated stroke 

units. Australia lags behind the world in the uptake of 

these dedicated units, with an estimated 25% of Australian 

hospitals providing a model of care which represents one 

of the most powerful interventions to save lives and reduce 

disability. Physiotherapists are an integral part of this care 

model. Post acute rehabilitation is also changing, with 

fewer beds available and greater pressure on services to 

get patients home within weeks of admission. So what does 

this all mean for physiotherapists? In this presentation, 



the opportunities and challenges facing physiotherapists 

treating people with stroke will be discussed. 

Fit and free: a falls prevention exercise program for 

community-dwelling rural elders 

Blackman KR, 1 Sherrington C, 2 Rivett DA, 1 Jones PJ 1 . 

1 

University of Newcastle, Newcastle, 2 The George Institute for 

International Health, Sydney 

This paper explores whether a specifically designed exercise 

program reduced risk factors for falls among communitydwelling 

elders. Consideration is also given to effects of the 

intervention on participant’s quality of life and the usability 

of the intervention in a rural clinical setting. A randomised 

control multi-centre trial was conducted in Northern NSW. 

All participants received a standard information booklet. 

Participants in the intervention group also received a 13- 

week exercise program (weekly class and home exercise 

program). Nine exercise programs were delivered to groups 

of 8–9 participants. The primary outcome measures were 

composite Physiological Profile Assessment (PPA) score 

and Berg Balance Scale total score. To evaluate the process 

and impact of the intervention, semi-structured interviews 

were undertaken with participants. Participants attended a 

mean of 9.1 (2.9 SD) exercise classes. The primary outcome 

measures of PPA score (p = 0.012) and Berg Balance 

score (p = 0.043) improved significantly in response to the 

intervention. Qualitative analysis revealed 4 main themes; 

delivery format, type of exercise, exercising in a group, and 

a range of biopsychosocial outcomes which led to enhanced 

quality of life. Results of the trial show a significant 

reduction in falls risk factors in response to the exercise 

program. Over and above the physical benefits, participants 

identified a variety of psychosocial outcomes. With respect 

to this and other falls prevention interventions, a number of 

considerations were identified to assist implementation into 

rural clinical practice. 

Prevalence of osteoporotic vertebral fractures in older 

Australian men: findings from the CHAMP study 

Bleicher,K 1 Naganathan V, 1 Seibel MJ, 1,2 Sambrook PN, 1,3 

Cumming RG 1 

1 

CERA and School of Public Health, University of Sydney, Sydney, 

2 

Bone Research Program, ANZAC Research Institute, Sydney, 3 Kolling 

Institute, University of Sydney, Sydney 

Vertebral fractures are a hallmark of osteoporosis, a sign 

of decreased bone strength and a risk factor for future 

osteoporotic fractures. We determined the prevalence of 

vertebral fractures in a large cohort of elderly Australian 

men, proportion of men presenting to physiotherapists with 

back pain and prevalent vertebral fractures, and association 

of vertebral fractures with back pain. In 2005–2007, 1705 

men aged ≥ 70 were recruited for a large epidemiological 

study focusing on the health of older men, (The Concord 

Health and Aging in Men Project (CHAMP). All men from 

a defined geographical region in Sydney were invited to 

participate. Data were collected through questionnaires and 

clinical assessments. Vertebral fractures were identified by 

vertebral morphometry from lateral DEXA scans. Of the 

1506 men with vertebral scans, vertebral fractures were 

present in 294 (19.5%) men, One hundred and eighty-three 

(12.2%) had pain between thoracic T6–12 and 597 (39.6%) 

had lost ≥ 5cm height since age 25. Height loss and thoracic 

pain were both associated with vertebral fractures (p < 0.001 

RR = 1.48 95% CI 1.21 to 1.81) and (p = 0.03 RR = 1.37 

95% CI 1.04 to 1.79) respectively. Of 17 men ≥ 85 years with 

thoracic pain, 7 (41%) had vertebral fractures. Two-hundred 

and sixty-three men had seen a physiotherapist at least once 

in the previous 12 months, of whom, 41 (15.6%) had prevalent 

vertebral fractures. Eighty-three percent of these men were 

unaware they had osteoporosis. Osteoporotic vertebral 

fractures are prevalent but under-diagnosed in elderly men 

who may present to physiotherapists with thoracic pain. 

Chronic pain 

Blyth F 

Pain Management Research Institute (Royal North Shore Hospital) & 

School of Public Health, University of Sydney 

Pain can represent a challenge to everyday functioning in 

older people, and evidence from population studies dispels 

the idea that it is a benign phenomenon in old age. Pain that 

intrudes on daily life requires attention, and often occurs in 

older people with dealing with other health-related demands 

of ageing. In this talk I will explore recent developments 

in understanding pain in older people, using findings from 

epidemiological studies. 

Nutritional status in relation to balance in the frail 

elderly: a preliminary look at vitamin D and albumin 

Boersma D, 1 Demontiero O, 1,2 Suriyaarachchi P, 1 

Sharma A, 1 Duque G 1,2 

1 

Department of Geriatric Medicine, Nepean Hospital, Penrith, 2 Aging 

Bone Research Program, Nepean Clinical School, University of Sydney, 

Penrith 

Balance problems are an important risk factor for falls, 

especially in the frail elderly population. The association 

between balance problems and nutritional status remains 

unclear. In this study, we investigated the impact of two 

nutritional elements (vitamin D and albumin) on balance 

disorder in a frail elderly population. Balance assessment 

was performed in 55 fallers attending the ‘Falls and 

Fractures Clinic’ at Nepean Hospital. Balance parameters 

namely limits of stability (LOS), eyes closed on foam (ECF) 

and visio-vestibular condition (VVC) were measured using 

a Balance Rehabilitation Unit (Medicaa). Blood tests for 

serum vitamin D [25(OH)D3] and albumin were conducted. 

Serum vitamin D was significantly lower (< 55 nmol/l) in 

patients with alterations in VVC (108 ± 2.1 vs. 127 ± 2 cm2, 

p = 0.02). No correlation between vitamin D deficiency and 

LOS or ECF was found. In contrast, serum albumin was 

significantly lower (< 35 nmol/l) in patients with alterations 

in LOS (45 ± 2 vs. 16 ± 4 cm2, p = 0.05) and ECF (38 ± 3 

vs. 4 ± 2 cm2, p = 0.02). In summary, low levels of vitamin 

D were associated to visio-vestibular alterations that have 

been correlated with increasing risk of falls. In contrast, 

low albumin was associated with balance parameters that 

require appropriate muscular strength. In conclusion, using 

an objective measurement of balance in a frail elderly 

population we have identified a different role of vitamin D 

and albumin in balance control. Further studies are required 

to elucidate the mechanisms of these associations. 



Effects of a physical therapy program with clientcentered 

approach on functional balance in the elderly 

4 

Boonyarat S, 1 Nualnetr N, 2 Eungpinichpong W, 2 

Emasithi A 2 

1 Khon Kaen Hospital, Thailand 

Falls are an important cause of death for adults aged 65 

years and above. Most studies about strategies to prevent 

falls have involved exercises to promote strength and 

balance. However, these exercise programs were designed 

by therapists without the participation of the elderly in 

designing the programs. The objective of this research was 

to study effects of a physical therapy program with clientcentered 

approach on functional balance in the elderly. A 

12-week study was conducted on 9 elders with fall risks (2 

men and 7 women, mean age 77.4 ± 5.8 years) of Samliam 1 

community, Khon Kaen Province. During the first 4 weeks, 

specific problems relating to functional balance of each 

subject were assessed and discussed between the subject 

and the investigator, after which a physical therapy program 

with client-centered approach to improve functional balance 

was cooperatively designed and individually tailored to 

each elder. The subject was then instructed to perform the 

program for 8 weeks. The subject’s functional balance was 

assessed at baseline and at every 4 weeks until the end of 

the study, and analysed by paired t-test. It was found that 

the physical therapy program with client-centered approach 

significantly improved the Berg Balance Scale (p < 0.05). 

However, it was observed that changes in the functional 

balance scores were frequently influenced by pain at any 

body part of the subjects, but the physical therapy program 

did not pay much attention on the issue of pain. Therefore, 

therapists should widen their approach to cover other factors 

relating to balance as much as possible. 

Environmental challenges to outdoor walking in 

community-dwelling elders 

Brauer SG, 1 Mackay A, 1 Chose L, 1 Hennessy A, 1 Mucci V, 1 

Simmons L, 1 Mulrain K, 2 Low Choy NL 3 

1 

The University of Queensland, Brisbane, 2 Eastern Health, Melbourne, 

3 

Bond University, Gold Coast 

The aim of this study was to determine what environmental 

challenges are most frequently reported by older adults 

who self-report difficulty with outdoor walking. A second 

aim was to determine the relationship between the level of 

difficulty and individual factors of walking ability, balance 

performance, balance confidence and global perceived 

control. Forty community-dwelling, ambulant adults aged 

> 65 years were asked to report if they did or did not 

experience difficulty when walking outside. They completed 

a questionnaire detailing their self-perceived difficulty 

when walking within eight domains of environmental 

challenges: walking distance, speed, ambient conditions, 

terrain characteristics, physical load, attention demands, 

postural transitions, and density (crowds). Walking ability 

was measured using Timed Up and Go and 10m walk tests. 

Balance was measured using a step test and timed stance 

performance. Balance confidence and global perceived 

control were also examined. Those subjects with selfreported 

difficulty with outdoor walking (50% of subjects) 

most frequently reported difficulties in the environmental 

domains of terrain (uneven surfaces), distance (walking > 

500m), and transitions (getting into and out of a car). Selfreported 

community walking was positively correlated with 

walking ability, balance performance, balance confidence 

and global perceived control. Environmental factors, 

particularly terrain, and individual factors were associated 

with self-reported difficulties with outdoor walking, thus 

should be addressed in assessment and management. 

Task switching during dual task gait training is 

difficult for people with Parkinson’s disease 

Brauer SG, 1 Morris M, 2 Lamont RL, 1 Woollacott M 3 

1 

The University of Queensland, Brisbane, 2 University of Melbourne, 

Melbourne, 3 University of Oregon, Eugene, USA 

The aim of this study was to determine the effect of 

prioritisation during dual task walking training on gait 

under dual task conditions in people with Parkinson’s 

disease (PD). Forty people with PD attended a 20 minute 

dual task walking training session. Half were instructed to 

attend equally to gait and a variety of added cognitive tasks 

(50–50%, fixed priority). The other half was instructed to 

switch attention between tasks with every trial (e.g. 80% 

attention on cognitive task trial 1, 20% trial 2, variable 

priority). Spatio-temporal gait performance under dual task 

conditions and added task performance were measured pre 

and post training and compared between groups. Attendance 

to each task during training was evaluated via self reported 

visual analogue scales (VAS). Both groups showed an 

increase in dual task step length and speed with training 

(p < 0.001). There was no difference between groups 

in improvement in step length (p > 0.511) or speed (p > 

0.686). The VAS scores indicated that the variable priority 

group did not switch attention between tasks as instructed 

(mean inaccuracy 36% ± 18%), whereas the fixed priority 

group reported maintaining attention closer to their goal 

(mean inaccuracy 10% ± 12%). Varying attentional priority 

between tasks is suggested to maximise dual tasking gains 

with training, however this cohort of people with PD found 

switching their attention between a gait and cognitive 

task from trial to trial (variable priority training) difficult. 

This strategy may be more useful as a progression in this 

population rather than an initial approach. 

Easy Moves for Active Ageing®-EMAA: 

from Active Ageing Australia® 

Brooks P 

Created and launched by Active Ageing Australia® in 

2000, Easy Moves for Active Ageing®-EMAA, has been 

developed by leading professionals in the fields of aged 

care, fitness, health promotion and active ageing, including 

Pauline Brooks OAM, Robin Townsend AUA (Physio), 

Grad Dip (Gerontology) and Bob Barnard, Chief Exercise 

Physiologist, Centre for Physical Activity in Ageing. EMAA 

has been designed to provide people working in the field 

of residential and community aged care with a foundation 

and framework from which to conduct a safe and effective 

physical activity and exercise program to cater for less active, 

older persons residing within residential care facilities as 

well as the community. Endorsed by the National Service 

Industries Skills Council, over 2000 leaders throughout 

Australia, including physiotherapy aides, diversional 

therapists, community and care workers, have participated 

in the two day EMAA training program. Central to the 

program is the EMAA manual, a clear guide and resource for 

core modules of Flexibility, Strength and Balance, set within 

the social context of active ageing. Participant feedback 



indicates that EMAA has provided skills, knowledge and 

confidence to those conducting exercise classes and working 

collaboratively with health professional colleagues in the 

implementation of rehabilitation programs. Pauline will 

explore the development of EMAA as a model of quality 

program design and, in their breakfast session, together 

with Sally Castell, will demonstrate practical aspects of 

program design and maintenance in response to changing 

population needs and in relation to the collaborative and 

integrated nature of today’s program and service delivery 

models. 

The Australian Longitudinal Study on Women’s 

Health: changes in physical activity and weight over 

time and the implications of this for healthy ageing 

Brown WJ 

The University of Queensland: School of Human Movement Studies. 

The Australian Longitudinal Study on Women’s Health 

is a broad-ranging prospective cohort study which is 

examining relationships between biological, physical, 

social and lifestyle factors and women’s physical health, 

emotional well-being, and use of and satisfaction with 

health services. It involves 3 age cohorts of women who 

have now been surveyed 4 or 5 times since 1996: young 

women who were born in 1973–1978 (age 18–23 years in 

1996), mid-age women born in 1946–1951 (45–50 years in 

1996), and older women born in 1921–1926 (aged 70–75 

years in 1996). Data collected over 10 years show falling 

levels of physical activity in the young and older cohorts, 

and increasing weight in the young and mid-age cohorts. 

In all age groups, life-events such as getting married and 

widowhood, having babies and grandchildren, are strongly 

associated with changes in physical activity in the young 

and mid-age cohorts. However, the main factor associated 

with declining physical activity in the older cohort is major 

surgery or illness. Higher weight in old age is associated 

with increasing incidence and prevalence of heart disease 

and diabetes, but lower prevalence of osteoporosis. The 

importance of maintaining healthy activity and weight in 

older age, and the potential role of physiotherapists in this 

will be considered. 

Get up, get active: exercise and the older adult 

Castell S 

Northern Sydney Central Coast Health Service 

There are multiple exercise recommendations, research 

evidence, choices and programs to select from but one 

program does not, will not and should not accommodate all. 

There are multiple levels of ability, health state and fitness 

in the older adult population. A variety of appropriate 

exercise programs are needed to reduce many health 

issues associated with aging. Virtually all older adults can 

benefit from regular physical activity as an active lifestyle 

is a key component of healthy and successful living. The 

evidence emerging in recent years concerning exercise has 

demonstrated exercise as being a major modifiable factor 

that plays an important role in the reduction of morbidity 

and mortality for many chronic diseases. There are also 

strong links relating with regular physical activity to a 

wide range of physical, social and mental health benefits. 

Exercise programs need to aim at: increasing the number 

of people undertaking appropriate exercise programs, 

improving the identified physiological problems, adapting 

and tailoring programs to suit individual needs and abilities 

that will provide the proper amount of physical activity to 

attain maximal benefits at lowest risk. Key issues to consider 

when planning and conducting exercise programs are that 

the strategies need to be in context, accessible, relevant, 

flexible and realistic to achieve the best results. This session 

will cover the big picture issues relating to exercise for the 

older adult (with a practical component where appropriate) 

Continence status of ageing Australian women: 

a fluid situation 

Chiarelli PM 

University of Newcastle 

Urinary incontinence (the accidental leaking of urine) is 

a major problem in Australia and has a significant impact 

on quality of life, affecting the social, psychological, 

physical and financial aspects of life. The prevalence of 

urinary incontinence is significantly higher in women 

than in men. The Australian longitudinal women’s health 

study provides a the opportunity to focus on a cohort of 

older women representative of a population group which 

is growing in size as the population as a whole ages 

and which is at high risk of falls and fractured bones. 

Overactive bladder symptoms associated with ageing have 

also been shown to be significantly associated with falls. 

The use of longitudinal data allows for the determination 

of new cases of incontinence (incidence) and also allows 

for the identification of temporal relationships between 

incontinence and associated disability. The Australian 

longitudinal women’s health study provided longitudinal 

data on the prevalence and incidence of incontinence from a 

large cohort of older women, over 9 years of follow-up. Over 

this time, 14.6% (95% CI: 13.9–15.3) of the women in the 

study who had previously reported ‘rarely’ or ‘never’ leaking 

urine, developed incontinence. Women participating in the 

latest survey were twice as likely to report incontinence 

as they had been 6 years earlier. Longitudinal models 

demonstrated significant associations between incontinence 

and a number of health issues including dementia, falls to 

the ground, Body Mass Index, constipation, urinary tract 

infection, history of prolapse and prolapse repair. These 

associations will be discussed further. 

Engaging older people in fall prevention activities 

Clemson L 

University of Sydney 

Working with older people to prevent falls also requires an 

understanding of key concepts that enable people to become 

more aware, make decisions to change lifelong habits and 

incorporate and sustain changes over time. It is about how 

we communicate and work with people as we engage them 

in falls prevention strategies and activities. This presentation 

will explore some of these key concepts: enablement, 

exerting control, efficacy beliefs, decision making and how 

we might use them in falls prevention. Several successful 

community programs and approaches will be used to 

provide illustrative examples. Programs include ‘Stepping 

On’, a group-based preventive program and LiFE, a new 

individualised program to incorporate balance and strength 

training into daily life activities. 



6 

Can we really change clinical practice 

Close JCT 

Prince of Wales Hospital and Prince of Wales Medical Research 

Institute, UNSW, Sydney 

There is limited research evidence to show that it is possible 

to prevent falls across a hospital yet policy and guidelines 

actively pursue this goal. This presentation will describe 

a three quality improvement program designed to reduce 

the rate of in-patient falls across a hospital using existing 

evidence and applying it using health service improvement 

techniques. In-patient falls prevention was identified as a 

key priority area for the hospital and over a 3-year period 

a series of hospital wide initiatives have been put in place 

including regular education and training for staff, sharing of 

data at a team level, use of assistive technology and a drive 

to reduce the use of night sedation and improve the use of 

calcium and vitamin D. Falls rates have reduced from 5.78 to 

4.41 falls/1000 occupied bed days from 2006 to 2008. The 

reduction in falls across the hospital over time is statistically 

significant (r -0.39, p = 0.036). The reduction has been most 

notable but not exclusive to aged care wards (r -0.402, p 

= 0.031). The reduction in falls has been accompanied 

by a significant reduction in use of night sedation across 

the hospital (r -0.740, p < 0.0001) and increase in use of 

Vitamin D (r 0.907, p < 0.0001) with evidence of change in 

practice across most medical and surgical wards. Previous 

in-patient falls prevention studies have focused on aged care 

wards and have involved additional resource. This is one 

of the first studies to demonstrate a significant reduction in 

falls at a hospital level. 

Difference in functional capacity of geriatric medical 

patients at discharge from an acute geriatric medical 

unit: implications for service delivery 

Crouch, T 1 Dolecka U, 2 Kuys S, 2 Low Choy N, 1 Steele M 1 

1 

Bond University, Gold Coast; 2 Princess Alexandra Hospital, Brisbane 

Acute hospitalisation may reduce functional capacity in 

older adults requiring rehabilitation prior to discharge home. 

This study investigated the difference in functional capacity 

of older adults before discharge home compared to those 

transferred for rehabilitation in order to validate a measure 

of functional capacity. Outcomes from the Balance Outcome 

Measure for Elderly Rehabilitation (BOOMER) and the de 

Morton Mobility Index (DEMMI) were compared to the 

outcomes from the Berg Balance Scale (BBS) to determine 

an appropriate measure of functional capacity in the acute 

setting. Participants were over 65 years, had no cognitive 

impairments (MMSE > 24) and gave informed consent. 

Balance confidence (ABC Scale), self perception of falls 

risk, and measures of balance (BBS and the BOOMER) 

and functional capacity (the DEMMI) were recorded. 

Differences between those admitted to rehabilitation were 

compared to those who were discharged home. The group 

who were discharged home performed significantly better 

on the BBS (t = 4.175; p = < 0.001), BOOMER (t = 4.967; p 

= < 0.01) and DEMMI (t = 6.240; p = < 0.01) compared to 

those discharged to rehabilitation. There was no significant 

difference in perceived balance confidence or self perception 

of falls risk (p > 0.05) between the two groups. Spearman 

rank order correlations showed strong associations between 

the Berg Balance Scale and the BOMMER (r = 0.91; p = 

< 0.01) and a high level of association between the Berg 

Balance Scale and functional capacity determined by the 

DEMMI (r = 0.73; p = < 0.01). The BOOMER and the 

DEMMI were highly associated with the Berg Balance 

Scale and are thus appropriate measures to determine 

balance and functional capacity of older adults during acute 

hospitalization. 

The reliability and validity of the de Morton Mobility 

Index (DEMMI) in healthy community dwelling 

older adults 

Davenport SJ, 1 de Morton NA 2 

1 

Monash University, Melbourne, 2 Northern Health, Melbourne 

The aim of this study was to calculate the reliability and 

validity of the de Morton Mobility Index (DEMMI) for 

healthy community dwelling older adults. The DEMMI 

is a new mobility instrument that was developed in the 

hospital setting and has face validity for measuring across 

the mobility spectrum in healthy community dwelling older 

adults. It consists of 15 hierarchical items and participants 

are scored from 0–100 (where 0 represents lowest level of 

mobility and 100 represents highest level). The reliability 

and validity of the DEMMI has been well established in an 

acute medical population, however there has been no research 

of its clinimetric evidence amongst a healthy community 

dwelling older population. Sixty-one participants (65 years 

and older) were recruited from a retirement village and their 

mobility was assessed using the DEMMI. All participants 

were included in the validity study and a subset of 13 was 

included in the inter-rater reliability study. Evidence of 

convergent and discriminant validity was obtained for the 

DEMMI by identifying a moderate and significant (p = 0.05) 

correlation with Lower Extremity Functional Scale scores 

and a low and non significant correlation with Quality Of 

Life scores (p = 0.05), respectively. Participants without a 

gait aid had significantly higher DEMMI scores than those 

using a gait aid (p < 0.001) and provided evidence of known 

groups validity. No floor or ceiling effect was identified. 

The MDC90 for the inter-rater reliability study was 7.58 

points. The DEMMI has the clinimetric properties required 

for application in a healthy community older population. 

Community physiotherapy services: an example 

of an evidence-based program reaching large 

numbers of people 

Devereux K, 1,2 Middleton B, 1 Fabling M, 1 Ganderton L 1 

1 

Community Physiotherapy Services, Department of Health, Western 

Australia, 2 Ambulatory Care, Department of Health, Western Australia 

Community Physiotherapy Services (CPS) delivers programs 

developed for chronic conditions that have been identified 

in the research as benefiting from physical activity and/or 

specific rehabilitation programs. Clinical interventions are 

delivered according to condition-specific evidence-based 

guidelines and incorporate targeted physical activity and 

education to empower the client to better manage their own 

health. CPS receives in excess of 1800 referrals per year. 

Referrals are received from numerous sources including 

primary care, tertiary and secondary hospitals, specialist 

physicians, community services and the private sector. CPS 

delivers over 190 rehabilitation classes per week across the 

Perth metropolitan area servicing more than 2500 clients. 

Programs are supervised by senior physiotherapists and 

conducted in community based settings such as recreation 

centres. In delivering an evidence-based, cost-effective 



service CPS aims include reducing unplanned health care 

utilisation, supporting the clients transition for hospitalbased 

care to community care, minimising the complications 

associated with chronic conditions and improving quality 

of life. 

Osteoporosis in the elderly: a new approach to 

an old geriatric syndrome 

Duque G 

Aging Bone Research Program and Discipline of Geriatric Medicine, 

Nepean Clinical School, University of Sydney, Penrith 

In addition to the socioeconomic costs, osteoporotic fractures 

often cause significant morbidity and disability mostly in the 

older population. The classic model to prevent fractures is to 

screen for osteoporosis by bone densitometry and then treat 

people with low bone density with antiresorptive or other 

bone-specific drugs. However, recent studies have shown 

that, in a significant number of cases, bone densitometry 

does not give reliable estimates of a person’s true bone 

mineral density. Partly because of the limitations of bone 

densitometry, the World Health Organisation is devising a 

new model to calculate absolute fracture risk: the FRAX 

tool. The model combines, age specifically, 6 clinical risk 

factors (previous fracture, glucocorticoid use, family history 

of fracture, current cigarette smoking, excessive alcohol 

consumption, and rheumatoid arthritis) with bone mineral 

density to estimate the 10-year probability of hip and other 

fractures. In addition to the identification of fracture risk, 

and considering that falls, and not osteoporosis, are the 

strongest single risk factor for fracture, identification of risk 

of falls, as well as interventions to prevent falls constitute 

a logical approach to preventing fracture. In fact, risk of 

falling is also completely overlooked in many important 

publications on preventing fractures. Considering that there 

is a progressive shift of the focus in fracture prevention 

from osteoporosis to falls, the role of geriatric medicine 

in this focus shifting is pivotal. This session will review 

the principles of a combined risk assessment for falls and 

fractures. In addition, the optimal structure and general 

recommendations for implementing a Falls and Fractures 

Clinic will be discussed. 

Is group work-circuit physiotherapy an effective model 

for orthopaedic rehabilitation or is individual therapy 

more beneficial? 

Earles LE, 1 Low Choy N, 1 Abery P, 2 Young C, 2 Steele M, 1 

Fields M 2 

1 

Bond University, Gold Coast, 2 John Flynn Private Hospital, Tugun, 

Queensland 

This study aimed to examine the effectiveness of group 

work-circuit physiotherapy for orthopaedic rehabilitation 

compared to individual therapy. A single-blind randomised 

control pilot study was carried out in a rehabilitation unit. 

Twenty-one in-patients with an orthopaedic problem were 

randomly allocated into individual physiotherapy (n = 11) or 

group work-circuit physiotherapy (n = 10). All participants 

received physiotherapy twice daily, 6 days a week for a 

variable period depending on their length of stay (LOS). Each 

participant had an individualised session in the morning for 

30 minutes and then was randomly allocated a further 30 

minutes of individualised treatment (group A) or participated 

in a group work-circuit physiotherapy program (group B) 

in the afternoon. Measures were undertaken at admission/ 

discharge for patients admitted to the study. Demographics 

(age, gender, condition, LOS), pain level (Visual Analogue 

Scale) and ability to straight leg raise (able/unable) were 

recorded. Balance and mobility measures included: the 

Berg Balance Scale, the Modified Elderly Mobility Scale, 

the 10-metre walk test and the Timed Up and Go test. There 

were no significant differences in the outcomes between 

the individual and group work-circuit programs (p = 0.05). 

Within group analysis of change showed that participants in 

individual and group work-circuit interventions improved 

in all balance and mobility outcome measures (p < 0.05), 

but only the work-circuit group reported less pain (p < 

0.05). This pilot study demonstrated that both the individual 

and group work-circuit interventions are effective treatment 

options for a mixed group of orthopaedic patients and 

indicate that group work-circuit therapy is a cost-effective 

model for orthopaedic rehabilitation. 

Participation restriction: nature, extent and associated 

factors in frail, community-dwelling older people 

Fairhall N, 1,2 Sherrington C, 1 Cameron ID 1,2 

1 

The George Institute for International Health, The University of 

Sydney, Sydney, 2 Rehabilitation Studies Unit, Faculty of Medicine, The 

University of Sydney, Sydney 

Participation restriction is a key component of disability in 

the International Classification of Function, Disability and 

Health, yet it has not been previously examined in frail older 

people. This study aimed to determine the extent and nature 

of participation restriction in community-dwelling frail 

older people and identify which health and demographic 

factors were associated with participation restriction. A 

cross-sectional study involved 132 community-dwelling 

adults aged over 70 years (mean age = 84.2, SD = 5.85), 

who met the Fried criteria for frailty. Participation 

restriction was evaluated using the Reintegration to Normal 

Living Index. Eighty-eight percent of subjects reported 

participation restriction in at least one aspect of their life. 

Restricted participation was most prevalent in the areas 

of work in the home or community (55%) and community 

travel (60%), and least frequent with regard to indoor 

mobility (15%). Univariate linear regression analysis found 

age and measures of mobility, strength, health, mood, 

and activities of daily living to be significantly (p < 0.05) 

associated with degree of participation. Living with a carer 

and cognitive impairment were not significantly associated 

with participation. A multivariate regression model with 

age, mood, number of health conditions, muscle weakness 

and performance of activities of daily living explained 30% 

of the variance in participation restriction and could predict 

moderate to severe restriction with reasonable accuracy 

(area under the ROC curve = 0.73). Participation restriction 

is common in frail, community-dwelling older people. The 

contribution of psychological, physiological and healthrelated 

factors may warrant consideration when developing 

therapy to increase participation. 



Cost and effectiveness of a physiotherapistmanufactured 

temporary prosthesis program 

Fitzsimons TR, 1 Jones ME, 2 Collins R 3 

1 

Nepean Hospital, Sydney, 2 Port Kembla Hospital, Wollongong, 3 Prince 

of Wales Hospital, Sydney 

Changes to the Therapeutic Goods Act regarding prostheses 

highlighted the paucity of evidence in the literature 

regarding the compliance of physiotherapist-manufactured 

temporary prostheses for lower limb amputees. After human 

experimentation ethics approval, a 2-year longitudinal 

prospective study was carried out in 6 centres with the 

aim of determining the cost and safety of this training 

prosthesis. Consecutive transtibial amputees (n = 42) 

participated, average age 63.4 years, 71.4% male. Cause of 

amputation was peripheral vascular disease 48%, diabetes 

33%, trauma 10%, cancer 2%, and other 7%. The temporary 

prosthesis was fitted on average 50 days post amputation, 

with a variety of oedema management prior to fitting rigid 

dressings (45%), shrinkers (60%), and bandages (52%). 

Seventy-six plaster sockets were made for these amputees. 

Each socket consisted of $50.00 of disposable materials and 

3 hours of labour compared to a prosthetist manufactured 

definitive ($3000). Safety and effectiveness of the program 

was determined by socket abrasions (none), component 

failure (3 cracks in the plaster and 1 loose grub screw; no 

failures of prefabricated components) and definitive socket 

replacement required within 6 months of primary definitive 

fitting (17% of this cohort). While the final outcome could 

not be attributed to the use of temporary prostheses alone, 

this cohort achieved independent mobility (84.6%), with 

no walking aid (34.2%), and somewhat slower walking 

parameters (10-metre walk test in 19 seconds (range 4–60). 

In conclusion, physiotherapist-manufactured temporary 

prostheses are a safe, and cost effective means of initiating 

prosthetic rehabilitation in transtibial amputees. 

Osteoarthritis 

Fransen M 


The prevalence of osteoarthritis increases markedly with 

age. Osteoarthritis is mainly a disease of the articular 

cartilage and subchondral bone. There is no cure for 

osteoarthritis, nor any treatments proven to slow structural 

disease progression. While ageing cartilage is considered 

to be more vulnerable to mechanical insults, changes to the 

cartilage considered to typify osteoarthritis are not universal 

in older people. In addition, there are many older people 

with clear radiographic evidence of osteoarthritis who are 

not experiencing joint pain or physical limitations. For 

osteoarthritis, the greatest disability burden is attributable 

to lower limb joint involvement. Given osteoarthritis 

involving the lower limb joints has mainly a biomechanical 

pathogenesis, various non-pharmacology interventions 

should have great potential as effective treatment strategies 

for this chronic musculoskeletal condition. An overview 

of the current level of evidence for the symptomatic 

effectiveness of various non-pharmacological strategies 

frequently used by physiotherapists for older people with 

painful osteoarthritis of the hips or knees will be outlined 

in this presentation. 

Does adoption of a specific balance strategy training 

program [BSTP] approach to exercise improve quality 

of life in middle aged women? 

Fu SS, 1,2 Low Choy NL, 3 Nitz JC 1 

1 

The University of Queensland, Brisbane, 2 DAART Mater Health 

Services, Brisbane, 3 Bond University, Gold Coast 

This study investigated quality of life (QOL) across a 

2-year period in women aged 40–60 years who self-report 

a sedentary lifestyle but committed to a balance strategy 

training program compared to those who reported regular 

moderate to high physical activity level at baseline. Sixty 

healthy women were admitted to the comparative study 

conducted at The University of Queensland, Brisbane, 

Australia between 2004 and 2007. Subjects were allocated 

on the basis of their activity level into sedentary and active 

groups. The sedentary group of women participated in a 

12 week twice-weekly BSTP and encouraged to continue 

with this type of exercise on completion. The active group 

comprised women reporting regular moderate to high level 

exercise. Assessments including personal demographics, 

HRT use, prescribed medications, activity level and QOL 

using the SF36v2 health survey were at baseline, 3, 9 and 

24 months. At baseline, age, height, use of HRT, number of 

prescribed medications and menopausal status (p > 0.05) 

showed no group differences but mean body weight of the 

active group was significantly lighter (p < 0.05). Over time 

there was no difference between the groups for QOL using 

the SF36v2 health survey except the sedentary group had 

significant improvement in perceived social function (p 

< 0.012) and mental health (p < 0.043) immediately after 

BSTP. At 9 months vitality (p < 0.03) and 24-months mental 

summary score (p < 0.05) improved in sedentary women. 

BSTP participation does improve aspects of QOL. Women 

participating in regular moderately high intensity exercise 

regimes do not have superior QOL. 

Key health issues for older people: diabetes evidence 

update and practical implications 

Harmer AR 

Clinical & Rehabilitation Sciences Research Group, Physiotherapy, 

Faculty of Health Sciences, The University of Sydney, Lidcombe, 

Australia 

Most (80%) elderly Australians have 3 or more chronic 

conditions and in those with diabetes, the most common 

co-morbid conditions are hypertension, osteoarthritis, 

and cardiovascular disease. The prevalence of diabetes is 

increasing and it is projected that by 2025 the risk of diabetes 

in those aged 65–100 yrs in the Australian population will 

be 41–67%. Currently, half of the indigenous Australian 

population aged 55–64 years have diabetes. Modifiable 

risk factors for diabetes include metabolic syndrome 

components, smoking, and physical inactivity. A major 

medical goal of diabetes treatment is to reduce glycosylated 

haemoglobin and hence reduce the risk of macrovascular 

and microvascular diseases. Physiotherapy treatment may 

address the modifiable risk factors as well as complications of 

diabetes including balance disturbances, osteoarthropathy, 

and adhesive capsulitis. Current recommendations for 

aerobic and resistance exercise in older patients with 

diabetes will be reviewed. 

8 



What is the mobility status of older acute medical 

patients at hospital discharge? 

Harris B, 1 Nolan J, 1 de Morton NA, 2 Thomas S, 3 Govier 

A, 1 Sherwell K, 2 Markham N, 1 O’Brien M, 1 Keating JL 4 

1 

Flinders Medical Centre, Adelaide, 2 Northern Health, Victoria, 

3 

Flinders University, Adelaide, 4 Monash University, Victoria 

Mobility is a crucial determinant of discharge destination 

for older medical patients, and often an important focus 

of physiotherapy management for older acute medical 

patients. The aim of this study was to examine the mobility 

performance for older medical patients on discharge from 

an acute hospital, to understand the possible impact of 

mobility on discharge destination. This study used two 

mobility outcome measures, the de Morton Mobility 

Index, developed in an older acute medical population (15 

items, scored from 0–100), and the Elderly Mobility Scale, 

a commonly applied measure in this patient population 

(seven items, scored from 0–20). One hundred and twenty 

consecutive older acute medical patients admitted to hospital 

were followed from admission, and both mobility measures 

were administered within 48 hours of hospital discharge for 

87.5% of admissions (12.5% loss to follow-up). Preliminary 

analysis of 105 patients and discharge destinations show 

that those discharged home (n = 66) had highest average 

mobility scores (de Morton Mobility Index 52.12 ± 12.98; 

Elderly Mobility Scale 15.05 ± 4.23), and shortest average 

hospital stay, 9.32 ± 5.68 days. Patients discharged to high 

level care facilities (n = 5) had the lowest average mobility 

scores (de Morton Mobility Index 18.80 ± 11.99; Elderly 

Mobility Scale 2.20 ± 2.49) and longest average stay, 27.72 

± 20.84 days. These results support the value of mobility 

outcome measures in considering discharge destination 

for older medical patients. Analysis will be undertaken to 

investigate the possible use of mobility outcome measures 

to determine cut-off points for discharge destinations. 

The effect of patient education for the prevention of 

in-hospital falls in older patients: a randomised 


Hill AM, 1 Hill K, 2,3 Brauer S, 1 Oliver D, 4 Hoffmann T, 1 

Beer C, 5 McPhail S, 1,6 Haines TP 7,8 

1 

The University of Queensland, Brisbane., 2 National Ageing Research 

Institute, Melbourne., 3 LaTrobe University, Melbourne., 4 City 

University, London, UK., 5 University of Western Australia, Perth., 

6 

Princess Alexandra Hospital, Brisbane., 7 Monash University, 

Melbourne., 8 Southern Health, Melbourne 

Accidental falls in older hospital patients are a serious 

problem. Trials to date aiming to prevent older people 

falling whilst inpatients have produced conflicting results. 

The aim of this trial was to investigate the effect of 

providing individual patient education in addition to usual 

care on the rate of falls and falls related injuries in older 

hospital patients compared to the effect of providing usual 

care alone. A randomised controlled trial (n = 1206) was 

conducted at 2 hospitals in Australia. Inclusion criteria were 

that participants were over 60 years of age and they, or their 

family or guardian, gave written consent. Participants were 

randomised into 3 groups. The control group continued 

to receive usual care. Both intervention groups received 

a specifically designed patient education intervention on 

minimising falls in addition to usual care. The education 

was delivered by Digital Video Disc (DVD) and written 

workbook. One of the intervention groups also received 

follow up education training visits by a health professional. 

The primary outcome measure was falls by participants 

in hospital. Secondary outcome measures included falls 

at home after discharge, knowledge of falls prevention 

strategies and motivation to engage in falls prevention 

activities after discharge. The interim analyses conducted 

with data from (n = 500) participants indicated a trend 

towards a lower rate of falls and proportion of participants 

who became fallers in one of the three groups (investigators 

were blinded to group allocation in interim analyses). Data 

collection for this component of the study is anticipated to 

be complete by May 2009. 

Are our universities producing a new generation 

of aged care physiotherapists? 

Hill KD 

La Trobe University, Northern Health, National Ageing Research 

Institute, Parkville 

This presentation will describe the essential need for 

comprehensive gerontological training by universities (both 

theoretical and practical/skill based) at an undergraduate 

level for physiotherapists in coming years as demographic 

changes associated with Australia’s ageing population 

reflect that the population aged over 65 will grow from 13% 

in 2004 to 27% by 2051. With longer life spans, there will be 

increasing opportunities for physiotherapy and other allied 

health professions to optimise health for older people (roles 

in which physiotherapy can have a key preventive/healthy 

ageing role), as well as rehabilitative therapy, and supportive 

therapy for frail older people maintaining independent living 

at home with community services, and those in residential 

aged care facilities. Implications for practice are that in 

almost all areas of physiotherapy, practitioners will have at 

least a component of their caseload that will involve therapy 

for older people. How well our universities currently meet 

this growing need will be discussed. 

Exercise compliance: theory and practice 

Hopman-Rock M 

TNO Quality of Life, Leiden, the Netherlands, Body@Work Research 

Centre Physical Activity, Work, and Health TNO VU University Medical 

Centre, EMGO Institute for Health and Care Research, Amsterdam, 

The Netherlands 

Exercise and physical activity (PA) compliance is one of 

the emergent topics in research and practice. A review by 

Williams et al. (2007) revealed that 17 sedentary adults 

would need to be referred by primary care for only one to 

become moderately active. In 2002 a review by Kahn et 

al was published about the effectiveness of interventions 

to increase PA. Kahn and colleagues identified 2 effective 

informational interventions (for the population in general), 

these were ‘point-of-decision’ prompts to encourage stair 

use and community wide campaigns. In addition, ‘social 

support in community settings’ and ‘individual adapted 

health behaviour change’ were found to be effective. Also 

‘creation or enhanced access to places for PA’ is an effective 

strategy. A systematic review on methods of promoting 

PA conducted by the Swedish Council of Technology 

Assessment in Health Care (March 2007;) lead to the 

following conclusions: Advice and counselling of patients 

in everyday clinical practice increases PA by 12–50% for 

at least six months after the counselling session (strong 

scientific evidence, which means that it is supported by 

at least 2 studies with high study quality); More frequent, 



intensive counselling by means of repeated sessions for 

several months additionally boosts PA (limited scientific 

evidence, which means that it is supported by at least 2 

studies with medium study quality). Determinants and 

correlates of exercise compliance and adherence will be 

discussed in relationship to usefulness for practitioners. 

10 

Adaptive physical activity: 

lessons from the Netherlands 

Hopman-Rock M 

TNO Quality of Life, Leiden, the Netherlands, Body@Work Research 

Centre Physical Activity, Work, and Health TNO VU University Medical 

Centre, EMGO Institute for Health and Care Research, Amsterdam, 


During the last 10 years a lot of scientific effort has been put 

into the development and evaluation of effective adapted 

physical activity programmes for older adults. Many 

programs have been launched, but less is known about their 

fate. What happened to them after their introduction? Did 

they reach the intended public? What were the enabling 

factors and what were the barriers? The presentation 

addresses some theoretical and practical aspects of these 

issues, from the perspective of health promotion. The 

pathway from basic research to implementation is viewed 

from the perspective of the researcher and the perspective 

of the practitioner. Examples from own Dutch research are 

given. The practitioner works ‘opposite’ the researcher. He 

or she may use the usual programs in everyday practice and 

may be unwilling to change to a new program. Orlandi et 

al. (1990) proposed the ‘intermediary linkage system’ as an 

efficient method to ensure the transfer of innovations from 

the source to the users. The idea is that researchers and 

practitioners exchange information and communicate with 

each other from the start of an innovative project onwards. 

In this way collaborating partners can provide each other 

with training, technical support, and feedback. Also, some 

basic principles of the diffusion theory of Rogers are given 

and the RE-AIM framework of Glasgow is introduced to 

support research on innovation processes. Finally, discussion 

will be about the possibilities of the so-called ‘re-invention’ 

of programs. 

Coordinating ‘Stepping On’: implementing an 

evidence-based, multidisciplinary falls prevention 

program for community dwelling elderly 

Johns M 

North Coast Area Health Service, Coffs Harbour 

Stepping On is a best-practice program based on a 

published randomised controlled trial, which successfully 

demonstrated a 30% reduction of falls amongst program 

participants. The Stepping On program is planned to roll 

out across all NSW Health Areas, with the initial programs 

commencing in the North Coast and Northern Sydney 

Central Coast Health Areas. On the North Coast, the 

rollout of the program is jointly funded by NSW Health, the 

North Coast Area Health Service and the Mid North Coast 

Division of General Practice. The North Coast Stepping 

On programs have a local community focus, involving 

participants and health professionals from the communities 

of Coffs Harbour, Bellingen, Dorrigo, Nambucca and 

Urunga. Participants are aged 65 and over, community 

dwelling, independently ambulant or using a walking stick, 

cognitively intact, able to speak conversational English 

and not diagnosed with a neuromuscular condition. The 

program is enhancing individual, community group, public 

and private health practitioner awareness of strategies for 

falls prevention and promotion of positive health behaviours 

in the ageing population. The program is strengthening the 

links between public and private health services and existing 

community groups to ensure program sustainability. 

Australian and British amputee care guidelines 

merged for self assessment 

Jones ME 

Port Kembla Hospital, Warrawong 

A tool was needed to self assess amputee services based on 

approved guidelines. The Australian and British guidelines 

were reviewed and merged by the New South Wales 

Physiotherapists in Amputee Rehabilitation (NSWPAR) for 

relevance to local practice. In the 2005/6 cohort of 19 lower 

limb amputees with peripheral vascular disease (74%), 

diabetes (10%), trauma (10%) and infection (6%); it took 

75 days (SD = 46) to provide the temporary prosthesis, 119 

days (SC = 66) for the second temporary prosthesis and 209 

days (SD = 109) from amputation to receipt of the definitive 

prosthesis. Independent mobility was achieved by 85%, 74% 

required a walking aid and discharge destination was home 

for 94% of this cohort. Outcomes for this population were 

multi-factorial and encompassed several different sectors of 

public health: acute surgical, post-operative, rehabilitation 

and prosthetic services. So guidelines needed to encompass 

the entire patient journey. The NSW Health document from 

the Artificial Limb Service consisted of organisational 

requirements whereas the British documents were more 

detailed about the knowledge and components required. The 

total score of 136 out of a possible 147 was identified from 

the retrospective cohort of 19 participants in the Temporary 

Prosthesis Program. Two areas with room for improvement 

include: advancement of the multidisciplinary approach 

pre-surgically, and coordinated stump volume control from 

amputation to the definitive prosthesis. Self assessment of 

routine clinical practice against internationally presented 

guidelines proved to identify gaps in the care of amputees 

at a regional hospital and rehabilitation centre. 

Rehabilitation during and following treatment for 

breast cancer 

Kilbreath SL 


Breast cancer is common in older women, with 1 in 11 

women diagnosed with the disease by the age of 75 years. 

However, the 5-year survival is high, with 87.7% alive at 5 

years following diagnosis, in part due to early detection and 

aggressive treatment. The treatments that successfully treat 

the cancer include surgery, radiotherapy, chemotherapy 

and hormones. However, they can also cause chronic 

problems: localised to the arm and chest on the side of 

surgery such as shoulder stiffness, weakness, pain, and 

swelling (lymphoedema) and/or systemic problems such 

as fatigue, osteoporosis, and sarcopenia. These problems 

can interfere with activities of daily living, affect quality 

of life and are likely to be associated with increased levels 

of psychological distress. Exercise during and following 

treatments may reduce the impact of these side-effects. For 

example, post-operative exercises directed at muscles of the 



scapula, spine and upper limb, and aiming to increase range, 

strength and motor control in the upper quadrant, are likely 

to alleviate these chronic upper limb symptoms. Adoption 

of an exercise regimen that includes aerobic exercise 

and high impact exercises may also reduce osteoporosis 

and fatigue. One chronic side-effect, lymphoedema, is 

uncommon but is feared by many, and is still not wellunderstood. 

Nevertheless, at least some of the beliefs, such 

as exercise exacerbating lymphoedema, are not supported 

by recent studies. In conclusion, exercise has a substantial 

role in rehabilitation during and following treatment for 

breast cancer. 

Using digital video and photography as a clinical 

observational, feedback and recording tool 

Langron CP, Fairhall NJ, Cameron ID, Kurrle SE 


Digital video and photography are valuable tools in geriatric 

physiotherapy, yet they are under-utilised in the clinical 

and research settings. In a current randomised controlled 

trial of frail community dwelling, older people, digital 

video and photography is being used in conjunction with 

exercise intervention for individual participants. Digital 

video can enhance clinical observation and correction of 

abnormal movement by providing an instant, visual record 

for the therapist and participant. The compact digital 

camera has many simple functions, such as slow motion and 

enlargement of single frames that facilitate a more detailed 

movement analysis when compared to therapist observation 

in the clinical setting. Replaying videos to participants 

of their current and previous performances provides 

immediate visual feedback and encourages participant 

involvement and self correction in the intervention. Images 

can be recorded in different mediums and are being used in 

the trial for weekly multidisciplinary case conferences and 

large audience presentations. Recordings can be transferred 

to CD for safe storage to enable retrieval in the future. 

This digital technology has other applications such as 

telemedicine in remote areas or providing patients videos of 

themselves to practice their home exercise program. It has 

been readily accepted by participants as part of the normal 

intervention in this trial and 5 cases will be presented to 

illustrate the use of this clinical tool. 

Aboriginal people 

Latimer J 

The University of Sydney, The George Institute for International Health 

This 25 minute session will outline how a physiotherapy 

researcher worked to support a group of older indigenous 

women from a remote community in North Western 

Australia to share their story with the world. The impact of 

this sharing has been enormous and enabled these Australian 

indigenous women to influence women’s policy worldwide. 

Every day in the Australian media there are reports of family 

violence and child abuse, much of this committed while 

under the influence of alcohol. In the Northern Territory of 

Australia alone, alcohol consumption has risen from 2.3 to 

3 billion litres in the 6 years spanning 2000–2006. While 

there are no accurate estimates of the exact extent of alcohol 

related violence, it is widely acknowledged that the majority 

of family violence is committed while under the influence 

of alcohol. In 2007 a group of Aboriginal women from 

the Fitzroy Valley in Australia’s remote northwest decided 

enough was enough. Their community had experienced 

13 suicides in 13 months. Reports of family violence and 

child abuse were commonplace and alcohol consumption 

was rising at an alarming rate. Something had to be done. 

Something had to change. A group of courageous Aboriginal 

women from the Fitzroy Valley came together to fight for a 

future–for their community, and for their children. In 2008 

A/Prof Latimer co-produced a powerful, short movie called 

‘Yajilarra’ that was shown to Australians and a global 

audience at the United Nations Commission on the Status 

of Women in New York in 2009. In this presentation A/ 

Prof Latimer will talk about the exceptional ‘old women’ 

of Fitzroy Crossing and their journey, how the movie was 

made and the far reaching impact that this movie has had. 

Normative data for the de Morton Mobility Index 

(DEMMI) 

Lewis JA, 1 de Morton NA 2 

1 

Monash University, Victoria, 2 Northern Health, Victoria 

The aim of this study was to obtain normative data, stratified 

by age and gender, for the de Morton Mobility Index 

(DEMMI) for healthy community dwelling older adults. The 

DEMMI is a new and advanced mobility outcome measure 

that can accurately measure the mobility status of older 

people. The DEMMI consists of 15 hierarchical items with 

interval-level scoring from 0–100 (where 0 represents lowest 

level of mobility and 100 represents highest level). Normative 

data provides an essential benchmark for comparing the 

mobility status of older people and can facilitate goal setting 

for therapeutic intervention. Participants aged 65 years and 

older were screened and recruited from a retirement village. 

Sixty-one participants were included and their mobility 

was assessed using the DEMMI. Normative data for the 

DEMMI were reported in 3 age categories: 65–74, 75–84 

and 85+ years and mean DEMMI scores (SD) were 80.10 

(14.88), 75.40 (14.02) and 69.86 (7.54), respectively. Males 

had a mean DEMMI score of 81.15 (12.39) and females had 

a mean DEMMI score of 74.78 (14.49). A significant agerelated 

decline in mobility was identified between persons 

in the oldest age category (85+ years) and the youngest age 

category (65–74 years) (p = 0.03). There was no significant 

difference between DEMMI scores for males and females 

(p = 0.08). The findings of this study are consistent with the 

known physiological effects of ageing and provide clinicians 

and researchers with important information regarding the 

physical health of community dwelling older adults. 

Functional outcome one year after hip fracture: results 

from the sarcopenia and hip fracture (SHIP) study 

Lloyd BD, 1 Williamson DA 1 , Singh NA, 2,3 Hansen RD, 4 

Diamond TH, 3 Finnegan T,P 4 Allen B, 7 Grady JN, 8 

Stavrinos TM, 1,2 Smith EUR, 1 Diwan AD, 5 Singh MAF 1,6 

1 

The University of Sydney, NSW; 2 Balmain Hospital, and Royal Prince 

Alfred Hospital, NSW; 3 Royal North Shore Hospital, NSW, 4 St George 

Hospital, NSW; 5 University of New South Wales, NSW, 6 Hebrew 

SeniorLife, Boston, USA, and Tufts University, Boston, USA 

The aim of this study was to investigate change in function 

over the first 12 months following hip fracture. A prospective 

cohort study was undertaken in 193 community-dwelling 

older persons admitted with hip fracture (81 ± 8 years, 72% 

women) to three acute care hospitals in Sydney, Australia. 

Function was assessed at baseline (in reference to pre- 



fracture status), and four and 12 months after hip fracture 

using Part C (Activities of Daily Living) of the National 

Health and Nutrition Examination Survey I. This survey 

was administered by in-person interview and determined 

independence in 23 functional tasks across 8 areas (dressing, 

eating, hygiene, walking, transferring, errands/chores, 

reaching, and grip strength). Independence levels were 

lower for 19 of the 23 tasks four months after hip fracture 

as compared with pre-fracture, and this was the same at 12 

months. The largest losses in independence at 12 months 

as compared with pre-fracture were for walking (prefracture 

proportion independent vs. 12 months proportion 

independent; 79% vs 49%), errands/chores (61% vs. 39%), 

and hygiene (79% vs. 57%). Similar results were obtained 

at four months. Loss in functional independence early after 

hip fracture is not restored at 12 months after hip fracture. 

However, large inter-individual variation in recovery was 

observed. 

12 

Are we meeting the challenges in residential 

aged care physiotherapy? 

Louis JL 

Anglican Retirement Villages, Sydney 

Our APA Vision is that all Australians will have access to 

quality physiotherapy, when and where required, to optimise 

health and wellbeing. Older Australians who reside in 

residential aged care facilities require quality physiotherapy 

to optimise their mobility and dexterity, prevent functional 

decline and treat both acute and chronic conditions. A new 

funding instrument was introduced in March 2008 with the 

aim of streamlining and simplifying the funding system 

and separating it from the prescribing of care. This paper 

canvasses the issues around the funding and provision of 

physiotherapy for residents of aged care facilities, the Aged 

Care Funding Instrument, Medicare Enhanced Primary 

Care program and Accreditation. 

Associations between vestibular system function, 

perceived confidence, falls efficacy, balance and 

mobility in older fallers undertaking rehabilitation 

in the home 

Low Choy N, 1 Hooper P, 1 Weston H 2 

1 

Bond University, Gold Coast, 2 Mobile Rehabilitation, Brisbane 

This study investigated associations with dynamic visual 

acuity (DVA), reported dizziness, motion sensitivity during 

movement, vestibular system tests and perceived confidence, 

balance and mobility in injurious and non-injurious fallers 

undertaking rehabilitation within the home. All participants 

(n = 9) were not hospitalised but sustained head abrasions 

(n = 3), trunk haematoma (n = 2) and bruising (n = 4). 

Age, general health, medications and social history were 

recorded. Measures for perceived confidence (ABC Scale), 

falls efficacy, dizziness handicap (DHI), motion sensitivity, 

dynamic visual acuity, Hall-Pike Dix (HPD) test, head thrust 

(left/right) test, visual acuity, functional balance (5 x SST; 

BERG) and mobility (TUG test) were undertaken. Moderate 

(r > 0.5–7) and stronger Spearman Rho correlations (r > 

0.7) from preliminary data are reported. DVA was highly 

associated with standing on foam (EO) and edge contrast 

sensitivity with moderate associations determined with 

motion sensitivity when rolling, bending; turning the head, 

head thrust and HPD tests. Motion sensitivity during rolling, 

bending and standing tasks showed moderate to high 

associations with the VOR Cancellation test, head thrust 

and HPD tests, DVA and DHI. The DHI was associated 

with age, medication use, falls efficacy, VOR cancellation 

and motion sensitivity during lying down, rolling and when 

standing up. Perceived confidence was associated with 

general health, falls efficacy, DVA, DHI, motion sensitivity 

standing up, balancing on foam (EO), 5 x STS and TUG 

tests. Falls efficacy was associated with general health, 

medications, perceived confidence, standing up, 5 x STS 

and the TUG test. Vestibular deficits require consideration 

along with balance, mobility, falls efficacy and perceived 

confidence for holistic management of the older faller. 

Visually induced postural sway in elderly fallers, 

vestibular disorders and controls 

McLoughlin JV, 1 Lord SL, 2 Crotty M 3 . 

1 

The University of New South Wales, Sydney, 2 Prince of Wales Medical 

Research Institute, Sydney, 3 Flinders University, Adelaide 

Visual dependence occurs when there is a greater 

dependence on visual information for spatial orientation 

and is likely to be a compensation for reduced vestibular 

and proprioceptive balance functions. Visual dependence 

can occur in central and peripheral vestibular disorders as 

well as in the elderly. It can trigger dizziness and anxiety 

in many functional situations. This phenomenon has been 

termed ‘space and motion discomfort’. The aim of this 

study is to describe the destabilising effects of optokinetic 

visual stimulus on postural sway in elderly fallers, 

vestibular patients and controls. Physiological measures 

associated with falls risk will be determined. Subjects will 

be exposed to immersive visual stimuli in standing while 

data will be collected from force plates and markers on the 

body measuring 2-dimensional sway. We will also examine 

any possible correlation of induced sway with physiological 

characteristics associated with falls risk as well as symptoms 

of space and motion discomfort, anxiety, dizziness and fear 

of falling. 

Are comparisons of longitudinal health-state 

evaluations amongst physiotherapy patients valid? 

The clinical implications from a narrative review of 

response shift 

McPhail S, 1,2 Haines T 1,3,4 

1 

The University of Queensland, Brisbane, 2 The Princess Alexandra 

Hospital, Brisbane, 3 Monash University, Melbourne, 4 Southern Health, 

Melbourne 

The purpose of this investigation was to provide a 

narrative review of the response shift phenomenon 

with a discussion of the clinical implications to avoid 

making invalid comparisons between longitudinal health 

assessments in physiotherapy practice. Many instruments 

have been developed and validated with the intention of 

quantitatively evaluating health-related constructs relevant 

to physiotherapists such as health-related quality of life, 

pain and fatigue. These evaluations frequently involve 

patients self-reporting answers to survey-based instruments 

at their initial assessment, then again at subsequent 

assessments. Comparisons of evaluations taken over time 

are intended to identify meaningful changes in patients 

underlying health or condition. However, response shift 

is a potential confounder of these comparisons. Response 

shift, primarily considered a process of internal adaptation, 



has been defined as a change in how one conceptualises, 

prioritises or calibrates a health construct or components of 

it. If response shift occurs between assessments then each 

self-reported evaluation may not be measuring the same 

concept (or construct), with the same priorities, with the 

same scale calibration despite the use of a standardised and 

validated instrument. The resulting shift in response may be 

either a positive or negative, indicating more or less change 

than has actually occurred. Considerable effort has been 

made to develop ways to detect response shift including 

individualised, preference-based, and qualitative methods 

as well as successive comparison, design and statistical 

approaches. Steps should be undertaken to reduce the effect 

of the response shift phenomenon during evaluation of 

physiotherapy practice to avoid clinical reasoning decisions 

based on inaccurate information. 

Health-related quality of life: do physiotherapists and 

their patients agree? 

McPhail S, 1,2 Beller E, 2 1,3 ,4 

Haines T 

1 



Melbourne 

This investigation aimed to identify agreement levels between 

self-reports of health-related quality of life (HRQoL) from 

patients in a tertiary hospital rehabilitation unit and proxyreports 

from treating physiotherapists at admission and 

discharge assessments. Two possible perspectives from 

which to complete a proxy-report exist; answer as the patient 

would (proxy-patient) or from the proxy’s own perspective 

(proxy-proxy). A repeated measures, inter-rater agreement 

investigation of clinician proxy-report and patient selfreport 

incorporating two, 6-month data collection phases 

was undertaken with proxy-patient reports in Phase A and 

proxy-proxy reports in Phase B. The Mini Mental State 

Examination was used to assess patient cognition. 150 (89%) 

proxy-patient and 130 (98%) proxy-proxy datasets were 

complete. Proxy-patient assessments had strong agreement 

with self-report at discharge across all cognition levels 

(kappa 0.76–0.95), but at admission had stronger agreement 

among patients with better cognition (kappa = 0.70–0.86) 

than patients with lower cognition (kappa = 0.47–0.76). At 

admission and discharge proxy-proxy assessments generally 

had moderate agreement with self-report among patients 

with poor cognition on most domains with proxies giving 

lower scores than patients (kappa 0.23–0.81), this is in 

contrast to proxy-proxy assessments and patients with better 

cognition (kappa 0.55–0.95). In summary, physiotherapists 

demonstrated understanding of how patients were likely 

to report their HRQoL (as indicated by the proxy-patient 

reports), but chose to disagree with patients who had 

poorer cognition scores, systematically reporting lower 

levels of HRQoL than self-reports from patients with lower 

cognition scores (proxy-proxy reports). It is important 

that an appropriate consensus between stakeholders be 

established when assessing HRQoL issues amongst patients 

with reduced cognitive ability. 

Telephone and face-to-face assessment of participation 

in functional activites and health-related quality of life 

yield equivalent responses amongst older adults 

McPhail S, 1,2 Lane P, 1 Russell T, 2 Brauer SG, 2 Urry S, 3 

Jasiewicz J, 3 Condie P, 3 Haines T 2,4,5 

1 

Princess Alexandra Hospital, Brisbane, 2 The University of 

Queensland, Brisbane, 3 Queensland University of Technology, 

Brisbane, 4 Southern Health, Melbourne, 5 Monash University, 

Melbourne 

Attending hospital or clinic appointments may be difficult 

for older adults due to problems associated with travelling 

to, within and from health facilities for the purpose of a faceto-face 

assessment. The purpose of this investigation was to 

examine whether telephone and face-to-face administration 

of the Frenchay Activities Index (FAI) and the Euroqol-5D 

(EQ-5D) generic health-related quality of life instrument 

amongst an older adult population yielded equivalent 

responses. Patients aged >65 (n = 53) who had been 

discharged to the community following an acute hospital 

admission underwent telephone administration of the FAI 

and EQ-5D instruments seven days prior to attending a 

hospital outpatient appointment where they completed a 

face-to-face administration of the same instruments. Overall, 

40 subjects’ datasets were complete for both assessments 

and included in analysis. The FAI items had high levels of 

agreement between the two modes of administration (item 

kappa’s ranged 0.73 to 1.00) as did the EQ-5D (item kappa’s 

ranged 0.67 to 0.83). For the FAI, EQ-5D VAS and EQ-5D 

utility score, intraclass correlation coefficients were 0.94, 

0.58 and 0.82 respectively with paired t-tests indicating no 

significant systematic difference (p = 0.100, p = 0.690 and 

p = 0.290 respectively). Telephone administration of the 

FAI and EQ-5D instruments provides comparable results to 

face-to-face administration amongst older adults deemed to 

have cognitive functioning intact at a basic level, indicating 

that this is a suitable alternate approach for collection of 

this information for clinical or research purposes. The 

ability to administer these instruments via the telephone 

may help reduce the burden of health assessments for this 

patient group. 

The strength of association between physical function 

and health-related quality of life amongst patients in a 

tertiary hospital rehabilitation unit 

McPhail S, 1,2 Beller E, 1,2 1,3 ,4 

Haines T 

1 



Melbourne 

This study aimed to investigate the strength of association 

between self-report of health-related quality of life 

(HRQoL) and commonly used physical performance 

measures amongst tertiary hospital rehabilitation patients. 

The Euroqol-5D (EQ-5D) was used to evaluate HRQoL. 

The Step-Test, Functional Reach test, Timed Up and 

Go (TUG), Static Balance with eyes closed, Balance 

Outcome Measure for Elder Rehabilitation(BOOMER) 

and Functional Independence Measure (FIM) were used 

as performance measures. Each measure was completed 

at admission and discharge assessments for older adults 

undergoing rehabilitation at a tertiary hospital (n = 272). 

The strength of association between each performance 

measure and the EQ-5D (both utility and VAS components) 

were investigated using multiple regressions. 231 (85%) 

participants had all admission and discharge measures 



completed and were included in analysis. The three 

strongest associations were evident at admission between 

EQ-5D utility and TUG (r 2 = 0.359), BOOMER (r 2 = 0.365) 

and FIM (r 2 = 0.399) respectively amongst patients with a 

mini-mental state examination score>23/30. The strength 

of association was weakest amongst change scores, where 

all combinations of utility or VAS scores and performance 

measure regressions ranged between r 2 = 0.019 and r 2 = 0.193. 

Overall a moderate positive correlation existed between 

performance measures and self-reported HRQoL evaluated 

at the same assessment, particularly amongst the patients 

with higher cognition scores. However, the association 

between improvement or decline in physical function and 

self-report of HRQoL (change scores) was weak at best. 

When selecting performance outcome measures for clinical 

or research assessments those which measure multiple 

aspects of physical function, such as the TUG, BOOMER 

and FIM, are likely to be more representative of patients’ 

HRQoL. 

14 

Dementia with Lewy bodies as an alternative 

diagnosis to Parkinson’s disease 

Nicholson KA 

The University of Melbourne, Melbourne 

The aim of this qualitative, heuristic study was to explore 

the experience of caring for a person with dementia with 

Lewy bodies. An alpha synucleinopathy, dementia with 

Lewy bodies is a recently classified component of a 

spectrum of Lewy body diseases which include Parkinson’s 

disease and Parkinson’s disease dementia. The criteria 

for a diagnosis of dementia with Lewy bodies include sub 

cortical dementia, Parkinsonism, and fluctuations with the 

diagnosis often secondary to a diagnosis of Parkinson’s 

disease. Thirteen spousal carers of people with a confirmed 

diagnosis of dementia with Lewy bodies were recruited 

for the study through memory clinics and Parkinson’s 

Australia. All completed a questionnaire relating to their 

spouses’ presenting signs and were interviewed using 

and open ended, conversational approach about their 

experiences of caring and negotiating the health care system. 

Seven also participated in a group discussion focusing 

on education and support. Their experiences substantiate 

the anecdotal evidence that this is a poorly recognised 

and understood disease in the medical, allied health and 

wider communities. Carer burden is high because of the 

behavioural and psychological symptoms of the dementia 

which are complicated by the physical disabilities. People 

with the disease respond better to dementia medication, 

when it is prescribed, than to Parkinson’s medication and 

the fluctuations are such that a person who is ambulant one 

day or hour can be chair bound the next. Physiotherapists 

have a role in raising the profile of this condition. 

Gentlemen, are you as stable as you think? 

Nitz JC, 1 Illing S, 1 Nolan M, 1 Low Choy NL 2 

1 

The University of Queensland, Brisbane; 2 Bond University, Gold Coast 

This observational cross-section cohort study examined 

the effect of age on balance, stability and sensorimotor 

components of balance in 106 men aged 30–80 years. 

Personal demographics, health and activity level were 

recorded. Balance and mobility was measured using the 

timed up and go test, the step test, functional and lateral reach, 

velocity of sway during bilateral stance on a firm and foam 

surface (eyes open and eyes closed) and while balancing on 

one leg (eyes open and eyes closed). The limits of stability 

test provided reaction time. Lower limb muscle strength, 

ankle flexibility, somatosensation (tactile acuity, vibration 

threshold and joint position error), high and low contrast 

visual acuity, edge contrast sensitivity and vestibular-ocular 

reflex (VOR) control were also measured. Results showed 

all balance, strength and flexibility measures declined by 

the 60s and reaction time increased with age. Men aged 

in their 60s and 70s were less stable than the younger age 

decades when standing on a firm and foam surface. One-leg 

stance stability with eyes closed was reduced in those aged 

in the 40s and 50s. Lower limb somatosensation and high 

and low contrast visual acuity were significantly reduced by 

the 60s. While age-related changes in VOR control did not 

emerge until the 70s, reductions in edge contrast sensitivity 

emerged by the 50s. The decline in balance and stability of 

men by the 60s was similar to the findings for women. Thus, 

screening for falls risk should include men and women with 

pre-emptive interventions offered to those aged in the 50s 

to foster healthier ageing. 

Advising older people with fall related hospital 

admissions: how can we better communicate evidence 

based fall prevention recommendations? 

Nolan JS 

The University of Adelaide, Adelaide, Flinders Medical Centre, 

Adelaide 

This study aimed to understand the views of older people 

admitted to hospital with fall-related injuries about 

evidence-based fall prevention advice. A cross-sectional 

sample of community dwelling people aged 65+ years 

admitted to hospital with fall-related injuries during 

August and September 2006 was obtained. Individual 

semi-structured interviews which explored vulnerability 

to falls and attitudes to language, timing and mode of 

fall prevention advice were conducted, analysed and key 

themes summarised. Demographic and descriptive data 

about falls were collected and analysed. Thirteen adults (8 

female, 5 male) aged 65–95 years, with 2–12 falls in the 

previous year, hospitalised for 2–91 days with fall-related 

injuries participated. Qualitative results indicated that 

participants viewed falls as unpredictable and unavoidable 

events, which commonly threatened their independence. 

Language of falls prevention advice which promoted safety 

and independence was strongly preferred to ‘fall prevention’ 

language. To promote engagement in fall prevention 

strategies, participants preferred individual discussion with 

a trusted person in combination with written material during 

hospitalisation, but expressed concern about individual 

ability to act on fall prevention strategies. To promote 

uptake of prevention strategies by older people admitted to 

hospital with fall-related injuries, advice should avoid use of 

‘falls prevention’ language, and instead promote concepts 

considered positive by older people such as independence, 

with written information provided by a trusted person 

during hospitalisation. These recommendations require 

further testing regarding impact on uptake and adherence 

in a controlled trial before incorporation into practice. 



Developing higher quality initial 

physiotherapy documentation for acute hospital 

patients 

Nolan J, Harris B, Craven G, Govier A 


With the ageing population and increased pressure on 

hospital services, acute hospital physiotherapists in Australia 

are facing a period of increasing demand. Physiotherapists 

at Flinders Medical Centre, Adelaide identified, that to 

maintain high quality physiotherapy in this increasingly 

complex workplace, it was desirable to provide a consistent 

and measurable process to standardise documentation of 

initial in-patient assessment. From 2002–2006, the Flinders 

Medical Centre Physiotherapy Department has worked to 

develop a standard in-patient adult assessment pro-forma. 

The aims of this standardisation were to promote quality of 

documentation, promote ease of locating assessment within 

the case notes for physiotherapists and hospital staff, and to 

provide a summary of the initial patient presentation. Initial 

work focused on elective use of the assessment pro-forma, 

and subsequently progressed to compulsory use of the initial 

physiotherapy assessment pro-forma, for appropriate adult 

patients. Survey responses from physiotherapists within 

the hospital indicated that the pro-forma is useful to the 

department or hospital (35% strongly agreed, 65% agreed), 

and useful to the individual (41% strongly agreed, 47% 

agreed, 12% neutral). Ease of use of the pro-forma was also 

supported (47% strongly agreed that the pro-forma was easy 

to use, 53% agreed, no neutral or disagreeing responses). 

Compliance with use of the initial physiotherapy assessment 

pro forma has increased from 26% in 2006 to 90% in 2009. 

On-going work is planned to improve quality of information 

documented within the pro-forma, particularly in relation 

to goal setting and discharge planning. 

Rasch analysis of the 

Elderly Mobility Scale 

Nolan J, 1 de Morton NA 2 

1 

Flinders Medical Centre, Adelaide, 2 Northern Health, Victoria 

The aim of this study was to assess the unidimensionality of 

the Elderly Mobility Scale, a mobility outcome measure that 

consists of 7 items, administered by observation of physical 

performance (scored from 0–20 where 20 represents a high 

level of independent mobility). Despite its common use in 

an older acute medical population, a Rasch analysis has 

not previously been conducted on this outcome measure. 

In this study Elderly Mobility Scale scores were collected 

from 120 consecutive older acute medical patients admitted 

to Flinders Medical Centre, Adelaide, at admission and 

discharge. Admission scores (n = 120), fitted the Rasch 

model (chi2 = 18.31, p = 0.19, df = 14). The hierarchy of item 

difficulty ranged from the easiest item, lying to sitting, to 

the hardest item, functional reach. One item, the timed walk 

test, had a high positive fit residual (+ 3.93) suggesting that 

this item may measure another construct to the other items. 

At discharge (n = 105), Elderly Mobility Scale data did not 

fit the Rasch model (chi2 = 25.66, p = 0.03, df = 14). Item 

and person scores were not well matched due to a ceiling 

effect where 35% of persons had a logit location higher 

than the most difficult item. The functional reach item 

showed some misfit to the Rasch model and the gait item 

had a disordered threshold. Although the Elderly Mobility 

Scale fitted the Rasch model at hospital admission, an 

unacceptable ceiling effect at discharge limits the validity 

of this scale for measuring and monitoring the mobility of 

older acute medical patients. 

Targeted individual exercise programs for older 

medical patients are feasible, and change hospital and 

patient outcomes: a service improvement project 

Nolan J, 1 Thomas S, 2 Gaughwin B 1 

1 

Flinders Medical Centre, Adelaide, 2 Flinders University, Adelaide 

With an ageing Australian population, older medical patients, 

at higher risk of functional decline and prolonged admissions, 

are predicted to occupy an increasing proportion of hospital 

beds. This service improvement project was undertaken to 

assess the impact of individually prescribed exercises for 

older medical patients. A cohort of general medical patients 

aged 70 and over, admitted to Flinders Medical Centre, at 

higher risk of functional decline, able to commence exercise 

within 48 hours of admission, was included in this project. 

A functional maintenance exercise program, individually 

tailored to maintain functional mobility, prescribed and 

progressed by a physiotherapist, supervised 6 days per week 

by an allied health assistant, was provided in addition to 

usual care. Outcomes included mobility, length of hospital 

stay, aged care assessment referrals and approvals, and 

hospital readmissions within 28 days. In this study 89% 

(n = 196) of suitable patients commenced the intervention. 

Those unable to commence due to resource limitations were 

considered the usual care group (11%, n = 24). An average 

15.6% shorter hospital stay, 8% fewer re-admissions, and a 

small difference in mobility were demonstrated in favour 

of participants, none of which were statistically significant 

in this cohort. Logistic regression analyses showed a 

statistically significant decreased likelihood of referral to 

aged care assessment (OR = 0.228, 95% CI 0.088–0.587) 

and decreased likelihood of aged care assessment approval 

(OR = 0.307, 95% CI 0.115–0.822) for exercise patients. 

This project showed it is feasible to identify older medical 

patients likely to benefit from this exercise program and 

supports investigation in a randomised controlled trial. 

A head-to-head comparison of the de Morton Mobility 

Index (DEMMI) and Elderly Mobility Scale (EMS) in 

an acute medical population 

O’Brien M, 1 de Morton NA, 2 Nolan J, 1 Thomas S, 1 Govier 

A, 1 Sherwell K, 1 Harris B, 1 Markham N, 1 Keating JL 3 

1 

Flinders Medical Centre, Adelaide, 2 Northern Health, Victoria, 

3 

Monash University, Victoria 

The aim of this study was to compare 2 methods for 

measuring mobility of older people, the de Morton 

Mobility Index (DEMMI) and the Elderly Mobility Scale 

(EMS), with a head-to-head comparison. The DEMMI was 

recently developed in an older acute medical population. It 

consists of 15 items and is scored from 0–100. The Elderly 

Mobility Scale (EMS) is commonly used in this patient 

population. It consists of 7 items and is scored from 0–20. 

A direct comparison of these instruments has not been 

previously conducted. One hundred and twenty consecutive 

older acute medical patients admitted to Flinders Medical 

Centre, Adelaide, were included. The DEMMI and EMS 

were administered within 48 hours of hospital admission 

and discharge. A coin toss determined the order of test 

administration. At hospital admission, 6% and 15% of 



participants scored the lowest scale score for the DEMMI 

and EMS respectively. At hospital discharge, a ceiling 

effect was identified for the EMS (17% scored the highest 

scale score) but not for the DEMMI. Validity data were 

comparable for the 2 instruments. A significant and high 

correlation was identified between the DEMMI and EMS 

(r = 0.95, p = 0.00). There was no significant difference 

in responsiveness. The EMS was significantly quicker to 

administer compared to the DEMMI but this difference is 

unlikely to be of clinical significance. The DEMMI has a 

broader scale width than the EMS and therefore provides 

a more accurate method for measuring and monitoring 

changes in mobility for older acute medical patients. 

16 

Disorders in manual dexterity in Parkinson’s disease 

Proud EL, Morris ME 

Melbourne Physiotherapy School, The University of Melbourne 

This aim of this study was to investigate the extent to which 

manual dexterity is compromised in people with Parkinson’s 

disease, in uni-task and dual-task conditions. Upper limb 

performance in 22 hypokinetic people with idiopathic 

Parkinson’s disease was compared with the performance 

in 22 age and sex matched unimpaired people. Dexterity 

was quantified using the number of pegs inserted into the 

Purdue Pegboard in 30 seconds. The secondary task was a 

verbal cognitive task requiring serial subtraction of sevens 

from a randomly assigned number. The Unified Parkinson’s 

Disease Rating Scale was used to quantify Parkinson 

disability, and all participants rated their functional hand 

ability using the Manual Ability Measure-16. The uni-task 

results showed that people with Parkinson’s disease had 

significantly reduced hand dexterity (p < 0.001), inserting 

a mean of 10.27 (SD ± 2.31) pegs compared to a mean of 

13.62 (SD ± 1.73). In those with Parkinson’s disease there 

was a strong negative linear relationship between the motor 

Unified Parkinson’s Disease Rating Scale and the number of 

pegs inserted. Those who were more disabled inserted fewer 

pegs. For the dual task conditions both groups declined in 

performance but there was no significant effect for group 

in this sample. There was, however, a significant decline in 

the number of correct subtractions by the Parkinson’s group 

(p = 0.031). These results confirm clinical impressions that 

manual dexterity is compromised in people with Parkinson’s 

hypokinesia. Dexterity disorders were most pronounced in 

those who had greater disease severity. 

Predictors of low-tech choice stepping reaction time 

test performance in older people 

Ramsay E, 1,2 Sherrington C, 1,2 Barraclough E, 1,2 

O’Rourke S, 1,2 Lord SR 1,2 

1 


Sydney, Sydney, 2 Prince of Wales Medical Research Institute, University 

of New South Wales, Sydney 

Choice stepping reaction time (CSRT) has been found to 

be a composite measure of falls risk in older people. We 

developed a portable low-tech CSRT procedure which 

involves a thin flexible rubber mat and 20 verbal cues to 

step onto 1 of 4 rectangles marked on the mat as quickly as 

possible. The time to complete the last 12 steps is recorded. 

This study aimed to establish whether physiological function, 

age, cognition and health status predicted low-tech CSRT 

performance. Eighty-eight older people who had recently 

been in hospital were tested on the CSRT mat. Measures of 

standing balance (maximal balance range), knee extension 

strength, hand reaction time, visual contrast sensitivity 

(Melbourne Edge test), cognition (Mini Mental State 

Examination score) and health (number of co-morbidities) 

were also taken. Univariate linear regression analyses 

revealed that better maximal balance range (p < 0.001, r2 = 

0.20), faster hand reaction time (p = 0.03, r2 = 0.05), better 

Melbourne Edge test (p = 0.02, r2 = 0.07), decreased age (p 

< 0.001, r2 = 0.20), and higher MMSE Score (p = 0.02, r2 = 

0.06) were associated with better CSRT mat performance. 

There were no significant associations between CSRT mat 

performance and knee extension strength (p = 0.10) or 

number of co-morbidities (p = 0.26). A multivariate model 

which included age (p < 0.001) and maximal balance range 

(p


been informed by a 20-year research program consisting of: a 

series of epidemiological studies to determine the risk factors 

for falls, randomised controlled trials to test the efficacy of 

a range of interventions based on risk factor identification, 

pragmatic trials, clinical trials to test methods of delivery, 

and economic evaluations. The controlled trials have 

determined the effectiveness of a number of interventions 

in specific populations. These include the Otago Exercise 

Programme for strength and balance retraining, now used 

internationally, home safety and behaviour modification 

for elderly people registered blind, and psychotropic drug 

withdrawal for those 65 years and over who are taking 

these medications. The research has also shown a number 

of interventions, including some multifactorial ones, do not 

work in certain populations. The lessons to be learned from 

the New Zealand experience include: application of the 

findings from the comprehensive and systematic research 

program on falls and their prevention, identifying the most 

cost effective strategies for falls prevention in the community 

and in residential care homes, challenges encountered in the 

implementation and sustainability of nation wide, targeted 

fall prevention strategies. Physiotherapists can play an 

important role in promoting and delivering effective and 

cost effective strategies for preventing falls in older people 

at both a population and individual level. 

Falls: updating the evidence for prevention 

Robertson MC 

University of Otago, New Zealand 

There is a wealth of evidence regarding the effectiveness 

and cost effectiveness of falls prevention strategies in 

older people for health professionals to apply directly at 

a population level and in everyday clinical practice. The 

Cochrane systematic review published this year identified 

111 randomised controlled trials (RCTs) that tested a falls 

prevention program in a community setting. There are an 

additional 41 RCTs in nursing care facilities or hospital 

wards. The strongest evidence concerns exercise programs 

for community living older people. Certain exercise 

programs, particularly those addressing balance, whether 

delivered to the individual at home or in a group, reduce the 

number of falls. Also effective are multifactorial approaches 

that include an assessment of the individual’s particular 

risk factors and referral or treatment based on these risk 

factors. Successful interventions in nursing care facilities 

include multifactorial programs, review of medications, 

and vitamin D supplementation. Exercise interventions 

used alone have not reduced falls in this setting. Supervised 

exercise and targeting multiple risk factors may be effective 

for longer stay patients in rehabilitation wards. An economic 

evaluation was reported as part of only 8 of the RCTs, but 3 

programs in the community have demonstrated the potential 

for falls strategies to be cost saving if targeted correctly. 

These are the Otago Exercise Program in those aged 80 

years and older, an Australian home safety assessment and 

modification program in people with a previous fall recently 

discharged from hospital, and a home based multifactorial 

program addressing 8 specific fall risk factors. 

Increasing physical activity in older people receiving 

inpatient rehabilitation: a feasibility study 

Said CM, 1,2 Morris M, 2 Bernhardt J, 3 Woodward M, 1 

Cumming T, 3 Pownell C, 1 Marsiglio R 1 

1 

Austin Health, Heidelberg, 2 The University of Melbourne, Parkville, 

3 

National Stroke Research Institute, Heidelberg 

Studies have shown that older adults receiving inpatient 

rehabilitation are not very active during their stay and often 

have poor mobility outcomes. Strategies to increase physical 

activity may improve mobility outcomes in this population. 

The purpose of this pilot study was to establish the feasibility 

of a randomised controlled trial of enhanced physical 

activity in older adults receiving rehabilitation. Fortyseven 

participants admitted to an aged care rehabilitation 

facility were randomly allocated to a control (n = 25) or 

intervention group (n = 22). Both groups received usual care, 

but the intervention group received an additional targeted 

program of physical activity. Participants were assessed 

within 48 hours of admission, on discharge from hospital 

and 3 months following discharge. Results indicated that 

the study design was feasible. A recruitment rate of 34% 

was achieved. Discharge data could not be collected from 2 

participants due to sudden readmission to an acute facility. 

Usual care therapists remained blind to group allocation and 

there was no evidence of change in ‘usual care’ practice. 

The majority of the physical activity targets were met, and 

strategies to ensure remaining targets are met in future 

have been identified. Feedback from participants suggested 

that the new program was acceptable to older adults. Based 

on these results, a larger multi-centre RCT is planned to 

establish whether providing enhanced physical activity 

to older adults receiving rehabilitation leads to improved 

mobility outcomes and is cost effective. 

Funding was provided by the Austin Health Medical Research 

Foundation and the Gait CCRE. 

Predicting discharge destination for elective hip and 

knee arthroplasty patients: a comparison of nursing 

staff judgement and the Risk Assessment 

and Prediction Tool 

Schofield C, 1 Barker AL 2,3 

1 

The Northern Hospital, Melbourne, 2 The Northern Clinical Research 

Centre, Melbourne, 3 Division of Physiotherapy, School of Health and 

Rehabilitation Sciences, The University of Queensland, Brisbane 

The aim of this study was to investigate the comparative 

predictive accuracy of pre-admission nursing staff 

prediction and the Risk Assessment and Prediction Tool 

(RAPT) in predicting acute care discharge destination 

for elective hip and knee arthroplasty patients. Data were 

utilised from a retrospective chart audit of a consecutive 

sample of 249 patients admitted for elective hip or knee 

arthroplasty between 1st June 2005 and 31st May 2008 at an 

acute public hospital in metropolitan Melbourne. Fifty-three 

patients were excluded from the study, yielding a sample of 

196. The area under receiver operating characteristic curve 

(AUC), proportion of people correctly classified, sensitivity 

and specificity were calculated to establish the accuracy of 

each method. The overall accuracy of the RAPT (AUC = 

0.74) was significantly higher (p = 0.001) than nursing staff 

prediction (AUC = 0.60). The RAPT provided a definite 

discharge prediction for a higher proportion of patients 

than nursing staff, although both tools left a large number 

of patients unclassified. These patients were classified by 



both methods as ‘home versus rehabilitation’. For patients 

with a definite discharge prediction 72 (80.0%) of RAPT 

predictions were correct, while only 35 (71.43%) of nursing 

staff predictions were correct (p = 0.688). The specificity of 

the RAPT was significantly higher (p = 0.038) than nursing 

staff prediction, while differences in sensitivity were not 

significant (p = 0.523). The RAPT is a tool able to more 

accurately predict patients’ discharge destination than 

nursing staff judgement and should be included as a key 

component of pre-admission assessment for elective hip and 

knee arthroplasty patients. 

Development of the prediction of falls in rehabilitation 

settings tool (Predict FIRST): a prospective 

cohort study 

Sherrington C, 1,2,3 Lord SR, 2 Close JCT, 2,4 Barraclough 

E, 1,2 Taylor M, 2,4 O’Rourke S, 1,2 Kurrle S, 5 Tiedemann A, 2 

Cumming RG, 3 Herbert RD 1 

1 

The George Institute for International Health, University of Sydney, 

Sydney, 2 Prince of Wales Medical Research Institute, University of New 

South Wales, Sydney, 3 School of Public Health, University of Sydney, 

Sydney, 4 Prince of Wales Hospital, Sydney, 5 Hornsby Ku-ring-gai 

Hospital, Sydney. 

This prospective cohort study aimed to develop and 

internally validate a simple falls prediction tool for 

rehabilitation settings (Predict FIRST). Participants were 

533 patients aged 50 years and over consecutively admitted 

to rehabilitation wards in 2 hospitals. A range of possible 

risk factors for falls was collected from medical records, 

interview and physical assessment. Fourteen percent of 

participants fell during their inpatient stay. A multivariate 

model to predict falls included: male gender (OR 2.66, 95% 

CI 1.53–4.63), prescription of Central Nervous System 

(CNS) medications (OR 2.33, 95% CI 1.36–3.98), a fall in the 

previous 12 months (OR 2.10, 95% CI 1.01–4.35), frequent 

toileting (OR 1.92, 95% CI 1.12–3.27), FIM Communication 

item score (OR 0.93, 95% CI 0.85–1.01), and standing 

balance time in 5 positions (OR 0.97, 95% 0.94–0.99). This 

model was used to develop the Predict FIRST tool which 

includes male gender, CNS medication use, a fall in the 

past year, frequent toileting and the inability to perform a 

tandem stance. People with none of these risk factors had a 

2% probability of falling during their inpatient stay, those 

with 3 risk factors had an 18% probability and those with 

all 5 risk factors a 52% probability of falling. The AUC 

for the Predict FIRST tool was 0.73 (95% CI of 0.68–0.79, 

bootstrap-corrected AUC also 0.73). The Predict FIRST 

tool provides good discrimination between fallers and nonfallers 

and enables the probability of falling (absolute risk) 

to be calculated for individual patients. 

