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Introduction: Perturbation-based balance training (PBT) is reported to effectively reduce falls in older adults and may even be superior compared with various exercise programmes. Due to the nature of the intervention, requiring unpredictable balance perturbations, the question arises whether acceptability is an issue in PBT., Objective: To evaluate the acceptability of PBT in older adults with a recent history of falls., Design, Method, Participants and Setting: This is a qualitative study in which semistructured interviews were conducted in 16 older adults (14 women and 2 men, mean age 73.6±6.0 years) who completed a three-session PBT protocol as part of another study in a university medical centre in the Netherlands. Typical case and purposive sampling strategies were applied. Interviews were based on the theoretical framework of acceptability (TFA) alongside context-specific factors and analysed using a template analysis approach., Results: The results indicate that this PBT protocol is perceived as acceptable by older adults with a recent history of falls and highlight key areas for potential future modifications. Enjoyment of the novel training and technology, being able to feel safe during training, and perceived impact of increased self-efficacy and balance confidence were identified as facilitating factors. Potential issues included initial apprehension or anxiety during training and perceived impact being predominantly psychological instead of physical. Complementary to the TFA one additional theme emerged which described challenges regarding the training setting, such as preference for group training in some participants and travel to the training location., Conclusions: The results suggest that PBT is perceived acceptable by older adults with a history of falls. Increasing the social aspect of training and sharing the experiences of peers may be considered to enhance acceptability to new participants who initially feel apprehensive or anxious about their ability to participate in future implementation of PBT., Trial Registration Number: The article is linked to a randomised clinical trial registered on https://www.trialregister.nl/trial/7680, NL7680; Results., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objective: When appraising the quality of randomised clinical trial (RCTs) on the merits of exercise therapy, we typically limit our assessment to the quality of the methods. However, heterogeneity across studies can also be caused by differences in the quality of the exercise interventions (ie, 'the potential effectiveness of a specific intervention given the potential target group of patients')-a challenging concept to assess. We propose an internationally developed, consensus-based tool that aims to assess the quality of exercise therapy programmes studied in RCTs: the international Consensus on Therapeutic Exercise aNd Training (i-CONTENT) tool., Methods: Forty-nine experts (from 12 different countries) in the field of physical and exercise therapy participated in a four-stage Delphi approach to develop the i-CONTENT tool: (1) item generation (Delphi round 1), (2) item selection (Delphi rounds 2 and 3), (3) item specification (focus group discussion) and (4) tool development and refinement (working group discussion and piloting)., Results: Out of the 61 items generated in the first Delphi round, consensus was reached on 17 items, resulting in seven final items that form the i-CONTENT tool: (1) patient selection; (2) qualified supervisor; (3) type and timing of outcome assessment; (4) dosage parameters (frequency, intensity, time); (5) type of exercise; (6) safety of the exercise programme and (7) adherence to the exercise programme., Conclusion: The i-CONTENT-tool is a step towards transparent assessment of the quality of exercise therapy programmes studied in RCTs, and ultimately, towards the development of future, higher quality, exercise interventions., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Falls are a common cause of injuries and hospitalization among older adults. While conventional balance training appears effective in preventing falls, a relatively large number of training sessions are needed and retention of the effects after the training period is hard to accomplish. This may be because these interventions are not sufficiently task-specific for the mechanism of falls. Many falls in older adults occur due to unexpected external perturbations during gait, such as trips. Therefore, there is increasing interest in perturbation-based balance training (PBT), which is a more task-specific intervention to improve reactive balance control after unexpected perturbations. The literature suggests that PBT may be more effective and require fewer training sessions to reduce falls incidence in older adults, than conventional balance training. We aim to evaluate the effect of a three-session PBT protocol on balance control, daily life falls and fear of falling. Secondly, we will evaluate the acceptability of the PBT protocol., Methods: This is a mixed-methods study combining a single-blind (outcome assessor) randomized controlled trial (RCT) using a parallel-group design, and qualitative research evaluating the acceptability of the intervention. The study sample consists of community-dwelling older adults aged 65 years and older who have recently fallen and visited the MUMC+ outpatient clinic. Subjects are randomized into two groups. The control group (n = 40) receives usual care, meaning referral to a physical therapist. The intervention group (n = 40) receives usual care plus three 30-min sessions of PBT in the Computer Assisted Rehabilitation Environment. Subjects' balance control (Mini-BESTest) and fear of falling (FES-I) will be assessed at baseline, and 4 weeks and 3 months post-baseline. Daily life falls will be recorded with falls calendars until 6 months after the first follow-up measurement, long-term injurious falls will be recorded at 2-years' follow-up via the electronic patient record. Acceptability of the PBT protocol will be evaluated with semi-structured interviews in a subsample from the intervention group., Discussion: This study will contribute to the evidence for the effectiveness of PBT using a training protocol based on the available literature, and also give much needed insights into the acceptability of PBT for older adults., Trial Registration: Nederlands Trial Register NL7680 . Registered 17-04-2019 - retrospectively registered.

Objective: To assess the efficacy of a 12-week aquatic cycling training program for improving knee pain and physical functioning in patients with knee osteoarthritis (OA)., Design: Two-arm, single-blind, parallel-group randomized controlled trial., Settings: OA outpatient clinic of the Maastricht University Medical Center+., Participants: Patients (N=111, 50-70y) with unilateral mild-to-moderate knee OA., Interventions: Participants (aquatic cycling [AC] group, n=55) received AC sessions of 45 min each 2 times per week. Each session combined upright seated cycling with out-of-saddle positions and exercises for the upper and lower body. The usual care (UC) group (n=47) continued with UC and was offered 12 AC sessions in a local swimming pool after their trial participation., Main Outcome Measures: The Knee Injury and Osteoarthritis Outcome Score (KOOS) on knee pain and physical function was assessed at baseline, postintervention, and at 24-wk follow-up. Multilevel (mixed regression) analysis examined the effects., Results: Average attendance rate for the AC sessions was 80%. Statistically significant differences at postintervention and follow-up were found for knee pain in mean ± SD (UC pretest, 57.89±15.26; posttest, 55.90±18.04; follow-up, 57.24±19.16; and AC pretest, 56.96±12.96; posttest, 63.55±15.33; follow-up, 64.35±17.26; estimate, 8.16; SE, 3.27; 95% confidence interval [CI], 1.67-14.64; effect size [ES], 0.50) and physical functioning (UC pretest, 66.32±16.28; posttest, 66.80±19.04; follow-up, 65.42±17.98; and AC pretest, 61.89±17.151; posttest, 70.14±17.52; follow-up, 69.00±16.84; estimate, 7.16; SE, 3.19; 95% CI, 0.83-13.49; ES, 0.43) in favor of the aquatic group., Conclusions: The results suggest that a 12-week AC training program improves self-reported knee pain and physical functioning in patients with mild-to-moderate knee OA compared to UC., (Copyright © 2020 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

Background: Adherence to an exercise programme impacts the outcome of physiotherapy treatment in patients with non-specific low back pain., Objectives: The aim of this study was to explore the patients' perspectives on long term adherence to such exercise programmes., Design: This qualitative study was embedded in a randomised controlled trial (RCT) which compared the effectiveness of two types of exercise programme on patients with nonspecific low back pain., Methods: Answers from 44 participants to three open-ended questions were analysed using thematic analysis., Results/findings: Patients' perceptions related to the following themes: 1) the role of knowledge in long-term exercise adherence; 2) strategies to support exercise adherence; 3) barriers to exercise adherence 4) the role of perceived effects of exercise., Conclusions: Adherence to long-term exercise is supported through knowledge of the exercises and correct performance. A self-initiated training strategy is the most successful in the perception of participants. Individually supervised physiotherapy treatment that includes coaching towards strategies for post-treatment long term exercise behaviour is recommended., (Copyright © 2018 Elsevier Ltd. All rights reserved.)

