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With the next Journal just around the corner, the current issue still offers plenty of top-quality research to guide your clinical practice. 


Distal radius fracture is the most common fracture in adults, with a predicted increase in incidence and costs. Sue Reid participates in a Q&A on research into adding mobilisation with movement to range of motion exercises and advice providing better outcomes.

The distal radius is a common fracture site. What is the usual  management?

Distal radius fractures account for approximately 20 per cent of adult fractures. There is an anticipated increase in incidence of 20 per cent by 2028 and 60 per cent by 2051 compared to 2018 in Australians over 35 years of age (International Osteoporosis Foundation 2017, Silman 2003).

The increase in incidence and subsequent costs is concerning because best management (what rehabilitation, for how long and by whom) has not been established (Handoll & Elliott 2015). Normally these fractures are treated with range of motion exercises and advice—but we wanted to see if we could improve management of this common condition by physiotherapists.

What physiotherapy interventions did you compare in your clinical trial?

All participants performed upper limb range of motion exercises twice daily at home. They were provided advice about swelling control and gradually increasing use of the upper limb during activities of daily living. The experimental group also received a mobilisation with movement (MWM) (six to 20 reps per session) to improve forearm supination and another MWM to improve extension at the wrist. The physiotherapist also instructed the participant to self- administer the MWM into supination and wrist extension (six reps) twice daily.

What is the theory behind ‘mobilisation with movement’? How is it purported to affect joint range of movement?

The theory behind MWM is speculative at best. While our study was not designed to answer this question, there are some interesting insights to be gained. In our study, there were several inadvertent differences between the groups, which were largely due to the nature of the MWM. For example, the MWM group performed at least 300 more extensions and 300 more supination movements— and had a focus on pain relief with this movement over the four weeks.

In addition, the MWM group most likely had more manual contact of their injured wrist. How the MWM provides pain relief is unknown—it is likely related to sufficient afferent input stimulating endogenous mechanisms that favour the patient experiencing less pain with movement. These endogenous mechanisms are likely multifaceted and more intricate than the positional fault hypothesis proposed by Mulligan, and often promulgated in the teaching of MWM techniques.

For how long were the interventions applied in your study, and for how long after the interventions did you continue to follow up participants?

All participants in both intervention groups received four physiotherapy consultations over four weeks. Physical measures and participant ratings of pain and disability (wrist-related activity limitations) were assessed at baseline, week four (immediately after the course of treatment) and week 12. Participant- rated outcomes were also recorded at weeks 26 and 52.

Which outcomes showed greater improvement when mobilisation with movement was added to the exercises and advice?

Compared with the control group, the primary outcome of forearm supination was greater in the MWM group by 12 degress (95% CI 5 to 20) at four weeks and eight degrees (95% CI 1 to at 12 weeks. Although the addition of MWM produced a moderate effect on supination at four weeks and the 12-degree difference between groups exceeds the MCID of 8 degrees, the confidence interval around this estimate spans the MCID, indicating that there is some uncertainty about whether the true average effect of MWM on this outcome is large enough to be clinically worthwhile.

There was still a moderate effect at 12 weeks with the 8-degree difference between groups equalling the MCID, and with the confidence interval not excluding the possibility of a trivial effect. Adding MWM also caused moderate to large improvements in wrist extension and flexion range at both four and 12 weeks.

The abbreviated disabilities of the arm, shoulder and hand questionnaire (QuickDASH) showed benefits for the MWM group; there was less disability than the control group at four and 12 weeks. Pain and function with upper limb tasks were improved on the total patient-rated wrist evaluation (PRWE) in the MWM group at four weeks.

Participants were more likely to report that they were ‘improved’ on a global rating of change scale at four weeks if in the experimental group. The improvement in function was also evident in tests of difficulty pouring where MWM increased the likelihood that participants could pour into supination and into pronation without difficulty at both four and 12 weeks by between 12 per cent and 19 per cent.

What about in the longer term?

