Physical Therapy Reviews 2006; 11: 49–56

PHYSIOTHERAPY IN THE INTENSIVE CARE UNIT LINDA DENEHY1 AND SUSAN BERNEY2 1

School of Physiotherapy, Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Melbourne, Victoria, Australia 2 Department of Physiotherapy, Austin Hospital, Heidelberg, Victoria, Australia

Physiotherapy is reported to be an integral part of patient management in the intensive care unit (ICU) of hospitals in industrialised countries. There is substantial literature which supports the role of respiratory management and rehabilitation of critically ill patients, although there is a paucity of randomised controlled trials in this area and trials examining patient outcomes. The aims of this review are to present the current evidence for the role of physiotherapists in the adult ICU. The efficacy of ‘chest physiotherapy’ on short-term patient physiological outcomes has been studied extensively and there is moderate-to-strong evidence in support of its role. The safety of physiotherapy treatment in ICU has also recently been established. In addition, there is growing evidence for the role of exercise rehabilitation beginning in ICU and extending to beyond ICU discharge. Urgent research is required by physiotherapists to establish the effectiveness of such treatments.

Keywords: Chest physiotherapy, exercise, intensive care, non-invasive ventilation, rehabilitation

Intensive care is a dynamic environment where physiotherapists are vital members of the multidisciplinary team providing a spectrum of care from acute respiratory to rehabilitation. The education and training of physiotherapists and their role in relation to other health professionals such as nurses and respiratory therapists varies greatly. This withstanding, physiotherapy is reported to be an integral part of patient management in the intensive care unit (ICU) of hospitals in industrialised countries.1 The aims of this review are to present the current evidence for the role of physiotherapists in the adult ICU in relation to respiratory management including non-invasive ventilation (NIV), exercise, and short and longer term rehabilitation of patients. Literature searches were performed using the databases MEDLINE and CINAHL (cumulated index to nursing and allied health literature) with appropriate subject headings including intensive care, rehabilitation, physiotherapy, physical therapy, critical care, critical illness, chest physiotherapy, manual hyperinflation and exercise; searches were limited to English © W. S. Maney & Son Ltd 2006

language. The reference lists of extracted articles were also reviewed. Several surveys report on specific physiotherapy practice in the ICU;2–4 generally, these are limited to respiratory management. However, the assessment and management of neurological and musculoskeletal complications form an important part of the physiotherapist’s role.1,5 It is this individualised, multisystem patient assessment and treatment that defines the role of physiotherapists compared with respiratory therapists and nurses. Physiotherapists may be involved with specific patient positioning, suction, mobilisation, exercise, passive movements, manual airway clearance techniques, manual (MH) and ventilator hyperinflation (VH), NIV and weaning.1,6–8 The country of origin of published research reflects differences in types of healthcare professionals employed in the ICU, with research from the US predominately reporting respiratory therapist roles. In the UK, parts of Europe and Canada, South Africa, and Australia, the role of physiotherapists encompasses respiratory as well as neurological and musculoskeletal patient DOI 10.1179/108331906X98921

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Table 1. Summary of research into physiotherapy in ICU, 2000–2005, presented chronologically Reference Study type (n) Study design Comparisons Outcomes

Maa et al. (2005)16 RCT (23) Manual hyperinflation versus control Sputum wet/dry ratio, tidal volume, maximal inspiratory pressure, ratio of arterial oxygen to fraction of inspired oxygen (PaO2:FiO2), chest X-ray Improved tidal volume and chest X-ray findings. Trend improvement in ratio of arterial oxygen to fraction of inspired oxygen (PaO2:FiO2)

Reference Study type (n) Study design Comparisons Outcomes

Choi & Jones (2005)21 Crossover (15) Manual hyperinflation and suction versus suction alone Static lung compliance, airway resistance Improvement in both with manual hyperinflation

Reference Study type (n) Study design Comparisons Outcomes

Berney et al. (2004)13 Crossover (20) Manual hyperinflation in side lying versus manual hyperinflation in side lying with head down tilt Sputum wet weight, peak expiratory flow rate, static lung compliance Head down tilt improved sputum wet weight and peak expiratory flow rate

