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.
Objective: A randomized controlled trial was conducted to investigate the effects of a 3-week stretch program on muscle extensibility and stretch tolerance in patients with chronic musculoskeletal pain.
Design: A within-subject design was used, with one leg of each participant randomly allocated to an experimental (stretch) condition and the other leg randomly allocated to a control (no-stretch) condition.
Patients and Setting: Thirty adults with pain of musculoskeletal origin persisting for at least 3 months were recruited from patients enrolled in a multidisciplinary pain management program at a hospital in Sydney, Australia.
Intervention: The hamstring muscles of the experimental leg were stretched daily for 1 minute over 3 weeks; the control leg was not stretched. This intervention was embedded within a pain management program and supervised by physical therapists.
Measurements: Primary outcomes were muscle extensibility and stretch tolerance, which were reflected by passive hip flexion angles measured with standardized and nonstandardized torques, respectively. Initial measurements were taken before the first stretch on day 1, and final measurements were taken 1 to 2 days after the last stretch. A blinded assessor was used for testing.
Results: Stretch did not increase muscle extensibility (mean between-group difference in hip flexion was 1°, 95% confidence interval=–2° to 4°), but it did improve stretch tolerance (mean between-group difference in hip flexion was 8°, 95% confidence interval=5° to 10°).
Conclusion: Three weeks of stretch increases tolerance to the discomfort associated with stretch but does not change muscle extensibility in patients with chronic musculoskeletal pain.
]]>Objective: The primary purpose of this study was to determine whether preterm infants born at less than 33 weeks of gestational age contacted a toy with their feet at 2 months of corrected age, before doing so with their hands, and whether movement training advanced feet reaching.
Design: This study was a randomized controlled trial.
Methods: Twenty-six infants born preterm were randomly assigned to receive daily movement training or daily social training. During the 8-week training period, the infants were videotaped in a testing session every other week from 2 to 4 months of age.
Results: Both groups contacted the toy with their feet at 2 months of age during the first testing session prior to training, at an age when no infants consistently contacted the toy with their hands. After 8 weeks of training, the movement training group displayed a greater number and longer duration of foot-toy contacts compared with the social training group.
Conclusions: These results suggest that movement experiences advance feet reaching as they do for hand reaching. For clinicians, feet-oriented play may provide an early intervention strategy to encourage object interaction for movement impairments within the first months of postnatal life. Future studies can build on these results to test the long-term benefit of encouraging early purposeful leg movements.
]]>Objectives: The objectives of this study were to identify practitioner, organization, and research characteristics that are associated with searching or reading the research literature among physical therapists involved in stroke management.
Design: A cross-sectional study design was used.
Methods: A survey questionnaire was mailed to 1,155 physical therapists in neurological practice in Ontario, Canada. Therapists who treated people with stroke were eligible to participate.
Results: Of the 334 eligible respondents, 270 (80.8%) completed a questionnaire. Among participants with complete data, 37.7% of 265 participants conducted online literature searches and 73.3% of 266 participants read the research literature 2 or more times in a typical month. The following factors were associated with conducting online literature searches 2 or more times in a typical month: participation in research, self-efficacy for implementing evidence-based practice (EBP), being male, perceived facility support of research use, and Internet access to bibliographic databases at work. The following factors were associated with reading the literature 2 or more times in a typical month: participation in research, EBP self-efficacy, membership in a professional organization, perceived facility support of research use, and positive perceptions about the usefulness of the research literature and the relevance of walking interventions evaluated in the stroke rehabilitation research literature. A positive association between searching and reading was observed (odds ratio=16.5, 95% confidence interval=5.8–47.1).
Limitations: The cross-sectional design limited inferences of causality.
Conclusion: Despite a low frequency of searching, the majority of the participating therapists acquired and read the research literature on a monthly basis. Online searching and reading are closely linked behaviors. Modifiable practitioner characteristics, including self-efficacy for implementing EBP and participation in research, appear to be key determinants of EBP.
]]>Objective: The purpose of this study was to evaluate the effects of a structured hand cycle training program in individuals with chronic tetraplegia.
Design: Pretraining and posttraining outcome measurements of physical capacity were compared.
Setting: Structured hand cycle interval training was conducted at home or in a rehabilitation center in the Netherlands.
Participants: Twenty-two patients with tetraplegia (American Spinal Injury Association Impairment Scale classification A-D) at least 2 years since injury participated.
Intervention: The intervention was an 8- to 12-week hand cycle interval training program.
