Functional recovery of patients after a total knee arthroplasty (TKA) usually is measured with questionnaires. However, these self-report measures assess the patient's perspective on his or her ability to perform a task. Performance-based tests are needed to assess the patient's actual ability to perform a task.
The main purpose of this study was to quantify improvement in performance of the sit-to-stand movement of patients with a TKA.
In this prospective study of 16 patients with end-stage knee osteoarthritis followed by a TKA, the maximal knee angular extension velocity and amount of unloading (shifting weight) of the affected leg during the sit-to-stand movement and the visual analog scale score for pain were assessed preoperatively and 6 months and 1 year postoperatively. These data were compared with data for a control group of individuals who were healthy (n=27).
Before surgery, the participants in the TKA group unloaded their affected leg, but within 6 months after implantation, the affected leg was almost fully loaded again and comparable to the loading symmetry ratio of the control group. Furthermore, knee extension velocity also had increased, but remained lower than that of the control group. The changes in knee extension velocity took place during the first 6 months, after which a plateau was visible.
A potential limitation of the study design was that the patients were not perfectly matched with the control subjects.
Implantation of a total knee prosthesis partly improved performance of the sit-to-stand movement. Participants in the TKA group could fully load their operated leg, but they could not generate enough knee angular velocity during rising compared with the control group.
Previous studies have demonstrated that the performance of a secondary task during walking alters gait.
This study investigated the effects of task prioritization on walking in young and older adults to evaluate the "default" prioritization scheme used, the flexibility to alter prioritization and cortical resources allocated to gait and a secondary cognitive task, and any age-associated changes in these abilities.
A cross-sectional study that explicitly altered the focus of attention was used to investigate the effects of prioritization in young and older adults who were healthy.
Gait speed and gait variability were evaluated in young adults (n=40) and older adults (n=17) who were healthy, both during usual walking and under 3 dual-task conditions: (1) no specific prioritization instructions, (2) prioritization of gait, and (3) prioritization of the cognitive task.
Young adults significantly increased gait speed in the gait prioritization condition compared with gait speed in the no-instruction condition; a similar tendency was seen in the older adults. Gait speed was reduced when priority was given to the cognitive task in both age groups; however, this effect was less dramatic in the older adults. In the young adults, prioritization of gait tended to have different effects on gait speed among both men and women. In the older adults, but not in the young adults, all dual-task conditions produced increased gait variability, whereas prioritization did not alter this gait feature.
The sample size and the relative homogeneity of the older adults could be considered as possible limitations of the study.
Even among young adults, the effects of secondary, cognitive tasks on gait speed are strongly influenced by prioritization. This finding was less significant in the older adults, suggesting that there is an age-associated decline in the ability to flexibly allocate attention to gait. Somewhat surprisingly, when prioritization was not explicitly instructed, gait speed in both young and older adults most closely resembled that of the condition when they were instructed to focus attention on the cognitive task.
When people with stroke recover gait speed, they report improved function and reduced disability. However, the minimal amount of change in gait speed that is clinically meaningful and associated with an important difference in function for people poststroke has not been determined.
The purpose of this study was to determine the minimal clinically important difference (MCID) for comfortable gait speed (CGS) associated with an improvement in the modified Rankin Scale (mRS) score for people between 20 to 60 days poststroke.
This was a prospective, longitudinal, cohort study.
The participants in this study were 283 people with first-time stroke prospectively enrolled in the ongoing Locomotor Experience Applied Post Stroke (LEAPS) multi-site randomized clinical trial. Comfortable gait speed was measured and mRS scores were obtained at 20 and 60 days poststroke. Improvement of ≥1 on the mRS was used to detect meaningful change in disability level.
Mean (SD) CGS was 0.18 (0.16) m/s at 20 days and 0.39 (0.22) m/s at 60 days poststroke. Among all participants, 47.3% experienced an improvement in disability level ≥1. The MCID was estimated as an improvement in CGS of 0.16 m/s anchored to the mRS.
Because the mRS is not a gait-specific measure of disability, the estimated MCID for CGS was only 73.9% sensitive and 57.0% specific for detecting improvement in mRS scores.