Reference Study type (n) Study design Comparisons Outcomes

Anning et al. (2003)35 Sheep within subject (9) Manual hyperinflation for 2 min at 294% tidal volume Cardiac output, systemic vascular resistance, mean arterial blood pressure, pulmonary artery pressure Reduced cardiac output, mean arterial blood pressure; increased systemic vascular resistance, pulmonary artery pressure

Reference Study type (n) Study design Comparisons Outcomes

Berney & Denehy (2002)20 Crossover (20) Manual hyperinflation versus ventilator hyperinflation Sputum wet weight, static lung compliance Both methods improved static lung compliance and cleared equal volume of sputum

Reference Study type (n) Study design Comparisons Outcomes

Ntoumenopolous et al. (2002)23 Cohort study (60) Side lying or head down tilt, and vibration versus sham Incidence of ventilator-associated pneumonia, mechanical ventilation time, ICU length of stay Reduced incidence of ventilator-associated pneumonia if higher APACHE score; no difference for others

Reference Study type (n) Study design Comparisons Outcomes

Patman et al. (2001)56 Randomised, controlled trial (236) Physiotherapy treatment versus control in intubated postoperative cardiac surgery patients Postoperative pulmonary complications, mechanical ventilation time, ICU length of stay, hospital length of stay No differences in measures. Provision of physiotherapy during intubation does not improve outcomes after cardiac surgery

Reference Study type (n) Study design Comparisons

Patman et al. (2000)22 Randomised, controlled trial (100) 4 min of manual hyperinflation versus no manual hyperinflation Static lung compliance, alveolar-arterial oxygen gradient, ratio of arterial oxygen to fraction of inspired oxygen (PaO2:FiO2) Manual hyperinflation improved static lung compliance, alveolar-arterial oxygen gradient, and ratio of arterial oxygen to fraction of inspired oxygen (PaO2:FiO2)

Outcomes

Reference Study type (n) Study design Comparisons Outcomes

Hodgson et al. (2000)14 Within subject (18) Side lying, manual hyperinflation and suction versus side lying and suctioning Static lung compliance, sputum wet weight, mean arterial blood pressure Increased static lung compliance and sputum wet weight, no difference in ratio of arterial oxygen to fraction of inspired oxygen (PaO2:FiO2) and mean arterial blood pressure

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management.1,8 Factors influencing physiotherapy representation in the ICU also include the size of the unit, levels of expertise and staffing, and educational profile of physiotherapists.8,9 Additionally, the perceptions of physiotherapy and referral attitudes of intensivists may also impact upon their role.7 Rationale and evidence for the role of physiotherapy in reference to the techniques listed above follows with review under specific subheadings.

CARDIORESPIRATORY MANAGEMENT The goals of respiratory physiotherapy management are to promote secretion clearance, optimise oxygenation, improve lung volume and prevent respiratory complications in both the intubated and spontaneously breathing ICU patient.10 The rationale for treatment of intubated patients is based upon the effects of positive pressure ventilation on respiratory and cardiovascular systems and the impaired function of the mucociliary escalator.11 The resultant disturbance of normal secretion clearance potentially leads to sputum retention with a subsequent increase in airways’ resistance and work of breathing. These patients are at particular risk as the incidence of ventilator-associated pneumonia increases substantially following 24 h of mechanical ventilation.12 The efficacy of ‘chest physiotherapy’, defined variously as combinations of positioning, MH, VH, and percussion and vibrations, on short-term patient physiological outcomes has been studied extensively.13–17 Table 1 summarises this research for studies performed in the last 5 years. There is moderate-tostrong evidence (NHMRC level II and III)18 to suggest that physiotherapy treatment is effective in: recruiting alveoli;16,19 improving secretion clearance;13,14 compliance;13,14,20 airway resistance;21 gas exchange;22 and reducing the incidence of ventilatoracquired pneumonia.23 The technique which has been included in the majority of this research is manual hyperinflation. The most significant finding in relation to ‘chest physiotherapy’ treatment in the ICU is that it has been found to be safe, with adverse physiological changes (APCs) reported in only 29 of 12,800 physiotherapy treatments from five Australian tertiary hospitals (0.22%).24 Several studies have examined the effects of MH on secretion removal, oxygenation and static pulmonary compliance. The results have been difficult to interpret and compare due to variations in definition of MH, different circuits that have been used, and inconsistency in therapists’ technique and treatment dosage.5,25,26 In the last 5 years, several authors have