Measures: Primary outcomes of physical capacity were: peak power output (POpeak) and peak oxygen uptake (V
Results: Significant improvements following a mean of 19 (SD=3) sessions of hand cycle training were found in POpeak (from 42.5 W [SD=21.9] to 50.8 W [SD=25.4]), V
Limitations: Common health complications, such as urinary tract infections, bowel problems, and pressure sores, led to dropout and nonadherence.
Conclusion: Patients with tetraplegia were able to improve their physical capacity through regular hand cycle interval training, without participant-reported shoulder-arm pain or discomfort.
]]>Objective: The purpose of this study was to determine relationships between ST scores and measures of activity and participation during the first 6 months after stroke.
Design: This was a prospective cohort study.
Methods: Thirty-three individuals (18 men, 15 women) with a diagnosis of a single, unilateral stroke participated in the study. Participants were tested one time per month from 1 to 6 months poststroke. The ST was considered an impairment-level measure. Self-selected gait speed and the Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36) Physical Function Index (PFI) were used to assess physical function. Three domains (mobility, basic and instrumental activities of daily living, participation) of the Stroke Impact Scale were used to assess self-reported disability. Regression analyses were conducted to examine the bivariate associations between ST scores and each physical function and disability measure at each time point (1–6 months).
Results: The ST scores were positively associated with both physical function measures. The associations were stronger for self-selected gait speeds (R2=.60–.79) than for the PFI scores (R2=.32–.60). During the first 6 months after stroke, each additional step with the paretic lower extremity on the ST corresponded to a 0.07-m/s to 0.09-m/s increase in gait speed, and each additional step with the nonparetic lower extremity was associated with a 0.07-m/s to 0.08-m/s gait speed increase. The impairment-disability associations were weaker than the impairment-physical function associations.
Limitations: Limitations of the study include a relatively small sample size and lack of examiner blinding with regard to participant characteristics.
Conclusions: Impairments in balance and paretic–lower-extremity motor control, as measured by the ST, relate to physical function and disability during the first 6 months following stroke.
]]>Objective and Design: The aim of this cross-sectional study was to determine the extent of deficits in knee extensor and flexor muscle torque and power (ability to perform work over time) and in the extensor muscle cross-sectional area (CSA) after knee joint replacement. In addition, the association of lower-leg muscle deficits with mobility limitations was investigated.
Methods: Participants were 29 women and 19 men who were 55 to 75 years old and had undergone unilateral knee replacement surgery an average of 10 months earlier. The maximal torque and power of the knee extensor and flexor muscles were measured with an isokinetic dynamometer. The knee extensor muscle CSA was measured with computed tomography. The symmetry deficit between the knee that underwent replacement surgery ("operated knee") and the knee that did not undergo replacement surgery ("nonoperated knee") was calculated. Maximal walking speed and stair-ascending and stair-descending times were assessed.
Results: The mean deficits in knee extensor and flexor muscle torque and power were between 13% and 27%, and the mean deficit in the extensor muscle CSA was 14%. A larger deficit in knee extension power predicted slower stair-ascending and stair-descending times. This relationship remained unchanged when the power of the nonoperated side and the potential confounding factors were taken into account.
Limitations: The study sample consisted of people who were relatively healthy and mobile. Some participants had osteoarthritis in the nonoperated knee.
Conclusions: Deficits in muscle torque and power and in the extensor muscle CSA were present 10 months after knee replacement, potentially causing limitations in negotiating stairs. To prevent mobility limitations and disability, deficits in lower-limb power should be considered during rehabilitation after knee replacement.
]]>Objective: The purpose of this study was to compare the attentional demands of ascending and descending a set of stairs (stair ambulation) in older adults and younger adults.
Design: This was a nonblinded, prospective, single-site, observational cohort study.
Methods: Ten older (>65 years of age) and 10 younger (21–33 years of age) adults without disabilities were recruited. A dual-task approach was used for 2 task conditions: the first task was standing and responding verbally to an unanticipated auditory tone as quickly as possible (probe task), and the second task was ascending or descending a set of stairs with the same probe task. A 2-factor (group x task) analysis of variance with repeated measures on task (standing and stair ambulation) was performed for voice response time (VRT). Significance for the analysis was set at P<.05.
Results: The group x task interaction was significant for VRT. Post hoc analyses indicated that during stair ambulation, the VRT for older adults was significantly longer than that for younger adults. For the standing task, the VRTs (X±SD) were similar for younger (322±65 milliseconds) and older (306±22 milliseconds) participants. For stair ascent and descent, the average VRTs were more than 100 milliseconds longer for older participants (493±113 and 470±127 milliseconds, respectively) than for younger participants (365±56 and 356±67 milliseconds, respectively).
Limitations: Because of the small sample size and generally fit older group, generalization of findings to older people at risk for falls is not recommended until further research is done.