Background: Over the last decade aquatic exercise has become more and more popular. One of the latest trends is aqua-cycling, where participants sit on a water-resistant stationary bike and, while immersed chest deep in the water, combine continuous cycling with upper body exercises that utilise water resistance. Since stationary cycling and aquatic exercises are frequently recommended to patients with knee osteoarthritis, combining both would seem an obvious step, and an aqua-cycling exercise programme for patients with knee osteoarthritis has indeed been developed. This study protocol gives a detailed description of the exercise programme and the methodology of a study to compare this programme with treatment involving usual care only., Methods: The study is a single-blind, parallel-group, randomised controlled trial of Maastricht University Medical Centre+, the Netherlands., Inclusion Criteria: knee pain of four to seven on a 10-point pain rating scale; a Kellgren/Lawrence score between one to three; ability to cycle; good mental health; sufficient language skills; indication for physical therapy in conjunction with impairments due to OA., Exclusion Criteria: any contra-indication for aquatic exercise; planned total knee replacement; corticosteroid injection <3 months and/or hyaluronic acid injection <6 months; severe joint complaints (other than knee joint); symptomatic and radiological apparent hip OA; inflammatory joint diseases; inability to safely enter and exit the pool; fear of water. Participants will receive two 45-min moderate intense aqua-cycling sessions weekly over a period of 12 weeks in addition to usual care or usual care only. Usual care consists of an individual intervention plan comprising lifestyle recommendations, medication routine and referral to a physical therapist. Participants will be assessed at baseline, and at 12 and 24 weeks after baseline. The primary outcome is self-reported knee pain and physical functioning. Secondary outcomes are lower limb muscle strength, functional capacity, self-reported disease severity, physical activity level, quality of life, self-efficacy and fear of movement. Daily diaries will collect information on knee pain, physical functioning, level of physical activity, pain medication routine and physical therapy (control group only) or exercise participation over two 30-day periods (during the intervention period)., Discussion: To our knowledge the present study is the first randomised controlled trial evaluating the effects of aqua-cycling in the pre-surgical stage of knee osteoarthritis. This trial will demonstrate if the newly designed aqua-cycling intervention, in supplement to usual care, can help to improve impairments due to knee osteoarthritis., Trial Registration: Netherlands Trial Register NTR3766 (21-12-2012).

Background: Exercise is an effective treatment for patients with sub-acute and chronic low back pain (LBP). Patients with a movement control impairment (MCI) can be diagnosed as a subgroup of patients with LBP. Unknown is which exercise intervention is most beneficial for this subgroup. This study assessed the short-term effect of a specific exercise program targeting movement control impairment versus general exercise treatment on disability in patients with LBP and MCI., Methods: In a multicentre parallel group randomised controlled pragmatic trial, patients with sub-acute and chronic LBP were included. Further inclusion criteria were disability of ≥5 points on the Roland-Morris Disability Questionnaire and ≥2 positive tests out of a set of 6 movement control impairment tests. A total of 106 patients were randomly assigned to either tailored movement control exercise intervention (MC, n = 52) or a general exercise intervention (GE, n = 54); both 9-18 individual treatment sessions, over a maximum of 12 weeks. The primary outcome was disability measured with the Patient Specific Functional scale (PSFS). Secondary outcome was the Roland-Morris disability scale (RMDQ). Measurements were taken pre- and posttreatment., Results: No significant difference was found following the treatment period. Baseline-adjusted between-group mean difference for the PSFS was 0.5 (SD = 0.5; p = 0.32) in favour of MC exercises. The Roland-Morris Disability Questionnaire revealed a significant, but not clinically relevant, between-group difference of 2.0 points (SD = 0.8; p = 0.01)., Conclusion: Disability in LBP patients was reduced considerably by both interventions. However, the limited contrast between the two exercise programs may have influenced outcomes., (Copyright © 2015 Elsevier Ltd. All rights reserved.)

Background: Exercise is an effective treatment for patients with sub-acute and chronic non-specific low back pain (NSLBP). Previous studies have shown that a subgroup of patients with NSLBP and movement control impairment (MCI) can be diagnosed with substantial reliability. However, which type of exercises are most beneficial to this subgroup is still unknown., Objectives: The effectiveness of a specific exercise treatment to improve movement control was tested in this study., Methods: Using a multicentre randomised controlled trial (RCT), we compared exercises that targeted MCI (MC) with a general exercise (GE) treatment. After randomisation, patients in both groups n(MC = 52; GE = 54) were treated in eight private physiotherapy practices and five hospital outpatient physiotherapy centres. Follow-up measurements were taken at post-treatment, six months and 12 months. The primary outcome measurement was the Patient Specific Function Scale (PSFS)., Results: PSFS showed no difference between groups after treatment, or at six months and 12 months. Secondary outcome analysis for pain and disability, measured with the Graded Chronic Pain scale and the Roland Morris Disability Questionnaire respectively, showed that a small improvement post-treatment levelled off over the long term. Both groups improved significantly (p < 0.001) over the course of one year., Conclusion: This study found no additional benefit of specific exercises targeting MCI., (Copyright © 2015 Elsevier Ltd. All rights reserved.)

Background and Purpose: Cardiovascular fitness is greatly reduced after stroke. Although individuals with mild to moderate impairments benefit from conventional cardiovascular exercise interventions, there is a lack of effective approaches for persons with severely impaired physical function. This randomized controlled pilot trial investigated efficacy and feasibility of feedback-controlled robotics-assisted treadmill exercise (FC-RATE) for cardiovascular rehabilitation in persons with severe impairments early after stroke., Methods: Twenty individuals (age 61 ± 11 years; 52 ± 31 days poststroke) with severe motor limitations (Functional Ambulation Classification 0-2) were recruited for FC-RATE or conventional robotics-assisted treadmill exercise (RATE) (4 weeks, 3 × 30-minute sessions/wk). Outcome measures focused on peak cardiopulmonary performance parameters, training intensity, and feasibility, with examiners blinded to allocation., Results: All 14 allocated participants (70% of recruited) completed the intervention (7/group, withdrawals unrelated to intervention), without serious adverse events occurring. Cardiovascular fitness increased significantly in both groups, with peak oxygen uptake increasing from 14.6 to 17.7 mL · kg · min (+17.8%) after 4 weeks (45.8%-55.7% of predicted maximal aerobic capacity; time effect P = 0.01; no group-time interaction). Training intensity (% heart rate reserve) was significantly higher for FC-RATE (40% ± 3%) than for conventional RATE (14% ± 2%) (P = 0.001)., Discussion and Conclusions: Substantive overall increases in the main cardiopulmonary performance parameters were observed, but there were no significant between-group differences when comparing FC-RATE and conventional RATE. Feedback-controlled robotics-assisted treadmill exercise significantly increased exercise intensity, but recommended intensity levels for cardiovascular training were not consistently achieved. Future research should focus on appropriate algorithms within advanced robotic systems to promote optimal cardiovascular stress.Video abstract available for more insights from the authors (Supplemental Digital Content 1, http://links.lww.com/JNPT/A107).

Background: Aqua-cycling is easy to learn, acceptable, and safe for patients with knee osteoarthritis. It can therefore be an ideal component of aquatic circuit training., Objective: To investigate the feasibility of a small group-based aquatic exercise programme including aqua-cycling., Design: A feasibility study using quantitative (pre-post) and qualitative (cross-sectional) assessments., Participants: A volunteer cohort of 10 women and men, age range 46-77 years, with knee osteoarthritis., Methods: Focus group interviews explored participants' experience with the training. Pre- and post-exercise knee pain, attendance, progression in training, and adverse events were registered., Results: Seventy percent of patients attended all sessions. Focus groups revealed high levels of satisfaction with the selection of exercises, and participants valued the immediate pain relief experienced. Participants progressed well. However, aqua-cycling in an out-of-the-saddle position was too demanding for most participants., Conclusion: An aquatic circuit training that includes aqua- cycling is feasible for patients with knee osteoarthritis. Participants reported pain reduction and were positive about the diverse exercise programme. Aqua-cycling in a seated position is a safe and controlled type of movement.

Background: Exercise capacity is seriously reduced after stroke. While cardiopulmonary assessment and intervention strategies have been validated for the mildly and moderately impaired populations post-stroke, there is a lack of effective concepts for stroke survivors suffering from severe motor limitations. This study investigated the test-retest reliability and repeatability of cardiopulmonary exercise testing (CPET) using feedback-controlled robotics-assisted treadmill exercise (FC-RATE) in severely motor impaired individuals early after stroke., Methods: 20 subjects (age 44-84 years, <6 month post-stroke) with severe motor limitations (Functional Ambulatory Classification 0-2) were selected for consecutive constant load testing (CLT) and incremental exercise testing (IET) within a powered exoskeleton, synchronised with a treadmill and a body weight support system. A manual human-in-the-loop feedback system was used to guide individual work rate levels. Outcome variables focussed on standard cardiopulmonary performance parameters. Relative and absolute test-retest reliability were assessed by intraclass correlation coefficients (ICC), standard error of the measurement (SEM), and minimal detectable change (MDC). Mean difference, limits of agreement, and coefficient of variation (CoV) were estimated to assess repeatability., Results: Peak performance parameters during IET yielded good to excellent relative reliability: absolute peak oxygen uptake (ICC =0.82), relative peak oxygen uptake (ICC =0.72), peak work rate (ICC =0.91), peak heart rate (ICC =0.80), absolute gas exchange threshold (ICC =0.91), relative gas exchange threshold (ICC =0.88), oxygen cost of work (ICC =0.87), oxygen pulse at peak oxygen uptake (ICC =0.92), ventilation rate versus carbon dioxide output slope (ICC =0.78). For these variables, SEM was 4-13%, MDC 12-36%, and CoV 0.10-0.36. CLT revealed high mean differences and insufficient test-retest reliability for all variables studied., Conclusions: This study presents first evidence on reliability and repeatability for CPET in severely motor impaired individuals early after stroke using a feedback-controlled robotics-assisted treadmill. The results demonstrate good to excellent test-retest reliability and appropriate repeatability for the most important peak cardiopulmonary performance parameters. These findings have important implications for the design and implementation of cardiovascular exercise interventions in severely impaired populations. Future research needs to develop advanced control strategies to enable the true limit of functional exercise capacity to be reached and to further assess test-retest reliability and repeatability in larger samples.