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contributed to defining further the technique of MH as used by physiotherapists and added considerable knowledge to the body of literature in this area.13,27–31 Summaries and recommendations from their findings are given in Table 2. For an evaluation of research prior to 2000, readers are referred to an extensive review of MH published in 1999.5 Beyond this, the use of VH has been compared with MH, and effects on static lung compliance and wet weight of sputum produced have been found to be similar. The use of VH allows the operator to control airway pressure limits, monitor delivered volumes, and maintain positive expiratory pressure. This research offers support to the use of VH as an alternative to MH, and describes the technique of VH.20 There is consensus in the critical care literature supporting the protective properties of positive end expiratory pressure (PEEP) in preventing ventilator-induced lung injury;32 as VH can be performed without disconnection from PEEP, physiotherapists must now consider the potential risks associated with delivering large tidal volume breaths using a manual resuscitation bag, when potentially the same benefits can be achieved by using the ventilator. Ntoumenopolous and colleagues23 compared physiotherapy treatment versus a sham treatment in 60 intubated and ventilated critically ill patients. Physiotherapy treatment comprised chest wall vibrations and specific positioning (no MH). The authors found that the incidence of nosocomial pneumonia was 31% less in the group who received physiotherapy, although no difference in time on mechanical ventilation or time in the ICU was found. This is the first study to compare outcomes for patients of receiving physiotherapy treatment in the ICU.23 This research follows on from previous work by the same author examining the effect of physiotherapy treatment on nosocomial pneumonia in 46 patients, which found that the more severely ill patients (APACHE 2 score > 15), and those ventilated longer than 7 days, showed a trend toward benefiting from physiotherapy; however, the relatively small sample size limited the generalisability of this work.17 Evidence relating to the cardiovascular and metabolic effects of physiotherapy treatment in the ICU is conflicting. Berney and Denehy33 found that chest physiotherapy including ventilator hyperinflation in side-lying did not significantly increase VO2 in 20 intubated adult ICU patients. This result was not consistent with previous similar work;34 however, the effects of physiotherapy treatment on VO2 had not previously been isolated from those of positioning the patient and airway suctioning. Providing effective physiotherapy management without additional stress on the cardiorespiratory and metabolic systems is vital in critically ill patients.

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Table 2. Summary of research into the technique of manual hyperinflation presented chronologically Reference Components studied Recommendation

Savian et al. (2005)31 Effect of manual hyperinflation with positive end expiratory pressure valve on peak expiratory flow rate. Laerdal versus Mapleson C circuit Both manual resuscitation bag with positive end expiratory pressure > 10 cmH2O reduced peak expiratory flow rate. Mapleson C circuit best

Reference Components studied Recommendation

Maxwell & Ellis (2004)28 Effect of maintaining bag compression during expiration on peak expiratory flow rate Decreased peak expiratory flow rate but differences small (? clinical significance)

Reference Components studied Recommendation

Maxwell & Ellis (2003)29 Comparisons of 3 manual resuscitation bags using 2 volumes ± rapid release of bag Rapid release produced higher peak expiratory flow rate in all. Peak expiratory flow rate higher at higher inspiratory volume

Reference Components studied

Hila et al. (2002)27 Manual hyperinflation delivered to test lung at 30 cmH2O at 3 static lung compliance settings with manometer and then without Manometer increased accuracy of delivery of manual hyperinflation but benefits not retained on withdrawal of manometer

Recommendation

Reference Components studied Recommendation

Redfern et al. (2001)57 Effect of manual hyperinflation delivered to test lung on airway pressures using a manometer Manometer reduced error. Use a manometer during treatment.