Conclusions: The results demonstrated that although both older and younger adults required similar attentional resources for the standing task, older adults required significantly more resources during stair ambulation. The findings suggested that the dual-task method used here provided a clinically useful measure for detecting important changes in attentional demands in older adults who are healthy.
]]>Objective: The aim of this study was to examine how physical fitness developed over time in 2 groups of children: those with a low level of competence in motor skills (low motor competence [LMC]), and those with a high level of competence in motor skills (high motor competence [HMC]).
Design and Methods: From an initial sample of 67 children, a group of 18 was identified as having HMC or LMC on the Movement Assessment Battery for Children and was selected for the present study. Eight children (3 girls and 5 boys) comprised the LMC group, and 10 children (4 girls and 6 boys) made up the HMC group. A longitudinal design was implemented, and physical fitness in the 2 groups was evaluated by measuring different fitness components over a period of 32 months.
Results: A mixed-effects analysis of variance revealed significant main effects for group and for time but no group x time interaction effect. The LMC group performed less well on all physical fitness measures than the HMC group, and both groups scored significantly higher on the physical fitness test after a period of 32 months. The lack of a significant interaction effect indicated that the relative differences in physical fitness outcomes between the groups were relatively constant over time.
Limitations: This study was limited by the small sample size and lack of assessment of anthropometric variables and children's perceived self-efficacy.
Conclusions: Children with LMC are likely to have poor physical fitness compared with children with HMC. The differences in physical fitness outcomes between the groups were relatively constant over time. Given that various physical fitness components are linked to different health outcomes, these consequences are matters of concern for both current health status and later health status in children with LMC.
]]>Membership of the PRISMA Group is provided in the Acknowledgments.
This article has been reprinted with permission from the Annals of Internal Medicine from Moher D, Liberati A, Tetzlaff J, Altman DG, The PRISMA Group. Preferred Reporting Items for Systematic Reviews and Meta-Analyses: The PRISMA Statement. Ann Intern Med. Available at:
Copyright © 2009 Moher et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
]]>Objective: The purpose of this study was to investigate the impact of physical therapist–directed exercise counseling combined with fitness center–based exercise training on muscular strength and exercise capacity in people with type 2 diabetes.
Design: This study was a randomized clinical trial.
Setting: The study was conducted on a university campus, with patient recruitment from the local community.
Patients: Twenty-four people with type 2 diabetes were randomly allocated to either a group that received physical therapist–directed exercise counseling plus fitness center–based exercise training (experimental group) or a group that received laboratory-based, supervised exercise (comparison group).
Intervention: The experimental group received physical therapist–directed exercise counseling on an exercise program and was provided access to a fitness center. The comparison group received the same exercise program as the experimental group while under supervision.
Measurements: For all participants, chest press, row, and leg press muscular strength (1-repetition maximum [in kilograms]) and exercise capacity (graded exercise test duration [in minutes]) testing were conducted at baseline and 2 months later.
Results: No significant differences in improvements in muscular strength were found for the chest press (adjusted mean difference=1.2; 95% confidence interval [CI]=–5.5 to 7.8), row (adjusted mean difference=0.1; 95% CI=–9.0 to 9.1), or leg press (adjusted mean difference=2.7; 95% CI=–9.1 to 14.6) between the groups. No significant difference in improvement in exercise capacity (adjusted mean difference=0.2; 95% CI=–0.9 to 1.2) was found between the groups.
Limitations: Lack of group allocation blinding and the small sample size were limitations of this study.
Conclusions: The results suggest that physical therapist–directed exercise counseling combined with fitness center–based exercise training can improve muscular strength and exercise capacity in people with type 2 diabetes, with outcomes comparable to those of supervised exercise.
]]>Objective: The purpose of this study was to explore the influence of physician and practice characteristics on referral for physical therapy in patients with traumatic lower-extremity injury.
Design: A cross-sectional survey was conducted.
Methods: In 2007, a Web-based survey questionnaire was distributed to 474 surgeon members of the Orthopaedic Trauma Association. The questionnaire measured physician and practice characteristics, outcome expectations, and attitude toward physical therapy. Referral for physical therapy was based on case vignettes.
Results: The response rate was 58%. Surgeons reported that 57.6% of their patients would have a positive outcome from physical therapy and 24.2% would have a negative outcome. The highest physical therapy expectations were for the appropriate use of assistive devices (80.7%) and improved strength (force-generating capacity) (76.4%). The lowest outcome expectations were for improvements in pain (35.9%), coping with the emotional aspects of disability (44.1%), and improvements in workplace limitations (51.4%). Physicians reported that 32.6% of their patients referred for physical therapy would have no improvement beyond what would occur with a surgeon-directed home exercise program. Multivariate analyses showed positive physician outcome expectations to have the largest effect on referral for physical therapy (odds ratio=2.7, P<.001).
