Foot drop is a common gait impairment after stroke. Functional electrical stimulation (FES) of the ankle dorsiflexor muscles during the swing phase of gait can help correct foot drop. Compared with constant-frequency trains (CFTs), which typically are used during FES, novel stimulation patterns called variable-frequency trains (VFTs) have been shown to enhance isometric and nonisometric muscle performance. However, VFTs have never been used for FES during gait.
The purpose of this study was to compare knee and ankle kinematics during the swing phase of gait when FES was delivered to the ankle dorsiflexor muscles using VFTs versus CFTs.
A repeated-measures design was used in this study.
Thirteen individuals with hemiparesis following stroke (9 men, 4 women; age=46–72 years) participated in the study.
Participants completed 20- to 40-second bouts of walking at their self-selected walking speeds. Three walking conditions were compared: walking without FES, walking with dorsiflexor muscle FES using CFTs, and walking with dorsiflexor FES using VFTs.
Functional electrical stimulation using both CFTs and VFTs improved ankle dorsiflexion angles during the swing phase of gait compared with walking without FES (X±SE=–2.9°±1.2°). Greater ankle dorsiflexion in the swing phase was generated during walking with FES using VFTs (X±SE=2.1°±1.5°) versus CFTs (X±SE=0.3±1.3°). Surprisingly, dorsiflexor FES resulted in reduced knee flexion during the swing phase and reduced ankle plantar flexion at toe-off.
The findings suggest that novel FES systems capable of delivering VFTs during gait can produce enhanced correction of foot drop compared with traditional FES systems that deliver CFTs. The results also suggest that the timing of delivery of FES during gait is critical and merits further investigation.
Prior experience informs clinical decision making and shapes how reflection is used by novice and experienced physical therapist clinicians.
The aims of this research were: (1) to determine the types and extent of reflection that informs the clinical decision-making process and (2) to compare the use of reflection to direct and assess clinical decisions made by novice and experienced physical therapists.
Qualitative research methods using grounded theory were used to gain insight into how physical therapists use reflection to inform clinical decision making.
Three participant pairs (each pair consisting of one novice and one experienced physical therapist) were purposively selected from 3 inpatient rehabilitation settings. Case summaries of each participant provided the basis for within- and across-case analysis. Credibility of these results was established through member check of the case summaries, presentation of low-inference data, and triangulation across multiple data sources and within and across the participant groups.
Although all participants engaged in reflection-on-action, the experienced participants did so with greater frequency. The experienced participants were distinguished by their use of reflection-in-action and self-assessment during therapist-patient interactions. An intermediate effect beyond novice practice was observed.
The results of this study may be used by educators and employers to develop and structure learning experiences and mentoring opportunities to facilitate clinical decision-making abilities and the development of the skills necessary for reflection in students and novice practitioners.
Although therapeutic ultrasound is commonly used to treat shoulder injuries, research to date on the ability of ultrasound to improve outcomes for shoulder pathologies is conflicting.
This study aimed to systematically and critically review available literature to ascertain whether beneficial effects of ultrasound were associated with certain shoulder pathologies or particular ultrasound treatment protocols.
Five electronic databases were searched, and the included studies, identified through pair consensus, were randomized controlled trials (RCTs) that utilized ultrasound for soft tissue shoulder injury or pain.
Eight studies included in this review (n=586 patients, median PEDro score=8.0/10) evaluated various parameters, including the duration of patients' symptoms (0–12 months), duty cycle (20% and 100%), intensity (0.1–2.0 W/cm2), treatment time per session (4.5–15.8 minutes), number of treatments (6–39), and total energy applied per treatment (181–8,152 J).
Inconsistent outcome measures among studies precluded meta-analysis; however, 3 RCTs showed statistically significant benefits of ultrasound, 2 of which examined calcific tendinitis. Studies that showed beneficial effects of ultrasound typically had 4 times longer total exposure times and applied much greater ultrasound energy per session (average of 4,228 J) compared with studies that showed no benefit of ultrasound (average of 2,019 J). No studies that delivered ≤720 J per session showed improvement in treatment groups.
Current research involving ultrasound treatment protocols that delivered low levels of ultrasound energy do not adequately address whether ultrasound can improve outcomes for shoulder disorders.
Determining whether therapeutic ultrasound can affect soft tissue shoulder pathologies will require further research and systematic reviews that involve appropriate ultrasound treatment protocols.