18 

Does the Otago Exercise Program reduce mortality 

and falls in older adults: a systematic review and 

meta-analysis 

Thomas S 1 , Mackintosh S 2 , Halbert J 1 

1 

Flinders University, Adelaide, 2 University of South Australia, Adelaide 

The aim of this systematic review and meta-analysis was 

to evaluate the effect of the Otago Exercise Program on 

mortality and falls in older adults (65+). All randomised 

clinical trials and controlled clinical trials where the Otago 

Exercise Program was the primary intervention were 

included. Primary outcomes included mortality, fall rates, 

injurious fall rates, and compliance to the exercise program. 

Searches of the Cochrane Central Register of Controlled 

Trials, MEDLINE, CINAHL, TRIP, AARP Ageline, 

INFORMIT and a citation search of included articles 

through Web of Science (ISI) were carried out. Pearling 

occurred through review of conference proceedings, 

reference lists, the Australian Digital Theses Program, 

searches of the PEDro, and the Prevention of Falls Network 

Europe website, as well as contact with researchers in the 

field. Eight trials, involving 1481 participants were identified 

and included in meta-analysis. The mean (SD) age of all 

participants was 81.2 (3.9) years. The pooled estimate of 

the effect on mortality over 12 months was risk ratio = 0.47 

(95% CI 0.26–0.80, p = 0.006) indicating that the Otago 

Exercise Program significantly reduces the risk of death. 

The incidence rate ratio for falling (the effect of OEP on fall 

rates) was 0.70 (95% CI 0.59–0.81, p < 0.001), indicating a 

positive effect of the Otago Exercise Program on reducing 

fall rates in older people. In summary, the Otago Exercise 

Program reduces both the mortality and fall rates in older 

people. 

A brief performance-based fall risk assessment tool 

(QuickScreen) for community-dwelling older people: 

external validation and reliability 

Tiedemann A, 1 Lord SR, 1 Sherrington C 1,2 

1 

Prince of Wales Medical Research Institute, University of New 

South Wales, Sydney, 2 The George Institute for International Health, 


The QuickScreen enables quantification of risk of falling 

for community-dwelling older people after a brief 

assessment of risk factors: low-contrast visual acuity, tactile 

sensitivity, sit to stand, alternate step and near tandem stand 

ability, previous falls and medications. This study aimed 

to externally validate (test in a new sample) and assess 

the test-retest reliability of QuickScreen. The external 

validation study involved 362 community-living volunteers 

aged 74 years and over, the reliability study involved 30 

volunteers. In the validation study, 22% of participants 

suffered multiple falls during the 12-month prospective 

follow-up. The assessment items discriminated between 

multiple fallers and non-multiple fallers with relative risk 

values ranging from 1–2.8. The QuickScreen assessment 

score (number of risk factors present) demonstrated good 

discrimination between the multiple fallers and others-area 

under the ROC curve of 0.72 (95% CI 0.66–0.79). Based on 

their QuickScreen result, 7% of validation study participants 

with 0–1 risk factors were predicted to experience multiple 

falls, and 6% did have multiple falls during the follow-up. 

Of those with 2–3 risk factors, 13% were predicted to have 

multiple falls and 12% did, of those with 4–5 risk factors, 

27% were predicted to have multiple falls and 27% did and 

of those with 6 or more risk factors, 49% were predicted to 

have multiple falls and 52% did. The QuickScreen items 

exhibited moderate to excellent reliability (intra-class 

correlation coefficient range: 0.54 to 0.89). QuickScreen is 

a valid and reliable assessment that can accurately identify 

high-risk community-living fallers. 



Joint Plenary Session: Get Off The Couch 





Joint Plenary Session: Get Off The Couch 

10 000 steps in the northern and southern hemispheres: 

reflections on whole community interventions in 

Rockhampton (Australia) and Ghent (Belgium) 

Brown WJ 

The University of Queensland: School of Human Movement Studies. 

The 10 000 Steps Rockhampton project was a whole 

community intervention which simultaneously focused 

different intervention strategies around pedometer use and 

the 10 000 steps slogan. Following its completion in 2004, 

researchers in Ghent collaborated with the Rockhampton 

researchers to develop a Belgian ‘10 000 Stappen’ 

intervention. Common aspects of the two interventions 

were use of the media, local signage, workplace strategies 

and pedometer loan and sales. Formative data suggest that 

the project may have had greater ‘reach’ in Rockhampton, 

but this may reflect the smaller population of Rockhampton 

(60 000, with 220 000 in Ghent), and the more concerted 

effort there to involve GPs in PA promotion. At post-test 

18% of the Rockhampton sample and 13% of the Ghent 

sample reported that they had used a pedometer to count 

their steps (compared with 5.6% and 9.5% of the two 

comparison communities). Tropical heat in Rockhampton 

and the cold wet Ghent winter may have been barriers to 

behaviour change. A strong culture of bicycle use may also 

have impacted on the possibility for increased walking in 

Ghent. Pedometer use was more common in women than 

men in Rockhampton but this difference was not noted in 

Ghent. The results indicate that the 10 000 steps concept 

can be successfully adopted and adapted for use in different 

hemispheres, climates and cultures. 

Exercise in the community: Western Australian 

community physiotherapy groups 

Devereux K, 1,2 Middleton B, 1 Fabling M, 1 Ganderton L 1 

1 

Community Physiotherapy Services, Department of Health, Western 

Australia, 2 Ambulatory Care, Department of Health, Western Australia 

Community Physiotherapy Services (CPS) provide 

functional rehabilitation and physical activity programs for 

those with chronic disease throughout the Perth metropolitan 

area. The aim is to promote functional independence and 

to provide a safe environment for those who are not able 

to access physical activity programs which are generally 

available in the community for the well aged. The programs 

are based on evidence from reviewed literature and best 

practice exercise and physiotherapy rehabilitation of 

specific chronic diseases and physical activity in the frail 

elderly. The programs include disease specific classes: 

pulmonary and cardiac rehabilitation, chronic stroke, 

Parkinson’s disease, arthritis, osteoporosis, chronic pain, 

diabetes and specialised orthopaedic conditions. Water and 

land based programs for participants with mixed conditions 

provide falls prevention, rehabilitation and physical activity 

programs and the promotion of self management. CPS 

provide approximately 190 community based physiotherapy 

group classes each week. The groups of 6–15 participants 

(average = 8) attend one 50–minute class per week for 10 

weeks. 

Volunteer-led tai chi in a rural setting 

Gow AJ, Dubois LG 

Greater Southern Area Health Service, Queanbeyan 

This presentation summarises the planning, implementation 

and evaluation of a volunteer-led program of tai chi and 

other exercise designed to reduce the risk of falls injury 

in Greater Southern Area Health Service (GSAHS). There 

is good evidence to support the use of tai chi to prevent 

falls. However, there is less evidence to guide practitioners 

in implementing tai chi programs systematically across 

a large geographical area. GSAHS is a large rural health 

service, covering 166 000 square km with a population of 

approximately 468 000. The population is geographically 

dispersed and access to appropriate physical opportunity 

for older adults can be limited, particularly in smaller 

communities. A supported program of tai chi was 

implemented in 2007, building on a strong base of existing 

physical activity initiatives. The program relies largely on 

volunteer leaders who are trained and supported by GSAHS 

through strategies such as network meetings, newsletters 

and skills updates. As an equity strategy, leaders in smaller 

or otherwise disadvantaged communities are specifically 

sought. As of January 2009, 66 leaders were running tai 

chi classes across GSAHS. There were 1335 registered 

participants across 36 communities. Numbers of leaders, 

classes and participants fluctuate over time. Additional 

leader training will be run during 2009 and a comprehensive 

evaluation of the implementation model will commence. 

The issue of sustainability is a crucial consideration. 

2 




16th Biennial Conference 






Cryotherapy after total knee replacement: a systematic 

review and meta-analysis of randomised controlled 

trials 

2 

Adie S, 1,2 Naylor JM, 1,2 Harris IA 1,2 

1 

South West Sydney Clinical School, University of New South Wales, 

Sydney, 2 Whitlam Orthopaedic Research Centre, Sydney 

Cryotherapy is a safe and relatively cheap intervention 

with theoretical and practical applications in minimising 

trauma following injury. This systematic review and metaanalysis 

synthesised the evidence from randomised trials 

on the efficacy of cryotherapy after total knee replacement. 

We searched the Cochrane Database of Systematic 

Reviews, Cochrane Controlled Trials Register, MEDLINE, 

EMBASE, CINAHL and Web of Science, as well as the 

reference lists of articles for possible inclusions. Two authors 

independently extracted data and assessed the quality of 

trials. Outcomes investigated were blood loss, transfusion 

rate, pain, analgesia use, range of motion, swelling, and 

length of stay. Meta-analysis was performed using the 

inverse variance method for continuous measures, and 

the Mantel-Haenszel method for dichotomous variables. 

Where there was substantial heterogeneity, sensitivity 

analyses using the random effects model were performed. 

Eleven studies, including 793 total knee replacements in 

735 patients, were included. There was significant clinical 

and methodological heterogeneity. Cryotherapy resulted in 

significant benefits in blood loss (mean difference =-117ml; 

95% CI -216 to -19; p = 0.01) and range of motion at time of 

discharge (mean difference = 6.18 degrees of flexion; 95% 

CI 1.6–10.8; p = 0.009). There were no significant benefits 

in transfusion rate, pain, analgesia use, swelling, length of 

stay, and gains in range of motion after discharge. Longer 

term outcomes were generally not reported. Cryotherapy 

after total knee replacement has small benefits in blood loss 

and early range of motion, but these results are of uncertain 

clinical significance. 

Transabdominal ultrasound measurement of 

pelvic floor muscle function in women with chronic 

low back pain 

Arab AM, 1 Pourmakhdoom D 2 

1 

University of Social Welfare and Rehabilitation Sciences, Iran; 

2 

Private clinic, Melbourne 

Pelvic floor muscles are generally accepted as a part of 

the trunk stability mechanism. Loss of function of these 

muscles has been recently associated with the development 

of low back pain. Transabdominal ultrasound imaging has 

been established as an appropriate method for visualising 

and measuring muscle function. No study has directly 

evaluated pelvic floor muscles function in individuals with 

low back pain. The purpose of this study was to investigate 

the pelvic floor muscle activity in women with and without 

with low back pain using transabdominal ultrasound. 

Convenience sample of 40 non-pregnant female participated 

in the study. Subjects were categorised into two groups: 

with LBP (n = 20) and without LBP (n = 20). The amount 

of bladder base movement on ultrasound was measured in 

all subjects and considered as an indicator of pelvic floor 

muscles function and normalised to body mass index. The 

normalised value was used for data analysis. Significant 

difference in transabdominal ultrasound measurements for 

pelvic floor muscles function was found between two groups 

using independent t-test (p = 0.04, 95% CI of difference: 

0.002–0.27). The results of this study indicate pelvic floor 

muscles dysfunction in individuals with low back pain 

compared to those without low back pain. The results seem 

to be beneficial to clinicians when assessing and prescribing 

therapeutic exercises for patients with low back pain. 

Correlation of foot progression angle with Craig’s 

angle, medial longitudinal arch, foot length, foot 

breadth and arch index 

Bajaj D, 1,2 Rajpal H, 1 Dhakshinamoorthy P 1 

1 

Physiotherapy Department, Sardar Bhagwan Singh Pg Institute of 

Biomedical Sciences and Research, Dehradun, India, 2 St. Stephens 

Hospital, New Delhi, India 

The purpose of the study was to find out co-relation 

between foot progression angle and Craig’s angle, medial 

longitudinal arch, foot length, foot breadth and arch index. 

After obtaining Ethical committee approval 53 female 

subjects of mean age 20.45 + 1.31 were included according 

to the inclusion criteria. Consent form has been obtained 

from all the subjects. Craig’s angle has been measured in 

prone. Medial longitudinal arch, foot length, foot breadth, 

and arch index have been measured while standing and 

foot progression angle has been measured while walking. 

All the measurements have been taken three times and the 

average was used for the data analysis. Pearson correlation 

was performed in order to correlate the data. Statistical 

analysis revealed that there is over-all no co-relation 

which exists between foot progression angle with foot 

breadth, arch index and the Craig’s angle. There is weak 

negative co-relation between foot progression angle and 

medial longitudinal arch and weak positive co-relation 

between foot progression angle and foot length. During a 

musculoskeletal examination, emphasis should be placed 

on these measurements, as they can be a predisposing factor 

for an injury and medial longitudinal arch can be improved 

with strengthening of the intrinsic muscles to avoid injury. 

A comparative study between the efficacy of 

therapeutic ultrasound and soft tissue (friction) 

massage in supraspinatus tendinitis 

Bansal N, 1 Kshitija Pakti 2 

1 

Amity Institute of Physiotherapy, Amity University, Noida, INDIA, 

2 

Private Practise, Delhi, INDIA 

Supraspinatus tendinitis is the common condition faced 

by general population. In clinical setting it is treated by 

conservative management and physiotherapy. Ultrasound 

(US) and deep friction massage (DFM) is one of the treatment 

approaches. The objective is to study the effectiveness of US 

and DFM treatment and to compare them over the period 

of 10 days. Forty subjects with supraspinatus tendinitis 

were randomly assigned to US or DFM treatment group. 

US group received 6–8min of pulsed US at 0.8 w /cm2, 

with 1 MHz frequency, every day for 10 days. DFM group 

received 10–12min of DFM in transverse direction with tip 

of the index finger re-enforced by middle finger, every day 

for 10 days. Subjects were evaluated for pain with visual 

analogue scale (VAS) and shoulder abduction active range 

of motion (AROM) at the start and end of the treatment of 

day 1, 5 and 10. Student t-test was used to analyse data and 

at the end of 10 days of treatment, both the groups showed 

significant improvement and the difference between days 

1 and 10 in pain on VAS (US = 3.55, DFM = 4.40) and in 

shoulder abduction AROM (US = 25.95 degrees, DFM = 



32.65 degrees) was statistically significant. But when they 

both were compared, DFM showed significant improvement 

over US in pain on VAS (p = 0.014) and shoulder abduction 

AROM (p = 0.023).We concluded that both interventions 

reduce pain and increase abduction AROM but DFM is 

proved to be more effective when compared to US. 

Determining the reliability and sensitivity of foot 

posture measures in individuals with patellofemoral 

pain syndrome 

Barton CJ, Bonanno D, Levinger P, Menz HB 

Latrobe University, Melbourne 

The aims of this study were to: establish the intra-rater and 

inter-rater reliability for a range of foot posture measures, 

and evaluate differences in foot posture using each measure 

between individuals with and without patellofemoral pain 

syndrome. Three separate raters evaluated the foot posture 

of 20 cases and 20 controls on 2 separate days using; the 

foot posture index in relaxed stance; and calcaneal angle, 

longitudinal arch angle, normalised vertical navicular height, 

and normalised dorsal arch height in relaxed stance and with 

subtalar joint neutral as a reference posture. Good (ICC > 

0.75) to excellent (ICC > 0.90) intra-rater and inter-rater 

reliability was found for the foot posture index, normalised 

dorsal arch height, and normalised vertical navicular height 

in relaxed stance, and normalised navicular height when 

using subtalar joint neutral as a reference posture. Other 

measures were more variable and demonstrated lower 

reliability (ICCs < 0.75). In relaxed stance, the foot posture 

index (p = 0.02) and longitudinal arch index (p = 0.02) were 

the only measures to indicate a significantly greater pronated 

foot posture in the patellofemoral pain syndrome population. 

However, all measurements using subtalar joint neutral as a 

reference posture indicated a significantly greater pronated 

foot posture in the patellofemoral pain syndrome group (p 

= 0.003–0.007). The most sensitive measures were those 

using subtalar joint neutral as a reference posture, and of 

these, normalised navicular height was the only measure to 

also demonstrate adequate reliability. 

Increased physical load during an active straight leg 

raise in pain free subjects 

Beales DJ, O’Sullivan PB, Briffa NK 

Curtin University of Technology, Perth 

Bilateral bracing of the anterior abdominal wall with 

increased intra-abdominal pressure has been reported as 

an aberrant motor control strategy in pelvic girdle pain 

subjects during an active straight leg raise. This might 

represent a high-load motor control strategy for a low-load 

task. This premise was investigated by observing trunk 

muscle activation, intra-abdominal pressure, intra-thoracic 

pressure and pelvic floor motion in pain-free subjects (n = 14) 

during resting supine, active straight leg raise and an active 

straight leg raise with additional physical load. Incremental 

increases in muscle activation were observed between these 

tasks, with a simultaneous incremental increase in intraabdominal 

pressure in relation to raising the leg. Respiratory 

fluctuation of intra-abdominal pressure was maintained. 

Additional physical load also resulted in increased pelvic 

floor descent. Trunk muscle activation was equal between 

sides with additional physical load, except for the lower 

internal oblique which displayed greater activation on the leg 

lift side. These results have identified a general increase in 

anterior trunk muscle activation consistent with a high-load 

motor strategy during the additional physical load task, that 

preserved the pattern of greater internal oblique activation 

on the side of the leg lift as previously reported during an 

unloaded active straight leg raise in pain-free subjects. This 

contrasts to pelvic girdle pain subjects who, despite having 

a high-load strategy for performing an active straight leg 

raise on the symptomatic side of the body, display equal 

bilateral activation of the anterior abdominal wall muscles 

during the active straight leg raise. 

Depth of penetration and nature of interferential 

current in cutaneous, subcutaneous and muscle tissues 

Beatti A, Souvlis T, Chipchase L, Rayner A 

The University of Queensland, Brisbane 

The aims of this study were to investigate the depth of 

interferential current penetration through soft tissue and 

the area over which interferential current spreads during 

clinical application. Premodulated interferential current 

and ‘true’ interferential current at beat frequencies of 4, 40 

and 90Hz were applied via 4 electrodes to the distal medial 

thigh of 12 healthy subjects. The voltage was measured 

via three Teflon coated fine needle electrodes connected to 

Spike2 laboratory software and inserted into the superficial 

layer of skin, then into the subcutaneous tissue (1 cm deep) 

and then into muscle tissue (2 cm deep). The needles were 

placed in the middle of the 4 electrodes, between 2 channels 

and outside the 4 electrodes. Voltage readings were taken 

at each tissue depth from each electrode during each 

treatment frequency. All voltages were greater at all depths 

and locations compared to baseline (p < 0.01). Voltages 

decreased with depth. Lower voltages of all currents were 

recorded in the middle of the four electrodes with the 

highest voltage being recorded outside the four electrodes. 

For each frequency of interferential current, the voltage 

was higher in the muscle outside the electrodes (p ≤ 0.01). 

Premodulated had higher voltages in subcutaneous tissue (p 

≤ 0.01). In summary, interferential current passes through 

soft tissue and was more efficient than premodulated when 

targeting muscle tissue. Surprisingly, the measured voltage 

of interferential current was higher outside the electrodes 

than in the middle of the electrodes. The implications of 

these findings to clinical practice will be discussed. 

Hip osteoarthritis: understanding the interrelationship 

between impairments and physical 

function 

Bennell KL, Pua YH 

The University of Melbourne, Melbourne 

Hip osteoarthritis (OA) is a major cause of physical function 

limitations amongst the older population. It is associated 

with 3 main physical impairments: muscle performance 

deficits, hip range of motion restrictions and hip pain. This 

presentation will discuss a series of studies we conducted 

involving 100 people with hip OA that aimed to investigate 

the interactions and inter-relationships between these 

physical correlates and physical function. The main findings 

were first, that there is a relationship between hip flexion 

range and physical function which is mediated by hip 

extensor strength and pain. Thus, improving joint mobility 

is an important therapeutic focus in hip OA. Second, there 



is an inter-relationship between hip and knee extensors and 

function such that in individuals with hip muscle weakness, 

strong quadriceps muscles can allow them to achieve 

reasonable levels of physical function. Thus, if adequate hip 

extensor strengthening cannot be performed due to pain, then 

quadriceps strengthening should be emphasised. Third, both 

maximal quadriceps strength and rate of quadriceps force 

development (power) are independent predictors of physical 

function in hip OA. Furthermore, the importance of rate of 

force development to function is more pronounced in those 

with low quadriceps strength. This means that different 

exercise strategies may be needed to improve the different 

aspects of muscle performance and this may be particularly 

important in those with the weakest quadriceps. These 

results will help to identify musculoskeletal impairments 

that should be addressed in physiotherapy treatment in 

order to improve physical function. 

4 

The architecture of anconeus: implications 

for its function 

Bergin MJG, Mercer SR 


The function of anconeus has long been the subject of 

debate. Electromyographical studies have been undertaken 

to determine its function; however, conflicting evidence still 

remains. Some believe anconeus is a weak elbow extensor, 

while others have found it to be active in both pronation and 

supination of the forearm. Interestingly the site of electrode 

placement with regards to the morphology of anconeus 

has never been considered. The aim of this study was to 

determine the fascicular architecture of anconeus as a 

prelude to undertaking a more detailed functional anatomy 

study. The anconeus was examined in 2 embalmed elderly 

human upper limbs. Utilising distinct sites of attachment 

and natural cleavage planes the fascicular architecture 

of the muscle was determined. Anconeus consisted of 5 

distinct bands, having a transverse or increasingly oblique 

to longitudinal orientation. The muscle attached proximally 

via a variable tendon to the lateral epicondyle of the 

humerus. Muscle fibres diverged and passed transversely 

to the adjacent olecranon process or obliquely down the 

proximal posterio-lateral surface of the ulna. Muscle bands 

2–4 may also be bilaminar, arising from the medial margin 

(superficial lamina) or deep surface (deep lamina) of the 

tendon. The anconeus muscle has a complex fascicular 

architecture, with 2 separate lamina and 5 bands which 

have distinct fibre orientations. These findings highlight 

the need for electromyographical studies to consider the 

fascicular architecture of anconeus so its role at the elbow 

joint complex can be better understood. 

A randomised controlled trial of the effects of 

pre-treatment exercise for function in patients 

with shoulder pain 

Boland RA, 1,2 Refshauge KM 1 

1 

The University of Sydney, Faculty of Health Sciences, Sydney, 

2 

Fairfield Hospital, Sydney 

Patients in many hospitals in New South Wales are placed on 

a wait list for physiotherapy treatment until an appointment 

becomes available. The aim of this study was to determine 

whether prescribed exercises during the wait period for 

patients with shoulder pain was more effective for reducing 

pain and improving function than no exercises. A singleblind 

randomised controlled trial was undertaken in the 

physiotherapy department of a public hospital in Sydney. 

Eighty-four participants with shoulder pain referred from 

medical practitioners were randomised into an experimental 

(n = 42) or control (n = 42) group. Physiotherapists examined 

all participants at the commencement of the trial before 

a wait period for treatment. The experimental group was 

given advice, and individualised exercises to perform during 

the wait period. The control group was given only advice. 

Outcomes were self-ratings for; pain using a 100mm visual 

analogue scale (VAS); function using the American Shoulder 

and Elbow Surgeons Assessment; that were taken at the 

end of the wait period (when physiotherapy commenced), 

and at the conclusion of physiotherapy treatment. Baseline 

characteristics were similar between groups (p > 0.05). 

For both groups, physiotherapy was found to be effective 

when pre-and post-physiotherapy scores were compared 

(p < 0.05). However, both outcomes were similar between 

groups, with no differences (p > 0.05) detected for scores 

taken at the conclusion of both the wait and physiotherapy 

periods. These data infer that physiotherapist prescribed 

exercises for patients with shoulder pain on a wait list for 

treatment do not improve pain and function. 

Clinical application of tests for adverse neural tension 

and mechanosensitivity in carpal tunnel syndrome 

Boland RA 

The University of Sydney, Sydney; Fairfield Hospital, Sydney; Prince of 

Wales Medical Research Institute 

Carpal tunnel syndrome (CTS), the most common 

entrapment neuropathy, is thought to arise when elevated 

pressure in the carpal tunnel compromises the median 

nerve as it courses through the wrist. This results in 

conduction block, pain, paraesthesia, and numbness that 

can disrupt hand function, and severely disturb sleep. In 

fact, nocturnal waking is the classic symptom of CTS, 

because often it is the most disturbing feature. In addition to 

tests for conduction deficits, physiotherapists and medical 

practitioners use various tests of mechanosensitivity to 

assist with the diagnostic process in CTS, including Phalen’s 

test and Tinel’s sign. Other manoeuvres include the pressure 

provocation test, and carpal compression test. Such tests are 

used to localise the source of pathology to the wrist. Tests 

for adverse neural tension are used to implicate impaired 

movement of neural tissue in the patient’s presentation, 

specifically of the median nerve in the arm. Some have 

argued that such adverse cervicobrachial neural responses 

support the concept of a ‘double crush phenomenon’ in 

CTS, a thesis that probably has no physiological basis. 

Nevertheless, a mechanical view of CTS may be at the 

expense of other data that demonstrate that CTS involves 

local ischaemia of the median nerve in the region of the 

carpal tunnel. In addition, the nocturnal symptomology of 

CTS argues against an isolated mechanical phenomenon, 

particularly when the variable results of wrist splints 

are considered. This presentation will revisit the utility 

of selected examination procedures for CTS, applying 

the presenter’s research findings and current knowledge 

regarding CTS. 



Determining probability for total knee replacement 

Bourke MG, 1,2 Lumchee MW, 1 Jull GA, 2 Russell TG 2 

1 

QEII Jubilee Hospital, Brisbane, 2 The University of Queensland, 

Brisbane 

The aim of this study was to develop a statistical model that 

would help physiotherapists and primary care practitioners 

predict the probability of a surgeon offering a patient a total 

knee replacement. A case control study was conducted. 

Forty-two participants awaiting total knee replacement were 

matched by age and gender to 42 control subjects. Variables 

considered were current knee pain (numerical rating scale), 

knee range of movement, quadriceps lag, American Knee 

Society Score, Oxford Knee Score and the time from the 

3-metre timed up and go test. Statistical modelling is being 

undertaken using flexion and extension range of motion and 

preliminary results suggest that, based on this variable, the 

probability of a person requiring knee replacement can be 

predicted accurately 95% of the time. Further modelling is 

being undertaken and both the method for developing the 

model and the final data will be presented. 

An evaluation of a new multidisciplinary triage model 

in a persistent pain management service 

Blackburn MS, 1,2 Brentnall S, 1,2 Daly AE 1,2,3 

1 

Austin Health, Melbourne, 2 The University of Melbourne, Melbourne, 

3 

WorkSafe,Victoria, Melbourne 

The aim of this study was to evaluate the effectiveness of 

a new model of care in triaging referrals for a specialised 

persistent pain management service located within a public 

hospital. The new model of care involved pre-appointment 

management strategies, including the assessment of 

detailed patient surveys, and adherence to strict criteria for 

acceptance into the service. The new model also involved 

expanding the scope of practice of an appropriately qualified 

physiotherapist. The physiotherapist underwent additional 

training to perform the triage role which was formerly the 

responsibility of the pain physician. The evaluation of the 

new model demonstrated several significant improvements 

in service delivery, including a 32% reduction in acceptance 

of inappropriate referrals. Implementation of the new model 

resulted in a three-week interval between referral time and 

communication of the triage decision to the patient and 

GP. Previously the decision had taken a minimum of 16 

weeks. There was a 25% increase in the number of new 

appointments made for patients accepted into the service 

and an 8% reduction in missed first appointments. Under 

the new model, there was a 6% increase in patients who 

were managed by the physiotherapist and/or psychologist 

without input from the pain physician. The elimination of 

triaging responsibilities for the physician allowed him to 

perform an additional two hours of clinical work per week. 

The triaging physiotherapist was very satisfied with the 

diverse and challenging nature of this expanded role. 

Back pain beliefs and self-management practices in 

the community: relevance of health literacy 

Briggs AM, 1 Jordan JE, 2 Buchbinder R, 3 Straker LM, 1 

Burnett AF, 4 O’Sullivan PB, 1 Metcalf D, 1 Chua JC, 1 

Osborne RH 5 

1 


2 

Department of Medicine, University of Melbourne, Melbourne; 

3 

Cabrini Hospital Department of Clinical Epidemiology, Monash 

University, Melbourne; 4 School of Exercise, Biomedical, and Health 

Sciences, Edith Cowan University, Perth; 5 School of Health and Social 

Development, Deakin University, Melbourne. 

Health literacy is defined as an individual’s ability to 

seek, understand and utilise health information to make 

informed health decisions. Beliefs about back pain and 

self-management practices are likely to be influenced by 

health literacy. This study aimed to quantitatively examine 

the association between health literacy levels and back pain 

beliefs, and qualitatively explore beliefs, self-management 

and information-seeking practices among adults with 

chronic low back pain (CLBP) with the same socioeconomic 

index for area (SEIFA) score. Forty adults with CLBP and 

55 adults with no history of back pain in the previous 12 

months completed the Short-form Test of Functional Health 

Literacy in Adults (S-TOFHLA) and the Back Beliefs 

Questionnaire (BBQ). BBQ and S-TOFHLA scores did 

not differ between adults with and without CLBP (p = 

0.48 and p = 0.25), and there was no association between 

these instruments in either group (r2 = 0.008 and r2 = 

0.022). All adults in this community cohort had ‘adequate’ 

health literacy as defined by S-TOFHLA. However indepth 

interviews with individuals who had CLBP revealed 

several factors that affected seeking, understanding and 

utilising information for management of back pain. These 

included knowledge of where to seek resources, delivery 

of information by health professionals, poor treatment 

experiences and socioeconomic considerations. Furthermore 

gaps were identified between information needs and current 

sources within clinical and community settings. While a 

standardised questionnaire measure of health literacy was 

unrelated to back pain beliefs, qualitative data highlight 

broader factors that affect individual health literacy 

abilities which are important to interactions with healthcare 

professionals and self-management practices for CLBP. 

Neck/shoulder pain is not related to the level or nature 

of physical activity or type of sedentary activity in 

Australian adolescents 

Briggs AM, 1 Straker LM, 1,2 Bear N1, ,3 Smith AJ 1,2 

1 


2 

Telethon Institute for Child Health Research, Perth; 3 Department of 

Physiotherapy, Princess Margaret Hospital for Children, Perth 

It is widely believed that physical activity/inactivity is 

related to neck/shoulder pain (NSP) in adults and perhaps 

adolescents. However, the evidence for an association is 

inconsistent, possibly due to inadequate characterisation 

of physical activity, especially habitual activity patterns, 

and variability in definitions of pain. This study aimed 

to examine the association between NSP and detailed 

characterisation of activity. Six hundred and forty three 

adolescents (aged 14.0 years SD 0.19) participating in the 

Western Australian Pregnancy Cohort ‘Raine’ Study selfreported 

NSP experience via questionnaire and recorded 

daily activities with an electronic activity diary for 1 week. 

Activity was characterised by: level (sedentary, light, 



moderate or vigorous), nature (static/dynamic; standing/ 

sitting/lying), and type of sedentary activity (TV, computer, 

reading). Logistic regression models examined the 

association between NSP and weekly exposure to different 

aspects of activity. Females reported a higher prevalence 

of lifetime, 1-month and chronic NSP than males (50.9 vs. 

41.7%, 34.1 vs. 23.5%, and 9.2 vs. 6.2% respectively). No 

consistent, dose-response relationship was found between 

NSP and the level, nature, and type of physical activity. 

Despite a moderately large sample size and detailed and 

multiple characterisation of activity we were not able to 

identify a consistent relationship between activity and 

NSP in adolescents. This suggests either activity is not 

an important risk factor, or that study limitations meant 

the association was not detected. As the study was crosssectional, 

those with symptoms may have modified their 

behaviour to reduce exposure to exacerbating activity. 

Further, activity exposure may be important only when it 

interacts with other risk factors. 

6 

Managing shoulder disorders 

Buchbinder R 

Cabrini Institute and Monash University, Melbourne 

There is an array of commonly used treatments for shoulder 

disorders and evidence of their effectiveness and safety 

varies. Traditional treatments have included non-steroidal 

anti-inflammatory drugs, corticosteroid injections, physical 

therapies including manual therapy and exercise, and 

surgery, while more recently novel treatments such as 

extracorporeal shock wave therapy and topical nitroglycerin 

have been proposed. This talk will review the latest findings 

from Cochrane and other systematic reviews and recent trials 

and present suggestions for best evidence-based care. It will 

also discuss recent controversies in management such as the 

value of ultrasound as a diagnostic tool for shoulder pain in 

primary care and the increasing trend to use radiologicallyguided 

corticosteroid injections. 

Manual therapy: does it have a future? 

An outsider’s view 

Buchbinder R 


According to Wikipedia, manual therapy encompasses the 

treatment of health ailments of various aetiologies through 

‘hands-on’ physical intervention. Within the physical 

therapy profession, manual therapy is defined as a clinical 

approach utilising skilled, specific hands-on techniques, 

including but not limited to manipulation/mobilisation, 

used by the physical therapist to diagnose and treat soft 

tissues and joint structures. Manual therapy techniques are 

also practiced by a variety of other healthcare professionals 

including chiropractors, osteopaths and massage therapists, 

it is a feature of ayurvedic medicine and traditional Chinese 

medicine, and it forms the basis of many alternative therapies 

such as Rolfing and Bowen technique. Australia has played a 

prominent role in not only developing some commonly used 

manual therapy techniques such as McKenzie Therapy, it 

has also been at the forefront of assessing and assembling 

the evidence for manual therapy through randomised 

controlled trials, systematic reviews, and the establishment 

of the Physiotherapy Evidence Database (PEDro). This 

outsider will consider the history of manual therapy and its 

current status based upon the best available evidence. She 

will also gaze into her crystal ball to consider its future. 

An examination of the flexion-relaxation phenomenon 

in the cervical spine in lumbo-pelvic sitting 

Burnett A, 1,2 O’Sullivan P, 1 Caneiro JP, 1 Krug R, 1 

Bochmann F, 1 Helgestad G 1 

1 

School of Physiotherapy, Curtin University of Technology, Perth, 

2 

School of Exercise, Biomedical & Health Sciences, Edith Cowan 

University, Perth 

The flexion-relaxation phenomenon (FRP) is well 

documented at end-range lumbar spine flexion in both 

standing and sitting, however the FRP has been insufficiently 

investigated in cervico-thoracic musculature. The aim of 

this study was to determine whether the FRP occurs during 

forward flexion of the neck, in lumbo-pelvic sitting, amongst 

a pain-free population. Surface electromyography (EMG) 

was used to measure muscle activation in 20 (10 males) 

asymptomatic subjects in selected cervico-thoracic muscles 

during four, 5 s phases (upright posture, forward flexion, 

full flexion and return to upright) while subjects were 

positioned in lumbo-pelvic sitting. Spinal kinematics was 

simultaneously measured using an electromagnetic motion 

tracking device. No FRP was observed in upper trapezius or 

thoracic erector spinae (T4). When using visual methods to 

determine the presence/absence of the FRP, 5 subjects were 

believed to show evidence of the FRP in the cervical erector 

spinae. However, when using various non-visual criteria to 

determine the existence of the FRP, substantial variations 

(0–13 subjects) were evident. We recommend that criteria 

based upon relatively large differences in muscle activation 

should be considered when defining the FRP. These findings 

are of significance for future investigations examining 

specific cervical pain disorders. 

Interexaminer reliability of orthopaedic tests used in 

the assessment of shoulder pain 

Cadogan A, 1 Laslett M, 1,2 Hing WA, 1 McNair PJ, 1 

Williams MMN 1 

1 

AUT University, Auckland, NZ, 2 Physiosouth, Christchurch, NZ 

In symptomatic subjects, the interexaminer reliability 

of orthopaedic special tests (OST) has been found to 

be variable with little evidence available regarding the 

interexaminer reliability of these tests in a primary care 

patient population. The aim of this study was to determine 

the interexaminer reliability of a group of OST that 

have previously shown acceptable levels of diagnostic 

accuracy for specific shoulder pathology. Two examiners 

independently assessed 40 patients presenting with primary 

shoulder pain using the Active Compression (O’Brien’s) test 

for acromioclavicular joint and labral lesions, Hawkins- 

Kennedy test, modified Hornblower’s sign, Drop Arm 

test, Crank test, Jerk test, Kim test and Belly Press test. 

Overall kappa values ranged from -0.07–0.57 (‘virtually 

none’ to ‘fair’) for all tests. Highest levels of reliability were 

recorded for the Belly Press test (weakness) (kappa 0.68, 

95% CI 0.39–0.97). Only ‘slight’ reliability was recorded 

for the Crank test, Hawkins-Kennedy test and Active 

Compression test (labrum) (kappa 0.36–0.38). Prevalence 

of positive responses was low in several tests. Prevalence 

adjusted kappa statistics (PABAK) indicated ‘moderate’ 

reliability for the Active Compression test, Jerk test, Kim 

test, Drop Arm test and Belly Press test (kappa 0.65–0.75). 



Modified Hornblower’s sign demonstrated ‘virtually no’ 

reliability (-0.95). Results of this study suggest the Belly 

Press test appears the most reliable orthopaedic test. The 

unknown prevalence of conditions for which some OST are 

used at primary care level may affect reliability results in 

small sample studies. 

Diagnostic accuracy of clinical tests in detecting 

rotator cuff pathology: a pilot study 

Cadogan A, 1 Laslett M, 1,2 Hing, WA 1 McNair P,J 1 


1 


Little evidence exists to support the diagnostic accuracy 

of clinical tests in the diagnosis of rotator cuff pathology 

at primary care level. The aim of this pilot study was to 

determine the diagnostic accuracy of aspects of the history 

and physical examination in the diagnosis of rotator cuff 

pathology. Twenty-four subjects with primary shoulder pain 

were examined using a standardised clinical examination 

followed by a diagnostic ultrasound scan. Six rotator cuff 

tears were identified and calcification of the rotator cuff 

was identified in seven subjects. Aspects of the history 

most strongly correlated with the presence of any rotator 

cuff pathology included age > 50 years (p = 0.05) and male 

gender (p = 0.12). The presence of a tear of any rotator cuff 

muscle was also associated with traumatic mechanism of 

injury (p = 0.09). Symptom production during active range 

of motion (ROM) flexion and passive ROM glenohumeral 

abduction demonstrated good sensitivity (1.00) in detecting 

any rotator cuff pathology. The Hawkins-Kennedy test and 

production of symptoms during resisted abduction and 

resisted internal rotation were also highly sensitive (1.00) in 

detecting a tear of any rotator cuff muscle. Drop Arm test 

and weakness during resisted external rotation demonstrated 

high specificity (> 0.80) for the detection of any rotator 

cuff pathology. Results provide preliminary evidence that 

the presence of calcification in the rotator cuff may not be 

symptomatic. The absence of pain produced during resisted 

muscle tests shows some promise in assisting the clinician 

to confidently rule-out a tear of the rotator cuff within the 

context of a full clinical examination. 

Diagnostic accuracy of clinical tests and imaging 

findings in identifying the subacromial bursa as the 

source of pain: a pilot study 

Cadogan A, 1 Laslett M, 1,2 Hing WA, 1 McNair PJ, 1 


1 


Little evidence exists to support the diagnostic accuracy of 

clinical tests in the diagnosis of shoulder pain at primary 

care level. The aim of this pilot study was to determine the 

diagnostic accuracy of aspects of the history and physical 

examination in identifying pain arising from the subacromial 

bursa. Sixteen subjects with primary shoulder pain were 

examined using a standardised clinical examination (index 

test) including history and physical examination, followed 

by an ultrasound guided diagnostic injection of lidocaine 

into the subacromial bursa (reference standard procedure). 

Six subjects demonstrated a positive anaesthetic response 

(PAR) to subacromial injection determined by pre-and 

post-injection visual analogue pain scores. Duration of 

symptoms < 12 weeks (p = 0.06) and traumatic onset of 

symptoms (p = 0.13) were most closely associated with 

PAR. Production of pain during active ROM flexion and 

passive ROM glenohumeral abduction, and symptomatic 

bursal bunching on ultrasound all demonstrated good levels 

of sensitivity (1.00) for PAR. X-ray evidence of subacromial 

bursa calcification demonstrated high specificity (1.00) for 

PAR. These results provide preliminary evidence suggesting 

the subacromial bursa may be able to be ruled out as the 

source of pain in the absence of pain using the clinical and 

imaging results described. The presence of calcification of 

the subacromial bursa on X-ray may assist in ruling in this 

structure as the source of pain. Whether PAR to subacromial 

bursa injection predicts response to corticosteroid injection 

and its’ discriminate use as a treatment intervention is the 

subject for future research. 

Manipulation decreases thoracic spine stiffness in 

subjects with stiff spines 

Campbell BD, Snodgrass SJ 


Thoracic manipulation is a commonly performed manual 

technique, yet the biomechanical mechanisms that underpin 

its effectiveness are unknown. The aim of this study was 

to determine if spinal stiffness decreases following the 

application of thoracic manipulation, and if factors such 

as subject characteristics or manipulation force parameters 

are associated with the magnitude of stiffness change. 

Thoracic spine stiffness was measured in 24 asymptomatic 

subjects before and after a posteroanterior thoracic 

thrust manipulation applied in supine by a single titled 

musculoskeletal physiotherapist. Stiffness was quantified 

using a device that applied five cycles of standardised 

oscillating force to the spinous process while measuring 

resistance to movement and simultaneous displacement. 

Stiffness was defined as the linear portion of the forcedisplacement 

curve. Manipulation force parameters were 

quantified using an instrumented treatment table. Paired 

t-tests determined differences in thoracic stiffness pre-and 

post manipulation, and linear regression identified factors 

associated with the magnitude of stiffness change. Mean premanipulation 

spinal stiffness was 14.39 N/mm (SD 3.84). A 

stiffer thoracic spine was associated with a larger decrease 

in stiffness following manipulation (regression coefficient 

0.50, 95% CI 0.34–0.66, p < 0.001). In subjects with premanipulation 

stiffness ≥ 8 N/mm (n = 22), mean stiffness 

decreased following manipulation (mean decrease 0.95 N/ 

mm, 95% CI 0.10–1.81, p = 0.03). These results provide 

some evidence for a reduction in thoracic spine stiffness 

following manipulation, with larger effects in stiffer spines. 

This contributes to the biomechanical rationale for using 

manipulation to treat stiff thoracic spines. 

The influence of different sitting postures on head/neck 

posture and muscle activity 

Caneiro JP, 1 O’Sullivan P, 1 Burnett A, 1,2 Barach A, 1 O’Neil 

D, 1 Tveit O, 1 Olafsdottir K 1 

1 


2 



To date the influence that specific sitting posture has on 

the head/neck posture and cervico-thoracic muscle activity 

has been insufficiently investigated. Therefore the aim 

of this study was to investigate whether three different 



thoraco-lumbar sitting postures affect head/neck posture 

and cervico-thoracic muscle activity. Twenty (10 males) 

asymptomatic subjects were placed in 3 standardised 

thoraco-lumbar sitting postures (lumbo-pelvic, thoracic 

upright and slump) to investigate their influence on cervicothoracic 

muscle activity and head/neck posture. There were 

significant differences in lumbar and thoracic curvatures in 

the 3 different sitting postures (p < 0.002). Slump sitting 

was associated with greater head/neck flexion, anterior 

translation of the head (p < 0.001) and increased muscle 

activity of cervical erector spinae (CES) compared to 

thoracic and lumbo-pelvic sitting (p = 0.001). Thoracic 

upright sitting showed increased muscle activity of thoracic 

erector spinae (TES) compared to slump and lumbo-pelvic 

postures (p = 0.015). Upper trapezius (UT) demonstrated 

no significant difference in muscle activation in the 3 

sitting postures (p < 0.991). This study demonstrates that 

different sitting postures affect head/neck posture and 

cervico-thoracic muscle activity. It highlights the potential 

importance of thoraco-lumbar spine postural adjustment 

when training head/neck posture. 

8 

The development of sensory hypoaesthesia following 

whiplash injury 

Chien A, 1,2 Eliav E, 4 Sterling M 2,3 

1 

Melbourne Physiotherapy School, The University of Melbourne, 

2 

CCRE Spinal Injury, Pain and Health, The University of Queensland, 

Brisbane, 3 CONROD, The University of Queensland, 4 University of 

Medicine and Dentistry School of New Jersey, USA. 

The aims of this study were to investigate the development 

of hypoaesthesia from soon after the whiplash injury 

to 6 months post injury and to determine differences in 

detection thresholds between those with initial features 

of poor recovery and those without these signs. Fifty-two 

participants with acute WAD (< 1 month) were classified as 

either ‘high-risk’ (n = 17; Neck Disability Index > 30; sensory 

hypersensitivity) or ‘low risk’ (n = 35; without these signs). 

Detection thresholds to electrical, thermal and vibration 

stimuli and psychological distress were prospectively 

measured within one month of injury and then 3 and 6 months 

post injury. Detection thresholds were also measured in the 

38 controls. Both WAD groups demonstrated hypoaesthesia 

(vibration, electrical and cold) at 1 month post injury. 

Vibration and electrocutaneous hypoaesthesia persisted to 

3 and 6 months only in the ‘high-risk’ WAD group. Heat 

detection thresholds were not different between the groups 

at one month post injury but were elevated in the ‘high-risk’ 

group at 3 and 6 months. Both WAD groups were distressed 

at 1 month but this decreased by 3 months in the ‘low-risk’ 

group. The differences in IES did not impact on any of 

the sensory measures. Sensory hypoaesthesia is a feature 

of acute WAD but persists only in those at higher risk of 

poor recovery. These findings suggest the involvement of 

the central inhibitory mechanisms that may be sustained by 

ongoing nociception. C-fibre dysfunction may play a role in 

the development of chronic symptoms. 

If you’ve had recurrent back pain, it may require more 

effort to sit up with ‘good’ spinal posture 

Claus AP, 1 Hides JA, 1 Moseley GL, 2 Hodges PW 1 

1 

Centre of Clinical Research Excellence in Spinal Pain, Injury and 

Health, The University of Queensland, Brisbane, 2 Prince of Wales 

Medical Research Institute & School of Medical Sciences, The 

University of New South Wales, Sydney 

Three upright sitting postures have been clinically 

advocated as ‘good’ spinal posture: flat at thoracolumbar 

and lumbar regions, thoracolumbar lordosis (lordotic 

at both regions) and a lumbar lordosis sitting posture. 

This study compared back muscle activity between these 

three ‘good’ postures and a slumped posture (kyphotic 

at both regions, clinically described as ‘bad’) between 

people with (n = 10) and without (n = 14) recurrent low 

back pain. Intramuscular electromyography was recorded 

from lumbar multifidus muscles (deep and superficial at 

L4), iliocostalis thoracis (T11 and L2), and longissimus 

thoracis muscle (T11) with trials of each sitting posture in 

random order. Mean amplitude of activity for each muscle 

was compared between postures and between groups with 

linear mixed model analyses. In healthy subjects, multifidus 

showed distinctly different activity in the 3 upright sitting 

postures (all comparisons p < 0.05), but for subjects with 

recurrent back pain multifidus activity was similar during 

the thoracolumbar lordosis and lumbar lordosis sitting 

postures (p > 0.06). Longissimus thoracis muscle activity 

was not different between the three upright sitting postures 

in the healthy controls (p = 1.00), but was greater during 

thoracolumbar lordosis than the flat posture in people with 

recurrent back pain (p < 0.01). Subjects with recurrent back 

pain showed ~ 2–3 times the longissimus thoracis activity 

of the healthy subjects in upright sitting (thoracolumbar 

lordosis group comparison p = 0.037). These results suggest 

that to ‘sit up straight’ requires greater activity of the largest 

back muscles for people with recurrent back pain than 

healthy people. 

Motor control exercise for chronic low back pain: 

a randomised placebo-controlled trial 

Costa LOP, 1 Maher CG, 1 Latimer J, 1 Hodges PW, 2 Herbert 

RD, 1 Refshauge KM, 3 McAuley JH, 1 Jennings MD 4 

1 

Musculoskeletal Division, The George Institute For International 

Health, Sydney & Faculty of Medicine, The University of Sydney, 

2 

NHMRC Centre of Clinical Research Excellence in Spinal Pain, 

Injury and Health, School of Health and Rehabilitation Sciences, The 

University of Queensland, Brisbane, 3 Faculty of Health Sciences, The 

University of Sydney, 4 Liverpool Hospital, Sydney South West and 

Western Sydney Area Health Services, Sydney 

The aim of this study was to examine the efficacy of 

motor control exercise for chronic low back pain. In 

total, 154 participants with chronic low back pain of 

more than 12 weeks duration were randomly assigned to 

12 sessions of motor control exercise or placebo over 8 

weeks. Measures of outcomes were obtained by a blinded 

assessor at baseline and at follow-up appointments 2, 6 and 

12 months after randomisation. Primary outcomes were 

pain, function, and the participant’s global impression of 

recovery measured at 2 months. Of the 154 participants 

randomised to groups, 152 attended the 2-month follow-up 

(98.7%) and 145 attended both 6 and 12-month follow-up 

(94.2%). The exercise intervention improved function and 

patient’s global impression of recovery, but did not clearly 

reduce pain, at 2 months. The mean effect of exercise on 



function was 1.1 points (95% CI, 0.3–1.8), the mean effect 

on global impression of recovery was 1.5 points (95% CI, 

0.4–2.5) and the mean effect on pain was 0.9 points (95% 

CI,-0.01–1.8), all measured on 11 point scales. Secondary 

outcomes also favoured motor control exercise. Motor 

control exercise produced small short-term improvements 

in global impression of recovery and function, but not pain, 

for people with chronic low back pain. This pattern of 

results was similar at 6 and 12 months follow-up. 

Reproducibility of rehabilitative ultrasound imaging 

for the measurement of abdominal muscle activity: 

a systematic review. 

Costa LOP, Maher CG, Latimer J, Smeets RJEM 

Musculoskeletal division, The George Institute for International Health 

& Faculty of Medicine, The University of Sydney 

The purpose of this study was to systematically review 

reproducibility studies of rehabilitative ultrasound imaging 

for measuring thickness of abdominal wall muscles. 

Eligible studies were identified via searches in MEDLINE, 

CINAHL and EMBASE. We also searched personal 

files and tracked references of the retrieved studies via 

the Web of Science Index. Two independent reviewers 

extracted data and assessed methodological quality. Due 

to heterogeneity of the studies’ designs, pooling the data 

for a meta-analysis was not possible. Twenty-one studies 

were included. We found good to excellent reliability for 

single measures of thickness and poor to good reliability 

for measures of thickness change (reflecting the muscle 

activity). Interestingly, no studies checked reliability of 

measures of the difference in thickness changes over time 

(representing improvement or deterioration in muscle 

activity). Measures of agreement were poorly tested. We 

found evidence that RUSI is a reliable tool for measuring 

thickness of abdominal wall muscles. The few studies that 

analysed the reliability for the measurement of thickness 

changes found good to poor results. Evidence for the 

reproducibility of the difference in thickness changes over 

time necessary to evaluate the effectiveness of treatment is 

not available. The current evidence of the reproducibility of 

RUSI for measuring abdominal muscle activity is mainly 

based upon studies with suboptimal designs including 

mostly healthy subjects making generalisability to clinical 

settings uncertain. 

Heightened flexor withdrawal responses in individuals 

with anterior cruciate ligament rupture are enhanced 

by anterior tibial translation at the knee 

Courtney CA, 1 Durr RK, 1 Emerson-Kavchak AJ, 1 Witte 

EO, 1 Santos MJ 2 

1 

University of Illinois at Chicago, Chicago IL; 2 Universidade Federal de 

Santa Catarina, Florianópolis, Brazil | 

Anterior cruciate ligament (ACL) injury may alter pain 

pathways such that subsequent injury to the joint may more 

readily trigger pain responses and potentially hasten joint 

degeneration. Complaints of instability following ACL 

injury may be due to changes in flexor reflex excitability. 

The purpose of the study was to investigate the flexor 

withdrawal reflex (FWR) in subjects with ACL-rupture in 

positions with and without joint capsular strain. Ten subjects 

(age 21–50 years) with ACL rupture and 10 age-matched 

non-injured subjects participated. FWR was elicited by 

sural nerve stimulation (10 pulses, 1 ms duration, 200 

Hz) and FWR threshold determined. Electromyographic 

(EMG) responses of the biceps femoris (BF) and rectus 

femoris (RF) were recorded at 2 x FWR threshold with the 

subject reclined (60° hip flexion, 35° knee flexion) under 

2 conditions: knee neutral and maximal anterior tibial 

displacement. Displacement was measured using a KT1000 

arthrometer. ACL group FWR thresholds were significantly 

decreased on the injured vs. non-injured limb (p = 0.01). 

Mean joint laxity was 12.8 ± 2.4 mm on injured vs. 6.5 ± 

1.6 mm on non-injured limbs. EMG integrals consistent 

with spinally mediated reflexive activity (50–200 ms) 

demonstrated a 3-fold increase in the ACL group (injured 

limb; p = 0.05) following tibial translation, but were 

unchanged in non-injured limb (p = 0.26) and controls (p = 

0.36). RF EMG activity was increased in the ACL injured 

limb but not significantly. Consistent with these findings, 

onset latencies were significantly diminished in BF with 

tibial displacement (p = 0.02). FWR is facilitated post-ACL 

rupture and increased with joint strain. 

Hip muscle function and patellofemoral pain 

Crossley KM 

University of Melbourne, Melbourne, National ICT Australia, Victoria 

While much of the major clinical and research interest in 

patellofemoral pain (PFP) has been targeted to the local 

knee muscles, it has long been recognised that hip muscle 

function (strength or co-ordination) may be impaired in 

individuals with PFP. This clinical observation has led to 

recent research in pelvis and hip muscle contributions to 

PFP. Hip muscles (particularly the abductors and external 

rotators) are important in maintaining an optimal lower 

limb alignment during weight bearing activities. Reduced 

strength or neuromotor control of these muscles may be 

associated with an increase in hip internal rotation and 

adduction, with deleterious consequences at the knee. A 

growing body of contemporary evidence indicates that hip 

muscle function is compromised in PFP. This is highlighted 

by a recent systematic review, which found strong evidence 

for deficits in hip muscle strength (abduction, external 

rotation, extension) in women with PFP compared to 

uninjured controls. We have observed a delayed onset of 

gluteus medius electromyographic (EMG) activity in people 

with PFP compared to healthy controls, confirming earlier 

findings. Thus, the available evidence supports altered hip 

muscle function as an important feature of PFP, and has 

provided impetus for contemporary clinical management, 

favouring hip muscle retraining. However, there is a 

dearth of clinical trials investigating the clinical efficacy 

of hip muscle retraining in PFP. Similar to vasti muscle 

dysfunction, individuals with hip muscle dysfunction form 

a subgroup of people with PFP. Interventions designed to 

enhance hip muscle function are likely to benefit patients 

with PFP. Further scientific evidence is required to confirm 

the role of hip muscle dysfunction in the development and 

management of PFP. 



10 

A systematic review of methods used to assess 

competency in physiotherapy practice 

Dalton M, 1 Davidson M, 2 Keating J 3 

1 

Griffith University, 2 La Trobe University, 3 Monash University 

Valid, reliable and standardised assessment formats and 

procedures, suited to application in the workplace, are 

important for meaningful and consistent assessment of 

the clinical performance of physiotherapy students. This 

presentation reports on a systematic review conducted 

to identify all instruments currently used to assess the 

practice competencies of physiotherapy students and to 

identify what is known about the measurement properties 

of these instruments. A secondary aim of the review was 

to identify the skills and training requirements for use of 

these instruments. The systematic search was guided by the 

Best Evidence Medical Education (BEME) Collaboration 

guidelines for effective evidence retrieval. Electronic 

databases were searched without date limits until March 

2009. Databases included The Campbell Register of 

Controlled Trials (C2-SPECTR), Medline (via Ovid) 

Embase (Ovid), CINAHL (Ovid and EBSCO), ERIC, BEI 

(British Education Index), AMED, PsychINFO, TIMELIT, 

PEDro, Cochrane Register of Central Controlled Trials, 

ProQuest, conference proceedings, dissertation abstracts, 

ISI Web of Knowledge, Blackwell Synergy, and TRIP. 

Three raters independently extracted information on 

the instrument type, assessment context, and instrument 

quality including reliability, validity, feasibility, educational 

impact, acceptability, cost effectiveness, and opportunity 

for provision of feedback. Of 174 articles identified, 34 were 

included in the review. While the assessment of clinical 

competence remains universally accepted as essential in the 

physiotherapy education literature, results of the systematic 

review remains problematic due to lack of rigour in the 

instruments and methods used for assessment. The results 

of the review and recommendations for future research will 

be presented. 

Does evidence support physiotherapy management of 

adult complex regional pain syndrome type 1? 

A systematic review 

Daly AE, 1,2 Bialocerkowski AE 2 

1 

Austin Health, Heidelberg, 2 The University of Melbourne, Parkville 

The aim of this study was to source and critically evaluate 

the evidence on the effectiveness of physiotherapy to 

manage adult CRPS-1. Systematic literature review 

involved electronic databases, conference proceedings, 

clinical guidelines and textbooks which were searched 

for quantitative studies on CRPS-1 in adults where 

physiotherapy was a sole or significant component of the 

intervention. Data were extracted according to predefined 

criteria by two independent reviewers. Methodological 

quality was assessed using the Critical Review Form. The 

search strategy identified 1320 potential articles. Of these, 14 

articles, representing 11 studies, met inclusion criteria. There 

were 5 randomised controlled trials, one comparative study 

and 5 case series. Methodological quality was dependent on 

study type, with randomised controlled trials being higher 

in quality. Physiotherapy treatments varied between studies 

and were often provided in combination with medical 

management. This did not allow for the ‘stand alone’ value 

of physiotherapy to be determined. Heterogeneity across the 

studies, with respect to participants, interventions evaluated 

and outcome measures used, prevented meta-analysis. 

Narrative synthesis of the results, based on effect size, found 

there was good to very good quality level II evidence that 

graded motor imagery is effective in reducing pain in adults 

with CRPS-1, irrespective of the outcome measure used. 

No evidence was found to support treatments frequently 

recommended in clinical guidelines, such as stress loading. 

Graded motor imagery should be used to reduce pain in 

adult CRPS patients. Further, the results of this review 

should be used to update CRPS-1 clinical guidelines. 

Evaluation of the primary contact physiotherapy 

service in the emergency department 

Di Natale D, Crane J, Taylor D, Judkins S 

Austin Health, Melbourne 

This study aimed to evaluate the effectiveness of a 

primary contact physiotherapy service in the Austin 

Health emergency department (ED). We undertook a preand 

post-intervention study (May 2007 to January 2009) 

with the intervention being the ED physiotherapy service 

(introduced August 2007). Patients with knee or ankle 

injuries and triage categories 3, 4 or 5 were enrolled. 

Three patient groups were compared: treated only by 

doctors in the pre-intervention period (n = 74), treated 

only by doctors in the post-intervention period (n = 70), 

and treated by physiotherapist only in the post-intervention 

period (n = 85). For their patients, the physiotherapist was 

responsible for all investigations and management. The 

primary endpoints, patient satisfaction and unexpected 

events, were determined at telephone follow-up. Secondary 

endpoints were management time and length of stay (LOS). 

The physiotherapist patients reported significantly greater 

satisfaction for the physiotherapist’s interest, thoroughness, 

discussion time, follow-up advice and practitioner 

recommendation (p < 0.05). The physiotherapists had the 

lowest proportion of patients requiring management followup 

(63.1%, p = 0.27), with an alternate diagnosis postdischarge 

(18.4%, p = 0.79), with complications (12.9%, 

p = 0.27), but the greatest proportion with injuries that 

were considerably/much better at follow up (78.7%, p = 

0.41). Physiotherapist management time was significantly 

less than pre-and post-intervention doctor times (median 

50, 79, 60.5 min respectively, p = 0.01). Physiotherapist 

patient LOS was significantly less than the doctors’ times 

(median 92, 155, 134.5 min respectively, p = 0.01). The 

physiotherapist provides a service comparable to doctors 

in regard to clinical outcomes but has significantly better 

patient satisfaction and reduced ED times. 

Muscle activity patterns in isometric assessment of 

shoulder rotators 

Downes A, Cathers I, Ginn KA 


Maximal isometric tests are used to assess rotator cuff 

muscle function with multiple test positions used. Limited 

direct information is available to determine if any position 

preferentially activates the rotator cuff muscles. The aim 

of this study was to comprehensively examine activity 

levels in all shoulder rotator muscles during the manual 

muscle test positions commonly used to assess rotator cuff 

muscle function. Muscle activity was measured in shoulder 

internal rotators (subscapularis, pectoralis major, latissimus 



dorsi, teres major) and external rotators (infraspinatus, 

supraspinatus, posterior deltoid) in 15 normal subjects 

during maximal isometric rotation tests, using a combination 

of surface and indwelling electrodes. Eight rotation test 

positions were examined: external and internal rotation in 

sitting with the arm pendant and at 90º abduction and in 90º 

abduction in supine; the lift off (Gerber) test; and the belly 

press test. EMG data was normalised to standard maximal 

voluntary contractions (MVC). Mean EMG data for each 

subject and group mean EMG data for each exercise were 

then calculated. Repeated measures ANOVA with Tukey 

post hoc analysis were used to compare the activity level in 

all the muscles in all test positions. All test positions activated 

the rotator cuff muscles to equally high levels. Only the lift 

off position demonstrated significant differences between 

subscapularis and other muscles, with significantly higher 

activity in latissimus dorsi and teres major and significantly 

less activity in pectoralis major. None of the test positions 

examined recruited a rotator cuff muscles bat 

significantly 

higher levels than other shoulder rotators. 

Endurance and fatigue characteristics during submaximal 

neck muscle tests in patients with postural 

neck pain 

Edmondston SJ, 1 Bjornsdottir GB, 1 Palsson TS, 1 Solgard 

H, 1 Ussing K, 1 Allison GT 1,2 

1 

Curtin University of Technology, WA, 2 Royal Perth Hospital, WA 

The aim of this study was to evaluate neck muscle endurance 

and fatigue characteristics in female subjects with postural 

neck pain. Thirteen subjects with postural neck pain and 

12 asymptomatic control subjects were recruited for the 

study. Postural pain was defined as neck pain provoked by 

sustained postures during work or recreational activities. 

Subjects performed timed sub-maximal muscle endurance 

tests for the neck flexor and extensor muscles. Muscle 

fatigue, defined as the time-dependent decrease in median 

frequency EMG was examined using surface EMG analysis 

during the tests. The median extensor test holding time 

was for the neck pain group was 165 seconds (IQR = 111 

to 240), compared to 228 seconds (IQR = 190 to 240) for 

the control group (p = 0.12). The median holding time for 

the flexor test was 38 seconds (IQR = 14 to 83) for the neck 

pain group and 36 seconds (IQR = 25 to 63) for the control 

group (p = 0.74). The neck pain group was characterised 

by greater variability in muscle endurance. For both tests, 

the rate of decrease in median frequency EMG was highly 

variable within and between groups with no significant 

between group difference for the flexor (p = 0.29) or 

extensor test (p = 0.23). Subjects with postural neck pain 

did not have significant impairment of muscle endurance or 

accelerated fatigue compared to control subjects. However, 

greater variability in neck muscle endurance and fatigue 

characteristics was evident in the postural neck pain subjects 

compared to the control group. 

Fatty infiltration in the cervical flexor muscles in 

chronic whiplash 

Elliott JM, 1,3 O’Leary SP, 1 Sterling MA, 1,3 Pedler AR, 3 

Jull GA 1 

1 

The University of Queensland, CCRE-Spine, Brisbane, 2 The University 

of Queensland, Centre for Magnetic Resonance, Brisbane, 3 The 

University of Queensland, Centre of National Research on Disability 

and Rehabilitation Medicine, Brisbane 

The purpose of this study was to determine if subjects with 

chronic WAD demonstrate significantly larger amounts 

of fat in the cervical flexor muscles compared to controls. 

It was hypothesised that subjects with chronic whiplash 

would demonstrate higher fatty infiltrates in the cervical 

flexors than controls. Subjects consisted of 78 females with 

chronic whiplash (age: 29.8 ± 7.8) and 34 controls (age: 27.0 

± 5.6) within the age range of 18–45 years. A previously 

established MRI measure for fat infiltrate was performed on 

all participants to determine differences by group, muscle 

(longus capitis/colli and sternocleidomastoid) and spine 

level. A repeated measures linear mixed model was used 

to model the effects of cervical level by muscle by group. 

Subjects with chronic whiplash had significantly higher 

fatty infiltrate in the cervical flexors compared to controls 

(p < 0.001). Significant group differences were found based 

on muscle and level where the deeper longus capitis/colli 

had larger amounts of fatty infiltrate when compared to the 

SCM in the WAD group (p < 0.01), but this was reversed in 

the control group (p < 0.001). There is significantly greater 

fatty infiltration in the neck flexor muscles, especially in 

the deeper muscles, in subjects with chronic WAD when 

compared to controls. These changes are consistent with 

those observed in the posterior muscles and are of potential 

detriment to the optimal recovery of patients with chronic 

whiplash. Studies are underway to better investigate the 

mechanisms underlying these changes. 

An investigation of the association between C2 spinal 

alignment and cervicogenic headache 

Farmer P, Rivett DA, Snodgrass SJ 


Abnormal habitual postures are proposed to contribute to 

cervical spine and headache symptoms through altered 

spinal alignment. Cervicogenic headaches are associated 

with symptomatic palpation of the upper cervical spine, 

suggesting this area should be a focus of investigations 

into possible associations between spinal alignment and 

cervicogenic headache. This study aims to determine if C2 

spinal alignment is associated with cervicogenic headache, 

and if physiotherapists can reliability assess C2 alignment. 

A single blind comparative measurement design evaluated 

C2 alignment in subjects with cervicogenic headache and 

age and gender matched controls. Subjects with headache 

had symptoms consistent with the Cervicogenic Headache 

International Study Group diagnostic criteria, while 

controls had no history of neck trauma or treatment for 

neck/headache in the previous 12 months. Altered C2 

alignment was defined as ≥ 3 mm of C2 spinous process 

deviation from midline on anteroposterior radiograph, 

and 2 titled musculoskeletal physiotherapists assessed C2 

alignment using palpation. Preliminary analysis of the first 

46 recruited subjects indicates that 11 of 26 subjects with 

headache and 5 of 20 controls had altered C2 alignment (X2 

= 1.49, p = 0.22). Inter-therapist reliability of C2 alignment 



palpation assessment was poor (Kappa 0.11, 95% CI -0.10– 

0.32). These preliminary results suggest the association 

between cervicogenic headache and C2 alignment is weak 

or potentially does not exist, and that physiotherapists 

are unlikely to reliably identify patients with altered C2 

alignment. Therefore, clinicians may need to reconsider the 

role of static upper cervical spine alignment when treating 

patients with cervicogenic headache. 

12 

Gluteal tendon reconstruction: what can we tell 

our patients? 

Fearon AM, 1,2 Smith PN, 1,2 Cook JM, 3 Scarvell JM 1,2 

1 

The Australian National University, Canberra, 2 The Trauma and 

Orthopaedic Research Unit, Canberra, 3 Deakin University, Melbourne 

The aim of this study was to report the outcomes of gluteal 

tendons reconstructive surgery using validated clinical and 

functional outcome tools. Twenty-four patients underwent 

combined bursectomy and gluteal tendon reconstruction 

under one surgeon. They were contacted by mail, email, 

and telephone. An independent assessor undertook a 

clinical assessment on the 19 patients who were available 

for assessment. Surgical outcomes for pain and satisfaction 

(100mmVAS), modified Harris Hip Score; the Oswestry 

Disability Index; and strength via hand held dynamometry 

and the Trendeleburg sign. We found that. following surgery 

patients reported high levels of pain relief (p < 0.05 Wilcoxon 

signed rank test); satisfaction, median (IQR) of 8.5cm (70– 

100); and function: Harris Hip Score, median (IQR) 74 

(59–85): and inverted Oswestry Disabilty Index, median 

(IQR) of 85 (74–92). Patients were found to be weaker 

with abduction and external rotation on the ipsilateral leg 

compared to the contralateral leg (p = 0.0084, p = 0.0428 

respectively, Wilcoxon signed rank). This is the first paper to 

report patient satisfaction, Oswestry disability index results 

and dynamometry strength testing following this surgery. 

Combined bursectomy and gluteal tendon reconstruction 

appears to be an effective procedure for the relief of pain 

in most patients with recalcitrant greater trochanteric pain 

syndrome. High patient satisfaction levels suggest that 

function and quality of life are improved following surgery. 

A prospective longitudinal study has commenced to verify 

these results. 

Ultrasound imaging and histology results inform 

treatment choices in GTPS 

Fearon AM, 1,2 Scarvell JM, 1,2 Cook JM, 3 Smith PN 1,2 

1 

The Australian National University, Canberra, 2 The Trauma and 

Orthopaedic Research Unit, Canberra, 3 Deakin University, Melbourne 

The purpose of this study was to evaluate the site of 

pathology in greater trochanteric pain syndrome (GTPS). 

This retrospective study collected data on 24 people who 

had undergone combined gluteal tendon reconstruction 

and bursectomy. Preoperative ultrasound imaging 

was undertaken in 23 cases. Histological evaluation 

was undertaken on 17 tendon specimens and 19 bursa 

specimens collected during surgery. The results of the 

ultrasound examination were compared with surgical and 

histological findings. An isolated gluteus medius tear was 

reported in 10 cases, an isolated gluteus minimus tear in 2 

cases, and tears in both tendons in 5 cases. The remaining 

6 cases were reported to have tendinopathy without tears. 

Ultrasound examination of the bursa was reported in 21 

cases. Nineteen were reported to be abnormal, 2 were 

reported as normal and in 2 instances the report contained 

no comment on the bursa. At surgery, tendon tears were 

reported in all 24 cases, the majority of cases (n = 18) 

having a tear of both gluteus medius and minimus tendons. 

Two patients had an isolated tear of gluteus medius tendon 

and three patients had an isolated tear of gluteus minimus 

tendon. Abnormality of the bursa was reported in 12 cases. 

Histology assessment confirmed tendinopathy in 100% of 

cases and bursa pathology in 68% of cases. Ultra sound 

imaging has a positive predictive value of 1.0 of diagnosing 

a tear of either tendon, and a positive predictive value of 

0.82 for diagnosing bursa pathology. 

Can we explain heterogeneity among exercise 

randomised clinical trials in chronic back pain? 

A meta-regression of randomised controlled trials 

Ferreira M, 1 Smeets R, 2,3 Kamper S, 4 Ferreira P, 1 

Machado L 4 

1 

Faculty of Health Sciences, University of Sydney, Australia, 

2 

Rehabilitation Foundation Limburg, The Netherlands, 3 Department 

of Rehabilitation Medicine, Caphri, Maastricht University, The 

Netherlands, 4 The George Institute for International Health, University 

of Sydney, Australia 

Clinical practice guidelines usually endorse the use of 

exercise for the management of chronic back pain. However, 

exercise programs may vary in terms of their duration, 

frequency, dosage, type, among others. All these possible 

variations may influence interpretation of a set of trials 

included in systematic reviews or meta-analyses evaluating 

the effects of exercise for chronic low back pain. In this 

study, we aimed to establish the effect of exercise on pain 

and disability in patients with chronic low back pain, with a 

major aim of explaining between-trial heterogeneity, using 

a meta-regression approach. We conducted a computerized 

search of the databases PEDro, MEDLINE, CINAHL, 

LILACS, Cochrane Central Register of Controlled Trials 

and EMBASE up to August 2008. To be included, studies 

needed to be randomised clinical trials evaluating the 

effects of exercise for chronic non-specific low back pain. 

Outcomes of interest were pain and disability measured 

on a continuous scale. Univariate meta-regressions were 

conducted to assess the associations between exercise 

effect sizes and 8 study level variables which were 

grouped into 4 categories: population features (baseline 

severity of symptoms); dosage (number of exercise hours 

and sessions); program features (supervision, individually 

tailored program); or methodological features (analysis by 

intention to treat, concealment of allocation). Our results 

have shown that, although levels of heterogeneity among 

included trials were in general moderate to high, number 

of exercise sessions was the only statically significant trial 

level determinant of effect of exercise on pain, among those 

analysed. 



Factors defining care seeking in low back pain: 

a meta-analysis of population based surveys 

Ferreira ML, 1 Machado G, 2 Latimer J, 3 Maher C, 3 

Ferreira PH, 1 Smeets REM 4,5 

1 

Faculty of Health Sciences, The University of Sydney, Sydney, 

2 

Department of Physiotherapy, Federal University of Minas 

Gerais, Brazil, 3 The George Institute, University of Sydney, Sydney, 

4 

Department of Rehabilitation Medicine, Caphri, Maastricht 

University, The Netherlands, 5 Rehabilitation Foundation Limburg, The 

Netherlands 

Little is known about factors associated with care-seeking 

in low back pain. While a number of previous studies 

have described the general characteristics of patients who 

seek different types of care, only a few have aimed at 

appropriately assessing determinants of care-seeking in 

this population, by comparing seekers and non-seekers of 

care. The objective of this systematic review was to identify 

factors associated with health care-seeking in studies where 

well-defined groups of care seekers and non-seekers with 

non-specific low back pain are compared. A search was 

conducted in Medline, AMED, Cinahl, Web of Science, 

PsycINFO, National Research Register, Cochrane Library 

and LILACS looking for cross-sectional, population-based 

surveys of low back pain patients, older than 18 years, 

published since 1966. Methodological quality was assessed 

using a criteria list based on sampling, response rate, data 

reproducibility, power calculation and external validity. 

When possible, meta-analyses were performed, using a 

random effects model. Eleven studies met our inclusion 

criteria and were included yielding a total of 13 486 patients 

with non-specific low back pain. Pooled results show 

that women are slightly more likely to seek care for their 

back pain as are patients with a previous history of back 

pain. Interestingly, while pain intensity was only slightly 

associated with care-seeking behaviour, patients with high 

levels of disability were nearly 8 times more likely to seek 

care than patients with lower levels of disability. Patients 

presenting with good general health were slightly less 

likely to seek care than those with bad self-reported general 

health. 

Sufficiently important differences of physiotherapy 

interventions for non-specific low back pain 

Ferreira M, 1 Ferreira P, 1 Latimer J, 2 Barrett B, 3 Herbert R, 2 

Ostelo R, 4 Grotle M 5 

1 

Faculty of Health Sciences, The University of Sydney, Sydney, 2 The 

George Institute, University of Sydney, Sydney, 3 Department of 

Family Medicine, University of Wisconsin, USA, 4 EMGO Institute, 

VU University Medical Centre, The Netherlands, 5 Section for Health 

Science, University of Oslo, Norway 

Over the last decade extensive research has been conducted 

evaluating the efficacy of interventions for back pain using 

randomised controlled trials. These trials provide estimates 

of the mean effects of interventions; however clinicians and, 

more importantly, patients need to consider whether the 

estimated effects of these interventions make their costs, 

risks and inconveniences worthwhile. This study aimed to 

use the benefit-harm trade-off method to elicit estimates of 

worthwhile effects (the sufficiently important difference, 

SID) for treatments for non-specific low back pain. A total 

of 100 consecutive patients with non-specific low back pain 

seeking physiotherapy care will be included in the study. 

Subjects were interviewed by telephone before treatment 

commenced and 4 weeks later. The benefit-harm trade-off 

method was used to obtain estimates, for each participant, 

of the SID of both NSAIDs and a course of physiotherapy 

for treatment of low back pain. A brief description of each 

treatment was provided to each subject, along with an 

estimate of the expected benefit of treatment. Subjects were 

asked if they would choose to have the treatment. From there, 

the size of the hypothetical benefit was varied up and down, 

in progressively smaller increments, until it was possible 

to identify the smallest expected benefit of intervention for 

which the participant choose to have the intervention. Data 

have been collected from 30 subjects in Australia and 60 in 

Brazil. Data collection should be completed by July 2009, 

when results will be analysed. 

Is there an association between abdominal muscle 

recruitment and psychosocial factors in chronic low 

back pain? 

Ferreira P, 1 Oliveira W, 2 Morais G, 2 Pinto R, 2 Oliveira V, 2 

Ferreira M, 1 Salmela L 2 

1 

The University of Sydney, Sydney, 2 Universidade Federal de Minas 

Gerais, Belo Horizonte, Brazil 

The objective of this study was to investigate the association 

between the psychosocial factors kinesiophobia, health locus 

of control, and psychomotor speed with the recruitment of 

the abdominal muscles transversus abdominis, obliquus 

internus, and obliquus externus in patients with chronic 

non-specific low back pain. Fifty-four patients with 

chronic low back pain were included. Abdominal muscle 

recruitment was measured by ultrasonography during 

isometric contractions of the lower limbs at low loads. 

Changes in muscle thickness from resting baseline values 

were obtained for transversus abdominis, obliquus internus, 

and obliquus externus. Multiple linear regression models 

were used to assess the association between the three 

psychosocial factors and recruitment of the abdominal 

muscles. The regression models accounted for 12.0% (p = 

0.67), 21.0% (p = 0.23) and 32.0% (p = 0.03) of the variance 

of the transversus abdominis, obliquus internus and obliquus 

externus recruitment respectively. No psychosocial factors 

in isolation were found to be significantly associated with 

muscle recruitment. Internal locus of control, psychomotor 

speed and external locus of control tended to be associated 

with transversus abdominis (β = 0.005; p = 0.08), obliquus 

internus (β = -5.11; p = 0.09), and obliquus externus (β = 

-0.003; p = 0.09) recruitment respectively. Health locus of 

control, kinesiophobia, and psychomotor speed explained 

recruitment of the superficial muscle obliquus externus but 

not transversus abdominis or obliquus internus in low back 

pain. 

The therapeutic alliance between physiotherapists and 

patients predicts outcome in chronic low back pain 

Ferreira P, Ferreira M, Maher C, Refshauge K, Latimer J, 

Herbert H, Adams R 


The objective of this study was to investigate whether the 

alliance between physiotherapists and patients predicts 

outcome or response to treatment in chronic low back 

patients. Participants were 182 patients with chronic low 

back who volunteered for a randomised controlled trial that 

compared the efficacy of general exercises, motor control 

exercises and spinal manipulative therapy. Therapeutic 



alliance was measured by the Working Alliance Inventory. 

Function and global perceived effect of treatment were 

primary outcomes. Therapeutic alliance was a significant 

predictor of global perceived effect (β = 0.08; CI 0.03–13; 

p = 0.001) and function (β = 0.17; CI 07–28; p = 0.001). 

The difference in the final outcome of global perceived 

effect of a patient with a low therapeutic alliance (score of 

50/112) and a patient with a high therapeutic alliance (score 

of 100/112) would be change of 4/11 on the global perceive 

effect scale. This could represent an improvement from a 

status of ‘no change’ to a status of ‘completely recovered’. 

The effect of general exercise versus motor control exercise 

was larger in patients with a higher therapeutic alliance 

with their therapist for the global perceived effect outcome 

(β = 8.90; CI: 2.69–15.13; p = 0.005) but not for the function 

outcome (β = 0.10; CI -17–18; p = 0.91). The interaction 

between physiotherapists and chronic low back pain patients 

predicts the clinical outcomes of global perceived effect of 

treatment and function. The therapeutic alliance appears to 

play a more significant role when patients receive general 

exercises compared to motor control exercises. 

14 

Characteristics and sub-classification of patients 

diagnosed with non-specific chronic low back pain: 

a cross-sectional study 

Fersum KV, 1 Skouen JS, 1 O’Sullivan PB, 2 Kvåle A 1 

1 

University of Bergen/Section for Physiotherapy Science, Norway, 

2 

Curtin University of Technology, WA 

Few studies have looked at classification of non-specific 

low back pain considering the underlying mechanisms 

driving the disorder within a bio-psycho-social framework. 

Psychological factors such as anxiety and depression, 

avoidance behaviours, and poor coping strategies are known 

to promote disability and amplify pain in these disorders. 

This paper examined the main group’s characteristics for 

non-specific chronic low back pain classified according to 

the classification system developed by Peter O’Sullivan. Data 

were analysed from 168 consecutive patients. A disorder 

classification was made based on compilation of subjective 

and physical examination findings in relation to medical test 

and radiological imaging. Demographic information about 

pain intensity, duration and frequency; self-rated disability; 

fear avoidance; psychological distress; identification of 

risk for chronicity was collected. Out of the 168 patients, 

10 (5.9%) patients were classified as specific back pain, 5 

(3%) with hip arthrosis and 153 (91.1%) were classified as 

peripherally mediated back and pelvic pain. Within the 153 

patients, 135 (88.2%) were classified low back pain patients 

with a control impairment disorder, 8 (4,8%) as low back 

pain with a movement impairment disorder and 10 (6%) 

were classified as pelvic pain disorders. Fifty-three (31.5%) 

of the 168 had significant contribution of psychosocial 

influence on the disorder. These patients scored significantly 

higher on pain intensity, self rated disability, fear avoidance 

beliefs, psychological distress and risk for chronicity (p < 

0.01). Control impairment disorder seems to be the most 

dominant classification. This classification system seems to 

validly detect the contribution of psychosocial influence on 

the disorders of many of these patients. 

Efficacy of classification based ‘cognitive functional 

therapy’ in patients with non-specific chronic low back 

pain: a randomised controlled trial 

Fersum KV, 1 O’Sullivan PB, 2 Skouen JS, 1 Kvåle A 1 

1 


2 


Conservative management of non-specific chronic low back 

pain disorders has failed to effectively have an impact. In 

spite of calls for classification based management of nonspecific 

chronic low back pain disorders, few classification 

systems have been validated and shown to be reliable, few 

reflect a biopsychosocial model nor have they been tested in 

randomised controlled trials. Peter O’Sullivan has proposed 

a novel classification system with a management approach 

called ‘cognitive functional therapy’. This is a behavioral 

intervention that aims to impact on both the cognitive and 

functional behavioral features of the disorder. The purpose 

of this randomised controlled trial was to examine the 

outcome of patients receiving classification based cognitive 

functional therapy compared with patients receiving 

traditional manual therapy and exercise. One hundred and 

twenty-one patients with non-specific chronic low back 

pain (> 52 weeks) were randomised to cognitive functional 

therapy (n = 62) or manual therapy (n = 59). Demographic 

data were collected regarding, pain intensity, duration and 

frequency, self-rated disability pre, post and at 12 months 

follow-up. Complete 1-year follow up data will be available 

late May 2009. Post-treatment analysis will be performed by 

means of regression analysis and ANCOVA. Comparisons 

show no difference between the two groups at pretreatment 

across all domains. All patients had long-lasting back 

pain (> 52 weeks) with associated disability and cognitive 

impairments. Due to blinding, the main outcomes from the 

1-year follow-up for the two treatment approaches will be 

analysed in June 2009. 

Inter-examiner reliability of a classification system for 

patients with non-specific low back pain 

Fersum KV, 1 O’Sullivan PB, 2 Kvåle A, 1 Skouen JS 1 

1 


2 


There is a lack of studies examining whether classification 

systems acknowledging biological, psychological and social 

dimensions of chronic low back pain disorders can be 

performed in a reliable manner. The purpose of this study 

was to examine the inter-tester reliability of clinician’s 

ability to independently classify patients with non-specific 

low back pain, utilising a mechanism-based classification 

system developed by Peter O’Sullivan. Twenty- six 

patients underwent a full examination by four different 

physiotherapists (O’Sullivan and 3 others) independently. The 

therapists underwent a multilevel decision making process, 

based on disorder classification, primary directional pain 

provocation and the detection of dominant psycho-social 

factors. Percentage agreement and Kappa-coefficients were 

calculated for six different levels of decision-making. For 

levels 1–4, percentage agreement had a mean of 96% (range 

75–100%). In the 5 th level, deciding the directional pattern 

of provocation, Kappa agreement could be calculated. For 

the primary direction of provocation, Kappa and percentage 

agreement had a mean between the four testers of 0.82 (range 

0.66–0.90) and 86% (range 73–92%) respectively. Increased 

familiarity with the system increased the reliability scores. 



In the final decision making level, the scores for detecting 

psychosocial influence gave a mean Kappa-coefficient 

of 0.65 (range 0.57–0.74) and a mean agreement of 87% 

(range 85–92%). The findings suggest that the inter-tester 

reliability of the system is moderate to substantial for a 

range of patients within the non-specific low back pain 

population. Establishing the reliability of a classification 

system is an important step towards implementing targeted 

interventions programs for subgroups with non-specific low 

back pain. 

Movement strategy of sit-to-stand performance in 

young healthy adults: a new approach 

Fotoohabadi MR, 1,2,3 Tully EA, 3 Galea MP 3 

1 

La Trobe University, Melbourne, 2 Shiraz University of Medical 

Sciences (SUMS), Shiraz, IRAN, 3 The University of Melbourne, 

Melbourne 

The challenge for balance control and the wide range of 

different joint motions and body segments involved in sitto-stand 

make it a versatile and an important daily activity 

as well as a measure of independent function. Kinematics 

investigation of sit-to-stand has been well documented with 

respect to the angular displacement of lower limb joints 

and trunk segment. However, the movement strategy in 

regards to the contribution of different spinal segments has 

not been detailed. This study therefore aimed to perform 

a 2D sagittal kinematics investigation of STS using a new 

model of marker placement. Forty-seven physiotherapy 

students were videotaped from the side as they stood from a 

backless chair set at knee height at their self selected speed. 

The automatic digitisation mode of the 2D Peak Motus was 

used to track the movements of 10 markers attached on the 

thoracolumbar spine and right lower limb. The horizontal 

linear velocity of thoracic spine demonstrated a fast forward 

movement in the first 22% of sit-to-stand duration reaching 

a maximum of 256 (78) pixel/sec, after which decreased 

attaining a zero value at 52% of duration, well after lift off 

(34%). This pattern then changed to a backward horizontal 

movement, lasted to the end of sit-to-stand to attain an 

upright posture. Vertical linear velocity of the thoracic spine 

showed a concurrent pattern, but in reverse. These findings 

suggested that healthy young adults used a ‘momentum 

transfer’ strategy throughout sit-to-stand to successfully 

perform this activity, which has implications for clinical 

practice. 

Advances in treatment for the knee: latest 

evidence-based management 

Fransen M 


Osteoarthritis is primarily a disease of the articular 

cartilage and the subchondral bone. There are many factors 

that cause excessive mechanical stresses to these tissues 

in the knee joint, including obesity, joint malalignment, 

ligament or meniscus damage and poorly functioning lower 

limb muscles. Even genetic risk is now viewed as more 

likely attributable to a higher susceptibility to structurally 

abnormal joints or an inherited ‘micro-incoordination’ of 

weight-bearing activities, rather than genes that regulate 

cartilage or subchondral bone metabolism. There are 

many older people with clear radiographic evidence of 

osteoarthritis of the knee who are not experiencing joint 

pain, physical disabilities or structural disease progression. 