Conclusions: The results suggest that orthopedic trauma surgeons refer patients for physical therapy based mostly on expectations for physical and motor outcomes, but may not be considering pain relief, return to work, and psychosocial aspects of recovery. Furthermore, low referral rates may be attributed to a preference for surgeon-directed home-based rehabilitation. Future research should consider the efficacy of physical therapy for pain, psychosocial and occupational outcomes, and exploring the differences between supervised physical therapy and physician-directed home exercise programs.
]]>Objectives: The purpose of this study was to establish consensus among a group of experts regarding the clinical identifiers for the first or early stage of primary (idiopathic) adhesive capsulitis.
Design: A correspondence-based Delphi technique was used in this study.
Methods: Three sequential questionnaires, each building on the results of the previous round, were used to establish consensus.
Results: A total of 70 experts from Australia and New Zealand involved in the diagnosis and treatment of adhesive capsulitis completed the 3 rounds of questionnaires. Following round 3, descriptive statistics were used to screen the data into a meaningful subset. Cronbach alpha and factor analysis then were used to determine agreement among the experts. Consensus was achieved on 8 clinical identifiers. These identifiers clustered into 2 discrete domains of pain and movement. For pain, the clinical identifiers were a strong component of night pain, pain with rapid or unguarded movement, discomfort lying on the affected shoulder, and pain easily aggravated by movement. For movement, the clinical identifiers included a global loss of active and passive range of movement, with pain at the end-range in all directions. Onset of the disorder was at greater than 35 years of age.
Conclusions: This is the first study to use the Delphi technique to establish clinical identifiers indicative of the early stage of primary (idiopathic) adhesive capsulitis. Although limited in differential diagnostic ability, these identifiers may assist the clinician in recognizing early-stage adhesive capsulitis and may inform management, as well as facilitate future research.
]]>Objectives: The purpose of this study was to identify, implement, and evaluate the effectiveness of strategies aimed at enhancing the ability of 5 pediatric physical therapists to integrate scientific research evidence into clinical decision making.
Design: This study was a formative evaluation pilot project.
Methods: The participants in this study collaborated with the first author to identify and implement strategies and outcomes aimed at enhancing their ability to use research evidence during clinical decision making. Outcome data were analyzed with qualitative methods.
Results: The participants were able to implement several, but not all, of the strategies and made modest self-reported improvements in evidence-based practice behaviors, such as reading journal articles and completing database searches. They identified several barriers, including a lack of time, other influences on clinical decision making, and a lack of incentives for evidence-based practice activities.
Conclusions: The pediatric physical therapists who took part in this project had positive attitudes toward evidence-based practice and made modest improvements in this area. It is critical for the profession to continue to investigate optimal strategies to aid practicing clinicians in applying research evidence to clinical decision making.
]]>Objective: The purpose of this study was to illustrate the changes of plantar pressure distribution during the stance phase of gait in patients who underwent hallux valgus surgery and received a multimodal rehabilitation program.
Design: This was a prospective descriptive study.
Methods: Thirty patients who underwent Austin (n=20) and scarf (n=10) osteotomy for correction of mild to moderate hallux valgus deformity were included in this study. Four weeks postoperatively they received a multimodal rehabilitation program once per week for 4 to 6 weeks. Plantar pressure analysis was performed preoperatively and 4 weeks, 8 weeks, and 6 months postoperatively. In addition, range of motion of the first metatarsophalangeal joint was measured, and the American Orthopaedic Foot and Ankle Society (AOFAS) forefoot questionnaire was administered preoperatively and at 6 months after surgery.
Results: The mean AOFAS score significantly increased from 60.7 points (SD=11.9) preoperatively to 94.5 points (SD=4.5) 6 months after surgery. First metatarsophalangeal joint range of motion increased at 6 months postoperatively, with a significant increase in isolated dorsiflexion. In the first metatarsal head region, maximum force increased from 117.8 N to 126.4 N and the force-time integral increased from 37.9 N·s to 55.6 N·s between the preoperative and 6-month assessments. In the great toe region, maximum force increased from 66.1 N to 87.2 N and the force-time integral increased from 18.7 N·s to 24.2 N·s between the preoperative and 6-month assessments.
Limitations: A limitation of the study was the absence of a control group due to the descriptive nature of the study.
Conclusions: The results suggest that postoperative physical therapy and gait training may lead to improved function and weight bearing of the first ray after hallux valgus surgery.
