- Email: [email protected]
Diagnostic Criteria Imprecision
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letters Measuring Outcome Measures MADAM - The timely article ‘Outcome measures used in therapy departments in Scotland’ (Chesson et a/, 1996) has already helped to inform our choice of measures to evaluate new community services for older people in Cambridge. The preliminary results of our survey by Lifespan Healthcare of 25 rehabilitation wards in England suggest the type and range of measure5 used here broadly resemble the pattern in Scotland. However, three aspects of the results may deserve discussion. Patients’ views on their outcomes after rehabilitation are not necessarily less ‘validated’ than the measures scored by clinicians and they can be ‘reliably and routinely collected’ (Caan, 1996). In relation to goal attainment ratings, the results confirm that only a small minority of therapists are using these now. However, the impact of trying such ratings, both in benefiting individual care and in guiding the
side rural East Anglia and especially its utility as a measure of outcome. If any readers would be interested in collaborating to develop such a short measure for general use, we invite them to contact us at the address below.
development of services, may be out of all proportion to this modest level of use so far (Caan, 1995). Finally, my heart sank, reading that none of the Scottish departments used any measures of the quality of life as an outcome for therapy. However, it is very difficult to find off-the-shelf quality of life measures simple enough to use in routine practice. In Cambridge, with various clients, a range of measures as different as the Nottingham Health Profile, Harter or Oxford Happiness ratings which we tried have all failed to take root. Based on the suggestions of local occupational therapy day patients (with support from the Cancer Relief Macmillan Fund ) Lifespan Healthcare has evolved a simple four-item quality of life tool, the Fab-4. Over the last two years we have gradually rolled this out to a few different types of user., but we need many more subjects to determine its general validity out-
Woody Caan MA DPhil Douglas House 18b Trumpington Road Cambridge CB2 2AH
References Caan, W (1995). ‘Role of users of health care in achieving a quality service’, Quality in Health Care, 4, 65. Caan, W (1 996). ‘Clinical effectiveness and patient centred care’ in: Putting Evidence Based Medicine into Practice, IBC, London. Chesson, R, Macleod, M and Massie, S (1996). ‘Outcome measures used in therapy departments in Scotland’, Physiotherapy, 82,673-679. We hope that many readers will be able to contribute to this evaluation and look forward to publication of the results in Physiotherapy - Editor.
Diagnostic Criteria Imprecision MADAM - ‘Soft tissue disorders of the shoulder’ by Leisdek et a/ in last month’s issue of Physiotherapy showed a lack of inter-observer agreement in diagnosis. I suggest that the main reason was the choice of inadequate diagnostic criteria. I researched shoulder pain (Grieve, 1992a) and found that diagnostic criteria, more detailed than those used in this study, were inadequate. There was a relationship between pains in the shoulder and neck (Grieve, 1993) which confounded the diagnostic criteria for the shoulder conditions. The importance of excluding the cervical spine as a source of arm symptoms was recognised in 1976 by Gunn and Hilbrand, and by Cyriax long before that. Leisdek et a/ failed to exclude subjects with evidence of neck joint dysfunction, and in ignoring the neck, they also ignored the brachial plexus. Since developments in the study of neural mobility (Sunderland, 1978; Elvey, 1985, 1986; Butler and Gifford, 1989) there is much evidence that
have been more precisely defined, and confounding factors excluded, there is little value in attempting to assess reliability and treatment.