Given that for most people osteoarthritis of the knee can 

be attributed to a poor biomechanical environment, the role 

of physiotherapy as an effective management strategy has 

great potential for this chronic musculoskeletal condition. 

The latest evidence from laboratory-based studies will 

be presented to outline the rationale of various strategies 

to reduce the risk of progressive disease. An updated 

systematic review of randomized clinical trials evaluating 

therapeutic exercise in terms of reducing pain and disability 

will follow. The emphasis will be on subgroup analyses. 

The presentation will conclude with a discussion of the 

current clinical evidence from MRI or X-ray studies testing 

the hypothesis that reducing excessive mechanical stress 

on the knee can effectively slow down structural disease 

progression. In other words, are there truly ‘diseasemodifying’ 

intervention strategies available for people with 

osteoarthritis of the knee? 

Classification-based approaches to low back pain 

management 

Fritz JM 

University of Utah, Salt Lake City, Utah, USA 

Physical therapists employ a wide range of interventions in 

the management of patients with low back pain including 

spinal manipulation, various types of exercise, traction, 

modalities, etc. High-quality evidence from randomised 

clinical trials has often failed to offer conclusive support for 

most of these interventions. Over 1000 randomised clinical 

trials investigating the effectiveness of conservative and 

surgical interventions for the management of low back pain 

have been published. Despite this plenitude of research, 

the evidence remains contradictory and inconclusive for 

many interventions. One explanation offered for the lack 

of evidence for many common interventions relates to 

study designs with broad inclusion criteria resulting in 

heterogeneous samples. Research on interventions for LBP 

has traditionally not incorporated a reality recognised 

by clinicians; that it is not reasonable to expect everyone 

with non-specific LBP to benefit from any single treatment 

approach. It is proposed that the power of clinical research 

can be improved through the identification of methods to 

classify patients into more homogeneous sub-groups for 

whom an effective treatment strategy can be identified. 

Several classification systems have been developed to assist 

physical therapists in identifying smaller sub-groups of 

patients from within a larger clinical entity. The hallmark 

of a sub-group is that its members should be more likely to 

respond to a particular intervention approach. The purpose 

of this session is to review the development and contribution 

of classification systems in physical therapy, and discuss 

future directions for both research and clinical practice. 

Individualising treatment in the clinic 

Fritz JM 

University of Utah, Salt Lake City, Utah, USA 

Translating the findings of research evidence into everyday 

clinical practice is a challenge for all health care providers. 

Clinical practice across a variety of health care disciplines 

continues to be characterised by a surprising amount of 

variation in the quality of care provided, and an alarming 

degree of under-and over-utilisation of potentially beneficial 

or non-beneficial treatments respectively. Physical therapy 



practice is no exception, with research documenting 

concerns about under-and over-utilisation, and the overall 

quality of care. Improving the consistency and quality of 

clinical practice requires the development and dissemination 

of clinical decision-making strategies that can assist 

physical therapists in delivering the specific treatments to 

the individual patients who are most likely to benefit from 

them. Research on clinical decision-making is an important 

initial step, but is not sufficient to actually effect a change 

in clinical practice. Integrating evidence-based decisionmaking 

strategies into everyday practice to improve the 

outcome of care presents a separate challenge, requiring an 

understanding of behavioural science. The integration of 

new knowledge into practice can be facilitated by applying 

training and educational methods demonstrated to be 

effective for changing clinician behaviour, and improving 

the outcomes of patients receiving care. The purpose of this 

session is to discuss the process of developing and validating 

decision-making strategies for use by physical therapists, 

and to describe strategies for integrating evidence-based 

decision-making in clinical practice to standardise care and 

improve clinical outcomes. 

Accurate prediction of patient outcome can be achieved 

using bio-psycho-social screening 

Gabel CP 

University of the Sunshine Coast, Sunshine Coast 

The early identification of high risk, long term 

musculoskeletal patients is now a reality. However, new 

generation research is gaining the capacity to produce the 

accurate prediction of an individual patient’s actual future 

recovery rate, total recovery time and total costs. This is 

achieved through melding mobile interactive technology, 

integrated Patient-Reported Outcome (PRO) measures 

and screening within the bio-psycho-social (BPS) health 

model. Existing screening methods use either or both 

physical and BPS tools to provide data and evidence that 

dichotomises patients into risk categories. These categories 

are functional impairment levels on specific PROs at 

defined periods-such as 6 months post-injury; and directly 

measurable variables-such as total paid days off or total 

cost. Future methodologies integrate current research 

concepts, including decision support software programs 

and Computer Adaptive Technology (CAT) using Item 

Response Theory (IRT) to consider both compensable and 

general population groups. They reflect on statistically 

analysed test-case data through correlation coefficients, 

regression analysis, and mathematical modelling. These 

analytical methods, along with injury specifics, forecast 

changes in a patient’s overall status and the rate at which 

it does and will occur. This creates a common language 

and visual history, both retrospective and predictive, that is 

immediate, easy to use and can be communicated instantly 

between all stake holders-patient, GP, therapist, specialist 

and payer. This presentation details these practices and 

highlights the direction of future methods using real case 

examples, summarised data as clinical pathway indicators 

and what it means to the physiotherapy profession. The 

importance of this work: technology is rapidly altering the 

way in which patient status is measured and predicted. There 

is an agenda to move toward decision support software to 

determine current and future patient outcome status. This 

philosophy is driven by the international community and is 

funded by corporate, association and government sectors. 

16 

Common examples for Australian physiotherapists are 

the US-FDA PROMIS project, registration of PRO Tools 

through the PROQOLID-MAPI French database, and the 

push towards CAT technology using Item Response Theory 

(IRT). Physiotherapists must choose to embrace and utilise 

these imminent changes, becoming directive and involved 

within the process. Alternatively, the risk is having 

decision methodology and treatment justification dictated 

by government and corporate policies that relinquish any 

control and may not reflect patient and therapist interests. 

Flaws in the Neck Disability Index (NDI) make it 

unsatisfactory for clinical and research use 

Gabel CP 


The Neck Disability Index (NDI) is the most commonly used 

patient reported outcome (PRO) for cervical assessment in 

clinical and research settings. It is strongly advocated by 

professional associations and statutory body guidelines. 

However, two 2009 published studies respectively used 

‘Maximum Likelihood Extraction’-Factor Analysis (n 

= 61) and ‘Rasch Methodology’ analysis (n = 521) that 

demonstrated the NDI is unsound. This was due to the bidimensional 

structure that results in ordinal rather than 

interval scaling and questions the fundamental practice of 

calculating change scores and other parametric statistics on 

NDI data. To test these criticisms and analyse overall NDI 

performance, primary care data from a convenience sample 

(n = 95, responses = 284, invalid = 44) was analysed. Patients’ 

conditions expressed diversity in region and severity that 

included non-specific, soft-tissue, joint, whiplash and 

traumatic injuries. Overall PRO performance was assessed 

using the Measurement of Outcomes Measures (MOM) 

quantitative scale (25 x 3-point items = 100%) and the ‘Bot’ 

quantitative scale (12 dichotomous items). Psychometric 

properties were calculated and included factor structure, 

whilst practical characteristics included completion and 

scoring time and missing responses. In addition the total 

and individual item with-in tool scores were assessed and 

distribution analysed. The NDI was found to have suboptimal 

overall performance on both the MOM and Bot 

scales (66%) due to poor readability, inadequate distribution, 

narrow within-tool range, bi-dimensional factor structure 

and high scoring time in the presence of missing responses 

(8%). The study supports recent criticism and recommends 

the NDI not be used as a clinical or research PRO for cervical 

assessment. The importance of this work: patient reported 

outcome (PRO) measures for use in the clinical and research 

setting require a solid scientific support basis for both their 

methodological and practical characteristics. Much of the 

current research on cervical injuries and whiplash uses the 

NDI. However, in the recent literature, including that from 

respected Australian research and academic institutions, the 

properties of the tool itself are rarely if ever calibrated by 

the researchers themselves. This study supports the recent 

publications that have analysed the NDI and found that the 

recognised reasons for recommend use are predominantly 

subjectively based or rely upon psychometric properties and 

analysis performed up to 2 decades previously. There is a 

need to calibrate an instrument prior to its use in a research 

study or use standards from a study that has investigated 

either the same patient pool or alternatively a broad and 

diverse population that will have lower or more conservative 

values. This paper contributes to these areas of debate by 



highlighting recent concerns within the frame work of 

broader analysis and negative criticisms of the NDI. 

What is the optimal outcome measure for whiplash? 

Gabel CP 


Whiplash associated disorder (WAD) is extensively treated 

and investigated within the physiotherapy profession. 

Despite significant guidelines and recommendation, the 

patient reported outcomes (PROs) for measurement of 

individual status and progress are predominantly advocated 

from a subjective non-evidence based protocol. This study 

investigated the performance of seven PROs obtained from 

published and grey literature that were recommended for 

WAD: Neck Disability Index (NDI), Whiplash Disability 

Questionnaire (WDQ), Functional Rating Index (FRI), 

Numeric Rating Scale (NRS) 11-point, Patient Specific Index 

(PSI), Spine Functional Index (SFI) and Global Assessment 

(GABAL) composite scale. A total of 30 patients, age 37 ± 

14, 77% female, from a convenience sample in 8 primary 

care centres were measured at baseline, 1, 3 and 6 months 

to produce 120 measurements with 744 of 840 individual 

responses (11% missing responses). All PRO scores were 

on a 100% scale. Overall PRO performance was compared 

using the Measurement of Outcomes Measures (MOM) 

quantitative scale (25 x 3-point items = 100%) and the 

‘Bot’ quantitative scale (12 dichotomous items). The best 

performed tools were the PSI (96%, 12/12) however it cannot 

compare between patients, and the Global compositescale 

(92%, 12/12) which requires computer software. The 

optimal PRO was the SFI (90%, 12/12) then the NRS (86%, 

12/12), FRI (80%, 10/12), NDI (66%, 8/12) and WDQ (52%, 

5/12). The most commonly used and advocated PRO, the 

NDI, had poor distribution and within-tool item ranking. 

The best performed WAD measurements were the PSI 

and GABAL composite-scales, whilst the optimal clinical 

PRO was the SFI. Measurement of patient status and 

subsequent comparison to produce evidence that justifies 

current or further intervention is now obligatory in most 

physiotherapy and primary care settings. However, the role 

of advocacy for the optimal PRO to achieve these measures 

in a clinically practical and methodological sound manner 

is often flawed by the use of personal opinion and subjective 

attitudes rather than the scientific quantitative data to 

support such recommendations. Examples of this include 

those advocated by physiotherapy teaching institutions, the 

APA and most State government insurance group web sites. 

A re-evaluation of why a PRO is advocated is required and 

a need to quantify the choice using a-priori protocol. 

A short form questionnaire (ÖMSQ-15) improves 

screening through factor structure, psychometric and 

practical characteristics without loss of predictive 

performance 

Gabel CP 


Bio-psycho-social screening to predict patients with a high 

risk of prolonged recovery is advocated by professional 

and insurance groups. However, a suitable brief, accurate, 

and psychometrically sound questionnaire for general 

musculoskeletal patients is lacking. This study developed 

such a tool by modifying and shortening the 21-item 

Örebro Musculoskeletal Pain Questionnaire (ÖMPQ) to a 

15 item Screening Questionnaire (ÖMSQ-15). Two itemreduction 

methods were investigated: concept-retention: 

subjective qualitative, and factor analysis-statistical based. 

An a-priori minimum of 15-items was determined from 

the Spearman-Brown prophesy where internal consistency 

(α) would exceed 0.80. A data set derived from general 

symptomatic musculoskeletal compensation patients (n = 

194) was reanalysed with both ÖMSQ-15 versions to assess 

psychometric and practical characteristics at baseline and 

predictive performance at 6 months, then compared with 

the full length version. The concept-retention version 

performed best with higher correlation (Pearson’s r = 

0.99 p < 0.01) whilst reliability regressed marginally (r = 

0.95 p < 0.01, ICC 2,1). Predictive performance improved 

at an 86 ÖMSQ-15-points (57%) cut-off value where 

convergent validity gave higher subsequent positive 

likelihood ratios (3.9–4.8) and correlated highly (r = 0.73 

p < 0.01) with recovery time. Divergent validity showed 

mean scores as significantly different (p < 0.001) between 

patients with positive and negative outcome traits. Factor 

structure (maximum likelihood extraction) gave a coherent 

four-factor model that accounted for 56% of variance. 

Practicality improved markedly through reduced missing 

responses (4.9%) and a 21% reduction in scoring time and 

completion time (4.42 + 2.39 min). A qualitative conceptretention 

version rather than a statistically driven approach 

produced improved validity, reliability and practicality in 

the final tool. Screening questionnaires, particularly the 

Örebro tool, are now advocated by various professional 

groups and statutory state government insurance authorities 

as a means of providing early recognition of potential 

prolonged recovery and long term claimants. However, 

the most commonly advocated and recommended tool: 

the Örebro Musculoskeletal Pain Questionnaire (ÖMPQ), 

has been modified from the original low back tool without 

validation of the changes and subsequent interpretation 

within the target populations. Further more, it is not a pain 

questionnaire but a screening tool that provides cut-offs for 

levels of risk determination. In its current non-validated 

form, the advocated ÖMPQ gives rise to significant missing 

responses, poor interpretation and erroneous scores that 

can be both time consuming and difficult to calculate and 

interpret. The shortening of the tool to a validated 15 item 

screening questionnaire reduces missing and erroneous 

responses which improves practicality, patient acceptance, 

predictive capacity and the ease of clinical use. 

Multidirectional control of the shoulder complex 

Ginn KA, 1 Cather I, 1 Coppetiers M, 2 Hodges P 2 

1 

The University of Sydney, Sydney, 2 The University of Queensland, 

Brisbane 

The objective of this study was to determine the specificity 

of muscle activity for directions of force production at the 

glenohumeral joint in order to test hypotheses proposed in 

the clinical literature that the muscles of the rotator cuff 

and the scapular muscles would be active with all directions 

of movement to control the stability of the glenohumeral 

joint and scapula. Fourteen subjects with normal 

dominant shoulder function participated in this study. 

Electromyographic data were collected simultaneously 

from supraspinatus, infraspinatus, subscapularis, deltoid, 

pectoralis major, latissimus dorsi, teres major, trapezius 

and serratus anterior using a combination of surface and 

intramuscular electrodes. With their humerus supported 



in a sling at 90º shoulder abduction, subjects exerted 

isometric force into shoulder flexion, extension, abduction 

and adduction as well as the 4 angles between these. The 8 

angles were randomised and subjects exerted 2 repetitions 

of a maximal force in the specified direction. Based on the 

force achieved for each direction, the subject exerted two 

repetitions of forces of 25%, 50% and 75% of maximum 

in random order. All forces were corrected to take into 

account the passive weight force of the arm. The mean value 

of filtered, rectified EMG was determined for each muscle 

and normalised to a standard set of maximum isometric 

contractions. A two-way repeated measures ANOVA (loads 

and angles) was undertaken for each muscle individually, 

followed by Tukey post hoc analysis. Results indicate the 

scapulothoracic and posterior rotator cuff muscles are not 

equally active in all directions of shoulder movement. 

18 

Lateral stability mechanisms of the pelvis and the 

relationship with lateral hip and knee pain 

Grimaldi AM 


The degree of hip adduction in single leg stance has been 

shown to directly influence specific muscle recruitment 

within the hip abductor synergy, and compression forces 

developed beneath the iliotibial band. A major factor in 

the development of tendinopathy or enthesopathy is now 

believed to be excessive or prolonged compressive loading 

particularly of the deep surface of a tendon against the 

underlying bone. The tensor fascia lata origin at the pelvis, 

the gluteus medius and minimus tendon insertions at the 

greater trochanter, and the highly innervated fat pad at the 

lateral knee are all at risk of compression from the overlying 

iliotibial band. Management of these conditions appears 

most successful when the approach involves avoidance 

of excessive or prolonged functional adduction in sitting, 

standing and lying, thereby reducing compressive loading. 

Iliotibial band stretching is for the same reason generally 

unhelpful. Therapeutic exercise prescription should consider 

a specific approach based on use of the abductor synergy 

to minimise hip adduction in single leg tasks, thereby 

optimising ‘pelvic stability’. Use of real-time ultrasound is 

a valuable tool in early deep muscle recruitment, integral 

in ideal pelvis on femur control. Strength progressions are 

essential and should consider the functional nature of the 

abductor synergy. 

Physiotherapy functional restoration for lumbar disc 

herniation with associated radiculopathy: 

a retrospective file review 

Hahne AJ, 1,2 Surkitt LD, 1,2 Walters AG, 2 Ford JJ, 1,2 

McMeeken JM 3 

1 

La Trobe University, Melbourne, 2 Spinal Management Clinics of 

Victoria, 3 The University of Melbourne, Melbourne. 

Functional restoration has been shown to be effective 

for non-specific low back pain, but functional outcomes 

have not been reported for people who have lumbar disc 

herniation with associated radiculopathy. We undertook a 

retrospective file review involving three physiotherapists 

who utilised functional restoration for people with 

radiologically confirmed lumbar disc herniation and 

associated radiculopathy between 2001 and 2007. Outcomes 

had typically been measured at baseline, 2 months, and 

6 months using the Oswestry Low Back Pain Disability 

Questionnaire and global improvement rating scale 

(improved, unchanged, worse). A total of 77 of the 1013 

files (7.6%) met the inclusion criteria. The mean duration of 

leg symptoms at baseline was 13.9 months (SD = 20.8). The 

mean baseline Oswestry score was 44.8/100 (SD = 15.6, n 

= 63). A mean of 32 treatment sessions were attended over 

mean 10.5 months (SD = 10.0). Global improvement was 

reported by 87% and 82% of the patients at the 2 month 

and 6 month follow-up respectively. Mean improvement in 

the Oswestry score was 8.8/100 (SD = 11.7) at 2 months 

and 12.4/100 (SD = 16.6) at 6 months. Reason for discharge 

was independence in 69%, and drop-out in 16%. Five 

patients (6%) went on to undergo surgery. Minor adverse 

events (short-term pain following exercises) were reported 

by 8 patients (10.4%), while 1 (1.3%) frozen shoulder was 

attributed to upper limb weights. People with lumbar 

disc herniation and associated radiculopathy can achieve 

positive functional and global improvements with a low 

risk of adverse events when undertaking a physiotherapy 

functional restoration program. 

Conservative management of lumbar disc herniation 

with associated radiculopathy: a systematic review 

Hahne AJ, 1 Ford JJ, 1 McMeeken JM 2 

1 

La Trobe University, Melbourne, 2 The University of Melbourne, 

Melbourne 

A systematic review of randomised controlled trials 

was undertaken to determine the efficacy and safety 

of conservative treatments for people with lumbar disc 

herniation with associated radiculopathy. Computer 

database searches were conducted of Medline, CINAHL, 

Embase, PEDro, Current Contents, Cochrane central 

register of controlled trials, AMED, Web of Science and 

the Australasian Medical Index for the period between 1971 

and August 2008. Randomised controlled trials published 

in English were included if they focused on people with 

referred leg symptoms and radiological confirmation of a 

lumbar disc herniation, where at least one group received 

a conservative treatment. A total of 18 trials involving 

1671 participants were included in the review. Seven trials 

(39%) were considered high quality. Meta-analysis on 2 

high quality trials revealed that advice is less effective than 

microdiscetomy surgery at short-term follow-up, but equally 

effective at long-term follow-up, for people with sub-acute 

symptoms. Individual high quality trials provided moderate 

evidence that stabilisation exercises are more effective than 

no treatment at short term follow-up, manipulation is more 

effective than sham manipulation at short and intermediate 

follow-up for people with acute symptoms, the addition 

of mechanical traction to medication and electrotherapy 

provides some additional short-term benefits, and that no 

difference exists between traction, laser and ultrasound. 

Adverse events were associated with traction (pain, 

anxiety, lower limb weakness, fainting) and ibuprofen 

(gastrointestinal events). Additional high quality trials are 

required to determine which conservative treatments are 

the safest and most effective for people with this condition. 



An evaluation of the anatomical basis of a clinical test 

for superior labrum anterior to posterior (SLAP) lesion 

Hairodin Z, 1,3,5 Green RA, 1,2 Taylor NF, 1,3 Watson L, 1,3,4 

Balster S 4 

1 

Musculoskeletal Research Centre, 2 School of Human Biosciences, 

3 

School of Physiotherapy, La Trobe University, Melbourne, 4 Lifecare 

Prahran Sports Medicine, Melbourne, 5 Tan Tock Seng Hospital, 

Singapore 

The Resisted Supination External Rotation (RSER) test 

was designed to detect SLAP lesions by placing maximal 

tension on the tendon of biceps brachii long head in order to 

stress the unstable bicipital labral complex. The aim of this 

study was to determine whether the RSER test has a valid 

anatomical basis in shoulders with a suspected SLAP lesion. 

Eight patients with a suspected SLAP lesion and 8 gender and 

age-matched controls were recruited. Electromyographic 

(EMG) activity levels of biceps brachii long head and short 

head, brachialis, supinator, middle deltoid, subscapularis 

and infraspinatus were detected using a combination 

of surface and intramuscular electrodes to provide an 

indication of active tension. The RSER test is conducted in 

supine with a starting position of 90° shoulder abduction, 

70° elbow flexion and forearm mid-prone. The participant 

supinates their forearm against an examiner’s resistance 

maximally and is then passively moved into full shoulder 

external rotation while maintaining maximal forearm 

supination resistance. Mean EMG activity were normalised 

to the maximal voluntary isometric contractions (MVIC) 

and compared between patient and control groups. Biceps 

brachii long head activity was moderately strong to marked 

(40–64 % MVC). Biceps brachii short head and supinator 

muscles were also moderately strongly active, while all 

other muscles demonstrated lower levels of activity. There 

was no significant difference between patients and controls 

in activity for long head of biceps (p = 0.74) or any of the 

surrounding muscles. These results provide evidence of the 

anatomical validity of the RSER test in a clinically relevant 

population. 

The Patient-Specific Functional Scale is more 

responsive than the Roland Morris Disability 

Questionnaire in patients with low back pain 

Hall A, 1 Maher C, 1 Latimer J, 1 Ferreira M, 2 Costa L 1 

1 

The George Institute For International Health, The University Of 

Sydney, Sydney, 2 Faculty of Health Sciences, The University of Sydney, 

Sydney 

The Roland Morris Disability Questionnaire and the Patient- 

Specific Functional Scale are commonly used to assess 

disability in patients with low back pain. It is essential to 

determine the relative responsiveness of these questionnaires 

in order to choose which one is best to measure outcomes of 

treatment. The primary aim of this study was to compare the 

internal and external responsiveness of each questionnaire 

in a large cohort of patients with low back pain. A secondary 

aim was to determine if the responsiveness was influenced by 

length of follow-up or duration of pain. Responsiveness was 

calculated using effect size statistics, Pearson r correlations 

and Receiver Operating Characteristic Curve analysis on 

831 patients with low back pain at 2 time-points; directly 

after treatment (termed short-term) and several weeks posttreatment 

(termed mid-term). The data were subsequently 

re-analysed on sub-sets of the full cohort according to 

duration of pain. The Patient-Specific Functional Scale 

consistently demonstrated a greater internal and external 

responsiveness compared to the Roland Morris Disability 

Questionnaire at both short-term and mid-term follow-up 

time points. These results were statistically significant for 

all indices of responsiveness. Further, this superiority was 

evident in different durations of pain symptoms. When 

choosing between these two questionnaires, the Patient- 

Specific Functional Scale is the most responsive and so the 

preferred choice to investigate change resulting from an 

intervention. 

The therapeutic alliance as a predictor of treatment 

outcome in physical rehabilitation: a systematic review 

Hall AM, 1 Ferreira PH, 2 Ferreira ML, 2 Maher CG, 1 

Latimer J 1 

1 


Sydney, 2 Faculty of Health Sciences, The University of Sydney 

The therapeutic alliance, broadly defined as the collaborative 

bond between client and therapist has been found to be 

moderately related to outcome in psychotherapy. It is of 

interest if this finding also exits in physical rehabilitation 

settings. A sensitive search of six databases identified a total 

of 1599 titles. Fourteen of which were included for having 

a measure of alliance and outcome for patients undergoing 

physical rehabilitation. Included studies were predominately 

cohort studies (71%). The populations varied among trials, 

including patients with brain injury (29%), musculoskeletal 

conditions (36%), cerebral palsy (7%), cardiac conditions 

(7%), or multiple pathologies (21%). All trials included a 

physical rehabilitation component, lead predominantly by 

a physiotherapist (76%). Various outcomes were measured 

including pain, disability, quality of life, depression, 

compliance and satisfaction with treatment. The alliance 

most commonly measured with the Working Alliance 

Inventory (50%) rated by both patient and therapist on the 

3or 4treatment session. The results indicate that a good 

alliance is associated with (i) good treatment compliance in 

brain injury patients and patients with multiple pathologies 

seeking physiotherapy, (ii) reduced depressive symptoms in 

cardiac and brain injury patients, (iii) improved treatment 

satisfaction in cerebral palsy and musculoskeletal pain 

patients, (iv) improved function in geriatric and chronic low 

back pain patients. The alliance between therapist and patient 

appears to have a positive effect on treatment outcome in 

physical rehabilitation settings; however, more research is 

needed to determine the strength of this association. 

Independent evaluation of a clinical prediction rule for 

spinal manipulative therapy: lessons learnt 

Hancock MJ, 1 Maher CG, 2 Herbert RD 2 

1 

Back Pain Research Group, University of Sydney, Sydney, 2 The George 

Institute for International Health, University of Sydney, Sydney 

Identifying subgroups of patients who respond best to 

specific physiotherapy treatments has the potential to 

advance the profession and improve outcomes for patients. 

One such example is the subgroup of patients identified by 

the highly cited clinical prediction rule for patients who 

respond best to spinal manipulative therapy. This rule has, 

however, not been shown to generalise to different settings. 

We therefore performed a pre-planned secondary analysis 

of a randomised controlled trial investigating the efficacy 

of spinal manipulative therapy in 239 patients presenting 

to general practitioner clinics for acute, non-specific, low 

back pain. Patients were randomised to receive spinal 



manipulative therapy or placebo, 2–3 times per week for 

up to 4 weeks. All patients received general practitioner 

care (advice and paracetamol). Outcomes were pain and 

disability measured at 1, 2, 4 and 12 weeks. Status on 

the clinical prediction rule was measured at baseline. 

The clinical prediction rule performed no better than 

chance in identifying patients with acute, non-specific low 

back pain most likely to respond to spinal manipulative 

therapy (pain, p = 0.805; disability, p = 0.600). At some 

follow-ups the clinical prediction rule predicted outcome 

regardless of treatment but at no time point identified those 

who responded best to spinal manipulative therapy. The 

results of this study highlight two key issues for future 

investigation into subgroups of patients who respond best 

to physiotherapy treatments. First, subgroups can only be 

adequately identified in controlled trials. Second, findings 

of subgroups should be subject to external validation. 

A primary contact musculoskeletal physiotherapy 

service in the emergency department can prevent the 

admission of patients with back pain 

Harding P 

The Alfred Hospital 

In 2008, The Alfred hospital commenced a primary 

contact musculoskeletal physiotherapy service within their 

emergency department. Twelve months after commencement 

of the service, an audit for patients under 65 years of 

age, with musculoskeletal back pain, presenting to the 

emergency department database was conducted. The audit 

compared patients seen by the physiotherapist in a primary 

contact role with patients where there was no physiotherapy 

involvement. The audit showed that only one out of the 76 

patients seen by the primary contact physiotherapists was 

admitted to the hospital, an admission rate of 1.3%. In 

comparison, 90 of the 450 patients with no physiotherapy 

involvement were admitted, an admission rate of 20%. 

The length of stay for the 1 admitted patient seen by the 

primary contact physiotherapist was 7:27 (h:mm) hours. In 

comparison, the average length for those patients, who were 

admitted, with no physiotherapy involvement, was 47:59 

hours. The average length of stay, for non admitted patients 

seen by the primary contact physiotherapist was 2:46 hours. 

In comparison, the average length of stay, for non admitted 

patients, where there was no physiotherapy involvement, 

was 4:15 hours. In summary, if a person is not seen by a 

primary contact physiotherapist, for musculoskeletal back 

pain, he/she will spend additional 1:29 hours within the 

emergency department. Furthermore, the person will not 

meet the Four Hour Length of Stay for Non Admitted 

Patients Key Performance Indicator. More importantly a 

person is 15.2 times more likely to be admitted spending, 

on average, 2 days in hospital. 

Altered response of the anterolateral abdominal 

muscles to simulated weight-bearing in subjects with 

low back pain 

Hides JA, 1,2 Belavý DL, 3,4 Cassar L, 1 Williams M, 1,2 

Wilson SJ, 3 Richardson CA 1 

1 

Division of physiotherapy, The University of Queensland, Brisbane, 

2 

The University of Queensland/Mater Back Stability Clinic, Mater 

Health Services Brisbane Limited, Brisbane, 3 School of Information 

Technology and Electrical Engineering, The University of Queensland, 

Brisbane, 4 Zentrum für Muskel-und Knochenforschung, Charité 

Campus Benjamin Franklin, Berlin 

20 

Subjects with low back pain have been shown to exhibit 

impairments in motor control of key muscles, which 

contribute to stabilisation of the lumbo-pelvic region. 

However, test of automatic recruitment that relates to 

function has been lacking. A previous study used ultrasound 

imaging to show that healthy subjects automatically 

recruited the transversus abdominis and internal oblique 

muscles in response to a simulated weight-bearing task. 

This task has not been investigated in subjects with low back 

pain. The aim of this study was to compare the automatic 

recruitment of the abdominal muscles among 20 subjects 

with and without low back pain in response to the simulated 

weight-bearing task. Real-time ultrasound imaging was 

used to assess changes in thickness of the transversus 

abdominis and internal oblique muscles as well as lateral 

movement (‘slide’) of the anterior fascial insertion of the 

transversus abdominis muscle. Results showed that subjects 

with low back pain showed significantly less shortening of 

the transversus abdominis muscle (p < 0.0001) and greater 

increases in thickness of the internal oblique muscle (p = 

0.002) with the simulated weight-bearing task. There was 

no significant difference between groups for changes in 

transversus abdominis muscle thickness (p = 0.06). This 

study provides evidence of changes in motor control of the 

abdominal muscles in subjects with low back pain. This 

test may provide a functionally relevant and non-invasive 

method to investigate the automatic recruitment of the 

abdominal muscles in people with and without low back 

pain. 

Long–term effects of ankle sprain 

Hiller CE, Raymond J, Kilbreath SK, Refshauge KM 


Many people have residual problems following ankle sprain, 

however there is little information about their severity. The 

aim of this study was to determine the longterm severity 

of functional ankle instability following ankle sprain. Data 

were collated from 804 participants (26.8 ± 11.3 years) 

who participated in a number of studies of ankle sprain. 

Participants had suffered at least one ankle sprain and were 

recruited from the general community, sporting groups, 

physiotherapy practices and university population. Main 

outcomes examined were severity of ankle instability 

measured by the Cumberland Ankle Instability Tool 

(CAIT, score range 0 – 30, ≤ 27 denotes instability, 0 

denoting most severe instability), number of ankle sprains, 

and pain occurrence. Data were divided into decade age 

bands, commencing at 10 years and concluding at 59 

years. Average CAIT score was 19 ± 6.5 with the lowest 

average score in the 50–59 years group (12.9 ± 6.5). The 

severity of functional instability was greatest (15.4 ± 6.7) in 

participants who sprained in the last month and least (19.7 

± 6.9) in participants 10 years post sprain. Across all age 

bands the proportion of repeat sprains was 70–80%, except 

in the youngest group in which it was 62%. Pain in the ankle 

during walking was experienced by 15.1% of participants 

with 64% experiencing pain during some activity. This study 

demonstrated higher than expected severity of functional 

ankle instability and frequency of pain in all ages, and 

demonstrates feasibility for a larger community based study 

of severity of residual problems and impact on activity. 



Recovery from low back pain: patients’ perspective 

Hush J, 1 Refshauge K, 1 Sullivan G, 1 De Souza L, 2 

Maher C, 3 McAuley J 1,3 

1 

Back Pain Research Group, Faculty of Health Sciences, University of 

Sydney, Sydney, 2 School of Health Sciences and Social Care, Brunel 

University, Middlesex, England, 3 The George Institute for International 

Health, University of Sydney, Sydney 

The aim of this study was to explore patients’ perceptions 

of recovery from low back pain (LBP), about which little 

is known. The views of 36 participants, either recovered or 

unrecovered from LBP, were investigated in 8 focus groups. 

Interviews were audio-recorded and transcribed verbatim. 

Framework analysis was used to identify emergent themes 

and domains of recovery. It was found that patients’ views 

of recovery encompassed a range of factors that could be 

broadly classified into the following domains: symptom 

attenuation, improved capacity to perform a broad scope 

of self-defined functional activities, and achievement of an 

acceptable quality of life. An interactive model is proposed 

to describe the relationships between these domains, 

cognitive appraisal of the pain experience and self-rated 

recovery. Central to this model is the use of behavioural 

and cognitive adaptive strategies. Pain attenuation alone 

was not a reliable indicator of recovery. The construct of 

recovery for ‘typical’ back pain patients seeking primary 

care is more complex than previously recognised and is a 

highly individual construct, determined by appraisal of the 

impact of symptoms on daily functional activities as well as 

quality of life. The findings of this study will be valuable to 

re-assess how to optimise measures of recovery from LBP 

and target the domains patients consider meaningful. 

Disc replacement and spinal fusion outcomes: the 

physiotherapy rehabilitation challenge region between 

chronic low back pain and healthy normal 

Hobbs AJ, 1,2 Adams RD, 1 Shirley D, 1 Hillier T 3 

1 

The University of Sydney, Sydney, 2 Healthfocus Physiotherapy, Albury, 

3 

Alpine Orthosport, Albury 

In cases of unremitting discogenic pain, the spinal surgeries 

of lumbar disc replacement or fusion may be performed to 

improve function and prevent continuing pain-related activity 

restriction. In order to compare groups who had undergone 

spinal surgery involving lumbar disc replacement or lumbar 

fusion with a group with chronic discogenic pain and with 

a group of healthy peers, ratings of functional ability over a 

range of activities were obtained from all four groups. The 

aim was to identify functional deficits that may still exist 

following spinal surgery, so that physiotherapy intervention 

could be directed towards these deficits in order to improve 

outcomes. Ability to perform each of 23 functional activities 

was rated on a 7-point (0 to 6) scale ranging from ‘totally 

unable to perform’ to ‘fully able to perform’. A total of 247 

participants responded to the survey (healthy normal 38; 

disc pain 51; fusion 62; disc replacement 96). Total ability 

scores (maximum score possible 138) across all activities 

for the groups were analysed using planned contrasts within 

ANOVA. All patient groups had significantly lower mean 

rated functional ability than healthy controls (71 vs 133), 

and those with chronic discogenic pain had lower rated 

ability than the two spinal surgery groups (51 vs 81), who 

did not differ from each other (83 vs 80). The mean ability 

rating post-surgery was thus 37% of the distance between 

un-operated chronic disc pain and healthy normal function. 

The remaining 63% represents the rehabilitation challenge 

region for physiotherapists working with these post-surgery 

groups. 

Gain of postural responses is increased in anticipation 

of pain 

Hodges PW, Simms K, Tsao H 



Movement changes during pain, but the mechanisms 

remain unclear. One hypothesis is that the nervous system 

adopts a protective strategy during pain to reduce the risk 

for further pain/injury. This could be achieved by adopting 

a new strategy of muscle activation, or by increasing the 

gain of postural responses (i.e. the strategy reserved for 

higher load tasks is adopted at a lower load). This study 

investigated these possibilities in ten male volunteers. 

Electromyographic (EMG) activity of gluteus maximus 

and tensor fasciae latae were recorded with fine-wire and 

surface electrodes. Subjects stepped down from steps of 0, 

5, 15 and 30 cm onto a force plate, and down from a 5 cm 

step during trials in which pain was induced by electrical 

stimulation over the sacrum (7/10) trigger by foot contact 

on the force plate. An extra condition was completed that 

involved painful stimulus during 75% of trials and resulted 

in trials in which the pain was anticipated. EMG onset 

and amplitude were compared between conditions. Hip 

muscles were active in advance of foot contact. Stepping 

down from higher steps (15 and 30 cm) involved earlier 

and larger muscle activation. Hip muscle activity from a 

5 cm step during real or anticipated pain was identical to 

activity from a 15 cm step during the no pain condition. 

The findings suggest that changes in muscle response with 

pain are consistent with an increased gain of the postural 

response. Changes in activation with anticipation of pain 

exclude a direct effect of nociceptor activation. 

Motor control synergy between the hip and 

lumbopelvic region 

Hodges PW 


and Health, The University of Queensland, Brisbane. 

Function of the hip and spine are inextricably linked in 

terms of anatomy, biomechanics and motor control. This has 

relevance for physiotherapy from a number of perspectives. 

First, optimal function of the lumbar spine is dependent 

on the hip, and visa versa. Simple examples include the 

interaction between lumbopelvic motion and hip during 

gait to modulate stride length, and the complex interaction 

between lumbar and hip motion to shift the centre of mass 

to enable the complex challenge of performance of the hip 

flexion phase of a sit-up. Second, when the function of 

one region is compromised this has potential implications 

for the adjacent segment. For instance, hip osteoarthritis 

changes mechanical demand on the spine, impaired spinal 

proprioception is associated with increase risk of lower 

limb injury, and clinical arguments have been presented 

to link trunk control and abdominal muscle control with 

hip and groin conditions. Third, specific complex muscles 

have the capacity to concurrently affect spine and pelvis. 

One such poorly understood example is the psoas muscle, 

which has the capacity to flex the hip and flexor, extend or 

control the spine. The role of this muscle in coordination of 



hip and lumbar motion is only beginning to be understood 

due to the challenges associated with recording activity 

from the compartments of this muscle. On the basis of the 

importance of coordination between the hip and lumbar 

motion, clinical models have been presented that emphasise 

evaluation of this interaction for the management of hip and 

spine pain and injury. 

Incidence and risk factors for neck pain in Australian 

office workers: a one–year longitudinal study 

Hush J, 1 Michaleff Z, 2 Maher C, 2 Refshauge K 1 

1 

Back Pain Research Group, The University of Sydney, 2 The George 

Institute for International Health, The University of Sydney 

Neck pain is more prevalent in office workers than in the 

general community. To date, findings from prospective 

studies that investigated causal relationships between 

putative risk factors and the onset of neck pain in this 

population have been limited by high loss to follow-up. The 

aim of this exploratory study was to prospectively evaluate 

a range of risk factors for neck pain in office workers, 

using validated and reliable objective measures as well as 

attain an estimate of one year incidence. We assembled a 

cohort of 53 office workers without neck pain and measured 

individual, physical, workplace and psychological factors at 

baseline. We followed participants for one year to measure 

the incidence of neck pain. We achieved 100% participant 

follow-up. Cox regression analysis was used to examine 

the relationship between the putative risk factors and the 

cumulative incidence of neck pain. The one year incidence 

proportion of neck pain in Australian office workers was 

estimated in this study to be 0.49 (95% CI 0.36 to 0.62). 

Predictors of neck pain with moderate to large effect sizes 

were female gender (HR: 3.07; 95% CI 1.18 to 7.99) and 

high psychological stress (HR: 1.64; 95% CI 0.66 to 4.07). 

Protective factors included increased mobility of the cervical 

spine (HR: 0.44; 95% CI: 0.19 to 1.05) and frequent exercise 

(HR: 0.64; 95% CI 0.27 to 1.51). These results reveal that 

neck pain is common in Australian office workers and that 

there are risk factors that are potentially modifiable. 

22 

Pain assessment: patients’ views on Numerical 

Rating Scales 

Hush J, 1 Refshauge K, 1 Sullivan G, 1 De Souza L, 2 

McAuley J 1,3 

1 


Sydney, 2 School of Health Sciences and Social Care, Brunel University, 

Middlesex, England, 3 The George Institute for International Health, 


Elevenpoint Numerical Pain Scales are widely used as patient 

report outcome measures in clinics and by researchers. The 

aims of this study were (1) to examine the views of patients 

with back pain about 11point Numerical Rating Scales 

for pain and (2) to evaluate whether low scores on these 

scales indicate recovery. We used typical case sampling 

to recruit working adults, either recovered or unrecovered 

from an episode of non-specific low back pain. Thirty-six 

participants were interviewed in 8 focus groups. Participants’ 

views about the pain scales were explored and they were 

asked to rate themselves as recovered or unrecovered from 

back pain. Audio recordings were transcribed and data deidentified. 

Emergent themes were identified and framework 

analysis used to chart participants’ views. An interpretive 

analysis of the charts was performed to explain the findings. 

Descriptive statistics were used to analyse whether patients’ 

pain scores from Numerical Rating Scales aligned with 

their self-rated recovery status. Participants reported that 

uni-dimensional 11point Numerical Rating Scales were 

not adequate to capture their complex, multidimensional 

experiences of pain. We also found that the participants’ 

pain scores did not provide a clear indication of recovery 

status. Forty two percent of those who rated themselves 

as unrecovered had low (0–1) pain scores of ≤ 1. Eighteen 

percent of those who considered themselves recovered had 

pain scores of ≥ 2. This study provides empirical data that (1) 

patients with persisting back pain consider these commonly 

used Numerical Pain Rating scales largely inadequate and 

(2) that patients’ scores on these instruments may not be 

valid measures of recovery from back pain. 

Generic treatment is dead, long live specific treatment 

Jull GA 


The effect size gained in most clinical trials of interventions 

applied generically to a population of patients with mechanical 

neck pain, as the example, can be best described as modest. 

However such data present the overall response of the cohort. 

In most clinical trials, inspection of individual responses 

will reveal subjects with both excellent and poor responses. 

This suggests that there is little to gain in continuing to 

pursue generic ‘one size fits all’ interventions. There are 

indicators which suggest that investigating treatments more 

specific to the individual might better enhance outcomes. At 

the clinical level, it is readily evident that the generic label, 

‘mechanical neck pain’ encompasses a very heterogeneous 

population in terms of clinical presentation which does 

not support a generic approach to management. Research 

investigating features across the biological, psychological 

and social domains is revealing that changes in association 

with neck pain disorders can be complex but their presence, 

nature and extent are highly variable between individuals. 

Furthermore, research is only on the edge of informing 

about the interactions between these features, the nature 

of which is likely to moderate treatment responses. Not 

surprisingly, evidence is also accumulating that specific 

functional impairments respond better to a specific rather 

than a generic intervention. Specific treatment is the tenet of 

evidence based practice. It may be time to design a clinical 

trial which follows EBP principles and tests physiotherapy 

intervention by considering and integrating the features of 

the individual patient and clinical expertise with the best 

available evidence. 

How little pain and disability do patients with low back 

pain have to experience to feel they have recovered? 

Kamper SJ, 1 Maher CG, 1 Herbert RD 1 , Hancock MJ, 2 

Hush JM, 2 Smeets RJ 3 

1,2 

The George Institute, University of Sydney, Faculty of Health 

Sciences, University of Sydney, 3 Rehabilitation Foundation Limburg 

and Department of Rehabilitation Medicine, Caphri, Maastricht 

University, the Netherlands 

Epidemiological and clinical studies of people with low 

back pain commonly report on incidence of recovery as 

an outcome measure. The Numerical Rating Scale for 



pain intensity and Roland Morris Disability Questionnaire 

are two instruments commonly used chart symptomatic 

progress, and also to define recovery. There is no consensus, 

however, as to what cut-off scores on these two scales should 

be used to classify people as recovered. We used data from 

four clinical studies to determine which scores on the pain 

Numerical Rating Scale and Roland Morris Disability 

Questionnaire align best with patients’ perceptions of 

complete recovery from low back pain. Diagnostic odds 

ratios were calculated for candidate scores on the two scales 

to determine which scores performed best. Scores of 0 on 

the Numerical Rating Scale and ≤ 2 on the Roland Morris 

Disability Questionnaire most accurately identify patients 

who consider themselves completely recovered. The odds 

ratio for predicting recovery was 43.9 for a score of 0 on 

the Numerical Rating Scale and 17.6 for a score of ≤ 2 on 

the Roland Morris Disability Questionnaire. There was no 

apparent systematic effect of symptom duration or length 

of follow-up period on the optimal cut-off score. Odds 

ratios for the Numerical Rating Scale were generally higher 

than those for Roland Morris Disability Questionnaire, 

indicating that patients attend to pain more than disability 

when judging if they have recovered. 

The short term effect of taping, stretching and 

strengthening exercises prescribed separately or in 

combination for patients with patellofemoral pain 

Keays SL, 1,2, Mason M, 2 Newcombe PA 3 

1 

The University of the Sunshine Coast, 2 SippyDowns Private practice, 

Nambour, 3 The University of Queensland, Brisbane 

Quadriceps strengthening, quadriceps stretching and 

patellar taping are commonly prescribed for most subgroups 

of patellofemoral pain. This study aimed to examine the 

effectiveness of each of these techniques in isolation and in 

combination over a one-week period. A blind, controlled, 

randomised study was designed involving 46 patients 

with 60 knees diagnosed with patellofemoral pain. The 

knees were randomized into one of 4 groups (n = 15): 

Quadriceps (specifically vastus medialis) strengthening; 

quadriceps stretching; infra-patellar taping and control. 

The strengthening group followed an intensive program 

of non-weight-bearing quadriceps exercises, the stretching 

group followed a program of rectus femoris stretching. The 

infrapatellar taping was worn continually for the week. The 

control group received advice but no treatment. Pre and 

post-treatment measures included isokinetic quadriceps 

strength, quadriceps length measured in prone, pain 

measured during four activities, and maximum eccentric 

knee flexion angle during a step down. Results showed 

significant changes over time (p < 0.01) in six of seven 

activities for the stretching group, in five of seven in the 

strengthening group, in two of seven for the taping group 

and in none of the activities for the control group. When the 

three treatment methods were combined for one week (n = 

60) all seven measures improved significantly (p < 0.005). 

In isolation, quadriceps stretching resulted in improvements 

in more measures than other treatments. Combining these 

three generic treatments is recommended as the initial 

approach to treating patellofemoral pain but further specific/ 

individualized treatment for subgroups is essential. 

Measuring anterior tibial translation in anterior 

cruciate ligament deficient and healthy individuals 

during open and closed chain exercises 

Keays SL, 1,2, Sayers,M, 1 Mellifont D, 1 Richardson C 1 

1 

The University of the Sunshine Coast, 2 Sippy Downs Private Practice, 

Nambour 

It is well established that, in anterior cruciate ligament 

deficient patients, open chain exercises increase anterior 

tibial translation. Such exercises can lead to stretching or 

pull-out of the reconstructed graft post surgery and should 

initially be avoided. This study hypothesises that anterior 

tibial translation can occur during both open chain and 

closed chain exercises. Fifteen patients with chronic anterior 

cruciate deficiency and 15 healthy subjects matched for age, 

gender and sports history were assessed using an infra red 

tracking system. Markers were carefully positioned on the 

tibial tuberosity and the patella and the subjects performed 

the following therapeutic exercises initially without and then 

with quadriceps/hamstring co-contraction. Open chain: 

straight leg raising with the knee at zero degrees, leg raising 

with the knee flexed to 30 degrees, knee extension over a 

bolster (resisted and non-resisted). Closed chain: wall squat 

with the knees at 30 and 60 degrees of flexion and single leg 

squat to 30 and 60 degrees Analysis of variance was used to 

compare the amount of tibial translation occurring during 

the above therapeutic exercises in the injured and uninjured 

legs of anterior cruciate deficient subjects and in healthy 

individuals with and without hamstring co-contraction. 

This study provides important information regarding the 

choice of safe exercises that do not cause tibial translation 

or graft stretching post-operatively. It also clarifies the 

role of co-contraction during anterior cruciate ligament 

rehabilitation. 

Physical and radiological characteristics of patients 

with patellofemoral pain 

Keays SL, 1,2, Mason M 2 

1 

The University of the Sunshine Coast, 2 Sippy Downs Private Practice, 

Nambour 

Patients presenting with patellofemoral pain demonstrate a 

wide range of potentially causative physical variations in 

lower limb posture, in joint flexibility related to the hip, 

knee and ankle, in lower limb muscle strength and tightness 

and in patellofemoral radiology. Forty-six patients with 60 

knees diagnosed with patellofemoral pain were included 

in this study. Patients were excluded if they presented with 

anterior knee pain unrelated to the patella or if meniscal 

pathology was suspected. Inclusion criteria included pain 

with two of: stair descent, squatting, prolonged sitting, 

running or kneeling. Assessment included standing 

lower limb posture; muscle tightness of the quadriceps, 

hamstrings, iliotibial band and calf; quadriceps and 

hamstring muscle weakness/isokinetic performance and 

patellofemoral radiology. Standing lower limb posture 

was very variable ranging from normal alignment to genu 

valgus and genu varus. Rotational malalignment, most 

commonly involving hip internal rotation, was present in 

17% of patients. Muscle tightness was seen least frequently 

in the hamstrings, followed by calf muscle and the iliotibial 

band tightness. The most common deficits were quadriceps 

weakness/isokinetic performance and quadriceps tightness. 

It is unsure whether these features represented the cause 

or the consequence of patellofemoral pain. X-ray findings 



ranged from normal to varying degrees of lateralisation in 

18% of patients. Joint degeneration was present in 22% of 

patients ranging from mild to severe, occurring in patients 

younger than 40 years of age. Patellofemoral pain can 

be sub-grouped according to physical and radiological 

characteristics and treatment for each patient should be 

based on the individual presentation. 

24 

Implementation central: a dedicated web resource 

for stakeholders of evidence implementation and 

knowledge transfer 

Kumar S, Grimmer–Somers KG 

The Centre for Allied Health Evidence, University of South Australia, 

Adelaide 

With increased recognition for the importance of evidence 

based practice in health care, there have been a growing 

number of web resources dedicated to key processes 

underpinning evidence based practice. Much of these web 

resources nevertheless have focused on processes relating 

to accessing, assessing and synthesising evidence (such as 

Centre for Evidence Based Medicine) or providing access 

to synthesised evidence (such as The Cochrane Library). 

There has been a dearth of freely available, web resources 

targeted towards evidence implementation and utilisation 

in clinical practice. Recognising this gap, a dedicated web 

resource focused on evidence implementation has been 

developed. This web resource provides information about 

the science of implementation and emerging research 

underpinning evidence implementation and utilisation. It 

also provides various tools that can be used during evidence 

implementation into clinical setting. The web resource also 

contains lectures and podcasts on evidence implementation. 

There are opportunities for interaction via blogs where 

interested parties can discuss their perspectives on evidence 

implementation. The web resource also provides links to 

other similar resources across the world in order to improve 

accessibility of relevant materials. This freely available 

web resource acts as a ‘one stop shop’ and provides 

stakeholders of evidence implementation and knowledge 

transfer up-to-date information on theoretical and practical 

aspects of implementing evidence into clinical practice. 

With implementation of evidence into clinical practice 

gaining momentum, it is imperative such resources are 

developed, and made freely available, to support health care 

practitioners embrace evidence based practice. 

Implementing change in health care: a South 

Australian experience of guideline implementation for 

whiplash associated disorders 

Kumar S, Grimmer–Somers K 

The Centre for Allied Health Evidence, University of South Australia, 

Adelaide 

It is now widely recognised that all health care should be 

underpinned by safe, effective, timely, patient centred, 

efficient and equitable practices. Much of this drive 

has been championed by the Evidence Based Practice 

movement in health care which recognises the need for 

health care practices to be underpinned by an integration 

of research evidence, clinical expertise and patient values. 

While there is universal acknowledgment of the importance 

for evidence based practice, there are numerous examples 

of evidence–practice gaps in health care, where current 

practices are not aligned with best evidence. Whiplash 

associated disorders is one such example where despite 

high, recurring financial and health costs, physiotherapy 

and chiropractic management is not entirely evidence based. 

Recognising this evidence–practice gap, recommendations 

from a clinical guideline was chosen was implementation 

across practice in South Australia. Implementing change 

in clinical practice is a complex process, and the emerging 

science of evidence implementation highlights challenges 

and barriers in achieving change. This presentation will 

highlight evidence based processes which underpinned 

guideline implementation strategies and the key barriers 

and facilitators, as reported by stakeholders, in successful 

guideline implementation. Findings to date suggest that 

while physiotherapists and chiropractors recognise the 

importance of clinical guidelines, there are several barriers 

to guideline implementation. Broadly, these barriers can 

be categorised into professional, organisational, resource, 

consumers and research. Success and sustainability of 

implementation strategies will be dependent on effectively 

addressing these barriers, by targeted enabling initiatives, 

and facilitating behaviour and practice change. 

Effect of motor control retraining and general trunk 

strengthening on trunk muscle size after 60 days 

bed rest 

Lambrecht G, 1,2, Hides J, 3 Richardson C, 3 Damann V, 2 

Armbrecht G, 4 Pruett C, 4 Felsenberg D, 4 Belavy D 4 

1 

Krankengymnastikpraxis, Siegburg, Germany, 2 European Astronaut 

Centre, Linder Hoehe, Cologne, Germany, 3 The University of 

Queensland, Brisbane, 4 Zentrum für Muskel–und Knochenforschung, 

Charité Campus Benjamin Franklin, Berlin, Germany 

Bedrest is used by Space Agencies as a model to simulate the 

effects of the loss of axial gravitational loading experienced 

during spaceflight. Results of the first Berlin Bedrest study 

showed that prolonged bedrest resulted in atrophy of the 

multifidus muscle, but not the lumbar erector spinae and 

quadratus lumborum muscles. This pattern has also been 

documented in subjects with low back pain. The anterolateral 

abdominal, rectus abdominis and psoas muscles all increased 

in size over this time, and these changes were longstanding. 

For the second Berlin Bedrest study, subjects received 

rehabilitation after 60 days of bed rest in six degrees head 

down tilt. The aims of this study were to investigate, using 

MRI, the response of the trunk muscles to bedrest and to 

evaluate the effectiveness of two rehabilitation programs in 

restoring pre-bedrest muscle size and the balance between 

the anterior and posterior trunk muscles. Following bedrest, 

subjects showed localised atrophy of the multifidus and 

increased size of the psoas muscles. The two rehabilitation 

approaches delivered were specific motor control training 

and general trunk strengthening. Both programs were 

successful in restoring multifidus muscle size. However, for 

the psoas muscle, the general trunk strengthening program 

led to further increases in its already increased size, while 

specific motor control training restored the psoas muscle 

to its pre bedrest size. These results have implications for 

therapeutic exercise for people with low back pain, those 

who undergo prolonged bedrest for medical conditions and 

for astronauts following space travel. 



Anatomical diagnosis of low back pain 

Laslett M 

Auckland University of Technology, School of Rehabilitation & 

Occupation Studies, Health & Rehabilitation Research Centre, 


The identification of the anatomical source of low back 

pain is commonly regarded as impractical, unnecessary, 

too difficult or too invasive. Typically, the use of guided 

and controlled anaesthetic or provocation injection into the 

structures of the back are considered the reference standard 

diagnostic methods of choice. These are controversial, 

invasive, relatively expensive and cannot be justified for 

acute or subacute cases. Recently it has been shown that 

features of the patient history and clinical examination can 

predict the results of the reference standard procedures 

with clinically acceptable levels of diagnostic accuracy. 

The centralisation phenomenon is highly specific to pain 

provocation during hydraulic distension of the lumbar 

discs (provocation discography). Specificity is 100% in undistressed 

individuals and > 80% in the distressed). Three 

or more pain provocation sacroiliac stress tests in patients 

whose pain does not centralise have diagnostic accuracy 

of about 88% in relation to intra-articular blocks of the 

sacroiliac joints. The lumbar zygapophysial (facet) joints 

can be ruled out as a source of pain when the extension 

rotation test is painless (sensitivity 100%), but cannot be 

identified as a source of pain with current understanding. 

There is some evidence that disk herniation and lumbar 

spinal stenosis may be identifiable by an appropriate 

clinical examination but the evidence is of doubtful quality. 

Studies into the diagnostic accuracy of items from the 

patient history and clinical examination provide a fruitful 

future area for physiotherapy research, and are essential for 

the profession’s development as a primary care provider in 

musculoskeletal medicine. 

Clinical measurement of craniovertebral angle by 

electronic head posture instrument: a test of reliability 

and validity 

Lau MC, 1 Chiu TW, 1 Lam TH 2 

1 

Department of Rehabilitation Sciences, The Hong Kong Polytechnic 

University, Hong Kong, China, 2 Department of Community Medicine, 

The University of Hong Kong, Hong Kong, China 

The study was a cross-sectional reliability study with the 

objective of assessing the reliability and validity of the 

Electronic Head Posture Instrument (EHPI) in measuring 

the craniovertebral (CV) angle for subjects with or without 

neck pain. Twenty-six subjects (mean age = 36.88, SD ± 9.95) 

with chronic neck pain and 27 subjects (mean age = 31.85, 

SD + 7.63) without neck pain were recruited. The CV angle 

was measured by the EHPI which consists of an electronic 

angle finder, a transparent plastic base and a camera stand. 

Two therapists were recruited to assess the intra- and interrater 

reliability of the EHPI in two separate sessions of 

measurement. The difference in CV angle between the two 

groups was determined. The CV angle of the patient group 

(mean = 43.94, SD ± 3.61) was significantly smaller (p < 

0.001) than that of the normal group (mean = 50.58, SD 

± 2.09). Intra-rater (intra-class correlation coefficient (ICC) 

ranged from 0.86 to 0.94) and inter-rater (ICC ranged from 

0.85 to 0.91) reliability of the EHPI in measuring CV angle 

for both groups of subjects were high. In conclusion the 

EHPI was found to be reliable and valid in measuring the 

CV angle for subjects with or without neck pain. 

The effects of a three-week stretch program on 

hamstring muscle extensibility and stretch tolerance 

in patients with chronic musculoskeletal pain: a 

randomised controlled trial 

Law RYW, 1 Harvey LA, 2 Nicholas MK, 3 Tonkin L, 3 

De Sousa M, 3 Finniss DG 3 

1 

Royal North Shore Hospital, Sydney, 2 Rehabilitation Studies Unit, The 

University of Sydney 3 Pain Management and Research Institute, Royal 

North Shore Hospital, Sydney 

Stretch is commonly prescribed as part of physical 

rehabilitation in pain management programs, yet little 

is known of its effectiveness. A randomised controlled 

trial was conducted to investigate the effects of a threeweek 

stretch program on muscle extensibility and stretch 

tolerance in chronic pain patients. Thirty adults with 

musculoskeletal pain persisting for at least three months and 

limited hamstring muscle extensibility were recruited from 

patients enrolled in a multidisciplinary pain management 

program at a Sydney Hospital. A within-subject design was 

used, with one leg of each participant randomly allocated 

to an experimental (stretch) condition and the other to a 

control (no-stretch) condition. The hamstring muscles of 

the experimental leg were stretched daily for one minute 

over three weeks, whilst the control leg was not stretched. 

This intervention was embedded within a pain management 

program and supervised by physiotherapists. Primary 

outcomes were muscle extensibility and stretch tolerance, 

reflected by passive hip flexion angles produced with 

standardised and non-standardised torques respectively. 

Initial measures were taken before the first stretch on day 

one and final measures were taken one to two days after the 

last stretch. A blinded assessor was used for testing. Stretch 

did not increase muscle extensibility (mean between-group 

difference in hip flexion was 1 degree; 95% CI -2 to 4), but did 

improve stretch tolerance (mean between-group difference 

in hip flexion was 8 degrees; 95% CI 5 to 10). Three weeks 

of stretch increases tolerance to the discomfort associated 

with stretch but does not change muscle extensibility in 

patients with chronic pain. 

Physiotherapy interventions for non-specific low back 

pain: value for money? 

Lin CC, 1 Haas M, 2 van Tulder M, 3 Machado LAC, 1 

Maher CG 1 

1 


Sydney, 2 Centre for Health Economics Research Evaluation, University 

of Technology, Sydney, 3 EMGO Institute, VU University Medical 

Centre, Amsterdam, The Netherlands 

The aim of this systematic review was to evaluate the 

cost-effectiveness of physiotherapy interventions for nonspecific 

low back pain. Electronic databases and reference 

lists of included studies and relevant systematic reviews 

were searched for randomised controlled trials in which 

physiotherapy was the focus of at least one treatment group. 

Trials also had to include a full economic evaluation. Two 

independent reviewers screened search results and extracted 

data. Eighteen trials were included and most recruited 

participants with subacute or chronic low back pain. There 

was conflicting evidence of cost-effectiveness from the 

two trials that compared physiotherapy to surgery. There 

was some evidence that adding physiotherapy to general 

practitioner care or usual care may be cost-effective. For 

example, from the perspective of the health system, adding 

manipulation to general practitioner care was more effective 



than general practitioner care alone in improving qualityadjusted 

life-years (QALYs), yielding a mean incremental 

cost-effectiveness ratio of $12 550 (2008 Australian dollars) 

per QALYs gained. Three of the five trials comparing 

physiotherapy to usual care reported that physiotherapy was 

cost-effective. For example, advice, education and exercise, 

or acupuncture, were more effective and cheaper compared 

to usual care. When different physiotherapy interventions 

were compared (e.g manipulation versus exercise) or when 

physiotherapy was compared to another treatment (e.g pain 

management), there was generally no difference between 

treatment options in effects or costs. Our results suggest that 

physiotherapy may be cost-effective when added to general 

practitioner or usual care, or as a treatment alternative to 

usual care. 

26 

Aboriginal peoples’ beliefs about the management 

of chronic low back pain in remote and regional 

Australian settings 

Lin IB, 1,2 O’Sullivan PB, 2 Coffin JA, 1 Straker L, 2 Mak D, 3 

Toussaint S 4 

1 

Combined Universities Centre for Rural Health, Geraldton, 2 Curtin 

University of Technology, Perth, 3 Notre Dame University, Fremantle, 

4 


This qualitative study focused on the experiences of 

Aboriginal people living with chronic low back pain (CLBP). 

In-depth interviews were undertaken with 26 Aboriginal 

people with CLBP living in a regional country centre and 

two small remote towns. Interviews were conducted by a 

non-Indigenous principal investigator and male and female 

Indigenous co-investigators. A mix of theories influenced 

the analysis and interpretation. This presentation will 

explore one aspect of the study: how Aboriginal people 

managed their pain and, in particular, their experiences of 

local and distant health services. Health service experiences 

depended greatly on the individual characteristics of the 

health practitioner (doctors and physiotherapists) including 

their personality style, the quality of communication, and the 

relationship between health practitioner and the community. 

Financial concerns, direct and indirect experiences of 

racism in health services, and leaving remote regions in 

order to receive specialist care had negative impacts. Use 

of traditional remedies and bush medicines were common. 

Although most participants had seen a health practitioner 

for their pain, few of those who had tried exercises had 

done so under professional supervision or support. This 

paper suggests that optimising patient care in this context 

necessitates the delivery of culturally secure services that 

are acceptable and valued by Aboriginal men and women. 

These services should be delivered from a basis of trusting 

relationships. Likewise optimal care for CLBP requires the 

inclusion of strategies to address broader determinants of 

health such as social and geographical disadvantage as well 

as wide held community beliefs about back pain. 

Exploring chronic low back pain disability, and the 

beliefs of Aboriginal people and health practitioners in 

remote and regional Australian settings 

Lin IB, 1,2 O’Sullivan PB, 2 Coffin JA, 1 Straker L, 2 Mak D, 3 

Toussaint S 4 

1 

Combined Universities Centre for Rural Health, Geraldton, 2 Curtin 

University of Technology, Perth, 3 Notre Dame University, Fremantle, 

4 


Perceptions and beliefs are recognised as powerful 

influencing factors on chronic low back pain (CLBP) 

disability. This qualitative study explored CLBP disability 

and beliefs from the perspective of 26 Aboriginal people 

living in a regional country centre and two remote towns. 

This was contrasted with the beliefs of 11 health practitioners 

(doctors and physiotherapists) to gain an understanding of 

the same concepts from those who service these regions. 

In-depth interviews with Aboriginal participants were 

conducted by a non-Indigenous principal investigator and 

male and female Indigenous co-investigators. A mix of 

theories influenced the analysis and interpretation. For 

many Aboriginal people in this study, CLBP had profound 

individual, family and cultural impacts. Whilst health 

practitioners generally described a bio-psycho-social 

approach to CLBP, this contrasted with that of Aboriginal 

participants who had strong anatomical structural beliefs 

about the cause of their CLBP. Negative beliefs such as 

catastrophising were observed in those most disabled by 

CLBP. These beliefs were strongly influenced by what 

health practitioners had previously advised them, as well as 

advice given by people in their social surrounds. The study 

demonstrates that CLBP disability in Aboriginal people has 

a much greater cost in terms of cultural and community 

participation than previously reported. A mismatch in 

back pain beliefs between Aboriginal people and health 

practitioners suggests that in order to optimise management 

strategies, improvements in information exchange are 

required. Addressing CLBP beliefs in this context also 

needs strategies that address wider community knowledge 

and beliefs. 

Graded activity and graded exposure for persistent 

non-specific low back pain: a systematic review 

Macedo LG, 1 Smeets RJEM, 2 Maher CG, 1 McAuley JH, 1 

Latimer J 1 

1 


Sydney, 2 Rehabilitation Foundation Limburg, The Netherlands and 

Department of Rehabilitation Medicine, Caphri, Maastricht University, 


This study examined the effectiveness of graded activity 

and graded exposure for persistent low back pain. Electronic 

databases were searched. Pain, disability global perceived 

effect and work status were extracted and converted to a 

0–100 scale. Where possible, trials were pooled using 

Revman 5. Fifteen trials evaluating a total of 1398 patients 

were included. Six compared graded activity to a control 

group, five compared graded activity to another form of 

exercise, three compared graded activity to graded exposure 

and one compared graded exposure to waiting list. The 

pooling revealed no significant difference between graded 

activity and control for pain and disability at all time points 

except for disability at long term (weighted mean difference 

= -6.60, 95% confidence interval -11.77, -1.43). Perceived 

effect was better for graded activity versus control at 

short term (weighted mean difference = -7.52 points, 95% 



confidence interval -11.73, -3.32). One trial showed that 

patients receiving graded activity had an earlier return 

to work compared to a waiting list. Pooling also revealed 

no significant difference between graded activity and 

other forms of exercise for pain and disability at all time 

points. No difference was found between graded activity 

and graded exposure, but evidence was limited with results 

unable to be pooled. The results of one trial showed no 

difference between graded exposure and waiting list. Based 

on the reviewed studies there is some evidence that graded 

activity has a long term effect in disability and short term 

for perceived effect when compared to a control group. 

A systematic review of risk factors associated with low 

back pain in aged care workers 

Matulick TG, Boucaut RA, Mackintosh SF 


This systematic review aimed to identify the main 

psychological, physical and individual risk factors that are 

associated with low back pain in aged care workers and to 

assess the quality of the literature in this area. In November 

2008, using a systematic search strategy, ten databases 

were searched. Two reviewers applied the inclusion criteria 

to the 780 title and abstracts obtained in the search. Fulltext 

articles were obtained for relevant studies and the 

inclusion criteria re-applied. Two reviewers appraised the 

one prospective and six cross-sectional articles included 

using a checklist adapted from the National Health and 

Medical Research Council. The main areas for potential 

bias in the studies were recall bias, the healthy worker 

effect, low response rates, small sample sizes, mixed 

samples and not controlling for confounding variables. 

Results were not able to be pooled for meta-analysis due to 

the range of variable and statistics reported. Psychological 

factors (low decision authority, dissatisfaction with job) 

and physical factors (high work demands, transferring 

patients) were consistently associated with the presence of 

low back pain. No single factor appeared to greatly increase 

the likelihood of low back pain. Individual factors such as 

increasing age and more years working in aged care were 

also consistently associated with the presence of low back 

pain. To strengthen the evidence base, there is a need for 

larger sample, prospective studies using cohorts of a single 

occupation. 

Sleep problems are common and sleep quality is poor 

in non-specific LBP: a systematic review 

of the literature 

McAuley JH, 1,2 Spence L 1 

1 

The George Institute for International Health, Sydney 2 The Faculty of 

Health Sciences, the University of Sydney, NSW 

This aim of this study was to determine the prevalence 

of sleep disorders and problems for patients with nonspecific 

low back pain (NSLBP). A secondary aim was to 

determine whether sleep problems are associated with pain 

and/or disability. A systematic review of the literature was 

conducted using the MEDLINE, CINHAL, EBM Reviews 

and Web of Science. A study was included in the review if 

it assessed sleep disorders, sleep prevalence or sleep quality 

in patients with adults (> 18 yrs) with non-specific low back 

pain. The quality of included studies was determined by the 

prevalence quality criteria. The search strategy identified 

2940 studies, of which 24 matched inclusion and exclusion 

criteria. One study reported the prevalence of a sleep 

disorder in chronic NSLBP (53% of patients with chronic 

NSLBP had insomnia). The prevalence of sleep problems 

was reported in five studies and ranged from 39–82%. 

Sleep quality was reported in 14 studies and ranged from 

28–68/100. One study reported that insomnia and pain 

intensity were positively correlated, while another found a 

sleep quality and disability were correlated, but not pain 

intensity. The prevalence of sleep disorders in people 

with NSLBP is largely unknown. Sleep problems appear 

to be common, and sleep quality is typically poor. There 

is inconclusive evidence on whether sleep problems are 

associated with higher levels of pain or disability. 

The difficult knee 

McConnell J 

Private practitioner, NSW 

Identifying why a particular patient’s knee problem is 

more difficult to treat is a challenge facing all clinicians. 

A thorough assessment is the key to unravelling the issues, 

remembering too that pain (and its chronicity) affects 

individuals quite differently. This paper will cover the factors 

contributing to patellofemoral pain. Proximally, femoral 

anteversion or internal femoral rotation affects the position 

of the trochlea relative to the patella. Internal femoral 

rotation is associated with poor posterior gluteus medius 

activation, affecting the stability of the pelvis. Improving 

hip extension and external rotation mobility as well as 

gluteal control in weight bearing by simulating the stance 

phase of gait, can significantly improve the symptoms of 

many ‘difficult’ knees. Distally, pronation problems of the 

foot – too much, too long or too late, can cause an increase 

in the dynamic valgus vector force on the patellofemoral 

joint. Orthotics may be used to help foot control. Clinically, 

comfort is the most important and relevant feature when 

prescribing foot orthoses. Locally, tightness of the lateral 

retinacular structures and the iliotibial band as well as 

delayed onset of the VMO relative to the VL can cause 

pressure distribution variations of the patella on the femur. 

Fat pad irritation will also be discussed as a potent source 

of patellofemoral symptoms. 

Knee flexion precedes initial contact in normal walking 

McKenzie D ¹ , Lythgo N 1 , Baker R 2 

¹Rehabilitation Sciences Research Centre, The University of Melbourne, 

2 

Melbourne Royal Children’s Hospital, Melbourne 

The primary of this study was to examine the onset and 

amount of knee flexion before initial contact in human gait. 

A secondary aim was to determine the effect of walking 

speed on these measures. Sixteen healthy, young adults 

participated in this study. A Vicon 3-dimensional Motion 

System (Oxford Metrics Ltd., Oxford, England) and Force 

Plates (Advanced Medical Technology Incorporated) were 

used to record kinematic and kinetic data from a total of 

216 walking trials at each of three self-selected speeds: 

preferred; slow and fast. Data extracted were the timing 

of the onset of knee flexion prior to initial contact and the 

amount of knee flexion from the point of maximum knee 

extension (prior to initial contact) to initial contact. At the 

preferred speed, the knee was found to flex 1.9 degrees 

over the final 2.8% of the gait cycle. Confidence intervals 



showed the onset of knee flexion occurred prior to initial 

contact in all three speed conditions. Non-parametric tests 

showed significant differences (p < 0.001) in the timing of 

onset and amount of knee flexion prior to initial contact for 

each speed condition. The results support the hypothesis 

that knee flexion commences prior to initial contact in 

human walking. The amount and duration of flexion are 

directly related to walking speed. These findings suggest 

that a motor control strategy is implemented where the knee 

flexes in anticipation of initial contact. This phenomenon 

requires further investigation especially in pathological 

populations. 

28 

Differential atrophy in the anterior hip musculature 

during prolonged bed rest and the effect of exercise 

countermeasures 

Mendis MD, 1 Belavy DL, 2 Miokovic T, 2 Felsenberg D, 2 

Hides JA 1 

1 

The University of Queensland, School of Health & Rehabilitation 

Sciences, Brisbane, 2 Zentrum für Muskel-und Knochenforschung, 

Charité Campus Benjamin Franklin, Berlin, Germany 

Prolonged bed rest and inactivity is known to cause 

differential muscular atrophy which can lead to muscle 

imbalances and abnormal loading at joints. The anterior 

muscles of the hip joint are important in its function and 

stability, however, little is known about the effects of 

prolonged inactivity on these muscles. The aim of this 

study was to examine changes in individual hip flexor 

muscle size during prolonged bed rest and to investigate the 

effectiveness of resistive exercise alone and resistive exercise 

plus vibration as counter-measures. Twenty-four healthy 

men underwent 60 days of 6° head-down tilt bed rest in the 

2 nd Berlin Bed Rest Study. Subjects were randomly allocated 

to a control group (n = 9), a resistance exercise only group 

(n = 8) and a resistance exercise plus vibration group (n 

= 7). Magnetic resonance imaging of the hip region was 

conducted prior to bed rest, mid bed rest and end of bed rest 

and muscle size calculated from the images for the iliacus, 

psoas, iliopsoas, sartorius, rectus femoris and tensor fascia 

latae muscles. During bed rest, the rectus femoris (p = 0.04) 

and iliopsoas muscles (p < 0.001) atrophied in the control 

group but not in the exercise groups. Significant increases 

in size of the iliacus, psoas, and tensor fascia latae muscles 

(all p < 0.05) were evident in both exercise groups while 

resistance only exercise increased sartorius muscle size (p = 

0.03). Differential atrophy of the hip flexor muscles occurs 

with prolonged inactivity and can be prevented by exercise 

counter measures. 

Design of a randomised clinical trial of a combined 

exercise treatment for chronic whiplash 

Michaleff Z, 1 Sterling M, 2,3 Jull G, 3 Latimer J, 1 

Connelly L, 2 Lin C, 1 Rebbeck T, 4 Maher C 1 

1 


Sydney, 2 Centre for National Research on Disability and Rehabilitation 

Medicine (CONROD), The University of Queensland, 3 NHMRC CCRE: 

Spinal Pain, Injury and Health, The University of Queensland, 4 Faculty 

of Health Sciences, The University of Sydney 

Whiplash is the most common injury following a motor 

vehicle accident. Approximately 60% of people suffer 

persisting pain and disability six months post injury. Two 

forms of exercise, specific motor relearning exercises and 

graded activity, have been found to be effective treatments 

for this condition. Unfortunately the effect sizes for either 

exercise program were modest, however pilot data has 

demonstrated much larger effects in terms of pain and 

disability when these two treatments are combined. The 

aim of this study is to investigate the effectiveness and 

cost effectiveness of this combined exercise approach for 

chronic whiplash. A multi-centre randomised control trial 

will be conducted. One hundred and seventy-six voluntary 

participants with chronic grade I to II whiplash will be 

recruited from Sydney and Brisbane sites. All participants 

will receive an educational booklet on whiplash and in 

addition, those randomised to the exercise group will 

receive 20 progressive and individually tailored, 1-hour 

exercise sessions over a 10-week period (specific motor 

relearning exercises: 8 sessions over 4 weeks; graded 

activity: 12 sessions over 6 weeks). Pain intensity is the 

primary outcome being assessed; other outcomes include 

disability, quality of life and health service utilisation. 

Outcomes will be measured at baseline, 3 months, 6 months 

and 12 months. Recruitment is due to commence mid 2009. 

The outcomes of this trial will potentially present a simple 

and cost effective treatment option in the management of 

chronic whiplash. 

Clinical reasoning in musculoskeletal physiotherapy: 

the identification and accuracy of pattern recognition 

Miller PA, 1 Rivett DA, 1 Isles R 2 

1 

The University of Newcastle, Newcastle, 2 The University of 


Pattern recognition is theoretically an efficient and accurate 

clinical reasoning strategy, however its use in physiotherapy 

has not been well established and its purported benefits 

lack evidence. The aim of this study was to identify pattern 

recognition in musculoskeletal physiotherapy using high 

fidelity case methods and investigate its relationship with 

accuracy and efficiency. A single case study involving a 

real clinical case with a diagnosis of high grade lumbar 

spondylolisthesis was simulated using a trained actor and 

utilised with multiple participants. An expert group (n = 

10) and a novice group (n = 9) were included to explore 

the theoretical assumption that pattern recognition is an 

experience-based reasoning process. A videorecording of 

the participant taking a history from the simulated patient 

formed observation study data and was used as the stimulus 

for an immediate retrospective recall participant interview. 

Mixed method analysis used a quantitative pattern 

recognition identification tool applied to the qualitative data 

sources. The use of pattern recognition was identified in 4 

experts and 1 novice. Pattern recognition was found to be 

significantly more likely to produce an accurate diagnosis 

than hypothetico-deductive reasoning strategies (p = 0.01). 

However its use was not a guarantee of immediate success 

with only 3 of the 4 experts using pattern recognition 

nominating the correct diagnosis. The results confirm the 

use of pattern recognition in musculoskeletal physiotherapy 

and support a relationship between pattern recognition 

and diagnostic accuracy. Although early diagnosis likely 

promotes clinical efficiency, analysis of efficiency was 

limited by the study design which only included the 

history 



Importance of fear-avoidance belief questionnaire in 

non-specific chronic low back pain: a case review 

Nair MR, 1 Nagarajan M 2 

1 

Muller Medical College, Mangalore, India, 2 INTI University College, 

Laureate International Universities Nilai, Malaysia 

A fear avoidance belief questionnaire is widely used to 

discover the patient beliefs about how physical activity 

and work affect back pain. Also it has moderate to good 

correlation with disability recovery rate. The aim of this 

case review is to describe the role of fear avoidance belief 

questionnaire during examination and management of 

chronic non-specific low back pain. A 24 year-old female 

was referred for physiotherapy with a chronic history of 

low back pain. Thorough musculoskeletal examination was 

undertaken with Oswestry Disability Questionnaire and 

fear avoidance belief questionnaire as outcome measures. 

Subjective examination showed strong positive signs of 

psychological illness and there were no red signs. Physical 

examination showed painful guarded movement patterns 

in the lumbo-pelvic region, which made it difficult to 

indicate specific examination. Based on current findings 

and ongoing clinical reasoning, the patient was educated in 

terms of cognitive reconstruction regarding the nature of 

her low back pain and its relation with present disabilities. 

After cognitive reconstruction we requested her to perform 

functional activities. Interestingly, she was able to achieve 

smooth movement patterns in the spine, with minimal 

abnormalities. Following this, we were able to progress 

with further specific physical examination involving muscle 

power test, spine accessory movements and motor control 

tests without the help of further radiological evaluation. 

The patient was treated using a specific biopsychosocial 

approach. There were positive results for considering a 

fear avoidance belief questionnaire as a useful and highly 

economical diagnostic tool for evaluation and management 

of low back pain patients. 

Lower extremity hyperalgesia and allodynia: a case 

review for evidence based pain diagnosis 

Nagarajan M 

INTI University College, Laureate International Universities, Nilai, 

Malaysia 

The clinical presentation of pain may be influenced by 

multiple etiological factors. It is a clinician’s most important 

responsibility to determine the underlying causes of the 

patient’s symptoms with differential assessment based on 

sound multidimensional clinical reasoning. The aim of this 

case review is to describe evidence based pain diagnosis 

of the patient present with lower quarter hyperalgesia 

and allodynia. A 42-year old female was referred for 

physiotherapy with severe low back pain with progressive 

burning sensation in the left lower limb and left waist 

since three months. She had a past history of cervical spine 

myelomalacia (central cord syndrome) and right parital 

lobe epilepsy. During routine musculoskeletal evaluation, 

we found Grade I spondylolythesis at L5–S1 level, mild 

type II complex regional pain syndrome. Together with 

these findings the central cord syndrome and parital lobe 

epilepsy were considered as the major factors for developing 

the pain. She was found positive for psychosocial illness, 

which may also influence the pain. Based on the available 

evidence towards various models and classification of pain, 

the possible mechanisms for present ongoing pain were 

identified. The evidence for diagnostic options is reviewed. 

Sound clinical reasoning gave us a good explanation 

about the underlying causes of pain and helped us to 

concurrently think about prognosis with current medical 

management. Accordingly rehabilitative measures were 

tailored, considering a bio-psychosocial approach. This 

case reminded us that, the mechanism based pain diagnosis 

plays a major role in a broad understanding of pain, in order 

to effectively manage the clinical presentation of pain in 

musculoskeletal physiotherapy practice. 

Recipe for clinical practice: evidence, organisational 

constraint, patient preference, and a pinch of 

clinician bias 

Naylor JM, 1,2 Greenfield D, 2 Corbett A 2,3 

1 

Whitlam Orthopaedic Research Centre, Sydney, 2 The University of 

NSW, Sydney, 3 University of Technology, Sydney 

This study aimed to profile the evidentiary and nonevidentiary 

factors shaping physiotherapy service 

delivery for knee and hip replacement. Phase 1 involved a 

systematic literature search for Level 1 evidence (systematic 

reviews) for physiotherapy across all stages of the care 

continuum. Phase 2 audited physiotherapy services for joint 

replacement surgery across 10 hospitals via questionnaire, 

site visits and interviews. Phase 1: systematic reviews were 

available for 5 (pre-operative education, pre-operative 

physiotherapy, continuous passive motion, rehabilitation 

after knee replacement, and outcome assessment tools) 

of 10 practices identified. With the exception of the use 

of assessment tools, routine provision of such services 

was not supported. Qualified support for pre-operative 

physiotherapy (hip) and continuous passive motion (knee) 

was provided. In all reviews, considerable evidence-gaps 

were identified, indicating that for these interventions and 

processes, uncertainty persists in relation to their value. 

Phase 2: nineteen senior clinicians and service managers 

participated in the audit. Care delivery was provincial, with 

local clinician, organisational and patient factors such as 

clinician-bias, limited resources and patient willingness to 

access services, identified as strong drivers of care. These 

factors both necessarily and unnecessarily hindered the 

uptake of evidence and contributed to practice variation 

and consistency between providers. The study demonstrates 

high-level evidence is but one ingredient determining the 

care served to consumers. If clinical practice guidelines are 

to be useful in promoting consistent, high standard care, 

all the elements shaping practice need to be considered. 

Proactive strategies for addressing local organisational and 

cultural constraints will need to be developed. 

Impact of order of movement on nerve strain and 

longitudinal excursion: an anatomical study with 

implications for neurodynamic test sequencing 

Nee RJ, 1 Yang CH, 2 Liang CC, 3 Tseng GF, 3 Coppieters 

MW 1 

1 

The University of Queensland, St. Lucia, 2 Tzu Chi College of 

Technology, Hualien, Taiwan, 3 Tzu Chi University, Hualien, Taiwan 

Neurodynamic test accuracy can theoretically be increased 

if the test sequence starts with joint movements closest to 

the site of nerve injury. The main movements of a median 

nerve biased neurodynamic test (shoulder abduction, 

elbow extension, and wrist extension) were performed in 

3 different sequences on 7 fresh-frozen human cadavers. 



Strain and longitudinal excursion were measured in the 

median nerve at the distal forearm after each movement of 

each sequence. Strain (p = 0.07) and relative position (p = 

0.06) of the nerve at the end of a test did not differ between 

sequences. These non-significant results seem valid because 

less than half of the cadavers exhibited differences between 

sequences that exceeded measurement error (0.54% for 

strain; 1.7 mm for relative position). The nerve was subjected 

to higher levels of strain for a longer duration during the 

sequence where wrist extension occurred first (p < 0.005). 

The pattern of excursion during a test depended upon the 

order of movement (p < 0.001). The results highlight that 

neurodynamic test sequence does not affect strain or relative 

position of the nerve at the end of a test when joints are 

moved through comparable ranges of motion. If different 

neurodynamic test sequences produce clinically important 

changes in test response, the changes may be explained 

by potential differences between sequences in ranges of 

motion, durations of exposure to higher levels of nerve 

strain, or patterns of longitudinal excursion of the nerve. 

30 

Lumbar mobilisation skill acquisition and retention 

using objective real-time feedback on three force 

parameters 

Odelli RA, Snodgrass SJ 


Objective quantification of skill acquisition and feedback 

during manual therapy training can contribute to teaching 

methods, potentially leading to more effective practitioners. 

This study aimed to determine the amount of practise with 

objective real-time feedback needed for acquisition and 

retention of lumbar mobilisation skills in terms of applied 

force parameters: mean peak force, force amplitude and 

oscillation frequency. Thirty physiotherapy students 

applied 4 grades of L3 posteroanterior mobilisation (in 

pairs) while receiving real-time feedback, measured by an 

instrumented treatment table and displayed via computer 

screen. Force targets were determined using data from 

an expert physiotherapist who mobilised all participants. 

Students’ performance was tested before and after 3 

practise sessions with real-time feedback, with follow-up 

1 week and 3 months later. Improved performance was 

a smaller difference between student and expert applied 

force parameters, comparing performances using Wilcoxon 

signed ranks. For mean peak force, students improved at 

each practise session (pre-test median difference between 

student and expert, session one 17.5 N, two 14.4, and three 

10.8; post-test median differences 7.7, 8.2 and 7.0, p < 0.001 

for all pre-to post-test comparisons). Student retention 

increased at subsequent practise sessions (pre-test session 2 

compared with 3, p = 0.003), with similar patterns observed 

for force amplitude and oscillation frequency. Retention at 

follow-up was minimal (no difference between initial pretest 

and follow-up performances, all force parameters, p 

≥ 0.41). Thus, real-time objective feedback is effective in 

improving short-term performance. However, a lack of skill 

retention suggests that ongoing practice with feedback is 

required. 

How reliable are physiotherapists’ observations of 

scapular orientation? 