The Figure-of-8 Walk Test (F8W) involves straight and curved paths and was designed to represent walking skill in everyday life.
The purposes of this study were to validate the measure in older adults with walking difficulties and to explore correlates of the curved-path walking measure not represented by a straight-path walking measure.
Fifty-one community-dwelling older adults with mobility disability participated in 2 baseline visits as part of an intervention study.
The F8W time, steps, and smoothness and measures of gait (gait speed, modified Gait Abnormality Rating Scale [GARS-M]), physical function (Late Life Function and Disabilities Index [LLFDI], Survey of Activities and Fear of Falling in the Elderly [SAFFE], Gait Efficacy Scale [GES], Physical Performance Test [PPT], and fall history), and movement control and planning (gait variability, Trail Making Test B [Trails B]) were recorded in each test session. Bivariate correlations for the F8W with each variable were conducted to examine concurrent and construct validity. Adjusted linear regression analyses were performed to explore the variance in mobility explained by F8W independent of gait speed.
Figure-of-8 Walk Test time correlated with gait (gait speed, r=–.570; GARS-M, r=.281), physical function (LLFDI function, r=–.469; SAFFE restriction subscale, r=.370; PPT, r=–.353), confidence in walking (GES, r=–.468), and movement control (step length coefficient of variation, r=.279; step width coefficient of variation, r=–.277; Trails B, r=.351). Figure-of-8 Walk Test steps correlated with step width variability (r=–.339) and was related to fear of falling (t=–2.50). All correlations were significant (P<.05).
This pilot study had a small sample size, and further research is needed.
The F8W is a valid measure of walking skill among older adults with mobility disability and may provide information complementary to gait speed.
Despite legislative approval of direct access to physical therapy, other regulatory barriers and internal institutional policies often must be overcome before this practice model can be fully adopted. Few institutional initiatives have been published describing strategies designed to change policies restricting direct patient access. This case report describes steps and strategies associated with successful implementation of a direct access physical therapy model at a large academic medical center.
The process of obtaining institutional medical board and hospital authority board approval and implementing a pilot program is described. Program details, including therapist qualifications and scope of practice, required internal training program, and program outcome assessment, are provided. The therapist scope of practice includes the ability to refer patients directly to a radiologist for plain film radiography. Early pilot program findings, including challenges faced and subsequent actions, are described.
Reviewed patient care decisions by therapists participating in the pilot program were deemed appropriate 100% of the time by physician chart reviewers. Approximately 10% of the patients seen were referred to a radiologist for plain film imaging, and 4% and 16% of the patients were referred to physicians for pain medications or medical consultation, respectively. The pilot program's success led to institutional adoption of the direct access model in all physical therapy outpatient clinics.
Autonomy is described, in part, as self-determined professional judgment and action. This case report describes such an effort at a large academic medical center. The interdependent, collaborative relationship among physical therapists, physicians, and hospital administrators has resulted in the implementation of a patient-centered practice model based on the premise of patient choice.
Lower-extremity injuries constitute the leading cause of trauma hospitalizations among people under the age of 65 years. Rehabilitation has the potential to favorably influence the outcomes associated with traumatic lower-extremity injuries.
The objectives of this study were to explore variability in surgeon and physical therapist assessments of the need for physical therapy in patients with traumatic lower-extremity injuries and to determine the factors associated with assessments of need.
This study was a retrospective cohort investigation.
Participants were 395 patients treated by reconstruction in the Lower-Extremity Assessment Project. They were evaluated at 8 level I trauma centers at 3, 6, and 12 months after hospitalization by an orthopedic surgeon and a physical therapist to determine the need for physical therapy. Analyses included multilevel logistic regression.
Chi-square analyses showed that surgeon and therapist assessments of need differed statistically across trauma centers. Surgeons were more likely to assess a need for therapy at 3 months when participants had low work self-efficacy, impaired knee flexion range of motion (ROM), and weight-bearing limitations and at 6 and 12 months when participants had impaired knee flexion ROM and weight-bearing and balance limitations. Therapists were more likely to assess a need for therapy at 3 months when participants had moderate to severe pain and at 6 and 12 months when participants had low work self-efficacy, pain, impaired knee flexion ROM, and balance limitations.
The results revealed variability in assessments of the need for physical therapy at the provider and trauma center levels. Differences in provider assessments highlight the need for communication and further investigation into the outcomes and timing of physical therapy for the treatment of traumatic lower-extremity injuries.