shoulder pain can arise through impairment of mobility of the cervical nerve roots, trunks and brachial plexus, without there being neurological ‘signs’, which they did exclude. The painful arc in abduction, for instance, has been shown to be at the angle of maximum neural tension. For these reasons, I consider that any subject having neck pain, or reporting previous neck problems (such as whiplash) should have been excluded. In my research (Grieve, 1993), pain on shoulder flexion was shown to be related to impaired neural mobility in a proportion of subjects and many of the rotator cuff tests, such as tenderness of tendons, proved to be nonspecific (Grieve, 1992b). Other tests which I consider essential are acromio-clavicular joint compression for ‘sub-acromial bursitis’; proportional limitation in the capsular pattern for ‘capsulitis’; passive movements for ‘acromioclavicular syndrome’. In short, until the diagnostic criteria
Elizabeth Grieve PhD MCSP MMACP DipTP Birmingham
References Butler, D and Gifford, L (1989). ‘The concept of mechanical tension in the nervous system’, Physiotherapy, 75, 622-636. Elvey, R L (1985). ‘Abnormal brachial plexus tension and shoulder joint limitation’, Proceedings of the Fifth Seminar of the International Federation of Orthopaedic Manipulative Therapists, Vancouver, June 25-29, 1984, IFOMT, New Zealand. Elvey, R L (1986). ‘The investigation of arm pain’, in: Grieve, G P (ed) Modern Manual Therapy of the Vertebral Column, Churchill Livingstone, Edinburgh. Grieve, E F M (1992a). ‘A study of chronic arm pain in industry’, PhD thesis, University of Birmingham. Grieve, E F M (1992b). ‘The physical assessment of the musculo-tendinous unit - a revised interpretation of the findings’ (poster), Chartered Society of Physiotherapy, Annual Congress, Glasgow, October 4-9.
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Physiotherapy,February 1997, vol 83,no 2
104
Grieve, E F M (1 993). ‘The cervical contribution to arm pain in a sample of industrial workers’, Physiotherapy Theory and Practice, 9, 223-234. Gunn, C C and Hilbrandt, W E (1976). ‘Tennis elbow and the cervical spine’,
MADAM - ‘Soft-tissue disorders of the shoulder’ by Liesdek e t a / (Physiotherapy, January 1997) is an interesting research report which, in part, looks at the inter-observer agreement between GPs and physiotherapists in diagnosing shoulder pain. The tool used for the study is the clinical guidelines for the management of shoulder pain, based on the concepts of Cyriax. It is these concepts which are being researched. Unfortunately this key element is not acknowledged in the title, the summary or the key words. This I feel is an omission and could lead to some
Journal of the Canadian Medical Association, 114, 803-809.
Leisdek, C, van der Windt, D A W M, Koes, B W and Bouter, L M (1997). ‘Soft-tissue disorders of the shoulder’, Physiotherapy, 83,1, 12-21. Sunderland, S (1978).‘Traumatised nerve roots and ganglia: Musculoskeletal.factors and neuro-pathologicalconsequences’ in: Korr, I M (ed) The Neurobiologic Mechanisms of Manual Therapy, Plenum Press, New York, pages 137-1 66.
confusion when using the article to enhance one‘s understanding of soft-tissue disorders of the shoulder. As the authors of the article state, there are ‘several other proposals of the classification of shoulder pain ’(page 15) and the fact that only the concepts of Cyriax have been investigated is an important point which should have been highlighted both in the title and the summary, these being the initial, and unfortunately sometimes the only, elements of an article which are read.
Simon Rouse MSc BEd MCSP DipTP Leeds
The Origin of Cable Operated Reciprocal Orthoses - A Truly British Invention MADAM - It was sad to see an article published in the January issue of Physiotherapy (‘Development of orthoses for people with paraplegia’ by J Melia) which yet again gave credit to the Louisiana State University for the invention of reciprocal gait orthoses. In fact their team adopted this idea from work carried out in this country during the late 1960s, some of which was funded by the DHSS. About 25 children had a set made for them and these were later developed by a team including Bill Bond (an engineer), the late Trevor Bowen
(an orthopaedic surgeon), Moyna Gilbertson FCSP and myself. This work was published in Physiotherapy in two articles during 1971, a letter (in response to another inaccurate article) and several other nursing and specialist periodicals. An’MSc thesis in 1969 prepared at the University of Surrey was entitled ‘Interconnected hip hinges in lower limb bracing’. At the same time, and in the UK, John Florence was developing the Hartley brace, which used cable-operated reciprocation: and in Canada, at the Ontario Crippled Children’s Centre in Toronto, Wally Motloch
Looking through Different Spectacles MADAM - In her article ‘Epistemology, private knowledge, and the real problems in physiotherapy’ (Physiotherapy, September 1996), Robertson likens the claim that physiotherapists should know about the nature of knowledge (epistemology) in order to generate knowledge to the claim that someone who needs glasses should know about the laws of optics. She asserts that all one needs to know is that glasses ‘can provide suitable correction’. Physiotherapists do need to know about different theories of knowledge precisely because specific inquiry paradigms, with their associated epistemologies, provide a variety of lenses through which the world can be viewed. Part of ‘research awareness’ (Newham, 1997) is an appreciation of the importance of the epistemological question - t h e nature of the relationship between the would-be knower ~~~
and what can be known (Guba, 1990). French and Swain (1997) challenge physiotherapists to consider participatory and emancipatory research approaches, based in the critical theory paradigm, which question the objectivist epistemology of the positivist paradigm that dominates disability research. In her article entitled ‘Constructing realities: An art of lenses’, Hoffman (1990) explores the implications for her own practice as a family therapist of moving from a dualist epistemology influenced by the circular feedback loops of cybernetic theory to the transactional epistemology of social construction theory where meanings evolve as part of human interaction. A practice based on a search for shared understandings and ideas for action replaced ‘the visiting expert’ (Hoffman, 1990). Physiotherapists could usefully ~
Physiotherapy, February 1997, vol 83,no 2
published two designs for reciprocating gait orthoses, using non-cable systems. The article shows little evidence of research into the subject and I am as concerned about that as I am by the lack of credit to British workers for a device whose origins are firmly rooted in the UK, despite the persistent efforts to make it appear otherwise.