]]>Objective: The purposes of this study were: (1) to determine the levels of psychological job demands and job control reported by physical therapists in a national sample, (2) to compare those levels with national norms, and (3) to determine whether high demands, low control, or a combination of both (job strain) increases the risk for turnover or work-related pain.
Design: This was a prospective cohort study with a 1-year follow-up period.
Methods: Participants were randomly selected members of the American Physical Therapy Association (n=882). Exposure assessments included the Job Content Questionnaire (JCQ), a commonly used instrument for evaluation of the psychosocial work environment. Outcomes included job turnover and work-related musculoskeletal disorders.
Results: Compared with national averages, the physical therapists reported moderate job demands and high levels of job control. About 16% of the therapists reported changing jobs during follow-up. Risk factors for turnover included high job demands, low job control, job strain, female sex, and younger age. More than one half of the therapists reported work-related pain. Risk factors for work-related pain included low job control and job strain.
Limitations: The JCQ measures only limited dimensions of the psychosocial work environment. All data were self-reported and subject to associated bias.
Conclusions: Physical therapists’ views of their work environments were positive, including moderate levels of demands and high levels of control. Those therapists with high levels of demands and low levels of control, however, were at increased risk for both turnover and work-related pain. Physical therapists should consider the psychosocial work environment, along with other factors, when choosing a job.
]]>Objective: The purpose of this study was to describe meaningful interpretations of functional status (FS) outcome measures estimated with a body part–specific CAT developed from the Lower-Extremity Functional Scale (LEFS).
Design: This investigation was a prospective cohort study of 8,714 people who had hip impairments and were receiving physical therapy in 257 outpatient clinics in 31 states (United States) between January 2005 and June 2007.
Methods: Four approaches were used to clinically interpret outcome data. First, the standard error of the estimate was used to construct the 90% confidence interval for each CAT-generated score estimate. Second, percentile ranks were applied to FS scores. Third, 2 threshold approaches were used to define individual subject–level change: statistically reliable change and clinically important change. The fourth approach was a functional staging method.
Results: The precision of a single score was estimated from the FS score ±4. On the basis of the score distribution, 25th, 50th, and 75th percentile ranks corresponded to intake FS scores of 40, 48, and 59 and discharge FS scores of 50, 61, and 75, respectively. The reliable change index supported the conclusion that changes in FS scores of 7 or more units represented statistically reliable change, and receiver operating characteristic analyses supported the conclusion that changes in FS scores of 6 or more units represented minimal clinically important improvement. Participants were classified into 5 hierarchical levels of FS using a functional staging method.
Limitations: Because this study was a secondary analysis of prospectively collected data via a proprietary database management company, generalizability of results may be limited to participating clinics.
Conclusions: The results demonstrated how outcome measures generated from the hip LEFS CAT can be interpreted to improve clinical meaning. This finding might facilitate the use of patient-reported outcomes by clinicians during rehabilitation services.
]]>Objective: This study described psychomotor properties of a novel self-report measure, the Fear of Daily Activities Questionnaire (FDAQ).
Design: A prospective cohort design was used.
Methods: Reliability and validity cohorts were recruited from outpatient physical therapy clinics. Analyses for the reliability cohort included internal consistency and 48-hour test-retest coefficients, as well as standard error of measurement and minimal detectable change estimates. Analyses for the validity cohort included factor analysis for construct validity and correlation and multiple regression analyses for concurrent and predictive validity. Four-week responsiveness was assessed by paired t test, effect size calculation, and percentage of patients meeting or achieving MDC criterion.
Results: The FDAQ demonstrated adequate internal consistency (Cronbach alpha=.91, 95% confidence interval=.87–.95) and 48-hour test-retest properties (intraclass correlation coefficient=.90, 95% confidence interval=.82–.94). The standard error of measurement for the FDAQ was 6.6, resulting in a minimal detectable change of 12.9. Factor analysis suggested a 2- or 3-factor solution consisting of loaded spine, postural, and spinal movement factors. The FDAQ demonstrated concurrent validity by contributing variance to disability (baseline and 4 weeks) and physical impairment (baseline) scores. In predictive validity analyses, baseline FDAQ scores did not contribute variance to 4-week disability and physical impairment scores, but changes in FDAQ scores were associated with changes in disability. The FDAQ scores significantly decreased over a 4-week treatment period, with an effect size of .86 and 55% of participants meeting the minimal detectable change criterion.
Limitations: The validity cohort was a secondary analysis of a clinical trial, and additional research is needed to confirm these findings in other samples.
Conclusions: The FDAQ is a potentially viable measure for fear of specific activities in physical therapy settings. These analyses suggest the FDAQ may be appropriate for determining graded exposure treatment plans and monitoring changes in fear levels, but is not appropriate as a screening tool.