Patients with hand osteoarthritis are commonly treated by health care professionals (allied to medicine). Practice should be informed by updated evidence from systematic reviews of randomized controlled trials.
The purpose of this overview is to summarize the evidence from systematic reviews of the effectiveness of nonpharmacological and nonsurgical interventions for patients with hand osteoarthritis.
Systematic reviews published between January 2000 and October 2008 were identified by a comprehensive literature search.
Two reviewers independently selected reviews for inclusion, assessed their methodological quality, and extracted and synthesized data according to predefined criteria. Four systematic reviews finally were included. Based on single randomized controlled trials, there is some evidence of the effect of pain relief from topical capsaicin compared with placebo and for favorable functional outcomes for exercise and education compared with osteoarthritis information alone.
In overviews, results are dependent on available systematic reviews. They are important tools to guide directions in choice of interventions and locate areas where more research is needed, but they might not be useful for deciding specifically how interventions should be carried out.
There currently is insufficient high-quality evidence regarding nonpharmacological and nonsurgical interventions for hand osteoarthritis. Considering the limited research evidence and the prevalence and impact of the disease, there is an urgent need for more trials of nonpharmacological and nonsurgical interventions for hand osteoarthritis.
Women in early postmenopause and with low bone mineral density (BMD) may exhibit early markers for physical frailty as a result of sarcopenia and osteopenia.
The purpose of this study was to determine whether women in early postmenopause and with low BMD exhibit decreased physical performance and differences in gait variability and fall and fracture rates.
This study was an observational cohort design with participants assigned to groups on the basis of BMD status.
Fifty-four women, 31 with low BMD and 23 with normal BMD, participated. This study was conducted in a university research facility. Physical performance was measured by assessment of dynamic balance (timed backward tandem walk test), strength (handheld dynamometry of isometric quadriceps muscle force production), and free gait speed. Gait variability was assessed on the basis of the coefficient of variation for temporal-spatial gait characteristics. Falls and fractures were assessed for the year after initial testing.
Significant between-group differences were found for step time and stance time variability.
The limitations of this study included group assignment on the basis of the results of the most recent bone density scan within the preceding 2 years.
Women in early postmenopause and with low BMD exhibited increased gait variability in step time and stance time but did not exhibit differences in balance, strength, or gait speed. Gait variability may be more sensitive for detecting differences in women in early postmenopause and with or without low BMD than more typical measures of physical performance.
Through social and community participation, children and youth with cerebral palsy (CP) form friendships, gain knowledge, learn skills, express creativity, and determine meaning and purpose in life.
The purposes of this study were: (1) to determine whether social and community participation of children and youth with CP differ based on age, sex, and gross motor function; and (2) to identify the types of activities in which social and community participation are highest.
A prospective cross-sectional analytic design was used. The participants were a sample of convenience of 291 children (6–12 years of age) and 209 youth (13–21 years of age) with CP (55.4% males, 44.6% females) receiving services from 7 children's hospitals. Participants completed the Children's Assessment of Participation and Enjoyment (CAPE) by structured interview. Gross Motor Function Classification System (GMFCS) level was determined by the researchers.
Youth did a higher percentage of activities with friends and others and outside the home than children. Children and youth in level I did a higher percentage of activities with friends and others compared with children and youth in levels II and III and in levels IV and V. Children and youth in level I and in levels IV and V did a higher percentage of activities outside the home than children and youth in levels II and III. Differences were not found between females and males. The percentage of activities done with friends and others and outside the home was highest for physical and skill-based activities.
Findings cannot be attributed only to GMFCS level.
The ability to walk without restrictions is desirable for social and community participation. For children and youth with CP who have limitations in mobility, physical therapists have roles as consultants for accessibility, activity accommodations, and assistive technology and as advocates for inclusive environments.
Infants born preterm are at risk for developmental impairments related to postural control.
The purpose of this study was to determine whether infants born preterm and infants born at full term differed in postural control at 1 to 3 weeks after term age.
This study included 17 infants born preterm (mean gestational age=31.9 weeks, range=25.0–34.6) and 15 infants born at full term (mean gestational age=38.9 weeks, range=37.3–40.6) without diagnosed neurological or genetic conditions.