We estimate that the MCID for gait speed among patients with subacute stroke and severe gait speed impairments is 0.16 m/s. Patients with subacute stroke who increase gait speed ≥0.16 m/s are more likely to experience a meaningful improvement in disability level than those who do not. Clinicians can use this reference value to develop goals and interpret progress in patients with subacute stroke.
Task-specific training programs after stroke improve walking function, but it is not clear which biomechanical parameters of gait are most associated with improved walking speed.
The purpose of this study was to identify gait parameters associated with improved walking speed after a locomotor training program that included body-weight–supported treadmill training (BWSTT).
A prospective, between-subjects design was used.
Fifteen people, ranging from approximately 9 months to 5 years after stroke, completed 1 of 3 different 6-week training regimens. These regimens consisted of 12 sessions of BWSTT alternated with 12 sessions of: lower-extremity resistive cycling; lower-extremity progressive, resistive strengthening; or a sham condition of arm ergometry. Gait analysis was conducted before and after the 6-week intervention program. Kinematics, kinetics, and electromyographic (EMG) activity were recorded from the hemiparetic lower extremity while participants walked at a self-selected pace. Changes in gait parameters were compared in participants who showed an increase in self-selected walking speed of greater than 0.08 m/s (high-response group) and in those with less improvement (low-response group).
Compared with participants in the low-response group, those in the high-response group displayed greater increases in terminal stance hip extension angle and hip flexion power (product of net joint moment and angular velocity) after the intervention. The intensity of soleus muscle EMG activity during walking also was significantly higher in participants in the high-response group after the intervention.
Only sagittal-plane parameters were assessed, and the sample size was small.
Task-specific locomotor training alternated with strength training resulted in kinematic, kinetic, and muscle activation adaptations that were strongly associated with improved walking speed. Changes in both hip and ankle biomechanics during late stance were associated with greater increases in gait speed.
In individuals with motor incomplete spinal cord injury (SCI), ambulatory function determined in the clinical setting is related to specific measures of body structure and function and activity limitations, although few studies have quantified the relationship of these variables with daily stepping (steps/day).
The aim of this study was to quantify daily stepping in ambulatory individuals with SCI and its relationship with clinical walking performance measures and specific demographics, impairments, and activity limitations.
A cross-sectional study was performed to estimate relationships among clinical variables to daily stepping in self-identified community versus non–community (household) walkers.
Average daily stepping was determined in 50 people with chronic, motor incomplete SCI. Data for clinical and self-report measures of walking performance also were collected, and their associations with daily stepping were analyzed using correlation and receiver operating characteristic (ROC) analyses. Relationships between daily stepping and the measures of demographics, impairments, and activity limitations were identified using correlation and regression analyses.
The ROC analyses revealed a significant discriminative ability between self-reported community and non–community walkers using clinical gait measures and daily stepping. Stepping activity generally was low throughout the sample tested, however, with an average of approximately 2,600 steps/day. Knee extension strength (force-generating capacity) and static balance were the primary variables related to daily stepping, with metabolic efficiency and capacity and balance confidence contributing to a lesser extent.
The small sample size and use of specific impairment-related measures were potential limitations of the study.
Daily stepping is extremely limited in individuals with incomplete SCI, with a potentially substantial contribution of impairments in knee extension strength and balance.
Gait and cognitive functions can deteriorate during dual tasking, especially in people with neurological deficits. Most studies examining the simultaneous effects of dual tasking on motor and cognitive aspects were not performed in ecological environments. Using virtual reality technology, functional environments can be simulated to study dual tasking.
The aims of this study were to test the feasibility of using a virtual functional environment for the examination of dual tasking and to determine the effects of dual tasking on gait parameters in people with stroke and age-matched controls who were healthy.
This was a cross-sectional observational study.
Twelve community-dwelling older adults with stroke and 10 age-matched older adults who were healthy participated in the study. Participants walked on a self-paced treadmill while viewing a virtual grocery aisle projected onto a screen placed in front of them. They were asked to walk through the aisle (single task) or to walk and select ("shop for") items according to instructions delivered before or during walking (dual tasking).
Overall, the stroke group walked slower than the control group in both conditions, whereas both groups walked faster overground than on the treadmill. The stroke group also showed larger variability in gait speed and shorter stride length than the control group. There was a general tendency to increase gait speed and stride length during dual-task conditions; however, a significant effect of dual tasking was found only in one dual-task condition for gait speed and stride duration variability. All participants were able to complete the task with minimal mistakes.