O’Leary S, Lund M, Ytre-Hauge TJ, Holm SR, Naess K, 

Dalland LN, Jull G 

CCRE Spinal Pain, Injury and Health, Division of Physiotherapy, 


The judgement of scapular orientation is an integral 

component of the clinical assessment of patients with 

shoulder girdle and cervical spine disorders. The purpose 

of this study was to assess the inter-tester reliability of 

observational judgements of scapular orientation in multiple 

planes at rest, and during isometric loaded upper limb 

activities. Fifteen asymptomatic volunteers participated in 

the study. Judgements of scapular orientation were made 

by 5 physiotherapists during 4 standardised upper limb 

conditions; rest, isometric flexion, isometric abduction, 

isometric external rotation. Judgements of scapular 

orientation were made in the sagittal (anterior/posterior 

tilt), scapular (upward/downward rotation), and transverse 

(internal/external rotation) rotational planes, as well for 

superoinferior (elevation/depression) and medio-lateral 

(protraction/retraction) translational planes. Inter-tester 

reliability was expressed by percentage agreement between 

observers and by a reliability coefficient (Krippendorff 

alpha). The inter-tester agreement ranged from slight-fair 

(elevation/depression: alpha = 0.1–0.3, 84–88% agreement), 

slight-moderate (protraction/retraction: alpha = 0.1–0.5, 93– 

97% agreement), fair-moderate (upward/downward rotation: 

alpha = 0.3–0.5, 81–90% agreement), moderate (internal/ 

external rotation: alpha = 0.4–0.5, 83–89% agreement) 

and moderate-substantial (anterior/posterior tilt: alpha = 

0.5–0.7, 87–91% agreement). The results suggest that while 

observational judgements of scapular orientation during 

standardised isometric upper limb tasks may be a useful 

clinical tool, findings from them should be interpreted with 

caution and in combination with findings of other clinical 

tests when formulating decisions regarding an individual’s 

scapular kinematics. 

Altered behaviour of the trapezius muscle in 

chronic neck pain 

O’Leary S, Belousova E, Jull G, Johnson V 

CCRE Spinal Pain, Injury and Health, Division of Physiotherapy, 


Alterations in the function of the axio-scapular muscles 

are considered to be a feature of some chronic neck pain 

disorders. This study compared the behaviour of the 3 

portions of the trapezius muscle in patients with and without 

chronic mechanical neck pain when performing standardised 

isometric tasks of the shoulder girdle. Eighteen volunteers 

with chronic mechanical neck pain and 20 healthy controls 

participated in the study. Unilateral electromyography signals 

were recorded from the upper, middle, and lower portions 

of the trapezius muscle as participants performed isometric 

shoulder abduction, external rotation, and flexion, at three 

intensities of effort (maximal voluntary contraction, 50%, 

and 20%, maximal voluntary contraction). Significantly 

greater levels of lower trapezius muscle activity were 

observed in patients with mechanical neck pain compared 

to controls for the abduction (p < 0.03) and external rotation 

(p < 0.04) conditions, but not for the flexion condition (p 

> 0.39). No differences in activity were observed in the 

upper (p > 0.25) or middle (p > 0.05) portions of trapezius 



between groups during any of the isometric shoulder girdle 

conditions. These findings of altered lower trapezius muscle 

behaviour in individuals with chronic neck pain provides 

some evidence for the involvement of altered axio-scapular 

muscle function in some chronic neck pain disorders. 

How does health locus of control correlate with 

estimates of sufficiently important differences in 

outcome of low back pain? 

Oliveira V, 2 Ferreira,P 1 Ferreira M, 2 Pinto R, 2 Oliveira W, 2 

Dias R, 2 Tiburcio L 2 

1 


Gerais, Belo Horizonte, Brazil 

Previous research has attempted to determine estimates of 

clinical importance of effect sizes derived from randomised 

clinical trials and systematic reviews in back pain. However, 

when recipients of care are involved in deciding what this 

estimate should be, patients’ psychosocial characteristics 

should be considered. The aim of this study was to 

investigate the association between health locus of control 

and sufficiently important differences in outcomes for 

two recommended interventions (motor control exercise 

and manual therapy) in individuals with non-specific low 

back pain. Eighty-six patients were included in the study. 

Patients’ health locus of control was measured with the 

multidimensional health locus of control questionnaire. 

Clinical significance was measured in terms of sufficiently 

important differences in outcome and was estimated using a 

standardised script. Multiple linear regressions were used to 

predict the minimal worthwhile effect based on predictive 

factors. For each one of the two interventions (motor control 

exercise and manual therapy), explanatory variables included 

in the model were: internal health locus of control, external 

health locus of control, chance health locus of control and 

severity of the symptoms in the past 7 days. External health 

locus of control was shown to be significantly associated 

with estimates of sufficiently important differences in 

outcomes for motor control exercise (β = 0.74, p = 0.03), 

but not manual therapy (β = 0.41, p = 0.34). These results 

suggest that the more externalised patients’ beliefs about 

back pain management are, the larger the estimates for 

sufficiently important differences in outcomes for motor 

control exercises. 

Confirmatory examination of the deep craniovertebral 

ligaments using high resolution MRI 

Osmotherly PG, 1 Rivett DA, 1 Cowin G, 2 Mercer SR 2 

1 

The University of Newcastle, Newcastle, 2 The University of 


Descriptions of the radiological anatomy of craniovertebral 

ligaments using MRI have lacked detail. Both radiological 

and clinical assessment, including manual testing, is limited 

by inadequate structural understanding. MRI images of the 

craniovertebral segments of 6 embalmed adult cadavers 

were acquired using a 4.6T scanner. Imaging of specimens 

was repeated at clinical definition (3T). Findings of each 

examination were confirmed through fine dissection. Data 

collected included detailed descriptions of the structure 

and attachments sites of each ligament. Morphometric 

measurements included length and cross-sectional area. 

Orientation and included angle of alar ligaments were 

measured. The imaged structure of each ligament could 

be consistently described. Alar ligaments inserted into the 

superolateral aspect of the dens and the clivus. Bands of 

fibres were visualised anteriorly, spanning the dens without 

attaching to it. Inferior fibres blended with the medial 

portion of the lateral atlantoaxial joints. No separate ‘atlantal 

portion’ of the alar ligament was visualised in any specimen. 

Cross-sectional shape of alar ligaments varied from round 

medially to ovoid laterally as each ligament tapered toward 

its insertion. Orientation of the alar ligaments with respect 

to the dens was horizontal in 5, caudal in 4 and cephalad in 3 

ligaments. Horizontally, ligaments were oriented anteriorly 

with mean included angle of 129°. Tectorial membranes 

were discerned in the sagittal plane. Below the level of 

the transverse ligament, 2 distinct layers of the tectorial 

membrane were evident. A more thorough understanding of 

these structures may provide another step in the validation 

process of clinical assessment of these ligaments. 

The composite neck pain and disability questionnaire; 

development and factor structure 

Osmotherly PG, Attia JR, McElduff P 

The University of Newcastle 

Questionnaires developed to estimate pain and disability 

in the neck pain population have been shown to measure 

differing aspects of the neck pain experience, suggesting 

that they do not all provide the same information to the 

clinician or researcher. The aim of this study was to compile 

an easily completed instrument that is a composite of 

psychometrically stable questions representing the majority 

of domains of interest contained in existing neck pain and 

disability measurement instruments. Four questionnaires; 

Neck Disability Index, Neck Pain and Disability Scale, 

Northwick Park Neck Pain Questionnaire and Copenhagen 

Neck Functional Disability Scale were completed by 88 

people with mechanical neck pain. All responses were 

pooled and analysed using principle components factor 

analysis with a Promax rotation. Factors with Eigenvalues 

> 1 were retained. Subscale performance was improved 

through item reduction using item-total correlation and by 

maximising Chronbach α for each factor. A discrimination 

index was calculated for each remaining item. At the 

conclusion of this process, a composite set of items remained 

comprising 6 distinct factors. Factors were interpreted 

as pertaining to social functioning, sleep disturbance, 

concentration, physical work restriction and pain intensity. 

Items comprising the sixth factor assumed 2 distinct clusters 

relating to interference with activities of daily living and the 

emotional and psychosocial impact of neck pain and related 

disability. This scale reflects the multidimensional nature 

of cervical spine disorders and permits the examination of 

specific domains within the neck pain experience and the 

effect of interventions upon them. 

Slump sitting is associated with adolescent back pain 

provoked by sitting: what factors should we target for 

change? 

O’Sullivan PB, 1,2 Smith A,J 1,2 Beales DJ, 1 Straker LM 1,2 

1 


2 

Telethon Institute for Child Health Research, Perth 

Conflicting evidence exists regarding the relationship 

between sitting posture and back pain. This may be due to 

multiple individual factors that can influence sitting posture. 

The purpose of this study was firstly to determine if slumped 



sitting posture was associated with back pain provoked by 

sitting in adolescents, and second to evaluate the association 

of various physical, lifestyle, gender, psychosocial factors 

with slump sitting posture. Adolescents (n = 1596) completed 

questionnaires to determine the prevalence of back pain as 

well as lifestyle and psychosocial profiles. Sitting posture, 

body mass index and back muscle endurance were recorded. 

Standing posture sub-group categorisation was determined. 

Slump sitting posture significantly increased the odds of 

experiencing back pain provoked by sitting (Odds Ratio 

1.18 (1.01–1.35), p = 0.019), but not of the more generalised 

complaints of back pain ever or during the last month. With 

multivariate analysis the most significant factor associated 

with slump sitting posture was male gender, followed 

by non-neutral standing postures, lower perceived selfefficacy, 

lower back muscle endurance, greater TV use and 

higher body mass index. This study confirmed that slump 

sitting posture was specifically associated with adolescent 

back pain provoked by sitting. Slump sitting was not only 

associated with physical correlates, but also with gender as 

well as lifestyle and psychosocial factors. This highlights 

the complex and multidimensional nature of sitting posture 

in adolescents. Recognition of all these factors may be 

important for interventions aimed at changing sitting 

posture. 

32 

Chronic low back pain management 

O’Sullivan P 


Only a small percentage of lumbo-pelvic pain disorders 

have an identified patho-anatomical diagnosis, leaving 

a diagnostic vacuum. It is now widely accepted that 

these disorders are multi-factorial in nature. However the 

presence and dominance of the patho-anatomical, physical, 

neuro-physiological, psychological and social factors that 

can influence the disorder is different for each individual. 

Current evidence for physiotherapy treatment approaches 

in non-specific chronic low back pain (NSCLBP) patients 

is limited. Manual therapy, exercise therapy and cognitive 

behavioural therapy have similar marginal effects on 

NSCLBP. This knowledge leads us to a management 

dilemma and questions current approaches. Classification 

of NSCLBP pain disorders and identification of sub-groups, 

based on the mechanism/s underlying the disorder allows 

for targeted management. There is growing evidence that 

NSCLBP disorders can be reliably sub-grouped, based 

on physical, neurophysiological and psycho-social factors 

that drive the disorders. A classification model has been 

proposed, has been shown to be reliable and valid in 

localised NSCLBP disorders. Growing evidence supports 

that classification based management where the aim is to 

modify movement and cognitive behaviours (cognitive 

functional therapy) is effective in the long term management 

of these disorders. Cases will be presented to demonstrate 

the utility of this model. 

Outcomes of a clinical pathway for fractured ankles 

Page CJ, Brock KA, Black SJ 

St Vincent’s Hospital, Melbourne 

The purpose of this project was to develop a care plan 

to optimise physiotherapy management of fractured 

ankles. In this study, we investigated the utilisation of the 

pathway by therapists, including compliance with objective 

measurement and adherence to recommended management, 

and the association of resource utilisation with severity 

of ankle functional deficit. The study also aimed to 

identify the usual course of recovery for patients treated 

in accordance with the pathway for both conservative and 

surgically managed groups. Pathways were completed for 

63 consecutive patients over a 2-year period. Compliance 

in documenting key items of assessment on the pathway 

ranged between 52% and 91%. The ankle lunge test in the 

first three weeks achieved the highest compliance (> 90%). 

Adherence to recommended interventions was above 60% 

for most recommendations. The number of weeks attending 

physiotherapy had a mean of 6.6 (SD 3.3). There was a 

significant correlation between dorsi flexion at week 1 and 

week of discharge (r = 0.44, p > 0.01), with those having 

poor ankle lunge results more likely to have prolonged 

treatment. The surgically treated group had a significantly 

poorer lunge at week 1 (p < 0.01), continued to make a 

slower recovery at week 3 (p < 0.001) and overall had a 

significantly longer period of physiotherapy. This study 

has shown that a structured clinical pathway for patient’s 

post fractured ankles is an effective and efficient way to 

collect data on this population and has the capacity to detect 

patients that fail to progress as normal. 

Voluntary neuromuscular activation of the ankle 

plantar flexors following whole body vibration 

Pellegrini M, Lythgo N, Morgan DL, Galea MP 

Rehabilitation Sciences Research Centre, The University of Melbourne 

This study investigated the effect of whole body vibration 

on voluntary activation of the ankle plantar flexors during 

isokinetic dynamometer testing. Twelve healthy young adults 

were exposed to two treatments on separate occasions. The 

first (non-vibration) involved passive stretching of the plantar 

flexors at end range of motion for five 1-min bouts. The 

second involved the same passive stretch with superimposed 

vibration (26 Hz) for five 1-min bouts on a rotary vibration 

plate. Attempted maximal voluntary contractions were 

performed on an isokinetic dynamometer (30degrees). 

Twitch interpolation determined whether activation was 

maximal. Post treatment data were normalised against 

pre treatment data. Subjects were classified as maximally 

(n = 6) or sub-maximally (n = 6) activated using the pre 

treatment twitch interpolation data. Effects were assessed 

by Repeated Measures MANOVA. For sub-maximally 

activated subjects, vibration increased peak torque and rate 

of torque production (p < 0.05). Peak torque was generated 

earlier or at longer muscle length (p < 0.05). No significant 

changes resulted from the non–vibration treatment. For 

maximally activated subjects, no significant vibration effects 

were found. Following vibration, twitch amplitude reduced 

for sub-maximally activated subjects, indicating increased 

activation. Therefore, when sub-maximally activated ankle 

plantar flexors are held in a stretched position, they respond 

to vibration by increasing peak torque and rate of torque 

production, with peak torque generated at longer muscle 

length. Although not statistically significant, the twitch 

interpolation technique found increases in neural activity. 

This suggests voluntary activation increased after vibration 

in subjects who previously failed to maximally activate. 



Measurement of flexion and extension of the thoracic 

spine with the flexible electrogoniometer 

Perriman DM, 1,3 Scarvell JM, 1,3 Hughes A, 2,3 Ashman B, 3,4 

Smith PN 1,3 

1 

The Trauma and Orthopaedic Research Unit, The Canberra Hospital, 

2 

The Dept of Neurology, The Canberra Hospital, 3 The Australian 

National University, 4 The Dept of Orthopaedic Surgery, The Canberra 

Hospital 

The Biometrics flexible electrogoniometer (FEG) is capable 

of measuring dynamic joint range of motion but has not 

been validated for the thoracic spine. The first aim of this 

study was to examine the external validity and day-today 

reliability of the FEG when used to measure sagittal 

thoracic spine angle. The second aim was to discover which 

part of the FEG endblocks correlated most closely with 

the vertebral angle being measured. 12 subjects (6 F, 71 ± 

11years; 6 M, 65 ± 11) were X-rayed twice with the FEG 

attached to their thoracic spine. Cobb angles were obtained 

from the vertebrae underlying the FEG at the outer margins; 

the inner margins and the mid points of the FEG end blocks 

for each X-ray. The FEG and Cobb angles were compared 

with an intraclass correlation coefficient ICC (2,1). In a 

separate experiment, 12 subjects (8F, 43 ± 13; 4M, 35 ± 17) 

performed 7 functional activities one week apart in order to 

assess day-to-day reliability of the FEG. Time 1 and time 

2 angles were compared with an ICC (2,1). The FEG angle 

correlated best with the Cobb angle measured from the midendblocks 

ICC (2,1) = 0.87 (p < 0.0001). For the 7 activities 

performed to determine day to day reliability the mean 

correlation was ICC (2,1) = 0.96 (0.94–0.98; p < 0.0001). 

This study has shown that the FEG demonstrates excellent 

internal and external validity in the thoracic spine. Further, 

it has demonstrated that the FEG measures the segment of 

the spine between the mid-endblocks. Future studies are 

planned which will use the FEG to evaluate interventional 

studies for thoracic kyphosis. 

Thoracic kyphosis: a survey of Australian 

physiotherapists 

Perriman, DM, 1,3 Scarvell JM, 1,3 Hughes A, 2,3 Lueck CJ, 2,3 

Smith PN 1,3 

1 

The Trauma and Orthopaedic Research Unit, The Canberra Hospital, 

2 

The Department of Neurology, The Canberra Hospital, 3 The Australian 

National University 

The identification and treatment of postural abnormalities 

is a key component of the physiotherapist’s arsenal. The 

aim of this survey was to ascertain current physiotherapy 

practice with respect to thoracic kyphosis in Australia. 

Four hundred and sixty-eight questionnaires were sent to 

a random sample of hospital, community health centre 

and private practice physiotherapists working in all States 

and Territories in Australia. Two hundred and sixteen 

questionnaires (46%) were completed and returned. The 

results indicated that increased thoracic kyphosis was 

frequently encountered with 42% of respondents reporting 

that they encountered it daily. The most common number 

of treatment sessions offered was 3 (37% of responses). 

Visual inspection was the usual modality used to assess the 

severity of the curvature (69% of respondents). Postural reeducation 

was the most common treatment modality (37%) 

followed by strengthening exercises (23%) but the range of 

treatments reported was diverse, e.g. taping, hydrotherapy 

and acupuncture. The majority of respondents reported 

receiving education pertaining to the management of 

increased kyphosis only as an undergraduate, and there 

was a widespread view that physiotherapists lacked good 

evidence upon which to make therapeutic decisions in this 

area. The information collected by this survey emphasises 

the need for research into the efficacy of different treatment 

approaches for thoracic kyphosis and will help guide future 

research into this important and under-studied area. 

An examination of outcome measures for pain and 

dysfunction in the cervical spine: a factor analysis 

Pickering PM 1 , Osmotherly PG, 2 Attia JR, 3 McElduff P 4 

1 

Ethos Health, 2 School of Health Sciences, University of Newcastle, 

Newcastle, 3 Department of Medicine, John Hunter Hospital, Newcastle, 

4 

John Hunter Medical Research Institute, Newcastle 

Neck pain and disability in research and clinical practice 

is commonly measured using validated, condition-specific 

scales. Yet little attention is paid to the actual domains 

measured by these scales. The aim of this study was to 

examine and compare the factorial structure of 4 validated 

neck pain and dysfunction scales and qualify the use of 

individual scales to assess specific aspects of neck disability. 

Data were collected from 88 patients with mechanical 

neck pain who completed a package of 4 questionnaires. 

Exploratory principal components factor analyses were 

conducted to expose the underlying factors within each of the 

scales. Identified factors were then examined, characterised 

and compared. Factor analysis revealed a single factor for 

the Neck Disability Index, 2 factors for the Northwick Park 

Neck Pain Questionnaire, and 3 factors each for both the 

Copenhagen Neck Functional Disability Scale and the 

Neck Pain and Disability Scale. Factors identified include 

neck pain, dysfunction related to general activities, neckspecific 

function, cognition, emotion and the influence of 

participation restriction on psychosocial functioning. The 

3 Neck Pain and Disability Scale factors appear to assess 

the multidimensional nature of neck pain and dysfunction 

most comprehensively. When selecting and interpreting a 

neck pain and dysfunction scale, clinicians and researchers 

are encouraged to take into account the factors measured 

by these neck pain and dysfunction scales and their 

applicability to the specific neck patient population under 

examination. The decision of which factors are of greatest 

interest will influence the selection of an appropriate 

outcome instrument. 

The effect of lumbar posture on abdominal muscle 

recruitment during an isometric leg task 

Pinto R, 2 Ferreira P, 1 Ferreira M, 1 Salmela L, 2 Oliveira V, 2 

Melo W, 2 Ferreira M, 2 Franco M 2 

1 


Gerais, Belo Horizonte, Brazil. 

The objective of this study was to compare abdominal 

muscle recruitment, measured as a change in thickness 

with ultrasound imaging, between people with and without 

chronic low back pain in 2 different lumbar postures, 

neutral lumbar posture and slump lumbar posture, while 

performing an isometric leg task. The pattern of abdominal 

muscle recruitment of 30 subjects with chronic low back 

pain and 30 controls were tested in two conditions while 

performing isometric low load tasks with their limb 

suspended. The 2 conditions, neutral lumbar posture and 

slump lumbar posture, were used in order to simulate the 

lumbar curvature commonly found in upright and slump 



sitting. The pattern of recruitment of transversus abdominis, 

obliquus internus, and obliquus externus were assessed 

by ultrasonography imaging. In controls, neutral lumbar 

posture showed significantly greater increase in transversus 

abdominis thickness (p < 0.001) and obliquus externus (p 

= 0.027) compared to the slump lumbar posture. In chronic 

low back pain patients, no significant differences were found 

between the two positions. In a healthy non symptomatic 

population, lumbar curvature in a more neutral posture 

seems to preferentially recruit deep abdominal stabilizing 

muscles compared with slump or fully flexed lumbar 

curvature. However, in chronic low back pain patients, 

neutral lumbar curvature alone is not capable of improving 

the recruitment of these stabilizing muscles. 

A systematic review of economic evaluations for 

conservative, non-pharmacologic management of hip 

and/or knee osteoarthritis 

Pinto D, 1 Robertson MC, 2 Abbott JH, 1 Hansen P 3 

1 

University of Otago, Centre for Physiotherapy Research, Dunedin, New 

Zealand, 2 University of Otago, Department of Medical and Surgical 

Sciences, Dunedin, New Zealand, 3 University of Otago, Department of 

Economics, Dunedin, New Zealand 

Clinical guidelines recommend conservative interventions 

as the first line of treatment for osteoarthritis of the 

hip and/or knee. The objective of this review was to 

investigate the quality and findings of economic analyses 

of conservative interventions in the treatment of hip and/ 

or knee osteoarthritis. Databases searched include Medline, 

Embase, Pubmed, National Health Service Economic 

Evaluations Database, Cochrane Controlled Trials database, 

Econlit, and OpenSIGLE. Only articles that assessed costs 

and benefits that were collected as part of a randomised 

controlled trial were included. Data collected included 

study characteristics and cost-effectiveness results. The 

economic analyses were critically reviewed and scored 

using the Quality of Health Economic Studies Instrument. 

Randomised controlled trials were assessed for risk of 

bias. All costs were converted to 2008 Australian dollars. 

Our search identified 912 articles. Of these, 7 economic 

analyses and 1 trial reporting costs and effects met our 

inclusion criteria. Six of these 8 studies met the Quality of 

Health Economic Studies instrument’s threshold for higher 

quality economic evaluations. Interventions included 

water-based therapy, class-based exercise, individual/group 

rehabilitation, patient education, and acupuncture. Three 

of the 6 higher quality analyses reported cost per qualityadjusted 

life year results at levels regarded as cost-effective. 

There are a small number of cost-effectiveness analyses of 

conservative interventions for hip and/or knee osteoarthritis 

but these are methodologically dissimilar precluding data 

pooling. More high quality analyses following similar 

methodological standards are needed to guide providers 

and funders in choosing which conservative interventions 

are most efficient in the treatment of hip and/or knee 

osteoarthritis. 

Rehabilitation of the sporting knee: biomechanical 

considerations 

Powers CM 

University of Southern California, Los Angeles, CA USA 

The knee is the most common site of injury in persons who 

are physically active. An understanding of basic injury 

mechanisms is essential for the development of effective 

and efficient clinical interventions and injury prevention 

strategies. Recent evidence suggests that altered lower 

extremity mechanics play a contributory role in many overuse 

and traumatic knee injuries. This talk will highlight recent 

research that has provided insight into the pathomechanics 

of various knee injuries and discuss competing theories 

related to the causes of related movement dysfunction 

(iproximal vs distal factors). Implications for rehabilitation 

and injury prevention will be discussed. 

Attitudes and barriers towards continuing professional 

development and post graduate qualifications in 

musculoskeletal physiotherapy amongst Queensland 

public sector physiotherapists 

Raymer ME, 1 Swete Kelly PE 2 

1 

Queensland Health, 2 Royal Brisbane and Women’s Hospital, Brisbane 

The aim of this study was to explore attitudes and barriers 

to professional development and postgraduate qualifications 

in musculoskeletal physiotherapy amongst Queensland 

Health physiotherapists. An online survey was developed 

and piloted, with participation invited from all Queensland 

Health clinical physiotherapists. Results were analysed 

according to respondents’ likelihood to enrol in postgraduate 

study, age, gender, and locality in Queensland (Pearson Chi- 

Square analysis). Responses totalled 236 (29% response 

rate). Musculoskeletal physiotherapy was a primary area 

of interest for 60 % of respondents, of whom 44% were 

influenced to work or remain at Queensland Health by the 

development of advanced practice roles. Masters or doctoral 

qualifications were held by 14% of respondents. Only 2% of 

respondents currently employed outside advanced practice 

roles held these qualifications. Future enrolment is more 

likely amongst respondents under 40 years of age (p = 0.002) 

but not influenced by gender or locality. In selecting post 

graduate courses, the mode of course delivery was more 

important to respondents under 40 years (p = 0.002). The 

importance of the ability to maintain an acceptable income 

(p = 0.004) and course reputation (p = 0.04) were also 

influenced by age. Long-term sustainability of advanced 

practice roles in musculoskeletal physiotherapy relies on 

availability of a suitably experienced, qualified workforce. 

Outside of those currently in advanced practice roles, few 

Queensland Health employees have tertiary qualifications, 

posing a potential threat to future recruitment. Knowledge of 

factors influencing future plans for post graduate education 

can be used to build workforce development strategies. 

34 



Implementing the latest research into the examination 

of a complex whiplash patient 

Rebbeck T 

Discipline of Physiotherapy, Faculty of Health Sciences, 


Recovery after whiplash is poor and patients present with 

diverse symptoms. These factors together with the paucity of 

research supporting the efficacy of treatment for whiplash, 

has lead to frustration by clinicians and their patients in 

assessing and managing this condition. Clinical guidelines 

give us some direction with the assessment and management 

of whiplash, however implementing these guidelines into 

clinical practice is rarely accomplished. This paper will 

present a complex whiplash case study and discuss how 

the research can assists clinicians in the assessment of this 

case. The latest research directs the clinician to examine 

motor, sensory, and kinaesthetic impairments in a complex 

whiplash patient. For example, motor impairments reported 

to occur in people with whiplash include over-activity in 

superficial neck flexors, poor deep neck flexor endurance 

and over-activity in scapula muscles such as upper trapezius. 

Assessment of sensory hypersensitivity may include the 

brachial plexus provocation test, pressure and temperature 

thresholds, as each of these may be impaired in chronic 

whiplash. Assessment of kinaesthetic sense is relevant given 

the high proportion of whiplash patients reporting dizziness 

as one of their symptoms. In addition to impairments, 

the research assists the clinician in the assessment of 

psychological distress and functional capacity after whiplash. 

Whilst there are many potential constructs of psychological 

distress that may occur, recent systematic reviews find posttraumatic 

stress, low self efficacy, catastrophisation and 

anxiety as key constructs to evaluate. Similarly there are 

many ways to assess function in whiplash, however clinical 

guidelines highlight the usefulness of measures such as the 

Neck Disability Index and the Patient Specific Functional 

Scale The later has been shown to be the most responsive to 

change in whiplash. By implementing the latest research in 

the assessment of a whiplash patient, the clinician is able to 

develop more specific and targeted treatment plans. These 

in turn may therefore begin to improve the prognosis and 

outcomes for whiplash patients. 

Treatment of chronic whiplash associated disorders: 

a systematic review 

Rebbeck T, 1 Stewart M, 1 Stewart J, 2 Cameron I 3 

1 

Discipline of Physiotherapy, Faculty of Health Sciences, University 

of Sydney, 2 Jim Stewart Consulting, Pty Ltd, Sydney, Australia, 

3 

Rehabilitation Studies Unit, Northern Clinical School, Faculty of 

Medicine, University of Sydney 

This is the first systematic review to investigate the efficacy 

of treatment for chronic whiplash. Studies were eligible 

for inclusion if they were randomised controlled trials and 

evaluated an intervention for the management of chronic 

(≥ 3 months duration) whiplash. Trials were located by 

electronic searches of MEDLINE, CINAHL, EMBASE, 

PEDro, Healthstar, PsychINFO, Sportdiscus, Clinical 

Evidence and the Cochrane Library databases, citation 

tracking and contact with experts. Trials were rated for 

quality and the effects of the intervention extracted or 

calculated as mean differences (95%CI) for continuous 

data and relative risks (95%CI) for categorical data. 

Recommendations for treatment were determined using the 

Australian National Health and Research Council body of 

evidence matrix. Twelve trials were included in the review. 

Interventions with the highest grade of evidence (grade B) 

of benefit included active exercise (mean difference of 6% 

(-5.8/100 (-11.4 to-0.2) and 8%(-3.7/50 (-6.2 to-1.2) for short 

term disability outcomes) and radiofrequency neurotomy 

(mean difference of 255 days (11.6–498.4) until return 

of 50% pain). Interventions with a lower grade of benefit 

(grade C) included co-ordination exercises and cognitive 

behavioural therapy. Interventions with evidence of a lack 

of benefit included intraarticular and analgesic injections 

and jaw exercises. There was inconsistent evidence with 

regard to the efficacy of botulinum toxin injections. In 

conclusion, there is high level evidence that active exercise, 

and radiofrequency neurotomy in very carefully selected 

patients, are effective treatments of chronic whiplash. 

Radiofrequency neurotomy remains controversial. 

Diabetes-related hand disorders: function remains 

stable over a year 

Redmond CL, 1 Bain GI, 2 Laslett LL, 1 McNeil JD 1 

1 

The University of Adelaide, Adelaide, 2 Modbury Hospital, Modbury 

This study assessed whether measures of hand function 

change over 1 year in adults with diabetic hand conditions. 

Diabetes is increasingly prevalent and greater knowledge of 

its effects on the hand is needed. The Disability of the Arm, 

Shoulder or Hand (DASH) questionnaire, grip strength, and 

the nine-hole peg test of dexterity were administered on 2 

occasions a year apart. Sixty participants with diabetes and a 

diagnosis of limited joint mobility, carpal tunnel syndrome, 

trigger finger or Dupuytren’s disease were included. Changes 

in scores over the 2 periods were assessed by t-tests and 

analysed by standardised response means (SRMs). Fiftytwo 

participants completed both assessments, 7 were 

lost to follow-up and 1 had incomplete data. At baseline, 

the cohort were characterised by functional limitations 

and hand weakness compared to the general population. 

Negligible change was seen in DASH scores (SRM 0.03), 

grip strength (SRM 0.06) or dexterity (SRM 0.27). Dexterity 

was the most responsive, with a borderline improvement (p 

= 0.06) in test speed. Of the 14 participants who had recent 

surgery 2 were lost to follow-up. No significant changes 

in DASH scores, grip strength or dexterity were seen, 

which suggests that these measures are less responsive in 

longitudinal studies compared to intervention studies. In 

established diabetes-related hand disorders, decline in hand 

functioning occurs slowly and clinical measures remained 

stable over the period of a year. Chronic disorders are 

often monitored over periods of years. Measured outcomes 

depend on the responsiveness of clinical assessments and 

may be influenced by observation bias. 

Primary contact physiotherapy in the emergency 

department for musculoskeletal injuries results in a 

reduced length of stay: a controlled trial 

Roddy L, 1 Taylor NF, 1,2 Norman E, 1 Tang C, 1 Hearn K, 1 

Pagram A 1 

1 

Eastern Health, Melbourne, 2 La Trobe University, Melbourne 

We aimed to determine whether primary contact 

physiotherapy for patients presenting to emergency 

department with musculoskeletal injuries resulted in 

reduced length of stay without any adverse effects compared 



with secondary contact physiotherapy. A non-randomised 

controlled trial was carried out in 3 metropolitan emergency 

departments. Three-hundred and six adults with peripheral 

musculoskeletal injuries were allocated to a single episode 

of primary or secondary contact physiotherapy according to 

the day of the week. Patients with serious pathology, open 

fractures, and spinal pain were excluded. Primary outcomes 

were patient length of stay, waiting and treatment time. 

Secondary outcomes were re-presentations to emergency 

department, referrals for imaging, patient satisfaction, and 

staff acceptance. Primary contact physiotherapy resulted in 

a reduction in length of stay of 60.0 minutes (95% CI 41.0– 

79.0) compared with patients seen first by a doctor, with a 

reduced waiting time of 24.1 minutes (95% CI 12.6–35.6) 

and treatment time of 36.4 minutes (95% CI 19.8–52.9). 

There were no differences between the groups in referrals 

for imaging, or re-presentations. More than 82% of patients 

in each group were very satisfied with their management, 

and 94% of emergency department staff agreed that 

primary contact physiotherapist improved effectiveness 

of care. Primary contact physiotherapy in an emergency 

department managing peripheral musculoskeletal injuries 

saved time for patients, with no observed adverse effects 

and was well accepted by patients and staff. These results 

suggest primary contact physiotherapy for this population 

group could be more efficient in an emergency department 

than the traditional secondary contact model. 

Dizziness screening and end range rotation 

mobilisation techniques: what is current practice? 

Shirley D, 1 Refshauge K, 1 Rivett D, 2, Magarey M 3 

1 

The University of Sydney, Sydney, 2 The University of Newcastle, 

Newcastle, 3 The University of South Australia, Adelaide 

The aim of this study was to determine the attitudes 

of musculoskeletal physiotherapists towards dizziness 

screening and obtaining consent prior to performing end 

of range rotation mobilisation techniques (ERRT). All 

titled members of Musculoskeletal Physiotherapy Australia 

(724) were invited to participate in the survey and 394 

(54%) responded by completing a questionnaire. The 

questionnaire sought information about demographics and 

attitudes to the use of dizziness screening and obtaining 

consent prior to performing ERRT in the cervical spine. 

Descriptive analysis was used to provide a basic quantitative 

description of the data set. Most of the physiotherapists were 

currently practicing (96%). Dizziness screening was always 

performed by 29% and sometimes performed by 51%. The 

main reason for only using dizziness screening sometimes 

was when it was thought that the proposed technique would 

stress the vertebrobasilar system. Only 21% always and 

51% sometimes informed patients about risks associated 

with ERRT. Consent was obtained by 24% every time, 

26% on the first occasion and 30% never sought consent 

prior to performing ERRT. Most of those not seeking 

consent (67%) prior to ERRT considered it not relevant 

and 36% didn’t consider ERRT stressed the vertebrobasilar 

system. Dizziness screening prior to ERRT is not routinely 

performed by musculoskeletal physiotherapists despite the 

recommendations that these techniques can also potentially 

stress the vertebrobasilar system. These results highlight the 

need to ensure musculoskeletal physiotherapists understand 

the effect of the treatments they perform and the legal 

requirement relating to consent for treatment. 

Reliability and smallest real difference of the ankle 

lunge test post ankle fracture 

Simondson D, 1 Page C, 1 Brock K, 1 Cotton S 2 

1 

St Vincent’s Hospital, Melbourne, 2 ORYGEN Youth Health, 

University of Melbourne 

In the post immobilisation stage of ankle fracture, ankle 

dorsiflexion is an important measure of progress and 

outcome. The Ankle Lunge test measures weight bearing 

dorsiflexion, with severe restriction resulting in negative 

scores (knee to wall) and less restriction resulting in 

positive scores (toe to wall). Reliability data for this test has 

only been published in normal subjects. This study aims to 

determine the reliability and the smallest real difference of 

the Ankle Lunge test in an ankle fracture patient population. 

A consecutive sample of ankle fracture patients, attending 

outpatient physiotherapy and with permission to commence 

weight bearing was recruited to the study. Testing was 

performed by 2 physiotherapist raters prior to each therapy 

session over a 6-week period. Data from the first attendance 

(early) and last attendance (late) were used for analysis. Intra 

and inter rater reliability (intraclass correlations), systematic 

bias (ANOVA or t tests) and smallest real difference, 

utilising standard error of measurement, were investigated. 

Data were collected from 14 individuals, with an average 

age of 36 years (SD 14.8). For the ‘early’ measures, 72% of 

observations were negative. For ‘late’ measures, 85% were 

positive. Intra and inter rater reliability yielded intra class 

correlations at or above 0.96, p < 0.001. The smallest real 

difference was calculated for ‘early’ and ‘late’ measures, for 

both single rater and multiple rater testing, and ranged from 

7.6mm to 23.4mm. The Ankle Lunge test is a practical, 

reliable and sensitive tool, appropriate for use by clinicians 

and researchers dealing with ankle fracture. 

Shoulder and scapulo-thoracic motion in cricketers 

with and without a history of shoulder pain 

Sims K, 1 Portus M, 1 Pfitzner M, 1 Farhart P, 2 Orchard J 2 

1 

Cricket Australia Centre of Excellence, Brisbane, 2 NSW Cricket 

Association, Sydney 

This study examined the relationship between measures of 

shoulder function in cricketers with and without a history of 

shoulder pain. In a retrospective study 177 cricketers were 

screened over a 3-year period with a battery of shoulder and 

scapulo-thoracic motion tests and divided into groups with 

(62) and without (114) a history of shoulder pain. Univariate 

(one way ANOVA) and multivariate (discriminate analysis) 

statistics were then assessed to determine whether it was 

possible to classify the players into two groups on the basis 

of the screening data. Players with a history of shoulder pain 

had less total range of gleno-humeral rotation (p = 0.028) 

in the rotation range of motion test in shoulder abduction 

and an increased range of combined shoulder and thoracic 

elevation (p = 0.019) in the combined elevation assessment. 

Using these two variables in a discriminant analysis it was 

possible to correctly classify 68% of the group into those 

with and without a history of shoulder pain. The results 

suggest that a loss of shoulder rotation may be accompanied 

by an increase in shoulder and thoracic extension. The 

results also reinforce the common clinical view that a loss 

of shoulder rotation is a contributing factor in shoulder 

pathology. 

36 



An association of dominant hand grip strength with 

some anthropometric variables in Indian collegiate 

population 

Singh AP, Koley S 

Guru Nanak Dev University, Amritsar, India 

The present study deals with the correlations of dominant 

hand grip strength and 12 anthropometric variables, 

namely: height, weight, BMI, upper arm length, forearm 

length, total arm length, hand breadth, hand length, 

upper arm circumference, forearm circumference, biceps 

skinfold and triceps skinfold, in randomly selected 303 

unrelated, normal, healthy students (151 males and 152 

females) aged 18–25 years of Guru Nanak Dev University, 

India. The findings of the present study indicate a strong 

association of dominant right hand grip strength with all the 

anthropometric variables, except biceps skinfold in male 

students and with height (r = 0.200), weight (r = 0.275), 

BMI (r = 0.217), total arm length ( r = 0.218) and upper arm 

circumference (r = 0.199) in female students. Statistically 

significant positive correlations were also found between 

dominant left hand grip strength and height (r = 0.275), 

weight (r = 0.537), BMI (r = 0.472), hand breadth (r = 0.464), 

upper arm circumference (r = 0.570), forearm circumference 

(r = 0.464) and triceps skinfold (r = 0.343) only in male 

students, but no such association was found between grip 

strength of left hand dominant female students with any of 

the twelve anthropometric variables. It may be concluded 

that hand dominance, especially of right hand, has some 

close association with the anthropometric variables related 

to upper extremities. 

Enablers and barriers to participant engagement in 

exercise programs for non-specific chronic low back 

pain: a qualitative study 

Slade SC, 1 Molloy E, 2 Keating JL 1 

1 

Physiotherapy Department, Monash University, Melbourne, 2 Centre 

for Medical and Health Sciences Education, Monash University, 

Melbourne 

This study aimed to investigate participant experience of 

exercise programs for non-specific chronic low back pain 

and factors perceived as important for engagement and 

participation. Qualitative research methods were used with 

3 focus groups facilitated by an experienced facilitator. 

Eighteen participants aged over > 18 years, who could speak 

read and understand English and who had participated in an 

exercise program for NSCLBP met the a priori inclusion/ 

exclusion criteria. Participants were guided with a set of 

pre-determined questions and encouraged to give personal 

opinions freely. Data were transcribed verbatim, read 

independently by 2 researchers and analysed thematically 

using Grounded Theory. All focus group results concurred 

and the following themes emerged. Enablers for exercise 

participation included shared decision-making; effective 

communication; a history of exercise or fitness experience; 

levels of ability; individualised and supervised programs 

in a preferred environment; family support; variety and 

fun; motivation strategies; and education and explanation. 

Barriers included lack of time; cost; boring or unchallenging 

exercise programs; symptom aggravation; consequences of 

stigma; and dissatisfaction with formal exercise and gym 

‘culture’. Perceived benefits of exercise were improved 

general fitness, a sense of achievement and increased activity, 

participation and social engagement. People are likely to 

prefer and participate in exercise programs that are designed 

with consideration of their preferences, circumstances 

and past experiences. A mechanism for systematically 

recruiting information about patient preferences has not 

previously been proposed. These results have informed the 

development of a draft exercise preferences questionnaire 

that is being tested in a randomised controlled trial. 

Sensory responses to experimentally induced pain in 

the common extensor tendon (elbow) and the Achilles 

tendon of healthy subjects 

Slater H, 1 Gibson W, 1 Graven-Nielsen T 2 

1 

School Of Physiotherapy, Curtin University of Technology, Perth, 

2 

Laboratory for Experimental Pain Research, Center for Sensory-Motor 

Interaction, Aalborg University, Denmark 

This investigation aimed to quantify and compare sensory 

responses to hypertonic saline induced pain in the tendo 

achilles and the common extensor tendons (elbow). Healthy 

subjects (n = 14; 7 males) received in randomised order, 

injections of sterile saline (0.5ml, 5.8% hypertonic saline 

or 0.9% isotonic saline) into each tendon bilaterally at 

2 sessions separated by a week. Measures of mechanical 

sensitivity (pressure pain thresholds), muscle pain intensity 

(electronic visual analogue scale, VAS area under curve, 

pain duration, peak pain) and pain distribution were assessed 

pre, during and post saline-induced pain. Hypertonic saline 

induced pain intensity (VAS area under curve, duration, 

mean and peak) was significantly greater in the Achilles 

and common extensor tendons compared with the pain 

intensity induced by isotonic saline (p < 0.001). Hypertonic 

saline induced significantly higher VAS area (p < 0.01) and 

longer pain duration (p < 0.001) in tendo achilles compared 

with the common extensor tendon. Regardless of injection 

type, mechanical sensitivity increased significantly at 

tendo achilles during saline injection (p < 0.02) compared 

with pre injection but not at the common extensor tendon. 

Infrequent referred pain was reported only for hypertonic 

saline injections at both tendo achilles (n = 3) and common 

extensor tendon (n = 4). The greater induced deep tissue pain 

and hyperalgesia demonstrated at tendo achilles compared 

with common extensor tendon may relate to anatomical 

differences such as higher nociceptor density or different 

vascular perfusions. These findings may have impact for the 

future understanding of pain mechanisms in tendinopathy. 

Supported by the Physiotherapy Research Foundation 

Increasing evidence-based practice in the management 

of non-specific low back pain in primary care: a 

targeted education program for GPs 

Slater H, 1,2 Davies S, 3 Kermode,F 4 Quintner J, 3 Graham 

C, 3 Fortescue N, 5 Knight,P 3 Parkitny L, 3 Antill T, 3 Codde 

J, 6,7 Vickery A, 8,9 Reglier C, 10 Timms R, 11 Schug S 2,12 

1 

School of Physiotherapy, Curtin University of Technology, Perth; 2 Dept 

of Anaesthesia and Pain Medicine, Royal Perth Hospital, Perth; 3 Pain 

Medicine Unit, Fremantle Hospital and Health Service, Perth; 4 Move 

Well Physiotherapy, Perth; 5 Physiotherapy Department, Royal Perth 

Hospital; 6 South Metropolitan Area Health Service, Perth; 7 School of 

Population Health, University of Western Australia, Perth; 8 School 

of Primary, Aboriginal and Rural Health Care, University of Western 

Australia, Perth; 9 Osborne GP Network, Perth; 10 Fremantle GP 

Network, Perth; 11 Physiotherapy Department, Fremantle Hospital and 

Health Service, 12 Pharmacology and Anaesthesiology Unit, University 

of Western Australia, Perth 

This project is piloting a novel system of education delivery 



to general practitioners in Perth, who refer patients with 

non-specific low back to outpatient services in the public 

hospital system. The project aims to optimise the delivery 

of early, individualised and appropriate evidence-based 

management for non-specific low back pain patients with 

a potential for reducing the recurrence rate/progression to 

a persistent condition and the associated health burden. A 

specific aim is to broaden the reach of patient active selfmanagement 

for non-specific low back pain to the area 

of primary care. This educational approach uses an interprofessional 

learning model and a simultaneous push-pull 

strategy to optimise leverage for health system reform in the 

management of non-specific low back pain: a pull strategy, 

from health system to education system (requiring evidencebased 

practice from general practitioners) and a push strategy, 

from education system to health system (evidence-based 

practice delivered from academics, professional bodies to 

general practitioners). The project also aims to enhance the 

clinical health professional network to better enable shared 

knowledge and clinical solutions. Project outcomes to be 

presented will include: pre to post educational intervention 

comparison of general practitioner’s current evidence based 

clinical practice, attitudes, beliefs and knowledge of pain 

concepts, of patient’s pain management options (active 

and passive self management categories) and of possible 

pharmacological options for managing non-specific low back 

pain. Data regarding cost benefit per patient not referred to 

an established pain service and upstream efficiencies such 

as reduced wait-lists and wait-times will be discussed. 

Supported by a State Health Research Advisory Council 

(Department of Health, WA) grant. 

38 

Back muscle endurance in adolescence is associated 

with physical, lifestyle and psychological factors 

independently of back pain and gender 

Smith AJ, 1,2 O’Sullivan PB, 1,2 Campbell AC, 1 

Straker LM 1,2 

1 


2 


Poor back muscle endurance (BME) is commonly assessed 

due to a demonstrated link with back pain, although the 

nature of the association is unclear. Back pain and BME 

may directly affect each other although several physical, 

lifestyle and psychological factors may independently affect 

back pain and/or BME. Identifying modifiable factors that 

are associated with BME independently from gender and 

the presence of back pain can inform prevention of poor 

BME. This cross-sectional study aimed to identify if a 

range of physical, lifestyle and psychological factors are 

associated with the BME. 1608 adolescents (aged 14.1 ± 

0.2yrs) participating in the Western Australian Pregnancy 

Cohort (Raine) Study completed a questionnaire and 

physical examination. Variables collected by questionnaire 

included back pain prevalence, Child Behaviour Checklist, 

scores for self-efficacy and self-perception, television and 

computer usage, and physical activity. Variables collected 

by physical examination included the Beiring Sorenson 

test, height, weight and sitting posture. After adjustment 

for height, weight, gender and back pain in the last month, 

physical, lifestyle and psychological measures were 

independently associated with BME. Using a backwards 

stepwise regression model, degree of trunk flexion in sitting 

(p < 0.001), television usage (p = 0.009), weekly duration 

of exercise (p < 0.001), and self-worth (p = 0.002) were 

identified as additional independent correlates of BME. 

This cross-sectional study identifies factors that can be 

targeted for change when aiming to increase back muscle 

endurance in teenagers. 

Trajectories of childhood obesity are associated with 

adolescent sagittal standing posture 

Smith AJ, 1,2 O’Sullivan PB, 1,2 Straker LM, 1,2 De Klerk N 2 

1 


2 


It is postulated that the developing spine is influenced by 

a number of factors including mechanical factors such as 

obesity. Compensatory spinal sagittal alignment has been 

reported in obese adults, but the influence of childhood 

obesity upon the development of spinal sagittal alignment 

not been determined. The purpose of this study was to 

evaluate the association between trajectories of childhood 

Body Mass Index (BMI) and subgroups of standing sagittal 

spinal alignment at 14 years of age. 1373 adolescents 

participating in the Western Australian Pregnancy Cohort 

(Raine) Study contributed data to the study. US Centres for 

Disease Control and Prevention age and gender specific 

z-scores for BMI were obtained from height and weight 

at age 2,3,5,10 and 14 years. Latent class group analysis 

was used to identify 5 distinct trajectories of BMI z-score; 

Very Low (3%), Low (20%), Average (41%) High (30%) 

and Very High (6%). At age 14 years, adolescents were 

categorised into 1 of 4 subgroups of sagittal spinal posture 

using k-means cluster analysis of photographic measures of 

lumbar lordosis, thoracic kyphosis and trunk sway; Neutral 

(29%), Hyperlordotic (22%), Flat (22%) and Sway (27%). 

BMI trajectory group was strongly associated with posture 

subgroup (p < 0.001). For example, forty-seven of 85 

(55%) adolescents in the Very High BMI trajectory group 

displayed hyperlordotic posture at age 14, whereas only 6 

(7%) displayed neutral posture and 11 (13%) Flat posture. 

This prospective study provides evidence that childhood 

obesity influences standing sagittal posture in adolescence. 

Students apply more accurate cervical mobilisation 

forces when provided with real-time objective feedback 

Snodgrass SJ, Rivett DA, Robertson VJ, Stojanovski E 


The aim of this study was to determine if real-time objective 

feedback improves physiotherapy students’ ability to apply 

cervical mobilisation forces. Ensuring consistent forces are 

applied by different therapists is necessary for establishing 

optimal parameters for achieving patient outcomes. An 

expert physiotherapist mobilised C7 (all 4 Maitland 

mobilisation grades) of 21 asymptomatic subjects while 

forces were recorded using an instrumented treatment table. 

These data were used to set force targets for 51 physiotherapy 

students who mobilised 1 of these subjects on 2 occasions 1 

week apart. Students were randomised into an experimental 

group who received real-time computerised visual and 

audio feedback on their mobilisation performance, and a 

control group who practised without feedback. Superior 

performance (accuracy) was defined as a smaller difference 

between the expert and student applied forces for each 

mobilisation grade. Students who received real-time 

feedback applied more accurate forces (median difference 

between expert and student, experimental group, 4.0 N, IQR 

1.9–7.7) than controls (14.3 N, IQR 6.2–26.2, p < 0.001). 



After 1 week the difference between groups remained (p 

= 0.008), but performance in the experimental group was 

not as accurate as immediately after feedback (6.4 N, IQR 

3.1–14.7). Inter-rater repeatability (ICC 2,1) of applied 

forces improved from 0.45 (95% CI 0.19–0.92) to 0.82 (95% 

CI 0.57–0.98) immediately after receiving feedback. These 

results indicate consistent cervical mobilisation forces can 

be applied when real-time feedback is provided, supporting 

its use in manual therapy training and in research where 

specific manual treatment dosages are required. 

Critical appraisal of clinical prediction rules that aim 

to select treatments for musculoskeletal conditions 

Stanton TR 1 , Hancock MJ 2 , Maher CG 1 , Koes BW 3 

1 

The George Institute for International Health, Sydney, 2 Back Pain 

Research Group, University of Sydney, Sydney, 3 Department of General 

Practice, Erasmus Medical Centre, Rotterdam, The Netherlands 

The objective of this paper was to critically appraise the 

research evidence on clinical prediction rules for treatment 

selection in musculoskeletal conditions in primary care. A 

literature search was performed of MEDLINE, EMBASE, 

CINAHL, AMED, PEDro, and Pubmed. Studies that 

explicitly stated the aim was to develop/evaluate a clinical 

prediction rule for treatment response in musculoskeletal 

conditions were included. Two independent reviewers 

assessed eligibility criteria and extracted methodological 

data, the stage of development of each rule, and effect 

size information. Eighteen studies, representing 15 

separate clinical prediction rules, were included. In rules 

at a derivation level, all studies used a single arm trial 

design and all reported positive findings (found predictors 

significantly related to outcome). Only 1 rule investigating 

spinal manipulation for low back pain was evaluated within 

a randomised controlled trial and it was at the validation 

stage of development. This rule identified patients who had 

a significantly better response to manipulation than patients 

not meeting the rule (p < 0.001). In a separate study the 

rule did not generalise to a different clinical scenario. There 

is little evidence that clinical prediction rules can be used 

to predict treatment effects. The principal problem is that 

most rules have been derived from single arm studies and 

so may only predict outcome not response to treatment. 

Only 1 clinical prediction rule has been evaluated within 

a randomised controlled trial and so been shown to predict 

response to treatment. Focus on validation of these rules is 

imperative so they can be applied clinically. 

Spinal manual therapy increases nociceptive flexion 

reflex threshold but not pressure or thermal pain 

thresholds in chronic whiplash associated disorders 

Sterling M, 1,2 Pedler A, 1,2 Chan C, 2 Puglisi M, 2 Vuvan,,V 2 

Vincenzion, B 2 

1 

Centre for National Research on Disability and Rehabilitation 

Medicine, The University of Queensland, Brisbane, 2 CCRE: Spinal 

Pain Injury and Health, The University of Queensland, Brisbane 

Sensory hypersensitivity indicative of augmented central 

pain processing mechanisms is a feature of chronic 

whiplash associated disorders. This study investigated 

the immediate effects of a spinal manual therapy (SMT) 

technique on measures of central hyperexcitability. In a 

randomised, single blind, clinical trial, 39 participants with 

chronic whiplash were randomly assigned to a cervical 

SMT (lateral glide) or manual contact intervention. The 

Neck Disability Index and General Health Questionnaire-28 

were administered at baseline. Pressure pain thresholds, 

thermal pain thresholds (heat and cold) and Nociceptive 

Flexion Reflex (NFR) responses (threshold and VAS of 

pain) were measured pre and post intervention. There was 

a significantly greater increase in NFR threshold following 

SMT compared to the manual contact intervention (p = 

0.04). Ratings of pain with the NFR test did not change with 

either intervention. There was an increase in pressure pain 

thresholds at the cervical spine following both SMT (mean 

± SE: 24.1 ± 7.3%) and manual contact (21 ± 8.4%) with no 

difference between interventions. There was no difference 

between interventions for percentage change of pressure 

pain threshold at the median nerve or tibialis anterior, heat 

pain threshold or cold pain threshold. SMT (lateral glide) 

may be effective in reducing spinal hyperexcitability in 

chronic whiplash associated disorders. 

Developmental trajectories of pain and disability 

and posttraumatic stress symptoms following 

whiplash injury 

Sterling M, 1,2 Hendrikz J, 1 Kenardy J 1,2 

1 

Centre of National Research on Disability and Rehabilitation Medicine 

(CONROD), The University of Queensland, 2 CCRE Spinal Injury, Pain 

and Health, The University of Queensland 

The aim of this study was to explore the developmental 

trajectories of pain/disability and posttraumatic stress 

disorder (PTSD) symptoms following whiplash. Predictors 

of trajectory patterns were analysed. In a prospective study, 

155 individuals (62.6% female) with acute whiplash (Grade 

II or III) were assessed at < 4 weeks, 3, 6 and 12 months 

post injury. At each assessment point, pain/disability was 

measured with the NDI and PTSD with the Posttraumatic 

Stress Diagnostic Scale (PDS). Group-based trajectory 

modelling methods were used to identify individuals 

following distinct-level trajectories of pain/disability and 

PTSD symptoms. Logistic regression analyses were used 

to identify baseline variables (accident related features, 

pain intensity (VAS), pressure and cold pain thresholds) 

predictive of individual trajectory patterns. There were 

3 distinct pain/disability trajectories: initial lower pain/ 

disability that recovered (45.2%); initial moderate pain/ 

disability with some recovery but still disabled at 12 months 

(39%); initial and persistent moderate/severe pain/disability 

(15.8%). Three distinct trajectories for PTSD were identified: 

resilient to stress (39.6%); initial moderate stress symptoms 

but recovered quickly (43.4%); persistent moderate/severe 

levels of PTSD (16.9%). Predictors of the moderate/severe 

pain/disability trajectory were initial cold pain threshold > 

13ºC (p =0.0001); pain > 5/10 (p = 0.001) and older age (p 

= 0.0001). Predictors of the chronic PTSD trajectory were 

initial cold pain threshold > 13ºC (p = 0.002); pain > 5/10 

(p = 0.0002); age (p = 0.018) and decreased pressure pain 

thresholds at the neck (p = 0.045). These results indicate a 

relationship between the development of the physical and 

psychological presentations of whiplash. 



40 

Dynamic and functional balance tasks in subjects 

with persistent whiplash 

Stokell R, Yu A, Treleaven J 

Division of Physiotherapy, The University of Queensland 

Disturbances in static balance have been demonstrated 

in neck pain subjects of both idiopathic and traumatic 

origin, with whiplash subjects generally displaying greater 

disturbances. Some subjects with whiplash report loss of 

balance and actual falls. These postural disturbances may 

contribute to consequent difficulties in the completion of 

dynamic and functional balance tasks. The aim of this 

study was to determine whether subjects with whiplash 

had greater deficits in dynamic and functional balance 

tasks when compared to a healthy control group. Twenty 

subjects with persistent pain following a whiplash injury at 

least 3 months prior and 20 healthy control subjects were 

included in the study. Subjects were assessed on the step 

test, tandem walk on firm and soft surface, single leg stance 

with eyes open and closed, fuduka stepping test, singletons 

test, timed 10-metre walk with and with out head movement 

(horizontal and vertical) and 2-minute stair walking. The 

whiplash group had significant differences when compared 

to the healthy controls in the step test, tandem walk firm 

test, stair test and the timed 10-metre walk with and 

without head movements (p < 0.01). The results of the study 

demonstrate that subjects with persistent whiplash injury 

have impairments in selected measures of functional and 

dynamic balance tasks when compared to a healthy control 

group. Specific assessment and rehabilitation directed 

towards improving these deficits should be considered in 

the management of patients with persistent whiplash. 

Pain levels and fear of movement in chronic whiplash 

are associated with autonomic nervous system 

dysfunction 

Stone AM, 1 Sterling M 1,2 

1 

Centre for National Research on Disability and Rehabilitation 

Medicine (CONROD) The University of Qld, Brisbane, 2 CCRE: Spinal 

Pain, Injury and Health, The University of Queensland, Brisbane 

Whiplash is a heterogeneous condition involving both 

physical and psychological factors. The aim of this study was 

to investigate the association between pain and disability 

levels, fear of movement, cold hyperalgesia and autonomic 

nervous system dysfunction in 46 participants with chronic 

(> 3 months) whiplash associated disorder (grades II or 

III, Neck Disability Index (NDI) 37 (± 19%) and mean 

age 39 (± 12yrs). Autonomic nervous system function was 

measured continuously during waking hours for one or two 

days using an ambulatory measure of heart rate variability 

(Lifeshirt, Vivometrics, USA). Pain and disability (NDI), 

current pain (VAS), fear of movement (Pictorial Fear of 

Activity Scale-Cervical (PFActS)) and cold pain threshold 

were also measured. Heart rate variability (both time and 

frequency domain analyses) was significantly lower in 

participants with higher pain levels (VAS > 5/10; n = 21) (p 

< 0.05) and greater fear of movement (PFActS > 95/190; n 

= 15) (p < 0.05). Heart rate variability was not significantly 

different between participants with moderate to severe pain 

and disability (NDI > 30/100; n = 25) and those with milder 

pain and disability (NDI ≤ 30/100; n = 21) (p > 0.08), nor 

between those with cold hyperalgesia (cold pain threshold 

> 15ºC; n = 24) and those without cold hyperalgesia (p 

> 0.4). Clinically, these findings suggest that poor health 

outcomes linked to autonomic nervous system dysfunction 

may also be relevant to some patients with chronic whiplash 

associated disorder. 

The cultural divide between city and regional/rural 

practise 

Sutherland RL 

Cudgegong Physiotherapy Centre 

It has always been accepted that there are cultural differences 

between city dwellers and country people, but to what extent 

do these differences affect physiotherapists? The research 

demonstrates that 32% of the Australian population resides 

in a rural and regional area and their health status is 

significantly lower than their urban counterparts. Does the 

culture of health service delivery contribute to this? How 

can research assist physiotherapists to provide better care to 

their patients by developing their understanding of cultural 

factors? Can a better understanding of patients’ expectations 

and country life entice more physiotherapists to regional 

areas and reduce our rural workforce shortages? A review 

of the literature from physiotherapy, medicine and allied 

health from 1998–2008 revealed a number of cultural issues 

that affect the decision making of rural people when they 

need to access health care. Opinion, statistical information, 

demographic studies, and surveys formed the majority of 

the literature. It is obvious that there are cultural factors 

that reduce the health of rural residents, related to both 

the health care system and the characteristics of country 

people. Regional based physiotherapists are affected by a 

number of factors including stress which may reduce their 

professional abilities. Physiotherapists may be able to make 

a more informed decision about relocation based on this 

review. Educators may be able to tailor their syllabus to 

meet the needs of their students, particularly students from 

a rural background, and those driving technological change 

will find this review will challenge their initiatives. 

The influence of cervical traction, compression and 

Spurling’s test on cervical intervertebral foramen size 

Takasaki H, 1,2 Hall T, 3 Jull G, 1 Kaneko S, 2 Ikemoto Y 2 

1 

The University of Queensland, Brisbane, 2 Shinoro Orthopedic, 

Sapporo, Japan, 3 Curtin University, Perth 

The purpose of this study was to evaluate functional 

changes in the cervical intervertebral foramen during the 

axial compression test (ACT), axial distraction test (DT), 

and Spurling’s test (SST). Although alterations of the 

cross-sectional area of the cervical intervertebral foramen 

during flexion/extension and rotation have been reported, 

there are no studies that have measured functional changes 

in foramen cross-sectional area (FCSA) or shape during 

the simulation of clinical tests for cervical radiculopathy. 

Twenty-three participants (12 male, age 24–52 years) 

without history of significant spinal disorders were studied. 

The 3D sequence of the magnetic resonance imaging (MRI) 

of the foramen was performed with a 0.2-T horizontally 

open unit. Measurements were taken of FCSA and 

foramen shape (ratio of foramen height to FCSA). These 

measurements were conducted under 4 different conditions; 

control: resting in supine, DT-neck in neutral with a 12 kg 

distraction force, ACT: neck in neutral with a 7 kg axial 

compression force, SST: the cervical spine was extended 

(12.79˚), rotated (63.36˚) and laterally flexed (28.49˚), in a 



standardised manner. At all levels except for C7/Th1, the 

FCSA significantly increased (p < 0.05) during the DT to 

around 120% of control. In contrast FCSA significantly 

decreased to approximately 70% of control (p < 0.05) at 

all levels during the SST. In addition there were significant 

differences (p > 0.05) in foramen shape between the ACT 

and SST condition, but only at the C4/5 and C5/6 levels. 

Comparison of responses to the neuropathic 

painDETECT questionnaire and responses to 

laboratory quantitative sensory testing in patients 

with fibromyalgia 

Tampin B, Briffa K, Slater H 

School of Physiotherapy, Curtin University of Technology, Perth 

The painDETECT questionnaire is a self-reported tool to 

screen for the likelihood of a neuropathic pain component 

in chronic pain disorders. This study investigated if the 

somatosensory profile of patients who, using painDETECT, 

indicated sensitivity to slight pressure, cold and heat, light 

touch or numbness in the area of pain, was confirmed by 

corresponding laboratory tests. Twenty-six fibromyalgia 

patients (22 females, 46 ± 12 years) completed the 

painDETECT questionnaire. In addition, standardised 

quantitative sensory measures of pressure pain thresholds, 

cold and heat pain thresholds, dynamic allodynia, 

mechanical detection thresholds and vibration detection 

thresholds were recorded from the maximal pain area 

(upper trapezius in 14 cases). Data from 26 age-matched 

healthy controls (13 females; upper trapezius) were used 

for comparison. For each item, only those patients who 

responded positively on the questionnaire were included 

in the analysis. The 25 patients who indicated sensitivity 

to slight pressure demonstrated significantly decreased 

pressure pain thresholds (p < 0.001) compared with healthy 

controls. Fifteen patients reported sensitivity to cold/heat, 

and their cold and heat pain thresholds were significantly 

decreased (p < 0.001) compared to controls. Fifteen 

fibromyalgia patients indicated sensitivity to light touch, but 

only 3 demonstrated dynamic allodynia. In those patients 

reporting numbness (n = 16), no significant difference in 

mechanical and vibration detection thresholds compared to 

healthy controls was demonstrated. These preliminary data 

suggest that in fibromyalgia patients, quantitative sensory 

testing may be more sensitive in detecting alterations of 

sensory processing compared with painDETECT. 

Supported by the National Health and Medical Research Council, 

Arthritis Australia and the Physiotherapy Research Foundation. 

Comparison of the outcome of two neuropathic pain 

questionnaires: do they agree? 

Tampin B, Briffa K, Slater H 

School of Physiotherapy, Curtin University of Technology, Perth 

There are a number of screening tools available to assess 

the presence of a neuropathic pain component in chronic 

pain disorders. The LANSS requires input from a clinician, 

whereas the painDETECT is a self reported tool. This study 

investigated the agreement between these two screening 

tools in 2 patient groups: 50 neck/arm pain patients, 

referred to a neurosurgery department and 26 fibromyalgia 

patients, recruited for another study. All patients completed 

both questionnaires. Responses were scored and classified 

into two groups (LANSS ≥ 12 = neuropathic; painDETECT 

≥ 19 = neuropathic). In neck/arm pain patients, there was 

classification agreement between questionnaires in 35 

cases (5 neuropathic, Kappa = 0.27; 95% CI: 0.03–0.50). 

Of the 15 discordant cases, the LANSS classified 1 and the 

painDETECT 14 with a neuropathic pain component. Seven 

of these 14 cases selected no on the yes/no LANSS items 

yet indicated a positive response on the weighted sensory 

descriptor items of painDETECT. In the fibromyalgia group, 

agreement between questionnaires occurred in 21 patients 

(9 neuropathic, Kappa = 0.62, 95% CI: 0.32–0.91). Of the 

remaining 5, the LANSS scored 1 and the painDETECT 

4 with a neuropathic pain component. For both groups, the 

main discrepancies between questionnaire responses related 

to the presence/absence of: spontaneous pain; burning pain; 

and sensitivity to light touch. There is inconsistency between 

LANSS and painDetect in classifying neuropathic pain 

components in neck/arm pain and fibromyalgia patients. 

This may be important if this classification influences 

treatment decisions. 

Supported by National Health and Medical Research Council, 

Arthritis Australia, Physiotherapy Research Foundation. 

Time course of the effects of a shoulder mobilisationwith-movement 

(MWM) and a taping technique on 

pain limited shoulders 

Teys P 

Bond University, Gold Coast 

A cross over design study was implemented to investigate 

the time course of effects of a shoulder mobilisation-withmovement 

(MWM) technique, and the influence of a 

taping technique on the time course of the effects on the 

shoulders of participants with painful limitation of shoulder 

movement who had responded positively to the application 

of the shoulder MWM. A previous study investigating the 

initial effects of a shoulder mobilisation-with-movement 

demonstrated that the application of a Mulligan’s MWM 

technique to participants with painful shoulders produced 

an immediate and significant improvement in ROM and 

PPT pre- to post intervention Mulligan purported that the 

effects of an MWM were lasting and that taping had an 

added benefit, The study was designed to test this hypothesis. 

Twenty-one subjects to date have demonstrated an average 

increase in shoulder range of movement (ROM) of 23.3 

degrees with tape applied for 48 hours over time periods of 

½ hour, 24 hours and one week. Those who did not have the 

tape applied demonstrated an average increase in ROM of 

12.74 degrees over the same time frames. This study seems 

to support Mulligan’s theory that there is a lasting effect 

in range of movement after the application of the shoulder 

MWM. Theories of the mechanism of this response are still 

to be explored 

Risk factors and clinical features associated with 

craniocervical arterial dissection 

Thomas L, 1 Rivett D, 1 Levi C 1,2 

1 

The University of Newcastle, 2 John Hunter Hospital 

Craniocervical arterial dissection is a rare complication of 

cervical spine manipulation. If individuals at risk can be 

identified, appropriate contraindications for manipulation 

may be applied. In addition, if signs and symptoms of 

dissection can be more easily recognised medical treatment 

may be expedited. The aims of this study were to identify 



risk factors in the patient history and describe the presenting 

features of craniocervical arterial dissection. Medical 

records review of a retrospective cohort of patients from 

the Hunter and New England regions of New South Wales 

aged 55 years or less who had experienced radiographically 

confirmed vertebral or internal carotid artery dissection. 

These were compared with age and sex matched controls 

with stroke from some other cause. Records were inspected 

for details of clinical features, radiological investigations, 

presenting signs and symptoms, and preceding events. 

Medical records of 42 dissection patients (25 males) mean 

age of 37.7 years and 42 controls (21 males) mean age 42 

years were inspected. Eighteen patients had sustained 

internal carotid artery dissections, 23 vertebral artery and 

1 basilar artery dissection. Twenty-six (62%) dissection 

patients compared with 3 (7%) controls reported an episode 

of mild mechanical trauma to the neck or head within the 

preceding 2 weeks. Of these 11 (26%) dissection cases 

and 1 control, involved manual therapy applied to the 

cervical spine. Mild mechanical trauma to the head and 

neck, including manual treatment of the cervical spine 

may be associated with craniocervical arterial dissection. 

Cardiovascular risk factors for stroke were less evident in 

the dissection group (< 1 factor per case) compared to the 

controls (> 3). 

42 

Changes in corticomotor excitability to the trunk 

muscles during experimentally-induced acute low 

back pain 

Tsao H, Tucker K, Hodges PW 



Acute back pain is associated with altered motor coordination 

of trunk muscles. Whether acute pain can induce changes in 

excitability of corticomotor pathway to the trunk muscles, 

or whether this is related to changes in trunk muscle 

coordination remains unclear. Nine healthy individuals 

with no history of back or leg pain were recruited. Finewire 

intramuscular electrodes were positioned bilaterally 

in transversus abdominis (TrA) and obliquus externus 

abdominis (OE). Surface electrodes were placed bilaterally 

over the obliquus internus (OI), rectus abdominis (RA) and 

lumbar erector spinae (LES). Corticomotor excitability 

was assessed as the amplitude of motor evoked potentials 

(MEPs) to transcranial magnetic stimulation (TMS) at 

rest and during voluntary contraction to 10% maximum. 

Motor coordination was assessed as onset of trunk muscle 

activation during rapid arm movement. Acute pain was 

induced via injection of hypertonic saline (5% NaCl, 0.3 

ml) into L3/4 and L4/5 interspinous ligament. Corticomotor 

excitability and motor coordination were assessed before, 

during and after induced-pain. During pain, the amplitude 

of the response of TrA to contralateral cortex stimulation 

was reduced, whereas the responses of OE and LES to 

contralateral and ipsilateral cortical stimulation were 

increased. In addition, activation of TrA, but not the other 

muscles, was delayed during pain. The findings suggest that 

acute pain can induce changes in corticomotor excitability 

and motor coordination, but this depends on the individual 

and the muscle(s) involved. Further work is required to 

determine whether these changes during pain are explained 

by effects at the spinal cord or motor cortex. 

Driving plasticity in the motor cortex in chronic 

back pain 

Tsao H, 1 Galea MP, 2 Hodges PW 1 

1 

NHMRC Centre of Clinical Research Excellence in Spinal Pain, 

Injury and Health, The University of Queensland, Brisbane, 2 School of 

Physiotherapy, The University of Melbourne, Melbourne. 

The sensory and motor systems can reorganise following 

injury and learning of new motor skills. Recently we 

observed adaptive changes in motor cortical organisation 

in patients with chronic back pain, which are closely linked 

to changes in motor coordination. Although pain-related 

alterations in behaviour can be trained and are associated 

with improved symptoms, it remains unclear whether these 

meaningful functional outcomes are related to motor cortical 

reorganisation. Twenty individuals with chronic back pain 

performed either motor skill training or a control intervention 

of self-paced walking exercise for 2 weeks. Motor cortical 

excitability (motor threshold (MT)) and organisation (centre 

of gravity (CoG) and map volume) of the deep abdominal 

muscle, transversus abdominis (TrA), were investigated 

using transcranial magnetic stimulation (TMS). Postural 

motor behaviour of TrA was assessed during single rapid 

arm movements. Motor skill training induced an anterior 

and medial shift in motor cortical representation of TrA, 

towards that observed in healthy individuals. This shift was 

associated with improved postural motor performance. This 

was not observed following unskilled walking exercise. No 

changes in motor threshold or map volume were evident 

following either intervention. This is the first observation 

that motor training can reverse reorganisation of neuronal 

networks of the motor cortex in people with chronic pain. 

The observed relationship between cortical reorganisation 

and meaningful behavioural change provides unique 

insight into potential mechanisms that underlie recovery. 

The findings add weight to the benefits of specific motor 

training in chronic back pain management. 

Does an increase in active cervical rotation when sitting 

posture is corrected indicate the need for postural 

re-education? 

Tuttle NA, Newsham-West R, Offord S 


In the spirit of ‘Mythbusters’ we used a pragmatic approach to 

investigate assumptions underlying some aspects of clinical 

practice. Improvement in active rotation of the cervical spine 

when the patient’s posture is ‘corrected’ is often included as 

part of a physical assessment. We set out to determine if 

this improvement in active movement is a normal response 

rather than indicative of the need for postural re-education. 

Active cervical rotation was measured in 3 postures using a 

tri-axial orientation sensor in ten asymptomatic volunteers. 

Rotation in upright sitting was compared with sitting in a 

slumped posture and upright sitting and with the shoulders 

elevated. There was a significantly greater rotation in the 

upright sitting than in the slumped position (p = 0.02) of 6.5 

degrees (CI 0.1–12.9). There was a significant increase in 

rotation with the shoulders elevated (p = 0.01). The 7 of the 

subjects that had an improvement in rotation increased by an 

average increase of 11.2 degrees (CI 7.1–15.3 degrees) which 

is comparable to the increase reported in the literature for 

symptomatic patients. Possible causes of these differences 

will be discussed. Pain responses could not be assessed 

in our asymptomatic population, but it is suggested that 



any changes in either range of motion or pain in a patient 

population need to be greater than the changes in movement 

that occur with an asymptomatic population before the 

therapist would be justified in drawing conclusions on the 

need for postural re-education. 

Adhesive capsulitis: establishing consensus on clinical 

identifiers for stage one using the Delphi technique 

Walmsley S, Rivett DA, Osmotherly PG 


There is no gold standard for the diagnosis of stage 1 adhesive 

capsulitis. The aim of this study was to establish consensus 

among a group of experts regarding the clinical signs and 

symptoms indicative of the first or early stage of primary/ 

idiopathic adhesive capsulitis. The Delphi technique, a 

multi-stage process employing sequential questionnaires, 

each building on the results of the previous round to achieve 

expert consensus, was used in this study. Seventy Australian 

and New Zealand experts involved in the diagnosis and 

treatment of adhesive capsulitis completed the 3 rounds 

of questionnaires. Consensus was achieved on 8 clinical 

identifiers that, following factor analysis, clustered into 2 

discrete domains of pain and movement. For pain, these 

included a strong component of night pain, pain with rapid 

or unguarded movement, discomfort lying on the affected 

shoulder, and pain easily aggravated by movement. For 

movement, agreed clinical identifiers included a global loss 

of active and passive ranges of movement, with pain at the 

end of range in all directions. A final identifier was age of 

onset greater than 35 years. This is the first study to establish 

consensus on clinical identifiers indicative of the early stage 

of primary adhesive capsulitis. Whilst not constituting an 

exclusive or discriminatory set, these identifiers may assist 

the clinician in diagnosis as well as facilitate comparisons 

drawn across studies. The clinical identifiers that achieved 

consensus in this study form an important step in the process 

of establishing valid diagnostic criteria for the first stage of 

primary adhesive capsulitis. 

A case-control study investigating the effectiveness of 

scapular postural correction exercises on trapezius 

activity 

Wegner SE, Johnston V, Jull G 


Extensive computer use amongst office workers has 

lead to an increase in work-related neck pain. Aberrant 

activity within the 3 portions of the trapezius muscle has 

been identified as a contributing factor. The trapezius is a 

major scapular stabiliser, thus, scapular posture must also 

be considered. This study investigated the activity levels 

within the three portions of the trapezius muscle during the 

performance of a functional typing task in healthy controls 

with normal scapular posture (n = 20) and a group of neck 

pain patients with poor scapular posture (n = 18). A scapular 

postural correction exercise was used to determine if the 

correction altered activity in the trapezius in the case group. 

Surface electromyography was recorded from each portion 

of the trapezius-upper, middle and lower. During the typing 

task, a significant increase in the middle (p = 0.02) and 

lower portions (p = 0.03) of the trapezius was found in 

both groups. Despite variances in scapular posture, both 

groups had similar activity in the upper trapezius prior to 

the intervention (p = 0.99). Following the scapular postural 

correction exercise, activity recorded by the case group was 

similar in the middle and lower trapezeii (p = 0.93; p = 0.91) 

to the activity displayed by the control group. Upper trapezius 

activity remained similar between groups (p = 0.96). These 

findings indicate that scapular postural correction strategies 

may be effective in altering the distribution of activity in all 

portions of the trapezius to better reflect that displayed by 

controls. 

Usual care of low back pain in primary care 

and a comparison to evidence-based guideline 

recommendations 

Williams CM, 1 Maher CG, 1 Hancock MJ, 2 McAuley JH, 1,2 

McLachlan AJ, 4 Britt H, 4 Fahridin S, 4 Latimer J 1 

1 


2 


Sydney, 3 Faculty of Pharmacy, University of Sydney, 4 Family Medicine 

Research Centre, University of Sydney 

The aim of the study was to describe usual care provided 

by general practitioners to patients with acute low back 

pain (LBP) and to compare this with the care endorsed in 

evidence-based treatment guidelines. To determine usual 

care, data on 1706 patient visits to a general practitioner 

(GP) for new LBP were extracted from the Bettering the 

Evaluation and Care of Health study (a national survey 

of general practice) during the years 2005 to 2008. Care 

provided by GPs was mapped to key messages in treatment 

guidelines to evaluate whether current usual care aligned 

with international guidelines. New LBP patients accounted 

for only 2.2% of encounters seen by GPs. The most common 

treatment provided to patients was medication (65%). Nonsteroidal 

anti-inflammatory drugs were prescribed for 37.4% 

of patients and opioid medications for 19.6%. Over one 

quarter of patients were referred to imaging however only 

15.8% were recommended physiotherapy, which accounted 

for more than 90% of all allied health referrals. Less 

than 2% of patients were referred to a medical specialist. 

While guidelines advocate simple analgesics and advice as 

the first line of care for acute LBP, most patients did not 

get these two treatments (17.7% and 20.5% respectively). 

Usual care provided by GPs for patients with LBP does not 

appear to match care endorsed in international evidencebased 

guidelines. Further, GPs rarely refer patients to other 

providers who may be better placed to provide best evidence 

care. 

Spinal stabilisation exercise regime in subjects with 

chronic non-specific low back pain: a case series study 

Wisbey-Roth T 

Take Control Active Rehab 

The aims of this study were to investigate the short-term 

outcomes and prognostic indicators of outcome of a specific 

spinal stabilisation exercise regime (Bounce back classes) 

in subjects with chronic, non-specific low back pain. Five 

physiotherapy clinics that offered the Bounce Back exercise 

regime agreed to participate in this study. Data were 

collected prospectively from 51 participants with chronic 

non-specific low back pain. Outcome assessments for 

pain intensity (11-point Pain Numerical Rating Scale) and 

function (24-point Roland Morris Disability Questionnaire) 

were collected at baseline and after 8 weeks of intervention. 

Bounce back classes improved pain intensity and function 



in this population. The mean effect of exercise in pain 

intensity was 1.5 points (95% CI, 0.9–2.0, p < 0.001) 

and the mean effect in function was 3.1 points (95% CI, 

2.2–4.1, p < 0.001). We found evidence of an association 

between average of pain intensity at baseline and changes 

in pain (t48 = 2.987, p = 0.004) and also evidence of an 

association between average of Roland Morris at baseline 

and changes in function (t48 = 2.330, p = 0.024). We found 

preliminary evidence of effectiveness of Bounce Back 

classes in pain intensity and function in patients with 

chronic low back pain. This evidence should be confirmed 

in a randomised controlled trail design. This study has 

important implications for the management of chronic low 

back pain and represents an additional step towards the 

identification of those patients most likely to benefit from a 

spinal stabilisation rehabilitation approach. 

Functional outcome measures in patients with hip or 

knee osteoarthritis: the importance of a comprehensive 

assessment 

Wright AA, 1 Hegedus EJ, 2 Abbott JH 1 

1 

University of Otago, Dunedin, New Zealand, 2 Duke University Medical 

Center, Durham, USA 

Important decisions made by healthcare providers and 

health care policy makers regarding appropriate treatment 

and treatment effectiveness rely on the ability of outcome 

measures to represent patient outcomes adequately and be 

interpreted appropriately. Assessment of physical function 

is now regarded as an essential component to determining 

outcome in patients with hip or knee osteoarthritis. Selfreport 

and physical performance measures represent two 

ways of assessing function in patients with hip and knee 

osteoarthritis. Historically, self-report measures have been 

preferred over the use of physical performance measures 

when assessing function in patients with hip and knee 

osteoarthritis. However, recent evidence has questioned 

the long term responsiveness and content validity of selfreport 

measures for assessing function. In this perspective, 

we suggest self-report measures and physical performance 

measures address different constructs of function and 

offer complementary information, indicating a need for 

both. Further, we suggest using a ‘battery’ of physical 

performance measures representing several domains of 

interest, thereby capturing a more complete picture of 

function. We recommend the use of physical performance 

measures in all clinical trials – whether surgical or 

conservative interventions – to assess function in patients 

with hip and knee osteoarthritis. 

44 

Variables associated with progression of hip 

osteoarthritis: a systematic review 

Wright AA, 1 Cook CE, 2 Abbott JH 1 

1 

The University of Otago, Dunedin, New Zealand, 2 Duke University, 

Durham, USA 

As populations age and prevalence of hip osteoarthritis 

increases, healthcare providers must manage increasing 

demands for services. Evidence regarding progression 

of hip osteoarthritis can assist healthcare practitioners in 

determining expected patient prognosis and planning care. 

This systematic review of prospective cohort studies examines 

prognostic variables in patients with hip osteoarthritis. 

Articles were selected following a comprehensive search 

of MEDLINE, EMBASE, CINAHL, and AMED from 

database inception to October 2008 and hand searches of 

the reference lists of retrieved articles. Inclusion criteria 

involved estimates of the association between prognostic 

variables and progression of osteoarthritis; prospective 

cohort design; patients diagnosed with hip osteoarthritis 

based on established criteria; at least 1 year follow-up; and 

the full published text accessible. Two independent reviewers 

assessed the methodological quality of each study, and the 

association between prognostic variables and osteoarthritis 

progression. Eighteen articles met the inclusion criteria; 17 

were considered to be of ‘high quality’. Strong evidence 

of progression was associated with age, joint space width 

at entry, femoral head migration, femoral osteophytes, 

bony sclerosis, Kellgren/Lawrence hip grade 3, baseline 

hip pain, and Lequesne index ≥ 10. Strong evidence of no 

association with progression was associated with acetabular 

osteophytes. Evidence was weak or inconclusive regarding 

association between various other radiographic or clinical 

variables, molecular biomarkers, or use of non-steroidal 

inflammatory drugs. Overall, few variables were found to 

be strongly associated with progression of hip osteoarthritis 

and a variety of other variables were weakly predictive of 

outcome. 

Are passive mobilisations of shoulder region joints 

effective for the treatment of shoulder pain? 

Yiasemides R, Ginn KA, Cathers I 


The aim of this study was to examine the effectiveness 

of passive mobilisations applied to shoulder region joints 

for the treatment of shoulder pain of local mechanical 

origin. Following baseline outcome measurements of pain, 

functional impairment and painful range of motion, 98 

subjects with shoulder pain but no restriction of movement 

were randomly allocated to a control (n = 51) or experimental 

group (n = 47). Subjects in both groups received advice 

and exercises designed to restore neuromuscular control 

at the shoulder. In addition, subjects in the experimental 

group received passive mobilisations to shoulder region 

joints. The treating physiotherapists (n = 17) determined 

the specific mobilisation procedures applied. All subjects 

received between 4 and 8 treatments during a 1-month 

period. Baseline outcome measurements were then reassessed 

by a blinded researcher and self-perceived change 

in symptoms was measured. Treatment continued for a 

maximum of 12 treatment sessions over a maximum of 8 

weeks if deemed necessary. Blinded re-assessment of pain 

and functional impairment, self-assessed improvement and 

painful range of motion were repeated at 3 and 6 months. 

Outcome analysis was conducted using the intention-totreat 

principle. No statistically significant differences were 

detected between the control and experimental groups 

in any of the outcome measurements at 1, 3 or 6 months 

follow-up. This randomised controlled, clinical, trial clearly 

demonstrates that the addition of passive mobilisations to 

shoulder region joints is not more effective than advice and 

exercise alone in the treatment of shoulder pain without 

accompanying stiffness. 









2 

Establishing walking using treadmill training in 

non-ambulatory patients during inpatient stroke 

rehabilitation: the MOBILISE trial 

Ada L, 1 Dean C, 1 Morris M 2 

1 

The University of Sydney, Sydney, 2 The University of Melbourne, 

Melbourne 

The main objective of this randomised trial was to determine 

whether treadmill walking with partial weight support via an 

overhead harness was effective at establishing independent 

walking more often and earlier, than current physiotherapy 

intervention for non-ambulatory stroke patients. A 

prospective, randomised trial of inpatient intervention 

with a 6-month follow-up with blinded assessment was 

conducted. One hundred and twenty seven stroke patients 

who were unable to walk independently early after stroke 

were recruited and randomly allocated to an experimental 

group or a control group within 4 weeks of their stroke. The 

experimental group undertook up to 30 minutes of treadmill 

walking with partial weight support via an overhead 

harness per day while the control group undertook up to 

30 minutes of overground walking. The primary outcome 

was the proportion of participants achieving independent 

walking each week. At one month, 40% of the experimental 

group was walking independently compared with 28% of 

the control group, at 2 months 66% compared with 55% and 

at 6 months 69% compared with 60%. In addition, 50% of 

the experimental group were walking by 5 weeks whereas 

it took further 2 weeks until 7 weeks for 50% of the control 

group to be walking. There were few adverse events in 

either group. Treadmill walking with body weight support 

appears feasible, safe and results in more people walking 

independently after stroke and earlier. 

No change in the passive mechanical properties of the 

calf muscles in children with cerebral palsy following 

Botulinum toxin injections 

Alhusaini AA, 1 Crosbie J, 1 Shepherd RB, 1 Dean CM, 1 

Scheinberg A 2 

1 

The University of Sydney, Sydney, 2 Westmead Hospital, Sydney 

The aim of this study was to investigate the effect of 

Botulinum toxin type A injections (BTX-A) on the passive 

mechanical properties of the calf muscle in children with 

cerebral palsy (CP). A prospective biomechanical study 

before and 2–14 weeks after injection of BTX-A was carried 

out in a hospital outpatient clinic, using 16 children with CP, 

aged between 5 and 9 years, who were undergoing treatment 

for spasticity of the calf muscles using BTX-A injection. A 

specially constructed ankle measurement device was used 

to quantify the passive torque-angle characteristics of the 

calf muscle. The ankle was manually oscillated from full 

plantar flexion to full available dorsiflexion through 15 

passive cycles at velocities unlikely to elicit reflex muscle 

activity. Muscle activity was monitored using EMG analysis 

of the calf and anterior tibial muscles to ensure movement 

was passive. Measures of passive muscle compliance, 

torque to produce displacement at 3 angles, hysteresis and 

the gradient of the torque-angle curve, were analysed and 

compared before and after injection. Results indicate that 

there was slight increased angular displacement and torque 

required to move the ankle to 0º, and 5º DF after BTX-A 

injection. However, no significant differences in stiffness 

or hysteresis were detected following BTX-A. Despite any 

reduction in spasticity, the compliance of the calf muscle 

is relatively unchanged and continues to offer substantial 

resistance to passive motion. These findings suggest that 

additional treatment approaches are required to supplement 

the effects of BTX-A injections when managing children 

with calf muscle spasticity in cerebral palsy. 