Background: There is increasing evidence for the beneficial effects of exercise training in stroke survivors. In order to reach the desired training effects, exercise training principles must be considered as this ensures the prescription of adequate exercises at an adequate dose. Moreover, exercise training interventions must be designed in a way that maximizes patients' adherence to the prescribed exercise regimen. The objectives of this systematic review were (1) to investigate whether training principles for physical exercise interventions are reported in RCTs for sub-acute and chronic stroke survivors, (2) to evaluate whether the RCTs reported the prescription of the FITT components of the exercise interventions as well as (3) patients' adherence to this prescription, and (4) to assess the risk of bias of the included studies., Methods: We performed a systematic review of RCTs with exercise training as the primary intervention and muscular strength and/or endurance as primary outcomes. The Cochrane library's risk of bias (ROB) tool was used to judge the methodological quality of RCTs., Results: Thirty-seven RCTs were included in this systematic review. Eighteen studies (48.7%) focused on aerobic, 8 (21.6%) on resistance and 11 (29.7%) on combined interventions of aerobic and resistive strength exercise. Twenty-nine studies (78.4%) included only chronic stroke survivors, 5 studies (13.5%) only sub-acute stroke survivors whilst 3 studies (8.1%) included both. In terms of principle of exercise training, 89% reported specificity, 75.7% progression, 48.7% overload, 37.8% initial values, 32.4% reversibility and 13.5% diminishing returns. One RCT described all principles of physical exercise training and 19 (51.4%) all FITT components. Patients' adherence to exercise prescription was accounted for in 3 studies (8.1%). Failure to report blinding in patients and participants and failure to report allocation concealment were the most prevalent methodological shortcomings., Conclusions: Incomplete and inconsistent reporting of (1) training components, (2) underlying exercise training principles and (3) patient adherence together with (4) a broad variation in the methodological quality of the included RCTs limit both the utility and reproducibility of physical exercise programs in stroke patients.

Background: Chronic obstructive pulmonary disease (COPD) is recognized as a systemic illness with significant extra-pulmonary features, such as exercise intolerance and muscle weakness. Pulmonary rehabilitation has been shown to be very effective in counteracting these consequences in patients with more advanced COPD. However, limited data is available on the efficacy of a physical exercise training programme in patients with mild to moderate COPD in primary care. Furthermore, it is unknown if improved exercise capacity translates into enhanced daily physical activities. The aim of this paper is to describe the design of a randomized controlled trial to assess the efficacy of a physical exercise training programme in patients with mild to moderate COPD., Methods/design: In this randomized controlled trial situated in the primary care setting, 102 patients with mild to moderate airflow obstruction (FEV1 ≥ 50% of predicted), dyspnoea and a physically inactive lifestyle will be randomized to an intervention or control group. The intervention group receives a 4-month physical exercise training programme at a local physiotherapy practice, which includes exercise training, resistance training, breathing exercises and advises on how to increase the level of physical activity. The control group receives usual care, i.e. advises on how to increase the level of physical activity and a sham treatment at a local physiotherapy practice of which no physiological training stimulus can be expected. Primary outcome is functional exercise capacity at 4-months measured on the six-minute walk distance. Secondary outcomes include peripheral muscle strength, physical activity in daily life, health related quality of life, Medical Research Council (MRC) dyspnoea score and patients' perceived effectiveness. Follow-up measurement will take place at 6 months after baseline., Discussion: This will be one of the first studies to evaluate the efficacy of a physical exercise training programme in patients with mild to moderate COPD completely recruited and assessed in primary care. The results of this trial may give a unique insight into the potential of the implementation of an easy, close-to-home rehabilitation programme., Trial Registration: The Netherlands National Trial Register NTR1471.

Background: After experiencing a stroke, most individuals also suffer from cardiac disease, are immobile and thus have low endurance for exercise. Aerobic capacity is seriously reduced in these individuals and does not reach reasonable levels after conventional rehabilitation programmes. Cardiovascular exercise is beneficial for improvement of aerobic capacity in mild to moderate stroke. However, less is known about its impact on aerobic capacity, motor recovery, and quality-of-life in severely impaired individuals. The aim of this pilot study is to explore the clinical efficacy and feasibility of cardiovascular exercise with regard to aerobic capacity, motor recovery, and quality-of-life using feedback-controlled robotics-assisted treadmill exercise in non-ambulatory individuals soon after experiencing a stroke., Methods/design: This will be a single-centred single blind, randomised control trial with a pre-post intervention design. Subjects will be recruited early after their first stroke (≤20 weeks) at a neurological rehabilitation clinic and will be randomly allocated to an inpatient cardiovascular exercise programme that uses feedback-controlled robotics-assisted treadmill exercise (experimental) or to conventional robotics-assisted treadmill exercise (control). Intervention duration depends on the duration of each subject's inpatient rehabilitation period. Aerobic capacity, as the primary outcome measure, will be assessed using feedback-controlled robotics-assisted treadmill-based cardiopulmonary exercise testing. Secondary outcome measures will include gait speed, walking endurance, standing function, and quality-of-life. Outcome assessment will be conducted at baseline, after each 4-week intervention period, and before clinical discharge. Ethical approval has been obtained., Discussion: Whether cardiovascular exercise in non-ambulatory individuals early after stroke has an impact on aerobic capacity, motor recovery, and quality-of-life is not yet known. Feedback-controlled robotics-assisted treadmill exercise is a relatively recent intervention method and might be used to train and evaluate aerobic capacity in this population. The present pilot trial is expected to provide new insights into the implementation of early cardiovascular exercise for individuals with severe motor impairment. The findings of this study may guide future research to explore the effects of early cardiovascular activation after severe neurological events., Trial Registration: This trial is registered with the Clinical Trials.gov Registry (NCT01679600).

Questions: Do patients with chronic obstructive pulmonary disease (COPD) achieve a different distance on the six minute walk test (6MWT) conducted on a 10m course versus on a 30m course? When assessing the distance on a 6MWT conducted on a 10m course, is it valid to use existing reference equations that were generated on longer courses?, Design: A randomised double-crossover experimental study., Participants: Forty-five patients with COPD in primary physiotherapy care., Intervention: All patients performed a 6MWT twice over a 10m course and twice over a 30m course. The 6MWTs were performed in accordance with the American Thoracic Society guidelines., Outcome Measures: 6MWD was assessed and predicted distance was calculated based on a range of reference equations., Results: The 6MWD on the 10m course was 49.5m shorter than on the 30m course, which was statistically significant (95% CI 39.4 to 59.6). By using existing reference equations for a 6MWT conducted on the 10m course, the predicted distance is highly overestimated (with a range of 30% to 33%) and the average distance as a percentage of the predicted value is 8%pred lower compared to a 6MWT conducted on the 30m course, resulting in a worse representation of a COPD patient's functional exercise capacity., Conclusion: This study shows that the impact of course length on the 6MWD and on the use of reference equations in patients with COPD is substantial and clinically relevant (based on the most conservative published minimum clinically important difference). Therefore, existing reference equations established for a 6MWT conducted over a 30m (or longer) course cannot be applied to predict the distance achieved on the 6MWT on a 10m course, which is frequently used in primary care physiotherapy practices for patients with COPD., (Copyright © 2013 Australian Physiotherapy Association. Published by .. All rights reserved.)

Background: Primary treatment for patients with intermittent claudication is exercise therapy. Diabetes mellitus (DM) is a frequently occurring comorbidity in patients with intermittent claudication, and in these patients, exercise tolerance is decreased. However, there is little literature about the increase in walking distance after supervised exercise therapy (SET) in patients with both intermittent claudication and DM. The objective of this study was to determine the effectiveness of SET for intermittent claudication in patients with DM., Methods: Consecutive patients with intermittent claudication who started SET were included. Exclusion criteria were Rutherford stage 4 to 6 and the inability to perform the standardized treadmill test. SET was administered according to the guidelines of the Royal Dutch Society for Physiotherapy. At baseline and at 1, 3, and 6 months of follow-up, a standardized treadmill exercise test was performed. The primary outcome measurement was the absolute claudication distance (ACD)., Results: We included 775 patients, of whom 230 had DM (29.7%). At 6 months of follow-up, data of 440 patients were available. Both ACD at baseline and at 6 months of follow-up were significantly lower in patients with DM (P < 0.001). However, increase in ACD after 6 months of SET did not differ significantly (P = 0.48) between the DM group and the non-DM group (270 m and 400 m, respectively)., Conclusion: In conclusion, SET for patients with intermittent claudication is equally effective in improving walking distance for both patients with and without DM, although ACD remains lower in patients with DM., (Copyright © 2012 Annals of Vascular Surgery Inc. Published by Elsevier Inc. All rights reserved.)