Reference Components of studied Recommendation

Patman et al. (2001)58 Manual hyperinflation delivered to test lung by 16 physiotherapists Good consistency in tidal volume and minute ventilation

In several studies performed examining ‘chest physiotherapy’ in patient populations, no adverse cardiovascular consequences have been encountered:13,14,16,33 measures of heart rate (HR), cardiac output (CO) and mean arterial blood pressure (MAP) were recorded during and after physiotherapy including MH in these studies. Conversely, others have recorded changes in HR, MAP and pulmonary vascular resistance in patients following coronary artery surgery,22 and in an animal model.35 Comprehensive reviews of haemodynamic responses to some aspects of physiotherapy in the ICU are available.36 Based upon the findings outlined above, care must to taken to monitor the patient at all times and to treat only if the stability of the cardiovascular system can be maintained. In a recent audit of APC during 12,800 physiotherapy treatments, changes to blood pressure (BP) in patients on inotropes was the most common finding in the small number of treatments where APC occurred.24 It is important to note that patient demographics in the studies discussed above did not include acute respiratory distress syndrome (ARDS). Recent evidence to provide lung protective strategies, including moderateto-high PEEP and low tidal volumes for patients with

ARDS also supports the use of periodic recruitment manoeuvres to improve oxygenation and reduce mortality.32 However, currently, the efficacy of such strategies may be limited to patients with non-pulmonary ARDS.37 There is an abundance of evidence to support the role of NIV in the ICU in the management of patients with acute hypercapnic respiratory failure and acute cardiogenic pulmonary oedema; however, controversy exists regarding its role in the management of hypoxaemic respiratory failure.38 Recent research supports the use of NIV in the prevention, rather than the treatment, of hypoxaemic respiratory failure, where failure to intubate patients may lead to increased mortality in the NIV group.39 Synthesis of findings from the NIV research to date is confounded by differing treatment regimens and the ability of staff to apply the technique effectively. NIV is an evolving specialty in ICU which requires specific training and application by professionals skilled in patient management. Although the role of physiotherapists in the decision-making process and application of NIV varies world-wide, physiotherapists are ideally suited to this role through their combined skills in physiology, knowledge of equipment and clinical management.

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The use of continuous positive airway pressure (CPAP) in preventing intubation in hypoxaemic patients following abdominal surgery was compared with administration of 50% oxygen in 209 patients: those who received CPAP had a lower intubation and pneumonia incidence and a shorter ICU stay.40 Findings from this randomised, controlled trial (RCT) support the work of previous authors55 and extends the effectiveness of CPAP in influencing important outcomes in hypoxaemic patients following abdominal surgery. In order to contribute further to this growing area, physiotherapists need to become involved in research into the role of NIV (including CPAP) in patient management, and to be strong advocates for their knowledge and ability in its application. Furthermore, physiotherapy undergraduate education should include the principles of management associated with NIV, which can be built upon at postgraduate level.

EXERCISE AND REHABILITATION Rehabilitation in the ICU has been defined in a position paper by The European Respiratory Society as a process to achieve optimal daily functioning and health-related quality of life of individual patients as measured by clinically and/or physiologically relevant outcome measures.41 The methods by which these broad aims are achieved vary significantly between and even within countries. There is substantial published literature which supports the role of rehabilitation of critically ill patients, although there is a paucity of both randomised controlled trials in this area and research examining patient outcomes.25 The progress of intensive care medicine has dramatically improved survival in critically ill patients;32,42 such improvement is, however, associated with deconditioning, muscle weakness, dyspnoea, depression, and a reduction in quality of life. Ultimately, the goal of intensive care is quality long-term, rather than shortterm survival, but international literature reports poor quality of life and physical outcomes in ICU survivors compared to age-matched controls.43 Changes in patient conditions result from prolonged periods of inactivity, catabolism and drug administration (e.g. sedative and neuromuscular blocking agents, corticosteroids); these factors contribute to weakness that can last for months following ICU discharge.44 Severe and prolonged weakness (critical illness neuromyopathy) is present in up to 25% of patients mechanically ventilated for greater than 7 days.45 Critical illness neuromuscular abnormality (CINMA) is also an independent predictor of