David Scrutton MSc MCSP Honorary Senior Lecturer The Institute of Child Health and UMDS, Guy’s & St Thomas’ Hospitals London
consider trying on different epistemological glasses to see how their professional worlds and the worlds of their clients change with different lenses.
Diana Jones BA MCSP GradDipPhys Research Physiotherapist University of Northumbria at Newcastle
References French, S and Swain, J (1997). ‘Changing disability research: Participating and emancipatory research with disabled people’, Physiotherapy, 83,1, 26-32. Guba, E G (1990). ‘The alternative paradigm dialog’ in: Guba, E G The Paradigm Dialog, Sage Publications, Newbury Park. Hoffman, L (1990). ‘Constructing realities: An art of lenses’, Family Process, 29, 1, 1-12. Newham, D (1997).‘Physiotherapyto best effect’, Physiotherapy, 83,1, 5-1 1. Robertson, V (1996). ‘Epistemology, private knowledge, and the real problems in physiotherapy’,Physiotherapy, 82,9, 534-539.
letters Measuring Outcome Measures MADAM - The timely article ‘Outcome measures used in therapy departments in Scotland’ (Chesson et a/, 1996) has already helped to inform our choice of measures to evaluate new community services for older people in Cambridge. The preliminary results of our survey by Lifespan Healthcare of 25 rehabilitation wards in England suggest the type and range of measure5 used here broadly resemble the pattern in Scotland. However, three aspects of the results may deserve discussion. Patients’ views on their outcomes after rehabilitation are not necessarily less ‘validated’ than the measures scored by clinicians and they can be ‘reliably and routinely collected’ (Caan, 1996). In relation to goal attainment ratings, the results confirm that only a small minority of therapists are using these now. However, the impact of trying such ratings, both in benefiting individual care and in guiding the
side rural East Anglia and especially its utility as a measure of outcome. If any readers would be interested in collaborating to develop such a short measure for general use, we invite them to contact us at the address below.
development of services, may be out of all proportion to this modest level of use so far (Caan, 1995). Finally, my heart sank, reading that none of the Scottish departments used any measures of the quality of life as an outcome for therapy. However, it is very difficult to find off-the-shelf quality of life measures simple enough to use in routine practice. In Cambridge, with various clients, a range of measures as different as the Nottingham Health Profile, Harter or Oxford Happiness ratings which we tried have all failed to take root. Based on the suggestions of local occupational therapy day patients (with support from the Cancer Relief Macmillan Fund ) Lifespan Healthcare has evolved a simple four-item quality of life tool, the Fab-4. Over the last two years we have gradually rolled this out to a few different types of user., but we need many more subjects to determine its general validity out-
Woody Caan MA DPhil Douglas House 18b Trumpington Road Cambridge CB2 2AH
References Caan, W (1995). ‘Role of users of health care in achieving a quality service’, Quality in Health Care, 4, 65. Caan, W (1 996). ‘Clinical effectiveness and patient centred care’ in: Putting Evidence Based Medicine into Practice, IBC, London. Chesson, R, Macleod, M and Massie, S (1996). ‘Outcome measures used in therapy departments in Scotland’, Physiotherapy, 82,673-679. We hope that many readers will be able to contribute to this evaluation and look forward to publication of the results in Physiotherapy - Editor.