Intermittent claudication (IC) has a high prevalence in the older population and is closely associated with cardiovascular and cerebrovascular disease. High mortality rates are reported due to ongoing atherosclerotic disease. Because of these serious health risks, treatment of IC should address reduction of cardiovascular events (and related morbidity/mortality) and improvement of the poor health-related quality of life (QoL) and functional capacity. In several randomized clinical trials and systematic reviews, supervised exercise therapy (SET) is compared with non-supervised exercise, usual care, placebo, walking advice or vascular interventions. The current evidence supports SET as the primary treatment for IC. SET improves maximum walking distance and health-related QoL with a marginal risk of co-morbidity or mortality. This is also illustrated in contemporary international guidelines. Community-based SET appears to be at least as efficacious as programs provided in a clinical setting. In the Netherlands, a national integrated care network (ClaudicatioNet) providing specialized care for patients with IC is currently being implemented. Besides providing a standardized form of SET, the specialized physical therapists stimulate medication compliance and perform lifestyle coaching. Future research should focus on the influence of co-morbidities on prognosis and effect of SET outcome and the potential beneficial effects of SET combined with a vascular intervention.

Introduction: Intermittent claudication (IC) is a manifestation of peripheral arterial occlusive disease (PAOD). Besides cardiovascular risk management, supervised exercise therapy (SET) should be offered to all patients with IC. Outdated guidelines, an insufficient number of specialized physiotherapists (PTs), lack of awareness of the importance of SET by referring physicians, and misguided financial incentives all seriously impede the availability of a structured SET program in The Netherlands., Description of Care Practice: By initiating regional care networks, ClaudicatioNet aims to improve the quality of care for patients with IC. Based on the chronic care model as a conceptual framework, these networks should enhance the access, continuity, and (cost) efficiency of the health care system. With the aid of a national database, health care professionals will be able to benchmark patient results while ClaudicatioNet will be able to monitor quality of care by way of functional and patient reported outcome measures., Discussion: The success of ClaudicatioNet is dependent on several factors. Vascular surgeons, general practitioners and coordinating central caregivers will need to team up and work in close collaboration with specialized PTs. A substantial task in the upcoming years will be to monitor the quality, volume, and distribution of ClaudicatioNet PTs. Finally, misguided financial incentives within the Dutch health care system need to be tackled., Conclusion: With ClaudicatioNet, integrated care pathways are likely to improve in the upcoming years. This should result in the achievement of optimal quality of care for all patients with IC.

Background: Non-specific low back pain (NSLBP) in subacute and chronic stages can be treated effectively with exercise therapy. Research guidelines recommend evaluating different treatments in defined subgroups of patients with NSLBP. A subgroup of patients with movement control impairment (MCI) improved significantly on patient specific function and disability in a previous case series after movement control exercises., Methods/design: In a randomised controlled trial (RCT) we will compare the effectiveness of movement control and general exercise in patients with MCI. 106 participants aged 18 - 75 will be recruited in 5 outpatient hospital departments and 7 private practices.Patients randomly assigned to the movement control exercise group will be instructed to perform exercises according to their MCI. The general exercise group will follow an exercise protocol aimed at improving endurance and flexibility. Patients in both groups will receive 9 - 18 treatments and will be instructed to do additional exercises at home.The primary outcome is the level of disability assessed using the patient specific functional scale (PSFS) which links the perceived pain to functional situations and is measured before treatment and at 6 and 12 months follow-up. Secondary outcomes concern low back pain related disability (Roland Morris questionnaire, RMQ), graded chronic pain scale (GCPS), range of motion and tactile acuity., Discussion: To our knowledge this study will be the first to compare two exercise programs for a specific subgroup of patients with NSLBP and MCI. Results of this study will provide insight into the effectiveness of movement control exercise and contribute to our understanding of the mechanisms behind MCI and its relation to NSLBP., Trial Registration: Current Controlled Trials ISRCTN80064281.

Background: Shoulder impingement syndrome is a common musculoskeletal complaint leading to significant reduction of health and disability. Physiotherapy is often the first choice of treatment although its effectiveness is still under debate. Systematic reviews in this field highlight the need for more high quality trials to investigate the effectiveness of physiotherapy interventions in patients with subacromial impingement syndrome., Methods/design: This randomized controlled trial will investigate the effectiveness of individualized physiotherapy in patients presenting with clinical signs and symptoms of subacromial impingement, involving 90 participants aged 18-75. Participants are recruited from outpatient physiotherapy clinics, general practitioners, and orthopaedic surgeons in Germany. Eligible participants will be randomly allocated to either individualized physiotherapy or to a standard exercise protocol using central randomization. The control group will perform the standard exercise protocol aiming to restore muscular deficits in strength, mobility, and coordination of the rotator cuff and the shoulder girdle muscles to unload the subacromial space during active movements. Participants of the intervention group will perform the standard exercise protocol as a home program, and will additionally be treated with individualized physiotherapy based on clinical examination results, and guided by a decision tree. After the intervention phase both groups will continue their home program for another 7 weeks. Outcome will be measured at 5 weeks and at 3 and 12 months after inclusion using the shoulder pain and disability index and patients' global impression of change, the generic patient-specific scale, the average weekly pain score, and patient satisfaction with treatment. Additionally, the fear avoidance beliefs questionnaire, the pain catastrophizing scale, and patients' expectancies of treatment effect are assessed. Participants' adherence to the protocol, use of additional treatments for the shoulder, direct and indirect costs, and sick leave due to shoulder complaints will be recorded in a shoulder log-book., Discussion: To our knowledge this is the first trial comparing individualized physiotherapy based on a defined decision making process to a standardized exercise protocol. Using high-quality methodologies, this trial will add evidence to the limited body of knowledge about the effect of physiotherapy in patients with SIS.

Aims: To identify prognostic indicators independently associated with poor outcome of physiotherapy intervention in women with primary or recurrent stress urinary incontinence (stress UI)., Methods: A prospective cohort study was performed in physiotherapy practices in primary care to identify prognostic indicators 12 weeks after initiation of physiotherapy intervention. Patients were referred by general practitioners or urogynecologists. Risk factors for stress UI were examined as potential prognostic indicators of poor outcome. The primary outcomes were defined as poor outcome on the binary Leakage Severity scale (LS scale) and the binary global perceived effectiveness (GPE) score., Results: Two hundred sixty-seven women, with a mean age of 47.7 (SD = 8.3), with stress UI for at least 6 months were included. At 12 weeks, 43% and 59% of the women were considered recovered on the binary LS scale and the binary GPE score, respectively. Prognostic indicators associated with poor outcome included 11 indicators based on the binary LS scale and 8 based on the binary GPE score. The prognostic indicators shared by both models show that poor recovery was associated with women with severe stress UI, POP-Q stage > II, poor outcome of physiotherapy intervention for a previous UI episode, prolonged second stage of labor, BMI > 30, high psychological distress, and poor physical health., Conclusions: This study provides robust evidence of clinically meaningful prognostic indicators of poor short-term outcome. These findings need to be confirmed by replication studies., ((c) 2009 Wiley-Liss, Inc.)

Aim: To determine the psychometric properties of the total Vaizey score and its individual items., Methods: The study was conducted as part of a prospective cohort study assessing the outcome of pelvic floor rehabilitation in patients with fecal incontinence., Results: One hundred ninety-four patients were analyzed, 53 of whom provided data on the global perceived effect (GPE) score. Pelvic floor rehabilitation resulted in a significant reduction of the total Vaizey score and most individual items. The total Vaizey scores changed in agreement with the GPE scores. The total Vaizey score was responsive, but some individual items yielded inconsistent results for three different measures. The test-retest reliability was adequate or excellent for six individual items and the total Vaizey score. The internal consistency was low for the total Vaizey score at baseline, in contrast to the follow-up and change scores. The estimates for the minimally important change (MIC) and smallest detectable change yielded moderately consistent results. An MIC of -5 points seemed preferable and yielded the lowest misclassification rate., Conclusions: More research is required to confirm conclusions on the psychometric properties of the total Vaizey score and its individual items, and to justify its use in research and routine clinical practice., ((c) 2009 Wiley-Liss, Inc.)