The small size and heterogeneity of the sample were limitations of the study.
It is feasible to use a functional virtual environment for investigation of dual tasking. Different gait strategies, including an increase or decrease in gait speed, can be used to cope with the increase in cognitive demands required for dual tasking.
Stiff knee gait, which may be seen in patients with upper motor neuron injury, describes a gait pattern with a relative loss of sagittal knee motion. It interferes with foot clearance during swing, often leading to inefficient compensatory mechanisms and ambulatory dysfunction. Distal rectus femoris muscle transfers and fractional lengthening of the vastus muscles have been performed in adult patients.
The purpose of this study was to describe a unique surgical technique and report on initial outcomes.
A retrospective case-series study design was used.
The patients were adults with stiff knee gait due to stroke or traumatic brain injury who underwent distal rectus femoris muscle transfer with fractional lengthening of the vastus muscles. The patients (19 men and 18 women) had an average age of 51 years at the time of surgery. Lower-extremity examinations, clinical gait analyses, and satisfaction levels were recorded preoperatively and postoperatively.
At a mean follow-up time of 10 months, 36 (97%) of the 37 patients were satisfied with their clinical and functional results, and the average Viosca score improved from 3.1 to 3.5.
Limitations of the study include use of a retrospective design, lack of a control group, and limited quantitative measures of gait.
Distal rectus femoris muscle transfer and fractional lengthening of the vastus muscles were found to be a possible treatment for adults with stiff-knee gait caused by stroke or traumatic brain injury.
Computer simulations have demonstrated that excessive hip and knee flexion during gait, as frequently seen in ambulatory children with cerebral palsy (CP), can reduce the ability of muscles to provide antigravity support and increase the tendency of hip muscles to internally rotate the thigh. These findings suggest that therapies for improving upright posture during gait also may reduce excessive internal rotation.
The goal of this study was to determine whether strength training can diminish the degree of crouched, internally rotated gait in children with spastic diplegic CP.
This was a pilot prospective clinical trial.
Eight children with CP participated in an 8-week progressive resistance exercise program, with 3-dimensional gait analysis and isokinetic testing performed before and after the program. Secondary measures included passive range of motion, the Ashworth Scale, and the PedsQL CP Module. To identify factors that may have influenced outcome, individual and subgroup data were examined for patterns of change within and across variables.
Strength (force-generating capacity) increased significantly in the left hip extensors, with smaller, nonsignificant mean increases in the other 3 extensor muscle groups, yet kinematic and functional outcomes were inconsistent. The first reported subject-specific computer simulations of crouch gait were created for one child who showed substantial benefit to examine the factors that may have contributed to this outcome.
The sample was small, with wide variability in outcomes.
Strength training may improve walking function and alignment in some patients for whom weakness is a major contributor to their gait deficits. However, in other patients, it may produce no change or even undesired outcomes. Given the variability of outcomes in this and other strengthening studies in CP, analytical approaches to determine the sources of variability are needed to better identify those individuals who are most likely to benefit from strengthening.
People with physical disabilities often face barriers to regaining walking ability and fitness after discharge from rehabilitation. Physical therapists are uniquely positioned to teach clients the knowledge and skills needed to exercise on functionally relevant equipment available in the community, such as elliptical trainers. However, therapeutic use is hindered by a lack of empirical information.
The purpose of this study was to examine joint kinematics and muscle activation recorded during walking and elliptical training to provide evidence-based data to guide clinical decision making.
This was a prospective, controlled laboratory study using a repeated-measures design.
Twenty adults free from impairments that might hinder gait participated. After familiarization procedures, subjects walked and trained on 4 elliptical devices while kinematic, electromyographic (EMG), and stride characteristic data were recorded.
Movement similarities between elliptical training and walking were supported by the documentation of relatively high coefficients of multiple correlation for the hip (.85–.89), thigh (.92–.94), knee (.87–.89) and, to a lesser extent, the ankle (.57–.71). Significantly greater flexion was documented at the trunk, pelvis, hip, and knee during elliptical training than during walking. One of the elliptical trainers most closely simulated sagittal-plane walking kinematics, as determined from an assessment of key variables. During elliptical training, gluteus maximus and vastus lateralis muscle activation were increased; medial hamstring, gastrocnemius, soleus, and tibialis anterior muscle activation were decreased; and gluteus medius and lateral hamstring muscle activation were relatively unchanged compared with muscle activation of those muscles in walking. On the basis of EMG findings, no elliptical trainer clearly emerged as the best for simulating gait.