We did not test any of the physical measures such as range of motion or pouring ability after 12 weeks. With the participant-rated questionnaires there were no clear differences between groups at 26 and 52 weeks.

Do you think these benefits are worth the extra time and trouble of undertaking the mobilisations with movement?

Common impairments reported after a distal radius fracture are limited wrist range of motion, especially into supination and extension, which could be due to the immobilisation position as well as the injury itself. At the time of the fracture, 48 per cent of participants in our study were still employed and 40 per cent fractured their dominant hand.

This injury could have major implications on ability to work and participate in sport and usual physical activity, so a quicker return of movement and function and less pain would be beneficial. Participants were only required to attend physiotherapy on four occasions where they were taught self-MWM and thus performed much of the treatment in their own time.

Dr Sue Reid is a senior lecturer in musculoskeletal physiotherapy at the Australian Catholic University in Sydney. She is a Titled Musculoskeletal Physiotherapist, a Certified Mulligan Practitioner and an Honorary Member of the Mulligan Concept Teachers Association.

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Carpal tunnel syndrome is a nerve-entrapment problem that can cause pain, paraesthesia and weakness, typically in the region of the hand supplied by the median nerve. Surgery is often recommended. Q&A with Annina Schmid.

What is carpal tunnel syndrome and how common is it?

Carpal tunnel syndrome is a condition which affects the median nerve as it travels through the carpal tunnel at the wrist. It is the most common entrapment neuropathy with a lifetime prevalence of 11 per cent, which increases to a staggering 84 per cent in patients who have diabetes.

Is surgery common for carpal tunnel syndrome?

Carpal tunnel decompression is the most common upper limb orthopaedic surgery with a lifetime prevalence of over three per cent. It is predicted that the demand for carpal tunnel surgery will double over the next decade—which puts a substantial financial and logistic strain on healthcare systems. The development of alternative management pathways to expedite access to care and reduce surgical waitlists is therefore a priority.

What about conservative interventions?

Surgery is recommended for patients with severe or prolonged symptoms, along with patients whose conservative management has failed—however, a trial of non-surgical interventions is indicated for patients with mild or moderate symptoms. Commonly recommended non-surgical interventions include use of night splints, nerve and tendon gliding exercises, activity modification and steroid injections.

What conservative interventions did your study test?

We tested a combination of group education, night splinting and home exercises, which can readily be administered in physiotherapy or hand-therapy settings. The education involved a 20–30 minute group education presentation during which a physiotherapist or occupational therapist explained the pathophysiology of carpal tunnel syndrome, treatment options and posture and activity modification principles.

Patients also received a booklet containing this information. The home exercises consisted of median nerve and tendon-gliding exercise that patients were asked to perform five times per day. The night splint was an over- the-counter splint that helps keep the wrist in a neutral position.

What design did you use to test that combination of education, splinting and exercises?

A multicentre randomised clinical trial was designed to investigate the effect of non-surgical intervention (education, splinting and exercises) on patient outcomes while on the waitlist for carpal tunnel surgery. This care pathway was therapist-led, and we compared this to a control group—which continued on the surgery waiting list as per current practice without receiving any additional interventions. Fifty-two patients with carpal tunnel syndrome were included in the experimental group and 53 in the control group.

Our main outcome measures were the number of patients converting to surgery, patients’ perceived improvements measured with the global rating of change scale, and patient satisfaction. As secondary outcome measures, we also recorded symptom severity and functional limitations. These outcome measures were evaluated at six weeks and six months. We also included a post-hoc long-term follow up at an average of over three years after trial completion.

What did the results show?

The therapist-led care pathway had benefits over remaining on the surgery waiting list with no other intervention. It resulted in a 21 per cent reduction in need for surgery at six months—with a 15 per cent greater perceived improvement and a 12 per cent higher satisfaction at six weeks follow up. The post-hoc long-term analysis suggested that the majority (73 per cent) of patients who were not recommended surgery at the completion of the trial continued to avoid surgery for an average follow up of over three years. 