Passive mechanical properties of the calf muscles 

in children with cerebral palsy compared to 

healthy children 

Alhusaini AA, 1 Crosbie J, 1 Shepherd RB, 1 Dean CM, 1 

Scheinberg A 2 

1 

The University of Sydney, Sydney, 2 Westmead Hospital, Sydney 

We examined the passive length-tension relationship in 

the myotendinous structure of the calf muscles of children 

with and without cerebral palsy (CP) under conditions 

excluding reflex muscle contraction. A cross sectional, 

non-interventional study was carried out in a hospital 

outpatient clinic. We quantified passive torque-angle 

characteristics of the ankle from full plantar flexion to full 

available dorsiflexion in 26 independently ambulant CP and 

26 age-matched typically developing (TD) children. Care 

was taken to ensure the child made no active contribution 

and the movement was unlikely to elicit reflex muscle 

activity, confirmed by the absence of EMG activity. There 

were no significant difference between the two groups 

for maximum ankle dorsiflexion, but we found a highly 

significant difference in the torque required to produce 

the same displacement (p < 0.001). Further, the hysteresis 

of the average loading cycle in the children with CP was 

over 3 times that of the TD children (p < 0.001). We 

believe that the calf muscles of children with CP are stiffer 

and intrinsically more resistant to stretch, although they 

retain normal excursion. This increased stiffness is often 

erroneously labelled as spasticity but is a non-neurally 

mediated feature of passive tissue compliance. The extent to 

which it influences function and predisposes these children 

to later development of soft tissue contracture is unknown. 

Support-group based exercise to address risk factors 

for falls in people with Parkinson’s disease: 


Allen NE, 1 Canning CG, 1 Sherrington C, 2 Fung VSC, 3 

Murray SM, 1 O’Rourke SD 1 

1 


International Health, The University of Sydney, Sydney, 3 Westmead 

Hospital, Sydney 

Leg muscle weakness, reduced balance and freezing are 

potentially remediable risk factors for falling in people 

with Parkinson’s disease. This randomised controlled trial 

with blinded assessment aimed to determine the effect of 

a 6-month support-group based exercise program on these 

risk factors. Forty-eight participants with Parkinson’s 

disease who had fallen or were at risk of falling were 

randomised into an exercise (n = 24) or control (n = 24) 

group. The exercise group attended one exercise class each 

month which included progressive leg strengthening and 

balance exercises as well as techniques to reduce freezing. 

Participants also exercised 3 times a week at home. Risk 

of falling was assessed with tests of: knee extensor muscle 

strength (kg); balanced standing (coordinated stability test) 

and freezing (Freezing of Gait Questionnaire). Physical 

abilities (fast walking speed and time to complete five 

repetitions of sit to stand), fear of falling and quality of 



life were also measured. The exercise group had greater 

improvements in freezing (mean = -2.8, 95% CI -5.4 to 

-0.3) and sit to stand time (mean = -1.9 s 95% CI -3.6 to 

-0.2) compared to the control group. The exercise group 

also showed trends toward improvement in knee extensor 

strength (p = 0.08), fast walking speed (p = 0.21) and fear of 

falling (p = 0.10) when compared to the control group. There 

were no between-group differences in balanced standing 

or quality of life. The exercise program improved two risk 

factors for falling in people with Parkinson’s disease. 

Does the ability to walk predict physical activity and 

community ambulation in community-dwelling people 

with chronic stroke? 

Alzahrani M, Dean C, Ada L 


The purpose of this study was to investigate whether walking 

performance as commonly measured in the clinic predicts 

free-living activity in community-dwelling stroke survivors. 

A cross-sectional observational study was carried out on 42 

community-dwelling people with stroke. Four aspects of 

walking performance were measured (speed, automaticity, 

capacity, and stairs ability). Two aspects of physical activity 

(time and activity counts) and two aspects of community 

ambulation (distance walked and average speed) were 

measured using an activity monitor. Pearson’s correlation 

coefficient was used to examine the relationship between 

walking performance and physical activity and community 

ambulation and then stepwise multiple regression analysis 

was used to examine which aspect of walking performance 

was the best predictor. Three aspects of walking performance 

(speed, capacity and stairs ability) were correlated with all 

aspects of physical activity and community ambulation (r 

= 0.53 – 0.74, p < 0.001). Fifty-four percent of the variance 

of time on feet (p < 0.001), 45% of the variance of activity 

counts (p = 0.02), 40% of the variance of distance walked 

(p = 0.05) and 48% of the variance of average speed (p < 

0.01) was explained solely by stairs ability. Adding any 

other measurement of walking performance explained a 

maximum additional 2% of physical activity or community 

ambulation. Although walking performance predicts 

physical activity and community ambulation in communitydwelling 

people after stroke, the ability to use stairs is the 

best single predictor. Adding up to three more measures 

walking performance does not increase the accuracy of 

prediction. 

Clinical measurement of muscle length 

Barber LA, Lichtwark GA, Barrett R 


Individuals with upper motor neuron disorders can develop 

spasticity and contracture which presents clinically as 

movement restrictions with reduced joint range of motion 

and muscle-tendon lengths. Muscle-tendon length is 

reduced in contracture due to shortening of the muscle belly 

length, however this is very difficult to quantify because 

a simple clinical measure of muscle belly length does not 

exist. Ultrasound imaging is effective at localising and 

allowing in vivo visualisation of superficial bony and soft 

tissue structures. This study compared a novel ultrasoundtape 

length measuring device to make measures of the 

medial gastrocnemius muscle belly length. In five subjects, 

the ultrasound-tape was used to measure the medial 

gastrocnemius muscle-tendon length (calcaneus to muscle 

insertion) and tendon length (calcaneus to muscle tendon 

junction) at 3 ankle joint angles (maximum dorsiflexion, 

30° and 60° maximum ankle range of motion) 3 times 

and muscle belly lengths were calculated (muscle-tendon 

minus tendon length). The muscle belly of the medial 

gastrocnemius was also scanned at the same ankle joint 

angles, three times using freehand 3D ultrasound. The 

ultrasound-tape was found to be a valid measure of muscle 

belly length, overestimating muscle belly length by only 

0.3 ± 1.9 mm (0.1 ± 0.8% difference) compared to the 

3D ultrasound measure. This simple tool may be used to 

monitor changes in muscle-tendon, muscle belly and tendon 

length during the development of contracture following 

neurological disorders such as cerebral palsy, stroke and 

multiple sclerosis. 

Resistance-exercise induced fatigue reduces 

performance on clinical tests of balance in women 

with multiple sclerosis 

Bathersby S, 1,2 Minahan C, 1 Kuys S, 2 Stroud N, 1 

Broadley S 1 

1 

Griffith University, Gold Coast, 2 Princess Alexandra Hospital, 

Brisbane 

The purpose of this study was to compare the effect of 

resistance-exercise induced fatigue on balance in women 

with multiple sclerosis (MS) and healthy controls. Nine 

with MS and nine age and physical activity matched women 

underwent lower-body resistance exercise to manifest 

resistance-exercise induced fatigue using a hack-squat 

machine at 70% 1RM. The main outcome measures were a 

series of balance tests including Functional Reach, Standing 

with Eyes Closed, Tandem Stance, Turn to Look Behind, 

Timed Up and Go, and the Shoulder Tug Test. Measures 

were recorded prior to, immediately, and 10 mins following 

the resistance-exercise induced fatigue protocol. At 

baseline, the MS group demonstrated significantly reduced 

performance for Tandem Stance and the Shoulder Tug 

Test. There were no significant differences in other balance 

measures between the two groups at baseline. Immediately 

following the resistance-exercise induced fatigue protocol 

the MS group had significantly reduced performance in the 

Functional Reach (25.8 cm, 95% CI 1.71–5.73) and Tandem 

Stance (5.78 s, 95% CI 6.24–19.76) but had returned 

to baseline following 10 minutes of rest (p > 0.615). 

Matched controls demonstrated no significant difference in 

balance following the resistance-exercise induced fatigue 

protocol (p > 0.999). In conclusion, immediately after 

resistance-exercise, women with MS demonstrated reduced 

performance on clinical tests of balance where the limits of 

stability (Functional Reach) were challenged and base of 

support (Tandem Stance) was decreased. Reduced balance 

after resistance-exercise induced fatigue has important 

safety implications for the prescription of resistanceexercise 

programs in women with MS. 



4 

Thirty hospitals and counting: developing a 

multicentre, international, stroke rehabilitation trial 

(AVERT) 

J.Bernhardt, 1,2 on behalf of the AVERT Collaboration 

1 


Institutes), Melbourne, 2 La Trobe University, Melbourne 

Large clinical trials are needed in stroke rehabilitation to 

help increase the evidence base. Over the past five years, 

we have developed and piloted a pragmatic trial protocol 

testing whether earlier and more intensive out of bed activity 

(mobilisation) commenced within 24 hours of stroke onset 

was safe and feasible, compared to usual care. The aim of 

A Very Early Rehabilitation Trial (AVERT) Phase III, is 

to now test whether the intervention is effective and cost 

effective. To detect a statistical and clinically meaningful 

difference in death and disability at 3 months post stroke, 

2104 patients need to be recruited to AVERT. A study of 

this size requires considerable engagement of the clinical 

community, particularly physiotherapists who play a major 

role in this study. Prior to study commencement, 10 hospital 

sites had expressed interest and participated in preliminary 

discussions. In 2006, key staff from these hospitals 

attended the investigators meeting, and by December 

2006 nine were recruiting. Since that time, a further 20 

hospitals from Australia, New Zealand, Canada, Scotland, 

Northern Ireland, Singapore and Malaysia have joined 

the collaboration. In our experience, critical requirements 

for building such a collaboration have been: clear, sound 

protocols; excellent communication with all stakeholders; 

user friendly trial interface for data entry, recruitment; 

flexibility of trial coordination procedures; genuine respect 

for contributors; and committed, enthusiastic collaborators. 

Developing a trial of this size has been challenging but 

rewarding. Few formal research networks exist within 

Australian physiotherapy. We hope that this network will 

continue beyond the life of the trial. 

How can physiotherapists help improve the quality 

of stroke care? 

Bernhardt J, 1 Kwakkel G, 2 von Koch L 3 

1 

Director, Very Early Rehabilitation Research Program & National 

Heart Foundation Fellow,National Stroke Research Institute (part 

of Florey Neuroscience Institutes), Melbourne; Assoc Professor, 

Department of Physiotherapy, La Trobe University, 2 Professor of 

Neurorehabilitation, VU University of Amsterdam, Movement Scientists 

and Physical Therapist, Department of Rehabilitation Medicine, VU 

University Medical Centre, Amsterdam and Rudolf Magnus Institute of 

NeuroScience, University Medical Centre Utrecht, The Netherlands, 

3 

Associate professor, Department of Neurobiology, Care Sciences and 

Society, Division of Occupational Therapy, & Department of Clinical 

Neuroscience, Division of Neurology, Karolinska Institutet, Stockholm, 

Sweden 

Physiotherapists belong to one of the few professions to 

have the privilege of practising with very little interference 

from their interdisciplinary colleagues. This privilege 

brings with it a strong responsibility to provide the very 

best care we can for our patients. Keeping up to date with 

changes in evidence and acting to overcome barriers to 

implementation of new and better practices is a considerable 

challenge for us all. Ensuring that physiotherapists remain 

valued as core members of any multidisciplinary stroke 

care team represents another challenge, particularly with 

the contracting health dollar. In the last 10 years we have 

seen the development of a range of tools designed to help 

improve the quality of care provided to people with stroke. 

These include best practice guidelines, local and national 

care audits, and stroke registries. In this session, speakers 

will provide an overview of the many efforts, nationally and 

internationally, to establish or improve stroke care standards. 

Julie Bernhardt will review process of care ‘indicators’ used 

to measure care as part of audit and feedback processes, 

how these align with Australian best practice standards 

and how well physiotherapy/rehabilitation practices are 

reflected within models. Gert Kwakkel will discuss how 

clinical guideline development interfaces with research, the 

limitations of guidelines and challenges of implementation 

as experienced in the Netherlands and beyond. Lena von 

Koch will share her experiences of guideline and registry 

development in Sweden and pose questions about how 

physiotherapists can best engage in the process of care 

improvement for people with stroke. A lively discussion of 

the issue should follow. 

Does Tai Chi improve strength and balance in people 

with multiple sclerosis: a pilot study 

Binns EE, 1,2 Taylor D, 1,2 Kayes NM, 1 McPherson KM 1 

1 

Health and Rehabilitation Research Centre, 2 School of Physiotherapy, 

AUT University, Auckland, New Zealand 

The aim of this pilot study was to examine the effect of Tai 

Chi practice on lower limb strength and balance in people 

with multiple sclerosis. A waiting list randomised design 

using two groups was employed. Adults with a diagnosis of 

multiple sclerosis were invited to participate in a 20-week 

Tai Chi program and were allocated to a group according 

to where they lived (north n = 14, west n = 15). One group 

was randomly selected to receive Tai Chi first while the 

other group was delayed entry into the Tai Chi program and 

thus acted as a non-intervention control group. Outcomes 

were the Timed Up and Go as a measure of functional 

mobility; 30 s chair stand test as a measure of lower limb 

strength; the Step test, 1 leg stand and the Berg Balance 

Scale as measures of balance. Pre-and post-intervention 

measurements were made. In the intervention group 

median scores on the 30 s Chair Stand test, Step test (right 

leg), 1 leg stand, and the Berg Balance Scale improved. In 

the control group median scores on the 1 leg stand and the 

Berg Balance Scale improved. None of the improvements 

in scores reached statistical significance (p > 0.05). Tai Chi 

may be an effective intervention to improve strength and 

balance in people with multiple sclerosis. As this was a pilot 

study it wasn’t powered to detect statistical significance 

although it does give us information to use in planning a 

larger study. 

Is achievement of short term goals a valid measure 

of patient progress in inpatient neurological 

rehabilitation? 

Black S, 1 Brock K, 1 Kennedy G, 2 Mackenzie M 1 

1 

St Vincent’s Hospital, Melbourne; 2 Peter James Centre, Melbourne 

The purpose of the study was to determine whether the use 

of short term goal setting is effective in monitoring patient 

progress in rehabilitation, with regard to achievement of 

goals for discharge and predicted length of hospital stay. 

Patients with neurological diagnoses were included in the 

study if their anticipated length of stay was three weeks 

or longer. At the first team meeting following admission, 

the team established goals for discharge, predicted length 



of stay and short term goals for the first two weeks of the 

admission. Goals were set in the domains of health, social, 

communication and cognition, mobility and activities of 

daily living (ADLs) and a composite goal of global function. 

Actual length of stay and discharge destination were 

recorded. Data from 54 consecutive cases were examined, 

with 46 cases returning home. The median length of stay 

was 49 days (IQs 30–73). Significant correlations (p < 0.05) 

were demonstrated between short term goal achievement 

and discharge goals for continence (rho = 0.62), transfers 

(rho = 0.5), walking (rho = 0.53), personal ADLs (rho = 0.47) 

and global function (rho = 0.65). For those who returned 

home, there were significant correlations (p < 0.05) between 

adherence to predicted length of stay and achieving their 

initial goals in transfers (rho = 0.42), walking (rho = 0.51) 

and global function (rho = 0.52). Short term goal setting is 

a valid measure of patient progress in inpatient neurological 

rehabilitation and can be used to identify patients who are 

not progressing as anticipated, facilitating review of the 

rehabilitation plan. 

Exploration of dynamic three-dimensional shoulder 

motion in people with stroke 

Blennerhassett JM, 1 Lythgo N, 2 Muir C, 1 Galea, MP 2 

1 

Austin Health: Royal Talbot Rehabilitation Centre, Melbourne, 

2 

Rehabilitation Sciences Research Centre, The University of Melbourne, 

Melbourne 

This study investigated shoulder motion in 6 people with 

stroke who scored 5 or more on the Upper Arm item of 

the Motor Assessment Scale. Participants were seated 

and performed 3 trials of bilateral shoulder flexion and 

abduction. Three-dimensional shoulder joint motion 

relative to the trunk was recorded by an eight camera Vicon 

Motion System and analysed using BodyLanguage software 

(Upper Body Model). The measures extracted were: angular 

displacement from the start position to the highest point 

of lift; and peak velocity and peak acceleration in early 

lift. Differences between the unaffected and affected arm 

were examined using Repeated Measures MANOVA. Start 

position for both shoulders did not differ significantly, and 

fell within 3 degrees. On average, peak abduction (p = 

0.002) and peak flexion (p = 0.04) at the highest point of 

the lift were 10 degrees less on the affected side. Early in 

the lifting phase, greater peak velocity was exhibited for 

the unaffected arm (abduction: affected = 62.8 degrees/s, 

unaffected = 70.9 degrees/s, (p = 0.006); flexion: affected 

= 79.6 degrees/s, unaffected = 84.4 degrees/s, (p = 0.05)). 

Peak acceleration was not significantly different for either 

movement. These findings support that the affected shoulder 

exhibits disordered motion relative to the unaffected side 

following stroke. This type of movement impairment may 

contribute to the development of shoulder pain but needs 

further investigation. 

Risk factors for developing shoulder pain 

following stroke 

Blennerhassett JM, Mackechnie K, Crean R. 

Austin Health: Royal Talbot Rehabilitation Centre, Melbourne 

This study explored factors that may increase the risk 

of developing shoulder pain during inpatient stroke 

rehabilitation. Ninety-four medical histories (63% of the 

available cohort) were audited retrospectively. Information 

about factors proposed to contribute to shoulder pain was 

obtained from the initial physiotherapist and occupational 

therapist assessments. People were deemed to have shoulder 

pain if it was documented within the clinical notes. Data 

were analysed to document the incidence of shoulder 

pain, and determine if the presence of risk factors differed 

between people with and without pain. Preparatory analyses 

were conducted to avoid overfitting and redundancy within 

the multivariate model. Logistic regression was then used 

to examine the multivariate relationship between risk 

factors and the development of shoulder pain. During 

inpatient rehabilitation, 35% of the sample experienced 

shoulder pain. 24% had shoulder pain on admission. The 

people with pain differed significantly (p ≤ 0.04) to those 

without pain for the presence of several factors such as 

younger age, longer time between onset and rehabilitation 

admission, impaired movement control of the arm (defined 

by Motor Assessment Scale (MAS) items), reduced passive 

range of movement, subluxation, and altered tone and 

sensation. No differences were found for many factors 

including neglect, cognitive impairment, side of stroke, and 

weight. The multivariate relationship between 5 key risk 

factors (shoulder range, MAS, subluxation, altered tone 

and sensation) and shoulder pain will be discussed. These 

findings may assist physiotherapists to identify people 

with stroke at risk of shoulder pain in order to implement 

preventative strategies. 

Hemiplegic shoulder pain: new mechanisms to explain 

an old problem 

Bosisto P 

Greenslopes Hospital Brisbane 

The most widely accepted theory to explain the cause of 

hemiplegic shoulder pain (HSP) and subluxation is that: 

‘Shoulder pain is caused by flaccid paresis, atrophic shoulder 

musculature and gleno-humeral subluxation resulting from 

the weight of the unsupported arm stretching the shoulder 

capsule and ligaments’. To date, much of the research to 

prevent HSP has been aimed at finding better ways to 

support the weight of the hemiplegic arm. Yet supports have 

been found to be ineffective in preventing pain. Despite 

this, nobody has so far questioned the Tobis theory. The 

paper challenges whether the Tobis theory for HSP deserves 

such wide acceptance. Passive stability mechanisms that are 

responsible for maintaining the integrity of the glenohumeral 

joint are examined and evidence is shown to demonstrate 

that these mechanisms, in an intact shoulder, are indeed 

competent at supporting the weight of the dependent arm. 

Primary injury to the hemiplegic shoulder must therefore 

be caused by mechanisms other than the effects of gravity. 

Evidence from anatomical studies on hemiplegic shoulders 

are analysed to determine what injuries have been found to 

occur most frequently in the hemiplegic shoulder. A review 

of common recommended practice for the management of 

the hemiplegic arm has identified 3 previously unreported 

mechanisms that may be responsible for these injuries. 

Discussion follows on how end of range internal rotation 

impingement, internal hyper-rotation injury and long head 

of biceps dysfunction could be implicated in the problem of 

HSP. New directions are proposed for researchers interested 

in the problem of HSP. 



6 

The reliability of assessment tools to measure 

unsupported sitting ability in people with 

spinal cord injuries 

Boswell-Ruys C, 1 Sturnieks D, 1 Harvey L, 2 

Sherrington C, 3 Middleton J, 2 Lord S 1 

1 

Prince of Wales Medical Research Institute, University of New South 

Wales, Sydney, 2 Rehabilitation Studies Unit and The University of 

Sydney, Sydney, 3 The George Institute, Sydney 

The aim of this study was to develop simple and reliable 

assessment tools to measure unsupported sitting ability 

in people with spinal cord injuries. Thirty adults with 

spinal cord injuries between C6 and L1 participated in 

this study. Subjects performed a battery of tests which 

were modifications of balance tests used in other health 

populations. Each subject was assessed on 2 different 

occasions to determine the test-retest reliability. The battery 

included a test of fast alternating arm reaching; timed 

unsupported sitting; a maximal torso leaning test; a test of 

co-ordinated stability; a seated upper body/arm reach test; 

and the donning/doffing of a T-shirt. Intraclass correlation 

coefficients demonstrated good to excellent reliability (0.72– 

0.91) for all 6 tests. The most repeatable tests were donning 

a T-shirt (ICC 0.91) and the test of unsupported maximal 

torso leaning (ICC 0.90). The Mann Whitney U test was 

applied to detect differences in chronicity and injury level. 

The fast alternating reach and T-shirt tests appeared to 

discriminate between subject injury level (p = 0.005 and 

0.003 respectively). The torso leaning, co-ordinated stability 

and seated reach tests appeared to discriminate chronicity 

(p = 0.002, 0.008 and 0.002 respectively). The tests were 

simple, quick to administer and reliable. The tests would be 

appropriate for research and clinical use in the assessment 

of unsupported sitting ability in people with spinal cord 

injuries. 

Task-specific training for improving unsupported 

sitting ability in people with chronic spinal cord 

injuries: a randomised controlled trial 

Boswell-Ruys C, 1 Harvey L, 2 Barker J, 3 Ben M, 3 

Middleton J, 2 Lord S 1 

1 



Sydney, Sydney, 3 Royal Rehabilitation Centre Sydney, Sydney 

The aim of this trial was to evaluate the effectiveness of 

a 6-week task-specific training program on the abilities of 

people with chronic spinal cord injuries to sit unsupported. 

Thirty adults with spinal cord injuries between T1 and T12, 

of at least 1 year duration, participated in this randomised, 

assessor-blinded trial. Participants in the training group (n 

= 15) performed up to 1 hour of task-specific training in 

unsupported sitting 3 times a week for 6 weeks. Participants 

in the control group (n = 15) did not receive any training 

or additional therapy. Primary outcome measures were the 

Canadian Occupational Performance Measure (COPM), 

and tests of Upper Body Sway, Maximal Balance Range and 

donning and doffing a T-shirt (the T-shirt test). The betweengroup 

mean difference (95% CI) for the Maximal Balance 

Range was 64 mm (95% CI 20–108 mm; p = 0.006). There 

were no significance between-group mean differences for 

the COPM and the Upper Body Sway and T-shirt tests. This 

trial shows preliminary support for intensive task-specific 

training to improve the abilities of people with chronic 

spinal cord injuries to sit unsupported. Further study is 

needed to determine the real-world implications of the 

observed treatment effects. 

The development of a falls efficacy scale for people with 

spinal cord injuries 

Boswell-Ruys C, 1 Harvey L, 2 Lord S 1 

1 



Sydney, Sydney 

The first aim of this trial was to develop a falls efficacy 

scale for people with spinal cord injuries to assess their 

fear of falling. The second aim was to determine the testretest 

reliability and concurrent validity of the scale. The 

scale was developed in consultation with spinal cord injury 

professionals. It was then administered to a cohort of 125 

people with either acute or chronic spinal cord injuries 

who used manual wheelchairs. The scale included 16 items 

describing activities of daily living specific to people with 

spinal cord injuries. The scale has excellent internal and 

test-retest reliability (Cronbach’s α = 0.92, ICC 0.93). Factor 

analysis revealed 3 underlying dimensions assessing fear in 

activities that require differing amounts of hand support 

and movement of the body’s centre of mass. The scale has 

good concurrent validity: it discriminates differences in fear 

of falling between groups differentiated by level of injury, 

falls incidence, independence in vertical transfers, as well as 

self-reported fear of falling and sitting ability. The scale is a 

valid and reliable tool for assessing falls efficacy in people 

with spinal cord injuries who use manual wheelchairs. It 

provides a way of evaluating different treatments aimed at 

addressing excessive fear of falling, and enhancing mobility 

and participation. 

The Toronto Western Spasmodic Torticollis Rating 

Scale (TWSTRS): a preliminary assessment of interrater 

reliability of neurologists and physiotherapists 

Boyce MJ,¹ Canning CG,² Latimer J, 3 Morris J,¹ Fung V,¹ 

Mahant N¹ 

¹Westmead Hospital, Sydney, ²The University of Sydney, Sydney, 3 The 

George Institute of International Health, Sydney 

The TWSTRS is the most widely-recognised assessment 

scale for measuring severity, disability and pain associated 

with cervical dystonia. Inter-rater reliability has been 

determined for neurologists, but not for neurologists and 

physiotherapists. As physiotherapists are involved in the 

treatment of people with cervical dystonia, it is important 

to gather some preliminary data that addresses the question 

of whether the TWSTRS can also be rated reliably by 

physiotherapists. We assessed the inter-rater reliability of 

scoring the clinical severity subscale of the TWSTRS with 2 

neurologists, who were experienced in rating the TWSTRS, 

and 2 physiotherapists, who were recently trained in the 

use of the scale. Nine individuals with cervical dystonia 

were assessed a total of 26 times and each assessment was 

videotaped. The assessments were then randomised onto a 

DVD and rated by the neurologists and physiotherapists. 

Reliability assessed by the inter-class correlation coefficient 

ICC (3,1) was 0.619 (p < 0.001, 95% CI 0.434–0.783). The 

clinical severity subscale of the TWSTRS can be assessed 

with good inter-rater reliability when physiotherapists and 

neurologists are represented in the rater pool. 



Task switching during dual task gait training is 

difficult for people with Parkinson disease 

Brauer SG, 1 Morris ME, 2 Lamont RL, 1 Woollacott M 3 

1 

The University of Queensland, 2 University of Melbourne, 3 University of 

Oregon, USA 

The aim of this study was to determine the effect of 

prioritisation during dual task walking training on gait 

under dual task conditions in people with Parkinson disease 

(PD). Forty people with PD attended a 20 minute dual task 

walking training session. Half were instructed to attend 

equally to gait and a variety of added cognitive tasks (50– 

50%, fixed priority). The other half was instructed to switch 

attention between tasks with every trial (e.g. 80% attention 

on cognitive task trial 1, 20% trial 2, variable priority). 

Spatio-temporal gait performance under dual task conditions 

and added task performance were measured pre and post 

training and compared between groups. Attendance to each 

task during training was evaluated via self reported visual 

analogue scales (VAS). Both groups showed an increase in 

dual task step length and speed with training (p < 0.001). 

There was no difference between groups in improvement in 

step length (p > 0.511) or speed (p > 0.686). The VAS scores 

indicated that the variable priority group did not switch 

attention between tasks as instructed (mean inaccuracy 

36% ± 18%), whereas the fixed priority group reported 

maintaining attention closer to their goal (mean inaccuracy 

10% ± 12%). Varying attentional priority between tasks is 

suggested to maximise dual tasking gains with training, 

however this cohort of people with PD found switching their 

attention between a gait and cognitive task from trial to trial 

(variable priority training) difficult. This strategy may be 

more useful as a progression in this population rather than 

an initial approach. 

Physiotherapy management of Friedreich ataxia 

Campagna EJ, Corben LA 

Friedreich Ataxia Clinic, Southern Health, Melbourne 

Friedreich ataxia is the most commonly inherited ataxia 

affecting approximately 1 in 29 000 people. This autosomal 

recessive neurodegenerative disease, affecting primarily the 

nervous system and heart, is characterised by progressive 

ataxia, peripheral neuropathy and spasticity. Other 

symptoms may include cardiomyopathy, hearing loss, visual 

disturbance and diabetes. Symptoms usually manifest in 

childhood, with average age of onset being 10 years. To date 

there are no proven therapies available to halt the progression 

of this condition, hence the main goal of multidisciplinary 

intervention is to reduce symptoms, prevent complications 

and maintain quality of life. Physiotherapists are an integral 

component of the multidisciplinary team in providing a 

holistic approach to the care of this complex progressive 

condition. Physiotherapists at the Friedreich ataxia clinic 

have developed a unique program for people with the 

condition that includes managing spasticity; maintaining 

gait, muscle strength, ankle range of motion, calf muscle 

length; core stability work; lower limb stretches; balance 

re-training and a generalised exercise program. This paper 

will present an overview of Friedreich ataxia, highlighting 

the international Friedreich ataxia clinic at Southern Health 

and the specialised physiotherapy program developed to 

meet the many needs of this condition. 

Online video-clip demonstrations of practical skills 

with supporting text enhances student learning 

Canning CG, Dean CM, Ada L, Harvey L, Crosbie J, 

Stark A, Kilbreath S 


Physiotherapy students are required to develop a large 

number of practical skills in their academic program prior 

to applying these skills during clinical placements. The 

purpose of this study was to evaluate the implementation 

of a new eLearning resource to support student learning 

of practical skills. Sixty physiotherapy students (92 %) 

enrolled in Neurological Physiotherapy II participated in the 

study. This unit incorporates two modules and each module 

includes 19 practical skills to be learnt. The eLearning 

resource was made available to students for all skills in 

one module, and no skills in the other module. For each 

skill, the resource includes a video-clip demonstration of 

correct skill performance with supporting text, embedded 

in a customised flash player. The resource was provided 

in addition to the usual live demonstration and supervised 

practice with feedback. The resource was used extensively 

by students, with over 90% of students accessing each skill 

online during the semester. All students who had used 

the eLearning resource reported that it made it easier for 

them to learn the practical skills and that the use of the 

resource should be extended to other units of study. Student 

performance in the end of semester practical exam was 8 

% (95% CI 4–12) better for skills included in the online 

eLearning resource compared to skills not included in the 

resource. Both performance and experience were enhanced 

by the use of this eLearning resource and further evaluation 

in academic and clinical environments is underway. 

The reliability of measuring scapula position in 

patients following stroke 

Choolun P, 1 Bisset L, 1,2 Tjin F, 1,3 Low Choy N 3 

1 

Royal Brisbane and Women’s Hospital, Brisbane, 2 Griffith University, 

Gold Coast, 3 Bond University, Gold Coast 

Stroke is the leading cause of chronic disability in Australian 

adults. Altered scapula position may be associated with 

development of hemiplegic shoulder pain, which occurs in 

up to 70% of stroke patients. The aim of this study was to 

establish intra-and inter-tester reliability of a simple clinical 

measure of scapula position in patients with hemiplegic 

stroke. Eighteen adults with hemiplegic stroke and no 

shoulder pain were recruited from the Royal Brisbane 

and Women’s Hospital. Three physiotherapists, blinded 

to each other and to their own measures, measured static 

scapula position. Participants were seated with support, and 

the distance between the scapula and thoracic spine was 

recorded using string and adhesive markers placed on the 

scapula and thoracic spine. Another investigator measured 

the string against a standard ruler and recorded the data. 

Intra-tester Intraclass Correlation Coefficients (ICC) were 

excellent (0.919–0.973), as were inter-tester correlations 

(ICC 0.881–0.941). ICCs for individual measures were 

fair to excellent (0.677–0.962). The poorest correlation 

between testers (session 1: ICC 0.727 and session 2: ICC 

0.677) was in measurement of the unaffected side (posterior 

acromion process to thoracic spine). Standard Error of the 

Measure (SEM) ranged from 7–12 mm. Simple clinical 

measures of static scapula position are reliable in patients 

with hemiplegic stroke, particularly for the affected side. 



Furthermore, a change in scapula position exceeding the 

SEM of 12 mm is indicative of a clinically relevant change, 

providing therapists with a reliable means of charting 

changes in scapula position over time. 

8 

Community ambulation: perceptions of clients after 

discharge from rehabilitation 

Corrigan RH 

Charles Sturt University, Albury, NSW 

Community ambulation is an activity only variously 

achieved by clients upon discharge from rehabilitation. The 

findings presented are part of a larger qualitative study using 

grounded theory methodology to explore the perceptions 

of clients and physiotherapists in rural and regional NSW 

around the topic of community ambulation. Ten clients 

who were receiving inpatient rehabilitation and were able 

to return to walking in their community were interviewed 4 

weeks post discharge. The interview, conducted in the client’s 

home, explored perceptions of barriers and facilitators to a 

return to community ambulation. Observational notes were 

taken to document client’s interactions with the interviewer, 

family members or friends that would add to the richness 

of the data collected. The barrier identified by clients to 

a return to community ambulation was fatigue. Fatigue, 

described as weakness, tiredness or lack of energy was 

perceived as influencing safety and endurance to complete 

activities in the community. Community connection or 

support was identified as facilitating community ambulation. 

The benefits of community interaction or support overrode 

client concerns about fatigue limited ambulation. Social 

interactions with members of the community and family 

were positive motivation for the resumption of community 

ambulation. These findings suggest that the mobility 

retraining received by these participants was not the 

primary factor in a return to community ambulation, and 

tools to evaluate improved mobility performance should 

include measures of social connection. 

A method of management of the severe acquired 

brain injury client that aims to establish a consistent 

environment to assist clients to reduce the time they 

spend in mass tonic patterns and enhance their 

opportunities to interact with the world around them 

Darcy M 

Private Practice 

People who sustain catastrophic brain injuries are frequently 

socially and physically isolated, with severe physical 

and communicative impairments. A great challenge for 

therapists working with such a population is to develop a 

highly skilled team of carers who know how to manage 

their family member or client’s severe tonic movement, and 

in doing so are able to enhance their physical, social and 

emotional well-being. This paper will explore the dynamics 

and outcomes achieved by establishing procedural routines 

for all aspects of care over a 24-hour period. It will present 

a model of care that addresses manual handling, positioning 

and movement procedures. By having well document 

procedural care guidelines and specific skills training 

carers are provide with the specialised knowledge to safely 

manage and provide comfortable positioning for people 

with extreme spasticity and minimal communication skills. 

Through the presentation of 3 case histories, this paper 

seeks to demonstrate how the establishment of a consistent 

procedural environment can facilitate greater range of 

movement and reduce fixed mass tonic patterns that often 

lead to significant muscle contracture. By establishing a 

consistent environment clients are able to learn to ‘let go’ of 

their tonic patterns and achieve more relaxed positions and 

establish greater consistent interaction with others. 

Improving walking using treadmill training in 

non-ambulatory patients during inpatient stroke 

rehabilitation: the MOBILISE trial 

Dean C, 1 Ada L, 1 Morris M 2 

1 

The University of Sydney, Sydney, 2 The University of Melbourne, 

Melbourne 

One of the objectives of this randomised trial was to 

determine whether treadmill walking with partial weight 

support via an overhead harness was more effective at 

improving walking than current physiotherapy intervention 

for non-ambulatory stroke patients. A prospective, 

randomised trial of inpatient intervention with a 6-month 

follow-up with blinded assessment was conducted. One 

hundred and twenty seven stroke patients who were unable 

to walk independently early after stroke were recruited and 

randomly allocated to an experimental group or a control 

group within 4 weeks of their stroke. The experimental 

group undertook up to 30 minutes of treadmill walking 

with partial weight support via an overhead harness per 

day while the control group undertook up to 30 minutes of 

overground walking. At 6 months, the 10-m Walk Test and 

the 6-min Walk Test were collected. There was no betweengroup 

difference in walking speed (p = 0.23). However, 

there was a trend towards participants in the experimental 

group walking faster (mean difference 0.09 m/s, 95% CI- 

0.06–0.25). At 6 months, the experimental group walked 62 

m (95% CI 13–111, p = 0.01) further than the control group 

in 6 min. For non-ambulatory stroke patients, treadmill 

walking with body weight support results in better walking 

capacity in the long-term. 

Recruitment of community-dwelling stroke survivors to 

the AMBULATE trial 

Dean CM, Lloyd G, Ada L 


Recruitment to clinical trials is often slow and difficult with 

a growing body of literature examining this issue. However 

there is very little work related to stroke. Studies in acute 

stroke report recruitment rates of 10–20%. The aim of 

this study was to examine the effectiveness of recruitment 

of the first 60 community-dwelling stroke survivors to a 

clinical trial (the AMBULATE trial) aiming to improve 

community ambulation. Recruitment strategies fell into 2 

broad categories: written (such as newspaper advertising 

and media releases), and professional and personal contact 

(hospital and community physiotherapists, a stroke liaison 

officer and other researchers). Records were kept of the 

number of people who were screened, were eligible and 

were recruited for each strategy. The recruitment target of 

60 was not met. One hundred and eleven stroke survivors 

were screened and 57 were recruited (a recruitment rate of 

51%). The most successful strategy was contact via hospitalbased 

physiotherapists (47% of recruited participants) and 

the least successful were media release and local newspaper 



advertising. The professional and personal contacts were all 

more efficient than any of the written strategies. In general, 

recruitment was inefficient and costly in terms of human 

resources. Given that stroke research is under-funded, it is 

important to find efficient ways of recruiting stroke survivors 

to clinical trials. A national database similar to other 

disease-specific data bases (such as the National Cancer 

Database) is urgently needed. In the interim, recruiting for 

several clinical trials at once may increase efficiency. 

Passive mechanical properties of gastrocnemius 

muscles of spinal cord injured patients with ankle 

contractures 

Diong JHL, 1,2 Kwah LK, 1,2 Clarke JL, 2 Hoang PD, 4 Martin 

JH, 4 Clarke EC, 1,4 Gandevia SC, 4 Bilston LE, 4 Ling M, 5 

Harvey LA, 3 Herbert RD 1 

1 

The George Institute for International Health, Sydney., 2 The University 

of Sydney, 3 Rehabilitation Studies Unit, Sydney, 4 Prince of Wales 

Medical Research Institute, Sydney, 5 Prince of Wales Hospital, Sydney 

Contracture is common after spinal cord injury. It is thought 

that contracture may be due to adaptations of the muscle 

fascicles, tendons or both. Until recently it has not been 

possible to measure the passive mechanical properties of 

muscles and tendons in humans in vivo. The aim of this 

study is to compare the passive length-tension properties of 

the gastrocnemius muscle-tendon unit, muscle fascicles and 

tendons of people with contractures in the calf muscles after 

spinal cord injury with healthy controls. Four participants 

(aged 24–42 years) with a spinal cord injury and 6 control 

subjects (aged 28–47 years) have been tested; the intention is 

to test a further 16 spinal cord injured subjects and a further 

14 control subjects. Data on spasticity, lower limb strength, 

and the American Spinal Injury Association (ASIA) motor 

and impairment scores have been collected. In addition, 

passive ankle angle and torque data were obtained at 6 

knee positions and combined with ultrasound measures of 

fascicle length and pennation. These data will be used to 

obtain length-tension relationships of the gastrocnemius 

muscle-tendon unit, muscle fascicles and tendons. The data 

will be used to make inferences about changes in muscletendon 

properties, and the contribution of tendon and muscle 

fascicles to changes in muscle-tendon properties, in calf 

muscles of spinal cord injured patients with contracture. 

Loss of muscle mass after stroke: a systematic review 

English CK, 1 McLennan HJ, 1 Thoirs K, 1 Bernhardt J 2 

1 

University of South Australia, Adelaide, 2 National Stroke Research 

Institute, Melbourne 

Loss of skeletal muscle mass after stroke has potentially 

devastating health consequences. In addition to the impact 

on function, loss of muscle reduces the body’s ability to break 

down glucose. Research suggests this may lead to a 2–3 fold 

increase in the risk of future stroke. The aim of this review 

was to determine the current level of evidence about the rate 

and magnitude of loss of skeletal muscle mass after stroke. 

All relevant databases were searched using combinations 

and variations of the terms ‘stroke’ and ‘skeletal muscle 

mass’. Only primary research papers using direct measures 

of muscle mass in human, adult stroke participants were 

included. A total of 13 papers of moderate quality were 

included in the final review with a mean quality score 2.4 

out of 4. Twelve of the 13 studies included participants at 

least 6 months after stroke onset and examined differences 

in muscle mass between the paretic and non-paretic limbs. 

Only 4 studies included measures of muscle loss early after 

stroke. All except 1 study reported statistically significant 

reduction in lean muscle mass in the paretic versus nonparetic 

limb by 6 months after stroke in the order of 4.9 

± 2.3%. What is not known is when within the 6 months 

after stroke the majority of this loss occurs and the exact 

relationship between loss of muscle mass and metabolic 

dysfunction. Further research is required to determine the 

extent and rate of muscle loss early after stroke and whether 

exercise based therapy can ameliorate this loss. 

Ten-metre walking speed and six-minute walking 

distances: comparing between hemiplegic patients 

and matched-age healthy individuals 

Foongchomcheay A 

Department of Physical Therapy, Faculty of Allied Health Sciences, 

Chulalongkorn University, Thailand 

Ability to walk with an optimal speed and endurance is 

important for hemiplegic patients before being discharge 

from a rehabilitation program. Walking speed is typically 

measured by timing individuals while they walk over 

short distances, such as a 10-metre walking path. Walking 

endurance can be measured with the six-minute walk tests. 

This study aimed to compare comfortable walking speed over 

10 meters and distance walked in 6 minutes in hemiplegic 

patients and matched-age healthy individuals. This study 

was also compared the distance walked in 6 minutes 

with the distance predicted by 10-meter speed and by a 

reference equations reported by Enright and Sherrill (1998). 

Convenient samples were recruited from patients attending 

rehabilitation programs at the physical therapy department 

of Thai Red Cross Rehabilitation Center and staff at faculty 

of Allied Health Sciences, Chulalongkorn University. All 

hemiplegic patients with first stroke, matched-age healthy 

individuals, who were more than 50 years old, were invited 

into the study. Written consents were obtained before 

data were collected. Twelve hemiplegic patients and 12 

matched-age healthy individuals participated in this study. 

Hemiplegic patients had significant reductions in 10-meter 

speed and 6-minute distance compared with matched-age 

healthy individuals (p < 0.05). The average distance walked 

in 6 minutes by hemiplegic patients was only 17% of the 

distance predicted from the reference equations. Walking 

speed and walking endurance of hemiplegic patients is 

below from those of matched-age healthy individuals. 

The reference equations reported by Enright and Sherrill 

are unsuitable for calculating walking distance for Thai 

hemiplegic patients. 

Efficacy of electrical stimulation for increasing 

strength in the wrist muscles of people with tetraplegia: 


Glinsky J, 1 Harvey L, 1 van Es P, 2 Chee S, 3 Gandevia SC 4 

1 

Rehabilitation Studies Unit, University of Sydney, Sydney, 2 Maastricht 

University, The Netherlands, 3 Prince of Wales Hospital, Sydney, 

4 

Prince of Wales Medical Research Institute, Sydney 

The aim of this double blind randomised controlled trial was 

to determine whether the addition of electrical stimulation 

to progressive resistance training increases the voluntary 

strength of the wrist muscles in people with tetraplegia. 

Sixty-four wrists of 32 people with tetraplegia and bilateral 

weakness of the wrist extensor or flexor muscles (grade 2/5 to 



4/5 muscle strength) were recruited for the study. A withinsubjects 

design was used whereby subjects’ wrists were 

randomly allocated to one of two conditions. Wrist muscles 

of the experimental arm received electrical stimulation 

superimposed on progressive resistance training. The wrist 

muscles of the contralateral arm received sham electrical 

stimulation superimposed on progressive resistance 

training. Both arms received 6 sets of 10 contractions 

3 times a week for 8 weeks such that the only difference 

between arms was the application of electrical stimulation. 

The primary outcome was maximal voluntary isometric 

strength. Secondary outcomes were a fatigue resistance 

ratio representing voluntary and electrically-stimulated 

endurance. Measurements were taken at the start and end 

of the 8-week treatment period. The mean treatment effect 

(95% CI) of electrical stimulation for voluntary strength 

was 0.04 Nm (95% CI, -0.5–0.6). The mean treatment effect 

(95% CI) for fatigue ratio representing voluntary endurance 

and electrically-stimulated endurance was -0.01 (95% 

CI, -0.1–0.1) and -0.07 (95% CI, -0.3 to 0.1), respectively. 

Voluntary strength of the wrist is not enhanced by the 

addition of electrical stimulation to progressive resistance 

training programs in people with tetraplegia. 

10 

The reliability and validity of the RT3 accelerometer 

to measure daily physical activity in people with 

neurological disability 

Hale L, Pal J, Becker I 

Centre for Physiotherapy Research, University of Otago, Dunedin, New 

Zealand 

Participating in physical activity is an essential component 

for maintaining good health. A variety of motion sensors 

have been developed to measure physical activity in the 

free living situation but work is still required to establish 

their psychometric properties particularly for use with 

people with chronic disability. This repeated measures 

study investigated the reliability and validity of the 

RT3 accelerometer to measure daily physical activity in 

people with neurological disability. The voluntary sample 

comprised 47 independently mobile adults (aged 28–91 

years) with Parkinson’s disease (n = 7), multiple sclerosis 

(n = 11), chronic stroke (n = 20) and healthy but sedentary 

controls (n = 9). On 2 separate occasions participants wore 

the RT3 continuously during waking hours for 7 days and 

completed the 7-day recall questionnaire. The RT3 reliably 

measured free-living physical activity (ICC = 0.85, 95% CI 

0.74–0.92; p < 0.001); however on repeated testing the value 

of the second measurement may differ by 23% with that of 

the baseline value. Mean daily RT3 data collected in the 

first 3 days differed significantly to that of the mean daily 

RT3 data collected over 7 days. Scatter plots demonstrated 

that the RT3 appeared to better distinguish level of mobility 

and diagnosis than the 7-day recall questionnaire. The 

Parkinson’s disease group was least active, followed by the 

stroke group; the control group was the most active group. 

The RT3 provides a moderately stable measure of free-living 

physical activity and was well tolerated by participants. 

Are regular passive movements effective for the 

treatment and prevention of contractures? 

Harvey LA, 1 Herbert RD, 2 Glinsky J, 1 Moseley A, 2 

Bowden J 1 

1 


Medicine, University of Sydney, Sydney, 2 The George Institute for 

International Health, Sydney 

It is widely believed that passive movements are important 

for the treatment and prevention of contractures and 

therefore an essential part of the ongoing physical care of 

people with spinal cord injuries. However, the provision of 

passive movements throughout a patient’s life is a costly 

and time-consuming practice, and as yet no clinical trial 

has ascertained whether passive movements are truly 

therapeutic. The aim of this trial was to determine the 

effects of 6 months of regular passive movements on 

ankle joint mobility in people with spinal cord injuries. 

Twenty people with tetraplegia living in the community 

had 1 ankle randomised to a control group and the other 

to an experimental group. Carers administered passive 

movements to participants’ experimental ankles for 20 

minutes, 5 times a week over a 6-month period. The control 

ankles were left untreated. The primary outcome was 

passive ankle dorsiflexion. This decreased by a mean (SD) 

of 2 degrees (4) in control ankles and increased by 2 degrees 

(4) in experimental ankles. The mean (95% CI) effect on 

ankle dorsiflexion range of motion was 4 degrees (95% CI 

2–6). These results reflect a small treatment effect following 

a very intensive 6-month program of passive movements. 

Less intensive programs of passive movements, as typically 

used in the community, could be expected to have an even 

smaller therapeutic effect. Therefore, the routine provision 

of passive movements can only be justified if the effects of 

passive movements accumulate over many years. This may 

or may not be the case. 

Does a circuit class provide a fitness training stimulus 

for people with traumatic brain injury? 

Hassett LM, 1 Moseley AM, 2 Khatri B, 1 Barry SC, 1 Jones 

TM 1 

1 

Brain Injury Rehabilitation Unit Liverpool Health Service, Sydney, 

2 

The George Institute of International Health, University of Sydney, 

Sydney 

The primary aim of this study was to investigate the ability 

of a circuit class to provide sufficient exercise dosage (caloric 

expenditure of 300 kilocalories) for a fitness training effect 

in adults with traumatic brain injury. An observational 

descriptive study was conducted within a circuit class run 

3 days per week at a brain injury rehabilitation unit. The 

class consists of 10 exercise stations of strength, fitness, and 

task specific exercises; followed by a walking race. Heart 

rate monitors were used to record and collect the following 

data: average exercise duration, kilocalories burnt, average 

and maximum heart rates, and time spent above 50% heart 

rate reserve. Twenty-five adults with severe traumatic brain 

injuries from the inpatient (11), transitional living (10), and 

community (4) programs of a brain injury rehabilitation unit 

participated in the study. Participants attended on average 2.5 

sessions per week for average class duration of 51 minutes. 

Considerable variation in exercise intensity was measured 

within participants from session to session. The mean 

(SD) kilocalories burnt was 362 (120), with 14 participants 

(56%) exercising at sufficient exercise dosage for a fitness 

training effect. The mean (SD) average and maximum heart 

rates were 123 (17) and 156 (22) bpm respectively, and the 

mean (SD) time spent above 50% heart rate reserve was 12 

(13) minutes. The low intensity long duration structure of 

a circuit class can provide sufficient exercise dosage for a 

fitness training effect. Heart rate monitors should routinely 

be used during fitness training to monitor exercise dosage. 



Evaluation of balance and gait in subjects with 

multiple sclerosis 

Ilett P, 1,3 Lythgo N, 2 Martin C, 3 Brock K 1 . 

1 

St Vincent’s Health, Melbourne, 2 Rehabilitation Science Research 

Centre, The University of Melbourne, 3 School of Physiotherapy, The 

University of Melbourne 

This study investigated the balance and gait of 11 

participants with multiple sclerosis and 11 healthy ageand 

gender-matched control participants. Ground reaction 

forces and centre of pressure movements were recorded by 

force plates (2000Hz) in 3 trials of single limb standing. 

Balance was further evaluated by the distance reached in 

the Lateral Reach Test and the fastest time to complete the 

Four Square Step Test. Gait at self-selected velocity (6 trials) 

was evaluated by ground reaction forces (Advance Medical 

Technology Incorporated force plates 2000Hz), ankle 

kinematics (Vicon Motion Analysis System, 100Hz) and 

spatio-temporal measures (GAITRite® walkway system, 

80Hz). Statistical analysis compared the groups using unidirectional 

non-parametric testing incorporating family-wise 

Bonferroni error correction for repeated measures. Results 

demonstrated the multiple sclerosis group had impaired 

performance of balance with a statistically significant 

increase in vertical ground reaction force variability (p = 

0.008) in single limb standing, reduced distance reached 

in the Lateral Reach Test (p = 0.001) and increased time 

to complete the Four Square Step Test (p < 0.001). In the 

gait trials the multiple sclerosis group exhibited less vertical 

force at terminal stance (p < 0.001), less anteroposterior 

propulsive force (p = 0.004), less maximal ankle plantar 

flexion range of movement (p = 0.001), less self-selected 

gait velocity (p = 0.005), increased vertical ground reaction 

forces in midstance (p = 0.005) and increased percentage of 

the gait cycle in double limb support (p = 0.005). This study 

provides further evidence of balance and gait limitations in 

people with multiple sclerosis. 

The immediate effect of an intervention based on the 

Bobath concept on balance and gait of people with 

multiple sclerosis 

Ilett P, 1,3 Lythgo N, 2 Martin C, 3 Brock K 1 

1 

St Vincent’s Health, Melbourne, 2 Rehabilitation Science Research 

Centre, The University of Melbourne, 3 School of Physiotherapy, 

The University of Melbourne 

This study investigated the immediate effect of a single 

intervention based on the Bobath concept on the balance and 

gait of 11 subjects with multiple sclerosis. The intervention 

was delivered to the foot and ankle with the greater 

impairments. Ground reaction forces and centre of pressure 

movements were recorded by force plates (2000Hz) in three 

trials of single limb standing. Balance was further evaluated 

by the distance reached in the Lateral Reach Test and the 

fastest time to complete the Four Square Step Test. Gait 

at self-selected velocity (6 trials) was evaluated by ground 

reaction forces (Advance Medical Technology Incorporated 

force plates 2000Hz), ankle kinematics (Vicon Motion 

Analysis System, 100Hz) and spatio-temporal measures 

(GAITRite® walkway system, 80Hz). The measures of 

balance and gait were assessed immediately before and after 

a 20-minute intervention based on the Bobath concept to 

the most impaired foot and ankle. Analysis was completed 

with uni-directional non-parametric testing incorporating 

family-wise Bonferroni correction for repeated measures. 

Following the intervention the MS subjects had significant 

reductions in medio-lateral (p = 0.002) and vertical (p = 

0.016) ground reaction force variability in the single limb 

standing task, and reduced time to complete the Four Square 

Step Test (p = 0.006). Maximal ankle plantar flexion range 

(p = 0.002) during gait increased significantly following 

the intervention. The results show that a single treatment 

based on principles of the Bobath concept to the foot and 

ankle complex can result in improvements in balance and 

ankle plantar flexion during gait in people with multiple 

sclerosis. 

Implementation of stroke guidelines 

Judd EA, 1 Said CS 1,2 

1 

Austin Health, Melbourne, 2 University of Melbourne, Melbourne 

In 2006 a multidisciplinary working party evaluated whether 

rehabilitation of stroke patients in Austin Health Aged Care 

Inpatient Services complied with the Clinical Guidelines 

for Stroke Rehabilitation and Recovery developed in 2005. 

The working party reviewed the recommendations and 

completed a self-assessment of compliance. The working 

party determined that our service did not fully comply with 

24 of the 68 recommendations, which were identified in 

all 5 sections. Some of the unmet recommendations were 

resolved by the team, whereas others were assigned to 

individual disciplines for further review. Several changes 

in practice have been implemented following the review. 

One of the major recommendations addressed with hospital 

management was to have all people with stroke admitted 

to a rehabilitation stroke unit. Information Packs, using the 

National Stroke Foundation information sheets, are now 

distributed to all these patients. Coincidental development 

of a multidisciplinary discharge summary for all aged 

care inpatients assisted with meeting discharge guidelines. 

Education to nursing staff on care of the stroke shoulder 

and mobility has been provided, and is now part of their 

routine inservice program. Within the physiotherapy 

department, an FES shoulder protocol has been developed 

and implemented. Each of these changes has been evaluated 

using various methodologies ( patient surveys, clinical 

practice audits).Three years on 15 further guidelines have 

been met. While meeting the guidelines can be considered 

a ‘work in progress’, the results highlight how clinical 

guidelines can be used to change clinical practice and 

improve patient care. 

Stretch interventions for contractures: 

a Cochrane systematic review 

Katalinic OM, 1 Harvey LA, 1 Herbert RD, 2 Moseley AM, 2 

Lannin NA, 1 Schurr K 3 

1 

Rehabilitation Studies Unit, Sydney, 2 The George Institute for 

International Health, Sydney, 3 Bankstown Hospital, Sydney 

The aim of this systematic review was to determine the 

effectiveness of stretch interventions for the treatment and 

prevention of contractures in at-risk patients. We searched 

the Cochrane Central Register of Controlled Trials, DARE, 

HTA, Cochrane Musculoskeletal Group Specialised 

Register, MEDLINE, CINAHL, EMBASE, SCI- 

EXPANDED, PEDro, WHO international clinical trials 

registry platform as well as reference lists of included studies 

and relevant review articles. We considered all randomised 

controlled trials of stretch interventions (sustained passive 



stretching, positioning, splinting and serial casting) applied 

for the purpose of treating or preventing contractures. Two 

reviewers independently selected trials, extracted data, and 

assessed risk of bias. We contacted trialists for additional 

information. Pooled estimates were obtained using a fixedeffects 

model or, if there was evidence of heterogeneity, 

with a random-effects model. Here we present results from 

a preliminary analysis. Thiry-one trials were included. In 

neurological populations, stretch increased joint range of 

motion by 1 degree (95% CI 0–3) in the short-term (< 24 

hours after last stretch), by 1 degree (95% CI 0–2) in the 

intermediate term (< 1 week after last stretch) and by 0 

degrees (95% CI -2–2) in the longer-term (≥ 1 week after 

last stretch) when compared with no treatment or usual care. 

The results of this review do not support the use of stretch 

interventions for the treatment or prevention of contractures 

in neurological populations. 

12 

Physiotherapyexercises.com: where to from here? 

Katalinic O, 1 Glinsky J, 1 Harvey L, 1 Sydney 

physiotherapists 2 

1 


Medicine, University of Sydney, 2 Sydney’s government-funded hospitals 

and universities 

The physiotherapy exercise website is a not-for-profit 

initiative of Sydney physiotherapists (the website can be 

freely accessed at www.physiotherapyexericses.com). The 

website contains over 750 exercises appropriate for people 

with neurological disabilities. Each exercise is illustrated 

with a sketch and photograph, and has explanatory text 

written in two formats: one appropriate for therapists and 

the other appropriate for patients. The website enables 

users to search for appropriate exercises and then collate 

them into professional-looking exercise booklets. There are 

currently adult and paediatric exercises appropriate for those 

with spinal cord injury, stroke, brain injury and cerebral 

palsy with plans to expand to other disability groups. All 

exercises are selected by committees comprising Sydney’s 

leading clinicians and academics. In this way, the website 

provides a way of harnessing the training strategies of 

experienced therapists for all to use. The website has been 

translated into Chinese, Vietnamese, Russian and Arabic. 

The success of the website has been evaluated using on-line 

questionnaires and site tracking. For example, the website 

has attracted 200 000 visitors from over 150 countries in 

the last 18 months. There are now plans to further expand 

the website and develop online learning modules. 

The efficacy of the addition of group work to improve 

arm function for inpatients following traumatic or 

non-traumatic acquired brain injury 

Killington MJ, Snigg M 

Brain Injury Rehabilitation Services of South Australia, 

Hampstead Rehabilitation Centre 

There is a plethora of evidence to suggest that patients in 

rehabilitation units spend between one third to a half of 

their day not engaged in therapeutic activities. A number 

of studies indicate that arm function following an acquired 

brain injury (ABI) improves if arm therapy intervention or 

the amount of practise is increased. People with an ABI 

are often unable to practise physical activities on their 

own outside of therapy sessions. Some researchers have 

demonstrated that undertaking therapy in group situations 

can provide the extra intervention that is recommended 

by these studies and result in improved outcomes for 

patients. Group therapy is efficient use of staff resources, 

takes advantage of group dynamics, and facilitates healthy 

competition and cooperation between patients. The 

purpose of this research was to investigate the efficacy 

of group therapy to improve arm function in 7 young 

adults following an ABI. The research was in the form of 

a series of single case studies, with an A-B-A design. For 

each subject, a series of functional (Action Research Arm 

Test, Motor Assessment Scale, Goal Attainment Scaling) 

baseline assessments and 2 subsequent assessments at 

2-weekly intervals were performed. The last assessment 

was performed 2 weeks after cessation of the program to 

determine any carryover effect. The arm therapy provided 

in a group situation resulted in significant improvements 

in some measures (p < 0.05). These results indicate that 

a change in therapeutic approach may be useful and that 

group work may be an efficient way of providing additional 

resources to patients following an ABI. 

High prevalence of mobility-related predictors of 

falling in stroke club members 

Kirkham C, 1,3 Sherrington C, 1,2 Dean CM, 1 O’Rourke S, 1,2 . 

Sharkey M, 3 Rissel C 1,4 

1 


International Health, The University of Sydney, Sydney, 3 Stroke 

Recovery Association of NSW, 4 Sydney South West Area Health Service, 

Sydney. 

Falls are a major public health problem and are particularly 

common after stroke. Impaired sit-to-stand performance 

and slower gait speeds are predictors of multiple falls in 

the general older population. This study aimed to establish 

the prevalence of these risk factors in a group of long term 

community-dwelling stroke club members who agreed 

to take part in a clinical trial of support-group-based 

exercise. Data were available for 140 participants who were 

an average of 5.7 years post-stroke (SD = 6.2, median = 

3) and had an average age of 67.2 years (SD = 13.4). The 

average time to walking 10 metres at a comfortable speed 

was 24.7 seconds (SD = 31.1). The average time to sit-tostand 

5 times was 23.6 secs (SD = 13.2). A gait speed of 1 

m/s (10 seconds to complete a 10-metre walk) and a time 

to complete 5 sit to stands of 12 seconds have been found 

to be the optimal cut-offs for predicting multiple falls in a 

community-dwelling sample. The majority of participants 

performed more poorly than these cut-off values; 73% for 

gait speed and 88% for sit-to-stand. This population is at an 

increased risk of falling. Our ongoing study will investigate 

whether performance on these mobility-related predictors 

of falling can be improved by exercise. 

High-intensity treadmill walking during inpatient 

rehabilitation: feasibility of a randomised trial 

Kuys SS, 1,2 Brauer SG, 1 Ada L 3 

1 

The University of Queensland, Brisbane, 2 Princess Alexandra 

Hospital, Brisbane, 3 The University of Sydney, Sydney 

The aim of this study was to examine the feasibility and 

efficacy of conducting a 6-week high-intensity treadmill 

walking intervention in people with stroke newly able to 

walk. A single-blind randomised preliminary study was 

conducted. Thirty participants with stroke undergoing 

inpatient rehabilitation were recruited and randomised to 



an experimental group (n = 15) who received 30 minutes 

of high-intensity treadmill walking in addition to usual 

physiotherapy or a control group (n = 15) who received 

usual physiotherapy only. Main outcome measures for 

feasibility was compliance with the intervention and for 

efficacy were walking capacity (six-min walk test), walking 

speed at a self-selected and fast pace and walking quality 

measured using 3 observational rating scales. Overall 

compliance with the intervention was high (89%) and 

there were no adverse events. By Week 6, the experimental 

group had improved walking capacity by 62 m (95% CI 

10–114), self-selected walking speed by 0.18 m/s (95% CI 

0.07–0.29) and fast walking speed by 0.18 m/s (95% CI 

0.03–0.35) more than the control group. By Week 18, the 

experimental group had improved walking capacity by 51.5 

m (95% CI -33–110), self-selected walking speed by 0.26 

m/s (95% CI 0.12–0.41) and fast walking speed by 0.27 m/s 

(95% CI 0.07–0.42) more than the control group. Walking 

quality was not affected on any rating scales. High-intensity 

treadmill training is feasible and appears effective for those 

with stroke just able to walk. 

Passive mechanical properties of gastrocnemius muscle 

and tendon in stroke patients with contracture 

Kwah LK, 1 Diong JHL, 1 Clarke JL, 2 Hoang PD, 3 Martin 

JH, 3 Clarke EC, 3 Bilston LE, 3 Gandevia SC, 3 Herbert RD 1 

1 


2 

Faculty of Health Science, University of Sydney, 3 Prince of Wales 

Medical Research Institute, Sydney 

This study investigated the origins of contracture in calf 

muscles after stroke by comparing length-tension curves of 

gastrocnemius muscle-tendon units, muscle fascicles and 

tendons of stroke patients with ankle contracture with ageand 

gender-matched controls. To date 8 stroke subjects (4 

males and 4 females; 53–81 years, 1–4 years post-stroke) 

and 7 elderly controls (4 males and 3 females; 50–86 years) 

have been tested. The aim is to test 20 participants in each 

group. Clinical measures include spasticity (Tardieu scale), 

functional ability (items 4 and 5 of the Motor Assessment 

Scale) and torque-standardised ankle range of motion. 5 

of 8 stroke subjects had spasticity. Median score on the 

Motor Assessment Scale was 5 for item 4 and 3 for item 5. 

Mean (SD) range of ankle dorsiflexion was 95° (86°–107°) 

in control subjects and 78° (71°––85°) in stroke patients. 

Ankle torque-angle curves have been collected at a range 

of knee angles, and ultrasonography has been used to 

measure muscle fascicle lengths and pennation. These data 

will be used to estimate slack length and compliance of 

muscle fascicles, tendons and whole muscle-tendon units. 

This should enable quantification of the contribution of 

changes in muscle fascicles and tendons to development of 

contracture in the gastrocnemius muscle after stroke. 

Effects of intensity of stroke rehabilitation: 

issues for consideration 

Kwakkel G 

Chair Neurorehabilitation, Department Rehabilitation Medicine and 

Research Institute ‘MOVE’, VU University Medical Centre Amsterdam, 

and Department Rehabilitation Medicine of Rudolf Magnus Institute of 

NeuroScience, University Medical Centre Utrecht, The Netherlands. 

The lecture addresses a number relevant issues related 

to the impact of intensity of practise after stroke. First, 

from perspective of existing literature the evidence for a 

dose-response relationship in stroke rehabilitation will be 

discussed. Despite the existing evidence that early started 

intensive practise may enhance the pattern of functional 

recovery after stroke, in most countries patients receive an 

insufficient dose of therapy at working days. Despite the 

financial pressure to increase efficacy without increasing 

costs, a number of studies have shown that augmentation 

of task-oriented practise is often possible by increasing: 

the ability to practise in groups by using patient tailored 

workstations (circuit class training), using forced use 

paradigms such as constrained induced movement therapy 

for the upper limb; using (electronic) devices, including 

robotics that allow patients to practise on their own, and 

preventing poor compliance in physical and occupational 

treatment sessions by identifying factors that predict poor 

adherence. Finally, reported effects of stroke rehabilitation 

seem to be largely dependent on adequate control for therapy 

time in the control group in order to augment treatment 

contrast, as well as on the appropriate selection of patients 

with some potential for functional change. For example, this 

latter precondition in particular is critical for upper limb 

training, in which the increased probability of return of 

dexterity seems to be largely defined in the first 4 weeks post 

stroke. In other words, understanding the effects of intensity 

of practise requires knowledge about functional prognosis 

as well as the mechanisms underlying the non-linear 

recovery pattern after stroke. A number of longitudinally 

conducted studies show that almost all stroke patients 

experience at least some predictable degree of functional 

recovery in the first 6 months post stroke. However, the nonlinear 

pattern as a function of time is not well understood. 

Several mechanisms are presumed to be involved, such as 

recovery of penumbral tissues, neural plasticity, resolution 

of diaschisis and behavioural compensation strategies. 

Rehabilitation is believed to modulate this logistic pattern 

of recovery, probably by interacting with these underlying 

processes. In particular, kinematic-and EMG-conducted 

studies show that functional improvement is more than 

recovery from impairments alone, suggesting that patients 

are able to improve in terms of gait or dexterity by using 

behavioural compensation strategies. With that, future 

studies should include functional measures along with 

measures at impairment level (EMG and kinematics) to be 

able to distinguish between ‘true’ recovery and learning to 

use ‘compensation strategies’. A model for learning nonlearning 

dependent mechanisms of recovery will be shown 

in this key note lecture. 

Impact of rhythmic cueing in Parkinson’s disease: 

what is the evidence? 

Kwakkel G (on behalf of the RESCUE consortium) 





Gait and gait related mobility problems are common in 

Parkinson’s disease (PD). This study aimed to investigate 

a rehabilitation approach using cueing therapy delivered at 

home to improve gait and gait related activities in people 

with Parkinson’s disease as an adjunct to the overall 

disease management. In the present multi-centre, singleblind 

randomised clinical trial with cross-over design, 153 

patients with idiopathic Parkinson’s disease (PD) were 

recruited (65 women and 88 men, mean age of 67.1 (± 7.54), 

Hoehn & Yahr score 2.7 (± 0.6) and Unified Parkinson 



Disease Rating Scale part III (UPDRS III) 33.1 (± 11.3)). 

Patients were randomly allocated to receive an early or late 

intervention in their home consisting of three 30 minute 

sessions of cueing therapy per week for 3 weeks given by 

trained therapists using a prototype cueing device. Outcome 

measures were conducted at baseline, 3, 6, and 12 weeks 

by an independent assessor who was blinded to treatment 

allocation. The primary outcome measures were the Posture 

and Gait Score (PG-score), gait speed, step length, step 

frequency, Functional Reach test (FR), Falls Efficacy Scale 

(FES), Freezing of Gait Questionnaire (FOGQ), timed tests 

of tandem and single leg standing. Secondary outcome 

measures included Nottingham Extended Activities of Daily 

Living Scale, Parkinson’s Disease Questionnaire (PDQ-39), 

UPDRS III and the Carer Strain Index (CSI). In addition, 

Activity Monitoring (AM) was used for investigating 

static and dynamic activity profiles in patients own home 

situation during the trial. Seventy-six patients were included 

in the early and 77 in the late intervention group. Multiple 

linear regression models for repeated measures showed a 

significant improvement of cueing therapy on the PG-score 

(p = 0.005), gait speed (p = 0.005), step length (p < 0.0001), 

FES (p = 0.03), balance (timed tandem and single leg stance 

tests) (p = 0.003) and UPDRS III (p = 0.03). AM showed 

a significant increase of identical patterns with respect to 

static (p < 0.001) and dynamic activities (p < 0.001). There 

was no increase in risk of falling following intervention. 

Overall, the effects of intervention were significantly 

reduced at 12 weeks. Cueing therapy in the home improves 

gait and balance and does not increase the risk of falling in 

PD. These effects generalise to functional activities but do 

not affect overall health-related quality of life. The effects 

wear off when cueing therapy stops, pointing to the need 

to supplement therapy with permanent cueing devices and 

follow-up sessions. Cueing therapy can be seen as a useful 

adjunct to the overall multidisciplinary management of 

patients with PD. Future studies should aim to develop 

responsive measurement instruments able to monitor 

meaningful changes in gait-related activities. Finally, further 

research is needed to improve poorly understood symptoms 

such as freezing, rigidity and bradykinesia as well as the 

mechanisms that underlies rhythmic cueing in PD. 

14 

Improving quality of care in neurorehabilitation: 

what are the problems and how to proceed? 

Kwakkel G 





Evidence-based medicine (EBM) involves more than 

merely selecting the most effective therapy. It especially 

involves selecting the right patients, whose functional 

prognosis makes them suitable candidates for a specific 

therapy. The concept of EBM also imply that it is a matter 

of choosing the right outcome measures that will allow any 

clinically relevant changes, whether or not caused by the 

therapy, to be evaluated later. A look at all the evidencebased 

guidelines for the neurorehabilitation of patients with 

Parkinson’s disease, stroke or multiple sclerosis that have 

so far been developed all over the world shows that their 

recommendations are nearly exclusively limited to the choice 

of therapy. Most guidelines fail to provide recommendations 

for ways to establish a functional prognosis, which would 

allow practitioners to distinguish between those patients 

who could benefit from a particular therapy and those for 

whom it would not be suitable. Nor do these guidelines 

recommend ways to assess future changes in the patients’ 

condition. This means that the therapeutic guidelines that 

are currently being propagated all over the world actually 

reflect only part of the principles of EBM, precisely because 

they lack recommendations on prognostics and evaluation. 

Moreover, knowledge about functional prognostics, and 

hence about selecting the right patients for a specific therapy, 

is an important step towards understanding differential 

effects in neurorehabilitation medicine. The second cause 

for concern regarding the EBM concept is that it is as yet 

unclear what the appropriate assessment instruments are 

for measuring outcome in neurorehabilitation medicine. 

Fortunately, a useful framework to help us choose the right 

outcome measures has become available by the ICF model. 

This bio-psychosocial model has enabled us to understand 

health-related outcomes much better by distinguishing 

between the domains of Body Functions and Structure, 

Activity and Participation. In addition, this model supports 

the communication between care providers and hence 

promotes transparency in health care. Nevertheless, a look 

at developments in the use of measurement instruments 

for patients with Parkinson’s disease, stroke and multiple 

sclerosis clearly show that a multitude of outcome measures 

are being used. As a consequence, most of the effect studies 

into the added value offered by approaches like exercise 

therapy fail to produce clear results because their outcomes 

cannot be compared. A third problem hampering evidencebased 

knowledge in neurorehabilitation is the exponential 

grow of the literature that show evidence that is not fixed but 

is subject to constant change, with older therapies for which 

evidence is no longer available gradually being replaced by 

new ones. If we want to know the direction in which this 

mountain of evidence is currently shifting, we will first have 

to find the answer to the question: What do patients actually 

learn during functional improvement? As long as we lack 

the necessary insights into this question, we will not be 

able to understand the mechanisms underlying the learning 

process. It is precisely this understanding which could allow 

us to improve existing therapeutic options and develop new 

and more effective therapies. So far, little is known about 

what exactly patients learn in terms of restitution and 

compensatory behaviour, or about whether a patient’s own 

preferred strategy should be regarded as an optimal method 

for efficient and accurate motor control. The current view 

is that any improvement in the quality of movement after 

a stroke always involves adaptive movement strategies and 

that process of regaining skills are affected by learning as 

well as by mechanisms not depending on learning. The 

complexity of the overall question of what patients exactly 

learn when they recover skills cannot by solved by research 

within one discipline, but requires a translational approach 

seeking the interaction between knowledge obtained from 

pre-clinical or basic research and knowledge derived from 

the clinic or more applied forms of research. 

Biological and biomechanical adaptation to contracture 

Lieber RL 

Professor and Vice-Chair, Departments of Orthopaedic Surgery and 

Bioengineering, University of California, San Diego and Department of 

Veterans Affairs Medical Centers, La Jolla, CA 

Spasticity, secondary to upper motor neuron lesion, 

can result in muscle contractures. We have studied the 

mechanics and biology of muscle from children with wrist 



flexion contractures secondary to cerebral palsy (CP). 

Dramatic architectural changes are observed in these 

children whereby sarcomere lengths are dramatically altered 

relative to patients without upper motor neuron lesions. This 

suggests dramatic alterations in the regulation of muscle 

growth in these children. Biomechanical studies of isolated 

single muscle cells reveal an increased passive modulus and 

decreased resting sarcomere length suggesting alterations in 

the cellular cytoskeleton. Similar studies on small bundles 

of muscle fibre reveal increased extracellular matrix 

compliance and endomysial connective tissue proliferation. 

Thus, the passive biomechanical properties of muscle from 

children with CP are dramatically altered in ways that are 

unparalleled by other altered use models. A recent expression 

profiling study revealed a number of ‘conflicting’ biological 

pathways in spastic muscle. Specifically, this muscle 

adapts by altering processes related to extracellular matrix 

production, fibre type determination, fibre hypertrophy 

and myogenesis. We also obtained evidence that calcium 

handling is altered secondary to cerebral palsy and may 

be a significant component of this disease. Taken together, 

these results support the notion that, while spasticity is 

multifactorial and neural in origin, significant structural 

alterations in muscle also occur. An understanding of the 

specific changes that occur in the muscle and extracellular 

matrix may facilitate the development of new conservative 

or surgical therapies for this devastating problem. 

The incidence of lateropulsion post stroke in the sub 

acute setting 

McDonald E, 1 Hill K, 2 Punt D 3 

1 

Northern Health, Melbourne, 2 La Trobe University, Melbourne, 3 Leeds 

Metropolitan University, UK 

The aim of this study was to measure the incidence of 

lateropulsion or ‘Pusher Syndrome’ in the stroke population 

admitted to sub acute wards at Northern Health Service, 

Melbourne. The Burke Lateropulsion Scale is a 17-point 

ordinal scale that looks at resistance to correction of 

tilted posture during five functional tasks; rolling, sitting, 

standing, transfers and walking. If patients score > 2 

on the Burke Lateropulsion Scale they are diagnosed as 

suffering lateropulsion. Thus far, no studies have measured 

the incidence of lateropulsion in the stroke population 

using this scale. Over a 7-month period, 74 stroke patients 

were admitted to Northern Health sub acute wards. 

Seventeen stroke patients (23%) displayed symptoms of 

lateropulsion on the Burke Lateropulsion Scale. Average 

Burke Lateropulsion scores on admission were 8.7 (3–15) 

and on discharge 3.1 (0–7). The lateropulsion group had an 

average length of stay of 63 days (36–105 days). Currently 

lateropulsion rating scales are not used in routine clinical 

practice, suggesting lateropulsion, especially milder forms, 

may be under diagnosed. Given that lateropulsion leads to 

slower progress in rehabilitation and longer length of stay, 

there is a need for improved recognition and management 

of lateropulsion in stroke patients. 

Stroke? What stroke dear? Considering the impact of 

cognitive dysfunction following stroke 

McDonnell MN 


Neurological physiotherapy following stroke is often focused 

on improving mobility and motor performance in order to 

improve functional outcome with the aim of returning people 

to participating fully in society. Many stroke survivors do 

not achieve this, in part due to the impact of cognitive deficits 

on social functioning. In the acute stage following stroke 

the Mini Mental State Examination may be used to screen 

for dementia, but complete neuropsychological testing is 

required to fully evaluate post stroke cognitive impairment. 

Such testing reveals that almost two-thirds of stroke patients 

suffer from higher cortical function abnormalities, often 

dysphasia or dyspraxia, but amnesia and frontal network 

syndromes are common also. Deficits that are likely to 

impact upon our therapy in particular are mental slowness, 

and memory, visuospatial and constructional problems. 

Cognitive function frequently deteriorates following stroke. 

This may be due to recurrent stroke, but even in the absence 

of stroke recurrence a diagnosis of dementia is common in 

the first 2 years following stroke. This paper will present 

recent literature regarding cognitive dysfunction following 

stroke and describe screening instruments that enable 

physiotherapists to identify psychological disturbance 

following stroke so that earlier intervention may be 

possible. 

Ultrasound is a reliable and feasible method of 

measuring muscle thickness early after stroke 

McLennan HJ, 1 English CK, 1 Thoirs K, 1 Bernhardt J 2 

1 

University of South Australia, Adelaide, 2 National Stroke Research 

Institute, Melbourne 

By 6 months after stroke up to 20% of muscle tissue is 

lost leading to devastating health consequences including 

an increased risk of future stroke secondary to impaired 

glucose metabolism. There is very little information about 

loss of muscle early after stroke as usual measurement tools 

(CT, MRI, DEXA) are not practical for taking repeated 

measures in people very early after stroke. Ultrasound has 

been shown to be an accurate means of measuring muscle 

mass in healthy people. The aim of this study was to 

investigate the reliability and feasibility of using ultrasound 

to measure muscle loss early after stroke. Fourteen people 

within 1 week of stroke onset participated. A sonographer 

took measures from 4 anatomical sties bilaterally (total 

of 8 sites). Measures were immediately repeated. The 

sonographer remained blinded to the measurement values. 

Feasibility was defined as at least 90% of participants being 

able to complete all the measures within 20 minutes or 

less in the same position. There was substantial to almost 

perfect agreement between test and retest measures at the 4 

anatomical sites (Intra-class correlation co-efficient scores 

range 0.68–0.91). It took a mean of 10.0 ± 4.51 minutes to 

obtain all 8 measures and consistent positioning was used 

with all participants. This study showed that ultrasound 

measures of muscle thickness could be reliably taken from 

people in hospital early after stroke which is an important 

first step in developing this tool for use in the clinical setting. 

Further validation studies are required. 



Challenging our assumptions regarding rehabilitation 

of the low functioning upper limb following stroke 

16 

Miller KJ, 1 Galea MP, 1 Phillips BA 2 

1 

Rehabilitation Sciences Research Centre, Melbourne Physiotherapy 

School, The University of Melbourne, Parkville, 2 Faculty of Health 

Sciences, LaTrobe University, Bundoora 

The aim of this single-blind randomised controlled pilot 

study was to evaluate the efficacy of additional taskoriented 

upper limb training commenced in the subacute 

phase (≤ 6 weeks post-stroke) in individuals with poor upper 

limb function (Motor Assessment Scale Item 6 score ≤ 3) 

following their first ever stroke. All participants received 

fifteen 1:1 training sessions with assigned independent 

practice additional to their regular therapy over 3–4 weeks. 

The experimental group (n = 11) received training focused 

on initiation of voluntary muscle activity in the context 

of meaningful manual activities. The control group (n = 

11) received postural control and concentration exercises. 

Motor recovery was evaluated at baseline, post-intervention, 

and at follow-up 3-months post-intervention by the Rasch 

transformed composite score for Motor Assessment Scale 

Items 6–8, and NK Hand Dexterity Test performance. 

Quality of life was evaluated at follow-up using the Stroke- 

Adapted 30-Item Sickness Impact Profile. The experimental 

group reported better quality of the life (p = 0.009) than 

the control group. While measures of upper limb motor 

recovery did not statistically differ between groups, within 

group analyses revealed the experimental group had 

significantly improved from baseline to follow up (p < 

0.01), with 7/11 participants capable of using their affected 

hand as a ‘helping hand’. In contrast, the control group 

made no significant improvements, their median dexterity 

scores unchanged from baseline. Findings in this pilot study 

challenge previously held assumptions regarding upper limb 

prognosis, and the application of task-oriented training in 

the low functioning upper limb following stroke. 

The acute brain injury physiotherapy assessment: 

a reliability study 

Mitchell G, 1 Low Choy N, 1 Gesch J, 2 Nascimento M, 2 

Passier L, 2 Steele M 1 

1 

Bond University, Gold Coast; 2 Princess Alexander Hospital, Brisbane 

The Acute Brain Injury Physiotherapy Assessment (ABIPA) 

has been developed to assess changes in motor function for 

low functioning adults following traumatic brain injury. The 

validity of using the tool with this cohort has been established 

but reliability of physiotherapists using this tool required 

investigation. This study investigated the level of inter-rater 

agreement and intra-rater consistency when physiotherapists 

completed the ABIPA while observing the video-taped 

assessment of four people with an acute traumatic brain 

injury (TBI) who were being assessed by a physiotherapist 

using this tool. The design was a test-retest reliability study 

conducted over 2 consecutive weeks. Participants (n = 4) 

had sustained a severe TBI and were over 19 years of age. 

The participants were in the acute stage of rehabilitation 

at the Princess Alexandra Hospital. Physiotherapists (n = 

15) from the neuroscience field were invited to participate 

in this study. Eleven physiotherapists completed both 

stages of the study. The overall inter-tester reliability of 

the ABIPA was very high in both test periods (Cronbach 

alpha = 0.990–989) although the absolute agreement for 3 

items of the tool (upper limb tone, head/trunk alignment in 

supine lying) was lower (r = 0.486–575). The intra-tester 

reliability of the physiotherapists was high. Seven of the 11 

physiotherapists demonstrated absolute agreement when 

re-tested and 4 physiotherapists demonstrated a high level 

of consistency between assessments (Spearman rho > 0.7). 

Eleven physiotherapists demonstrated a high level of intertester 

and intra-tester reliability when using the ABIPA to 

assess people after TBI. 

New graduates’ self-perceived competence in 

neurological physiotherapy practice 

Morgan PE, Keating JL 

Monash University, Frankston 

The recently reported Australian entry-level physiotherapy 

neurological competencies were generated through survey 

of neurological academics and clinicians. Experienced 

clinicians were asked to describe the neurological skill set 

of new graduates. It is not known whether recent graduates 

agree with the opinions of experienced physiotherapists 

regarding their skills and abilities. Overestimation or 

underestimation of the skills of the recent graduate in the 

area of neurological physiotherapy practice by employers 

has implications for job satisfaction, workplace stress, and 

workforce longevity. Opinions regarding the neurological 

practice skills of Australian physiotherapy graduates (less 

than 12 months of clinical experience) were sought using 

online survey distributed via new graduate associations 

(Australian Physiotherapy Association and alumni) and 

informal clinical networks. Respondents were asked to 

rate (5-point Likert scale) their level of agreement with 

statements regarding their competency in managing a 

range of neurological clinical conditions and demonstrating 

components of neurological clinical practice. Ninety 

recently graduated physiotherapists from 12 universities 

across Australia responded to the survey. Their responses 

(perceptions of competency) were compared to the views 

of experienced physiotherapists. Areas of congruence and 

mismatch are explored with emphasis on the implications for 

the Australian neurological physiotherapy community with 

respect to supervision/mentoring, professional development 

requirements, and suitable caseloads for recent graduates. 

The research outcomes will inform the development of 

strategies to appropriately support recent graduates to 

develop confidence and competency within neurological 

physiotherapy practice. 

Reported quality of randomised controlled trials of 

physiotherapy interventions has improved over time 

Moseley AM, 1 Herbert RD, 1 Maher CG, 1 Sherrington C, 1 

Elkins MR 2 

1 


2 

Department of Respiratory Medicine, Royal Prince Alfred Hospital, 

Sydney 

The aim of the study was to describe the change with time 

of the methodological quality of reports of randomised 

controlled trials of physiotherapy interventions (including 

neurological physiotherapy). Data from 10 025 randomised 

controlled trials of physiotherapy interventions indexed 

on the Physiotherapy Evidence Database (PEDro) and 

published since 1960 were included. Consensus ratings 

(2 independent raters, with arbitration by a third rater if 

required) of methodological quality using the 11-item PEDro 

scale were extracted. The relationship between quality 



score and year of publication was evaluated using weighted 

linear and logistic regression. The total PEDro score was 

related to year of publication, with the total score increasing 

at a rate of 5.7% per year on average. Reporting of 8 of 

the 11 individual items from the PEDro scale (intentionto-treat 

analysis, concealed allocation, groups similar at 

baseline, reporting of results of between-group statistical 

comparisons, point measures and measures of variability 

reported, subjects randomly allocated to groups, eligibility 

criteria specified, and blinding of assessors) also improved 

with time. The reported quality of randomised controlled 

trials of physiotherapy interventions has improved over 

time. 

Promoting physical activity for people with chronic 

neurological disability: practices and perceived roles 

of physiotherapists 

Mulligan HF, 1 Fjellman-Wiklund A, 2 Hale LA, 1 Thomas 

DR, 3 Häger-Ross C 2 

1 

School of Physiotherapy, University of Otago, New Zealand, 

2 

Community Medicine and Rehabilitation, Physiotherapy, Umeå 

University, Sweden, 3 Social and Community Health, University of 


Individuals living with chronic disability need to be more 

physically active to prevent secondary conditions and counter 

diseases of a sedentary lifestyle. New Zealand and Sweden 

have similar health and disability policies. These policies 

promote participation for individuals with disability in 

community recreational activity for health and well-being. 

This qualitative study investigated whether physiotherapists 

foster physical activity through recreation for adults with 

long-term neurological conditions. Nine physiotherapists 

were interviewed and the data analysed for themes. The 

physiotherapists worked in public health services for 

individuals with chronic neurological disability in New 

Zealand and Sweden. Five themes emerged from the data. 