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prolonged weaning from mechanical ventilation.46 Among treatment strategies including intravenous immunotherapy, normalising blood glucose and minimising exposure to drug therapy, physiotherapy has been advocated.45 Exercise in the ICU aims to mobilise patients early and facilitate weaning,47 optimise oxygenation,48 and improve function by increasing strength and endurance.49 The role of physiotherapists in the application of exercise varies widely in response to scant evidence. Primarily, no reliable and valid exercise outcome measure has been developed to aid exercise prescription and measure patient outcomes, making research in the area difficult. As a result, there are currently no guidelines for rehabilitation of ventilated patients and few trials investigating effectiveness. Jones and colleagues44 studied 69 ICU patients at discharge provided with a 6-week self-help rehabilitation manual (including a self-directed exercise programme) compared to controls (n = 57), and found that scores on the SF-36 were significantly better for the intervention group than controls. There is an urgent need for research by physiotherapists into the long-term benefits in the terms of physical function and quality of life outcomes of ICU survivors using specifically designed exercise programmes in ICU survivors. Despite the paucity of evidence, the general consensus is that rehabilitation should commence as soon as possible during ICU admission. For ventilated patients in the ICU, the efficacy and use of physiotherapy interventions to improve deconditioning and weakness is variable. There is limited evidence that passive stretching is effective in maintaining muscle length or joint range of motion, most work having been performed using animal models. Furthermore, there are no data reporting the effectiveness of splinting to achieve the same aims of treatment. Despite this, there is anecdotal evidence that physiotherapists still use these techniques: further research is, therefore, required. The use of the tilt table in long-stay and neurological patients has been reported by 67% of Australian ICU physiotherapists surveyed;50 the aim of using a tilt table in rehabilitation is to re-introduce patients to the vertical position, especially following prolonged immobility. In the survey by Chang and colleagues,50 61% of physiotherapist respondents used tilting less than once per month or once a year. Reasons given for this were that other techniques were used in preference (46% of respondents), or that it was not clinically indicated (32% of respondents). Physiotherapists in high-level ICUs (level 3) used tilting more than in other units, reflecting the longer term patient demographics. These results highlight the lack of sound evidence for tilting currently available, and the preference for use of early

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Table 3. Safety recommendations for assessment and monitoring of exercise in critically ill patients

Other factors

Resting heart rate < 50% age predicted maximum heart rate Ratio of arterial oxygen to fraction of inspired oxygen (PaO2:FiO2) > 300. Oxyhaemoglobin saturation (SpO2) > 90% and < 4% recent decrease Haemoglobin stable and > 7 g/dl. Platelets stable and >20,000 cells/mm3

Cardiovascular reserve Respiratory reserve Other factors

Blood pressure < 20% recent variability Respiratory pattern satisfactory Body temperature < 38°C. Blood glucose 3.5–20 mmol/l

Cardiovascular reserve Respiratory reserve Other factors

Electrocardiograph normal Maintenance of mechanical ventilation during treatment No contra-indications from neurological, orthopaedic systems or lines

Cardiovascular reserve Respiratory reserve Other factors

Other cardiac conditions excluded

Cardiovascular reserve Respiratory reserve

Safe environment, appropriate staffing and expertise

From Stiller and Phillips (2003) Physiotherapy Theory and Practice.51

mobilisation such as assisted standing or marching on the spot exercise. Mobilisation can refer to many different activities, the exact definition of which are difficult to find. Commonly, there is a hierarchy in accepted mobilisation exercises in the ICU51 and this may include bed exercises, sitting over the edge of the bed, standing, transferring, and walking on the spot.52 These exercise strategies reflect specificity of training for future functional tasks. Mobilising critically ill patients requires an initial comprehensive assessment of the patient’s cardiorespiratory status. Until recently, there have been no published guidelines for patient safety and readiness for mobility. Stiller and Phillips51 recommend cardiovascular and respiratory parameters to be assessed prior to mobilisation (Table 3) in conjunction with a full patient assessment and use of clinical reasoning. The authors subsequently used these guidelines to study the effects of mobilisation on physiological parameters in 31 ICU patients and found that significant increases in HR and BP occurred during exercise while non-significant reductions in oxyhaemoglobin saturations were recorded. The authors concluded that, using the guidelines previously developed, they were able to institute mobilisation safely and effectively in the population of patients studied. Monitoring during and after exercise is vital and recommendations are to observe patient appearance, excessive changes in HR, BP SpO2, ECG arrhythmias, and patient appearance.51 Active exercise (including muscle training) has been shown to improve 6-min walking distance significantly more than standard care in 80 patients with chronic obstructive pulmonary disease and acute res-