]]>Objective: The purposes of this study were to identify and rate the quality of cost analysis literature in physical therapy and to report summary information on the findings from the reviewed studies.
Design: This study was a targeted literature review and rating of relevant studies published in the last decade using a quality evaluation tool for economic studies.
Measurements: The Quality of Health Economic Studies (QHES) instrument was used to obtain quality scores.
Results: Ninety-five in-scope studies were identified and rated using the QHES instrument. The average quality score was 82.2 (SD=15.8), and 81 of the studies received a score of 70 or higher, placing them in the "good" to "excellent" quality range. Investigators in nearly two thirds of the studies found the physical therapy intervention under investigation to be cost-effective.
Limitations: The small number of studies meeting the inclusion criteria was a limitation of the study.
Conclusions: The quality of the literature regarding the cost-effectiveness of physical therapy is very good, although the magnitude of this body of literature is small. Greater awareness of the strengths and limitations of cost analyses in physical therapy should provide guidance for conducting high-quality cost-effectiveness studies as demand increases for demonstrations of the value of physical therapy.
]]>Purpose: The purpose of this study was to systematically review reproducibility studies of RUSI for measuring thickness of abdominal wall muscles.
Data Sources: Eligible studies were identified via searches of MEDLINE, EMBASE, and CINAHL. The authors also searched personal files and tracked references of the retrieved studies via the Web of Science Index.
Study Selection: Studies involving any type of reliability and or agreement of any type of ultrasound measurements (B or M mode) for any of the abdominal wall muscles were selected.
Data Extraction: Two independent reviewers extracted data and assessed methodological quality.
Data Synthesis: Due to heterogeneity of the studies’ designs, pooling the data for a meta-analysis was not possible. Twenty-one studies were included, and these studies were typically of low quality and studied subjects who were healthy rather than people seeking care for low back pain. The studies reported good to excellent reliability for single measures of thickness and poor to good reliability for measures of thickness change (reflecting the muscle activity). Interestingly, no studies checked reliability of measures of the difference in thickness changes over time (representing improvement or deterioration in muscle activity).
Conclusions: The current evidence of the reproducibility of RUSI for measuring abdominal muscle activity is based mainly on studies with suboptimal designs and the study of people who were healthy. The critical question of whether RUSI provides reliable measures of improvement in abdominal muscle activity remains to be evaluated.
]]>Objective: The purpose of this study was to develop efficient yet accurate screening methods for identifying elevated levels of fear-avoidance beliefs regarding work or physical activities in people receiving outpatient rehabilitation.
Design: A secondary analysis of data collected prospectively from people with a variety of common neuromusculoskeletal diagnoses was conducted.
Methods: Intake Fear-Avoidance Beliefs Questionnaire (FABQ) data were collected from 17,804 people who had common neuromusculoskeletal conditions and were receiving outpatient rehabilitation in 121 clinics in 26 states (in the United States). Item response theory (IRT) methods were used to analyze the FABQ data, with particular emphasis on differential item functioning among clinically logical groups of subjects, and to identify screening items. The accuracy of screening items for identifying subjects with elevated levels of fear was assessed with receiver operating characteristic analyses.
Results: Three items for fear of physical activities and 10 items for fear of work activities represented unidimensional scales with adequate IRT model fit. Differential item functioning was negligible for variables known to affect functional status outcomes: sex, age, symptom acuity, surgical history, pain intensity, condition severity, and impairment. Items that provided maximum information at the median for the FABQ scales were selected as screening items to dichotomize subjects by high versus low levels of fear. The accuracy of the screening items was supported for both scales.
Limitations: This study represents a retrospective analysis, which should be replicated using prospective designs. Future prospective studies should assess the reliability and validity of using one FABQ item to screen people for high levels of fear-avoidance beliefs.
Conclusions: The lack of differential item functioning in the FABQ scales in the sample tested in this study suggested that FABQ screening could be useful in routine clinical practice and allowed the development of single-item screening for fear-avoidance beliefs that accurately identified subjects with elevated levels of fear. Because screening was accurate and efficient, single IRT-based FABQ screening items are recommended to facilitate improved evaluation and care of heterogeneous populations of people receiving outpatient rehabilitation.
]]>Objective: This study examined factors that may be common to these conditions, with the objective of detecting factors that could improve the course of these diseases.
Design: This was a prospective case control study.
Patients and Intervention: A group of patients with CLBP and WMP (CLBP+WMP group, n=97) was compared with a group of individuals who were pain-free and without a history of musculoskeletal problems (control group, n=97) and with a group of patients with CLBP but without WMP (CLBP-only group, n=52). The mean age of the participants was 42.9 years (SD=8.74); 76% were women, and 24% were men.