Physiotherapists supported health policies for promotion 

of physical activity. In their current scopes of practice they 

were broad and innovative and used their expertise to enable 

clients to be physically active through recreation. However 

barriers and constraints from the public environment 

and from within the health systems were identified that 

hindered their implementation of disability policy. Finally, 

they provided specific reflections on health and disability 

policies related to their experiences. Physiotherapists have 

the expertise to enable people with disability into suitable 

and sustainable levels of physical activity. Addressing 

constraints identified from within the public environment 

and health systems would allow physiotherapists to enable 

improved levels of physical activity for people with longterm 

disability. 

Ankle dorsiflexion contracture and walking 

in early stroke 

Nguyen JQ, Collier JM 

National Stroke Research Institute, Melbourne 

Development of ankle dorsiflexion contracture in 

the impaired lower limb is an important secondary 

impairment after stroke which limits activity. This study 

aimed to describe the development of ankle dorsiflexion 

contracture and the amount of walking in the first 14 days 

after stroke. The primary objective was to determine the 

association between the development of ankle contracture 

and amounts of walking over 14 days. An observational 

study was conducted at the Austin Hospital acute stroke 

unit. Eligible participants were within 48 hours of stroke 

onset and medically stable; those with severe premorbid 

disability were excluded. Outcome measures were passive 

ankle dorsiflexion range (Lidcombe template) and number 

of steps from 8:00–18:00 (Stepwatch Activity Monitor). 

Measures were conducted at 3 time points: baseline (within 

48 hours), day 5 and day 14. Ten consecutively admitted 

participants were recruited, 3 (30%) developed 5 or more 

degrees of ankle contracture by day 14. At baseline, day 

5 and 14, participants walked a median (IQR) of 999 

(334–1917), 2450 (1201–3362) and 4485 (1045–6243) steps 

respectively. There was a moderate to strong negative linear 

association between representative steps (sum of steps for 3 

time points) and ankle dorsiflexion contracture at day 14 (r 

=-0.578, p = 0.04, 95% CI -0.857 to -0.035). The daily step 

count was below one standard deviation of walking reported 

in healthy elderly. The percentage of early stroke patients 

with ankle contracture was comparable to research at 1 year 

post stroke. Participants who walked relatively fewer steps 

displayed reduced ankle dorsiflexion range. 

Evaluation of a home-based physiotherapy program for 

those severely affected by multiple sclerosis: a single 

blind randomised control trial 

Paul L, 1 Miller L, 2 Mattison P, 2 McFadyen AK 3 

1 

University of Glasgow, Scotland, 2 NHS Ayrshire and Arran, Scotland, 

3 

Glasgow Caledonian University, Scotland 

An audit of our 8-week hospital based wheelchair 

maintenance class for people with multiple sclerosis (MS) 

found improvements in, e.g. muscle stiffness, spasms and 

pain. Due to the difficulties of travelling to hospital and the 

paucity of evidence on the effectiveness of physiotherapy 

for those more severely affected by MS the aim this 

study was to evaluate the effectiveness of a home-based 

physiotherapy program. Thirty patients with secondary 

or primary progressive MS, an extended disability status 

score (EDDS) of 6.5–8 and 3 identifiable physiotherapy 

goals were recruited. The treatment group (15 subjects) 

received an individualised physiotherapy program at home 

twice weekly for 8 weeks and the control group continued 

with ‘standard care’. Both groups were assessed at baseline, 

8 weeks and at 16 weeks. The primary outcome measures 

used were the MSIS29 and the Functional Independence 

measure (FIM). Secondary outcome measures assessed 

spasticity, pain, MS symptoms, quality of life, mood, range 

of movement, muscle strength and functional abilities. All 

30 patients have been recruited; average age 54.6 years; 

time since diagnosis 16 years and EDSS 7. At baseline there 

was no significant difference between the intervention and 

control group in terms of age (p 0.249), time since diagnosis 

(p = 0.078) or EDSS (p = 0.577). The final data set will 

be complete in June. Initial observation suggests a variable 

responsive to treatment but a trend toward improvement 

of outcome measures at impairment level. Final analysis 

of the data will be presented and future areas of research 

explored. 



18 

Physiological cost of walking in people with 

neurological conditions 

Paul L, 1 Rafferty D, 2 Mattison P, 3 Miller L, 3 Marshall R 1 

1 

University of Glasgow, Scotland, 2 Glasgow Caledonian University, 

Scotland, 3 NHS Ayrshire and Arran, Scotland 

Physiotherapists often consider cardiovascular fitness within 

neuro-rehabilitation however there is little evidence on the 

energy required to walk for individuals with neurological 

conditions. This series of studies examined the physiological 

cost of walking across a number of neurological conditions. 

Twelve subjects with multiple sclerosis (MS) (established 

users of Functional Electrical Stimulators, FES), 13 stroke 

survivors, 17 people with chronic fatigue syndrome (CFS), 

and 32 age matched controls were recruited. Each subject 

walked for five minutes, at their preferred walking speed, 

following a 20m elliptical path. A portable gas analysis 

system measured the percentage of expired oxygen. The 

controls repeated the experiment walking at the same speed 

as the subject to which they were matched. MS subjects 

completed the protocol with and without the aid of their 

FES. The average gait speed and VO 2 

kg 1 per unit distance 

walked (metabolic cost of gait) were recorded between 

minutes 3 and 4.The walking speed of the control group 

(1.21ms 1 ) was significantly higher than the patient groups; 

CFS -0.84ms 1 , MS without FES 0.43ms, MS wearing 

FES -0.49ms -1 and stroke -0.39ms. The oxygen uptake 

per unit distance walked was significantly lower for 

controls (0.16mL·min -1·kg-1·m-1 ) compared to CFS 

(0.21mL·min -1·kg -1 ·m -1 ) MS without FES (0.46mL·min - 

1 

·kg -1·m 1 ), MS wearing FES (0.43mL·min -1·kg -1·m-1 ) 

and stroke (0. 63mL·min -1·kg 1·m 1 ). People affected by 

these neurological conditions, notably young stoke 

survivors, have a slower gait speed and a higher 

energy requirement to walk. For people with MS, 

FES increases the gait speed and reduces the energy 

demand when walking. 

Funding acknowledgement. Thanks to ME Research UK for 

funding the CFS project 

Length of stay and functional outcomes of stroke 

rehabilitation 

Proud E 1 , Harding K, 1 Rosen K, 1 Kennedy G, 1 Taylor N 1,2 

1 

Eastern Health, Melbourne, 2 La Trobe University, Melbourne 

We aimed to document the average length of stay and 

functional outcomes of patients admitted with a primary 

diagnosis of stroke to a Victorian metropolitan rehabilitation 

centre, and to compare the results with published 

Australasian data. We completed a retrospective audit of 

188 patients admitted with a primary diagnosis of stroke 

over two years. At the time of the audit, the centre employed 

a traditional model of care and did not have a specialised 

stroke service, but is currently implementing a new model 

of care. The length of stay in rehabilitation averaged 33.4 

days (SD 17.4) and functional outcomes measured with FIM 

motor scores were 45.1 (SD 14.0) on admission and 69.8 (SD 

16.2) on discharge. Of patients with a severe stroke (FIM 

< 47), 50.2% achieved a good functional outcome (FIM > 

65) at discharge. Length of stay and functional outcomes 

were similar to published data from Australia and New 

Zealand, but time from stroke to admission to rehabilitation 

was longer (15.7 days versus 11.5 days, p < 0.001) and fewer 

patients were discharged home (65.4% versus 77.2%, p = 

0.049) compared to New Zealand facilities. These results 

suggest this rehabilitation centre with a traditional model 

of care achieved outcomes comparable to other centres and 

provide data against which the new model of care at the 

centre can be evaluated in the future. The results suggest 

strategies to quicken patient flow from acute hospital to 

rehabilitation and support discharge to home could improve 

outcomes. 

Benign paroxysmal positional vertigo: clinical 

guidelines and considerations for physiotherapy 

practice 

Reynolds P, 1 Murray K 2 

1 

On-Balance Physiotherapy, Sydney; 2 Dizzy Day Clinics, Melbourne 

Benign paroxysmal positional vertigo (BPPV) is the most 

commonly encountered peripheral vestibular disorder 

in the community. Its treatment has been embraced by 

musculoskeletal and neurological physiotherapists in recent 

years. Posterior canalithiasis constitutes a large proportion 

of BPPV; positional vertigo of lateral and anterior canal 

origin are encountered less commonly. The diagnosis and 

management of BPPV relies heavily on the characteristics 

of eye movements observed on positional testing. A 

summary of typical eye movements observed in posterior, 

lateral and anterior canal BPPV and a treatment algorithm 

for each subtype will be proposed. A literature review of 

current treatment options for each subtype and a summary 

of outcomes for 50 patients diagnosed, using infra red video 

oculography, and treated at a physiotherapy practice will be 

presented. Recent guidelines from the American Academy 

of Otolaryngology–Head and Neck Surgery Foundation 

and their implications for physiotherapy will be presented. 

Indications for referral of BPPV for treatment in the Epley 

Omniaxial Rotator will be discussed. 

Randomised trial of night casting for ankle contracture 

in children with Charcot-Marie-Tooth disease 

Rose K, 1 Raymond J, 2 Refshauge K, 2 North K, 1 Burns J 1 

1 

Institute for Neuromuscular Research, The Children’s Hospital at 

Westmead/The University of Sydney, 2 The University of Sydney 

Ankle contracture is prevalent in paediatric Charcot- 

Marie-Tooth disease (CMT) and can cause significant 

disability. Conservative therapies such as night splinting 

and serial casting are frequently implemented in the early 

stages of the disease to increase ankle flexibility, however 

night splinting has limited effect and serial casting can be 

complicated by pressure areas due to sensory impairment, 

and is often poorly tolerated. The aim of this study was 

to conduct a single-blind randomised controlled trial 

comparing the effect of night casting vs. no intervention 

on ankle flexibility and functional ability in children with 

CMT. Thirty children with CMT of any type were recruited 

from the neuromuscular clinics at The Children’s Hospital 

at Westmead (Sydney, Australia) and randomly allocated to 

receive eight weeks of night casting and manual stretching 

for the triceps surae or a control group receiving eight weeks 

of manual stretching only. The night cast was fabricated 

according to the principles of serial casting, but bi-valved 

and worn only at night. Outcome measures included ankle 

dorsiflexion range of motion, functional motor ability, foot 

alignment, compliance and adverse events. Treatment effect 

between groups will be determined on an intention-to-treat 

basis at 8 weeks using a linear regression approach to analysis 



of covariance (ANCOVA) to adjust for baseline differences 

of respective covariates. The trial is near completion and 

will be presented at the APA National Paediatric Group 

Conference. 

Do patients with acquired brain impairments 

benefit from additional therapy specifically directed 

at the hand? 

Ross L, Harvey LA, Lannin N 


Medicine, University of Sydney, Sydney 

The aim of this study was to determine whether patients 

with acquired brain impairments benefit from additional 

one-to-one therapy specifically directed at the hand. 

An assessor-blinded randomised controlled trial was 

conducted. Forty adults with hand impairment following 

stroke (90%) or traumatic brain injury (10%) were recruited 

at 1–6 months post injury (median: 0.5–3.5 months). The 

experimental group received an additional 1-hour session 

of task-specific motor training for the hand 5 times a week 

over a 6-week period. The training was administered on a 

one-to-one basis. The control group received standard care 

which consisted of 10 minutes of hand therapy 3 times a 

week. Both groups continued to receive therapy directed at 

the shoulder and elbow. The primary outcomes were the 

Action Research Arm and Summed Manual Muscle Tests 

measured at the beginning and end of the 6-week period. 

Both groups improved over this time, however, the mean 

between-group differences for the Action Research Arm 

and Summed Manual Muscle Tests were-6 points (95% CI, 

-20–8) and 3% (95% CI, -10–16), respectively. These results 

indicate that not all patients benefit from additional oneto-one 

therapy specifically directed at the hand. The future 

challenge is to identify those who do and those who do not 

benefit from additional one-to-one hand therapy. Possibly, 

time and resources could be better employed setting 

up systems which enable semi-supervised but intensive 

practice of hand activities outside formal therapy sessions 

than providing fully-supervised but limited practice within 

formal therapy sessions. 

Obstacle crossing performance predicts falls in people 

with stroke 

Said C, 1,2 Galea M, 1,2 Lythgo N 1 

1 

Rehabilitation Sciences Research Centre, University of Melbourne, 

2 

Austin Health, Heidelberg 

Obstacle crossing is impaired following stroke. It is not 

known whether the movement strategies used place people 

with stroke at risk of obstacle contact or loss of balance 

(classified as a fail), or whether failure on an obstacle crossing 

task increases the odds of falling. Thirty-two subjects with 

a recent stroke were recruited. Subjects stepped over a 4 

cm high obstacle while walking at comfortable speed. 

Performance was rated as pass or fail, and spatiotemporal 

and centre of mass (COM) data were collected. Following 

testing, 20 subjects recorded falls in the subsequent six 

months. Univariate logistic regressions were performed 

to determine whether specific variables were predictive of 

failure, and whether failure was predictive of falls. Subjects 

who walked slowly, had greater separation between their 

supporting heel and COM at affected lead toe clearance or 

had greater affected trail toe clearance were more likely 

to fail. Subjects were also more likely to fail if they had 

increased time from affected lead toe clearance to landing, 

from affected trail toe off to clearance or unaffected trail 

toe clearance to foot contact, even after allowing for slow 

speed. The odds of falling were 30.0 times greater (95% CI 

=.19–4.11) in people who failed, and 17/20 subjects were 

correctly classified as either fallers or non-fallers. While 

data is from a small sample, results indicate that obstacle 

crossing may be useful in identifying people at risk of falls 

following stroke. 

Salary support for CS was provided by NHMRC Grants 

Nos. 310612 and 385002. 

Writer’s cramp and musician’s dystonia: treatment 

strategies for a case of bad plasticity? 

Schabrun SM, 1,2 Ridding MC 1 

1 

The University of Adelaide, 2 The University of Queensland 

Writer’s cramp and musician’s dystonia are examples of 

neurological conditions in which excessive cortical plasticity 

plays a role. In these conditions, too much plasticity results 

in problems with movement isolation and control, leading 

to difficulties with everyday activities and ending promising 

careers. Here, we examined the effect of asynchronous 

electrical stimulation applied to two hand muscles in the 

reduction of excessive plasticity and in the alleviation of 

symptoms. Twenty subjects (10 symptomatic and 10 healthy 

controls) participated. Three hand muscles were mapped 

using transcranial magnetic stimulation before and after 

one-hour of electrical stimulation. Functional outcomes 

were measured using handwriting, cyclic drawing and griplift 

tasks. Participants with writer’s cramp and musician’s 

dystonia had larger, more overlapped cortical maps and 

demonstrated significant impairments in handwriting, 

cyclic drawing and grip-lift tasks. Following electrical 

stimulation, the size of the cortical maps and the degree 

of overlap was reduced. This reduction was accompanied 

by small improvements in cyclic drawing. These findings 

suggest that electrical stimulation may be a therapeutic 

option in those with writer’s cramp and musician’s dystonia. 

In particular, repeated applications of electrical stimulation 

may lead to more robust and maintained functional 

improvements in the future. 

An observational study of rehabilitation outcomes after 

stroke in a comprehensive stroke unit 

Scrivener KM, 1,2 Schurr K, 1 Sherrington C 2 

1 

Bankstown-Lidcombe Hospital, 2 The George Institute for International 

Health, The University of Sydney 

The Bankstown-Lidcombe Hospital stroke unit is a 

comprehensive 20 bed unit with co-located acute and 

rehabilitation beds. Therefore it was possible to examine 

the outcomes of stroke survivors throughout their inpatient 

journey. An observational study of 100 consecutive stroke 

survivors was conducted which compared functional 

performance at admission and discharge. The study 

included stroke survivors who were admitted for a period 

of at least two weeks. Data were collected by treating 

therapists within 48 hours of admission/discharge; 52% of 

subjects were female; their average age was 77.8 years (48 to 

96). There were complete data sets for 94% of subjects. On 

admission 45% of subjects could walk and 12% could stand 

from 50 cm independently. On discharge 72% of subjects 

could walk and 54% could stand from 50 cm. Sixty-one 



percent of subjects returned to their homes on discharge 

however 25% were discharged to an aged care facility. Five 

percent of subjects died during their admission. The average 

increase in walking velocity was 0.33m/s (95% CI 0.25– 

0.41m/s, p < 0.01). The average step test score improved by 

4.1 steps in 15 seconds (95% CI 3.1–5.1, p < 0.01). Motor 

Assessment Scale (MAS) items 4 (sit-to-stand) and 5 

(walking) improved by 1.9 points each (95% CI 1.4–2.3, p 

< 0.01). In conclusion functional improvements after stroke 

are possible. With further data collection we aim to explore 

the relationship of these improvements with the amount of 

practise completed. 

Central and peripheral contributions to neuromuscular 

fatigue in people with chronic stroke 

Signal NEJ, Taylor D, McNair P 

Health & Rehabilitation Research Centre, AUT University, Auckland, 

New Zealand 

Neuromuscular fatigue is an activity induced reduction in 

the ability to exert force and has been identified as a potential 

impairment in people with neurological pathologies. 

However, research investigating neuromuscular fatigue in 

people with stroke is limited. Therefore, the aim of this study 

was to examine the contribution of central neuromuscular 

fatigue and peripheral neuromuscular fatigue to total 

neuromuscular fatigue in people with physical disability 

following stroke. An experimental design using interpolated 

twitch methodologies compared adults with chronic stroke 

(n = 15) to age, height and weight matched controls (n = 

15). Participants’ physical function was evaluated using 

the 30 s Chair Stand Test, and comfortable and fast paced 

walking speeds. Neuromuscular function was measured 

using maximal voluntary isometric contraction force 

and voluntary activation of the quadriceps muscle. Total 

neuromuscular fatigue, central neuromuscular fatigue and 

peripheral neuromuscular fatigue were measured during a 

90-second maximal isometric contraction of the quadriceps 

muscle to evaluate the neuromuscular fatigue profile of 

both groups. Stroke participants demonstrated less total 

neuromuscular fatigue (p = 0.03) and less peripheral 

neuromuscular fatigue (p < 0.001) than control participants. 

While stroke participants did demonstrate greater 

central neuromuscular fatigue than control participants, 

this finding was not statistically significant (p = 0.82). 

Differences were found in the fatigue profile of people with 

stroke when compared to control participants; however the 

results should be interpreted with caution due to concerns 

about the validity of evaluating fatigue during a motor task 

normalised to muscle strength and the reliability of fatigue 

measures. 

20 

A comparison of immediate effect of cyclic and static 

stretching for calf muscle stiffness post stroke 

Singer BJ, 1 Dunne JW, 1,2 Singer KP 1 

1 

The University of Western Australia, 2 Royal Perth Hospital 

Increased calf stiffness is common post stroke and impairs 

the ability to rapidly dorsiflex the foot, for instance during 

the swing phase of gait, potentially contributing to falls risk. 

In the present investigation, 19 individuals with hemiplegia 

following first stroke (mean duration 3 years, range 6–59 

months) were studied. Subjects were randomly allocated 

to 20 minutes of slow cyclic (5°/sec -1 ) or sustained stretch, 

using a commercially available instrumented device (Breva, 

Surgical Synergies). The second stretch condition was 

tested one week later. Data were collected for both limbs. 

Excellent test re-test reliability was demonstrated. The 

foot was cycled from 10° plantarflexion to the individual’s 

maximal available dorsiflexion range of motion (DF ROM) 

(mean DF = 22°, range 18–30°), or maintained at maximal 

DF. Variables evaluated prior to and immediately following 

stretch were: Spasticity (Tardieu Scale plus surface EMG of 

tibialis anterior and medial soleus muscles and acceleration 

of the foot), maximal DF ROM (digitised from images of 

standardised squat task), and calf muscle stiffness (peak 

plantarflexor force). Spasticity decreased (Tardieu Grade 4 

to 3) and maximal DF ROM increased in only 3/19 cases, 

with no difference between stretch conditions. Statistically 

significant reduction in stiffness was achieved for both 

stretch conditions (mean reduction = 2.6N following static 

stretch, 1.57N following cyclic stretch; NS difference 

between conditions). In an open ended questionnaire, 

participants expressed a preference for cyclic stretching. A 

number of subjects commented on increased awareness of 

the limb and greater ease of walking after cyclic but not 

static stretching. 

The use of botulinum toxin (BoNT) for adults and 

children with hypertonicity: evidence based guidelines 

for assessment, intervention and after-care 

Singer BJ, 1 Fung V, 2 Graham K, 3 Novak I, 4 Olver J, 5 

Rawicki B 6 

1 

University of Western Australia, Perth, 2 Westmead Hospital, Sydney, 

3 

Royal Children’s Hospital, Melbourne, 4 Cerebral Palsy Institute, 

Sydney, 5 Epworth Rehabilitation Unit, Melbourne, 6 Monash Medical 

Centre, Melbourne 

The development of evidence based guidelines for treatment 

of focal muscle overactivity using Botulinum Toxin (BoNT) 

in adults and children has been a project supported by the 

Cerebral Palsy Institute (NSW). Seven topics were covered: 

The use of BoNT in conditions producing hypertonicity 

in the upper and lower limbs in adults and children; the 

treatment of pain associated with hypertonia, treatment of 

sialorrhea (drooling); and management of cervical dystonia. 

For the development of the guidelines, international 

multidisciplinary panels of experts were convened, 

extensive literature searches were undertaken, the evidence 

for each sub-section was graded according the American 

Academy of Neurology system and recommendations for 

clinical practice were developed according to the available 

evidence. Each sub-group addressed particular questions 

including: what is the evidence for BoNT use in each 

defined population, what is the optimal way to assess 

for treatment eligibility and outcomes, can an optimal 

intervention regimen be identified from the evidence, how 

should patients be monitored and what are the main areas 

for future research? The findings of this consensus project 

will be published in a supplement of the European Journal 

of Neurology in 2009. Botulinum toxin use in hypertonia 

and movement disorders is increasing and physiotherapists 

are frequently involved in recommending this intervention 

for their clients, and in providing adjunctive treatment. 

An overview of this new consensus document will be 

provided which highlights issues of particular interest 

to physiotherapists. It is hoped that these evidence based 

guidelines will facilitate more effective use of BoNT as an 

adjunct to rehabilitation. 



How does fatigue influence community-based exercise 

choices in people with multiple sclerosis? 

Smith CM, 1 Hale LA, 1 Schneiders AG, 1 Olson K, 2 Baxter 

GD 1 

1 

University of Otago, New Zealand, 2 University of Alberta, Edmonton, 

Canada 

The aim of this qualitative study was to describe, illustrate 

and interpret ways in which fatigue influences communitybased 

exercise choices of people with multiple sclerosis 

(MS), in order to better inform health care providers who 

often recommend community-based exercise activities 

for this population. Nine women from Wellington, New 

Zealand; five with relapsing remitting, three with secondary 

progressive and one with an unconfirmed type of MS, were 

purposefully sampled for one to one, audio-taped interviews. 

Participants, who had experienced increased fatigue since 

diagnosis, were able to walk a short distance with or 

without a walking aid, and who participated in community 

exercise activities were included in the study. Interpretive 

Description was the methodology of choice for this study 

and guided methods of data collection, transcript analysis 

and verification of emerging categories and themes. Two 

interrelated categories emerged from the data: ‘Making 

choices’ and ‘Nature of the beast’. Within the category of 

‘Making choices’ were two sub-categories; ‘Choosing to 

exercise’ and ‘Choosing type of exercise’. The sub-category 

of Choosing to exercise was influenced by three themes: 

wellness philosophy, feeling better and achieving goals. The 

sub-category of Choosing type of exercise was influenced 

by four themes: finding limits, defining self, being safe 

and level of support. Results from this study highlight the 

unique yet pervasive influence of fatigue on communitybased 

exercise choices for this population. Findings strongly 

support the importance of assessing fatigue prior to making 

exercise recommendations for individuals with MS. 

Students’ perceptions that complete lecture outlines 

are better than skeleton outlines at promoting a deep 

approach to learning are correct 

Stark AM, Ada L, Canning CG, Dean CM 


The purpose of this study was to investigate (i) whether 

complete lecture outlines are better than skeleton outlines 

at promoting recall and clinical reasoning in physiotherapy 

undergraduate students and (ii) the students’ perceptions 

of the different outlines. One hundred and twenty-eight 

(80%) students participated in the study. Two academics 

each delivered two lectures, randomised for type of lecture 

outline. The skeleton lecture outline consisted of headings 

and spaces for note taking while the complete lecture 

outline consisted of a pdf of the PowerPoint slides used 

during the lecture. A questionnaire was used to collect data 

on recall, reasoning and the students’ perceptions of the 

outlines. When compared to the skeleton lecture outlines, 

the complete lecture outlines resulted in a mean better mark 

of 7% (95% CI 3–12, p = 0.001) for the recall questions and 

a mean better mark of 13% (95% CI 8–17, p < 0.001) for 

the reasoning questions. Students felt that they understood 

concepts 6% (95% CI 1–11, p = 0.01) better when they 

were given complete outlines. Overall, students did quite 

well on recall questions (mean 72%, SD 22) but poorly on 

clinical reasoning questions (mean 30%, SD 23). It seems 

that students’ perceptions that complete lecture outlines 

assist their learning better than skeleton lecture outlines 

is correct. However, although complete lecture outlines 

allowed students to recall information and understand 

concepts better than skeleton lecture outlines, overall, 

students’ clinical reasoning was poor. 

Effects of a structured progressive task-oriented circuit 

class training to enhance walking competency after 

stroke: protocol of the FIT-Stroke trial 

van de Port IGL, 1 Wevers L, 1 Kwakkel G 1,2 

1 

Rehabilitation Centre De Hoogstraat, Centre of Excellence for 

Rehabilitation Research Utrecht and University Medical Centre 

Utrecht, The Netherlands, 2 Vrije Universiteit Medical Centre, 

Amsterdam, The Netherlands 

In a recent meta-analysis of 6 RCTs we concluded that the 

use of task-oriented circuit class training improves gait 

and gait-related activities in patients with chronic stroke. 

However further research is needed to investigate the cost 

effectiveness and the effectiveness of this intervention 

in the subacute phase after stroke. Also studying the 

generalisability of physical intervention programs to psychoemotional 

outcome (fatigue and depression) is required 

since we know that these aspects have a large influence on 

the rehabilitation process and outcome. The primary aim 

of this study is to evaluate the (cost-) effectiveness of a 

structured, progressive task-oriented circuit class training 

(CCT) program after stroke, when compared to individual 

physiotherapy during outpatient rehabilitation on gait, gaitrelated 

ADLs and HRQoL. In this multi-centred, singleblinded 

randomised controlled trial, 220 stroke patients 

will be recruited in 9 selected rehabilitation centres. 

Patients who are able to communicate and walk at least 10 

meters independently will be recruited for the trial. Those 

patients allocated to the experimental group will receive 

CCT 2 times a week for 12 weeks, whereas the control 

group will receive individual physiotherapy. During two 

seminars 50 physiotherapists and sports therapists of the 

selected rehabilitation centres were educated as teachers in 

CCT. Since July 2008 more than 100 participants have been 

included in the present trial. The training locations have 

been visited by an independent researcher. Preliminary 

results show that CCT is feasible for the included patients. 

More results will follow in the near future. 

Multiple sclerosis: challenges for rehabilitation 

von Koch L 

Karolinska Institutet, Stockholm, Sweden 

Many people with multiple sclerosis (MS) will experience 

disabilities. However, knowledge is sparse concerning the 

prevalence and longitudinal variations of disabilities; their 

association with contextual factors and perceived impact on 

health; and the perceived needs, use, and satisfaction with 

health services in people with MS. In one study, 219 people 

with MS, (59% having mild MS), were followed up every 

6 months over a 2-year period regarding their disability, 

perceived impact on health, contextual factors and 

perceived needs, use, and satisfaction with care. At baseline 

49% had cognitive impairment; 76% fine motor limitations; 

43% ambulatory limitations; 67% fatigue; 29% depressive 

symptoms; 44% limitations in activities of daily living; 

and 47% participation in social activities was restricted. 

Variations were found in perceived impact on health and 



presence of disability, including both improvements and 

declines. Fatigue and depressive symptoms were predictors 

of increased perception of impact on health. In addition 

cognitive impairment and weak sense of coherence were 

predictors of an increase in perceived impact on physical 

health. Variations were found in perceived needs and 

satisfaction with care. People with fatigue and mild MS 

used more outpatient care than those without fatigue; people 

with severe MS perceived a greater need of most health 

services and women a greater need for psychosocial support 

and counselling than men. Considering the variability and 

complexity, individualised health promotion and flexible 

health services, including rehabilitation, are imperative in 

order to meet the needs of people with MS. 

22 

There is no place like home? Studies on stroke 

rehabilitation in the home environment 

von Koch L 

Karolinska Institutet, Stockholm Sweden 

Rehabilitation after stroke, in general, has been delivered 

in hospitals or in outpatient clinics. However, in the last 

decade there has been an increasing interest in delivering 

rehabilitation in the patient’s home environment. Two 

divisions of rehabilitation can be distinguished among 

randomised controlled trials of home interventions. In the 

first division, the initial inpatient rehabilitation is followed 

by rehabilitation at home. In contrast the second division 

aims to shorten the inpatient stay by providing earlier 

supported discharge. Hence, the early supported discharge 

followed by continued rehabilitation at home is an alternative 

rehabilitation model to the more traditional model of 

inpatient rehabilitation followed by outpatient rehabilitation. 

Results from randomised controlled studies comparing 

home rehabilitation to outpatient rehabilitation after stroke 

are inconclusive and no definite recommendations can 

be made. In contrast, results from randomised controlled 

studies and meta-analyses of early supported discharge and 

continued rehabilitation at home have shown a reduction 

in hospital stay as well as a reduction in adverse outcomes 

– dependency in activities of daily living or death. 

Furthermore, a five-year follow-up study of early supported 

discharge showed beneficial effects on instrumental 

activities of daily living and a maintained level of quality 

of life. Thus there is evidence for beneficial effects of early 

supported discharge and continued rehabilitation at home 

for people with mild to moderate impairments after stroke. 

Qualitative studies of rehabilitation at home after stroke 

have further increased the understanding of the importance 

of context in rehabilitation. 

Reduced ankle power generation at push off leads to 

slow gait following TBI 

Williams G, 1,2 Morris ME, 2 Schache A, 2 McCrory P 2 

1 

Epworth Hospital, Melbourne, 2 The University of Melbourne 

The aim of this study was to identify the reasons why 

people with traumatic brain injury (TBI) walk at a reduced 

gait speed. A sample of 55 TBI participants receiving 

therapy for gait disorders was recruited; 3D motion analysis 

of self-selected and maximum safe walking speed was 

conducted. A comparison group of 10 HCs performed gait 

trials matched to the mean self-selected TBI gait speed and 

at their maximum walking speed. TBI participants walked 

at a reduced gait speed when compared to age appropriate 

norms. When matched to HCs for speed, TBI participants 

displayed increased peak hip power generation during initial 

and terminal stance compared to the HCs. It is likely that 

this strategy was a consequence of reduced ankle power 

generation during terminal stance. The majority of TBI 

participants had equivalent ability to accelerate to faster gait 

speeds, but used an alternative method to HCs. Ankle power 

generation was significantly reduced, as was the ability to 

increase hip extensor power generation. Hip flexor power 

generation was significantly increased compared to HCs in 

order to accelerate. Postural instability, measured by lateral 

centre of mass displacement, was significantly increased for 

the TBI participants but did not deteriorate with increasing 

gait speed. These findings suggest that, despite the presence 

of postural instability, people with TBI appear unable to 

increase ankle plantarflexor muscle activity effectively for 

faster gait speeds when compared with HCs. 

Visual observation of gait following traumatic brain 

injury is inaccurate 

Williams G, 1,2 Morris ME, 2 Schache A, 2 McCrory P 2 

1 

Epworth Hospital, Melbourne, 2 The University of Melbourne 

The aim of this study was to determine the accuracy of 

visual observation of gait problems following traumatic 

brain injury (TBI). Thirty participants with TBI were 

recruited for this project. Spatio-temporal, kinematic 

and kinetic data was collected concurrently with video 

recordings in the coronal and sagittal planes. Data were 

also collected for a group of 25 healthy control subjects for 

comparison. Thirty-eight observers were recruited to rate 

the gait performance of people with TBI. Observers were 

required to rate 20 gait parameters for each patient. The 

observers were permitted to view the sagittal and coronal 

footage repeatedly, and use slow-motion control, but were 

not permitted to take direct measurements from the screen. 

Observer judgments were compared to the 3DGA analysis 

for accuracy. The 30 subjects with TBI were predominantly 

male (23/7), young (29.2 years), had sustained extremely 

severe TBI (mean PTA = 85 days) and ranged from 2 

months to 20 years post accident. There was no significant 

difference for any of the demographic parameters between 

the TBI and control sample. Clinicians demonstrated 

greatest inaccuracy when rating kinematic parameters (> 

40% of observations inaccurate), followed by kinetic and 

spatio-temporal parameters. Across all parameters, over 

a third of all judgments were inaccurate. These results 

highlight the inability of clinicians to make accurate 

observations of human gait following TBI. Improved 

methods for patient assessment may lead to better targeted 

treatment interventions and optimise patient outcomes. 

Does adding otolith specific exercise to standard 

vestibular rehabilitation improve outcomes for adults 

with unilateral peripheral vestibular dysfunction? 

Winoto A, 1 Murray K, 2 Hill K, 3 Enticott J 2 

1 

Latrobe University, Melbourne, 2 Royal Victorian Eye and Ear 

Hospital, Melbourne, 3 University of Melbourne 

The aim of this ongoing study is to investigate the role of 

otolith specific exercises when added to exercises given in 

standard vestibular rehabilitation therapy. In the labyrinth 

of each inner ear, otolith organs are sensitive to linear 



acceleration and static tilt of the head while semicircular 

canals are sensitive to angular acceleration. Traditionally, 

exercises stimulating the semicircular canals only are 

prescribed in standard vestibular rehabilitation protocols. A 

single-blind randomised control study is being conducted 

at a tertiary referral centre. To date, 36 participants (of the 

desired 48 sample size) with unilateral peripheral vestibular 

dysfunction have been recruited and randomised into an 

experimental (n = 18) or control (n = 18) group. Participants’ 

mean age was 51.2 (SD13.9), 61% were female, 28% had 

mixed otolith and canal pathology, 23% canal only,10% 

otolith only and 39% had inconclusive or normal vestibular 

function test results. Recruitment will be concluded by 

beginning June 2009 and re-assessments completed by end 

July 2009. Control group participants were given a standard 

vestibular therapy home exercise program. Experimental 

group participants received standard vestibular therapy 

exercise with additional exercises designed to stimulate the 

otolith organs. All participants were asked to perform these 

exercises daily for nine weeks. Pre and post home exercise 

therapy measurements were made. Primary outcome 

measures were the Dizziness Handicap Inventory and 

Computerized Dynamic Posturography. All participants 

continued usual care under their medical specialist. If 

positive, the results from the study will contribute to an 

evidence based framework for modifying current practice 

by physiotherapists in vestibular rehabilitation. 

The effect of whole body vibration on strength, 

mobility and quality of life in individuals with multiple 

sclerosis 

Wunderer K, 1 Chipchase LS, 2 Schabrun SM 3 

1 

The University of South Australia, Adelaide 2 The University of 

Queensland, 3 The University of Adelaide 

The aim of this study was to examine the effectiveness of 

regular whole body vibration training on lower limb muscle 

strength, functional mobility and health-related quality 

of life in individuals with multiple sclerosis. A single 

subject experimental design consisting of three phases was 

replicated on three subjects. Phases included a four-week 

baseline phase without intervention, six weeks of twice 

weekly whole body vibration on a VibroGym apparatus 

(frequency 40 Hz, amplitude 2 mm) and another four-week 

period without intervention (ABA design). A progressive 

exercise protocol was used. Muscle strength of the ankle 

plantarflexors and knee extensors was assessed twice 

weekly with the Nicholas Manual Muscle tester, functional 

mobility with the Timed Up and Go test and the Multiple 

Sclerosis Walking Scale, and health-related quality of life 

with the Multiple Sclerosis Impact Scale and the Fatigue 

Severity Scale. Data were analysed visually and statistically 

with the two standard deviation band method. Results 

varied between subjects. While one subject improved 

significantly in all outcomes (p < 0.05), another subject 

showed only significant changes in lower limb strength and 

quality of life. The third subject improved significantly in 

right plantarflexor strength and mobility. Improvements 

were maintained in the final baseline phase. These results 

suggest that whole body vibration training can be effective 

for some individuals with multiple sclerosis, especially for 

those who do not perform any other regular exercise, are in 

a moderate stage of disease progression and have a more 

intensive exercise protocol. However, further high quality 

studies are needed. 

Pilot randomised controlled trial assessing the graded 

cortical retraining program in the management of 

acute upper limb burns 

Zorzi LM, 1, 2 Edgar D, 2 Wand B, 1 Wood F 2 

1 

University of Notre Dame Australia, Perth , 2 Royal Perth Hospital 

The aim of this study is to examine how prophylactic 

physiotherapy cortical training techniques alter neuropathic 

pain after acute upper limb burn. A single blinded 

randomised controlled pilot study is being carried out at 

the Royal Perth Hospital (RPH) Telstra burns outpatient 

department. Thirty subjects who have sustained upper limb 

burns and presented to RPH within seven days of injury 

are randomised into experimental (n = 15) or control (n = 

15) groups. In addition to their usual treatment, subjects 

in the experimental group participate in four weeks of 

mirror box therapy, hand laterality recognition and sensory 

discrimination, with the patients also being given a take 

home diary to record treatment independently. The control 

group is also given a take home diary including normal 

range of motion exercises and stretches to control for placebo 

effect. Outcome measures include five questionnaires; 

QuickDASH, Pain Detect Measure, Pain Self Efficacy 

Questionnaire, Post Traumatic Checklist and Modified 

Tampa Scale of Kinesophobia. These are performed pre 

and post training. Subjects have their hand laterality 

recognition measured pre and post training. QuickDASH 

and Pain Detect Measure are done weekly to monitor for 

adverse affects. To date, eight patients have been recruited 

into the program with recruitment ongoing. Initial results 

are promising in the demonstration of patient benefit, 

feasibility and safety of implementing cortical training in 

burns cohort. 




8th Biennial Conference 

Paediatric Physiotherapy – 

Extending our Horizons 






2 

Identification of developmental coordination disorder 

in primary school-aged Kuwaiti children 

Alanzi SE, 1,2 Piek JP, 1 Jensen LM 1 

1 

Curtin University of Technology, Perth, 2 Ministry of Health, Kuwait 

The aim of this study was to identify Developmental 

Coordination Disorder (DCD) in Kuwaiti children by 

determining the prevalence of DCD in primary schoolaged 

children and measuring their motor performance 

in relation to children from the UK. The Movement 

Assessment Battery for Children version 2 (MABC-2) was 

administered to 303 Kuwaiti children (5–9 years old) who 

were recruited from public and private primary mainstream 

schools representing urban and rural areas. SPSS-16 was 

used to analyse data which were categorised according to 

3 groups: competence group where the MABC score was > 

15th percentile, the at risk of DCD group where the score 

was ≤ 15th and > 5th percentile, and DCD group where the 

score was ≤ 5th percentile. Scores were compared with the 

UK norms provided by the MABC-2. Other variables which 

were investigated were gender differences and differences in 

motor ability between children in public and private schools. 

The results of the study indicated 17.7% of the group had 

DCD and 26.7% were in the ‘at risk’ category - these results 

are increased compared with the UK data. The questions 

raised regarding this result are whether the environment 

contributed to the increase in the number of children with 

low motor performance, or whether the assessment tool is 

culturally appropriate for Kuwaiti children. Children in 

Kuwait lead a sedentary lifestyle, spending most of their 

time with computer games. Further analysis is ongoing. 

The effects of early intravenous pamidronate therapy 

on gross motor function and fracture frequency in 

children with osteogenesis imperfecta 

Alcausin M, 1 Ault J, 1 Pacey V, 1 Briody J, 1 McQuade M, 1 

Sillence D, 1,2 Munns C 1,2 

1 

The Children’s Hospital at Westmead, Sydney; 2 The University of 


Intravenous pamidronate therapy is increasingly being 

used for treatment of children with moderate to severe 

osteogenesis imperfecta. Literature to date reports the 

use of pamidronate therapy in these children results in 

improved vertebral height and bone density, however the 

effects on fracture rate remain unclear and the effects on 

gross motor function have not been described. The only 

published report on the gross motor function of children 

with osteogenesis imperfecta was prior to the use of 

pamidronate therapy, reporting no child with Type III ever 

achieved unassisted walking. A retrospective chart review 

was performed of all patients at The Children’s Hospital at 

Westmead with moderate to severe osteogenesis imperfecta 

who had commenced intravenous pamidronate therapy 

under 12 months of age. This cohort included children 

with Type I (n = 1), Type III (n = 8) and Type IV (n = 1) 

osteogenesis imperfecta. Our aim was to report the effect of 

this treatment on the fracture rate and gross motor function 

in these children. The annualised fracture rate decreased 

from 9.1 to 0.9/year over 12 months of treatment, with 

improved vertebral shape in all patients who had previously 

demonstrated vertebral collapse. All gross motor milestones 

were achieved earlier than previously published in Types I 

and III osteogenesis imperfecta children, but not in Type IV. 

All children with Type III osteogenesis imperfecta achieved 

unassisted walking (median age 23 months). Therefore, the 

use of early pamidronate therapy results in reduced fracture 

frequency and improved gross motor function in children 

with moderate to severe osteogenesis imperfecta. 

Paediatric physiotherapists and frogs: support and 

innovation in rural and remote practice 

Ashworth EJ 

Country Health SA, South Australia 

Frogs are considered to be a barometer of environmental 

wellbeing, and consideration of requirements for them to 

thrive is believed to be valuable in promoting the health of 

the environment. Like frogs, paediatric physiotherapists 

working in remote and rural Australia have specific needs 

to enable them to survive and thrive. They are not unique 

in this – there is a growing body of evidence about the 

conditions required to support allied health professionals in 

remote and rural Australia. As a relatively small subset of 

this group, paediatric physiotherapists could be considered 

a barometer for allied health professionals in general in 

remote and rural practice. In 2007, examination of some of 

the many reviews of the allied health workforce in a number 

of jurisdictions, the limited workforce data available and 

consultation with allied health professionals in country 

South Australia provided a wealth of information about the 

conditions required for these scarce and, at times, apparently 

endangered species to thrive. This information has guided 

the development of a range of initiatives and service models 

to support the growing allied health workforce in country 

South Australia in meeting the needs of their communities. 

While some of these initiatives are still at the tadpole 

stage, others are undergoing metamorphosis to emerge as 

mature and healthy frogs. These challenges and solutions 

are presented as just one example of the initiatives in place 

nationally to ensure that remote and rural communities have 

access to the allied health services they need, including 

those focusing on children and families. 






conditions and the impacts of an increased burden to the 

health system and families with limited physiotherapy 

resources available. Medical advances have lead to earlier 

diagnosis of chronic respiratory conditions, and significantly 

improved survival rates. The Royal Children’s Hospital, 

Brisbane, has had progressive and significant increases in 

referrals for these conditions and subsequent increases in 

activity. In this presentation, we review current models of 

care; including quality measurements and patient health 

outcomes, and will offer potential solutions which include 

flexible but targeted services across the continuum and 

incorporate a variety of domiciliary care models and the 

indicators for success. Current literature shows that existing 

domiciliary programs demonstrate mixed results, primarily 

in the cystic fibrosis population group. However, domiciliary 

care across the continuum, inclusive of specialised allied 

health professionals, has shown to be cost and clinically 

effective, in the presence of appropriate referrals and 

resources. Unfortunately, in the Queensland experience, the 

quality and extent of domiciliary care is being adversely 



affected by limited community physiotherapy funding, 

decreased availability of specialist paediatric physiotherapy 

and limited accessibility of domiciliary services. 

Considerable re-thinking is required to provide appropriate 

care to this patient group, which can be modified to support 

and adapt to individual, local and state-wide needs to ensure 

a seamless approach to paediatric physiotherapy for chronic 


Clubfoot: 12-month follow-up of patients using the 

Ponseti Technique 

Bagley C, 1 Astori I, 2 Byrom L 1 

1 

Physiotherapy Department, Mater Health Services, 2 Department of 

Orthopaedics, Mater Health Services, South Brisbane, Queensland 

The aim of this hospital based cohort study was to review 

the results of treatment of babies with idiopathic clubfoot 

referred to author 2 at the Mater Children’s Clubfoot Clinic, 

born between July 2006 and July 2008. Forty babies with 69 

clubfeet were treated using the Ponseti technique of casting, 

splinting and in the majority of cases, a percutaneous 

tendo achilles tenotomy. The primary outcome was the 

requirement for surgery, in particular a posterior medial 

release by the age of 12 months. Secondary outcomes 

included the ongoing Pirani scores, a 12-month McGuire 

score, recurrence requiring casting and/or surgery and the 

presence of adverse events, especially skin excoriation and 

cast slippage. By 12 months no feet had relapsed sufficiently 

to require any surgery, but 1 baby required 1 cast for 

recurrence due to problems with boots and bar. There 

were 2 children lost to follow-up. No significant adverse 

events were reported. These 12-month results demonstrate 

that the treatment of clubfoot using the Ponseti method is 

highly recommended. However, longer term follow-up is 

recommended. 

Osteomyelitis in indigenous Australian children 

Bradford K, Donald G 


It is well established that Australian indigenous children 

possess lower health status than their non-indigenous 

cohorts across a multitude of indicators, including 

acquisition of infectious diseases. Reasons for this 

are multi-factorial and include a range of lifestyle and 

environmental factors. Susceptibility to certain pathogens, 

in particular staphylococcus aureus, has also been identified 

as a contributor. Osteomyelitis is one of the less common 

infectious diseases seen in indigenous communities, but 

the incidence has been reported as up to 6 times higher 

than in the non-indigenous population. Additionally, 

clinicians report than when osteomyelitis does occur, it 

tends to pose more serious threats to life and limb than 

for non-indigenous children. This presentation will outline 

a series of cases of osteomyelitis in indigenous children 

who presented to Royal Children’s Hospital, Brisbane, for 

tertiary management. Clinical and non-clinical influences 

to care, the potential for long-term effects on mobility and 

function, and the risk of permanent limb deformity will 

be discussed as critical to the clinical decision making of 

the multi-disciplinary team. A diverse range of clinicians, 

including physiotherapists, orthopaedic surgeons, infectious 

disease physicians, and local health care providers, is 

imperative to effectively identify and manage these unique 

challenges. Comprehensive, co-ordinated, targeted, timely, 

multi-dimensional, and long-term interventions across the 

continuum of care are vital to ensure optimal outcomes for 

this already disadvantaged group. 

Transition to adult care: getting it right for 

young people 

Brodie LS, Cullen S 

The Greater Metropolitan Clinical Taskforce, Sydney 

The Greater Metropolitan Clinical Taskforce (GMCT) 

Transition Care Network was established in 2004 with 

the aim to improve the systems and processes around 

transition for young people with chronic illnesses and 

disabilities moving from paediatric to adult health services. 

The program targets young people with a broad range of 

conditions arising in childhood such as cystic fibrosis, 

spina bifida, cerebral palsy, rare genetic metabolic diseases, 

developmental disability and cancer. The topic of transition 

has particular relevance for all paediatric clinicians who 

have often cared for these young people and their families 

for a very long time and who can play a pivotal role preparing 

young people to move to adult health facilities. This paper 

will describe the achievements and current directions of the 

Transition Network and provide an overview of the journey 

being taken by young people once they leave paediatric 

health services. Data will be provided on the numbers of 

young people requiring ongoing care and the ideal models 

of service delivery. It will outline some of the services 

and resources available in adult facilities and discuss the 

collaborative relationships that have been developed with 

various government and non government organisations 

such as the Department of Education and Training. Patient 

stories will be used to highlight the challenges faced by 

young people and their families and a personal experience 

will be provided by a young woman who suffered a stroke 

at the age of 14 years. 

Early childhood intervention service family toolkit: 

supporting trans-disciplinary practice 

Butchart JL 

Cerebral Palsy League, Hervey Bay 

In an innovative approach to address therapist time 

constraints and promote trans-disciplinary practice, the 

Cerebral Palsy League is developing the Early Childhood 

Intervention Service Family Toolkit. The Early Childhood 

Intervention Service is a goal-based program and uses a 

trans-disciplinary model to support families in promoting 

their child’s development. The Family Toolkit is an 

interactive web-based resource for therapists to produce 

customised activity cards for families. Based on the 

International Classification of Function (WHO, 2001), cards 

are selected to address goals at the participation and activity 

levels. When constructing activity cards, the function to 

individualise cards allows the personal and environmental 

needs of the families to be met. Unlike existing resources 

that provide exercises, the cards give ideas of games and 

activities to promote the child’s development in multiple 

domains, including gross motor, fine motor, communication 

and social/emotional. Importantly, the cards explain the 

rationale, based on body structure and function, behind 

the activities, enabling families to strengthen their skills 

and to use their own resources to create additional games 



and activities to address their child’s goals. This resource 

will save therapists and early intervention workers time in 

putting together information and exercise programs and will 

promote role release reflective of trans-disciplinary practice. 

This enables more efficient service delivery and provision of 

services to more families in the current economic climate 

where time and funding is limited. 

4 

The state of play for physiotherapy intervention for 

children with cerebral palsy 

Butler JM 


The major focus of physiotherapy intervention for 

children with cerebral palsy is to limit impairments and 

promote activity and participation in age-appropriate 

community activities. Currently, there are varied 

physiotherapy interventions for children with cerebral 

palsy. Interventions may be specific or may include a 

combination of interventions. Such interventions include 

neurodevelopmental therapy, dynamic systems theory, 

constraint induced movement therapy, casting, orthoses, 

physical fitness, strengthening, and electrical stimulation. 

These interventions predominantly address issues defined 

by the International Classification of Functioning, 

Disability and Health (ICF) model of impairment in body 

structure and function (weakness, spasticity, contracture), 

activity limitation (upper limb, gait), and participation 

restriction (home, school or community activities, or 

quality of life). Of interest to clinicians is knowing whether 

an intervention has either, a beneficial effect, no effect or 

is less effective in improving impairment, activity and 

participation. Controlled trials, systematic reviews and 

practice guidelines are methods which provide clinicians 

with evidence of effect of interventions. There are many 

controlled trials of physiotherapy for cerebral palsy located 

on the electronic databases. Furthermore, there has been an 

exponential increase in the number of trials in the last 8 years 

suggesting that there is increased interest in research in this 

area. Organising the available trials into systematic reviews 

is a way to provide specific evidence about the effect of 

physiotherapy intervention. The aim of this presentation is 

to discuss the evidence currently available for physiotherapy 

intervention in children with cerebral palsy. 

Pedal Power: increasing endurance and participation 

in physical activity for children with cerebral palsy 

Butterfield TS 

The Spastic Centre, Rural Services 

The aim of this study was to evaluate the effects of the bike 

riding program, Pedal Power for 5 children with cerebral 

palsy. A pilot case study was completed with a purposive 

sample of 5 children with cerebral palsy, unable to ride a 

bike independently and whose abilities ranged between 

GMFCS Level 2 to Level 5. Participants were supplied with 

a modified bike individually adapted and an individualised 

10-week bike riding program. The program was reviewed 

and outcome measures reassessed both 5 and 10 weeks 

after the initial assessment. An additional reassessment 

of outcome measures was taken 8 weeks after completion 

of the program. Outcome measures included a six-minute 

walk, six-minute ride, Timed Up and Go, physical activity 

questionnaires, and GAS goals including at least 1 physical 

goal and 1 goal relating to participation in activity. At 

completion of the program, all participants demonstrated 

an improvement in all physical outcome measures. 

Four participants achieved above the expected level of 

performance (T-Score > 60) in their physical GAS goals 

and at the expected level of performance (T-Score = 50) for 

their participation GAS goals at week 10. All participants 

increased their participation in physical activity. Further 

increase in the physical outcome measures was seen 8 

weeks after completion of the program in the 4 children 

who continued to ride. An individualised home bike riding 

program for children with cerebral palsy can lead to and 

maintain improvements in riding ability, walking endurance 

and participation in physical activity with their families. 

Seated lateral reach: a new measure of trunk postural 

control in children 

Carroll KM, 1,2 Lythgo N, 1 Galea MP 1 

1 


Melbourne, 2 The Royal Children’s Hospital, Melbourne 

The seated lateral reach is a maximal lateral reach in sitting 

that requires control of trunk posture and movement and 

can be quantified clinically by recording the distance 

reached. The aims of this study were to analyse trunk 

motion during the seated lateral reach test (SitLRT) in 

ambulant children with cerebral palsy (CP) or Duchenne 

muscular dystrophy (DMD) and to examine reliability of 

the SitLRT in this population. Nineteen children (9 CP, 10 

DMD) aged between 4 and 12 years performed the SitLRT 

while three dimensional motion analysis was performed. 

Results indicated children with CP or DMD showed less 

displacement of their trunk than able-bodied children 

previously tested (µ = -2.21SD). Seventeen children (9 CP, 

8 DMD) participated in reliability testing of the SitLRT. 

Overall moderate agreement was achieved between two 

raters (ICC = 0.74, 95% CI 0.59–0.89) with the CP group 

proving more reliable (ICC = 0.85, 95% CI 0.68–0.97). 

Intra-rater reliability was higher (ICC ≥ 0.93). The seated 

lateral reach test has potential clinical application as a low 

tech measure of trunk control that produces ratio data and 

is suitable for use with children. 

Developmental dysplasia of the hip: a review of 

assessment and management 

Charlton SL, Schoo AMM 

Greater Green Triangle University Department of Rural Health 

(Flinders and Deakin Universities) 

The aims of the study were to identify risk factors and 

protocols for diagnosis and management of developmental 

dysplasia of the hip and to examine incidence rates between 

urban, regional and rural areas of South Australia and 

Victoria. Results showed a difference in the detection 

rate between urban and rural Australia. Evidence-based 

Swedish protocols for examination and management were 

explored. Guidelines were suggested for Australian setting 

that include physical examination, the use of ultrasound 

and recommendations about wrapping and positioning of 

infants. 



Differentiating the influence of gestation and 

birthweight centile on age-appropriate motor 

development in children 

Drysdale JL, 1,2 Robinson JS, 1,2 Haslam RR, 1,3 Pitcher JB 1,2 

1 

School of Paediatrics & Reproductive Health1 and the Robinson 

Institute, 2 University of Adelaide; Department of Neonatal 

Medicine, 3 Women’s & Children’s Hospital 

We aimed to determine if gestational age at birth and 

birthweight centile (birthweight relative to predicted 

term optimal weight) influence age-appropriate motor 

development in 132 children (11.7 ± 0.6 years) assessed 

using the Movement Assessment Battery for Children 2 

(MABC-2). Gestation ranged from 25–41 weeks. Exclusion 

criteria included cerebral palsy and congenital abnormality. 

Gestation correlated with total MABC-2 score (r = 0.20, 

p = 0.02) which was higher in girls than boys (r = 0.22, p 

= 0.02). Of the skill components, gestation correlated with 

balance (r = 0.22, p = 0.02) and aiming/catching (r = 0.21, 

p = 0.02) but not with manual dexterity, and this differed 

when the sexes were analysed separately. In girls, gestation 

correlated with aiming/catching (r = 0.35, p = 0.008), but 

not dexterity or balance. In boys, gestation correlated with 

balance (r = 0.27, p = 0.03) but not with aiming/catching or 

manual dexterity. Regression modelling including gestation, 

birth weight, mother’s BMI at first antenatal presentation 

and child’s percentage body fat at assessment indicated 

that the strongest independent predictors of total MABC-2 

score in both boys and girls were gestation (p = 0.008) and 

percentage body fat (p ≤ 0.0001). The degree of prematurity 

at birth influences age-appropriate motor development 

in both boys and girls and is exacerbated in overweight 

children. However, balance scores in girls and aiming/ 

catching scores in boys suggest that the main effects of 

shortened gestation can be ameliorated and/or compensated 

for by postnatal practise of specific motor skills. 

A qualitative study about the attitudes, values and 

knowledge of parents and staff of preschool-age 

children about physical activity 

Dwyer GM, 1,2 Higgs J, 3 Hardy LL, 4 Baur LA 1,4 

1 

Discipline of Paediatrics and Child Health, University of Sydney, 

Sydney, 2 Discipline of Physiotherapy, University of Sydney, Sydney, 

3 

The Research Institute for Professional Practice, Learning & 

Education, Charles Sturt University, Sydney, 4 Physical Activity, 

Nutrition and Obesity Research Group, University of Sydney, Sydney 

Physical activity and small screen recreation (SSR) are 

two modifiable behaviours associated with childhood 

obesity. Parents and preschool staff potentially shape 

such behaviour habits in young children. The aims of this 

study were to explore the attitudes, values, knowledge and 

understanding of parents and staff about physical activity 

and SSR in young children, and to identify influences 

upon these behaviours. Thirty-nine participants took part 

in 9 focus groups. All participants understood the value of 

physical activity and the impact of excessive SSR but were 

unfamiliar with national guidelines for these behaviours. 

While participants clearly described the nature and activity 

patterns of young children, the concept of ‘intensity’ was not 

a meaningful term. Factors that promoted activity included 

a child’s preference for being active, positive parent or peer 

modelling, access to safe play areas, organised activities, 

preschool programs and a sense of social connectedness. 

Barriers to activity included safety concerns exacerbated by 

negative media stories, time restraints, financial constraints, 

cultural values favouring educational achievement, and 

safety regulations about equipment design and use within 

the preschool environment. Parents considered that young 

children are naturally ‘programmed’ to be active, and 

that society ‘de-programs’ this behaviour. Staff expressed 

concern that free, creative active play was being lost and 

that alternate activities were increasingly sedentary. In 

this age group, efforts may best be directed at emphasising 

national guidelines for SSR and educating carers about the 

importance of creative, free play to reinforce the child’s 

inherent nature to be active. 

The Physical Activity Questionnaire for preschool-age 

children (Pre-PAQ®): a study of concurrent validity 

Dwyer GM, 1,2 Baur LA, 1,3 Hardy LL 3 

1 

Discipline of Paediatrics and Child Health, University of Sydney, 

Sydney, 2 Discipline of Physiotherapy, University of Sydney, Sydney, 

3 

Physical Activity, Nutrition, Obesity Research Group, University of 


The Pre-PAQ®) was developed as an epidemiological tool 

to measure physical activity in young children. We assessed 

the PrePAQ’s concurrent validity for the period 8am–6pm 

against accelerometry in 67 children who completed both 

tools (mean age 3.97, SD 0.72; males 52%). The Pre-PAQ 

categorises activity into five levels but Levels 1–2 (stationary 

activities) were combined for analyses. Mean daily time 

(minutes) reported was Levels 1–2: 222.0 (SD 69.4), Level 

3: 66.0 (SD 46.6), Level 4: 72.4 (SD 36.8), Level 5: 18.4 

(SD 18.8), Levels 4–5: 90.8 (SD 46.5) and Levels 3–5: 156.7 

(SD 69.5). Accelerometer data were categorised according 

to Sirard et al’s cut-points for sedentary (SED), low (LPA), 

moderate (MPA) and vigorous physical activity (VPA). 

Mean daily time spent in these activity levels was SED 

488.6 (SD 34.3), LPA 70.8 (SD 18.7), MPA 24.2 (SD 12.6), 

VPA 16.5 (SD 10.9), MVPA 40.7 (SD 19.7) and LMVPA 

111.4 (SD 34.3). Bland-Altman analysis was used to assess 

agreement (Pre-PAQ 1-2-SED, Pre-PAQ 3-LPA, Pre-PAQ 

4-MPA, Pre-PAQ 5-VPA, Pre-PAQ 4–5-MVPA, Pre-PAQ 

3–5-LMVPA). Agreement varied between categories and 

was good for Pre-PAQ 3-LPA (mean difference -4.8 mins 

UL 95.9 LL -105.5) and Pre-PAQ 5-VPA (1.9 mins UL 

41.3 LL -37.5) but poor for Pre-PAQ Levels1–2 compared 

with SED (mean difference -226.4 mins UL -128.1 LL 

-404.9). As developed, the Pre-PAQ does not measure SED 

behaviour accurately but is otherwise valid and should be 

a useful tool for measuring levels of active behaviour in 

epidemiological studies of young children. Refinement is 

ongoing to optimise its use. 

Developing a new paediatric workforce in outer 

metropolitan Melbourne 

Edgar JV, Smith J, Smith R 

Northern Health, Melbourne 

Melbourne’s outer north is a rapidly growing area with 

significant growth in the need for health services. This paper 

describes the demographic and needs analysis completed 

prior to the commencement of allied health paediatric 

services within a major health service. It discusses workforce 

strategies for supporting, training and retaining staff. These 

include a supervision framework, competency standards, 

professional development activities, clinical redesign, and 

student education. Population demand, service development 

and effective workforce strategies have driven the growth 



and development of allied health paediatric staff equivalent 

full time positions and built expertise in the management 

of infants at risk of developmental delay. For example: 

the 3-day per week, part time service provided by 2.2 

equivalent full time allied health staff in 2004 has grown to 

become a full-time service offered across two campuses and 

comprising 10.8 equivalent full time allied health staff, plus 

sessional developmental paediatricians and 0.6 equivalent 

full time paediatric fellows. A pilot project to investigate 

the need for an allied health developmental service in the 

special care nursery informed a successful business case 

that has resulted in 2.3 equivalent full time allied health 

staff employed into this service. This is an overall allied 

health paediatrics workforce increase from 2.2 equivalent 

full time in 2004 to 13.1 equivalent full time in 2008. This 

paper will outline the successes and challenges of this 

service growth and discuss strategies for sustainability and 

further development 

6 

Treatment of the recurrent clubfoot with the Ponseti 

technique 

Evans KG, Gibbons P, Latimer M 

The Children’s Hospital at Westmead, Sydney 

The successful use of the Ponseti Technique in the 

treatment of recurrent clubfoot has been documented but not 

quantified in the literature. Prior to the introduction of this 

technique, those children with recurrent congenital talipes 

equinovarus deformity were treated with surgery. It is now 

well established that extensive surgery leads to poor long 

term outcomes. At The Children’s Hospital at Westmead 

it has become common practice to treat the recurrent 

clubfoot with the same Ponseti serial casting technique 

used in neonates. A retrospective chart audit of 55 patients 

with 96 clubfeet who underwent Ponseti serial casting for 

congenital talipes equinovarus between 2001–2008 was 

performed. Our aim was to quantify the outcome of these 

patients following serial casting. Outcome was measured 

according to surgical intervention required after casting. 

Major surgery was considered a failure; minor or no surgery 

was considered a success. Major surgery was defined as 

intra-articular procedures including posteromedial soft 

tissue release. Minor surgery was defined as extra-articular 

procedures including tibialis anterior tendon transfer. Our 

results post casting showed a marked decrease in surgery 

with 4 feet requiring major surgery (4%); 25 feet (26%) 

undergoing minor surgery and 67 feet (70%) requiring no 

surgery. Thus there was an overall success rate of 96%. The 

use of the Ponseti technique for the treatment of recurrent 

talipes equinovarus is recommended to reduce the need for 

both major and minor surgery in this population and thus 

produce good long term outcomes. 

Improving reliability of the clinical assessment of 

spasticity: the Australian Spasticity Assessment Scale 

Gibson N, 1,2,4 Love SC, 1,2,3,4 Blair E 1,2,4 

1 

Princess Margaret Hospital, Perth, 2 University of Western Australia, 

Perth, 3 Curtin University of Technology, Perth, 4 The Telethon Institute 

for Child Health, Perth 

We sought to improve our current methods of identifying 

and assessing spasticity by developing a more valid, 

reliable and clinically applicable tool, the Australian 

Spasticity Assessment Scale. The most frequently used 

tool, the Modified Ashworth Scale does not conform to the 

definition of spasticity and has poor to mediocre reliability. 

The Australian Spasticity Assessment Scale was developed, 

using the framework of the Modified Ashworth Scale but 

conforming to the definition of spasticity. An explicit yet 

simple standardised test protocol is provided together 

with unambiguous, mutually exclusive scoring criteria, 

so that every muscle tested fits into one and only one 

category. Inter-rater reliability of the Australian Spasticity 

Assessment Scale was assessed in an outpatient setting of a 

tertiary paediatric hospital. Three raters used the Australian 

Spasticity Assessment Scale to independently assess the 

spasticity of muscles in 23 children with a wide range of 

subtypes and functional levels of spastic cerebral palsy (n = 

322 muscle groups). Agreement was measured with kappa, 

and, in order to compare with estimates of reliability of preexisting 

methods, with intra-class correlation. Substantial 

agreement was demonstrated by kappa = 0.71 (95% CI 0.67– 

0.75). Intraclass correlation was 0.88 (95% CI 0.86–0.90), 

significantly better than that published for other methods 

of assessment. The Australian Spasticity Assessment Scale 

conforms to the definition of spasticity, is easily clinically 

applicable and reliability exceeds that of other commonly 

used spasticity scoring systems and we suggest it should 

be the tool of choice for assessing spasticity in the clinical 

setting. 

Towards a sustainable clinical education model for 

paediatric physiotherapy: the experience of building 

capacity for physiotherapy students at the Children’s 

Health Service District in Queensland 

Henderson DR, 1 Wright S, 1 Maharaj S, 2 Moller M 1 

1 

Dept of PT, Royal Children’s Hospital, Brisbane, 2 Queensland 

Paediatric Rehabilitation Service, Brisbane 

It is well recognised nationally that clinical education for 

entry level physiotherapy students faces building pressure 

from increasing clinical demands, growing student numbers 

and reducing educational funding. The way forward is 

unclear with systematic review of physiotherapy clinical 

education literature concluding that ‘no model is more 

effective than another’. How does a busy physiotherapy 

department build sustainable capacity to support the next 

generation of therapists? What model of clinical education 

best supports the local needs, what steps are involved in its 

formation and are they transferable to other physiotherapy 

departments? The purpose of this study is to analyse the 

efficacy of an innovative pilot model of clinical education and 

describe the lessons learnt to facilitate broader adaptation. 

This model aims to incorporate strategies to unload busy 

clinicians while supporting students’ learning curve of skills 

attainment. A mixed action research design used features 

of qualitative semi-structured interviews, focus groups and 

observational analysis combined with quantitative time/ 

motion study tools and survey data. Innovative models 

for assessing student attainment of competencies e.g the 

MiniCEX, an assessment tool of clinical skills validated in 

medicine, are investigated. Participants include members 

of the paediatric physiotherapy services in the Children’s 

Health Service District of Queensland based at Royal 

Children’s Hospital (RCH) in Brisbane, and other key 

stakeholders such as students, parents and patients. The 

results of the pilot are still being gathered in collaboration 

with university educators in Queensland and the project is 

due to report in August 2009. 



Physiotherapyexercises.com: where to from here? 

Katalinic O, 1 Glinsky J, 1 Harvey L, 1 Sydney 

physiotherapists 2 

1 

University of Sydney, 2 Sydney’s Government funded hospitals 

and universities 

The physiotherapy exercise website is a not-for-profit 

initiative of Sydney physiotherapists. The website can be 

freely accessed at www.physiotherapyexericses.com. The 

website contains over 750 exercises appropriate for people 

with neurological disabilities. Each exercise is illustrated 

with a sketch and photograph, and has explanatory text 

written in two formats: one appropriate for therapists and 

the other appropriate for patients. The website enables 

users to search for appropriate exercises and then collate 

them into professional-looking exercise booklets. There are 

currently adult and paediatric exercises appropriate for those 

with spinal cord injury, stroke, brain injury and cerebral 

palsy with plans to expand to other disability groups. All 

exercises are selected by committees comprising Sydney’s 

leading clinicians and academics. In this way, the website 

provides a way of harnessing the training strategies of 

experienced therapists for all to use. The website has been 

translated into Chinese, Vietnamese, Russian and Arabic. 

The success of the website has been evaluated using on-line 

questionnaires and site tracking. For example, the website 

has attracted 200 000 visitors from over 150 countries in 

the last 18 months. There are now plans to further expand 

the website and develop online learning modules. 

Aquatic therapy in children requiring long-term 

ventilation 

Jenkins AV, Pacey V, Evans K 

The Children’s Hospital at Westmead 

The aim of this paper is to present an overview of the 

clinical practice of aquatic therapy in children requiring 

long-term ventilation (LTV) at The Children’s Hospital 

at Westmead (CHW). Since the implementation of the 

weekly aquatic therapy program for LTV children 5 years 

ago, 9 inpatient LTV children have participated, aged 16 

months to 9 years old. These children have all presented 

with physical limitations and/or developmental delays 

contributed to by their underlying condition, the physical 

restrictions of being attached to a ventilator and long-term 

hospitalisation. Aquatic therapy is a common therapy tool for 

developmentally delayed children and is well documented 

in the literature, however, there are no publications on 

aquatic therapy in LTV children. Furthermore, aquatic 

therapy for LTV children is not commonly practised due to 

medical and clinicians’ resistance, as there are significant 

risks involved with maintaining an artificial airway and 

ventilation safely in the water environment. Feedback from 

patients, families and therapists has indicated positive 

musculoskeletal, respiratory, social and emotional outcomes 

from the program. Specific goals and associated benefits 

of aquatic therapy with LTV children will be discussed, 

as will the practical considerations of accessing the pool 

and the provision of therapy by a multi-disciplinary team. 

The paper will also address the risks of performing aquatic 

therapy in this population and the strategies implemented to 

reduce these risks. The program at CHW has demonstrated 

that aquatic therapy can be performed safely and effectively 

with LTV children, and as this population increases in the 

community, the provision of aquatic therapy needs to be 

considered. 

Recovery of fitness and musculoskeletal changes 

in children and adolescents who have had treatment 

for cancer 

Laird K, 1 Johnston KN, 2 Monterosso L 1,3 

1 

Princess Margaret Hospital Perth, 2 University of South Australia, 

3 

Curtin University of Technology Perth 

The aim of this study was to determine changes in 

measures of fitness and musculoskeletal variables in 

children and adolescents who were in remission from 

cancer, and whether these changes improved over time 

without specific intervention. Eleven subjects aged from 

8–19 years in early remission from leukaemia or lymphoma 

were assessed three times over 12 months at 0, 6 and 12 

months. Outcome measures investigated were fitness 

(VO 2 

peak), fatigue, depression, quality of life, range of 

movement, muscle strength and endurance, lung function 

and activity time. Results demonstrated that there were no 

significant differences in aerobic fitness (VO 2 

peak), range 

of movement, muscle strength, quality of life or fatigue over 

time, but depression scores decreased significantly (p = 

0.04). Five subjects had a BMI > 85th percentile throughout 

the study. On average, quality of life, fatigue (moderate to 

low levels) and depression were within the range of normal 

values. Mean VO 2 

peak and ankle range of movement 

were lower in study participants than age-matched healthy 

reference values.. Daily moderate activity time of less than 

60 minutes occurred in 33% of measures. This study found 

that children in the early stages of remission from cancer 

(up to 18 months) may not have spontaneous recovery 

in fitness or joint range of movement. However, as some 

subjects did achieve normal reference values, for these and 

other outcome measures, exercise intervention programs 

(that increase health costs and are time consuming to the 

patient) need to be targeted only to those who require them 

most. 

Physiotherapy intervention for positional plagiocephaly 

at an Australian community health facility 

Leung AY, 1,2 Watter P, 1 Gavanich J 2 

1 

The University of Queensland, Brisbane, 2 Therapy and Support Service 

for Children, Ipswich 

The aim of this study is to explore the outcomes of infants 

with positional plagiocephaly referred for physiotherapy at an 

Australian community health centre. A retrospective study 

using a total cohort convenience sample was conducted. 

Of 156 infants with positional plagiocephaly referred for 

physiotherapy from 2004–2007, 25 were excluded (23 not 

contactable, 1 diagnosed with cerebral palsy, and 1 with 

parent not concerned). Data were retrieved from their 

community health records. Eighty percent of the infants 

were referred by child health nurses who also educated 

the parents about re-positioning strategies. There was an 

association of more limited active neck rotation in those 

with more severe plagiocephaly (p = 0.066). Nearly 85% of 

mothers reported that they complied with the physiotherapy 

home program. Mean number of physiotherapy sessions 

was 2.27 +/- 1.6 and length of intervention was 9.17 

+/- 8.48 weeks. Significant reduction in the severity of 

plagiocephaly as measured by cranial vault asymmetry 

index (p < 0.001) and clinical presentation (p < 0.001) was 

noted after physiotherapy intervention. The severity of the 

plagiocephaly did not correlate with the severity of clinical 

presentation, age appropriate developmental milestones, 



the number of physiotherapy sessions or the total length 

of physiotherapy service received. Sixty-eight percent 

of infants were discharged with optimal results and only 

3 infants needed referral for helmet therapy. In infants 

with positional plagiocephaly, physiotherapy intervention 

can be focused on individualised repositioning strategies 

which will facilitate parents’ compliance to implement the 

strategies and lead to improved infant head shape. 

8 

Muscle adaptation in neuromuscular disease 

Lieber RL 




Skeletal muscle is one of the most adaptable tissues in 

the body. In order to understand muscle adaptation to 

neuromuscular disease, other model systems have been 

studied that can generally fall into one of two categories — 

models of increased muscle use and models of decreased 

muscle use. Increased use models include exercise, chronic 

stretch, electrical stimulation and hypergravity while 

decreased use models include spaceflight, immobilisation, 

tenotomy, spinal cord injury and hindlimb suspension. 

Denervation, that is, loss of lower motor neuron innervation 

of muscle, represents a completely distinct model not to 

be confused with either decreased or increased use. In 

most increased use models, skeletal muscles demonstrate 

a stereotypical response in which muscles get stronger, 

physiologically slower, and change their structural properties 

accordingly. In contrast, with decreased use, muscles get 

weaker, physiologically faster and change their structural 

properties accordingly. These models will be discussed 

in order to explain muscle adaptation that occurs after 

upper motor neuron lesion, myopathies such as Duchenne 

muscular dystrophy, physical denervation and chemical 

denervation, such as occurs with neurotoxins. 

Neonatal physiotherapy: update on factors influencing 

service provision in Australia 

Lucas B 

Royal North Shore Hospital, Australia 

The role of the physiotherapist within neonatal intensive care 

units is one of the most specialised fields of practice within 

physiotherapy today. Across Australia there are 22 neonatal 

intensive care units, reflecting both the specialisation of the 

service and the limited numbers of physiotherapists with 

neonatal skills. Preterm birth (less than 37 weeks gestation) 

is associated with a higher risk of neonatal problems that 

cause significant morbidity and mortality in newborn babies. 

Of the 282 169 babies born in Australia in 2006, 8.2 % were 

preterm with higher rates of 13.7% recorded in Aboriginal 

and Torres Strait Islander populations. Trends show that 

neonatal admissions are growing with 15% of all live born 

babies admitted to a special care nursery or neonatal intensive 

care unit. (All data obtained from the Australian Institute of 

Health and Welfare). The physiotherapists’ background as 

movement specialists, places them in a unique position to 

contribute to the preterm infant’s neurodevelopmental care, 

especially with respect to differing developmental patterns 

and their neurological sequelae. They hold key roles in the 

use of assessment tools which predict gross motor outcome 

and assess developmental status. The past decade has seen 

a significant reduction in chest physiotherapy referrals, 

largely due to improvements in mechanical ventilation 

and synthetic surfactant. Chest physiotherapy guidelines 

supported by evidenced based practice provide direction 

for current respiratory services and the maintenance of 

competency. This session informed on factors influencing 

physiotherapy service provision in neonatal intensive care 

units with respect to neurodevelopment, assessment tools, 

chest physiotherapy and parent education. 

Development of best practice model for management of 

babies with developmental dysplasia of hips, at Royal 


Lucas B, Cameron M, Selby P, Croxall P, Wines A, 

Evans P 

Royal North Shore Hospital, Sydney 

The aim of this study was to develop a best practice 

management model for babies with developmental dysplasia 

of hips requiring treatment with a hip abduction orthosis. 

The key objectives were to ensure that 100% of infants 

diagnosed with hip dysplasia and involving management by 

hip abduction orthosis would be referred for treatment within 

24 hours of diagnosis, and subsequently suffer no adverse 

outcomes during the intervention period. A multidisciplinary 

team review process was commenced in response to an 

adverse event, utilising a Failure Mode and Effects Analysis 

tool. This process included an extensive literature review, 

consultation with parents and other services, and the 

development of key performance indicators. Problems in 

relation to the diagnosis and management of hip dysplasia 

at RNSH were identified, and a risk priority number was 

scored, then recalculated after design improvements were 

instigated, with the goal of reducing the risk priority 

number by 50%. The new service delivery was evaluated by 

parent satisfaction surveys. The risk priority number was 

reduced by 77% and 100% of key performance indicators 

were met. Parent satisfaction surveys showed that 100% of 

parents rated the overall care of their baby as good (14%) 

to excellent (86%). This study resulted in the development 

of clinical practice guidelines, a formalised clinic, parent 

information pamphlet, competency of orthosis application 

and improved area health networks. This model provides a 

defined pathway for the treatment of hip dysplasia which is 

easily transferable and applicable for all multidisciplinary 

teams involved in hip dysplasia management. 

Gait and symmetry measures of children and young 

adults walking barefoot and with shoes 

Lythgo N, Galea MP 


Melbourne 

Reference data are required to assess gait. This investigation 

recorded the gait of 898 healthy school-aged children (5–13 

years) and re-examined gait maturation by comparing the 

children’s gait to 82 young adults (18–30 years). Participants 

walked 6 times across a GAITRite mat (80 Hz) at selfselected 

speed wearing shoes and barefoot. Spatial measures 

were normalised to leg length, whereas temporal measures 

were normalised to the gait cycle. Non-normalised measures 

of speed, step and stride length, support base and foot angle 

increased with age whereas cadence reduced. The majority 

of normalised measures remained unchanged with age 

(r-values of -0.243–0.115). Compared to children, however, 



the adults exhibited a 5.1% increase in double support, a 

2.6% increase in stance and a 2.3% reduction in single 

support (p < 0.0001). On average, shoes increased speed 

by 8 cm·s-1, step and stride length by 5.5 cm and 11.1 cm 

respectively, and base of support by 0.5 cm. In contrast, foot 

angle and cadence reduced by 0.1 degree and 3.9 steps·min-1 

which were reflected in the normalised data. On average, 

shoes increased double support by 1.6% and stance time by 

0.8% whereas single support reduced by 0.8%. Symmetry 

remained unaffected by age. On average, step and stride 

differentials were 1.1 cm and 0.9 cm, whereas step time, 

stance time, single and double support were 0.81%, 0.82%, 

0.88% and 0.44%. Footwear significantly affects gait. Gait 

may not be mature by age 13 years. Symmetry is unaffected 

by age and footwear. 

Assessment of a group program for adolescent 

anterior knee pain 

MacPhail CE 

Women’s and Children’s Hospital, Children, Youth and Women’s 

Health Service, Adelaide 

Adolescent anterior knee pain is recognised as a benign, 

self-limiting condition that is a common presentation at the 

Women’s and Children’s Hospital physiotherapy department 

in Adelaide. Reported incidence in the literature ranges from 

7%–30% in adolescent and young adult populations. There 

is no consensus within current available evidence regarding 

either best practice management or well researched and 

clinically useful outcome measures. A new initiative is 

being developed at the Women’s and Children’s Hospital 

that follows a client-orientated, group-based approach to 

management of this condition. Importantly, the outcomes 

of this program will add to the current body of evidence 

and aims to provide a service that is effective, equitable 

and sustainable. The program spans over 5 weekly sessions 

and incorporates concepts of patient and family education, 

chronic condition self-management and health promotion in 

a group setting. Subjects will be between 10 and 18 years 

of age, and will be recruited through referral systems to the 

physiotherapy department. Data will be collected using the 

Patellofemoral Pain Syndrome Severity Scale, the SF-36 

questionnaire and a functional measurement of the number 

of step-ups, step-downs and squats that the participant can 

perform before pain onset or increase. Outcome measures 

will be implemented at initial assessment and 4–6 weeks 

following completion of the program. This innovative 

program is due to commence in April 2009, and early 

program results will be presented, along with an outline of the 

program structure. Early conclusions and recommendations 

will be discussed, including relevant consumer feedback. 

A novel exercise program for young people with cystic 

fibrosis: extending physiotherapy practice horizons 



1 


Brisbane 

Physiotherapy management for young people with cystic 

fibrosis is extending to include targeted exercise, driving 

clinical research to develop effective exercise programs 

tailored for this population during inpatient and outpatient 

treatment phases. This paper aims to describe the 

development of the Cystic Fibrosis: Fitness Challenge and its 

accompanying portable exercise package (FitKit), which 

was directed by recommendations from the research base, 

and by limitations in current clinical practice in this field. The 

content, design and delivery of this program and its resources 

will be described, in the context of both the inpatient and 

outpatient setting. Of central importance is the portable 

design of the program, to facilitate exercise performance in 

limited space environments such as at the hospital bedside, 

necessary when inpatients with cystic fibrosis are isolated 

according to infection control procedures. Strategies to 

enhance acceptance and adherence to the program include 

involvement of the individual in developing their program, 

provision of a variety of age-appropriate physical activities, 

and integration of educational elements. The range of 

physical activities was selected to address recommendations 

from the field, including the promotion of vigorous intensity 

activities. Facilitating continuity of exercise performance 

between the inpatient and outpatient phases of management 

is a key focus of this program. Overall, this novel program 

and resources present attractive, clinically useful tools 

for promoting physical activity for young people with 

cystic fibrosis. The effectiveness of these tools as part of 

management in the inpatient and outpatient setting was 

investigated using randomised controlled trials (presented 

elsewhere). 

Pain management (Sydney Children’s Hospital Pain 

Clinic): multidisciplinary approach to treating chronic 

regional pain syndrome in children. Facts and fibs: 

explain pain to kids 

McCormick M, 1 Moseley L, 2 Glogauer M 1 

1 

Sydney Children’s Hospital, Randwick, 2 Prince of Wales Medical 

Research Institute 

This workshop will give an insight into chronic pain and 

how this manifests itself in the paediatric population. The 

multidisciplinary approach used at the Sydney Children’s 

Hospital, Randwick (SCH) will be described, with detailed 

explanation given of the physiotherapy and psychology 

involvement, including new treatments. In striving to achieve 

best practices when dealing with children who have chronic 

pain, the SCH pain team have been collating objective 

measures when assessing these children. The physiological 

measures include cardiovascular factors, sensation, strength 

and thermal imaging. These ongoing assessments have been 

used to objectively measure the impact of treatments in an 

attempt to achieve best practice. The psychologist from the 

pain team will describe emotional, thought and behavioural 

responses to pain, their intervention, and the interrelations 

these have with physiotherapy management. Findings and 

further research proposals will be presented. 

Predictors of mobility status on discharge for children 

with a traumatic brain injury: a retrospective review at 

Sydney Children’s Hospital 

McDonald RM 

Physiotherapy Department, Sydney Children’s Hospital, Sydney 

Traumatic brain injury (TBI) is a major cause of disability 

in children. The aim of this retrospective review was 

to determine the rate of walking recovery and establish 

if certain characteristics can predict mobility status on 

discharge in children who have sustained a TBI. Patients, 

aged 2–18 years who sustained a TBI during 2006–2007 



were identified through the Sydney Children’s Hospital 

Brain Injury Rehabilitation Program (SCH BIRP) database 

and patient medical records. Data regarding age, gender, 

injury and duration of hospital stay (LOS) was analysed. 

Hours of physiotherapy, need for mobility aids at discharge 

and referral to local services were also considered. A 

total of 91 patients were referred to the SCH BIRP during 

2006–2007. The majority of patients were male (84%) and 

sustained their injury at a mean age of 14 years. Falls were 

identified as the most common cause of TBI in both years. 

Increased LOS and post traumatic amnesia (PTA) duration 

was associated with non independent mobility on discharge. 

From this cohort, it was identified that children who were 

not independently mobile on discharge also presented 

with multiple lower extremity injuries or hemiplegia. Due 

to inconsistency in data collection and reporting, loss of 

consciousness (LOC) and Glasgow Coma Score (GCS) could 

not be used as a predictor in the SCH population. Predictors 

of mobility status can assist physiotherapists prepare for 

early and effective discharge planning and allocation of 

appropriate rehabilitation resources for children who have 

sustained a TBI. 

10 

How NSW is supporting allied health professionals 

working with children 

Miller JM 

Sydney Children’s Hospital, Randwick 

Three child health networks exist in New South Wales linked 

to the three tertiary paediatric hospitals: Sydney Children’s 

Hospital, Randwick; The Children’s Hospital at Westmead; 

and John Hunter Children’s Hospital. The need to support 

allied health professionals working with children was 

identified through surveys, focus groups and committees. 

Sixty-eight percent of rural allied health professionals work 

as either a sole clinician or with only 1 peer compared 

to 17.5% of metropolitan allied health professionals. To 

address this, the ‘Supporting Allied Health Professionals 

working with children’ project was initiated in 2006. The 

project now includes: the Allied to Kids newsletter; Allied 

Health Telehealth program; discipline-specific ‘Paediatric 

Listserves’ including PaedPT; and the development of 

discipline-specific webpages to be linked to the static 

Child Health Network webpage. In addition the Greater 

Eastern and Southern Child Health Network commenced 

the Allied Health Secondment Program in September 2006 

to enhance and support allied health professionals working 

with children. A further Capacity Building Project allowed 

for the recruitment of a physiotherapist (0.2 full-time 

equivalent) in March 2008 to assist in the secondments. 

From May–October 2008 there were 10 physiotherapy 

secondments to Sydney Children’s Hospital, totalling 17 

days. The learning objectives were met utilising one-to-one 

training and education targeting the specific tertiary areas 

of their clinical caseload. A high level of satisfaction has 

been reported. 

Helping families improve participation in home 

therapeutic activities: a new DVD for children with 

mild cerebral palsy 

Morrell JR, 1 Lau SK 2 

1 

Wollongong Hospital, Wollongong, 2 University of Wollongong, 

Wollongong 

This project was initiated in response to parents’ desires for 

clearer demonstrations of stretches, exercises and activities 

commonly suggested by paediatric physiotherapists for 

children with cerebral palsy (CP). Parents described their 

frustration with deciphering stick figures and exercise sheets, 

and difficulty remembering how to best perform passive 

stretches. Exercises for left and right side impairment were 

deemed important as was the need for the final resource 

to be widely and readily available. Funding was obtained 

through a community engagement grant from the University 

of Wollongong for film production of 36 exercises, and 

development of a website by the University of Wollongong. 

Four clients with CP aged 8–11 years were recruited. 