To date, only 4 elliptical trainers have been studied, and the contributions of the upper extremities to movement have not been quantified.
Although one of the elliptical trainers best simulated sagittal-plane walking kinematics, EMG analysis failed to identify one clearly superior device. This research provides evidence-based data to help guide clinical decision making related to the use of elliptical trainers across the health care continuum and into the community.
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.
It has been reported that manipulative therapy directed at the cervical and thoracic spine may improve outcomes in patients with shoulder pain. To date, limited data are available to help physical therapists determine which patients with shoulder pain may experience changes in pain and disability following the application of these interventions.
The purpose of this study was to identify prognostic factors from the history and physical examination in individuals with shoulder pain who are likely to experience rapid improvement in pain and disability following cervical and thoracic spine manipulation.
This was a prospective single-arm trial.
This study was conducted in outpatient physical therapy clinics.
The participants were individuals who were seen by physical therapists for a primary complaint of shoulder pain.
Participants underwent a standardized examination and then a series of thrust and nonthrust manipulations directed toward the cervicothoracic spine. Individuals were classified as having achieved a successful outcome at the second and third sessions based on their perceived recovery. Potential prognostic variables were entered into a stepwise logistic regression model to determine the most accurate set of variables for prediction of treatment success.
Data for 80 individuals were included in the data analysis, of which 49 had a successful outcome. Five prognostic variables were retained in the final regression model. If 3 of the 5 variables were present, the chance of achieving a successful outcome improved from 61% to 89% (positive likelihood ratio=5.3).
A prospective single-arm trial lacking a control group does not allow for inferences to be made regarding cause and effect. The statistical procedures used may result in "overfitting" of the model, which can result in low precision of the prediction accuracy, and the bivariate analysis may have resulted in the rejection of some important variables.
The identified prognostic variables will allow clinicians to make an a priori identification of individuals with shoulder pain who are likely to experience short-term improvement with cervical and thoracic spine manipulation. Future studies are necessary to validate these findings.
Total knee arthroplasty (TKA) has been shown to be an effective surgical intervention for people with end-stage knee osteoarthritis. However, recovery of function is variable, and not all people have successful outcomes.
The aim of this study was to discern which early postoperative functional measures could predict functional ability at 1 year and 2 years after surgery.
One hundred fifty-five people who underwent unilateral TKA participated in the prospective longitudinal study. Functional evaluations were performed at the initial outpatient physical therapy appointment and at 1 and 2 years after surgery. Evaluations consisted of measurements of height, weight, quadriceps muscle strength (force-generating capacity), and knee range of motion; the Timed "Up & Go" Test (TUG); the stair-climbing task (SCT); and the Knee Outcome Survey (KOS) questionnaire. The ability to predict 1- and 2-year outcomes on the basis of early postoperative measures was analyzed with a hierarchical regression. Differences in functional scores were evaluated with a repeated-measures analysis of variance.
The TUG, SCT, and KOS scores at 1 and 2 years showed significant improvements over the scores at the initial evaluation (P<.001). A weaker quadriceps muscle in the limb that did not undergo surgery ("nonoperated limb") was related to poorer 1- and 2-year outcomes even after the influence of the other early postoperative measures was accounted for in the regression. Older participants with higher body masses also had poorer outcomes at 1 and 2 years. Postoperative measures were better predictors of TUG and SCT times than of KOS scores.
Rehabilitation regimens after TKA should include exercises to improve the strength of the nonoperated limb as well as to treat the deficits imposed by the surgery. Emphasis on treating age-related impairments and reducing body mass also might improve long-term outcomes.
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.
Bending down and kneeling are fundamental tasks of daily living, yet nearly a quarter of older adults report having difficulty performing or being unable to perform these movements. Older adults with stooping, crouching, or kneeling (SCK) difficulty have demonstrated an increased fall risk. Strength (force-generating capacity) measures may be useful for determining both SCK difficulty and fall risk.