Measurements: A total of 74 variables were measured, including sociodemographic, physical, and psychosocial variables. After univariate examination for group differences and analyses of variables available for all 3 groups, logistic regression on selected factors was performed. The level was set at .05, but was adjusted to avoid randomly significant results.
Results: For a number of variables, significant differences among the 3 groups were observed. For regression model 1 for the CLBP+WMP and control groups, 4 out of 9 variables showed significant likelihood tests: income (lower in the WMP group), depression, anxiety, and fear-avoidance behavior. For regression model 2, 2 out of 13 variables showed significant likelihood tests: endurance capacity (more in the CLBP+WMP group) and balance capability (worse in the CLBP+WMP group). The models predicted at least 91.2% of all cases to the correct group. The regression analysis regarding the CLBP+WMP and CLBP-only groups predicted 86.7% of all cases to the correct group. Three out of 10 variables showed significant likelihood tests: high disability, fear-avoidance behavior, and number of treatments.
Limitations: Some variables in testing the patients with WMP and the individuals who were pain-free were not used with the patients with CLBP only.
Conclusions: Patients with CLBP and WMP should be examined for indicated physical and psychosocial factors. Therapeutic management should consider them in the early stage of the disease. These findings also might apply to patients with fibromyalgia or myofascial pain.
]]>Objective: The objectives of this study were to determine physical therapists’ attitudes, knowledge, and practice approaches regarding obesity and to explore the relationships between attitudes and knowledge.
Design: A prospective paper mail survey was designed to obtain demographic characteristics, attitudes, knowledge, and practice approaches regarding obesity. Participants were randomly selected members of the American Physical Therapy Association.
Methods: Descriptive statistics were used to explore physical therapists’ attitudes, knowledge, and practice approaches regarding obesity. Pearson product moment and Spearman rank correlations were used to test the relationships between attitudes and knowledge. The a priori alpha value was set at .05.
Results: The response rate was 34.5%. Physical therapists indicated that physical inactivity (92.8%, n=320) and overeating (78.5%, n=270) are the most important causes of obesity and that diet modifications and exercise are the most effective treatments. Respondents frequently recommended exercising more (87.4%, n=263) but rarely recommended changes in nutritional habits or referred clients to other health care disciplines. Attitude scores regarding obesity were neutral. The mean knowledge score was 6.7 (of 10). A significant correlation (r=.133, P=.043) was found between the respondents’ knowledge scores and attitudes regarding statements about obesity. Inverse correlations were seen between the respondents’ age and knowledge scores (r=–.195, P<.0005) and between years in practice and knowledge scores (r= –.216, P<.0005).
Limitations: The descriptive nature of this study did not allow for further investigation. The survey questionnaire was adapted from a nonvalidated tool.
Conclusions: The results suggested that physical therapists have neutral attitudes toward people who are obese. Physical therapists appropriately indicated that lack of physical activity and poor nutritional habits contribute to obesity. Younger respondents, who had recently entered the work force, had higher knowledge scores than respondents who were older and had worked longer. Improvements in physical therapists’ referral patterns may assist in the health care team approach to the treatment of obesity. Education to enhance physical therapists’ knowledge about obesity should be emphasized.
]]>Objective: The purpose of this study was to examine the accuracy of clinical measures representing various domains of the International Classification of Functioning, Disability and Health (ICF) relative to their ability to identify individuals with a history of multiple falls.
Design: A case series study design was used.
Setting: The study was conducted in a community setting.
Participants: Twenty-seven people with stroke participated in the study.
Measurements: Clinical assessment tools included the lower-extremity subscale of the Fugl-Meyer Assessment of Sensorimotor Impairment (FMLE) and Five-Times-Sit-to-Stand Test (STS) representing the body function domain, the Berg Balance Scale (BBS) representing the activity domain, the Activities-specific Balance Confidence (ABC) Scale as a measure of personal factors, and the physical function subscale of the Stroke Impact Scale (SIS-16) as a broad measure of physical function. We used receiver operating characteristic (ROC) curves to generate cutoff scores, sensitivities, specificities, and likelihood ratios (LRs) relative to a history of multiple falls.
Results: The FMLE and the STS showed a weak association with fall history. The BBS demonstrated fair accuracy in identifying people with multiple falls, with a cutoff score of 49 and a positive LR of 2.80. The ABC Scale and the SIS-16 were most effective, with cutoff scores of 81.1 and 61.7, respectively, positive LRs of 3.60 and 7.00, respectively, and negative LRs of 0.00 and 0.25, respectively.