Exercises on the DVD demonstrate passive and active 

stretches on the floor, in sitting and standing, to perform at 

home in the lounge and kitchen. The activities demonstrate 

use of common household items or easily available therapy 

items such as phone book, wedge, footstools, and footy 

socks. Families and therapists will be able to load specific 

exercises onto a disc, save on a flash drive, or email using 

the website link. 

The clinimetric properties of neonatal 

neurobehavioural/neuromotor assessments for the 

premature infant to four months corrected age: 

a systematic review 

Noble Y, 1 Boyd R 1,2 

1 

Royal Children’s Hospital, Brisbane, 2 The University of Queensland, 

Brisbane 

The aim of this review was to analyse the clinimetric 

properties of published neonatal longitudinal 

neurobehavioural and neuromotor assessments. Inclusion 

criteria consisted of standardised assessments for preterm 

infants up to 4 months corrected age, which were 

discriminative, predictive or evaluative and/or criterion 

or norm referenced. Exclusion Criteria were those not 

published in English, not peer-reviewed, and screening 

assessments. Databases searched included Medline 

Advanced, CINAHL and PsycINFO (1996–March 2008). 

Twenty tools were identified, 9 of which met criteria. These 

were the Assessment of Preterm Infants’ Behaviour (APIB), 

Neonatal Intensive Care Unit Network Neurobehavioural 

Scale (NNNS), Test of Infant Motor Performance (TIMP), 

Prechtl’s Assessment of General Movements (GMs), 

Neurobehavioural Assessment of the Preterm Infant (NAPI), 

Einstein Neonatal Neurobehavioural Scale (ENNAS), 

Dubowitz Neurological Assessment of the Preterm and 

Full-term Infant, Neuromotor Behavioural Assessment 

(NMBA) and the Neonatal Behavioural Assessment Scale 

(BNBAS). Clinimetric properties were evaluated using a 

modified Outcome Measures Rating form by 2 independent 

reviewers. Most assessments demonstrated moderate content 

and construct validity. The APIB demonstrated strong 

concurrent validity with EEG and MRI, the NAPI with the 

ENNAS and the GMs and ENNAS with neurological exams. 

Interrater reliability was strong in the TIMP (ICC = 0.95), 

GMs (K = 0.8), and ENNAS (r = 0.97). Intra-rater reliability 



was reported in the TIMP (ICC 0.98–0.99) and GMs (K = 

1.0). Clinical utility was variable for administrative burden, 

scoring, interpretability and cost of training. The GMs, 

TIMP and NAPI have strong psychometric properties and 

have better utility for the clinical setting, although their 

primary purpose varies. 

R Boyd is supported by an NHMRC Career Development 

Fellowship and a Queensland Smart State Fellowship. 

Reliability of the Alberta Infant Motor Scale on infants 

born at less than 30 weeks of gestation 

Pin TW, 1 de Valle K, 2 Eldridge B, 2 Galea MP 1 

1 

The University of Melbourne, Parkville, 2 Royal Children’s Hospital, 

Parkville 

The Alberta Infant Motor Scale (AIMS) is a standardised 

assessment tool used to identify motor delay in infants from 

birth to 18 months of age. This study aimed to investigate 

the intra- and inter-rater reliability of the AIMS in a cohort 

of preterm infants from 4–18 months of corrected age (CA). 

Fifty-eight preterm infants born at less than 30 weeks of 

gestation were recruited from a neonatal intensive care unit 

in Melbourne. Two experienced paediatric physiotherapists 

were the raters in this reliability study. The infants were 

assessed at 4, 8, 12 and 18 months CA using the AIMS. 

A total of 229 assessments were used for the inter-rater 

reliability study and 30 of these assessments were repeated 

for the intra-rater reliability study. The results were 

analysed using the intra-class correlation coefficient (ICC) 

and standard error of measurement (SEM). The intra-rater 

reliability was very high with ICC ≥ 0.99 (SEM ≤ 0.82). The 

ICC for the inter-rater reliability varied from 0.84 to 0.97 

(SEM ≤ 1.69) in the sub-scores and total scores at all age 

levels. The ICC was lowest at 4 and 18 months CA, despite 

very consistent agreement in the AIMS scores between the 

two raters, possibly due to limited variance in the scores 

at these 2 ages. The AIMS has been shown to be a reliable 

discriminative tool for evaluating motor development in 

infants born at less than 30 weeks of gestation. 

Prediction of developmental trajectory of infants born 

at or less than 29 weeks of gestation 

Pin TW, 1 Eldridge B, 2 Darrer T, 3 Galea MP 1 

1 


Parkville, 3 Mercy Hospital for Women, Heidelberg 

This study was designed to investigate the predictive value 

of the Alberta Infant Motor Scale (AIMS) at 4, 8, 12 and 18 

months corrected age (CA) in infants who were born at or less 

than 29 weeks of gestation, at 2 years CA when the infants 

were assessed using the Bayley Scale of Infant and Toddler 

Development (Bayley III). The association of risk factors 

including medical co-morbidities, positioning practices, 

early intervention and developmental stimulation with 

motor development based on the AIMS percentile rankings 

at 4, 8, 12 and 18 months CA and with infant development 

based on the Bayley III composite scores at 24 months CA 

were also investigated. Thirty-nine of 58 preterm infants 

were assessed using the Bayley III at 24 months CA to 

date. Almost all of the assessed preterm infants developed 

within normal limits as shown by the Bayley III composite 

scores. Our preliminary results showed that there were high 

false-positive and false-negative rates of the AIMS if the 

cut-off point at the 10th percentile at 4 months CA was 

used. Consistent trends were found of poorer performance 

in overall development at 24 months CA and early motor 

development up to 12 months CA in infants with premature 

co-morbidities, who received early intervention, who did not 

attend developmental stimulation and were born at shorter 

gestation. Future studies with a larger sample size and using 

more vigorous statistical analyses are recommended. 

A study of extremely preterm birth on infant motor 

development using the Alberta Infant Motor Scale 

Pin TW, 1 Eldridge B, 2 Darrer T, 3 Galea MP 1 

1 


Parkville, 3 Mercy Hospital for Women, Heidelberg 

Infants born at or less than (≤) 29 weeks of gestation are 

recognised as developing at a significantly slower rate 

than their full-term peers and having a different quality of 

movement. The aim of this prospective longitudinal cohort 

study was to describe the longitudinal motor development of 

these infants in the first 18 months (corrected age) of life. A 

convenience sample of 58 preterm infants born ≤ 29 weeks 

of gestation were recruited from a neonatal intensive care 

unit and 52 control full-term infants were recruited from the 

community. The infants were assessed and video-recorded 

at 4, 8, 12 and 18 months of corrected age (CA) using the 

Alberta Infant Motor Scale (AIMS). The preterm infants 

scored significantly lower on various sub-scores at all age 

levels than the control infants (all p < 0.05). Almost half of 

the preterm infants demonstrated less progression in the sit 

subscale from 4–8 months CA than the controls, possible 

due to an imbalance between flexor and extensor activity in 

the trunk. At 12 and 18 months CA, although most of the 

preterm infants caught up with their full-term peers in their 

motor abilities, limited variations in their movements were 

evident in some preterm infants as demonstrated by their 

significantly lower AIMS sub-scores in 4-point, sitting and 

standing positions. This study systematically documented 

the differences in motor trajectories and invariant movement 

patterns in the preterm infants in the first 18 months postterm. 

These observations have implications for clinical 

intervention. 

Factors associated with foot and ankle weakness in 

preschool-age children 

Rose KJ, Burns J, North KN 

Discipline of Paediatrics & Child Health, Faculty of Medicine, The 

University of Sydney/ Institute for Neuromuscular Research, The 

Children’s Hospital at Westmead, Sydney, New South Wales, Australia 

Charcot-Marie-Tooth disease type 1A (CMT1A) affects the 

foot and ankle from the earliest stages of the disease. In very 

young children little is known about the factors influencing 

normal strength development, or the pathological processes 

affecting the foot and ankle in CMT1A. We investigated 

factors associated with foot and ankle strength in healthy 

preschool-age children, and compared to foot and ankle 

weakness in age-matched cases of CMT1A. Isometric 

foot inversion, eversion, plantar flexion and dorsiflexion 

strength was measured by hand-held dynamometry in 

60 healthy children aged 2–4 years and 11 age-matched 

children with CMT1A from the Australasian Paediatric 

CMT Registry. A series of demographic, physical and 

anthropometric characteristics were also collected. In the 

healthy children, apart from body size, regression modelling 

identified restricted ankle dorsiflexion range of motion 

as the strongest independent correlate of foot and ankle 



weakness. In CMT1A, ankle dorsiflexion range of motion 

was considerably lower than normal, as was dorsiflexion 

strength. Imbalance of inversion-to-eversion strength and 

plantar flexion-to-dorsiflexion was also apparent. However 

foot structure, inversion, eversion and plantar flexion 

strength were similar to normal. Given the association 

between ankle dorsiflexion range of motion and muscle 

strength in healthy preschool-age children, and the obvious 

abnormality of these factors in children with CMT1A, 

investigation of the cause-effect relationship is warranted 

to help identify more targeted therapy. These results also 

imply that ankle equinus and muscle imbalance precede 

foot deformity in paediatric CMT1A and may contribute to 

the characteristic cavus foot deformity. 

12 

A randomised controlled trial on the effects of a 

community-based exercise program for adolescents 

with Down syndrome 

Shields N, 1 Taylor N 1,2 

1 

La Trobe University, Melbourne, 2 Eastern Health, Melbourne 

The aim of this study was to investigate if progressive 

resistance training improved muscle strength and physical 

function in adolescents with Down syndrome. A singleblind 

randomised controlled trial was completed. Twenty 

adolescents with Down syndrome (14 boys, 6 girls; mean 

age 15.9 ± 1.5 years) were assigned by a concealed method to 

either an intervention (n = 9) or a control group (n = 11). The 

intervention group received progressive resistance training 

twice a week for 10 weeks at their local gymnasium. The 

training consisted of 6 exercises using weight machines 

and participants completed 3 sets of 12 repetitions of each 

exercise until they reached fatigue. Participants completed 

the program with a physiotherapy student mentor. The 

control group continued with their usual activities. Outcome 

measures were muscle strength (one repetition maximum) 

for chest press and leg press, the timed up and down 

stairs test and the grocery shelving task. Participants were 

assessed at baseline and immediately post intervention by 

an assessor blind to group allocation. Data were analysed 

using analysis of covariance with the baseline measure 

used as the covariate. The intervention group demonstrated 

a significant improvement in lower limb muscle strength 

compared to the control group (mean difference 11.0 kg 95% 

CI 2.9–19.0, p < 0.01). There were no significant differences 

between the groups for upper limb muscle performance or 

physical function measures. No major adverse events for 

the intervention were noted. Progressive resistance training 

improved lower limb muscle strength in adolescents with 

Down syndrome but this did not carry over into improved 

physical functioning. 

Learning outcomes for physiotherapy students who 

engaged in an alternate paediatric clinical experience 

Shields N, 1 Taylor N, 1,2 Bruder A 1 

1 

La Trobe University, Melbourne, 2 Eastern Health, Melbourne 

An alternate paediatric clinical experience model was 

developed and involved first and second year physiotherapy 

students exercising with an adolescent with Down syndrome 

for 10 weeks at a local community gymnasium. The aim 

of this study was to identify the learning outcomes of the 

students who participated in the experience. Twenty students 

(18 female, 2 male; mean age 19.5 ± 1.3 years) were matched 

by location with an adolescent with Down syndrome. The 

student-adolescent pair completed a progressive resistance 

training program consisting of 6 exercises using weight 

machines twice a week. The participants completed 3 sets 

of 12 repetitions of each exercise until they reached fatigue. 

The main outcome measures were the Barriers to Exercise 

Scale, and an in-depth interview and were completed at 

baseline and immediately post intervention. Quantitative 

data were analysed using analysis of covariance. Qualitative 

data were analysed by thematic analysis. Students who 

participated in the experience demonstrated a significant 

positive change in their attitudes on 9 of the 18 items of 

the Barriers to Exercise Scale. They identified three key 

benefits of the experience: personal benefits (gaining 

confidence, organisation skills and getting to know a person 

with a disability), knowledge application (teaching an 

exercise programme, motivational strategies, and applying 

physiotherapy skills) and communication skills (building 

rapport with an adolescent with a disability and developing 

ways to communicate effectively). This alternate clinical 

experience is effective in positively changing physiotherapy 

students’ perceptions of disability and provides them with 

an opportunity for learning clinical skills. 

Transition of young people with chronic illnesses and 

disabilities from paediatric services to adult services 

Singer BJ, 1 Love SC, 1,2,3,4 Gibson N 1,2,3 

1 

The University of Western Australia, Perth, 2 Princess Margaret 

Hospital, Perth, 3 Telethon Institute for Child Health Research, Perth, 

4 

Curtin University of Technology, Perth 

Transition has been defined as the purposeful, planned 

movement of adolescents and young adults with chronic 

physical and medical conditions from child-centred to 

adult orientated care. Many lifelong conditions which 

begin in childhood, require care and therapy to continue 

throughout life. More than 90% of children with chronic 

conditions now survive into adulthood. In addition, rates 

of chronic conditions in young adults are increasing. 

Failure to adequately address transition has serious long 

term implications for the physical and psychosocial well 

being of young people with chronic health issues and/or 

disability, for their families, as well as for health funding. 

Increasingly, it is being recognised that adolescents require 

support to become effective users of preventive and 

interventional health services; this is particularly so in the 

case of long standing illness/disability. The transition from 

childhood to adulthood occurs at different times and at a 

different pace in different young people, thus it is essential 

that the individual’s readiness to undergo transition is 

evaluated. Although a national approach does not yet 

exist, key elements of health care transition processes 

are well accepted. Principally, it is essential that care is 

planned and coordinated, and responsibility for transition is 

shared amongst adult and paediatric service providers and 

the client/family. Self management strategies, including 

access to primary care providers, must be supported and 

encouraged. Services must be affordable, accessible and 

comprehensive. Improved education and training of health 

care professionals around transitional care is needed. 

Finally optimal outcomes of transition services need to be 

identified and measured. 



Innovative practice: physiotherapy in psychiatry and 

mental health 

Spencer FB 


There is growing evidence supporting the use of exercise 

and body-oriented treatment tools for managing mental 

illness. Physical interventions provide young people with 

an additional avenue for expression and interaction as well 

as providing tangible strategies for managing emotion. The 

physical corollaries of mental illness are well addressed 

in a supportive psychiatric physiotherapy framework that 

promotes holistic self care. Physiotherapists are skilled 

in prescription and promotion of physical activity. In the 

mental health context we provide interventions that not 

only improve physical wellbeing, but positively impact 

mood, emotion regulation and self esteem. However, in 

Australia the physiotherapist’s role is not well defined. 

Few dedicated positions exist, many in our profession are 

unsure of how we could be involved and most in the mental 

health field are naïve to the contributions available from 

psychiatric physiotherapy. Since 2003 Sydney Children’s 

Hospital has provided a dedicated physiotherapy service 

to our inpatient child and adolescent mental health unit. 

In collaboration with colleagues in the multidisciplinary 

team, through continuing education in various treatment 

approaches and international networking, the physiotherapy 

service has evolved to offer innovative individual, family 

and group interventions to young people and their families 

managing mental illness. This presentation will present and 

explore the evidence based treatment modalities available 

to physiotherapists that assist in managing mental illness 

and outline continuing education possibilities for those 

interested in working in this rewarding area. 

Physiotherapy in the management of eating disorders: 

what can we do? 

Spencer FB 


This workshop aims to explore the vital and varied role 

physiotherapists play in the management of children 

and adolescents with eating disorders. Characterised by 

extreme physical compromise, body image dissatisfaction 

and obligatory exercise behaviour, this population benefits 

from a diverse range of physiotherapy assessments and 

interventions that directly address these key concerns. 

There is a small but growing body of evidence reporting 

the positive outcomes that we can achieve, however few 

treatment programs are described in detail. Many overlook 

qualitative aspects such as body experience and motivation 

to exercise. We must endeavour to provide safe and 

structured interventions that address not only the physical 

but the cognitive aspects of the illness. The workshop will 

discuss and practically explore the assessment of exercise 

behaviour and cognition, body perception and dissatisfaction, 

management of musculoskeletal consequences of 

malnutrition and excessive exercise, and graded physical 

activity approaches. Participants will be equipped with the 

knowledge and skills to positively contribute to patient care 

in both inpatient and outpatient settings. An information 

pack from the Sydney Children’s Hospital Eating Disorders 

Unit including physiotherapy assessment tools, graded 

treatment plans and patient handouts will be provided. The 

session will close with a panel of expert clinicians from 

various disciplines participating in group discussion on 

the benefits of including physical activity and other body 

oriented approaches in the management of this challenging 

illness. 

How to choose and evaluate a bicycle or tricycle for a 

child with a disability 

Thomas BM 

The Children’s Hospital at Westmead, Sydney 

Riding a bicycle or tricycle is an activity that can be enjoyed 

by people of all ages, for recreational, social, sporting, fitness, 

or competitive reasons, or simply for fun. The National 

Physical Activity Guidelines for Australians outline the 

minimum levels of physical activity to gain a health benefit, 

for different age groups. Children with a disability may be 

even less likely than their non-disabled peers to achieve 

these levels of activity. Thus there are many good reasons 

to consider pedal power for this group. Knowledge of the 

skills needed to learn to ride, how to evaluate if a bicycle or 

tricycle is suitable for a particular child, and knowledge of 

what is available and how particular features suit different 

needs will give physiotherapists increased ability and 

confidence in assisting families pursuing this option for 

their family member. 

Department of Education and Training physiotherapy 

services: celebrating 20 years of efficient, current and 

effective school based paediatric physiotherapy services 

Truscott LM, Noack CM, De Regt E, Ogilvie KM, 

Collins E 

Department of Education and Training Disability Services Support 

Unit, Brisbane 

In December 2007, the Council of Australian Governments 

agreed to a partnership between the Commonwealth, state 

and territory governments to pursue substantial reform in the 

areas of education, skills and early childhood development, 

to deliver significant improvements in human capital 

outcomes for all Australians. With work continuing towards 

a national curriculum, access to early childhood education, 

determining priorities for social inclusion and indigenous 

reform to reduce disadvantage, as well as long term health 

reform, it is timely to review physiotherapy services provided 

in educational settings across Australia. Since 1999, the 

Department of Education and Training in Queensland 

have employed school based paediatric physiotherapists to 

provide physiotherapy services to students with disabilities. 

During this time frameworks have been developed to ensure 

efficient and effective physiotherapy services are provided. 

This paper will describe these services and how they fit 

with current legislative requirements, with the International 

Classification of Function, Disability and Health and 

current evidence informed, outcome focused and familycentred 

practices. It will also showcase the way these school 

based physiotherapy services support the prevention of 

health related problems of people with disabilities through 

input to school health and physical education programs and 

the support in the transition of adolescents from school to 

work and community by preparing the learner for life post 

school. This presentation will provide an opportunity for 

collaboration with paediatric physiotherapists from other 

service providers in schools across Australia. 



Do personnel and environment impact on intervention 

outcomes for developmental coordination disorder? 

14 

Ward E, 1,2 Hillier S, 1 Raynor A 1 

1 

University of South Australia, Adelaide, 2 Flinders Medical Centre, 

Adelaide 

There is scarce information on the delivery of intervention 

for developmental coordination disorder (DCD). This study 

compares different environments and personnel in service 

delivery. Ninety-three children from 13 South Australian 

schools, aged 5–9 years were recruited to participate in 

this RCT. Participants received a group intervention for 13 

weeks, addressing motor skills. Schools were randomised 

using cluster randomisation to receive 1 of 3 modes of 

delivery. Group 1 schools received the program at school 

run by a school assistant, group 2 received the program 

in school run by a physiotherapist, and group 3 received 

the intervention in a health clinic run by a physiotherapist. 

Participants were assessed pre and post-intervention, and 

6 months after program completion. The Movement ABC 

(MABC), Test of Gross Motor Development (TGMD-2) and 

Pictorial Scale of Perceived Self Competence and Social 

Acceptance (PSPSCSA) were used to assess participants. 

A parent questionnaire was administered. For time effects, 

participants demonstrated a significant improvement in 

motor skills (p = 0.000), following the intervention, for 

all modes of delivery. This effect was maintained at the 

6-month follow-up. There was no significant group effect. 

The results for the PSPSCSA show participants to have 

better self perception of physical abilities, but poorer self 

perception of peer acceptance following intervention. A 

summary of questionnaire data found parents to prefer 

programs to be run in schools by health professionals. 

The study showed that the program can be run by either 

a professional or school assistant in the school or health 

environment and provide successful outcomes 

Characteristics of young people with primary language 

disorder: extending physiotherapy practice horizons 

Watter P, Beevers M, Eckersley K, Kanianthra A, 

Luckhart K, Webster-Tight C, Nicola, K 


This pilot study aims to present data describing the history 

and performance of children with Primary Language 

Disorder (PLD) on physiotherapy assessment. School 

records were audited to extract relevant data for all children 

admitted to The Glenleighden School, Queensland, from 

2005–2008 (n = 43, 33 males). Assessments used reflected 

the age of the child, and included: NSMDA, clinical 

assessment, Peabody, BOT-2, and Carolina Preschool 

screening tool. These tests mainly lie in the body structure 

and functions and activity domains of the ICF. Age at 

admission ranged from 47–152 m (mean = 0 77), while 

age at diagnosis ranged from 36–157 m (mean = 0 51). 

Histories revealed: ASD/ADHD (1 child); chronic middle 

ear infections (n = 19); developmental problems (n = 31); 6 

were born premature; 8 needed special care nursing and 8 

experienced emergency caesareans. On NSMDA (n = 28), 

27 presented with deviation from normal performance. For 

the Peabody, total gross-motor Z score ranged from -2.33 to 

+ 0.15, mean = -1.71; and fine-motor Z score ranged from 

-2.33 to 0, mean = -1.6. For those completing BOT 2 (n = 14), 

8 scored below average. The Carolina provided descriptive 

information about development, and with the clinical tool, 

helped to set goals and direct physiotherapy intervention. 

It is clear that children with PLD frequently have motor 

performance difficulties, and that an interprofessional 

model utilising an ICF framework and incorporating 

physiotherapy management may be optimal. 

Paediatric orthopaedic physiotherapy screening clinics: 

the Queensland experience 

Wilson R, 1 Bradford K 2 

1 

Mater Children’s Hospital, Brisbane, 2 Royal Children’s Hospital, 

Brisbane 

The use of appropriately skilled, experienced physiotherapists 

to triage and assess adult outpatients referred to orthopaedic 

surgeons in public health systems has been well established 

since the early 1990s, particularly in the United Kingdom 

and Australia. However, similar services aimed at reducing 

wait times for paediatric orthopaedic consultation have 

existed only in more recent times. A paediatric orthopaedic 

physiotherapy screening service involving the 2 tertiary 

paediatric hospitals in Brisbane commenced in early 2008. 

Its model consists of 2 distinct clinical streams designed 

to accommodate both normal variance and musculoskeletal 

referrals. This presentation will outline the methodology 

involved in establishing the service, benchmarking activities, 

development of best practice assessment and management 

guidelines for conditions commonly seen, communication 

and administrative pathways, inclusion indicators, 

consideration of the unique physiotherapy skill-set required 

for service delivery, and relevant risk management issues. 

Outcomes to date will be presented, including occasions of 

service data over a 12-month period, stakeholder perceptions 

as ascertained from survey processes, characteristics of 

patients seen, and specific clinical outcomes. Discussion 

will also involve plans for service expansion, educational 

requirements of staff involved, perceived longevity of the 

service, and succession planning. Adaptability of this model 

both to other sites and other paediatric diagnostic groups 

such as neurodevelopmental, respiratory, and incontinence 

will be proposed. 


with Cardiorespiratory Physiotherapy 

Australia 






conditions and the impacts of an increased burden to the health 

system and families with limited physiotherapy resources 

available. Medical advances have lead to earlier diagnosis of 

chronic respiratory conditions, and significantly improved 

survival rates. The Royal Children’s Hospital, Brisbane, 

has had progressive and significant increases in referrals for 

these conditions and subsequent increases in activity. In this 

presentation, we review current models of care; including 

quality measurements and patient health outcomes, and 

will offer potential solutions which include flexible but 

targeted services across the continuum and incorporate a 

variety of domiciliary care models and the indicators for 



success. Current literature shows that existing domiciliary 

programs, demonstrate mixed results and primarily in the 

cystic fibrosis population group. However, domiciliary care 

across the continuum, inclusive of specialised allied health 

professionals, has shown to be cost- and clinically- effective, 

in the presence of appropriate referrals and resources. 

Unfortunately, in the Queensland experience, the quality 

and extent of domiciliary care is being adversely affected 

by limited community physiotherapy funding, decreased 

availability of specialist paediatric physiotherapy and 

limited accessibility of domiciliary services. Considerable 

re-thinking is required to provide appropriate care to 

this patient group, which can be modified to support and 

adapt to individual, local and state-wide needs to ensure a 

seamless approach to paediatric physiotherapy for chronic 



children with intellectual disability: a randomised 



1 

Semnan University, Semnan, Iran, 2 Royal Prince Alfred Hospital, 

Sydney 












running and cycling for 30 minutes, 5 days per week, for 

8 weeks) or a control group (usual daily activities only). 

The exercise was supervised, with a target of moderate 

intensity. Lung function was measured again at 8 weeks. 

Of the 44 participants enrolled (mean age 12 (1.5) years and 

IQ 42 (8) points), randomisation allocated 24 participants to 

exercise and 20 participants to control. For the full cohort 

after coaching, FEV 1 

was a mean of 87% (95% CI, 84–91) 

and FVC was 93% (95% CI, 90–96) of normative values. 

Both FEV 1 

and FVC improved significantly more in the 

exercise group than in the control group. For change in 

FEV 1 

, the mean between-group difference was 160ml (95% 

CI, 30–290). For change in FVC, the mean between-group 

difference was 330ml (95% CI, 200–460). Lung function 








systematic search of 6 databases was undertaken using terms 

synonymous with the active cycle of breathing technique. 

Hand searching of reference lists was conducted and 

experts contacted. Two assessors independently allocated 

each reference to an evidence hierarchy and assessed 

methodological bias. One-hundred and five articles were 

identified. Twenty-four studies reporting primary data on 

the technique were included (1970–2007), including several 

high level, low risk of bias studies. Ten comparators were 

identified with the most common including conventional 

chest physiotherapy (n = 5), positive expiratory pressure (n 

= 5) and a control (n = 4). A total of 36 outcome measures 

were identified in the included studies. The most commonly 

assessed outcomes were sputum wet weight (n = 17), forced 

vital capacity (n = 13) and forced expiratory volume in one 

second (n = 13). Meta-analysis was completed on the primary 

outcome measure of sputum wet weight. Preliminary results 

indicate that the standardised mean difference (SMD) across 

studies showed an increase in sputum weight during and up 

to 1 hour post treatment (SMD 0.29, 95% CI 0.20–0.37), but 

no difference in the during and up to 24 hour post treatment 

weight (SMD 0.15, -0.03–0.34). The majority of studies 

(92%) demonstrated excellent generalisability to the target 

population. Assessing the body of evidence was problematic 

due to the diversity of research designs, comparators and 

outcomes used. 





1 


Brisbane 








FitKit) (n = 15) compared to the current physiotherapy 










contributed to significant improvements for participants for 

a range of measures, including respiratory function (p = 
















A prospective multi-centre study: physiotherapy during 



16 









and chest percussion initially taught to parents, with further 

progressions or modifications made at physiotherapist 

discretion. In the ACFBAL study 168 children diagnosed 

by newborn screen were randomised to BAL directed 

therapy or standard care. Three-monthly reviews included 

physiotherapy interventions used, respiratory symptoms, 

and clinical assessments for the first 5 years of life. Final 

outcomes (5 years, n = 100) included lung function. One 

hundred and fifty-nine have complete data to three years 

of age. Analysis included combined manual and other 

techniques (75%); PEP (52%); physical activity(100%). 

Postural drainage (PD) incorporating head-down tipping 

was infrequently used in all ages (3%). No cough is reported 

60% of the time, whereas 92% of children have cough 

symptoms at hospital admission. Cough is the most frequent 

indicator of clinical change; secretions, night cough, 

wheeze, and decreased activity levels occur less frequently 

during exacerbation. Eighty-six percent of participants 

had normal FEV 1 

(> 85% predicted) at final outcome, 

with no participants below 60% predicted. Multivariate 


interventions and clinical findings in the first 5 years of 


practice in CF, including more interventions comprising 

chest physiotherapy. Although wellness is expected 

most of the time, the burden of treatment can be high. A 

clearer picture is emerging of clinical features at baseline, 

exacerbation, admission, and the range of physiotherapy 

interventions during wellness and illness in CF. 



of age? 













made at physiotherapist discretion. This prospective 

investigation reports PEP and clinical records when 

physiotherapy techniques were changed. Baseline, 



to other techniques. One hundred and fifty-nine of 168 

enrolled children (mean age 3.6 mths, SD 1.6) from 8 

Australasian sites have three year data. Thirty-two of 159 

children (20%) used PEP before 3 years of age; 3 of these 

(9%) were diagnosed with significant tracheomalacia prior 

to commencing PEP. In PEP users, there was no association 

between barking or croupy coughs typically associated with 

tracheomalacia. Forty percent of the cohort had a cough (any 

description) compared with 72% of PEP users. This report 

is limited by data collection methodology which does not 

record physiotherapy clinical reasoning. Reasons for early 

initiation of PEP may include physiotherapist familiarity 

with PEP, presence of persistent cough or unexpected 

bronchoscopy findings indicating need for changed therapy 

regimen. Our expectation that early use of PEP would be 

associated with barking or croupy cough; nocturnal cough, 

and/or malacia was not supported. Further systematic study 

of this emerging trend is warranted, particularly where 

airway malacia is identified in young children. 


with National Neurology Group 

Passive mechanical properties of gastrocnemius 

muscles of spinal cord injured patients with ankle 

contractures 

Diong JHL, 1,2 Kwah LK, 1,2 Clarke JL, 2 Hoang PD, 4 Martin 

JH, 4 Clarke EC, 1,4 Gandevia SC, 4 Bilston LE, 4 Ling M, 5 

Harvey LA, 3 Herbert RD 1 

1 

The George Institute for International Health, Sydney., 2 The University 

of Sydney, 3 Rehabilitation Studies Unit, Sydney, 4 Prince of Wales 

Medical Research Institute, Sydney, 5 Prince of Wales Hospital, Sydney 

Contracture is common after spinal cord injury. It is thought 

that contracture may be due to adaptations of the muscle 

fascicles, tendons or both. Until recently it has not been 

possible to measure the passive mechanical properties of 

muscles and tendons in humans in vivo. The aim of this 

study is to compare the passive length-tension properties of 

the gastrocnemius muscle-tendon unit, muscle fascicles and 

tendons of people with contractures in the calf muscles after 

spinal cord injury with healthy controls. Four participants 

(aged 24–42 years) with a spinal cord injury and 6 control 

subjects (aged 28–47 years) have been tested; the intention is 

to test a further 16 spinal cord injured subjects and a further 

14 control subjects. Data on spasticity, lower limb strength, 

and the American Spinal Injury Association (ASIA) motor 

and impairment scores have been collected. In addition, 

passive ankle angle and torque data were obtained at 6 

knee positions and combined with ultrasound measures of 

fascicle length and pennation. These data will be used to 

obtain length-tension relationships of the gastrocnemius 

muscle-tendon unit, muscle fascicles and tendons. The data 

will be used to make inferences about changes in muscletendon 

properties, and the contribution of tendon and muscle 

fascicles to changes in muscle-tendon properties, in calf 

muscles of spinal cord injured patients with contracture. 

Stretch interventions for contractures: 

a Cochrane systematic review 

Katalinic OM, 1 Harvey LA, 1 Herbert RD, 2 Moseley AM, 2 

Lannin NA, 1 Schurr K 3 

1 

Rehabilitation Studies Unit, Sydney, 2 The George Institute for 

International Health, Sydney, 3 Bankstown Hospital, Sydney 

The aim of this systematic review was to determine the 



effectiveness of stretch interventions for the treatment and 

prevention of contractures in at-risk patients. We searched 

the Cochrane Central Register of Controlled Trials, DARE, 

HTA, Cochrane Musculoskeletal Group Specialised 

Register, MEDLINE, CINAHL, EMBASE, SCI- 

EXPANDED, PEDro, WHO international clinical trials 

registry platform as well as reference lists of included studies 

and relevant review articles. We considered all randomised 

controlled trials of stretch interventions (sustained passive 

stretching, positioning, splinting and serial casting) applied 

for the purpose of treating or preventing contractures. Two 

reviewers independently selected trials, extracted data, and 

assessed risk of bias. We contacted trialists for additional 

information. Pooled estimates were obtained using a fixedeffects 

model or, if there was evidence of heterogeneity, 

with a random-effects model. Here we present results from 

a preliminary analysis. Thiry-one trials were included. In 

neurological populations, stretch increased joint range of 

motion by 1 degree (95% CI 0–3) in the short-term (< 24 

hours after last stretch), by 1 degree (95% CI 0–2) in the 

intermediate term (< 1 week after last stretch) and by 0 

degrees (95% CI -2–2) in the longer-term (≥ 1 week after 

last stretch) when compared with no treatment or usual care. 

The results of this review do not support the use of stretch 

interventions for the treatment or prevention of contractures 

in neurological populations. 

Biological and biomechanical adaptation to contracture 

Lieber RL 




Spasticity, secondary to upper motor neuron lesion, 

can result in muscle contractures. We have studied the 

mechanics and biology of muscle from children with wrist 

flexion contractures secondary to cerebral palsy (CP). 

Dramatic architectural changes are observed in these 

children whereby sarcomere lengths are dramatically altered 

relative to patients without upper motor neuron lesions. This 

suggests dramatic alterations in the regulation of muscle 

growth in these children. Biomechanical studies of isolated 

single muscle cells reveal an increased passive modulus and 

decreased resting sarcomere length suggesting alterations in 

the cellular cytoskeleton. Similar studies on small bundles 

of muscle fibre reveal increased extracellular matrix 

compliance and endomysial connective tissue proliferation. 

Thus, the passive biomechanical properties of muscle from 

children with CP are dramatically altered in ways that are 

unparalleled by other altered use models. A recent expression 

profiling study revealed a number of ‘conflicting’ biological 

pathways in spastic muscle. Specifically, this muscle 

adapts by altering processes related to extracellular matrix 

production, fibre type determination, fibre hypertrophy 

and myogenesis. We also obtained evidence that calcium 

handling is altered secondary to cerebral palsy and may 

be a significant component of this disease. Taken together, 

these results support the notion that, while spasticity is 

multifactorial and neural in origin, significant structural 

alterations in muscle also occur. An understanding of the 

specific changes that occur in the muscle and extracellular 

matrix may facilitate the development of new conservative 

or surgical therapies for this devastating problem. 

Randomised trial of night casting for ankle contracture 

in children with Charcot-Marie-Tooth disease 

Rose K, 1 Raymond J, 2 Refshauge K, 2 North K, 1 Burns J 1 

1 

Institute for Neuromuscular Research, The Children’s Hospital at 

Westmead, The University of Sydney, 2 The University of Sydney 

Ankle contracture is prevalent in paediatric Charcot- 

Marie-Tooth disease (CMT) and can cause significant 

disability. Conservative therapies such as night splinting 

and serial casting are frequently implemented in the early 

stages of the disease to increase ankle flexibility, however 

night splinting has limited effect and serial casting can be 

complicated by pressure areas due to sensory impairment, 

and is often poorly tolerated. The aim of this study was 

to conduct a single-blind randomised controlled trial 

comparing the effect of night casting vs. no intervention 

on ankle flexibility and functional ability in children with 

CMT. Thirty children with CMT of any type were recruited 

from the neuromuscular clinics at The Children’s Hospital 

at Westmead (Sydney, Australia) and randomly allocated to 

receive eight weeks of night casting and manual stretching 

for the triceps surae or a control group receiving eight weeks 

of manual stretching only. The night cast was fabricated 

according to the principles of serial casting, but bi-valved 

and worn only at night. Outcome measures included ankle 

dorsiflexion range of motion, functional motor ability, foot 

alignment, compliance and adverse events. Treatment effect 

between groups will be determined on an intention-to-treat 

basis at 8 weeks using a linear regression approach to analysis 

of covariance (ANCOVA) to adjust for baseline differences 

of respective covariates. The trial is near completion and 

will be presented at the APA National Paediatric Group 

Conference. 



Occupational Health Physiotherapy 

Australia 

2nd Biennial Conference 






2 

Effective report writing for workplace assessments 

Aickin CM 

Workability Pty Ltd, Sydney 

This presentation will discuss the key points of successful 

workplace assessment report writing. It will address issues 

around the scope of the report, who is the audience, what 

does the audience need to know, what have you been asked 

to address, what to cover, how to lay out the report, using a 

writing style which facilitates reading, use of photographs 

and other summary tools. 

Manual handling training: does it work? 

Aickin CM 

Workability Pty Ltd, Sydney 

This presentation will present an overview of recent 

research into what constitutes effective manual handling 

training. The results of research indicate that ergonomic 

interventions including manual handling risk assessment, 

observation of workers, tailored training and task/equipment 

redesign are beneficial. This presentation will also address 

what the speaker has found, through practical experience, 

to be effective. This, in a large organisation, has included a 

train-the-trainer approach containing 3 separate modules. 

These cover the introduction a musculoskeletal injury 

prevention program and risk identification, risk assessment 

and risk control and skills training which is tailored to the 

specific requirements of the organisation and which covers 

specific handling skills. However, in a small organisation 

the approach has been one-one-one. Training evaluation is 

also imperative to ensure that the required outcomes are 

being achieved and it is always important to remember 

that some of these outcomes will not necessarily happen 

immediately. 

Evidence-based prevention of work disability due to 

low back pain: workplace, clinical or insurance 

policy interventions? 

Anema JR 

Department of Public and Occupational Health and EMGO+ Institute, 

VU University Medical Center, Amsterdam, The Netherlands, Research 

Center for Insurance Medicine AMC-UWV-VUmc, Amsterdam, 


Over the last decades work disability rates and corresponding 

costs have risen in most industrialised countries. In the 

western world, work disability has become a major public 

health problem. Long term sickness absence and work 

disability is associated with (work related) health risks, 

future serious illness and even an increased mortality risk. 

From a societal and economical perspective, the total yearly 

work disability costs are large. In the United Kingdom, the 

yearly costs are estimated at 24 billion pounds, and up to 

75% of the total absence costs are associated with long-term 

absence. Low back pain (LBP) is the most common reason 

for long-term absence and work disability in industrialized 

countries. There are, however, substantial differences in the 

prevalence of disability benefits and claim rates due to LBP 

among countries. For example, the back claim rate in the 

United States is 60-fold higher than that in Japan. In the back 

pain literature, it is often suggested that different disability 

policies may explain these cross country differences. Work 

disability due to LBP is a complex problem as a result of 

interactions between personal factors and factors in the 

health care system, the workplace system and compensation 

system. It is suggested that some clinical practices and/or 

insurance policies may cause long-term work disability. 

Applying the new work disability prevention paradigm may 

not only mean changing clinical care, but also changing 

workplace and compensation policies. This keynote will 

address the current evidence on prevention of work disability 

due to LBP. 

Implementation of the Sherbrooke model in the 

Netherlands: context analysis of stakeholders, 

barriers and facilitators 

Anema JR 

Department of Public and Occupational Health and EMGO+ Institute, 

VU University Medical Center, Amsterdam, The Netherlands, Research 

Center for Insurance Medicine AMC-UWV-VUmc, Amsterdam, 


The Sherbrooke model has shown to be effective in a 

number of RCTs in different jurisdictions in Canada and 

the Netherlands. In spite of growing evidence for prevention 

of work disability due to low back pain (LBP), there is 

little uptake in practice. Possible explanations include 

the complexity of the work disability problem. Applying 

this new knowledge in disability prevention in practice 

means not only changing clinical care, but also changing 

workplace policies. There are different theories and models 

related to implementing change, all of which are useful 

for identifying factors such as barriers and facilitators for 

the implementation of a new intervention or innovation. 

These factors can be identified on 4 main levels: the level 

of the patients, the professionals who have to adopt the 

innovation, the characteristics of the innovation itself, or the 

organisation and the environment in which the innovation is 

adopted. So far, little attention has been paid to evaluation of 

the implementation of an innovation in practice. However, 

it is important to implement an innovation properly, 

because insufficient or incorrect implementation can have 

an effect on the outcome. To obtain insight into how the 

Sherbrooke model was implemented in different settings in 

the Netherlands, several process evaluations and a context 

analysis were carried out. Insight into the feasibility, timeinvestment, 

users’ experiences, adherence, beliefs and 

attitudes towards the intervention were obtained. In this 

keynote a context analysis of stakeholders, barriers and 

facilitators regarding implementation of the Sherbrooke 

model in the Netherlands will be presented. 

Managing difficult clients 

Bell D 

Manager, Injury Management, Allianz Australia Workers Compensation 

(NSW) Limited 

Twenty percent of workers’ compensation claims go 

beyond 12 weeks. The reasons for this prolonged disability 

frequently extend beyond the pathology of the original 

injury and include workplace conflict, psychosocial issues, 

fear avoidance behaviors, employer size and lack of suitable 

duties and nominated treating doctors who do not promote 

the benefit of an early return to work. To address these 

barriers a different approach is required to that adopted for 

acute injury management. This approach must be strategic 

in nature, commencing with the identification of the barriers 

that exist and an understanding of the nominated treating 



doctors’ approach to injury management and return to 

work. A workplace visit is important in order to understand 

the functional requirements of the injured worker’s original 

position as well as the requirements of any other positions 

identified as appropriate for the return to work program. 

This information needs to be shared with all treating 

practitioners. Rehabilitation programs need to focus on 

transitioning the injured worker from passive to active 

treatment, and collaboration between all health professionals 

and the workers’ compensation insurer is essential. Flareup 

management plans implemented by treating practitioners 

can assist in setting the expectations of the injured worker 

regarding recovery and can prevent unnecessary visits to the 

nominated treating doctor, which often result in the injured 

worker being declared unfit and interrupting recovery and 

return to work. In order to be successful in the management 

of difficult clients a practitioner’s focus must therefore 

extend far beyond the injury itself. 

Implications of precarious employment, working hours 

and work-life conflict for worker health 

Bohle P 

Work and Health Research Team, The University of Sydney, Australia 

Precarious employment includes various forms of insecure 

and contingent work, such as casual, sub-contract, and 

agency work. There is evidence that it is often associated 

with increased health and safety risks. Shiftwork 

(particularly night work) and non-standard hours also linked 

to sleep disruption, fatigue, and diminished subjective 

health, in part through increased work-life conflict. Recent 

evidence suggests heightened risks for disease. Despite the 

highly irregular hours often associated with precarious 

employment, there has been little research on the effects of 

working hours on the health of precarious employees. Using 

data from interviews and questionnaire surveys, this paper 

examines the structural relationships between precarious 

employment, working hours, work-life conflict and health 

in different occupational contexts. Questionnaire and 

interview data were collected from 187 call centre operators 

and 217 short-haul truck drivers. Questionnaire data were 

also collected from a national sample of 860 paid workers 

aged between 45 and 64 years. Variables examined included 

employment status, demographic characteristics, and health. 

Structural relationships between precariousness, working 

hours, hours control, work characteristics, psychosocial 

factors, work-life conflict and health are examined using 

partial least squares modelling. Results reveal significant 

structural relationships between flexibility and variability 

of working hours, control over hours, other organisational 

factors, work-life conflict and health. However, the more 

variable hours of casuals are not consistently associated 

with greater work-life conflict or poorer subjective health. 

Labour market factors, and associated differences in control 

over working hours, appear to be key elements explaining 

the impact of precarious employment on health. 

In pursuit of establishing an international group of 

occupational health physiotherapists 

Boucaut R 

University of South Australia 

This paper describes steps taken to date, and future 

requirements, to establish an occupational health (OH) 

subgroup as an entity of the World Confederation of 

Physiotherapy (WCPT). At the 2007 World Congress of 

Physical Therapy in Vancouver a group met to share their 

common professional interest with two main purposes. 

First, to recommend that a dedicated stream of OH be 

established for the 2011 Netherlands world congress. Recent 

communication from WCPT indicates that plans for this 

are underway. The second proposition was to work towards 

establishing a subgroup within WCPT. The broad intent of 

such a subgroup is to establish an international network, 

share knowledge and resources, and promote discussion 

about work related health and safety physiotherapy practice. 

Following the congress the steps required to become a WCPT 

member were investigated. Ten member associations are 

required from three different world regions. To date three 

countries from two regions, Europe and South America, 

have formally expressed their interest. The challenge 

has been to attain a formal expression of interest for the 

subgroup from the countries where individual members have 

informally expressed their interest. Discussion is currently 

underway about developing a webpage on the WCPT site 

as a discussion forum for physiotherapists working in OH. 

Progress to date has been slow, but hopefully in the future 

an OH subgroup of WCPT will become a reality. 

Reflections on the specialisation journey in 

occupational health physiotherapy: perspectives from 

both candidates and examiners 

Boucaut R, 1 McPhee BJ, 2 Otto B, 3 Rothmore P, 4 Worth D 5 

1 

University of SA, Adelaide, 2 Jim Knowles Group, Kurri Kurri, 

3 

AJ Lucas Sydney, 4 University of Adelaide, Adelaide, 5 Rankin 

Occupational Safety & Health Adelaide 

The Australian Physiotherapy Association has actively 

encouraged a graduated recognition of skill sets within the 

special interest groups of Members. In 2002 a Professional 

Development Panel (PDP) was established within the 

Occupational Health Physiotherapy Australia (OHPA) to 

develop a pathway for Titled Membership in Occupational 

Health Physiotherapy. Subsequently in 2007 the PDP was 

asked to set up criteria and facilitate learning for Titled Members 

of Advanced Standing who were to be part of an accelerated 

program until 2009 proceeding to final examination for the 

award of Fellow of the Australian College of Physiotherapy. To 

date there are 10 Titled Members and 4 Occupational Health 

Physiotherapy Specialists in Australia. As a relatively new 

field in physiotherapy there were many challenges for both 

candidates and examiners, the most difficult of which were 

setting the operational definitions such as what a specialist 

occupational health physiotherapist does; knowing what 

standards were required and the range of knowledge and 

skills; and merging the Professional Practice Standards 

into the examination process. Additional challenges for the 

examiners included developing valid examination criteria; 

working with the College to clarify the broad range of OHP 

practice and how this differs from the traditional clinical 

model of physiotherapy; and the practicalities of setting up 

examinations at a distant location. 



4 

General practitioners’ beliefs and stated management 

of low back pain 

Buchbinder R 


Despite increasing evidence that positive advice to stay 

active and continue or resume ordinary activities is more 

effective than rest and early investigation and specialist 

referral are unwarranted in the majority of cases, studies 

continue to demonstrate a wide variability in how back 

pain is managed in the community. It is well recognised 

that many factors influence health professional behaviour 

in regard to the management of back pain. Even within the 

same professional group there is a widely variable approach. 

It is known that management approaches are influenced by 

the patients’ past experiences of back pain, interpretations 

of their preferences, and the inclination to give in to patients’ 

preferences for non evidence-based care (e.g. X-rays). Health 

professionals may also have alternate beliefs with respect to 

the association of pain and activity that may influence their 

practice behaviour. Recently we demonstrated that contrary 

to what might be expected, general practitioners who report 

a special interest in back pain have poorer knowledge about 

how to treat back pain compared to doctors who don’t report 

a special interest. This difference remained even after 

adjusting for recent continuing medical education (CME) 

about back pain. This talk will elaborate on the findings 

of this study and discuss its implications. It will also relate 

them to what is known about influences on physiotherapist 

beliefs and management of back pain. 

Physiotherapy graded activity programs incorporating 

a pain science knowledge model can improve outcomes 

in work related ankle injuries 

Craig M, 1 Hiller CE 2 

1 

bounceREHAB, Sydney, 2 The University of Sydney, Sydney 

The aim of this study was to investigate whether a 

physiotherapy-led graded activity program that incorporated 

pain science education and cognitive behavioural principles 

was successful for rehabilitation of work-related ankle 

injury. A retrospective audit of 79 patient files was 

undertaken. The average age was 38.7 ± 12.5 years and 70% 

were male. The program is a self-management gym based 

program supervised once a week, with a daily home activity 

program. It also involves education based on the physiology 

and biology involved in pain and how stress, anxiety, worry, 

depression and other thoughts will affect behaviour and 

shape the overall pain experience. The program commenced 

at 4 weeks post surgery and took 8–12 weeks to complete. 

Seven patients did not complete the program; 5 due to noncompliance 

and 2 for unrelated personal issues. Pre and 

post program data were extracted for 72 patients. There 

was a significant improvement in weight-bearing and nonweight-bearing 

dorsiflexion, heel raise ability, work status, 

and scores on the Cumberland Ankle Instability Tool, Foot 

and Ankle Outcome Score, and Fear-Avoidance Beliefs 

Questionnaire (all p < 0.001). This study demonstrates 

the feasibility of proceeding to a RCT to determine if the 

program is more effective than conventional physiotherapy 

in returning patients to work following an ankle injury. 

Managing musculoskeletal disorders in a 

physiotherapy department using a participative 

approach 

Davies KN, 1 Nankervis R 2 

1 

Queensland Health, Brisbane, 2 Northern Sydney Central Coast Area 

Health Service, Gosford 

A workplace intervention to systematically manage the 

risks associated with manual tasks performed by workers 

(therapists and therapy assistants) in a large, multi-site 

physiotherapy department remains strong after nearly 

10 years. The intervention was designed to specifically 

minimise the risk of musculoskeletal disorders (MSD), using 

a participative ergonomics approach. The intervention was 

initiated in response to a history of worsening prevalence 

and severity of MSD in the department. A worker survey 

was conducted and has since been repeated, which identified 

demographic and work profile, perceived high risk tasks, 

self reported symptoms and treatment. Work groups were 

formed based on clinical stream and existing work teams. 

Education about how to apply risk management to manual 

tasks and effect consultation was provided to the work 

group leaders and ongoing support was provided. The work 

groups successfully worked through the risk management 

process and implemented improvements in their own areas 

and continue to do so. This presentation will outline the 

intervention methodology and will specifically highlight 

the operational management commitment and strategies 

needed. The intervention has been successful within this 

department, with improvement in the control of MSD risk 

factors, in related key indicators and in culture, with this 

approach now part of ‘business as usual’ for management 

and clinicians. 

Taking up the challenge: development and 

implementation of a comprehensive healthcare facility 

patient handling risk management tool 

Davies KN 

Queensland Health, Brisbane 

Although having a general understanding of the principles 

of risk management, many staff, managers and OHS 

professionals differ in their understanding and application 

of these, particularly to patient handling. Risk assessment of 

patient handling is applicable at many levels: organisational, 

work area, task and individual patient. The aim of this 

project was to develop and implement a systematic risk 

management approach to patient handling in healthcare 

facilities, particularly at the work area level. Queensland 

Health has developed and implemented the patient handling 

facility/ unit risk assessment tool (FURAT). The FURAT 

was developed over an 18-month period in consultation 

with internal stakeholders and others involved in evaluating 

patient handling tasks and is currently being implemented in 

clinical areas. The FURAT provides a structured framework 

to bring hazard identification, assessment of the direct and 

contributory risk factors, risk analysis and the elimination 

or minimisation of risks into one step by step process. 

The FURAT is used to evaluate the baseline standard in 

an existing work area; planned changes to a work area, 

or, to inform planning of a new work area. The output is a 

documented risk control action plan and a patient handling 

unit profile form, which summarises the key risk controls 

and arrangements for patient handling in the work area. 

The FURAT is to be completed and reviewed in specified 



timeframes and conditions. The project has presented many 

challenges and in return offers many potential rewards, 

which will be highlighted. 

Fostering self management in injured workers using 

health coaching 

Gale J 

Health Psychologist, Managing Director, Health Coaching Australia 

Adherence to medical recommendations is poor across all 

chronic health conditions (WHO 2003), including injury 

management and rehabilitation. The barriers to chronic 

condition self-management (CCSM) include beliefs, 

attitudes, expectations, thoughts, emotional responses 

such as anger, depression and resistance, memory issues, 

sub-optimal problem solving and poor planning. The 

presentation briefly introduces a combined theoretical and 

practice model of health coaching that has gained wide 

acceptance among health practitioners and within health 

services around Australia. Health coaching is one of the 

few models that provide a structured method to identify and 

minimise potential barriers to health behaviour change and 

subsequent self-management. Health coaching techniques 

assist clients firstly to decide that self-management is in 

their own interests, and secondly to be more successful in 

achieving self-management goals. It also offers techniques 

that allow health practitioners to provide education and 

treatment advice without increasing resistance to engagement 

in their clients. The model works with clients’ readiness to 

change and actively seeks to increase perceived importance 

in engaging in self-management activities and confidence in 

being able to do so successfully. The model operationalises 

concepts such as building self-efficacy, respecting patient 

autonomy and choice, increasing patient responsibility, and 

avoiding the ‘Yes, but’ syndrome. Health coaching is based 

on well-regarded theory and evidence-based interventions 

from motivational interviewing, solution-focused 

counselling/coaching and cognitive change techniques. The 

model’s structure and processes increase clinical efficiency 

by actively guiding health professionals’ attempts to assist 

clients to change health behaviours and self-manage injury 

and other health issues 

A study of behavioural, psychological and 

psychophysiological risk factors for musculoskeletal 

symptoms in sample of Australian Public Sector 

employees 

Griffiths KL, Mackey MG, Adamson BJ 


The aim of this study was to measure the behavioural, 

psychological and psychophysiological predictors of 

musculoskeletal symptoms with computer work. Evidence 

is growing that the risk of musculoskeletal symptoms 

increases with hours worked with a computer per day, 

and with exposure to psychosocial stressors such as high 

workloads, excessive work time and unrealistic deadlines. 

How individuals attempt to meet these demands and 

respond to the psychosocial stressors may contribute to the 

development, continuation or exacerbation of musculoskeletal 

symptoms. Australian public sector employees were invited 

to complete an on-line survey consisting of the ASSET 

to measure perceived organisational stressors, the Nordic 

Musculoskeletal Questionnaire to measure reported 

musculoskeletal symptoms and additional questions relating 

to work behaviours and responses. Logistic regression was 

used to identify significant predictors for the 12-month 

prevalence of musculoskeletal symptoms. Results from 

1306 respondents demonstrated a linear relationship 

between average hours worked with a computer per day and 

the 12-month prevalence of symptoms for all upper-body 

areas. For neck symptoms, the strongest predictor was the 

tendency to tense neck and shoulders when busy (OR = 2.47, 

95% CI: 2.12–2.86), followed by being mentally exhausted 

by work (OR = 1.69, 95% CI: 1.49–1.95) and pressured 

by deadlines (OR = 1.54, 95% CI: 1.34–1.77). Ergonomic 

adjustment of chair or workstations were non-predictors for 

all upper-body areas These findings highlight the need for 

management and health personnel to also focus on work 

system issues such as workloads and scheduling in addition 

to physical ergonomics, in order to better control the risk of 

work-related musculoskeletal disorders. 

Supporting a healthy workplace: IBM approach 

Hobbs KM 

IBM 

IBM approach to workplace health is driven by the 

company’s senior management belief that employee health 

and well-being are fundamental values that determine 

business success. This is codified in the IBM Global 

Policy ‘Responsibility for Well being and Product Safety. 

IBM health promotion programs are designed to enhance 

the health, well-being and productivity of employees; to 

raise awareness of and promote the adoption of health 

risk reduction behaviours and to reduce health insurance 

benefits costs. These programs may include education on 

health topics (both work related and personal) delivered 

via multiple media, well-person screening activities, and 

preventive health programs such as immunisation. All 

health promotion programs offered are required to be 

evidence-based, with clearly defined objectives and outcome 

measures; they address the health priorities of the particular 

IBM population, workplace or country, taking account of 

any national recommendations or focus areas; they are 

focused at multiple levels, e.g. individuals, ‘at risk’ groups, 

sites or particular IBM communities. IBM also encourages 

employees to be aware of and to participate in national and/ 

or community based programs. IBM has used incentives 

to promote effectiveness of health promotion programs; 

examples of these will be covered in the presentation. 

Developing a screening tool to determine the functional 

capacity of ACT paramedics 

Howell DH 

Ergogym, Phillip ACT 

Between June 2007 and December 2007, 8% of the ACT 

operational paramedic workforce presented at Ergogym 

with work related injuries. All injuries were related to 

manual handling activities and 10/11 presented with 

average or less than average cardiovascular fitness. All 

operational paramedics and transport officers were offered 

an opportunity to attend a physical capacity screening test. 

Thirty-three responded with 28 completing the screen. From 

the 28 screened, 11 failed to meet at least 3 components of the 

screening test and were invited to participate in a 12-session 

pilot study. The aim of the pilot study was to assess whether 



a fitness program with a focus on cardiovascular fitness, 

functional activities and manual handling would assist in 

paramedics attaining a standard that would meet the criteria 

of the screening test. Results of the initial intervention 

are being finalised. This presentation will outline the 

background to developing a specific screening tool to assess 

the functional capacity of operational paramedics. It will 

describe how the tool has been tested and modified as a 

result of the testing and consultation to meet the needs of 

the ACT Ambulance Service. 

6 

Job coaching: drop and give me 20? 

Iles RA 

La Trobe University, Melbourne; Work Disability Prevention CIHR 

Strategic Training Programme, University of Sherbrooke, Canada 

The aim of occupational rehabilitation is the successful 

return of the injured worker to the workplace. It is 

acknowledged that the longer an injured worker remains off 

work the chances of a successful outcome become smaller. 

Providing workplace modifications and removing barriers 

to return to work are only likely to have moderate success 

if the worker is not motivated or confident in their ability 

to return to work. Enter the job coach. The aim of the job 

coach is to assist the worker with the changes required when 

returning to work after injury. This may involve exercise 

for the physical demands of work or preparing mentally for 

the challenges that returning to work can present. While 

job coaching in order to return workers with complex 

mental and physical challenges may require specific 

training, physiotherapists are ideally placed to begin the job 

coaching process for any injured worker. This session will 

describe theoretical approaches for coaching return to work 

and demonstrate some simple techniques physiotherapists 

can use to establish the motivation and confidence of their 

patients for return to work. Working together with the 

injured worker, physiotherapists can help to develop the 

motivation required to allow injured workers successfully 

return to work. 

Methods used by physiotherapists to identify barriers 

to return to work 

Johnston V 


Musculoskeletal disorders are costly to workers 

compensation and health care systems in Australia, in terms 

of lost productivity for the employer, and suffering for the 

individual and family. As a major provider of rehabilitation 

services, Physiotherapists are required to identify barriers 

to return to work; both physical and psychosocial. It is well 

accepted that physiotherapists have the skills to identify 

physical barriers to return to work such as pain levels and 

restricted movement, however, when and if they assess 

psychosocial barriers has not been documented. This study 

sought to understand and describe how physiotherapists 

determine an injured worker’s capacity to work and 

potential barriers to return to work. Focus groups and 

telephone interviews were held with physiotherapists (n = 

15) who regularly manage patients in receipt of workers’ 

compensation in Queensland. Preliminary results suggest 

that physiotherapists are cognisant of the potential negative 

impact of psychosocial barriers to recovery and return to work 

however, the assessment of these barriers is often based on 

clinical judgement and experience rather than standardised 

tools. There was consensus that physiotherapists are best 

placed to assess a worker’s capacity to return to work but 

that processes within the insurance industry and employer 

organisation often impede the smooth transition of the 

worker from the clinic to the workplace. It is likely that 

this research will highlight the need for physiotherapists to 

develop stronger skills in determining the barriers to return 

to work and to communicate these effectively to the various 

stakeholders. 

The role of legislation and the role of the Courts in 

motivating compliance with workplace health and 

safety obligations 

King R 

Milner Lawyers 

The employment relationship and the obligations on 

employers and workplaces now bear little resemblance to 

the original concepts of master and servant from which 

they evolved. Work and employment are identified as a 

significant part of a person’s identity. Treating it as just 

another legal ‘contract’ is no longer satisfactory. As a result, 

employers often see themselves as forced to walk a tightrope 

between productivity and work/life balance, safety and 

health and discrimination and commercial decision with 

liability for the risks created by the undertaking. Under the 

occupational safety and health obligation, employers cannot 

even rely on their employee’s experience to manage risks 

to safety and risks to health. This presentation will explore 

the niche role of legislation, safety and health, rehabilitation 

and discrimination in promoting compliance with the now 

accepted role of employment. Since the legislation itself only 

has a practical impact in the light of the Courts’ decisions, 

the presentation will also consider key aspects of recent 

decisions that are shaping the way in which employers must 

manage the risk of injury or illness (the risk of aggravating an 

injury or illness) within their workplaces. The presentation 

will also consider the role of health professionals-such as 

occupational physiotherapists-in supporting employers 

and workplaces, given the consequences that will befall an 

employer if the event of injury or illness from work or the 

workplace. 

Improving outcomes: integrated active management of 

workers with soft tissue injury 

Leaver AM 


Soft tissue injures are common, accounting for more than 

59% of reported workplace injuries in NSW in 2007/08, at 

a cost of $331 million. The majority of workers with a soft 

tissue injury recover and return to their usual work within 

4 weeks. For some workers however, these injuries result in 

long term disability and work loss with significant adverse 

health, social and financial outcomes. Work Cover NSW 

has adopted a management approach based on the available 

evidence and this is described in a practice advice and 

supported by a comprehensive training program for physical 

treatment providers with the aim of improving outcomes 

for workers with soft tissue injuries. The main objectives 

of the advice are the prevention of long-term disability 

and promotion of early, safe and durable return to work. 

The advice promotes active involvement of the worker in 

injury management and emphasises the need for effective 



communication and consistency between key parties. The 

advice includes resources for clinicians and injured workers 

that explain the rationale of active injury management 

throughout the stages of recovery from a soft tissue injury 

as well as practice tips to assist with implementing active 

management. Central to this approach is the identification 

and management of barriers to recovery and return to work. 

This presentation outlines the key principles underpinning 

this advice and reviews the theoretical basis and evidence 

supporting active management of soft tissue injuries. 

Effects of a walking program on the health and workability 

of an ageing sedentary workforce in a university 

community 

Mackey MG, 1 Bohle P, 1 Taylor P 2 , Di Biase T 2 

1 

Work and Health Research Group, The University of Sydney, Australia, 

2 

Business, Work and Ageing Centre for Research, Swinburne University 

of Technology, Australia 

Sedentary behaviour in the workplace, in transport and 

in the home is increasing and has harmful health effects. 

Walking is a familiar, convenient, and free form of exercise 

that can be incorporated into working life and sustained 

into older age. Using a cluster randomised design, this 

study evaluated the feasibility and impact of walking on 

the work-day step counts, health status and workability 

of academic and administrative employees at several 

campuses of an Australian university. A convenience 

sample of 63 male and female employees (age 53 ± 7 years) 

were provided with a pedometer and completed baseline 

and intervention measures for step count, % body fat, 

waist circumference, blood pressure, physical activity, 

psychological wellbeing and workability during a 12-week 

period. Before intervention, participants were randomly 

allocated to a control (maintain normal behaviour, n = 

27) and experimental (walking) group (n = 36). Walkers 

selected single or combined walking approaches (walking 

for transport, walking within tasks and/or walking routes) 

tailored to their individual preference, psychological 

characteristics or life circumstances. The program was 

divided into two distinct phases targeting adoption (weeks 

1–4) and adherence (weeks 5–12) using Stages of Behaviour 

Change principles. A regression model was used to test for 

the intervention effect with the baseline value entered as a 

covariate. Preliminary results (end-adoption phase) indicate 

the walking intervention is safe, feasible, and resulted in 

a significantly greater improvement in step count for the 

experimental group compared with the control group 

(mean difference 2655, 95% CI 1393–3917 steps/day). 

Findings have implications for work-based physical activity 

promotion. 

Health examination for preventing occupational 

injuries and disease in workers: a systematic review in 

the framework of the Cochrane Collaboration 

Mahmud N, 1 Schonstein E, 1 Lehtola MN, 2 de Bie R, 3 

Fassier JB, 4 Reneman MF, 5 Verbeek JH 2 

1 

Faculty of Health Sciences, University of Sydney, Lidcombe, Australia, 

2 

Finnish Institute of Occupational Health, Center of Expertise for 

Good Practices and Competence, Team of Knowledge Transfer in 

Occupational Health and Safety, Cochrane Occupational Health 

Field, Kuopio, Finland, 3 Department of Epidemiology, Maastricht 

University, Maastricht, Netherlands, 4 Service de Médecine et Santé 

au Travail, Université Claude Bernard-Lyon 1, Lyon, France, 5Center 

of Rehabilitation, University Medical Center Groningen, Groningen, 

Netherlands 

There is a widely held belief about the benefits of health 

examinations by stakeholders but there is no clear evidence 

of benefits of recommendations based on such health 

examinations. Therefore we performed a systematic review 

of the effectiveness of employment recommendations based 

on pre-employment examinations (PEE) in preventing 

occupational injuries and diseases and of return to work 

recommendations in preventing occupational injuries 

following functional capacity evaluations (FCE). To be 

eligible for inclusion studies had to be a controlled study 

or an interrupted time-series. PEE studies had to include 

job applicants, an intervention such as a recommendation, 

measure a health outcome or injury. FCE studies had to 

include injured workers, FCE, a return to work outcome 

measure. We searched the major databases. Two assessors 

independently assessed study eligibility, extracted data 

and judged the quality. Meta-analysis was performed if 

studies were homogenous. For PEE, we found 11 articles 

describing 10 studies with two RCTs, 3 interrupted time 

series and 5 controlled before after studies. All studies 

were of low quality. Four studies included FCE as part 

of the PEE. Six studies measured injuries as the main 

outcome, 1 study occupational asthma and 3 general health 

indicators. We found some evidence that PPEs that include 

FCE can reduce the injury rate. For FCE for return to work 

recommendations, we found 1 study that did not show 

evidence of enhancing return to work after injury. There 

is some evidence that recommendations following specific 

pre-employment examinations can reduce health problems 

in prospective workers. There is no evidence that functional 

capacity evaluations in injured workers enhance return to 

work rates. 

Improved OHS compliance can increase productivity 

Marlow P 

Sydney, Australia 

The link between safety and productivity is explored by 

use of a case study. Improving the ergonomics of a wash 

line in a brewery resulted in a 70% increase in productivity 

which was sustained at 12 month follow-up. During the 

same period injury absence was reduced from 54 days over 

a 12-month period to 0 days in the following 12 months. 

The reasons businesses continue to use unsafe, inefficient 

practices is discussed in terms of inefficiencies in business 

information systems. Ways OH&S professionals can work 

with business to improve safety and productivity are 

explored, including the use of cost-benefit analysis, analysis 

of business vision and metaphor and the use of productivity 

as a proxy variable for the value of people. 

Participative techniques in OHS problem solving 

McPhee B 

Jim Knowles Group, Kurri Kurri, NSW 

Participative risk assessments are focus groups that have 

uninterrupted time to solve problems using a systematic 

approach. The group brings a range of expertise and interests 

and a detailed knowledge of the job. The forum provides an 

opportunity for a group of stakeholders to concentrate on the 

problem with a view to solving it. Participative techniques 

have been used successfully by designers and in safety 

management systems for many years. They are an interesting 

and productive method for systematically identifying 



workplace Occupational Health and Safety (OHS) problems 

and developing solutions. Issues can be aired with respect 

to the wider work system providing a perspective that may 

not be achievable in any other way. Most importantly the 

processes are now well understood by many companies and 

outcomes can be integrated into a company’s OHS program. 

Team members provide expertise, experience and technical 

knowledge and must respect that provided by others. 

Outcomes are critically dependent upon the team providing 

a balanced view appropriate to the area under assessment. 

Sometimes further specific expertise may be required. The 

facilitator must understand the client’s requirements and 

advise on the best approach to meet the objectives. The 

participative approach allows practical issues associated 

with the selection and implementing of controls to be aired 

and worked through by the group thereby gaining support 

for the process. People take ownership of both the problems 

and the solutions and gain an appreciation of how continual 

small improvements can substantially reduce risks of illness 

and injury as well as improving the job. 

8 

Preparation of portfolios for OHP titling 

McPhee BJ, 1 Boucaut R 2 

1 

Jim Knowles Group, Kurri Kurri, 2 University of SA, Adelaide, 

This short workshop will address the requirements for 

candidates in preparing portfolios for Occupational Health 

Physiotherapy (OHP) titling. The aim is to clarify the process 

for OHP titling to ensure that the candidate can demonstrate 

his/her understanding and adherence to the Professional 

Practice Standards in OHP at the appropriate level. Topics 

selected by the candidate will need to address 5 main areas. 

These are: background information, development and 

planning, intervention, evaluation, reflections on practice. 

Short presentations will be followed by opportunities for 

discussion between the participants and the presenters. 

Performance based approach to OH&S hazard 

management 

Mockvitch M 

Working Environment Division, WorkCover NSW, Australia 

Some years ago, the focus of OH&S legislation in NSW 

moved from a prescriptive to a performance-based approach. 

The prescriptive approach was seen as broadly inflexible and 

unable to manage changing technologies. The performancebased 

approach was seen as more flexible, however the 

broader scope for managing hazards afforded by the this 

new approach reduced the extent of guidance available to 

an employer in that much of the decision making was left 

to their own devices. In recognising this, over a number of 

years WorkCover NSW has greatly increased the level of 

guidance and education it provides to employers regarding 

their OH&S concerns. Such a position inevitably leads to 

the consideration of what safety concerns are important 

to stakeholders as opposed to those that WorkCover, as 

a regulator, believes are important. Embedded in this 

approach is the true meaning of ‘public value’ and a desire 

on the part of government to provide the service that the 

stakeholder needs. This presentation will highlight the 

means that WorkCover NSW has chosen to achieve this 

position including the problem solving approach, industry 

partnerships and stakeholder consultation groups. 

Functional upgrading and return to work 

Morton L 

Peak Conditioning 

Functional upgrading programs play a role in the sub acute 

management of workplace injuries. These programs are 

important in transitioning injured workers from passive 

treatment to active treatment focused on returning injured 

workers to sustainable and durable work based on their 

functional capacity. A strategic approach to these programs 

begins with a thorough understanding of the functional 

requirements of the role, the functional capacity of the 

injured worker and their perceptions of their injury and 

an in depth understanding of the general practitioner’s 

perspective on the injured worker’s current presentation 

and management. A key driver in determining the success 

of this approach is making clear distinctions between the 

link between pain and functional ability and the distinction 

between acute pain and chronic pain. Ensuring that the 

injured worker and the practitioner understand and agree 

with these concepts is essential to the program. This dictates 

the treatment approach needed to address the functional 

gaps, the beliefs and behaviours displayed by the injured 

worker and practitioner’s current beliefs. Upon completion 

of the program it is the role of the treating professional to 

determine the functional capacity of the injured worker and 

to convey that professional opinion to the employer, the 

insurer and the general practitioner in order that the injured 

worker’s functional capacity is accurately understood and 

that the injured worker is accurately certified to reflect this 

functional capacity. 

It’s what you do that matters 

Nicholas MK 

Pain Management Research Institute, University of Sydney at Royal 


This session is intended to examine the importance of 

behaviour in work-related pain management. In injured 

workers with persisting pain, pain relief is commonly the 

focus of interventions and the usual underlying expectation 

is that once this is achieved rehabilitation will follow. But 

we now know that once pain becomes chronic, waiting 

for pain relief is likely to be both fruitless and a major 

barrier to return to work. This can effectively paralyse all 

stakeholders: the injured workers, their employers, their 

treatment providers and insurers. Australian data indicate 

that in 85% of those who have not returned to work within 

6 months after injury, concerns about pain and injury are 

key reasons for not returning to work. We also know that 

the longer an injured worker is away from work the less 

likely s/he is to return to work. Even so, many injured 

workers do manage to return to work despite their persisting 

pain. But many do not. Working out ways of doing things 

despite pain is a key task for this group. Magic bullets are 

unlikely. Fortunately, evidence is accumulating on effective 

management strategies for workers with persistent pain 

and other key stakeholders. These will be discussed as a 

framework for improving outcomes in this population. 



Regulation and enforcement: OHS and regulatory 

effects of changing work environments 

Quinlan M 


Extensive international research points to an association 

between changed work arrangements, especially those 

commonly labelled as contingent work, with adverse 

occupational health and safety (OHS) outcomes. Research 

also indicates these work arrangements have weakened 

or bypassed existing OHS and workers’ compensation 

regulatory regimes. However, there has been little if any 

research into how OHS inspectors perceive these issues 

and how they address them during workplace visits or 

investigations. Between 2003 and 2007 research was 

undertaken that entailed detailed documentary and 

statistical analysis, extended interviews with 170 regulatory 

managers and inspectors, and observational data collected 

while accompanying inspectors on 118 ‘typical’ workplace 

visits. Key findings are that inspectors responsible for 

a range of industries see altered work arrangements as a 

serious challenge, especially labour hire (agency work) and 

subcontracting. Though the law imposes clear obligations, 

inspectors identified misunderstanding/blame-shifting and 

poor compliance amongst parties to these arrangements. 

The complexity of these work arrangements also posed 

logistical challenges to inspectorates. 

Fatigue induced loading on the lumbar spine: an 

investigation on intra-shift variation in manual 

handling performance amongst physiotherapists 

Rothmore P, 1,2 Hewitt A, 1 Nguyen T, 1 Gunn S 1 

1 

Repatriation General Hospital, Adelaide, 2 The University of Adelaide, 

Adelaide 

Workers in health care are committed to the care of others, 

but this care can be at the expense of the worker’s own 

health. Despite evidence of the association between workrelated 

risk factors and musculoskeletal disorders, manual 

handling injuries in the health-care sector are disturbingly 

common. A previous study of manual handling injuries in SA 

hospitals identified that 41% of injuries occurred in the last 

quartile of the shift. This paper will examine 2 hypotheses 

for this ‘last quartile effect’. First, that manual handling 

performance during a shift is influenced by within-shift 

changes in muscle tone and supporting structures placing 

staff at risk of injury, irrespective of how movements were 

performed. Second, that muscle fatigue and other factors 

may lead to staff performing manual handling tasks in an 

energy saving, but more hazardous manner, at the end of a 

shift. Results will be presented on the loading forces on the 

lumbar spine in 40 physiotherapists during the performance 

of 2 manual handling tasks pre and post-shift. Data presented 

will include calculations of the compression and shear forces 

acting at L5/S1; electromyography analyses used to quantify 

the fatigue of the measured muscles; and participants selfreported 

fatigue levels using a visual analogue scale. This 

study seeks to contribute to an understanding of intra-shift 

variation in manual handling task performance to assist in 

the identification of activities which, if avoided or modified, 

may reduce the likelihood of manual handling injuries to 

the lower back as the shift progresses. 

The Sherbrooke Model of management of occupational 

back pain: is it effective in preventing work disability 

and why? 

Schonstein E 


The Sherbrooke model was based on the Quebec task 

force’s proposal of a diagnostic grid and evidencebased 

interventions to be implemented at specific times 

for the management of chronic low back pain. These 

interventions included advice of a medical specialist after 

seven weeks of work absence, active treatment, early 

vocational rehabilitation and an ergonomic intervention. 

The Sherbrooke model proposes to link these different 

approaches to provide an integrated management approach, 

directed at both the worker and jobsite. A randomised 

controlled trial established the cost effectiveness of this 

program. Many barriers to the prevention of work disability 

due to musculoskeletal disorders remain, not the least of 

which are the complexity of the problem and therefore the 

involvement of many stakeholders. There is an urgent need 

to create, disseminate and implement new knowledge in the 

prevention of work disability field and for this purpose an 

advanced training program was developed by 24 mentors 

affiliated with nine different universities. The main objective 

of this program is to develop transdisciplinary knowledge, 

skills and attitudes regarding work disability prevention 

and has been running since 2003 

Comprehensive evidence-based assessment of 

musculoskeletal injury risk in the industrial setting 

Snodgrass SJ, 1 Guest M, 1 James C, 1 Wilkinson RJ, 1 

Viljoen, DA 2 

1 

The University of Newcastle, Newcastle, 2 Hunter Industrial Medicine, 

Newcastle 

Work-related musculoskeletal injuries are common during 

manual handling in heavy industry, with risk assessment 

and control necessary to reduce injury and comply with 

occupational health and safety regulations. Traditional 

workplace risk assessment using observational tools such 

as the Manual Task Risk Assessment (ManTRA) may not 

definitively detect and quantify risk. This study investigated 

the utility of an innovative and evidence-based method 

using a combination of assessment tools to quantify 

musculoskeletal injury risk during manual handling tasks. 

Eight tasks at an aluminium production facility were 

assessed in 4 workers (per task) using a modified ManTRA 

that included force gauge measurements compared with 

Snook tables and biomechanical analysis using digital 

video. Tasks were assigned injury risk ratings, defined by 

the ManTRA exertion/awkwardness sum ≥ 8 or cumulative 

risk score ≥ 15. Results indicated that combining the Snook 

tables and biomechanical analysis with the ManTRA 

provided the most accurate assessment of overall risk. 

The ManTRA identified 4 potentially hazardous tasks, 

the Snook tables an additional 2 tasks (14% and 70% of 

an industrial population able to perform without increased 

risk), while the biomechanical analysis identified specific 

modifiable factors in task performance and machinery. 

These results indicate that a comprehensive risk assessment 

combining the ManTRA with force gauge measurements 

and biomechanical analysis is more effective than each of 

these on its own. The modified ManTRA can be effectively 

utilised in the industrial setting, and risk assessment 



results clearly communicated to workers, managers and 

health support staff with documentation applicable to task 

modification. 

10 

Developmental trajectories are critical to inform 

prevention initiatives for spinal pain 

Straker LM, 1,2 O’Sullivan PB, 1,2 Kendall GE, 2,3 Smith 

AJ, 1,2 Briggs AM, 1 Beales, D, 1 Campbell, A 1 

1 

The School of Physiotherapy and Curtin Health Innovation Research 

Institute, Curtin University of Technology, Perth, 2 Telethon Institute for 

Child Health Research, Perth, 3 The School of Nursing and Midwifery 

and Curtin Health Innovation Research Institute, Curtin University of 

Technology, Perth 

Spinal pain is a very common complaint in adulthood, with 

a significant proportion of adults experiencing disabling 

spinal pain. The burden of spinal pain is large and spinal 

pain is a major component of physiotherapy practice and 

research. However the main focus of most interventions 

and research has been adult spinal. This is despite evidence 

that spinal pain prevalence is high during adolescence and 

that a history of spinal pain is a major predictor of future 

spinal pain. The aim of this presentation is to outline 

progress towards understanding pathways to spinal pain 

in a longitudinal cohort study. The Western Australian 

Pregnancy Cohort (Raine) Study recruited 2868 mothers at 

around 18 weeks of gestation in 1989–1992. Comprehensive 

health, developmental and social factors were obtained at 

enrolment and at birth, 1, 2, 3, 5, 8, 10, 14 and 17 years of 

age. The uniquely rich data set of over 12 000 phenotypic 

variables and 660 000 genetic variables is enabling 

multidimensional analysis, including: physical correlates 

(spinal posture, back muscle endurance, cardiovascular 

fitness, obesity, motor coordination), lifestyle correlates 

(physical activity, sedentary behaviours, smoking, alcohol 

and other drug use), social correlates (early family 

life stress events, family functioning, socio-economic 

status), psychological correlates (anxiety, depression, self 

perception, self efficacy, catastrophising and fear avoidance 

beliefs), neurophysiological correlates (hypothalamicpituitary-adrenal 

axis function), co-morbidities (headache, 

abdominal pain, arthritis, cardiovascular, respiratory, 

allergic and inflammatory disorders, sleep problems), 

genetic factors (SNPs, genome wide scans), pathoanatomical 

correlates and gender. An overview of current findings will 

be presented along with an outline of the implications for 

prevention initiatives for spinal pain. 

Why office workers need more stress at work: 

harmful effects of inactivity in the office and 

how to promote activity 

Straker LM 

The School of Physiotherapy and Curtin Health Innovation Research 

Institute, Curtin University of Technology, Perth 

An increasing proportion of workers are performing low 

activity occupations. This is contributing to more people 

having insufficient physical activity, and thus being at 

greater risk of inactivity related health problems. The aim 

of this presentation is to highlight this emerging health 

issue and suggest new roles for physiotherapy in promoting 

health. The presentation will review the evidence for 

inactivity to be harmful to health and the population 

trends increasing inactivity. Occupational physiotherapy 

has usually reduced the risk of work-related disorders, 

particularly musculoskeletal disorders, by reducing physical 

stress. However it will be argued that greater physical stress 

is required for workers involved in sedentary occupations. 

Examples of how physical stress can be provided in a 

workplace will be presented. 

Musculoskeletal pain in a population of powerline 

workers in Country Energy: prevalence and 

management strategies used 

Thomas AJ, 1 Tonkin L, 2 Nicholas MJ, 2 Ashgari A 2 

1 

Regional Health Coordinator, Country Energy, 2 Pain Management 

Research Centre, University of Sydney at Royal North Shore Hospital, 

Sydney, Australia 

The aim of this pilot study was to gather information on the 

prevalence of musculoskeletal pain and pain management 

strategies used by Far North Coast field staff for both 

work and non-work related musculoskeletal pain. The 

incidence of musculoskeletal pain increases as people age, 

particularly for workers who primarily undertake manual 

tasks. Country Energy powerline workers are directly 

involved in constructing and maintaining around 200 

000 kilometres of powerlines and 1.4 million power poles 

across all environments. In line with national statistics, 

this workforce is ageing. A self-report questionnaire was 

developed based on the OMPQ and including work-related 

variables (blue flags) and distributed at local depots. 

Participation was voluntary. One hundred and fifteen 

responses were received from a possible sample of 300. 

Statistical analysis was performed. All but 2 respondents 

reported pain: 25.9% of respondents had experienced pain 

for greater than 12 weeks. A single site of pain was reported 

by 35% of respondents. Lower back was the most frequently 

reported site, followed by shoulder and leg. An average of 

4 separate pain management strategies was used by each 

respondent. Medical consultation was reported 32 times. 

The presence of pain did not impact on the expectation 

of ability to perform usual duties. The prevalence of pain 

is significantly greater than that reported in the workers 

compensation data for the same period. Multiple pain 

management strategies were utilised. A preventive program 

for shoulder injury has been developed to reduce the risk of 

pain related disability within this workforce. 

Choosing the right tool 

Thomas DT 

There are a multitude of tools available to help identify 

and assess the work-related musculoskeletal disorder 

risk. These range from measuring devices, checklists, 

surveys and analysis tools. These tools can be subjective 

or objective in nature. Many analysis tools attempt to 

quantify physical work load and psychosocial work factors 

placed on the employee. The choice of tool or tools to be 

used at the workplace will be determined by the task being 

assessed, the target audience of any findings, the assessors’ 

understanding of the tool and their competency with the use 

of the tool. Every tool is designed with a specific use in 

mind. Researchers often made assumptions when developing 

tools. No one tool is perfect or better than another tool in 

every situation and every tool has its limitations. It is only 

through the thorough understanding of a tool’s limitations, 

underlying assumptions and uses, can the most appropriate 

tools be chosen for the worksite assessment and then used 

effectively. This presentation will review some commonly 



used tools (Revised NIOSH lifting equation, RULA etc.) in 

terms of their use, limitations and underlying assumptions. 

Workplace assessments: crafting methodology to 

improve assessment credibility and dependability 

Travis JM 

Nth Degree, Sydney 

The purpose of this presentation is to identify the problems 

with the design and, therefore, administration of workplace 

assessments, and describe assessment methodology that 

eliminates or mitigates those problems. Work loss and 

disability following injury are the result of interrelating 

biomedical, psychosocial, cognitive-behavioural and 

environmental factors. However, workplace assessments 

are commonly limited to the analysis of physical work 

demands and the physical hazards or risks confronting 

injured workers. This approach simplifies an otherwise 

complex construct and is inherently problematic because 

the identification and management of physical risk factors, 

alone, does not determine a worker’s ability to return to work. 

Credibility and dependability of workplace assessments 

can be improved by establishing work-related assessment 

criteria, assessing a worker’s abilities against those criteria, 

identifying the salient factors affecting persisting work loss 

and disability, and selecting interventions to control those 

factors and return the worker to durable employment. 

Development of a multi-faceted approach to injury 

prevention in an emergency service: a case study of 

physiotherapy involvement 

Van Der Linden M 

Occupational health physiotherapists have provided 

over 10 years of consultation to the South Australian 

Ambulance Service. This commenced with a broad ranging 

evaluation of current practices in the late 1990s. Subsequent 

development of a train the trainer manual handling training 

program and implementation of pre employment functional 

capacity evaluations have affected outcome statistics. 

Functional capacity evaluation criteria have been based on 

significant job demands. Assessments have progressed to 

include assessment of paramedics applying for placement 

within the prestigious Special Operations Team. This paper 

will present the outcomes that have been achieved by an 

emergency services organisation through the involvement 

of occupational health physiotherapists as part of a multifaceted 

injury prevention program. 



Seven Years in Seven Minutes: 

short summaries of important recent research 





Seven Years in Seven Minutes: short summaries of important recent research 

2 

Seven years in seven minutes: neurology 

Bernhardt J 1, 2 

1 


Institutes), Melbourne 2 La Trobe University, Melbourne 

This very brief presentation will summarise advances 

in science over the past 7 years that are relevant to 

physiotherapists working in the fields of stroke, Parkinson’s 

disease, multiple sclerosis, spinal cord injury and traumatic 

brain injury. Hold onto your hats! 

Injury management after work related injury. 

predicting chronicity and management of acute low 

back pain 

Boland RA 1,2 

1 

The University of Sydney, Sydney 2 Fairfield Hospital, Sydney 

Work-related injury results in a significant burden to 

the community because of days off work and injury 

management costs. The highest costs are associated with 

management of chronic injury, and low back pain is the 

most ‘expensive’ injury to manage. Consequently, delivery 

of effective interventions for acute low back pain would 

be likely to reduce costs associated with time off work 

and injury management. Similarly, early identification 

after injury of workers at risk of delayed recovery might 

assist treatment providers to modify treatment accordingly. 

Workcover NSW has promoted a model of educating 

treatment providers about evidence-based management of 

acute work-related soft tissue injury that includes a strategy 

of early identification of workers at risk of delayed recovery, 

and management with activity-based interventions. Many 

treatment providers justify structured exercise programs 

for such workers to prevent ‘physical deconditioning.’ 

The literature regarding management for low back pain: 

challenges the traditional model for acute management 

of back pain; supports a strategy of early identification of 

workers demonstrating delayed recovery using the Orebro 

Musculoskeletal Pain Questionnaire and argues against 

physical deconditioning as a consequence of low back pain. 