The purposes of this study were: (1) to examine muscle strength differences in older adults with and without SCK difficulty and (2) to examine the relative contributions of trunk and leg muscle strength to SCK difficulty.
This was a cross-sectional observational study.
Community-dwelling older adults (age [X±SD]=75.5±6.0 years) with SCK difficulty (n=27) or without SCK difficulty (n=21) were tested for leg and trunk strength and functional mobility. Isometric strength at the trunk, hip, knee, and ankle also was normalized by body weight and height.
Compared with older adults with no SCK difficulty, those with SCK difficulty had significant decreases in normalized trunk extensor, knee extensor, and ankle dorsiflexor and plantar-flexor strength. In 2 separate multivariate analyses, raw ankle plantar-flexor strength (odds ratio [OR]=0.97, 95% confidence interval [CI]=0.95–0.99) and normalized knee extensor strength (OR=0.61, 95% CI=0.44–0.82) were significantly associated with SCK difficulty. Stooping, crouching, and kneeling difficulty also correlated with measures of functional balance and falls.
Although muscle groups that were key to rising from SCK were examined, there are other muscle groups that may contribute to safe SCK performance.
Decreased muscle strength, particularly when normalized for body size, predicts SCK difficulty. These data emphasize the importance of strength measurement at multiple levels in predicting self-reported functional impairment.
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.
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, the 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.
Clinical course and outcome connected to rehabilitation after hip or knee arthroplasty have been studied extensively, but few studies have assessed the content of team rehabilitation care for these patients.
The purpose of this study was to provide a thorough description of the structure, process, and outcome of team rehabilitation care for patients with hip or knee arthroplasty for osteoarthritis.
This was a multicenter, longitudinal observational study.
Patients (N=183) from 6 rehabilitation centers in Norway who were undergoing inpatient rehabilitation following hip or knee arthroplasty were included in the study. Structure and process components were recorded by participants and health care professionals in a patient diary. Participants also completed questionnaires regarding their experiences during their rehabilitation stay and recorded data for outcome measures at admission, at discharge, and 6 months after discharge. The main outcome measures were pain intensity and physical function, as assessed with the physical function scale of the Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36).
Data were complete for 172 participants (94%) at discharge and for 148 patients (81%) at the 6-month follow-up. Health care professionals, physical therapists, nurses, and physicians were most often involved in team care. Occupational therapists, social workers, and psychologists were seldom part of the rehabilitation team. Exercises provided by physical therapists were the most common treatment modality. Patient education, massage, and manual therapy also frequently were provided. The participants were very satisfied with their care and its organization, information, and communication and with the availability of health care professionals. They were moderately satisfied with the social environment of the rehabilitation setting. The participants had large improvements in the outcome measures during the rehabilitation stay and at the 6-month follow-up.
For typical physical therapy modalities such as exercises, electrotherapy, and acupuncture, there are limited descriptions and assessments of treatment doses.
Current team rehabilitation care involves a traditional team with physical therapists, nurses, and physicians. Several types of treatment modalities are used, with greatest emphasis on physical training. This detailed description of current team rehabilitation practice might help clinicians and researchers in planning clinical trials within a rehabilitation setting, as well as in improving rehabilitation practice.
The evidence that exercise intervention is effective for treatment of chronic low back pain comes from trials that are not placebo-controlled.
The purpose of this study was to investigate the efficacy of motor control exercise for people with chronic low back pain.
This was a randomized, placebo-controlled trial.
The study was conducted in an outpatient physical therapy department in Australia.
The participants were 154 patients with chronic low back pain of more than 12 weeks’ duration.
Twelve sessions of motor control exercise (ie, exercises designed to improve function of specific muscles of the low back region and the control of posture and movement) or placebo (ie, detuned ultrasound therapy and detuned short-wave therapy) were conducted over 8 weeks.
Primary outcomes were pain intensity, activity (measured by the Patient-Specific Functional Scale), and patient's global impression of recovery measured at 2 months. Secondary outcomes were pain; activity (measured by the Patient-Specific Functional Scale); patient's global impression of recovery measured at 6 and 12 months; activity limitation (measured by the Roland-Morris Disability Questionnaire) at 2, 6, and 12 months; and risk of persistent or recurrent pain at 12 months.