piratory failure.53 The work of Nava53 supports the prescription of specific exercises such as bilateral arm elevation, hip/knee flexion, and knee extension exercises, in addition to functional activities such as sit-tostand, and walking on the spot, for intubated critically ill patients. Whilst the need for exercise rehabilitation in ICU has been recognised,47 there is no clinical research that identifies the most effective mode, intensity or frequency of exercise prescription. As a result, exercise is applied by physiotherapists in the ICU using physiological principles, underpinned by clinical training and a comprehensive understanding of pathophysiology. Physiotherapists are well placed to provide exercise but, again, there is an urgent need for research into exercise outcome measurement and the value of specific exercise regimens, particularly in intubated and ventilated patients. In the acutely ill patient, for example, the value of upper and lower limb strengthening exercise should be measured together with patient oxygen demands during and after exercise.

CONCLUSIONS AND RECOMMENDATIONS Rationalisation of the limited government resources to critical care has demanded that physiotherapists provide evidence for their continued role in patient management.54 Physiotherapy in the ICU needs to demonstrate cost-effective returns. In reviewing the literature, a lack of randomised clinical trials is evident. Previously, physiotherapists have concentrated on examining the effects of their treatment interventions on short-term physiological outcomes: authors

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attempting to determine the effects of treatment on longer term outcomes have been limited by small patient numbers. The benefits of physiotherapy treatment may be better evaluated as a part of a package of care that includes mobilisation, positioning, and variable nurse-to-patient ratios. It is plausible that physiotherapy treatment as a part of a multidisciplinary approach to care is integral in promoting lung recruitment, reducing the incidence of ventilatoracquired pneumonia, facilitating weaning, and promoting safe discharge from the ICU. Obtaining evidence and implementing practice remain a major barrier for physiotherapists who work in the ICU. Ntoumenopoulos and colleagues23 have provided sound evidence for the role of physiotherapy in reducing the incidence of nosocomial pneumonia in 60 ICU patients: this research was published in a journal with a high impact factor. It would be interesting to know whether the results have influenced intensivist physiotherapy referral attitudes. Certainly, physiotherapy referral in the unit where this research was undertaken has not changed (personal communication) highlighting that implementing change of practice based on evidence can be difficult. Given that nearly 60% of ICU directors from five different countries felt that certain aspects of physiotherapy work (predominately airway clearance) could be covered by nursing staff, it is imperative that physiotherapists promote their broader clinical role.7 Research measuring outcomes will become more available as physiotherapy students embrace a growing research culture in university physiotherapy schools and clinical training facilities,54 and more physiotherapists undertake postgraduate degrees in cardiorespiratory specialty areas. Research should focus on the broad aspects of physiotherapy service delivery in the ICU as a part of a multidisciplinary team using outcomes such as time on mechanical ventilation, time in ICU, re-admission to ICU, and discharge destination, together with quality of life and measures of physical function. Multicentre research in the form of a randomised controlled trial evaluating the effectiveness of ‘chest physiotherapy’ would be ideal, but extremely costly and virtually impossible to implement due to differences in both medical and physiotherapy clinical practices and disparity in roles and autonomy of therapists within ICU environments. In addition, the numbers of patients required to find a statistical difference in such a study mean it most likely will never be performed. Physiotherapy membership of, or recognition by, local critical care societies would enhance support and infrastructure to undertake research and help to facilitate changes to physiotherapy practice in critical care, based upon the best available evidence.

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ACKNOWLEDGEMENT The authors thank Ms Liz Skinner for her help with references and information relating to exercise, the topic of her PhD thesis.

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LINDA DENEHY (for correspondence) School of Physiotherapy, Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Melbourne, Victoria 3010, Australia Tel: +61 (0)3 8 34441171; Fax: +61 (0)3 83444188; E-mail: [email protected] SUSAN BERNEY Department of Physiotherapy, Austin Hospital, Heidelberg, Victoria 3054, Australia