Diagnostic Criteria Imprecision MADAM - ‘Soft tissue disorders of the shoulder’ by Leisdek et a/ in last month’s issue of Physiotherapy showed a lack of inter-observer agreement in diagnosis. I suggest that the main reason was the choice of inadequate diagnostic criteria. I researched shoulder pain (Grieve, 1992a) and found that diagnostic criteria, more detailed than those used in this study, were inadequate. There was a relationship between pains in the shoulder and neck (Grieve, 1993) which confounded the diagnostic criteria for the shoulder conditions. The importance of excluding the cervical spine as a source of arm symptoms was recognised in 1976 by Gunn and Hilbrand, and by Cyriax long before that. Leisdek et a/ failed to exclude subjects with evidence of neck joint dysfunction, and in ignoring the neck, they also ignored the brachial plexus. Since developments in the study of neural mobility (Sunderland, 1978; Elvey, 1985, 1986; Butler and Gifford, 1989) there is much evidence that
have been more precisely defined, and confounding factors excluded, there is little value in attempting to assess reliability and treatment.
shoulder pain can arise through impairment of mobility of the cervical nerve roots, trunks and brachial plexus, without there being neurological ‘signs’, which they did exclude. The painful arc in abduction, for instance, has been shown to be at the angle of maximum neural tension. For these reasons, I consider that any subject having neck pain, or reporting previous neck problems (such as whiplash) should have been excluded. In my research (Grieve, 1993), pain on shoulder flexion was shown to be related to impaired neural mobility in a proportion of subjects and many of the rotator cuff tests, such as tenderness of tendons, proved to be nonspecific (Grieve, 1992b). Other tests which I consider essential are acromio-clavicular joint compression for ‘sub-acromial bursitis’; proportional limitation in the capsular pattern for ‘capsulitis’; passive movements for ‘acromioclavicular syndrome’. In short, until the diagnostic criteria
Elizabeth Grieve PhD MCSP MMACP DipTP Birmingham
References Butler, D and Gifford, L (1989). ‘The concept of mechanical tension in the nervous system’, Physiotherapy, 75, 622-636. Elvey, R L (1985). ‘Abnormal brachial plexus tension and shoulder joint limitation’, Proceedings of the Fifth Seminar of the International Federation of Orthopaedic Manipulative Therapists, Vancouver, June 25-29, 1984, IFOMT, New Zealand. Elvey, R L (1986). ‘The investigation of arm pain’, in: Grieve, G P (ed) Modern Manual Therapy of the Vertebral Column, Churchill Livingstone, Edinburgh. Grieve, E F M (1992a). ‘A study of chronic arm pain in industry’, PhD thesis, University of Birmingham. Grieve, E F M (1992b). ‘The physical assessment of the musculo-tendinous unit - a revised interpretation of the findings’ (poster), Chartered Society of Physiotherapy, Annual Congress, Glasgow, October 4-9.
~~
Physiotherapy,February 1997, vol 83,no 2
104
Grieve, E F M (1 993). ‘The cervical contribution to arm pain in a sample of industrial workers’, Physiotherapy Theory and Practice, 9, 223-234. Gunn, C C and Hilbrandt, W E (1976). ‘Tennis elbow and the cervical spine’,
MADAM - ‘Soft-tissue disorders of the shoulder’ by Liesdek e t a / (Physiotherapy, January 1997) is an interesting research report which, in part, looks at the inter-observer agreement between GPs and physiotherapists in diagnosing shoulder pain. The tool used for the study is the clinical guidelines for the management of shoulder pain, based on the concepts of Cyriax. It is these concepts which are being researched. Unfortunately this key element is not acknowledged in the title, the summary or the key words. This I feel is an omission and could lead to some
Journal of the Canadian Medical Association, 114, 803-809.