The exercise intervention improved activity and patient's global impression of recovery but did not clearly reduce pain at 2 months. The mean effect of exercise on activity (measured by the Patient-Specific Functional Scale) was 1.1 points (95% confidence interval [CI]=0.3 to 1.8), the mean effect on global impression of recovery was 1.5 points (95% CI=0.4 to 2.5), and the mean effect on pain was 0.9 points (95% CI=–0.01 to 1.8), all measured on 11-point scales. Secondary outcomes also favored motor control exercise.
Clinicians could not be blinded to the intervention they provided.
Motor control exercise produced short-term improvements in global impression of recovery and activity, but not pain, for people with chronic low back pain. Most of the effects observed in the short term were maintained at the 6- and 12-month follow-ups.
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.
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.
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.
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, a 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."
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.
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). All infants were 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.
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 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.
Constraint-induced movement therapy (CIMT) is a potentially effective intervention for children with hemiplegic cerebral palsy (CP).
The objectives of this systematic review are: (1) to investigate whether CIMT is supported with valid research of its effectiveness and (2) to identify key characteristics of the child and intervention protocol associated with the effects of CIMT.
A search of MEDLINE (1966 through March 2009), Entrez PubMed (1966 through March 2009), EMBASE (1980 through March 2009), CINAHL (1982 through March 2009), PsychINFO (1887 through March 2009), and Web of Science (1900 through March 2009) produced 23 relevant studies.
The 2 objectives of the review were addressed by: (1) scoring the validity and level of evidence for each study and calculating evidence-based statistics, if possible, and (2) recording and summarizing the inclusion and exclusion criteria, type and duration of constraint, intervention and study durations, and outcomes based on the International Classification of Functioning, Disability and Health (ICF).
Only studies published in journals and in English were included in the systematic review.
Studies varied widely in type and rigor of design; subject, constraint, and intervention characteristics; and ICF level for outcome measures. One outcome measure at the body functions and structure level and 4 outcome measures at the activity level had large and significant treatment effects (d≥.80), and these findings were from the most rigorous studies. Evidence from more-rigorous studies demonstrated an increased frequency of use of the upper extremity following CIMT for children with hemiplegic CP. The critical threshold for intensity that constitutes an adequate dose cannot be determined from the available research. Further research should include a priori power calculations, more-rigorous designs and comparisons of different components of CIMT in relation to specific children, and measures of potential impacts on the developing brain.
Restoration of physical function following lumbar microdiskectomy may be influenced by the postoperative care provided.
The purpose of this study was to examine the effectiveness of a new interventional protocol to improve functional performance in patients who have undergone a single-level lumbar microdiskectomy.
The study was conducted in physical therapy outpatient clinics.
Ninety-eight participants (53 male, 45 female) who had undergone a single-level lumbar microdiskectomy were randomly allocated to receive education only or exercise and education.
The exercise intervention consisted of a 12-week periodized program of back extensor strength (force-generating capacity) and endurance training and mat and upright therapeutic exercises. The Oswestry Disability Index (ODI) and physical measures of functional performance were tested 4 to 6 weeks postsurgery and 12 weeks later, following completion of the intervention program. Because some participants sought physical therapy outside of the study, postintervention scores were analyzed for both an as-randomized (2-group) design and an as-treated (3-group) design.
In the 2-group analyses, exercise and education resulted in a greater reduction in ODI scores and a greater improvement in distance walked. In the 3-group analyses, post hoc comparisons showed a significantly greater reduction in ODI scores following exercise and education compared with the education-only and usual physical therapy groups.
The limitations of this study include a lack of adherence to group assignment, disproportionate therapist contact time among treatment groups, and multiple use of univariate analyses.
An intensive, progressive exercise program combined with education reduces disability and improves function in patients who have undergone a single-level lumbar microdiskectomy.
Previous literature has not fully described physical therapists’ management of patients across diagnoses in the acute care setting or how that management might vary by facility.
The purposes of this study were to describe patient management by physical therapists in the acute care setting and to examine variations in patient management across facilities.
This was an observational study.
Fifty clinicians practicing at 3 academic medical centers in the northeastern United States agreed to participate. Over a 2-week period, clinicians completed checklists indicating the details of patient visits. Logistic analyses, controlling for patient age and diagnosis and accounting for clustering of data, were conducted to examine the odds of patients having several categories of examinations, goals, and interventions.