Limitations: A limitation of the study was the small sample size.
Conclusion: The findings suggest that the ICF is a useful framework for selecting clinical measures relative to fall history and support the need for prospective study of tools in more-complex domains of the ICF for their accuracy for fall prediction in people with stroke.
]]>Objective: The purpose of this study was to determine whether LT with physical assistance as needed was superior to guided, symmetrical, robotic-assisted LT for improving kinematic coordination during walking poststroke.
Design: This study was a randomized clinical trial.
Methods: Nineteen people with chronic stroke (>6 months’ duration) participating in a larger randomized control trial comparing therapist- versus robotic-assisted LT were recruited. Prior to and following 4 weeks of LT, gait analysis was performed at each participant's self-selected speed during overground walking. Kinematic coordination was defined as the consistency of intralimb hip and knee angular trajectories over repeated gait cycles and was compared before and after treatment for each group.
Results: Locomotor training with therapist assistance resulted in significant improvements in the consistency of intralimb movements of the impaired limb. Providing consistent kinematic assistance during robotic-assisted LT did not result in improvements in intralimb consistency. Only minimal changes in discrete kinematics were observed in either group.
Limitations: The limitations included a relatively small sample size and a lack of quantification regarding the extent of movement consistency during training sessions for both groups.
Conclusions: Coordination of intralimb kinematics appears to improve in response to LT with therapist assistance as needed. Fixed assistance, as provided by this form of robotic guidance during LT, however, did not alter intralimb coordination.
]]>Objective: The purpose of this study was to compare the psychometric properties of 4 clinical measures for assessing upper-extremity motor function in people with stroke: the upper-extremity subscale of the Fugl-Meyer Motor Test (UE-FM), the upper-extremity subscale of the Stroke Rehabilitation Assessment of Movement, the Action Research Arm Test (ARAT), and the Wolf Motor Function Test.
Design: This was a prospective, longitudinal study.
Methods: Fifty-three people with stroke were evaluated with the 4 measures at 4 time points (14, 30, 90, and 180 days after stroke). Thirty-five participants completed all of the assessments. The ceiling and floor effects, validity (concurrent validity and predictive validity), and responsiveness of each measure were examined. Interrater reliability and test-retest reliability also were examined.
Results: All measures, except for the UE-FM, had significant floor effects or ceiling effects at one or more time points. The Spearman correlation coefficient for each pair of the 4 measures was ≥.81, indicating high concurrent validity. The predictive validity of the 4 measures was satisfactory (Spearman , ≥.51). The responsiveness of the 4 measures at 14 to 180 days after stroke was moderate (.52 ≤ effect size ≤ .79). The 4 measures had good interrater reliability (intraclass correlation coefficient [ICC], ≥.92) and test-retest reliability (ICC, ≥.97). Only the minimal detectable changes of the UE-FM (8% of the highest possible score) and the ARAT (6%) were satisfactory.
Limitations: The sample size was too small to conduct data analysis according to type or severity of stroke. In addition, the timed component of the Wolf Motor Function Test was not used in this study.
Conclusions: All 4 measures showed sufficient validity, responsiveness, and reliability in participants with stroke. The UE-FM for assessing impairment and the ARAT for assessing disability had satisfactory minimal detectable changes, supporting their utility in clinical settings.
]]>Objective: The purpose of this study was to compare the NMES muscle torques produced by stimulation trains consisting of 2 different pulse durations.
Design: During a single testing session, the 2 pulse duration conditions (50 and 200 microseconds) were tested on the opposite lower extremities of the participants.
Methods: The study participants were 10 adults without remarkable medical histories. The maximum tolerated isometric knee extensor torque was the primary dependent variable. The peak currents and phase charges that produced the maximally tolerated torques, as well as the sensory, motor, and pain thresholds for the 2 pulse conditions, were compared.
Results: The 200-microsecond pulse duration condition resulted in participants tolerating significantly greater muscle torques; it was associated with significantly greater phase charges but significantly lower peak currents.
Limitations: This study only compared muscle torques in response to stimulation trains consisting of pulses with short (50-microsecond) or medium (200-microsecond) durations and did not examine long (~400- to 600-microsecond) durations. Furthermore, the result of this study may not apply to NMES that uses stimulation patterns other than monophasic, square-wave pulsed current.
Conclusions: It has been suggested that short pulse durations are most appropriate for NMES because they are less likely to recruit nociceptors. The results of this study, however, support the use of a medium pulse duration rather than a short pulse duration when the goal is to produce a maximum torque response from a muscle. These observations may be related to the currents and phase charges for the pain thresholds for the 2 pulse duration conditions.
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