These studies indicate that the general practitioner may 

play a very significant role in the management of acute low 

back pain, and that risk factors for delayed recovery can be 

identified early during the recovery period. However, the 

notion that structured exercises should be routinely applied 

for workers with delayed recovery cannot be justified. 

Seven years in seven minutes: aquatic physiotherapy 

Geytenbeek JM 

Roberts Physiotherapy, Adelaide 

Seven years ago, according to the Cumulative Index of Allied 

Health and Research Literature, the second systematic 

review of hydrotherapy research and practice was published. 

Just as hydrotherapy education in the English speaking 

world in the eighties and nineties was heavily influenced 

by Australian hydrotherapists, the second systematic 

review was an Australian success. Seven years later, the 

Cumulative Index lists a further 10 systematic reviews of 

hydrotherapy and reviews including aquatic physiotherapy 

have grown from 10 to 191. Aquatic physiotherapist 

researchers have been busier, with the list of clinical trials 

published between 1994 and 2001 numbering 57, and 

increasing a further 195 in the subsequent seven years. The 

Australian Physiotherapy Association, through the Aquatic 

Physiotherapy Group, undertook a significant review in 

2008 collating and summarising the evidence-base for 

aquatic physiotherapy practice including 154 publications, 

expanding on the previously recognised bias toward research 

in aquatic physiotherapy for arthritic populations to include 

inquiry in the fields of musculoskeletal, cardiorespiratory, 

women’s health, sports, paediatric and neurologic practice. 

It is evident that research quality has improved. Aquatic 

physiotherapists and purchasers can feel more confident 

that measurable clinical outcomes are achievable. 

Seven year in seven minutes: gerontological 

physiotherapy 

Hill KD 

La Trobe University, Bundoora, Northern Health, Epping, 

National Ageing Research Institute, Parkville 

This presentation will provide a snapshot perspective of 

some of the recent developments across the broad range 

of practice relevant to gerontological physiotherapists, and 

large proportion of other physiotherapists whose practice 

includes treatment of older people. Research developments 

in the areas of falls prevention, hip fracture management, 

vestibular rehabilitation, and exercise to optimise function 

and independence will be presented, including evidence 

from both community and residential care settings. 

Seven years in seven minutes: cardiorespiratory 

physiotherapy 

Holland AE, 1,2 Berney S, 3,5 Berlowitz DJ, 4 Denehy L 5 

1 

La Trobe University, 2 Alfred Health, 3 Austin Health, 4 Institute for 

Breathing and Sleep, 5 The University of Melbourne, Melbourne 

The scope of cardiorespiratory physiotherapy practice 

has broadened over the last seven years, in parallel with 

an emerging literature on the efficacy of exercise-based 

rehabilitation and growing emphasis on community 

management of chronic disease. Evidence that survivors 

of critical illness have persistent functional disability and 

reduced quality of life following discharge from intensive 

care has led to new interest in early whole-body rehabilitation 

coupled with sedation interruption. These strategies are safe 

and increasing data suggest they improve important patient 

and health service outcomes. New studies indicate that 

pulmonary rehabilitation for people with chronic obstructive 

pulmonary disease is effective when delivered during acute 

exacerbations, and is just as successful when delivered at 

home as in the supervised outpatient setting, providing new 

impetus for delivery of rehabilitation in the community. The 

scope of pulmonary rehabilitation has widened to include 

patients that were previously thought to be at risk of adverse 

events during exercise, particularly idiopathic pulmonary 

fibrosis and pulmonary arterial hypertension. Exercise 

training has also become a standard of care for patients 

with chronic heart failure, with mounting evidence that 

this treatment decreases hospitalisation and mortality. Self 

management training for patients with chronic disease, with 

or without exercise interventions, reduces hospitalisation in 

patients with chronic disease and is now a pivotal element 

of many community-based chronic disease programs. The 

robust evidence for exercise-based rehabilitation programs 

across all health care settings suggests that cardiorespiratory 

physiotherapists will have an important role in designing 

and implementing new models for delivering care to our 

ageing population. 


Seven Years in Seven Minutes: short summaries of important recent research 

7 years of paediatric physiotherapy research 

in 7 minutes 

Rose K 

Institute for Neuroscience and Muscle Research, The Children’s 

Hospital, Westmead, NSW and Sydney Medical School, 

The University of Sydney, NSW 

The past 7 years has seen an emergence of high quality 

research in many paediatric physiotherapy sub-specialties, 

which makes the task of selecting which studies to present 

in 7 minutes very challenging. In order to narrow down a 

large body of research the studies presented were subject 

to the following criteria. The studies needed to be of high 

quality and published in a reputable peer reviewed journal 

with a physiotherapist as the principal author of the paper. 

Most importantly, the research needed to have had an impact 

on paediatric physiotherapy practice. The three areas which 

have consistently produced research fulfilling all of the above 

criteria in the 7 years have been in the areas of cerebral palsy, 

plagiocephaly and cystic fibrosis. Research from The Hugh 

Williamson gait laboratory at The Royal Children’s Hospital 

in Melbourne has greatly enhanced our understanding of 

gait biomechanics in cerebral palsy and helped to refine and 

direct management approaches. In particular, the research 

conducted by Jill Rodda has resulted in a classification 

system for spastic diplegic gait which has been used as 

the basis for providing comprehensive recommendations 

and guidelines for management. While the ‘back to sleep’ 

campaign significantly reduced the incidence of sudden 

infant death syndrome; the incidence of deformational 

plagiocephaly (or misshapen head) has increased. A large 

randomised controlled trial conducted in the Netherlands 

has shown physiotherapy intervention is effective in reducing 

the incidence and severity of deformational plagiocephaly. 

Cystic fibrosis has also received much research attention in 

recent years. Physiotherapists seldom have the opportunity 

to have their research published in high impact medical 

journals; however, in 2006 the results of a large, multicentre 

randomised controlled trial of hypertonic saline were 

published in the New England Journal of Medicine with 

physiotherapist, Mark Elkins as the principal author. This 

trial showed hypertonic saline preceded by a bronchodilator 

to be an inexpensive, effective and safe therapy adjunct for 

patients with cystic fibrosis. The addition of hypertonic 

saline to standard physiotherapy regimens is now commonplace 

in many institutions worldwide. This is only a small 

selection of a much wider body of literature which could be 

realistically presented in 7 minutes. The number of choices 

available for presentation is a testament to paediatric 

physiotherapy researchers worldwide. 



Sports Physiotherapy Australia 






Sound practice: reducing injury incidence 

in elite musicians 

Ackerman B 

The aim of this workshop is to focus on particular areas 

of clinical significance when managing injury in elite 

musicians. The assessment aspect of the workshop will 

present an overview of assessments used recently in a 

national orchestral physical assessment program including 

preliminary findings of relevance. The treatment aspects 

of the workshops will focus on effective posture correction 

with instrumental considerations, restoring sensitivity and 

freedom in the distal upper limb, incorporating forearm 

activity in kinetic chain function during musical technique 

and working on exercises to facilitate core and proximal 

upper limb support during movements used in music 

making. 

What’s different about my sport: orchestra? 

Ackerman B 

The aim of the musician session is to highlight the special 

considerations that are required in terms of both injury 

prevention and management when working with elite 

musical performers. Musicians can be considered as athletes, 

requiring approximately 10 000 hours of deliberate practice 

over many years to achieve high proficiency in their chosen 

instrument. The long hours of repetition of specific complex 

motor actions leads to physical adaptations as seen in many 

sports domains. In addition, there are many other special 

considerations that must be assessed when managing a 

musical performer to ensure a positive treatment outcome. 

Poor awareness by the health profession of the specialised 

needs of this group has resulted in a tendency to not 

seek professional medical help at appropriate times and 

consequently these performers suffer an unacceptably high 

rate of injury and disability. Main injury types and return to 

injury considerations will be highlighted. 

Motor learning after motor learning 

Adams R 


A recurring problem in motor learning occurs when a 

new version of an already established motor pattern must 

be learned. This is often due to pain or persistent injury 

associated with the use of the existing version of the motor 

pattern. Despite a persistent effort to replace the previous 

form, often with massed practice trials and conscious 

effort to avoid the former motor pattern, the individual’s 

experience is often one of reversion to the old form in critical 

performance circumstances, or drift toward it over time. 

This session focuses on the Old Way/New Way concept of 

motor skill learning as a solution to the problem of user 

acceptance and choice of the newly acquired form. The 

Old Way / New Way motor learning process is discussed in 

terms of its theoretical and empirical support. 

Eccentric muscle contractions: intracellular ionic and 

cytoskeletal protein changes 

Allen DG, Zhang BT, Whitehead NP 

Bosch Institute and School of Medical Sciences, University of Sydney 

Eccentric muscle contractions cause reduced force 

associated with sarcomere inhomogeneity and membrane 

damage. Another prominent finding is that cytoskeletal 

proteins such as desmin and titin show changes in 

immunoreactivity though the functional consequences of 

these changes are unclear. We show that the changes in 

immunoreactivity of desmin and titin require extracellular 

calcium and can be inhibited by the calpain inhibitor 

leupeptin. These findings support the idea that damage 

to cytoskeletal elements results from calcium-dependent 

activation of calpain. To further explore the Ca 2+ entry 

pathway we have used streptomycin, a blocker of stretch 

activated channels and TRPC1 knock-out mice. Both of 

these interventions reduced cytoskeletal damage suggesting 

that stretch-activated channels, at least partly encoded by 

TRPC1, are part of the Ca 2+ entry pathway. We also show 

that eccentric contractions reduce the passive stiffness of 

the muscles, thought to be a consequence of titin, and that 

this reduction in stiffness is also prevented by streptomycin. 

This demonstrates one functional consequence of eccentric 

contractions on cytoskeletal proteins and suggests that the 

eccentrically-induced damage to cytoskeletal proteins will 

have a role in sarcomere stability. 

Adapting to change: career plasticity 

Allingham C 

Redsok International 

In Darwinian terms, adapting to change is the key ingredient 

for species survival. In fact the phrase ‘survival of the 

fittest’ is more correctly interpreted as ‘survival of the best 

fit’, meaning those who fit best to changing circumstances 

have an increased success and survival rate. Sports 

physiotherapists in Australia have a high level skill base in 

their expertise; we are amongst the best in, if not leading, 

the world in our field. But are we the best fit for a changing 

environment? Recent developments in neuroscience 

have demonstrated a remarkable ability for the human 

brain to not only rewire existing neural pathways, but to 

generate new neural cells and connections in response to 

imposed demands; a property known as ‘plasticity’. To take 

advantage of internal and external changes in our selves and 

our working environments, to seek our ‘best fit’, we must 

individually and collectively respond, rewire and adapt. 

Our career paths must assume plasticity in the interests of 

us, our clients, our markets and the social responsibility of 

providing care to the general population. This presentation 

addresses this concept in the light of one person’s journey 

and a vision of what might come next. 

Predicting the efficacy of prefabricated foot orthoses in 

a patellofemoral pain syndrome population: 

a pilot study 

Barton CJ, 1 Menz HB, 1 Crossley K 2 

1 

La Trobe University, Melbourne, 2 Melbourne University, Melbourne 

Recent evidence indicates prefabricated foot orthoses 

provide similar benefits to physiotherapy in the treatment 

of patellofemoral pain. However, prescription guidelines for 

2 



this heterogeneous population remain unclear. This study 

will recruit 80 individuals diagnosed with patellofemoral 

pain. Participants will be prescribed Vasyli prefabricated 

foot orthoses without concurrent intervention. Foot posture 

index, relaxed calcaneal stance angle (and change in 

calcaneal stance angle with orthoses), change in footwear 

comfort during walking, change in ease of completing 5 

single leg squats, and change in pain during 5 single leg 

squats will be measured prior to prescription. Six weeks 

following prescription, each participant will rate the success 

of their intervention on a Likert scale for patient perceived 

clinical success. Using spearman rho statistical calculations, 

available pilot data (n = 12) indicates the only significant 

correlation with clinical success is change in pain during 

five single leg squats (r = 0.69). Trends for associations 

between enhanced footwear comfort during walking (r 

= 0.40) and ease of single leg squat task completion (r = 

0.55) indicate that present sample size may be insufficient 

to detect significant correlations. No significant correlations 

were found between clinical success and foot posture index 

(r = 0.09), relaxed calcaneal stance angle (r = 0.10), or 

change in relaxed calcaneal stance angle (r =-0.11). These 

preliminary findings indicate foot orthoses prescription 

should be considered in individuals with patellofemoral pain 

regardless of foot posture, and that reducing pain during 5 

single leg squats may be important in predicting efficacy. 

Can published research enable physiotherapists to 

improve lower extremity function with custom 

foot orthoses? 

Baycroft CM 

Foot Science International, Christchurch, New Zealand 

It has been assumed that a beneficial effect on symptoms 

validates the functional efficacy of foot orthoses. This 

assumption may well be fallacious. The findings of scientific 

research on the effects of various types of foot orthoses on 

lower extremity function have invalidated the assumptions 

on which Dr. Root based his biomechanical theory. Current 

evidence invalidates the belief that biomechanical orthotics 

made on a cast of the ‘neutral’ foot and incorporating 

measured posts and other technical adjustments have 

predictable and systematic effects on the kinematics lower 

extremity structures. It is suggested that the mechanical 

effects of foot orthoses are on kinetics (force vectors and 

moments) rather than kinematics and that their effects on 

lower extremity function may be neuromotor rather than 

mechanical. Published studies indicating that foot orthoses 

have widespread effects on the electrical activity of various 

muscles and can also improve balance and postural stability 

have not been practically applied to orthotic prescription 

and assessment. Studies comparing the efficacy of custom 

orthoses and various types of ‘prefabricated orthotics’ have 

questioned the cost-effectiveness of the custom devices 

and indicate that various mass produced products can be 

effectively and easily customised to provide excellent results. 

In this presentation, I will review some of this literature 

and suggest practical ways by which physiotherapists 

can improve their patients’ lower extremity function and 

treatment outcomes. 

Stretching: research findings into the real world 

Blanch P 


My apologies to Shakespeare, but to stretch or not to stretch, 

that is the question. In the last few years the answer to this 

question has gone from ‘Yes, it’s good for what ails ya!’ to 

‘No, when we have done large randomised control trials on 

military recruits the group that stretched had no different 

injury rates to those that did not therefore stretching is of 

no use.’ Of course that is a pedantic view of the literature 

(often quoted in the popular press) and not necessarily the 

whole belief of the researchers. The answer to the question 

is probably a less dogmatic and therefore less fulfilling 

‘Depends.’ Depends on what? Well depends on whether 

you have identified a loss or reduction in range of motion 

is a problem. If it has been identified that loss of ankle 

dorsiflexion ROM is a predisposing factor in injuries and 

you have a patient with poor dorsiflexion, what are your 

choices? It depends on whether for ROM requirements 

there is an optimal window. To swim fast certain shoulder 

flexibility is required, more flexibility does not make you a 

better swimmer but comes with its own set of problems as 

does the lack of range. Stretching those with appropriate or 

excessive range seems to make little sense. It depends on 

whether your sport requires you to be able to aesthetically 

achieve a pike position (divers) or a biomechanically 

efficient hurdle position. It seems pretty clear that stretching 

is not a panacea for all injuries but to not use it as part of a 

reasoned intervention strategy is maybe throwing the baby 

out with the bathwater. How much difference will it make? 

Well, that depends! 

What’s different about my sport: swimming? 

Blanch P 


Swimming fast has come under intense public scrutiny in 

the last few months. There seems to be a public feeling that 

if we could all put on the ‘super suits’ we would all be able 

to move like a dolphin. Certainly the reduction of drag is an 

important concept in swimming fast but there is more to it 

than putting on a suit. The concepts of moving fast through 

water, the musculoskeletal requirements and costs will be 

discussed. 

Where are we on the pendulum from pedant to 

pretender and where should we be? A discussion of 

the clinical implications of evidence 

Blanch P 


People get better, and they don’t always get better for the 

reasons we believe they get better. It is beguiling for clinicians 

and an anathema to scientists to use the ‘patient got better’ 

approach as the footing for creating belief in our evidence 

base. Conversely, there are no randomly controlled double 

blinded trials (the holy grail of scientists and an item of idle 

curiosity and amusement for clinicians) to demonstrate that 

adherence to an evidence based philosophy in physiotherapy 

practice is significantly better than an empathetic approach 

with and a strong belief in what the practitioner is doing. Do 

these paradoxes ensure that those who want the evidence 

chase their tails in tighter and tighter circles until they 



disappear and the believers break out the crystals and 

snake oil? Perhaps rather than being at different ends of a 

spectrum most of us are more towards the middle, but within 

ourselves are often paradoxical. We will frequently use the 

‘no evidence’ sword when talking of practices we don’t use 

and vehemently protect with the ‘clinical art’ shield those 

practices of our own that we believe to be highly effective. 

Now after using derivations of the word belief five times 

in six sentences, perhaps we need to include this in our 

examination of the evidence and practice. What we believe, 

what our patients believe and what we can convince them 

to believe are all powerful contributors to a positive clinical 

outcome in the often not so black and white world of ‘it 

hurts when I do this’. 

4 

Do manual muscle tests (maximal isometric 

contractions) isolate shoulder muscle activity? 

Boettcher CE, Ginn KA, Cathers I 


The aims of this study were to identify a series of tests that 

could be used to produce maximal activation for muscles 

of the shoulder and to quantify the relative EMG activation 

of these muscles during maximum effort isometric 

contractions. The dominant shoulder of 15 normal subjects 

between the ages of 18 and 50 years was examined. EMG 

activity was recorded from rotator cuff, scapulothoracic, 

and axio/scapulohumeral muscles using a combination of 

surface and intramuscular electrodes. Maximum isometric 

contractions were performed in 15 randomised shoulder 

positions. Maxima of rectified and low pass filtered (8th 

order, 3Hz) EMG were determined for all muscles during 

all test positions. Repeated measure ANOVAs were used 

to compare the activity level in all the muscles in all 

test positions. Results indicated that many test positions 

maximally activated many shoulder muscles and no single 

maximum isometric task activated any one muscle in all 

subjects. Isometric contractions in four test positions were 

adequate to reliably generate a maximum contraction from 

all 12 muscles examined, with many tests performed in midrange 

shoulder positions requiring high levels of activity in 

torque producing axio/scapulohumeral muscles as well as in 

muscles that stabilize the humerus and in those that maintain 

the position of the scapula. These results would suggest that 

the use of manual muscle tests to infer individual shoulder 

muscle pathology is not valid. 

Physiocise for medium level core control 

Bouvier AL 

Physiocise 

The Physiocise Circle of Rehab provides a simple 

framework for the assessment and progression of athletes 

as they move through rehabilitation from acute hands-on to 

return to function. The tool was specifically designed as a 

practical clinical tool, derived from the results of evidence 

based research, which facilitated communication between 

clinician and athlete as to status and progression. The 

Circle is based on the integration of evidence based tests 

in increasingly functional positions. There are three broad 

categories: low, medium and high level control. Low level 

failure on testing e.g. aberrant patterning of LMS would 

indicate need for specific LMS retraining with one-on-one 

supervision with their physiotherapist. Mid level failure on 

testing such as in single leg stance would indicate need for 

functional motor control retraining and exercises involving 

lumbopelvic integration and gluteal control in increasingly 

dynamic positions. High level failure such as inability to 

maintain neutral spine in a loaded position such as a squat 

would suggest the need for increased S and C supervision 

and a possible reassessment of program load and technique. 

Athletes may move back and forth through the levels 

depending on factors such as symptoms, training load, 

intensity and fatigue. This session focuses on the type of 

exercises which would be appropriate in the rehabilitation 

and progression of athletes displaying failure in medium 

level control activites. 

New evidence for physical therapies for anterior knee 

pain: a systematic review and meta-analysis 

Collins N, 1 Bisset L, 2,3 Crossley K, 4 Vicenzino B 1 

1 

The University of Queensland, Brisbane, 2 Griffith University, Gold 

Coast, 3 Royal Brisbane and Women’s Hospital, Brisbane, 4 The 


While a variety of physical therapy interventions have been 

advocated for anterior knee pain, it remains one of the most 

challenging musculoskeletal conditions managed by sports 

physiotherapists. In light of recent publications since the last 

published systematic review (2003), an updated systematic 

review and meta-analysis was conducted of the evidence for 

physical therapies in anterior knee pain. A highly sensitive 

search strategy yielded 42 randomised controlled trials, 

whose methodological quality rated between 2–13 out of 

14 on a modified version of the PEDro rating scale. Studies 

were grouped based on their primary intervention of interest 

(multimodal physiotherapy, exercise, manual techniques, 

knee braces, foot orthoses, tape, electrotherapy and 

acupuncture). Follow-up times were predominantly within 

3 months. Up to date findings of meta-analyses will be 

presented. The best evidence from individual studies is for 

multimodal physiotherapy (quadriceps muscle retraining, 

patellofemoral joint mobilisation and patellar taping). There 

is new evidence from a 12-month randomised controlled 

trial (n = 179) supporting the use of prefabricated foot 

orthoses. Moderate evidence was also found in favour of 

patellar taping and a specialised knee brace. This updated 

systematic review has found increasing evidence to support 

physical therapies for anterior knee pain, which highlights 

the fundamental role of sports physiotherapists in its 

management. However, more clinical trials incorporating 

larger participant numbers, longer follow-up times, and 

more consistent use of reliable and valid outcome measures 

are needed to provide further high-level evidence and 

more opportunities for meta-analysis for conservative 

interventions for anterior knee pain. 

Management of anterior knee pain: local contributors 

Crossley KM 

University of Melbourne, Victoria, Australia, National ICT Australia, 

Victoria, Australia 

The vastus medialis obliquus (VMO) is considered to be 

implicated in patellofemoral joint dysfunction and pain. As 

such, many physiotherapy interventions have focused on 

VMO retraining as part of a rehabilitation program. Research 

has identified a relationship between vasti dysfunction 

and patellofemoral pain. However, conjecture over the 

relationship between vasti dysfunction and PFP remains. 



The disparity in the evidence may be attributed to a number 

of factors, but a likely explanation is that the aetiology of 

patellofemoral pain is multi-factorial. Individuals with vasti 

dysfunction may comprise a subgroup in the entire cohort 

of individuals with PFP. While generalised quadriceps 

strengthening is effective in reducing patellofemoral 

pain, the subset of individuals with vasti dysfunction may 

require specific retraining of the vasti. This is especially 

the scenario for those with recalcitrant or recurrent 

symptoms. Vasti re-training follows the usual guidelines 

for motor retraining programs and has been shown to be 

efficacious in the management of patellofemoral joint 

dysfunction when combined with other therapies (patellar 

taping, hip muscle training and mobilisation). Furthermore, 

this combined intervention can improve the onset of VMO 

activity. Patellar taping involves applying adhesive, rigid, 

strapping tape to glide, tilt, and/or rotate the patella. Patellar 

taping has significant and clinically meaningful immediate 

effects on reducing patellofemoral pain. A systematic 

review and meta-analysis conducted by our research group, 

determined that medially-directed tape decreased pain in 

people with PFP by 14.7 mm (-22.8 mm to -6.9 mm) on a 

100 mm visual analogue scale, when compared to no tape. 

Importantly, patients can be taught to self-tape, increasing 

their responsibility in management. Despite the significant 

immediate effects of taping on patellofemoral pain, the 

mechanisms behind the pain relief remain unclear. Proposed 

taping effects include: changes in patellar alignment; 

improvements in quadriceps function; improvements in the 

onset or magnitude of vasti EMG activity; improvements 

in proprioception. Furthermore, the longer term effects 

of using patellar taping as an adjunct to physical therapy 

programs have been evaluated in clinical trials and the 

results are conflicting. Based on the available evidence, 

taping may be advocated as a pain relieving modality, 

potentially enhancing a patient’s ability to perform painfree 

exercises and/or activities of daily living. 

Leg muscle activation, not lower limb motion or foot 

posture, is different in exercise related leg pain 

Franettovich M, 1,2 Chapman AR, 1,2,3 Blanch P, 2 

Vicenzino B 1 

1 

The University of Queensland, Brisbane, 2 Australian Institute of Sport, 

Canberra, 3 McGill University, Montreal, Canada 

We compared muscle activation, 3-dimensional motion, 

foot posture and foot mobility between individuals with 

and without history of exercise related leg pain (ERLP). 

Fourteen females with ERLP and 14 age, weight and height 

matched control females participated. Electromyographic 

activity (normalised to maximum voluntary contraction, 

MVC) of 12 lower limb muscles and 3-dimensional motion 

analysis of the ankle, knee, hip and pelvis was performed 

during gait, whilst foot posture and foot mobility (difference 

between non-weight bearing and weight bearing posture) 

was measured before and after gait. The ERLP group 

demonstrated lower peak and average activation of gluteus 

medius by 13.7% MVC (95% CI 3.2–24.3, p = 0.01) and 

2.3% MVC (95% CI 0.3–4.3, p = 0.03) compared with 

controls. Lower gluteus medius activation was moderately 

determined (57.1%, p = 0.01) by duration (beta = 0.555) and 

severity of pain (beta = -0.516). Peak and average activation 

of lateral gastrocnemius was also lower than controls by 

20.5% MVC (95% CI 0.6–40.5, p = 0.04) and 1.7% MVC 

(95% CI 0.2–3.1, p = 0.03), but changes were not related 

to pain characteristics. No differences in 3-dimensional 

motion of the lower limb, or differences in foot posture and 

foot mobility were observed between groups (p > 0.05). This 

study provides evidence of altered neuromuscular control 

of gait in females with history of ERLP. Further work is 

required to discern the clinical relevance of this alteration 

and determine clinical interventions most effective in 

addressing these impairments. 

Looking for the right balance: what prevention 

intervention should be considered during the 

menopause transition? 

Fu SS, 1,2 Low Choy NL, 3 Nitz, JC 1 

1 



This study was to investigate the efficacy and long term 

benefits of a balance-strategy training program (BSTP) 

for healthy but less active women during menopause 

transition compared to other common exercise programs 

and whether participation leads to adoption of a more 

active lifestyle. Sixty healthy women were admitted to 

the study and allocated to groups on the basis of their 

activity level. Sedentary subjects attended the BSTP twiceweekly 

for 12 weeks and were compared to women who 

exercised at a moderate to high intensity level. Assessments 

made at baseline, 3, 9 and 24 months included personal 

demographics, HRT medication, activity level, balance 

measures, somatosensory function, ankle flexibility, lower 

limb muscle strength and cardiovascular endurance. The 

BSTP group showed significant improvement in balance 

measures (p < 0.003), tactile acuity (p = 0.027), ankle 

flexibility (p < 0.000), lower limb strength (p < 0.006) 

compared to controls immediately after intervention. At 

follow-up, most improvement had been maintained for the 

BSTP group with continued significant improvement in 

balance (p < 0.05), somatosensory function (p < 0.046) and 

muscle strength (p < 0.046). Cardiovascular endurance also 

significantly improved for the BSTP group (p = 0.000) and 

was now the same as the control group. When compared 

to baseline, women in the BSTP group showed sustained 

weight loss (p < 0.017) while controls showed a steady 

weight gain (2.21 ± 3.90 kg) across the 24 months period. 

These results provide evidence that a physiotherapist 

designed BSTP is as effective as other commonly selfprescribed 

exercise programs in assisting healthier ageing 

across the menopause transition by improving balance and 

sensorimotor function for healthy, but less active women. 

Are vigorous walking and keep-fit activities sufficient 

to improve strength, balance and mobility for middleaged 

women? 

Fu SS, 1,2 Low Choy NL, 3 Nitz, JC 1 

1 



This study investigated balance ability and lower limb 

strength in women aged 40–60 years who self-report 

moderate to high physical activity level compared to those 

who report more sedentary lifestyles. Sixty healthy women 

were admitted to the comparative study. Subjects were 

allocated on the basis of their activity level into sedentary and 

active groups. Assessment included personal demographics, 

HRT use, prescribed medications, activity level, postural 

stability, balance, mobility and lower limb muscle strength 

measures. There was no significance difference between the 



groups for age, height, use of HRT, number of prescribed 

medications or menopausal status (p > 0.05). The mean 

body weight of the active group was significantly lower 

(average 6.1kg lighter) than the sedentary group (p < 0.05). 

There was no significant difference between the groups 

for, postural stability, clinical balance, mobility and lower 

limb strength measures (p > 0.05). These results suggest 

that large gym classes and cardiovascular activities such 

as cycling, running and walking have minimum effect on 

lower limb strength, static balance or functional balance 

ability. More targeted training appears to be indicated to 

improve balance and specific leg muscle strength to achieve 

a desired impact on these risk factors for falls. Thus other 

exercise models for improving balance and fall prevention 

intervention should be considered for improving balance 

ability and strength in women across the 40–60 years age 

period to facilitate healthier ageing and a reduction in the 

falls rate later in life. 

Lisfranc injuries in surf life saving IRB crew personnel 

Gabel CP 


The Lisfranc injury to the foot has been well documented for 

nearly 200 years since first described by Napoleon’s surgeon 

for cavalry riders where the foot was injured by the stirrup. It 

involves the tarso-meta tarsal junction, predominantly TMT 

#2 that can include 1 or all 3 classifications from sprain to 

fracture and dislocation. Published literature recognises that 

significant forces are involved and include vehicle accident, 

falls and some sports, with the presence of a foot fixed 

within a stirrup/binding being a serious predisposing factor. 

The Australian Surf Life Saving movement holds the motto 

of ‘No preventable fatalities between the flags’ and are the 

guardians of the Australian beach providing thousands of 

interventions per years. The IRB (Inflatable Rubber Boat) 

is an integral part of the approach to team rescue and patrol 

and requires a driver and crew. The crew use foot-straps 

for stabilisation of themselves and consequently the boat on 

negotiation of the break and waves. This predisposes the 

right (front) foot on wave impact where the body passes 

over the foot, held within the stirrup, resulting in a forced 

mid-foot dorsi-flexion and potential Lisfranc injury. Case 

presentations of this injury, its mechanism and circumstances 

for IRB crews are presented. Emphasis is placed on early 

diagnosis, early management and the rehabilitation options. 

The clinical pathways are presented, as evidenced by 

delayed recovery from inappropriate early management 

due to misdiagnosis and the consequences of early loading 

versus appropriate management including physiotherapy 

intervention. The IRB is an essential part of the surf life 

saving team approach. The dangers of significant injuries 

that often present as trivial, and are often misdiagnosed, 

can have permanent and life changing effects of individuals 

who have volunteered for a community service. This 

information needs to be disseminated to the associations, 

its members and the therapists and medical teams who treat 

them. This will improve early recognition and diagnosis of 

the injury and assist in ensuring modifications are made to 

the existing protocol and patrol techniques to minimise the 

potential for occurrence of Lisfranc injury. Understanding 

the injury, its mechanism and the severity will enable 

physiotherapists and other health professionals, including 

surf life saving club first aid providers as the first contact 

point, to translate this knowledge to other injury areas and 

6 

ensure improvement of the early diagnosis and appropriate 

management of this potentially debilitating injury. 

Predicting outcome in individual and team athletes 

through technology based bio-psycho-social screening 

and repeated outcome measures 

Gabel CP 

University of the Sunshine Coast, Sunshine Coast, Coolum 

Physiotherapy, Qld 

The ability to predict an athlete’s recovery time and rate with 

a view to return to sport, particularly at the elite level, is a 

common goal for the sports health professional. At present, 

such predictions are approximated through subjective 

opinion, expert knowledge and guidelines from clinical 

pathways based on injury mechanism, region, tissue type, 

severity, pathology and physiology that has been garnered 

over years of clinical practice and continuing education. 

However, such opinions can vary between professions and 

practitioners and are not quantifiable. A new approach, 

integrates bio-psycho-social screening and patient-reported 

outcome (PRO) measures through a technology based 

computer system. This provides a prediction methodology 

that is both accurate and self rectifying by means of a 

real time progress extrapolation feedback loop. This is 

achieved through the use of a decision support software 

program that reflects on statistically analysed test-case 

data using correlation coefficients, regression analysis, and 

mathematical modelling. The real-time status assessment 

ensures both a quantifiable model and motivational tool 

with direct comparison to the immediate past history, 

previous injury recovery with subsequent direct prediction 

of future recovery and competition return. The use of such 

an integrated system with graphical representation of these 

values ensures a common language and visual history that 

is easy to use and provides instant communication between 

all parties-the athlete, medical, coaching, management 

and sponsorship support. This presentation uses case 

examples in both team and individual sports to detail and 

highlight the current level of progress in this technology 

and its future direction. The world of the elite athlete can 

enable specific sports to be through a professional team 

and individual competition. This provides a unique testing 

ground for the ability to forecast recovery time-frames 

for return to sport. However, technology currently plays a 

limited role in the measurement of the sporting individual’s 

status and the prediction of return to sport and competition. 

This presentation brings to light the area of interactive 

software that facilitates and quantifies this process which in 

turn drives the decision pathway for both rehabilitation and 

sporting endeavour. 

Low back pain is associated with changes in multifidus 

muscle size in ballet dancers 

Gildea J, 1,3 Hides J, 1,2 Stanton W, 2 Hodges P 3 

1 

Division of Physiotherapy, The University of Queensland, Brisbane, 

2 

Mater/UQ Back Stability Clinic, Mater Health Services, South 

Brisbane,. 3 Centre of Clinical Research Excellence – Spinal Pain, 

Injury and Health, School of Health and Rehabilitation Sciences, The 

University of Queensland, Brisbane. 

Low back pain is a common chronic condition seen in ballet 

dancers. The aim of this study was to investigate, using 

Magnetic Resonance Imaging, the size of the multifidus 

muscle among ballet dancers with and without low back 



pain. In the non-athletic population, people with a history 

of low back pain have been shown to demonstrate selective 

atrophy of the multifidus muscle. Participants in the current 

investigation were 31 professional Australian ballet dancers 

(14 males). Subjects were divided into 3 groups, including 

those with current low back pain, those with a history of 

low back pain and those who have never had low back pain. 

Magnetic resonance images of the multifidus muscle were 

obtained at 4 lumbar vertebral levels in the transverse plane. 

Results showed that the size of the multifidus muscles at 

the L2–L4 vertebral levels was smaller in the dancers 

from the 2 low back pain groups than in dancers who 

have never experienced low back pain (p < 0.05). These 

results highlight that despite functioning at high levels, 

deficits in the multifidus muscle may exist in professional 

dancers with low back pain. In non-athletes, atrophy of 

the multifidus muscle has been shown to be reversible with 

specific retraining. Increase in multifidus muscle size was 

commensurate with decreased pain levels and decreased 

disability. Future clinical trials could determine whether 

specific training can influence multifidus muscle size 

and decrease low back pain and disability levels in ballet 

dancers. 

Are rotator cuff muscles functioning to stabilise the 

shoulder joint during isometric flexion, extension and 

rotation contractions? 

Ginn KA, Boettcher CE, Cathers I 


The aim of this study was to examine the relative levels of 

activation in the rotator cuff (supraspinatus, infraspinatus, 

subscapularis) and axio/scapulohumeral muscles (deltoid, 

pectoralis major, latissimus dorsi) during flexion/extension 

and internal/external rotation contractions. EMG activity 

was recorded from the dominant shoulder of 15 normal 

subjects using a combination of surface and intramuscular 

electrodes. Collected data was rectified and low pass 

filtered (8th order, 3Hz) then normalised to a standard set of 

maximum isometric contractions to determine the relative 

levels of activation for each of the muscles examined. 

Results indicated that during both flexion/extension 

and internal/external rotation contractions anterior and 

posterior rotator cuff muscles did not co-contract but were 

activated reciprocally. During rotation contractions, both 

with the arm by the side and in 90° abduction, the rotator 

cuff muscles were activated as major torque producers 

with subscapularis activated during internal rotation and 

infraspinatus and supraspinatus activated during external 

rotation. During flexion and extension contractions the 

rotator cuff muscles were activated at levels comparable 

to those generated during maximum rotation contractions. 

The anterior cuff was significantly more highly activated 

than the posterior cuff during extension and the posterior 

cuff more highly activated during flexion, presumably to 

provide anteroposterior stability to the shoulder joint. The 

results of these studies indicate that the rotator cuff muscles 

do not always act as global stabilizers at the shoulder joint 

but change their contraction pattern and functional role 

dependent on the required shoulder task. 

The young athlete with intra-articular hip pathology: 

assessment and implications for management 

Grimaldi A 


The young athlete with deep anterior hip pain is often 

a clinical challenge for the physiotherapist. While 

determination of the exact source of pain may be difficult 

in a clinical assessment, determination of the mechanisms 

which may be predisposing the athlete to dysfunction are 

perhaps the key for long term successful management and 

identification of ‘at-risk’ athletes. Bony morphology such 

as acetabular shape and orientation, head neck shape, neck 

shaft angle, and femoral version can significantly effect 

joint or muscle function and increase risk of developing 

joint pathology. Integrity of the capsulo-ligamentous 

system and the labrum are also vital for joint health. Muscle 

dysfunction may have a direct impact on capsular tension, 

or on joint loading via relative orientation of the pelvis and 

femur against the forces of gravity. This presentation will 

cover assessment techniques for the hip joint, including 

what to look for in X-rays and MRI, clinical tests, and 

the use of real time ultrasound. The implications of this 

information for the management of the athlete with, or at 

risk of developing, joint pathology will also be discussed. 

A comparison of two methods for calculation of vertical 

leg stiffness during hopping 

Gupta A, 1,2 Purdam C, 3 Cook J, 4 Allison GT 5 

1 

La Trobe University, Melbourne, 2 Australian Institute of Sport, 

Canberra, 3 University of Sydney, Sydney, 4 Deakin University, 

Melbourne, 5 Curtin University & Royal Perth Hospital, Perth 

The purpose of this investigation was to compare a gold 

standard method of calculating vertical leg stiffness (kL) 

during hopping to a field test (FT) developed based on 

the model of a spring-mass model oscillating in simple 

harmonic motion. Nine subjects performed double-leg (DL) 

and alternate-leg (AL) hopping tasks on flat and decline 

surfaces at 2 frequencies (self-selected and 1.8 Hz). Peak 

vertical ground reaction force (Fmax) and height change 

during the first half of contact (hc) were derived from 

forceplate data. The FT uses flight (Tf) and contact (Tc) 

times to determine Fmax (Fmax = (Mg.π/2)(Tf/Tc + 1)) 

and hc (Fmax/M(Tc2/π2) + gTc2/8) where M is body mass 

and g is gravitational acceleration (9.81m/s2). Comparison 

of methods for calculation of Fmax, hc and kL for the 8 

tasks revealed the main difference in values being due to 

the task being either bipedal or unipedal. Although there 

was a strong correlation (Pearson’s r = 0.9) comparing 

the two methods for calculation of kL, the FT method led 

to an overestimation of Fmax for AL (1.7 times M) and 

underestimation in DL (0.6 times M) tasks. Similarly hc 

was overestimated for all tasks and 2.6 times greater for 

AL than DL tasks. Stiffness was underestimated by 47.1% 

(DL) and 18.3% (AL) with a significant difference (p < 

0.001) between DL and AL tasks for the FT method. The 

FT method provides an accurate value for kL if the nature 

of the task is considered. 



8 

Comparison of patellar tendon mechanical properties 

in jumping and non-jumping elite athletes 

Gupta A, 1,2,3 Purdam C, 3 Cook J, 4 Allison GT 5 

1 

La Trobe University, Melbourne, 2 Australian Institute of Sport, 

Canberra, 3 University of Sydney, Sydney, 4 Deakin University, 

Melbourne, 5 Curtin University & Royal Perth Hospital, Perth 

The purpose of this investigation was to determine the interside 

and group differences in patellar tendon (PT) mechanical 

properties of elite athletes. Fifty-one elite athletes: 18 male 

volleyballers (MVB), 13 male basketballers (MBB), 14 

female basketballers (FBB) and 6 swimmers (SW) with 

normal healthy tendons were recruited. Calculation of PT 

force and mechanical properties (stiffness, strain, stress 

and modulus) were made following in vivo ultrasound 

measurement of PT elongation and, cross-sectional area 

with knee extension moment. Two-way repeated ANOVA 

revealed no inter-side difference in variables in jumping 

athletes while SW had less PT stress on the left than right 

(21.2 (4.7) V 25.3 (5.6) MPa) (p < 0.02) with a trend (p = 

0.05) to be weaker on the left than right by 14. 6%. Between 

group comparison demonstrated MVB to experience greater 

PT stress than FBB (22.4 (7.6) v 15.5 (4.2) MPa) (p = 0.03). 

Groups were stratified by preferred landing and jumping leg 

and independent t-tests performed. This revealed that on 

the left side of MVB, those that prefer to land on their left 

leg had a lower PT stiffness than those who prefer to land 

on their right leg (p < 0.03). This may demonstrate a sport 

specific adaptive response in elite MVB based on landing 

leg preference when PT mechanical properties in jumping 

athletes are symmetrical. The PT may exhibit a strategy for 

maintaining a similar behaviour under load for all athletes 

regardless of the function to which the PT is exposed. 

Examination and sub-grouping towards better 

outcomes in low back pain treatment: who will respond 

to what and how to identify them 

Hancock MJ 

Back Pain Research Group, University of Sydney, Sydney 

Identifying subgroups of patients who respond best to 

specific physiotherapy treatments has the potential to 

advance the profession and improve outcomes for patients. 

In low back pain and some other musculoskeletal conditions 

it is not possible to identify an anatomical or pathological 

diagnosis for the majority of patients, resulting in the term 

non specific low back pain being used. The problem is that 

the majority of treatments for non specific low back pain 

investigated in randomised controlled trials and systematic 

reviews have been shown to have either no effect or small 

effects. Some researchers and clinicians argue that patients 

with non specific low back pain are heterogeneous and 

if we can match the right treatments to the right patients 

the outcomes will be much better. Recently there have 

been several papers published attempting to identify 

subgroups of patients who respond to best to specific 

treatment approaches but many of these have been of poor 

quality and lack external validation. This presentation will 

describe some of the different approaches used to identify 

sub groups of patients with low back pain and some of the 

current findings. Key points to help readers of this literature 

critically appraise the quality of studies investigating 

subgroups will be covered. 

Psoas and quadratus lumborum muscle asymmetry 

among elite Australian football league players 

Hides J, 1,2 Fan T, 1,2 Stanton W, 2 Stanton P, 3 McMahon K, 4 

Wilson S 5 

1 

Division of Physiotherapy, School of Health and Rehabilitation 

Sciences, The University of Queensland, Brisbane, 2 Mater/ UQ Back 

Stability Clinic, Mater Health Services, South Brisbane, 3 Brisbane 

Lions AFC, Brisbane, 4 Centre for Magnetic Resonance, The University 

of Queensland, Brisbane, 5 School of IT and Electrical Engineering, The 


The objective of this study was to determine if asymmetry 

relative to the preferred kicking leg exists for the psoas 

and quadratus lumborum muscles among elite Australian 

Football League players. Magnetic Resonance Imaging was 

used to investigate the cross-sectional areas of the psoas and 

quadratus lumborum muscles taken at the L4-5 and L3-4 

vertebral levels respectively. Measurements were taken at 

the start of pre-season (n = 36), end of season (n = 31) and 

end of pre-season training (n = 43) from a total of 54 players 

who were eligible for study participation. At the end of the 

playing season the largest group of players had sustained 

3 or more current injuries (25.8%). The amount of muscle 

asymmetry was similar at all 3 time points with the cross 

sectional area of the psoas muscle significantly greater 

ipsilateral to the kicking leg while the cross sectional area 

of the quadratus lumborum muscle was significantly greater 

on the side contralateral to the kicking leg. Asymmetry in 

muscle size was not related to number of injuries. 

Effect of motor control re-training on young elite 

cricketers with low back pain 

Hides J, 1,2 Stanton W, 2 McMahon,S 3 Wilson S, 4 Sims K, 3,1 

Freke M, 5 Richardson C1 

1 


2 

Mater/UQ Back Stability Clinic, Mater Health Services, South 

Brisbane, 3 Commonwealth Bank Centre of Excellence, Brisbane, 

4 

School of IT and Electrical Engineering, The University of 

Queensland, Brisbane, 5 Physiotherapy department, Second Health 

Support Battalion, Gallipoli Barracks, Enoggera, Brisbane. 

The incidence of low back pain among Australian cricketers 

is 8% and as high as 14% among fast bowlers. The aim of 

this study was to investigate, using MRI and ultrasound 

imaging, the size, symmetry and motor control of trunk 

muscles in elite cricketers with and without low back pain 

and to document the effect of a staged stabilisation training 

program. Results showed that the quadratus lumborum 

and lumbar erector spinae muscles were larger ipsilateral 

to the dominant arm in the cricketers studied, and the 

internal oblique muscle was larger on the contralateral side. 

Cricketers with LBP showed a reduced ability to draw-in the 

abdominal wall and decreased size of the multifidus muscle 

at the L5 vertebral level. In response to rehabilitation, 

the cross-sectional area of the multifidus muscles at the 

L5 vertebral level increased (p = 0.004) and the amount 

of multifidus muscle asymmetry among those with low 

back pain significantly decreased (p = 0.029) and became 

comparable to cricketers without low back pain. Following 

rehabilitation, cricketers with low back pain were also 

better able to draw in the abdominal wall and there was a 

50% decrease in the mean reported pain level. This study 

provides new insights into trunk muscle size and function 

in elite cricketers, and evidence of impaired motor control 

in elite cricketers with low back pain. Rehabilitation using 

a motor control approach was shown to be effective for elite 

cricketers with low back pain. 



Fun postcard and poster designs for conveying 

research conclusions in a novel and succinct way to 

busy staff and/or patients/patrons 

Hilton DJ 

Basic Statistical Consultancy 

Knowledge brokering customises information delivery to 

select stakeholder groups considering individual needs and 

other contextual factors. Printed postcards were invented 

in the pioneer era in Paris and have desirable attributes for 

conveying information including low production costs, they 

summarise succinctly and precisely a simple message and 

hence are often used in campaigns such as cancer council 

messages (antismoking) and transport accident commission 

(driving safely) campaigns. The synthesis of freely available 

research results from the Cochrane Library or Physiotherapy 

Evidence Database (PEDro) website related to physical 

activity onto posters or postcards is a targeted and novel way 

to reach groups who may not read purely informational type 

summaries for reasons such as unavailability of computer 

facilities, financial constraints, time and/or motivation. A 

pilot study of one hundred oversized postcards for women 

incorporating systemic review information on exercise 

and the impact on cardiovascular disease risk factors 

were created and distributed to gyms, swim schools, 

physiotherapists, fitness instructors and others to assess 

acceptability and general interest. This initial trial that 

included various select locations and individuals resulted 

in postcards either being displayed on notice boards or left 

in folders at physiotherapy, fitness centre or swim school 

reception counters for people to use or view. The second 

design related to exercise and having evidence-based 

physiotherapy informational summaries readily available 

is explained in this presentation. In conclusion picture 

postcards or posters incorporating summaries of evidence 

are simple to produce and hence potentially are a novel 

way to convey information and potentially modify exercise 

behaviour. 

NSW/Australian literature/dataset review comparing 

rugby union and league spinal injury incidence rate or 

odds ratios and scrum law sequence changes 

Hilton DJ 

Basic Statistical Consultancy 

A review and re-analysis of data reported in NSW and 

Australian literature that documented and compared spinal 

injury rates in rugby union and league was performed 

to enhance the understanding of scrum laws and other 

contributing factors on injury rates. Scrummage is a pivotal 

tactical phase of play yet is hazardous along with tackles, 

rucks and mauls and the absence of scrum injuries in league 

after 1996 when scrums stopped being contested supports 

this. Spinal injuries in union lessened significantly from 

1984–94 possibly related to phased scrum engagement 

sequence rule changes and later on due to the touch 

instruction elimination from the sequence however reports 

state the forceful scrum engagement returned. This analysis 

identified union to league incidence rate ratios as reported 

in the manuscripts and involved subsequent verification of 

statistics using the Centre for Evidence Based Medicine 

Statistical Calculator. If not originally calculated incidence 

rate or odds ratios were equated using injury cases and 

participant numbers. NSW data including claims, Australian 

Spinal Cord Injury Register and spinal unit data reported 

ratios comparing union to league injuries ranging from 1.3– 

4.0 with verification performed. Reanalysis of data from 6 

Australian spinal cord injury units resulted in odds ratio 

estimation from 1.7–2.5. Two AIHW published reports were 

identified and for one report the calculated ratio was 2.1. 

The International Rugby Board in 2007 introduced a new 

scrum law sequence change aimed to reduce the incidence 

of injuries and benefit likelihood is predicted and has 

been documented yet ongoing evaluation will substantiate 

benefit. 

Practical assessment of the footballer with groin pain 

Hogan A 

Given the ongoing unavailability of a ‘gold standard’ 

investigation for groin pain (hip joint-related groin pain 

excluded), sports physiotherapists are very reliant on the use 

of groin pain provocation tests in their clinical assessment 

and related clinical reasoning. A number of groin pain 

provocation tests have been described including the squeeze 

test and various pubic stress tests. This practical workshop 

will focus on the technical aspects of performing groin 

pain provocation tests. Particular emphasis will be given to: 

optimal handling, common handling errors, problem solving 

‘false positives’ and ‘false negatives’, interpretation of pain 

response, comparison of pubic stress tests, the role of these 

tests in reassessment and monitoring. This workshop should 

appeal to sports physiotherapists who are not familiar with, 

or have not used, groin pain provocation tests. Likewise, 

sports physiotherapists who have considerable experience 

with these tests will appreciate being updated with the latest 

developments. The workshop will conclude with a brief 

introduction to the role of dynamometry in the assessment 

of hip muscle strength. This demonstration will include 

a description of available equipment, advantages and 

limitations of current testing procedures. 

Managing a footballer with a challenging case 

of groin pain 

Hogan A, Turner A, Grimaldi A 

One of the great clinical challenges for a sports 

physiotherapist arises when a footballer presents, midseason, 

with multi-component groin pain significant 

enough to inhibit his capacity to run at the level required for 

competitive participation. One of the more common clinical 

presentations is bilateral groin pain assessed to have a pubicrelated 

component combined with unilateral adductorrelated 

and hip-related components. Case study: a 24 year 

old male professional footballer presents with unilateral 

groin pain, consistent with an adductor insertion problem, 

during pre-season training. This problem is successfully 

managed by the team physiotherapist (to regain full painfree 

function and return to unrestricted training and games). 

He is monitored weekly but mid-season experiences a rapid 

recurrence of similar symptoms. Within a few days, the 

groin pain has become bilateral, worse on the previously 

affected side. Clinical assessment and investigations 

indicates the likelihood of combined adductor-related and 

pubic-related components. MRI investigation of the hip joint, 

when compared to previous images, indicates an increase 

in articular cartilage degeneration. There is evidence of a 

small labral tear (unchanged from previous images) but no 

evidence of FAI. Referring to this case study, each presenter 

will address a component for which they have recognised 



clinical expertise. Established and emerging evidence 

for specific assessment and management strategies will 

be considered. Each presentation will describe: exercise 

selection, exercise progression, amendments required to 

accommodate the other components, difference in exercise 

protocol pre and post ‘return to running,’ re-assessment 

and monitoring during the rehabilitation process. The 

rehabilitation of a footballer with multi-component groin 

pain can challenge the clinical knowledge, expertise, 

problem solving skills, and confidence of the managing 

sports physiotherapist. More often that not, successful 

rehabilitation depends as much on, not making inconsistent 

exercise choices, as well as making correct rehabilitation 

decisions. 

A pragmatic randomised trial of stretching before and 

after physical activity to prevent injury and soreness 

Jamtvedt G, 1,2 Herbert RD, 3,4 Flottorp S, 1,5 Odgaard-Jensen 

J, 1 Håvelsrud K, 1 Barratt A, 4 Mathieu E, 4 Burls A, 6 

Oxman AD 1 

1 

Norwegian Knowledge Centre for the Health Services, Oslo, Norway, 

2 

Bergen University College, Norway, 3 The George Institute for 

International Health, Sydney, 4 University of Sydney, 5 University 

of Bergen, Norway, 6 International Network for Knowledge about 

Wellbeing (ThinkWell), University of Oxford, United Kingdom. 

A large, pragmatic randomised trial was conducted to 

determine the effects of stretching before and after physical 

activity on risks of injury and soreness in a community 

population. The trial was internet-based. 2377 adults who 

regularly participated in physical activity were randomised 

to stretch and control groups. Participants in the stretch 

group were asked to perform 30-second static stretches 

of 7 lower limb and trunk muscle groups before and after 

physical activity for 12 weeks. Participants in the control 

group were asked not to stretch. All participants were 

asked to provide weekly on-line reports of outcomes for 

12 weeks. Primary outcomes were any injury to the lower 

limb or back, and bothersome soreness of the legs, buttocks 

or back. Stretching did not produce clinically important or 

statistically significant reductions in all-injury risk (HR 

= 0.97, 95% CI 0.84–1.13), but analysis of a secondary 

outcome found that stretching reduced the risk of injuries 

to muscles, ligaments and tendons (incidence rate of 0.88 

injuries per person-year in the control group and 0.66 

injuries per person-year in the stretch group; HR = 0.75, 

95% CI 0.59–0.96). Stretching also reduced the risk of 

experiencing bothersome soreness (mean risk 32.3% in the 

control group and 24.6% in the stretch group; OR = 0.69, 

95% CI 0.59–0.82). It is concluded that stretching before 

and after physical activity does not appreciably reduce allinjury 

risk, but probably reduces the risk of some injuries, 

and does reduce the risk of bothersome soreness. 

10 

The scapula in shoulder function and dysfunction 

Kibler WB 

Shoulder Center of Kentucky 

The scapula is a key part of normal scapulohumeral rhythm 

to produce normal shoulder function. It allows ball and 

socket shoulder kinematics, is a stable base for muscle 

attachment and optimal activation, and is a key link in 

the kinetic chain. It is attached to the core, is coupled to 

allow force transfer through the shoulder, and its position 

and motion maximizes the distal links. Scapular dyskinesis 

is frequent in association with a wide variety of shoulder 

injuries. It creates a position and motion of protraction, 

which is biomechanically inefficient. Rotator cuff strength 

is only maximized off a stabilized scapula, impingement 

is associated with scapular protraction, and dyskinesis is 

part of the theorized cascade to injury in labral tears. The 

functional problems associated with shortened clavicle 

fractures and high grade A-C separations are due to the loss 

of the strut effect of the clavicle on the scapula, with resulting 

protraction. MDI is associated with altered scapular position. 

Since scapular dyskinesis is so frequently associated with 

shoulder injury, it must be evaluated in all patients with 

shoulder injury. The optimum evaluation sequence is not 

known, but recent research has highlighted several aspects 

of the exam that are promising. Clinical observation can 

be effective in determining the presence or absence of 

dyskinesis. A ‘yes/no’ (medial border prominence present/ 

absent) system of evaluation has a high enough clinical 

sensitivity and positive predictability to be effective in the 

clinical exam. The medial border prominence does signify 

that altered motion in excessive internal rotation is present. 

Corrective manoeuvres, including the Scapular Assistance 

Test (SAT) and Scapular Retraction Test (SRT) are helpful 

in determining the role of scapular dyskinesis in shoulder 

symptoms, and help point the way to specific interventions. 

Specific exercises to improve scapular control by increasing 

muscle activation include the low row, lawn mower, and 

inferior glide. 

GIRD: natural history and clinical effects 

Kibler WB 


GIRD (Glenohumeral Internal Rotation Deficit) is a number 

that reflects altered G-H rotation. It may cause changes 

in G-H kinematics and may be associated with shoulder 

injury. The proposed definitions are side to side difference 

in 25 degrees or total arc of motion difference of greater 

that 25 degrees. One recent report shows that deficits of 

more than 18 degrees are associated with labral injury. 

Bony, capsular, and muscle changes may cause GIRD. The 

kinematic alterations are related to changes in humeral 

rotation, both in cocking and follow through. Posterior 

stiffness also creates a ‘wind up’ of the scapula with arm 

internal rotation. GIRD is dynamic, in that it changes with 

exposure. The exact role of GIRD in shoulder function and 

dysfunction is not completely understood, as is the role of 

interventions to change the number. It may be that GIRD is 

a marker of stress on the shoulder, and its natural history 

can be used to determine how much continued use is safe. 

Scapular muscle detachment: clinical presentation and 

treatment results 

Kibler WB 


Scapular muscle detachment is a recently recognised clinical 

entity. It has a specific clinical presentation and exam. There 

is a history of traumatic injury (50% in a MVA with seat belt 

restraint), with early onset of localised pain (VAS-8.3/10) 

and functional limitation especially in forward flexion. The 

symptoms are decreased with corrective manoeuvres (SAT 

and SRT). Imaging has not been found to be beneficial. 

Surgical treatment includes mobilisation of the detached 



lower trapezius and rhomboids and reattachment through 

drill holes to the scapula. Results are encouraging, with 

good early pain relief (VAS-1.7 at 6 weeks post op). Muscle 

strength return is usually longer (around 4–6 months) due 

to the long time between injury and treatment. The exact 

incidence is not known, but it is suspected to be fairly 

high. 

What is different about my sport: tennis? 

Kibler WB 


Tennis serve motions are dependent on effective efficient 

kinetic chains. There appears to be a gender difference 

in how players develop the serving kinetic chains. Males 

use the ‘push through’ motion, using the back leg to push 

the body and shoulder ‘up and through’ the hitting zone. 

Females use the ‘pull through’ motion, using the trunk to 

pull the arm ‘into’ the hitting zone. The push through motion 

is more efficient, generating more speed and decreasing the 

loads at the shoulder and elbow. These different motions 

can be observed by evaluating ‘nodes’, or biomechanical 

positions and motion that occur in the motion. It may be 

that interventions based on the biomechanical analysis will 

be beneficial in tennis players who demonstrate the less 

efficient motions. 

Freehand 3D ultrasound: a novel method for assessing 

the effect of LASER phototherapy on repair of 

re-ruptured tendo achilles 

Laakso E-L, Barber L 

School of Physiotherapy and Exercise Science, Griffith University, 

Gold Coast 

LASER phototherapy is increasingly used for tissue 

healing. For closed tissue injuries, it is difficult to assess the 

effectiveness and progress of treatment after tendon repair 

and during immobilisation. We describe treatment and 

follow up after LASER applied in a professional stuntman 

with a history of re-rupture and surgical repair of the left 

tendo achilles. We examine the utility of axial B-mode 

ultrasound versus a freehand 3D ultrasound technique as 

a novel method for tracking the progress of tendon healing. 

Treatment consisted of 18 applications of LASER (830nm, 

continuous, 30mW, 0.5J/cm 2 to each of 9 points, increasing 

to 1J/cm 2 to a maximum 21 points) to the site of rupture and 

repair twice per week, over 7 weeks during immobilisation 

in a removable splint. Normal axial B-mode ultrasound 

images were taken at the commencement and completion 

of treatment and at 4 months. 3D ultrasound imaging of 

tendon and gastrocnemius morphology was conducted at 

4, 5 and 18 months. The clinical outcome using LASER 

phototherapy was successful and the patient returned to 

full duties against expectations. B-mode ultrasound images 

demonstrated difficulties (including hypoechoic shadows) 

associated with assessment using conventional 2D imaging. 

3D ultrasound imaging demonstrated decreasing tendon 

volumes associated with tissue remodelling. Achilles 

tendon volume of the unaffected leg was 6.47 ml; and of 

the affected side at 4 months: 38.15 ml, 5 months: 35.58 ml, 

and 18 months: 23.2 ml. The results demonstrated the utility 

of 3D ultrasound in providing morphological information 

and assisting visualisation chronologically and between 

affected and unaffected sides. 

Dynamic cellular response to acupuncture 

needle manipulation 

Langevin HM 

Departments of Neurology, Orthopaedics and Rehabilitation, 

University of Vermont 

Until recently, most research on acupuncture has focused 

on distant effects due to stimulation of sensory nerves and 

the central nervous system. These findings, however, do 

not explain an important aspect of traditional theory which 

postulates that acupuncture has effects via ‘meridians’ that 

interconnect both physical and functional aspects of the 

body. Connective tissue forms a body-wide network that has 

intriguing similarities to the acupuncture meridian network. 

This talk will summarise recent advances in connective 

tissue physiological responses to acupuncture needling and 

their potential relevance to acupuncture’s mechanism of 

action. 

Stretching effect on subcutaneous and deep fasciae: 

in vivo and in vitro research, an alternate explanation 

for the therapeutic effects of muscle stretch 

Langevin HM 

Departments of Neurology, Orthopaedics and Rehabilitation, 

University of Vermont 

In contrast to muscle in which tissue tension is determined 

by both cellular activity and passive tissue biomechanical 

behaviour, connective tissue is generally considered a purely 

passive viscoelastic ‘material’, whose stiffness and damping 

properties are determined by properties of the extracellular 

matrix. Recent evidence suggests that this is not the case, 

and that connective tissue fibroblasts can actively participate 

in the regulation of connective tissue tension under normal 

physiological conditions. The implication of these findings 

is that connective tissue can actively relax when tissue is 

stretched in response to changes in body position. The 

potential significance of such active connective tissue 

relaxation is many-fold: at the local, cellular level, changes 

in tissue ‘prestress’ have been shown to influence a wide 

variety of cellular events ranging from neuronal sprouting 

to angiogenesis, because connective tissue surrounds and 

permeates muscles, increased or decreased connective 

tissue tension may influence range of motion and muscle 

function, and because connective tissue forms a body-wide 

network, connective tissue tension regulation may play an 

active role in the integration of mechanical signals at the 

whole body level. 

Assessment of sacroiliac joint disorders 

Laslett M 




This session will provide an opportunity to explore the 

reliable and validated clinical tests for pain of sacroiliac 

origin. Depending on facilities available at the conference, 

demonstration of procedures and practise of techniques will 

enable participants to identify patients with a sacroiliac joint 

source of lumbosacral pain. Specifically, pain provocation 

stress tests and their variations will be demonstrated (and 

practised if possible) with opportunities for participants to 

resolve diagnostic problems and practical issues surrounding 



their use. For example: how can the tests be modified for 

use with pregnant women (a population with the highest 

proportion of sacroiliac joint pain). The means by which the 

assessment of pain response during a standardised repeated 

movements evaluation can improve the diagnostic accuracy 

of the tests will be explained. The diagnosis of sacroiliac 

joint pain does not automatically suggest an appropriate 

treatment for sacroiliac joint pain, and this session will 

explore how the tests may guide treatment choices. Specific 

sacroiliac provocation tests generate different loads and 

stresses on the pelvic structures, with some stretching the 

sacroiliac ligaments and others compressing the joint. The 

responses to different tests may lead to the prescription 

of stabilising exercises and others will indicate the use of 

rest and other interventions such as intra-articular steroid 

injection. In addition, new tests for diagnosis and treatment 

guidance will be demonstrated. These new tests do not 

currently have adequate evidence in support of their use, 

but are potential objects for future research. 

Assessment of sacroiliac joint disorders: towards the 

development of a clinical prediction rule 

Laslett M 




The sacroiliac joint is undoubtedly an infrequent but 

potential source of lumbosacral, gluteal, hip and referred 

lower extremity pain. There is considerable controversy 

about the role and value of movement asymmetries, 

positional faults and other mechanical anomalies; 

collectively grouped as ‘dysfunctions’-in lower quartile 

pain disorders. Current evidence supports the diagnostic 

value of pain provocation sacroiliac stress tests. They have 

adequate inter-examiner reliability (k > 0.4), and when 3 

or more are positive in any given patient, sensitivity > 90% 

and specificity is close to 80%. When this combination of 

provocation tests is applied in patients whose symptoms 

do not centralise during a repeated movements assessment 

of pain response, false positive responses are reduced and 

specificity rises to 87%. This clinical prediction rule of 3 

or more positive provocation tests and non-centralisation 

has a diagnostic accuracy of 88% and a positive likelihood 

ratio of 7.0 in relation to blinded double intra-articular 

sacroiliac blocks carried out under fluoroscopic guidance. 

The reliability and validity of individual and combinations 

of provocation tests have been replicated in separate studies 

conducted in different countries with different examiners 

and patients, with very similar results. As a consequence, 

the robustness of the construct is reasonably secure. Current 

evidence regarding movement and positional dysfunctions 

has opposite characteristics. Inter-examiner reliability 

is generally poor, and validity has never been examined 

because a credible and readily available reference standard 

is not currently available. However, it is likely that these 

dysfunctions are not related to pain arising from the 

sacroiliac joints. 

Mechanics and biology of skeletal muscle injury 

Lieber RL 




Forced lengthening of skeletal muscles (eccentric contractions) 

produce injury and, ultimately, muscle strengthening. Such 

contractions are common in everyday movements as well 

as sports activities. Because they are mechanically unique 

and have dramatic biological consequences, it is becoming 

increasingly popular to study the mechanics and biology of 

eccentric contraction-induced muscle injury. Current data 

suggest that the earliest events associated with injury are 

mechanical in nature and are based primarily on sarcomere 

strain. Unique biological events such as expression of genes 

and cytoskeletal remodeling are especially prevalent after 

eccentric contraction. Such strain results in relatively rapid 

breakdown or reorganisation of cytoskeletal elements within 

the muscle cell can causes waves of muscle-specific gene 

expression. We have developed animal models of muscle 

injury that mimic the effects seen in humans. In addition, the 

use of muscles with ‘knocked out’ or modified cytoskeletal 

proteins give insights into load bearing and transmission in 

skeletal muscle. Ultimately, an improved understanding of 

the damage mechanism may improve our ability to provide 

rehabilitative and strengthening prescriptions that have a 

rational scientific basis. 

Sports bras: what should we teach our patients? 

McGhee DE, Steele JR 

Biomechanics Research Laboratory, University of Wollongong, 

Wollongong 

Sports bras function as external breast support to limit 

excessive breast motion and its associated exercise-induced 

breast discomfort during physical activity. However, 

research indicates that a minority of females wear sufficient 

breast support during physical activity. This lack of 

support can contribute to upper quadrant musculoskeletal 

symptoms, negatively affect performance in terms of 

upper limb and trunk movement, and inhibit participation 

in physical activity. Adequate breast support depends on a 

female’s breast size, her age and level of physical activity. 

Breast kinematic and kinetic data will be presented to 

highlight factors that must be considered when assessing 

and advising patients on appropriate levels of breast support 

to suit their physical activity needs. The most supportive 

bra design, however, cannot function if it does not fit 

properly. Unfortunately, research suggests that females 

have a poor ability to fit themselves correctly in most 

bra types and are reluctant to use professional bra fitting 

services. Bra fit assessment and patient education will be 

discussed in relation to 2 studies assessing the bra fit, and 

bra wearing and purchasing behaviour of both adolescent 

and adult females. Key assessment criteria of bra fit and 

design for physiotherapists will be summarised, as well as 

practical education to enable you to advise your patients 

to independently choose a comfortable, correctly-fitted, 

supportive bra to wear during exercise. 

12 



Spinal loading in sports 


Curtin University, WA 

It is well known that sports that involve cyclical or sustained 

spinal loading are associated with a higher prevalence of 

low back pain (LBP). Recent research has revealed that 

fast bowlers couple spinal extension, rotation and side 

bending beyond their physiological range prior to front foot 

contact. These bowlers have high rates of spinal pathology 

and LBP. Fast bowlers also present with asymmetry of the 

spinal muscles such as the lumbar multifidus, quadratus 

lumborum and psoas. However neither spinal kinematics, 

bowling action nor muscle asymmetry predicted low back 

pain or pathology in these bowlers, suggesting that factors 

such as training volumes and spinal structural resilience 

may be more important factors. In rowers and cyclists with 

low back pain, the spine is exposed to sustained and cyclical 

flexion loading. Cyclists with low back pain have been 

shown to flex and rotate more in their lower lumbar spine 

than cyclists without LBP suggesting a flexion rotation 

strain mechanism to their pain. Similarly adolescent rowers 

with low back pain spend more time at the end range of 

flexion during the drive phase, also suggesting a flexion 

strain mechanism to their pain. Interventions directed at 

training altered movement patterns and conditioning of the 

back and lower limb muscles within a cognitive framework 

can reduce the incidence of LBP in adolescent rowers. Risk 

factors for LBP in sport are sport specific. These risks may 

relate to technique, training volume, levels of conditioning 

as well as individual motor control deficits. Management 

approaches that are specific and targeted hold hope for the 

athlete with LBP. 

What’s different about my sport: rowing? 


Curtin University, WA 

Rowing is a sport known to result in a high prevalence of 

low back pain (LBP). It involves repeated flexion loading of 

the lumbar spine. LBP in adolescent rowers is very common 

and is commonly associated with flexion sensitivity, passive 

sitting postures, deficits in back and lower limb endurance 

and increased end range flexion loading during the drive 

phase of the rowing stroke, as well as psychosocial factors. 

Interventions that train lumbo-pelvic postural control in 

sitting, squatting and rowing, as well as increasing the 

endurance of the lower limb and back muscles, based on a 

cognitive framework, can reduce LBP in these athletes. 

Generalised joint hypermobility and risk of lower limb 

joint injury during sport: a systematic review 

Pacey V, 1,2 Nicholson LL, 1 Adams R, 1 Munn J, 2 Munns C 2 

1 

The University of Sydney, Sydney; 2 The Children’s Hospital at 

Westmead, Sydney 

A systematic review was performed to determine whether 

individuals with generalised joint hypermobility have an 

increased risk of lower limb joint injury when undertaking 

sporting activities. A search without language restrictions 

of Pubmed, Cinahl, Embase and Sportsdiscus databases 

and subsequent hand searching of reference lists identified 

4841 studies. From inclusion criteria determined prior to 

searching, 18 studies were selected, the methodological 

quality of which ranged from 1/6–5/6. A standardised 

cut-off (Beighton score of ≥ 4/9 or equivalent) to indicate 

generalised joint hypermobility was employed in metaanalyses 

for lower limb, knee and ankle injuries using a 

random effects model. The difference in injury proportions 

between three hypermobility categories was tested with the 

Z-statistic. Using the standardised cut-off, a significantly 

increased risk of knee joint injury for hypermobile and 

extremely hypermobile participants compared to their nonhypermobile 

peers was demonstrated (p < 0.001), whereas 

no increased risk was found for ankle joint injury. For knee 

joint injury, a combined odds ratio of 5.62 (95% CI 1.00– 

31.62, p = 0.05) was calculated, indicating a significantly 

increased risk for hypermobile participants playing football. 

Thus sport participants with generalized joint hypermobility 

who play football have no altered risk of ankle injury 

but do have an increased risk of knee injury. Consistent 

utilisation of measures/criteria used to identify generalised 

joint hypermobility and definitions of injury adopted may 

assist clinicians to provide informed advice to hypermobile 

individuals seeking safe participation in sport. 

How foot orthoses work and how to use that 

information to prescribe them 

Payne C 

Department of Podiatry, LaTrobe University 

Foot orthoses are widely used to treat a whole range of lower 

limb dysfunctions. Excessive pronation of the foot is the 

most common dysfunction that foot orthoses are aimed at. 

However, risk factor studies have shown that there is either no 

relationship or a very weak relationship between excessive 

foot pronation and overuse injury. Laboratory based studies 

have shown mixed results if foot orthoses even affect 

rearfoot motion and if they do, the effects are not systematic 

and are small in magnitude. One study has shown that there 

is no relationship between changes in rearfoot motion and 

changes in clinical symptoms. Despite this paradox, the 

clinical based outcomes studies, patient satisfaction surveys 

and the randomised controlled trials have all shown their 

clinical usefulness. The potential solution to this paradox 

is the kinetic (force) effects of foot orthoses rather than the 

kinematic (motion). Current research is focusing on this. 

This has lead to a re-evaluation of the clinical tests that were 

used for foot orthotic prescription and the introduction of 

new clinical tests to better predict how a foot may function 

kinetically and how to better predict the reduction of the 

kinetic parameters with foot orthoses to reduce clinical 

symptoms. 

Proximal contributions to patellofemoral pain 

Powers CM 

University of Southern California, Los Angeles, CA USA 

Patellofemoral pain remains one of the most common 

lower extremity condition seen in orthopaedic practice. 

Despite its high prevalence however, treatment approaches 

remain highly variable and often lack scientific backing. 

One reason for the lack of consistency in managing 

patellofemoral joint problems is related to the fact that the 

pathomechanics of this disorder remain poorly understood. 

Recent evidence suggests that atypical movements resulting 

from poor proximal control may be a contributing factor. 

The purpose of this talk is to highlight recent research in 



the areas of in-vitro testing, biomechanical evaluation, 

dynamic imaging, and computational modelling that has 

lead to a better understanding of the proximal contributions 

to patellofemoral joint dysfunction. Implications for 

rehabilitation will be discussed. 

14 

Short cuts, potholes and dead-ends: the race against 

nature in injury management 

Purdam C 

Australian Institute of Sport 

In sport, clinicians face an ongoing challenge in returning 

players to train and compete following injury in the shortest 

possible time. New technologies are constantly emerging, 

however expectations of the athlete, coach or clinician are 

not always matched by efficacy. To a certain extent we are 

often constrained simply by nature’s complex sequential 

healing processes. This paper will explore a number of legal 

opportunities and constraints to reducing injury downtime 

using examples drawn from common injuries. The tissue 

sciences continue to provide an increasing sophistication to 

our understanding of tissue adaptation and repair, although 

there are still considerable gaps in our present knowledge. 

In seeking to optimise, or accelerate, normal or abnormal 

healing, practitioners may look to utilise a variety of 

interventions, including pharmaceuticals, growth factors, 

physical modalities and loading regimes. The use of some 

pharmaceuticals, notably anti-inflammatories, probably 

compromise healing in muscle and bone. Growth factors, 

or their inhibitors, although initially attractive, appear to 

be very specific in their effects. New developments may 

be through development and discovery, or alternatively 

as a result of more accurate or innovative uses of current 

treatments such as our loading regimes. Not uncommonly, 

we are faced with a paucity of specific clinical evidence for 

these interventions. Extrapolation from the tissue sciences 

is possible with caution, as applicability may be limited to 

an extent by the cell, animal, stage or method of injury in 

the model utilised. The clinical efficacy and applicability 

of new interventions is currently determined through single 

case and pilot studies progressed to randomised controlled 

trials. Further development is required to more accurately 

accommodate the variability of an individual’s response 

to load, injury and intervention, which in all probability is 

influenced by genetic predisposition. Furthermore, there 

may be attendant risks of an intervention, including longer 

term morbidity, shorter term recurrence or iatrogenic 

complications. The new millennium of sports medicine 

coincides with an information explosion in which innovative 

clinicians and researchers have the potential for some 

exciting breakthroughs, yet as history reminds us, ‘all that 

glitters is not gold’. 

An insight into developing an international 

multidisciplinary sports injury rehabilitation facility 

in the Middle East 

Saretsky M, Mitchell T. 

ASPETAR Orthopaedic and Sports Medicine Hospital, Doha, Qatar 

Qatar is a small Middle Eastern country gifted with 

abundant natural resources that have made it extremely 

wealthy in recent decades. The country is investing this 

newfound wealth to rapidly develop many aspects of 

society, including health. Improving the health of the 

citizens of Qatar through participation in sport is a priority. 

Consequently, a world class medical facility to treat sports 

related injuries and promote sports medicine in Qatar, the 

Middle East and North Africa has been developed. Aspetar is 

the Middle East’s first specialised sports medicine hospital. 

It boasts a range of departments including rehabilitation, 

sports medicine, orthopaedic surgery, sports science, and 

radiology. FIFA accrediting Aspetar as a Medical Centre 

of Excellence is a great achievement for this football proud 

nation. In the same complex is the Aspire Zone (world’s 

largest indoor sports stadium, and host to the 2010 World 

Indoor Athletics Championships). Aspetar rehabilitation 

department has one of the best equipped facilities in the 

world. The staff boasts a mix of 20 different nationalities, 

creating a melting pot of therapy approaches. As well as 

drawing on a range of international experiences to develop 

the rehabilitation department, Aspetar has had to consider 

sports physiotherapy issues specifically relevant to the 

Middle East. These include musculoskeletal effects of 

widespread vitamin D deficiency and a high incidence of 

ACL injuries. This presentation will outline some of the 

unique experiences and challenges encountered in the first 

2 years of developing an international sports physiotherapy 

facility to Western standards in a Middle Eastern culture. 

The unique neurobiology of myofascial pain: 

from peripheral to central sensitisation 

Shah JP 



Most of our scientific knowledge about pain mechanisms 

is derived from studies of cutaneous pain, and incorrectly 

applied to pain of muscular origin. In contrast to cutaneous 

pain, muscle pain causes an aching, cramping pain that is 

difficult to localise and often referred to deep and distant 

somatic tissues; muscle pain activates unique cortical 

structures in the central nervous system, particularly those 

which are associated with the emotional components of pain; 

muscle pain is inhibited more strongly by descending painmodulating 

pathways; and activation of muscle nociceptors 

is much more effective at inducing central sensitisation and 

maladaptive neuroplastic changes in dorsal horn neurons. 

Sensitisation is responsible for the transition from normal to 

aberrant pain perception; that is, when the central nervous 

system experience of pain outlasts the noxious stimulus 

coming from the periphery. There is a biochemical basis to 

the development of peripheral and central sensitisation in 

muscle pain. Continuous activation of muscle nociceptors 

leads to the co-release of substance P and glutamate at the 

pre-synaptic terminals of the dorsal horn and maximal 

opening of calcium-permeable ion channels. Moreover, 

prolonged noxious input may lead to long-term changes in 

gene expression, somatosensory processing and synaptic 

connections in the spinal cord and other higher structures. In 

addition, previously silent synapses may become effective. 

These mechanisms of sensitisation lower the activation 

threshold of afferent nerves and their central terminals, 

allowing them to fire even in response to daily innocuous 

stimuli. Consequently, even non-noxious stimuli such as 

light pressure and muscle movement can cause pain. 



Consistency in size and asymmetry of the psoas major 

muscle among elite footballers 

Stewart S,¹ Stanton W,² Wilson S,³ Hides JA¹,² 

¹School of Health and Rehabilitation Sciences, The University of 

Queensland, Brisbane, ²Mater/UQ Back Stability Clinic, Mater Health 

Services, South Brisbane, ³School of IT and Electrical Engineering, 


Repetition of an asymmetrical activity, such as kicking, 

is known to result in muscle hypertrophy and muscle 

asymmetry. One trunk muscle that is involved in the 

kicking action is the psoas major muscle. Psoas major is 

the only hip flexor muscle that attaches to the lumbar spine. 

The psoas major muscle has been studied in both athletic 

and non-athletic groups, with conflicting results regarding 

the size of the muscle in the presence of low back pain. 

Furthermore, many studies have taken measurements at 

a single spinal level and therefore investigation using a 

multi-level approach is required. The aims of the study 

were to determine the size of the psoas major muscle across 

multiple vertebral levels and document any asymmetry of 

the muscle. A third objective was to determine if there was 

a relationship between the size of the psoas major muscle 

and low back pain. Thirty-one male elite AFL players were 

allocated to either a ‘current low back pain’ group (n = 17) 

or ‘no current low back pain’ group (n = 13). The subjects 

underwent magnetic resonance imaging and muscle size 

was calculated for each subject at 4 pre-determined spinal 

levels. The cross-sectional area of the psoas major muscle 

was larger on the dominant kicking side at all 4 vertebral 

levels (p = 0.01) and was significantly larger in participants 

who reported a current episode of low back pain (p = 0.04). 

Asymmetry of the psoas major muscle is consistent at 

multiple points along the muscle’s length in elite Australian 

Rules football players. 

Assessing the efficacy of a specific physiotherapy 

intervention for the prevention of low back pain in 

female adolescent rowers 

Thorpe A, 1 O’Sullivan P, 1 Burnett A, 1,2 Caneiro JP 1 

1 


2 



This study assessed the efficacy of a specific physiotherapy 

intervention to reduce low back pain (LBP) prevalence and 

associated pain and disability levels in schoolgirl rowers. 

Eighty-two adolescent female rowers aged 13–17years, with 

and without LBP participated in this non-randomised control 

trial. The intervention included: educational session (both 

groups), musculoskeletal screening followed by a specific 

individually prescribed exercise intervention (experimental 

group) and physical conditioning program (both groups). 

Measures of LBP prevalence, pain intensity (visual analogue 

scale) and disability level (modified Oswestry) were 

taken at 4 time points over the rowing season. Secondary 

outcome measures of lower limb flexibility (sit and reach 

test) and endurance (timed squat test) were taken in the 

experimental group. The experimental group demonstrated: 

significant reduction in the prevalence of LBP across the 

season; significant increase in the proportion of pain-free 

subjects at mid-season compared with pre-season (p = 

0.007)-but no changes thereafter (p > 0.05), and reduced 

pain intensity over the season (p ≤ 0.05) compared to the 

control group. In the control group the proportion pain-free 

remained relatively stable across the season (p > 0.2 for 

changes between consecutive times). Levels of disability 

did not differ between groups. Significant improvements in 

lower limb endurance and flexibility were observed in the 

experimental group (p ≤ 0.05). The individually prescribed 

physiotherapy exercise intervention was effective in 

reducing the prevalence of LBP and pain intensity levels in a 

population of schoolgirl rowers during a rowing season. The 

findings of this research contribute to the development of a 

model for the management of LBP in sporting populations. 

Shoulder muscle activation patterns during flexionextension 

exercises 

Wattanaprakornkul D, Ginn KA, Cathers I 


Complex co-ordination of the many muscles of the shoulder 

region is crucial for normal shoulder function and exercises 

designed to improve shoulder muscle co-ordination are 

effective for the treatment of shoulder pain. However, 

normal shoulder muscle recruitment patterns during many 

commonly used shoulder exercises are not known. The aim 

of this study was to determine shoulder muscle recruitment 

patterns during flexion and extension exercises performed 

in prone lying. Activity was recorded from 9 shoulder 

muscles in 15 volunteers using a mixture of surface and 

indwelling electrodes. Four repetitions each of prone 

flexion and extension exercises were performed at 70% of 

each subjects’ maximal load. EMG data was normalised 

to standard maximal voluntary contractions (MVC). Mean 

EMG data for each subject and group mean EMG data 

for each exercise were then calculated. During flexion in 

prone, the posterior rotator cuff muscles (supraspinatus, 

infraspinatus), scapulothoracic muscles (trapezius, serratus 

anterior) and deltoid were recruited at similarly high levels 

of approximately 80% MVC. During extension in prone, 

latissimus dorsi and the anterior rotator cuff (subscapularis) 

were activated at high levels of approximately 100% and 

75% MVC, respectively. Therefore, during flexion and 

extension exercises the rotator cuff muscles demonstrate a 

reciprocal recruitment pattern with high levels of activity in 

the posterior cuff during flexion and high levels of activity 

in the anterior cuff during extension. These results indicate 

that rotator cuff muscles have a role to prevent sagittal plane 

torque producers from destabilising the shoulder joint in the 

anteroposterior direction. 

The effect of whole body vibration on the anterolateral 

abdominal muscles 

Wilkes M, 1 Belavy D, 2 Stanton W, 3 Erceg S, 1 

Toppenberg R, 1 Hides J 1,4 

1 


2 

Zentrum für Muskel-und Knochenforschung, Charité Campus 

Benjamin Franklin, Berlin, Germany, 3 Mater Health Services Brisbane 

Limited, South Brisbane, 4 Mater/UQ Back Stability Clinic, Mater 

Health Services Brisbane Limited, South Brisbane. 

Whole body vibration is currently being incorporated into 

fitness and training programs in gyms and sports clubs, 

and as a therapeutic modality in physiotherapy centres and 

rehabilitation settings. It has been proposed to enhance 

core stability, counteract pelvic instability and stimulate 

the deeper lying postural muscles. However, there is little 

evidence to support its current use in these settings and 

its affect on the deep lying postural muscles. This singleblinded 

repeated measures study aimed to investigate if 



exposure to whole body vibration combined with a closed 

chain weight-bearing exercise affects the transversus 

abdominis muscle in regards to resting tone as indicated 

by muscle thickness and voluntary contraction, measured 

with real-time ultrasound imaging. Twenty normal subjects 

were randomly assigned to either an exercise only group or 

an exercise plus whole body vibration group. Both groups 

performed an isometric, closed chain semi-squat exercise for 

5 minutes, with or without whole body vibration. Ultrasound 

imaging was used to obtain measures of transversus 

abdominis and internal oblique muscle thickness and slide 

of the anterior abdominal fascia, conducted pre-and postexercise 

intervention. The results indicated that whole body 

vibration had an effect on resting tone of the transversus 

abdominis muscle (p < 0.001). Voluntary contraction of the 

muscles was not influenced by five minutes of whole body 

vibration. Whole body vibration moderated the lengthening 

effect of the transversus abdominis muscle. However it 

did not improve voluntary contraction of the transversus 

abdominis muscle, possibly because these normal subjects 

were already able to voluntarily activate the muscle. 

Effects of muscular fatigue on ground reaction forces 

during drop landing 

Wongprasertgan M, 1 Vachalathiti R, 2 Vongsirinavarat M 2 

1 

Faculty of Physical Therapy, Huachiew Chalermprakiet University, 

Thailand, 2 Faculty of Physical Therapy & Applied Movement Science, 

Mahidol University, Thailand 

The purpose of this study was to investigate the effect of 

lower extremity muscular fatigue on ground reaction forces 

and time to peak forces during a single-leg drop landing. The 

positions of ankle, knee and hip joints were also investigated. 

The subjects in this study were 30 healthy males (age 20.87 

± 1.93 years) without history of lower extremity problems. 

The exercise protocol for single leg jumping in 4 directions 

was used to induce lower extremity muscle fatigue of the 

right leg. Subjects performed drop landing from a 45 cm. 

height wooden chair. Three video cameras with 100 Hz 

sampling frequency were used to detect lower extremity 

joint positions. The forceplate was used to determine 

ground reaction forces. The results showed significant 

increase in knee joint flexion (1.74° ± 0.78°) (p < 0.05), 

ankle dorsiflexion (2.75° ± 0.44°) (p < 0.05) at initial foot 

contact, maximum hip flexion (4.79° ± 3.77°) (p < 0.05) and 

maximum knee flexion (6.57° ± 1.54°) (p < 0.05) during 

drop landing tasks when LE muscular fatigued. There were 

increases in peak vertical ground reaction force (0.36 ± 

0.19 times of body weight) (p < 0.05), peak lateral ground 

reaction force (0.08 ± 0.01 times of body weight) (p < 0.05), 

peak anterior ground reaction force (0.16 ± 0.02 times of 

body weight) (p < 0.05) and decreases in time to peak 

vertical ground reaction forces (6.38 ± 2.14 ms) (p < 0.05) 

following muscular fatigue. However, muscular fatigue did 

not significantly affect the LE joint positions at peak vertical 

ground reaction force. In conclusion, muscular fatigue had 

increased ground reaction forces in both vertical and shear 

forces and decreased time to peak vertical ground reaction 

force during landing, which may increase LE loading, and 

risk of LE injury. 

16

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