Participants provided 2,364 visits to 896 patients. More than 75% of patients in each facility received examinations, goals, and interventions related to functional ability. Median number of visits per patient, duration of visits, and number of visits in which the patient was not treated varied across facilities. Patients with orthopedic conditions were more likely than those with medical/surgical conditions to receive several types of examinations, goals, and interventions. The odds of patients having examinations, goals, and interventions related to functional abilities were greater in facility 2 than in facility 1.
Limitations include the convenience sample, use of an untested data collection tool, and use of only age and diagnosis to control for case mix.
This study of physical therapist practice in 3 acute care facilities suggests that patient management focuses on functional activity. There was no clear pattern of examinations, goals, and interventions related to specific diagnoses. A small degree of variation was found in practice across the facilities.
Several factors have been shown to influence first-time pass rates on the National Physical Therapy Examination (NPTE). It is unclear to what extent academic difficulty experienced by students in a physical therapist education program may affect NPTE pass rates. The effects of institutional status (public or private) and Carnegie Classification on NPTE pass rates also are unknown.
The aim of this study was to quantify the odds of failure on the NPTE for students experiencing academic difficulty and for institutional status and Carnegie Classification.
This investigation was a retrospective population-based cohort study.
Quota sampling was used to recruit a random sample of 20 professional physical therapist education programs across the United States. Individual student demographic, preadmission, and academic performance data were collected, as were data on program-level variables and data indicating pass/fail performance on the NPTE. A generalized linear mixed-effects logistic regression model was used to adjust for confounding factors and to describe relationships among the key predictor variables—academic difficulty, institutional status, and Carnegie Classification—and the dependent variable, NPTE performance.
Academic difficulty during a student's professional training was an independent predictor for NPTE failure. The odds of students who had academic difficulty (relative to students who did not experience academic difficulty) failing the NPTE were 5.89 (95% confidence interval=4.06–8.93). The odds of NPTE failure also varied depending on institutional status and Carnegie Classification.
The findings related to Carnegie Classification and institutional status should be considered preliminary.
Student performance on the NPTE was influenced by multiple factors, but the most important, potentially modifiable risk factor for poor NPTE performance likely is academic difficulty during professional training.
There is growing involvement by US clinicians, faculty members, and students in global health initiatives, including international service-learning (ISL). Limited research has been done to examine the profession's increasing global engagement, or the ISL phenomenon in particular, and no research has been done to determine best practices. This study was intended as an early step in the examination of the physical therapy profession's role and activities in the global health arena within and beyond academics.
The purposes of this study were: (1) to identify and analyze the common structures and processes among established ISL programs within physical therapist education programs and (2) to develop a conceptual model of optimal ISL within physical therapist education programs.
A descriptive, exploratory study was completed using grounded theory.
Telephone interviews were completed with 14 faculty members who had been involved in international service, international learning, or ISL in physical therapist education programs. Interviews were transcribed, and transcriptions were analyzed using the grounded theory method.
Four major themes emerged from the data: structure, reciprocity, relationship, and sustainability. A conceptual model of and a proposed definition for optimal ISL in physical therapist education were developed. Seven essential components of the conceptual model are: a partner that understands the role of physical therapy, community-identified needs, explicit service and learning objectives, reflection, preparation, risk management, and service and learning outcome measures. Essential consequences are positive effects on students and community.
The conceptual model and definition of optimal ISL can be used to direct development of new ISL programs and to improve existing programs. In addition, they can offer substantive guidance to any physical therapist involved in global health initiatives.
Step-up exercises often are suggested for strengthening the hip abductor muscles and improving balance in older adults. Little is known, however, about whether the forward or lateral version of these exercises is best for activating the hip abductor muscles.
The purpose of this study was to examine the electromyographic (EMG) amplitude of the gluteus medius (GM) muscles bilaterally during forward and lateral step-up exercises.
The study design involved single-occasion repeated measures.
Twenty-seven community-dwelling adults (7 men and 20 women) with a mean (SD) age of 79.4 (8.0) years performed forward and lateral step-up exercises while the surface EMG activity of the GM muscles was recorded bilaterally. Pressure switches and dual forceplates were used to identify the ascent and descent phases. Subjects were instructed to lead with the right lower extremity during ascent and the left lower extremity during descent. Differences in normalized root-mean-square EMG amplitudes with exercise direction (forward versus lateral) and phase (ascent versus descent) were examined by use of separate repeated-measures analyses of variance for the right and left lower extremities. The alpha level was set at .05.