If someone on the surgical waiting list fully intended to go ahead with surgery when offered, do you think we should still encourage them to do the splinting and exercises in   the meantime? Wouldn’t they still potentially appreciate some reprieve from their symptoms and disability while they wait? 

Whereas our results are promising, the statistical analyses revealed wide confidence intervals in some measures, indicating that these benefits may not be worthwhile in every patient. With this in mind, we recommend that clinicians have an open discussion with each individual patient, weighing up the uncertainty of the benefit against costs, time commitment and risks before they decide to embark on the therapy.

The advantage of the studied therapist-led care pathway is its low cost and relatively low time commitment, as the intervention can be independently performed by the patients. We also did not identify any serious or unexpected adverse events. Some patients may therefore decide that the potential to experience some relief of symptoms while still planning to go ahead with surgery outweighs potential disadvantages.  

Associate Professor Annina Schmid is a musculoskeletal physiotherapist and neuroscientist affiliated with the Nuffield Department of Clinical Neurosciences at Oxford University in the UK. She qualified as a physiotherapist in Switzerland in 2001 and completed a PhD in neuroscience at the university in 2011.



Alan Reubenson answers questions on the recent study into the Assessment of Physiotherapy Practice (APP). The study involved the assessment of more than 500 physiotherapy students on clinical placements in various clinical subdisciplines.

Your recent study assessed the psychometric properties of the APP. Is this not already widely accepted in Australia and New Zealand?

The APP tool is widely accepted in Australia and New Zealand to assess clinical performance among undergraduate physiotherapy students—yet it is scored and interpreted differently across institutions. For example, some institutions use the tool as originally intended (using all 20 items to obtain a total score) whereas others have introduced one or more sub- total scores and/or assessment hurdles.

Empirically, there exists little systematic work on the reliability and validity of test scores obtained with the APP since the original development work by Megan Dalton and her colleagues. Ongoing tests of tools designed to operationalise concepts into measurement are essential because reliability and validity are properties of test scores rather than an instrument per se. Our study extended existing work on the APP by testing its robustness over time (ie, across a full year) and across contexts (ie, differing areas of practice or sub-disciplines).

 What data did you use to assess those psychometric properties?

We used clinical educators’ assessments of final-year clinical placements across four consecutive years (2014–2017). This data was extracted from archival records at the School of Physiotherapy and Exercise Science at Curtin University. The study was longitudinal in nature and therefore captured APP data across all four APP- assessed final-year clinical placements. Most students (542 of 561) were assessed on four five-week clinical placements in core areas of practice including musculoskeletal, neurology, cardiopulmonary, and lifespan (eg, paediatrics, gerontology).

 Do you think the data was representative?

Our data is representative of final-year physiotherapy students at Curtin University because we extracted clinical performance assessments on all students who completed the undergraduate physiotherapy degree during 2014–2017. There are subtle differences in the content and method of teaching physiotherapy to undergraduate students across Australian tertiary institutions, so the findings may not generalise fully.

As reliability and validity are properties of test scores rather than instruments, it is essential that APP data is assessed on an ongoing basis. We made our analysis scripts available and are happy to collaborate with others to assist them with such endeavours.

What did your analyses show?

Our analyses showed that the optimal representation of clinical performance scores obtained, with our sample, is achieved via two factors representing professional (items one–four) and clinical domains (items five–20). This two factor characterisation of APP test scores was robust across time and context.

What should clinical educators do in response to these findings?

Our findings provide the necessary evidence for updating the scoring protocol of the APP. An overall assessment of clinical performance, optimally scored and interpreted across two factors, encompassing professional (sum of items one–four) and clinical (sum of items five–20) dimensions. It is our hope that these findings will stimulate a conversation among tertiary institutions and clinical educators regarding a standardised approach to scoring of clinical performance. 

Alan Reubenson is the director of Clinical Education at the Curtain School of Physiotherapy and Exercise Science and a member of Clinical Education Managers Australia and New Zealand. Alan is undertaking his PhD studies exploring the physiological determinants of clinical performance in a physiotherapy undergraduate degree.


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