Background: Exercise therapies generate substantial costs in computer workers with non-specific work-related upper limb disorders (WRULD)., Aims: To study if postural exercise therapy is cost-effective compared to regular physiotherapy in screen-workers with early complaints, both from health care and societal perspective., Methods: Prospective randomized trial including cost-effectiveness analysis; one year follow-up., Participants: Eighty-eight screen-workers with early non-specific WRULD; six drop-outs., Interventions: A ten week postural exercise program versus regular physiotherapy., Outcome Measures: Effectiveness measures: Pain: visual analogous scale (VAS), self-perceived WRULD (yes/no). Functional outcome: Disabilities of Arm, Shoulder and Hand- Dutch Language Version (DASH-DLV). Quality of life outcome: EQ-5D.Economic measures: health care costs including patient and family costs and productivity costs resulting in societal costs. Cost-effectiveness measures: health care costs and societal costs related to the effectiveness measures. OUTCOME MEASURES were assessed at baseline; three, six and twelve months after baseline., Results: At baseline both groups were comparable for baseline characteristics except scores on the Pain Catastrophizing Scale and comparable for costs. No significant differences between the groups concerning effectiveness at one year follow-up were found. Effectiveness scores slightly improved over time. After one year 55% of participants were free of complaints. After one year the postural exercise group had higher mean total health care costs, but lower productivity costs compared to the physiotherapy group. Mean societal costs after one year (therefore) were in favor of postural exercise therapy [- euro622; 95% CI -2087; +590)]. After one year, only self- perceived WRULD seemed to result in acceptable cost-effectiveness of the postural exercise strategy over physiotherapy; however the probability of acceptable cost-effectiveness did not exceed 60%.Considering societal costs related to QALYs, postural exercise therapy had a probability of over 80% to be cost-effective over a wide range of cost-effectiveness ceiling ratios; however based on a marginal QALY-difference of 0.1 over a 12 month time frame., Conclusion: Although our trial failed to find significant differences in VAS, QALYs and ICERs based on VAS and QALYs at one-year follow-up, CEACs suggest that postural exercise therapy according to Mensendieck/Cesar has a higher probability of being cost-effective compared to regular physiotherapy; however further research is required., Trial Registration: ISRCTN 15872455.

Background: Aged-related loss of ankle dorsiflexion range of motion (ROM) and toe plantarflexor strength play an important role in gait performance. Further, conventional strength, balance and gait training can significantly improve the lower extremity muscle power and functional abilities of older individuals. It remains unclear, however, whether training effects can be enhanced by augmenting ankle ROM and toe plantarflexor strength complementary to training., Objective: This study investigated the effect of physical exercise combined with foot gymnastics on the gait performance in older adults., Methods: Fifty-six independent living, older adults aged 66-91 years were randomly assigned to either foot gymnastics group (FG; n = 28) or training group (TG; n = 28). Further, 14 subjects were integrated as a control group (CG; n = 14) (no exercise). The FG and TG completed the same training program consisting of aerobic exercises, progressive resistance strength training and stretching exercises twice per week for 12 weeks, whereas the FG performed additional foot gymnastic exercises at the end of the training session and a 10-min foot gymnastics home-program daily. Assessments included the Falls Efficacy Scale - International (FES-I), Expanded Timed Get-up-and-Go test (ETGUG), gait analysis and muscle power measurements of the knee and ankle joint at pre- and post-training. Results. No significant change in FES-I score occurred in either group. The FG showed a significant improvement of ankle ROM. There were significant time x group interactions in walking speed, step length, in several muscle power measurements and in ETGUG. The positive effects of gait parameters ranged between 1 and 11% and between 2 and 12%, of muscle power between 14 and 34% and 14 and 46% and of ETGUG were 10 and 8% for the FG and TG, respectively. The FG and TG did not differ significantly in their improvements. The CG showed a trend to deteriorations between 0 and -6% for gait parameters, between -4 and -14% for muscle power and 0% for ETGUG., Conclusions: The results of this study provide evidence of significant improvements in gait performance, muscle power and ETGUG after a conventional training program in independent living, older adults. However, there is no additional effect on physical performance after foot gymnastic exercises.

Objective: To evaluate the effectiveness of specific lumbar extensor training compared with regular physical therapy (PT) in workers with nonspecific nonacute low back pain (LBP)., Design: A multicenter randomized controlled trial with 1-year follow-up., Setting: PT department in (military primary care) health centers., Participants: Predominantly male soldiers (N=129) with 4 weeks or more of low back complaints who were referred by the health center's general practitioner for PT (mean age, 35.9+/-10.8 y; range, 20-56 y), of whom 127 randomized participants were included in the analyses. One patient withdrew because of adverse effects during treatment., Interventions: Participants were assigned to 1 of 2 treatment programs: (1) a 10-week device-supported isolated lumbar extension training, twice a week, or (2) regular PT, mainly consisting of exercise therapy and aerobic activities., Main Outcome Measures: Functional status (Roland-Morris Disability Questionnaire, Patient-Specific Functional Scale) and global perceived effect were assessed in the short term (5 wk, 10 wk) and long term (6 mo, 12 mo)., Results: Both groups showed a favorable development in main outcomes over time: short-term improvements (after 10 weeks of treatment) remained stable or even slightly increased throughout the 12-month follow-up. No significant differences between the 2 groups were shown for any of the outcome measures, at any time., Conclusions: Consistent with prior evidence, specific back strengthening does not seem to offer incremental benefits in LBP management compared with regular PT care that mainly consists of general exercise therapy. (ISRCTN identifier ISRCTN19334317.)

Question: Are postural exercises delivered by Mensendieck/Cesar therapists more effective in decreasing pain, reducing disability and improving health-related quality of life in visual display unit workers with early non-specific work-related upper limb disorders than strength and fitness exercises delivered by physiotherapists?, Design: Randomised trial with concealed allocation and intention-to-treat analysis., Participants: Eighty-eight (6 drop-outs) visual display unit workers with early non-specific work-related upper limb disorders., Intervention: One group received 10 weeks of postural exercises while the other group received 10 weeks of strength and fitness exercises., Outcome Measures: Pain was measured with a 10-cm visual analogue scale, disability was measured with the Disabilities of Arm, Shoulder and Hand questionnaire, and health-related quality of life was measured with the Short Form-36. Number of participants experiencing upper limb complaints was also collected. Outcome measures were collected at baseline and again at 3, 6, and 12 months., Results: There was no significant difference in decrease in pain between the groups at 3 months (0.6 cm, 95% CI 0.0 to 1.2), 6 months (0.2, 95% CI -0.3 to 0.7), or at 12 months (0.1, 95% CI -0.6 to 0.8). Differences between the groups in upper limb complaints, disability, and health related quality of life were also small and not significant at any measurement occasion., Conclusion: Postural exercises did not result in a better outcome than strength and fitness exercises. However, 55% of visual display unit workers with early non-specific work-related upper limb disorders reported being free of complaints one year after both interventions were commenced., Trial Registration: ISRCTN15872455.

Question: Is eight weeks of high-intensity strengthening of the isolated lumbar extensors more effective than low-intensity strengthening or no strengthening? Are any gains maintained 16 weeks later?, Design: Randomised, three-arm trial with concealed allocation, assessor blinding, and intention-to-treat-analysis. Participants in the waiting list control group were randomised again, after the first 8 weeks, to either the high-intensity or the low-intensity strengthening program., Participants: Sixty-five army personnel with non-specific chronic low back pain., Intervention: The high-intensity training group received 10 sessions of 15 to 20 repetitions for the isolated lumbar extensor muscles. The low-intensity training group received a nonprogressive, low-intensity resistance protocol., Outcome Measures: Primary outcomes were global perceived effect and disability. Secondary outcomes were health-related quality of life, fear of movement/(re-)injury, and isometric lumbar extensor muscle strength. Measures were taken before and after the training and 16 weeks later., Results: At eight weeks, SF-36 overall score was on average 7% (95% CI 1 to 13) greater in the high-intensity training group compared with the low-intensity training group and the waiting list control group, and self-assessed decrease of back symptoms was on average 39% (95% CI 14 to 64) greater in the high-intensity training group compared with the waiting list control group. There was no difference in improvement between the groups for any other outcome at 8 weeks or 24 weeks., Conclusions: Although some beneficial effects were found, the results of this high-intensity strengthening program of the isolated lumbar extensor muscles do not clearly support the generally-claimed beneficial influence of exercise for chronic non-specific low back pain.

Objective: The intervention process was evaluated in a randomised clinical trial on the effectiveness of a behavioural Graded Exercise Therapy (GET) programme for patients with chronic shoulder complaints in primary care settings. This process evaluation was done for three reasons: first, to know whether the programme was performed as planned; second, to know whether or not this treatment is feasible in normal practice; third, to identify needs for improvement of the protocol to facilitate implication., Methods: We evaluated the extent to which the programme is being applied according to protocol, patient adherence to the programme and the suitability of the programme according to patients and physiotherapists. Twenty participating physiotherapists and 87 patients allocated to GET were asked to evaluate the intervention process. Furthermore, a sample of 10 patients, taken from the total number of 87 patients allocated to GET, was invited to take part in a focus group interview at the end of the study. We evaluated the intervention process using a treatment registration form filled in by the physiotherapists during treatment, evaluation forms filled in independently by physiotherapists and patients 26 weeks after the start of the treatment period, and information gathered during the focus group interview at the end of the study., Results: GET was applied according to protocol to an acceptable extent, and participating patients showed satisfactory adherence to the programme., Conclusions: Clinical effectiveness of GET in this trial is not influenced by flaws in the application of the programme or by lack of patient adherence., Practice Implications: The programme could be improved in terms of the process of goal-setting, and the implementation of GET could be facilitated if the programme is embedded in a multidisciplinary approach in primary care.