Gluteus medius muscle EMG activity was significantly greater for lateral than for forward step-up exercises for the left lower extremity during the ascent phase and for both lower extremities during the descent phase. In addition, right GM muscle EMG activity was significantly greater during ascent than during descent for both exercise directions.
Study limitations include use of a convenience sample and collection of limited information about participants.
Step-up exercises are effective in activating the GM muscle, with lateral step-up exercises requiring greater GM muscle activation than forward step-up exercises. Further study is needed to determine whether exercise programs for hip abductor muscle strengthening in older adults should preferentially include lateral over forward step-up exercises.
Treadmill training in supported stepping has been used as part of rehabilitation programs for children with neurodevelopmental problems to facilitate earlier onset of walking. However, information concerning the developmental continuity between supported stepping and walking is limited.
The aims of this study were to longitudinally examine supported stepping in preterm and full-term infants and to explore the step parameters associated with walking attainment.
A cohort study with a longitudinal follow-up design was used.
Twenty-nine preterm infants and 20 full-term infants were examined bimonthly with supported stepping on a treadmill from 7 months of age until walking attainment or 18 months of corrected age. The associations between step variables and walking outcome were examined using Cox proportional hazard regression and logistic regression.
Walking attainment for preterm infants was later than for full-term infants (median=12.8 versus 11 months, respectively). The percentage of alternating steps, hip-knee correlation, hip-ankle correlation, and asymmetry ratio (AR) of stance time of stepping movement from 7 to 9 months of corrected age were found to be associated with age of walking attainment in all infants. Manifestation of at least 3 of 4 step features (ie, ≥80% alternating steps, ≤.37 hip-knee correlation, ≥.73 hip-ankle correlation, and ≤1.40 AR of stance time) at 7 months predicted walking attainment prior to 11 months of corrected age (accuracy=75%–77%). Failure to achieve such competencies at 7 or 9 months of corrected age was predictive of failure in walking attainment by 15 months (accuracy=72%–98%).
The limitations of this study included a small sample size and commencement of stepping assessment as early as 7 months of corrected age.
The emergence of walking may involve cooperation of alternating pattern generation, interjoint coordination, and interlimb coordination in supported stepping in preterm and full-term infants. The identified step predictors may assist clinicians in designing appropriate treadmill training programs for those infants with delayed walking.
The Patient Goal Priority Questionnaire (PGPQ) is a patient-specific measure for identification of behavioral goals and evaluation of clinically significant changes. The use of such a measure in clinical settings and research requires that identified goals be consistent over time. Self-reports of behaviors related to the goals should be reliably estimated.
The purpose of this study was to estimate chance-corrected agreement and test-retest reliability of the PGPQ. Chance-corrected agreement between the PGPQ and a similar therapist-guided goal identification tool, the Patient Goal Priority List (PGPL), also was estimated.
A correlative and prospective design with 3 measurement points (M1, M2, and M3) was used in the study.
Fifty-four people who consulted physical therapists in primary care for persistent musculoskeletal pain were included in the study. Analyses of chance-corrected agreement and test-retest reliability of the PGPQ were done at M1 and M2. Chance-corrected agreement between procedures (PGPQ and PGPL) also was analyzed at M1 and M3.
The percentage of agreement on content of the priority lists of the PGPQ at M1 and M2 was 52%. Cohen kappa values for agreement of rankings ranged between .47 and .64. Test-retest reliability coefficients for the self-report scales of the PGPQ ranged from .35 to .81. Chance-corrected agreement decreased when physical therapists were involved in the goal identification process using the PGPL (kappa=.08–.46).
Varying item content and a small, heterogeneous sample possibly increased variation and the standard error of measurements. The feasibility of using traditional approaches to psychometric evaluation of patient-specific measures is questionable.
Chance-corrected agreement and test-retest reliability of the PGPQ were moderate. Involving a physical therapist in the goal identification procedure possibly introduced further bias. The size of the measurement error must be taken into account when using the PGPQ for estimations of clinically important changes.