Leisdek, C, van der Windt, D A W M, Koes, B W and Bouter, L M (1997). ‘Soft-tissue disorders of the shoulder’, Physiotherapy, 83,1, 12-21. Sunderland, S (1978).‘Traumatised nerve roots and ganglia: Musculoskeletal.factors and neuro-pathologicalconsequences’ in: Korr, I M (ed) The Neurobiologic Mechanisms of Manual Therapy, Plenum Press, New York, pages 137-1 66.
confusion when using the article to enhance one‘s understanding of soft-tissue disorders of the shoulder. As the authors of the article state, there are ‘several other proposals of the classification of shoulder pain ’(page 15) and the fact that only the concepts of Cyriax have been investigated is an important point which should have been highlighted both in the title and the summary, these being the initial, and unfortunately sometimes the only, elements of an article which are read.
Simon Rouse MSc BEd MCSP DipTP Leeds
The Origin of Cable Operated Reciprocal Orthoses - A Truly British Invention MADAM - It was sad to see an article published in the January issue of Physiotherapy (‘Development of orthoses for people with paraplegia’ by J Melia) which yet again gave credit to the Louisiana State University for the invention of reciprocal gait orthoses. In fact their team adopted this idea from work carried out in this country during the late 1960s, some of which was funded by the DHSS. About 25 children had a set made for them and these were later developed by a team including Bill Bond (an engineer), the late Trevor Bowen
(an orthopaedic surgeon), Moyna Gilbertson FCSP and myself. This work was published in Physiotherapy in two articles during 1971, a letter (in response to another inaccurate article) and several other nursing and specialist periodicals. An’MSc thesis in 1969 prepared at the University of Surrey was entitled ‘Interconnected hip hinges in lower limb bracing’. At the same time, and in the UK, John Florence was developing the Hartley brace, which used cable-operated reciprocation: and in Canada, at the Ontario Crippled Children’s Centre in Toronto, Wally Motloch
Looking through Different Spectacles MADAM - In her article ‘Epistemology, private knowledge, and the real problems in physiotherapy’ (Physiotherapy, September 1996), Robertson likens the claim that physiotherapists should know about the nature of knowledge (epistemology) in order to generate knowledge to the claim that someone who needs glasses should know about the laws of optics. She asserts that all one needs to know is that glasses ‘can provide suitable correction’. Physiotherapists do need to know about different theories of knowledge precisely because specific inquiry paradigms, with their associated epistemologies, provide a variety of lenses through which the world can be viewed. Part of ‘research awareness’ (Newham, 1997) is an appreciation of the importance of the epistemological question - t h e nature of the relationship between the would-be knower ~~~
and what can be known (Guba, 1990). French and Swain (1997) challenge physiotherapists to consider participatory and emancipatory research approaches, based in the critical theory paradigm, which question the objectivist epistemology of the positivist paradigm that dominates disability research. In her article entitled ‘Constructing realities: An art of lenses’, Hoffman (1990) explores the implications for her own practice as a family therapist of moving from a dualist epistemology influenced by the circular feedback loops of cybernetic theory to the transactional epistemology of social construction theory where meanings evolve as part of human interaction. A practice based on a search for shared understandings and ideas for action replaced ‘the visiting expert’ (Hoffman, 1990). Physiotherapists could usefully ~
Physiotherapy, February 1997, vol 83,no 2
published two designs for reciprocating gait orthoses, using non-cable systems. The article shows little evidence of research into the subject and I am as concerned about that as I am by the lack of credit to British workers for a device whose origins are firmly rooted in the UK, despite the persistent efforts to make it appear otherwise.
David Scrutton MSc MCSP Honorary Senior Lecturer The Institute of Child Health and UMDS, Guy’s & St Thomas’ Hospitals London
consider trying on different epistemological glasses to see how their professional worlds and the worlds of their clients change with different lenses.
Diana Jones BA MCSP GradDipPhys Research Physiotherapist University of Northumbria at Newcastle
References French, S and Swain, J (1997). ‘Changing disability research: Participating and emancipatory research with disabled people’, Physiotherapy, 83,1, 26-32. Guba, E G (1990). ‘The alternative paradigm dialog’ in: Guba, E G The Paradigm Dialog, Sage Publications, Newbury Park. Hoffman, L (1990). ‘Constructing realities: An art of lenses’, Family Process, 29, 1, 1-12. Newham, D (1997).‘Physiotherapyto best effect’, Physiotherapy, 83,1, 5-1 1. Robertson, V (1996). ‘Epistemology, private knowledge, and the real problems in physiotherapy’,Physiotherapy, 82,9, 534-539.