This study critically reviews the effectiveness of exercise therapy and manual mobilisation in acute ankle sprains and functional instability by conducting a systematic review of randomised controlled trials. Trials were searched electronically and manually from 1966 to March 2005. Randomised controlled trials that evaluated exercise therapy or manual mobilisation of the ankle joint with at least one clinically relevant outcome measure were included. Internal validity of the studies was independently assessed by two reviewers. When applicable, relative risk (RR) or standardised mean differences (SMD) were calculated for individual and pooled data. In total 17 studies were included. In thirteen studies the intervention included exercise therapy and in four studies the effects of manual mobilisation of the ankle joint was evaluated. Average internal validity score of the studies was 3.1 (range 1 to 7) on a 10-point scale. Exercise therapy was effective in reducing the risk of recurrent sprains after acute ankle sprain: RR 0.37 (95% CI 0.18 to 0.74), and with functional instability: RR 0.38 (95% CI 0.23 to 0.62). No effects of exercise therapy were found on postural sway in patients with functional instability: SMD: 0.38 (95% CI -0.15 to 0.91). Four studies demonstrated an initial positive effect of different modes of manual mobilisation on dorsiflexion range of motion. It is likely that exercise therapy, including the use of a wobble board, is effective in the prevention of recurrent ankle sprains. Manual mobilisation has an (initial) effect on dorsiflexion range of motion, but the clinical relevance of these findings for physiotherapy practice may be limited.

Study Design: Systematic literature review., Objective: To compare the effectiveness of conventional treatment complemented by supervised rehabilitation training (supervised exercises) with conventional treatment alone for the rehabilitation of acute lateral ankle sprains., Background: Conventional treatment is advocated as a preferable treatment strategy. Whether supervised exercises should complement conventional treatment is unclear., Methods and Measures: We searched 5 computerized databases from 1966 to March 2004, checked the reference lists of all studies that fulfilled our eligibility criteria, and searched for nonindexed journals available on the Internet. Three reviewers independently selected randomized controlled trials (RCTs), and controlled clinical trials (CCTs), comparing conventional treatment alone with conventional treatment combined with supervised exercises for treating patients with an acute lateral ankle sprain. Two reviewers independently assessed the methodological quality of each included study. Two reviewers extracted data regarding outcomes, interventions, and results. Follow-up measurements were grouped as (a) immediate term, (b) short term, (c) intermediate term, and (d) long term. A best-evidence synthesis was conducted, weighting the studies with respect to their internal validity and statistical significance of the outcomes., Results: Seven RCTs were included. The quality assessment resulted in 1 high-quality and 6 low-quality studies. There is limited evidence that the addition of supervised exercises to a conventional treatment approach results in greater reduction in swelling and faster return to work. Studies reporting a lack of difference between treatment approach did not report statistical power, making interpretation of those results difficult., Conclusions: The retrieved data failed to demonstrate a clearly superior treatment approach, although preliminary support exists for supervised exercises. Additional high-quality RCTs are needed that are appropriately designed and reported.

An operant behavioural and time-contingent graded exercise therapy program was developed to improve functional ability irrespective of pain experience in patients with chronic shoulder complaints. The clinical effectiveness of graded exercise therapy compared to usual care was evaluated in a randomised clinical trial. Assessments were carried out before and after 12 weeks of treatment. Performance of daily activities was measured by two outcome measures: the main complaints instrument and the Shoulder Disability Questionnaire (SDQ). Patients were eligible for participation if they had suffered from shoulder complaints for at least three months. Patients suffering from systemic diseases, referred pain or severe biomedical or psychiatric disorders were excluded. Patients (n = 176) were randomised and allocated either to graded exercise therapy (n = 87) or usual care (n = 89). Graded exercise therapy led to greater improvement in the performance of daily activities than usual care. However, only mean differences between groups in performance of activities related to the main complaints reached statistical significance (p = 0.049; 95% CI 0.0 to 15.0). The observed beneficial effects were considered to be small to moderate (calculated effect sizes: 0.30 for the main complaints instrument and 0.07 for the SDQ). Subgroup analysis showed larger improvements on the mean complaints instrument in patients not reporting pain reduction over time. Graded exercise therapy seems to be less effective in restoring performance of daily activities as assessed by the SDQ in patients showing a painful arc during physical examination. Results showed that graded exercise therapy is more effective in restoring the ability to daily activities in patients with chronic shoulder complaints than usual care, although beneficial effects are small.

The purpose of this project was to summarise the available evidence on the effectiveness of exercise therapy for patients with disorders of the musculoskeletal, nervous, respiratory, and cardiovascular systems. Systematic reviews were identified by means of a comprehensive search strategy in 11 bibliographic databases (08/2002), in combination with reference tracking. Reviews that included (i) at least one randomised controlled trial investigating the effectiveness of exercise therapy, (ii) clinically relevant outcome measures, and (iii) full text written in English, German or Dutch, were selected by two reviewers. Thirteen independent and blinded reviewers participated in the selection, quality assessment and data-extraction of the systematic reviews. Conclusions about the effectiveness of exercise therapy were based on the results presented in reasonable or good quality systematic reviews (quality score > or = 60 out of 100 points). A total of 104 systematic reviews were selected, 45 of which were of reasonable or good quality. Exercise therapy is effective for patients with knee osteoarthritis, sub-acute (6 to 12 weeks) and chronic (> or = 12 weeks) low back pain, cystic fibrosis, chronic obstructive pulmonary disease, and intermittent claudication. Furthermore, there are indications that exercise therapy is effective for patients with ankylosing spondylitis, hip osteoarthritis, Parkinson's disease, and for patients who have suffered a stroke. There is insufficient evidence to support or refute the effectiveness of exercise therapy for patients with neck pain, shoulder pain, repetitive strain injury, rheumatoid arthritis, asthma, and bronchiectasis. Exercise therapy is not effective for patients with acute low back pain. It is concluded that exercise therapy is effective for a wide range of chronic disorders.

This paper discusses the rationale for and content of a newly developed treatment for shoulder complaints, and describes a randomised study which is currently being conducted to test effectiveness of the treatment. In current practice, approximately 50% of all patients with shoulder complaints mention limitations in the performance of daily activities and persisting pain after six months. To improve the functional ability of patients with chronic shoulder complaints, despite their pain, we have developed an operant behavioural and time-contingent graded exercise therapy programme for use in a primary care setting. We present the theory and conceptual model underlying this programme, report on its development and content, and describe the design of a randomised clinical trial to evaluate the programme's effectiveness and cost-effectiveness. One hundred and thirty-two patients who suffer from shoulder complaints for at least 3 months are being recruited in general practice. After inclusion in the study, patients are allocated randomly to the graded exercise therapy programme or to usual care. Questionnaires will be used to measure factors like severity of the main complaint, functional limitations of daily activities, perceived recovery, global health status, shoulder pain, generic health-related quality of life, and costs. These factors will be assessed at baseline, during treatment (6 weeks), and after treatment (12, 26, and 52 weeks).

* OBJECTIVE: To assess whether prehabilitation influenced knee functioning before and within the first year after total knee arthroplasty (TKA) surgery. * DESIGN: Intervention systematic review with meta-analysis. * LITERATURE SEARCH: The authors searched the MEDLINE/PubMED, EMBASE, CINAHL, Cochrane Library, Physiotherapy Evidence Database, Web of Science, and Scopus databases from their inception until March 2022. * STUDY SELECTION CITERIA: The authors included peer-reviewed articles comparing preoperative, short-, mid- or long-term effects of exercise-based physical therapy before primary unilateral TKA with TKA without prehabilitation. * DATA SYNTHESIS: We assessed bias using the Cochrane Risk-of-Bias tool (ROB 2.0) and therapeutic validity using the i-CONTENT tool. Standardized mean differences (Hedges' g) and 95% confidence intervals (CIs) were calculated for knee functioning. Certainty of evidence was assessed using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach. * RESULTS: Sixteen trials (968 participants) were included; 14 qualified for meta-analysis. Low to very low certainty of evidence favored prehabilitation over no intervention for improving knee functioning before (g = 1.23; 95% CI: 0.49, 1.97) and up to 3 months after TKA (short-term: 1 day to 1 month, g = 0.90; 95% CI: 0.18, 1.61; mid-term: 6 weeks to 3 months, g = 0.45; 95% CI: 0.06, 0.84). There were no significant between-group differences at long-term follow-up (6-12 months, g = 0.07; 95% CI: -0.17, 0.30). * CONCLUSION: There was low to very low certainty of evidence that prehabilitation promotes superior knee functioning before and up to 3 months after TKA, compared to TKA alone. The long-term postoperative effects were inconclusive. [ABSTRACT FROM AUTHOR]