Center-of-pressure (COP) data were recorded at 5 Hz while each infant was positioned supine on a pressure-sensitive mat in an alert behavioral state. Root mean square (RMS) displacement and approximate entropy (ApEn) were used to describe the COP movement variability in the time series. Differences between groups were identified using independent t tests.
The COP time series were found to be deterministic, suggesting order in the time series. Infants born preterm exhibited significantly larger RMS values in the caudal-cephalic direction than infants born at full term (1.11 and 0.83 cm, respectively; t=–2.6, df=30, P=.01). However, infants born at full term had significantly larger ApEn values in the caudal-cephalic direction (1.19 and 1.11, respectively; t=2.4, df=30, P=.02). The 2 groups did not differ in RMS or ApEn values in the medial-lateral direction or the resultant.
Infants born at full term exhibited COP displacements in the caudal-cephalic direction that were smaller in amplitude, but may be considered more complex or less predictable, than those of infants born preterm. One explanation is that infants born preterm exhibited more stereotypic patterns of movement, resulting in large, but repetitive, COP excursions. A combination of linear and nonlinear measures may provide insight into the control of posture of young infants.
Current evidence suggests that spinal manipulative therapy (SMT) is effective in the treatment of people with low back pain (LBP); however, the corresponding mechanisms are unknown. Hypoalgesia is associated with SMT and is suggestive of specific mechanisms.
The primary purpose of this study was to assess the immediate effects of SMT on thermal pain perception in people with LBP. A secondary purpose was to determine whether the resulting hypoalgesia was a local effect and whether psychological influences were associated with changes in pain perception.
This study was a randomized controlled trial.
A sample of convenience was recruited from community and outpatient clinics.
Thirty-six people (10 men, 26 women) currently experiencing LBP participated in the study. The average age of the participants was 32.39 (SD=12.63) years, and the average duration of LBP was 221.79 (SD=365.37) weeks.
Baseline demographic and psychological measurements were obtained, followed by quantitative sensory testing to assess temporal summation and A fiber–mediated pain perception. Next, participants were randomly assigned to ride a stationary bicycle, perform low back extension exercises, or receive SMT. Finally, the same quantitative sensory testing protocol was reassessed to determine the immediate effects of each intervention on thermal pain sensitivity.
Hypoalgesia to A fiber–mediated pain perception was not observed. Group-dependent hypoalgesia of temporal summation specific to the lumbar innervated region was observed. Pair-wise comparisons indicated significant hypoalgesia in participants who received SMT, but not in those who rode a stationary bicycle or performed low back extension exercises. Psychological factors did not significantly correlate with changes in temporal summation in participants who received SMT.
Only immediate effects of SMT were measured, so the authors are unable to comment on whether the inhibition of temporal summation is a lasting effect. Furthermore, the authors are unable to comment on the relationship between their findings and changes in clinical pain.
Inhibition of A fiber–mediated pain perception was similar for all groups. However, inhibition of temporal summation was observed only in participants receiving SMT, suggesting a modulation of dorsal horn excitability that was observed primarily in the lumbar innervated area.
Although spontaneous use of the more-affected arm and hand after stroke is an important determinant of participation and quality of life, a number of patients exhibit decreases in use following rehabilitative therapy. A previous neurocomputational model predicted that if the dose of therapy is sufficient to bring performance above a certain threshold, training can be stopped.
The aim of this study was to test the hypothesis that there exists a threshold for function of the paretic arm and hand after therapy. If function is above this threshold, spontaneous use will increase in the months following therapy. In contrast, if function is below this threshold, spontaneous use will decrease.
New computer simulations are presented showing that changes in arm use following therapy depend on a performance threshold. This prediction was tested by reanalyzing the data from the Extremity Constraint-Induced Therapy Evaluation (EXCITE) trial, phase III randomized controlled trial in which participants received constraint-induced movement therapy for 2 weeks and were tested both 1 week and 1 year after therapy.
The results demonstrate that arm and hand function measured immediately after therapy predicts, on average, the long-term change of arm use. Above a functional threshold, use improves. Below this threshold, use decreases.
The reanalysis of the EXCITE trial data provides a "group" threshold above which a majority of patients, but not all, improve spontaneously. A goal of future research is to provide the means to assess when patients reach their individual threshold.
Understanding of the causal and nonlinear relationship between limb function and daily use is important for the future development of cost-effective interventions and prevention of "rehabilitation in vain."