Abstract Background A large proportion of patients with spinal cord injury (SCI) regain ambulatory function. However, during the first 3 months most of the patients are not able to walk unsupported. To enable ambulatory training at such an early stage the body weight is partially relieved and the leg movements are assisted by two therapists. A more recent approach is the application of robotic based assistance which allows for longer training duration. From motor learning science and studies including patients with stroke, it is known that training effects depend on the duration of the training. Longer trainings result in a better walking function. The aim of the present study is to evaluate if prolonged robot assisted walking training leads to a better walking outcome in patients with incomplete SCI and whether such training is feasible or has undesirable effects. Methods/Design Patients from multiple sites with a subacute incomplete SCI and who are not able to walk independently will be randomized to either standard training (3-5 sessions per week, session duration maximum 25 minutes) or an intensive training (3-5 sessions per week, session duration minimum 50 minutes). After 8 weeks of training and 4 months later the walking ability, the occurrence of adverse events and the perceived rate of exertion as well as the patients' impression of change will be compared between groups. Trial registration This study is registered at clinicaltrials.gov, identifier: NCT01147185.

Objective: To assess predictors for adherence to a home-based pelvic floor muscle exercise (PFME) program supplemented with three physical therapy sessions in women with urinary incontinence (UI). Design: Secondary analysis of a randomized controlled trial of interventions to enhance self-efficacy with respect to PFME. Setting: Patients were referred from public primary or secondary care providers in Florianópolis, Brazil. Participants: Adult women with UI. Intervention: Three supervised physiotherapy sessions for the treatment of UI combined with home-based PFME program. Treatment groups were combined for predictive modelling because there was no difference after intervention between groups regarding UI and adherence rates. Main Outcome Measures: Adherence to PFME at 3-month follow-up (structured questionnaire). Baseline Predictors: self-efficacy and outcome expectation scales; severity of UI (ICIQ-SF), pelvic floor muscle strength, age, body mass index (BMI), and educational level. Results: 86 women with UI of whom 72 completed the study. An intention-to-treat analysis was performed. Forty-three women reported carrying out PFME every day. Adherence was correlated to: baseline self-efficacy (r = 0.299); age (r = 0.242); and educational level (r = −0.273). Hierarchical regression analyses incorporating treatment group, age, education, disease-related factors (severity of UI; pelvic floor muscle strength; BMI), and outcome expectations and self-efficacy showed that only baseline self-efficacy predicted adherence (R2 = 0.217). Conclusions: Adherence to home-based PFME is a complex phenomenon. Assessing self-efficacy may help physiotherapists to detect patients' confidence in performing home-based exercises and, when necessary, give patients additional incentives. [ABSTRACT FROM AUTHOR]

This guideline aimed to advance current understandings regarding the diagnosis, prevention and therapeutic interventions for ankle sprains by updating the existing guideline and incorporate new research. A secondary objective was to provide an update related to the cost-effectiveness of diagnostic procedures, therapeutic interventions and prevention strategies. It was posited that subsequent interaction of clinicians with this guideline could help reduce health impairments and patient burden associated with this prevalent musculoskeletal injury. The previous guideline provided evidence that the severity of ligament damage can be assessed most reliably by delayed physical examination (4-5 days post trauma). After correct diagnosis, it can be stated that even though a short time of immobilisation may be helpful in relieving pain and swelling, the patient with an acute lateral ankle ligament rupture benefits most from use of tape or a brace in combination with an exercise programme.New in this update: Participation in certain sports is associated with a heightened risk of sustaining a lateral ankle sprain. Care should be taken with non-steroidal anti-inflammatory drugs (NSAIDs) usage after an ankle sprain. They may be used to reduce pain and swelling, but usage is not without complications and NSAIDs may suppress the natural healing process. Concerning treatment, supervised exercise-based programmes preferred over passive modalities as it stimulates the recovery of functional joint stability. Surgery should be reserved for cases that do not respond to thorough and comprehensive exercise-based treatment. For the prevention of recurrent lateral ankle sprains, ankle braces should be considered as an efficacious option. [ABSTRACT FROM AUTHOR]

* SYNOPSIS: Claudication from peripheral artery disease (PAD) may mimic or coexist with musculoskeletal conditions and represents an important diagnostic consideration in patients over 50 years of age. Physical therapists are optimally positioned to recognize this condition by incorporating a vascular history and physical examination in appropriately selected patients. Recognition of PAD is important both from the standpoint of addressing the ischemic risk to the limb and because PAD is associated with high cerebrovascular and cardiovascular risk. Therefore, multidisciplinary management of patients with PAD is essential. Extensive evidence supports treatment of PAD-related claudication with supervised exercise, and physical therapists are well positioned to play an important role in this treatment. [ABSTRACT FROM AUTHOR]

Background: Exercise interventions in physical therapy (PT) are often not well described in research reports. Omitting details of the intervention hampers the transfer to daily clinical practice. Objective: To develop a framework for describing goals and content of exercise interventions, in order to provide structured and detailed information for use in research reports. Methods: A framework was developed in three steps using a mixed method approach. First, the scientific literature was systematically searched for available methods to describe PT interventions. An inventory of these methods was made and relevant elements were extracted. Second, based on the results of the literature search, a global framework was developed by a focus group of experts in the field of PT. Third, the framework was field tested by describing four different exercise interventions, leading to a final version. Results: In the developed framework intervention goals at the level of body functions and activities/participation were listed using the International Classification of Functioning, Disability and Health. To guide the description of the content of the exercise intervention a list of intervention details was developed, which was derived from an existing classification of PT interventions. Goals and content of exercise interventions were linked. Field testing of the framework led to adequate descriptions of exercise interventions. Conclusion: The developed framework is a promising first step in offering a feasible guide for a structured and detailed description of goals and content of exercise interventions within research reports. [ABSTRACT FROM AUTHOR]

Background: Our aim was to develop a rating scale to assess the therapeutic validity of therapeutic exercise programmes. By use of this rating scale we investigated the therapeutic validity of therapeutic exercise in patients awaiting primary total joint replacement (TJR). Finally, we studied the association between therapeutic validity of preoperative therapeutic exercise and its effectiveness in terms of postoperative functional recovery. Methods: (Quasi) randomised clinical trials on preoperative therapeutic exercise in adults awaiting TJR on postoperative recovery of functioning within three months after surgery were identified through database and reference screening. Two reviewers extracted data and assessed the risk of bias and therapeutic validity. Therapeutic validity of the interventions was assessed with a nine-itemed, expert-based rating scale (scores range from 0 to 9; score ≥6 reflecting therapeutic validity), developed in a four-round Delphi study. Effects were pooled using a random-effects model and meta-regression was used to study the influence of therapeutic validity. Results: Of the 7,492 articles retrieved, 12 studies (737 patients) were included. None of the included studies demonstrated therapeutic validity and two demonstrated low risk of bias. Therapeutic exercise was not associated with 1) observed functional recovery during the hospital stay (Standardised Mean Difference [SMD]: 21.19; 95%-confidence interval [CI], 22.46 to 0.08); 2) observed recovery within three months of surgery (SMD: 20.15; 95%-CI, 20.42 to 0.12); and 3) selfreported recovery within three months of surgery (SMD 20.07; 95%-CI, 20.35 to 0.21) compared with control participants. Meta-regression showed no statistically significant relationship between therapeutic validity and pooled-effects. Conclusion: Preoperative therapeutic exercise for TJR did not demonstrate beneficial effects on postoperative functional recovery. However, poor therapeutic validity of the therapeutic exercise programmes may have hampered potentially beneficial effects, since none of the studies met the predetermined quality criteria. Future review studies on therapeutic exercise should address therapeutic validity. [ABSTRACT FROM AUTHOR]

Question: What are the effects of strength training alone, exercise therapy alone, and exercise with additional passive manual mobilisation on pain and function in people with knee osteoarthritis compared to control? What are the effects of these interventions relative to each other? Design: A meta-analysis of randomised controlled trials. Participants: Adults with osteoarthritis of the knee. Intervention types: Strength training alone, exercise therapy alone (combination of strength training with active range of motion exercises and aerobic activity), or exercise with additional passive manual mobilisation, versus any non-exercise control. Comparisons between the three interventions were also sought. Outcome measures: The primary outcome measures were pain and physical function. Results: 12 trials compared one of the interventions against control. The effect size on pain was 0.38 (95% CI 0.23 to 0.54) for strength training, 0.34 (95% CI 0.19 to 0.49) for exercise, and 0.69 (95% CI 0.42 to 0.96) for exercise plus manual mobilisation. Each intervention also improved physical function significantly. No randomised comparisons of the three interventions were identified. However, meta-regression indicated that exercise plus manual mobilisations improved pain significantly more than exercise alone (p = 0.03). The remaining comparisons between the three interventions for pain and physical function were not significant. Conclusion: Exercise therapy plus manual mobilisation showed a moderate effect size on pain compared to the small effect sizes for strength training or exercise therapy alone. To achieve better pain relief in patients with knee osteoarthritis physiotherapists or manual therapists might consider adding manual mobilisation to optimise supervised active exercise programs. [ABSTRACT FROM AUTHOR]

Background: A large proportion of patients with spinal cord injury (SCI) regain ambulatory function. However, during the first 3 months most of the patients are not able to walk unsupported. To enable ambulatory training at such an early stage the body weight is partially relieved and the leg movements are assisted by two therapists. A more recent approach is the application of robotic based assistance which allows for longer training duration. From motor learning science and studies including patients with stroke, it is known that training effects depend on the duration of the training. Longer trainings result in a better walking function. The aim of the present study is to evaluate if prolonged robot assisted walking training leads to a better walking outcome in patients with incomplete SCI and whether such training is feasible or has undesirable effects. Methods/Design: Patients from multiple sites with a subacute incomplete SCI and who are not able to walk independently will be randomized to either standard training (3-5 sessions per week, session duration maximum 25 minutes) or an intensive training (3-5 sessions per week, session duration minimum 50 minutes). After 8 weeks of training and 4 months later the walking ability, the occurrence of adverse events and the perceived rate of exertion as well as the patients' impression of change will be compared between groups. [ABSTRACT FROM AUTHOR]

Background: Disease severity and functional impairment in patients with intermittent claudication is usually quantified by the measurement of pain-free walking distance (intermittent claudication distance, ICD) and maximal walking distance (absolute claudication distance, ACD). However, the distance at which a patient would prefer to stop because of claudication pain seems a definition that is more correspondent with the actual daily life walking distance. We conducted a study in which the distance a patient prefers to stop was defined as the functional claudication distance (FCD), and estimated the reliability and validity of this measurement. Methods: In this clinical validity study we included patients with intermittent claudication, following a supervised exercise therapy program. The first study part consisted of two standardised treadmill tests. During each test ICD, FCD and ACD were determined. Primary endpoint was the reliability as represented by the calculated intra-class correlation coefficients. In the second study part patients performed a standardised treadmill test and filled out the Rand-36 questionnaire. Spearman's rho was calculated to assess validity. Results: The intra-class correlation coefficients of ICD, FCD and ACD were 0.940, 0.959, and 0.975 respectively. FCD correlated significantly with five out of nine domains, namely physical function (rho = 0.571), physical role (rho = 0.532), vitality (rho = 0.416), pain (rho = 0.416) and health change (rho = 0.414). Conclusion: FCD is a reliable and valid measurement for determining functional capacity in trained patients with intermittent claudication. Furthermore it seems that FCD better reflects the actual functional impairment. In future studies, FCD could be used alongside ICD and ACD. [ABSTRACT FROM AUTHOR]

Abstract: Kool J, Bachmann S, Oesch P, Knuesel O, Ambergen T, de Bie R, van den Brandt P. Function-centered rehabilitation increases work days in patients with nonacute nonspecific low back pain: 1-year results from a randomized controlled trial. Objective: To compare the effect of function-centered treatment (FCT) and pain-centered treatment (PCT) on the number of work days, permanent disability, and the unemployment rate. Design: Randomized controlled trial. Setting: Inpatient rehabilitation center. Participants: Patients (N=174; 79% male; mean age, 42y) with previous sick leave of 6 weeks or more. Interventions: FCT (4h/d for 3wk) emphasized activity despite pain by using work simulation, strength, endurance, and cardiovascular training. PCT (2.5h/d for 3wk) emphasized pain reduction and included passive and active mobilization, stretching, strength training, and a 4-hour mini back school with education and exercise. Analysis was by intention to treat. Main Outcome Measures: Work days, return to work, rate of patients receiving financial compensation for permanent disability, and unemployment rate. Effect sizes (Cohen d) were defined as small (0.2–0.5), moderate (0.5–0.8), and large (>0.8). Results: After 1 year, the FCT group had significantly more work days (mean, 118; median, 39.5; interquartile range [IQR], 0−198) than the PCT group (mean, 74; median, 0; IQR, 0−160; Mann-Whitney U test, P=.011). The odds ratio of returning to work in the FCT group relative to the PCT group was 2.1 (95% confidence interval, 1.1−3.9). The differences in unemployment rates and in the numbers of patients receiving compensation for permanent disability were not significant. Conclusions: FCT is more effective than PCT for increasing work days. [Copyright &y& Elsevier]

Study design: A systematic review of randomized controlled trials. Objectives: To evaluate the effectiveness of segmental stabilizing exercises for acute, subacute and chronic low back pain with regard to pain, recurrence of pain, disability and return to work. Methods: MEDLINE, EMBASE, CINAHL, Cochrane Controlled Trials Register, PEDro and article reference lists were searched from 1988 onward. Randomized controlled trials with segmental stabilizing exercises for adult low back pain patients were included. Four comparisons were foreseen: (1) effectiveness of segmental stabilizing exercises versus treatment by general practitioner (GP); (2) effectiveness of segmental stabilizing exercises versus other physiotherapy treatment; (3) effectiveness of segmental stabilizing exercises combined with other physiotherapy treatment versus treatment by GP and (4) effectiveness of segmental stabilizing exercises combined with other physiotherapy treatment versus other physiotherapy treatment. Results: Seven trials were included. For acute low back pain, segmental stabilizing exercises are equally effective in reducing short-term disability and pain and more effective in reducing long-term recurrence of low back pain than treatment by GP. For chronic low back pain, segmental stabilizing exercises are, in the short and long term, more effective than GP treatment and may be as effective as other physiotherapy treatments in reducing disability and pain. There is limited evidence that segmental stabilizing exercises additional to other physiotherapy treatment are equally effective for pain and more effective concerning disability than other physiotherapy treatments alone. There is no evidence concerning subacute low back pain. Conclusion: For low back pain, segmental stabilizing exercises are more effective than treatment by GP but they are not more effective than other physiotherapy interventions. [ABSTRACT FROM AUTHOR]

Objectives: To investigate whether exercise alone or as a part of a multidisciplinary treatment reduces sick leave in patients with non-specific non-acute low back pain. Methods: A meta-analysis of randomized controlled trials was performed. A qualitative analysis of the sick leave results was performed applying pre-defined levels of evidence. In studies comparing exercise with usual care, pooled effect sizes were computed. Results: Fourteen trials were identified allowing 22 comparisons between treatments. The qualitative and the quantitative analysis showed strong evidence that exercise reduces sick days during the first follow-up year, the effect size (95% confidence interval) was -0.24 ( -0.36, -0.11). In a subgroup of studies on the treatment of severely disabled patients (>90 sick days under usual care) the effect size was -0.30 (-0.42, -0.17). The effect size of the number of patients receiving a disability allowance was small and not significant. Conclusion: The reviewed trials provide strong evidence that exercise significantly reduces sick days during the first follow-up year. [ABSTRACT FROM AUTHOR]

Background: Total Knee Replacement (TKR) is the standard treatment for patients with severe knee osteoarthritis (OA). Significant improvement in pain and function are seen after TKR and approximately 80% of patients are very satisfied with the outcome. Functional status prior to TKR is a major predictor of outcome after the intervention. Thus, improving functional status prior to surgery through exercise may improve after surgery outcome. However, results from several previous trials testing the concept have been inconclusive after surgery.Methods/design: In a randomized controlled trial (RCT) we will test the effect of a pre-operative neuromuscular training program versus an attention control program on lower extremity function - before and after surgery. We will enroll 80 participants, aged between 55-90 years, who are scheduled for TKR. In this single-blinded RCT, the intervention group will receive a minimum of 8 and a maximum of 24 training sessions plus 3 educational sessions of the knee school. The control group will receive the 3 educational sessions only. Assessments are performed immediately before and after the intervention (before surgery), at 6  weeks, 3  months and 12  months (after surgery). The primary outcome will include the Chair Stand Test as a measure of leg strength and reaction time. Secondary outcomes are knee function and pain assessed with the self-reported Knee Injury and Osteoarthritis Outcome Score (KOOS). All measurements will be carried out by a specially trained physical therapist, blinded to group allocation.Discussion: To our knowledge this is the first single-blinded RCT to test the effect of pre-operative neuromuscular training plus knee school against knee school alone--on knee function and pain, assessed immediately after the interventions prior to surgery and repeatedly after surgery.Trial Registration: Clinical Trials NCT00913575. [ABSTRACT FROM AUTHOR]