Fatigue is one of the most common symptoms experienced by older people both with and without chronic disease. It is unpleasant, distressing and can affect functioning and quality-of-life. Fatigue may also inhibit an older person from participating optimally in a physical therapy program aimed at rehabilitation or promotion of better health. However, confusion surrounds the concept of self-reported aging-related fatigue partly because of the complexity of the problem itself but also because of lack of clarity of definition and the use of the term 'fatigue' to describe a range of different concepts. This paper aims to provide clarification of the concept in the context of physical therapists' clinical practice. The intention is to increase awareness and interest among physical therapists, to assess and consider the problem when planning health interventions involving functioning, physical activity and exercise for older people.

BACKGROUND:

Psychometric limitations of balance measures for community-dwelling elderly may be related to gaps in task and environmental representation.

OBJECTIVE:

To conduct item-level content analysis of balance measures for community-dwelling elderly based on task and environmental factors, and develop profiles of individual measures summarizing their task and environment representation.

DESIGN:

Systematic content analysis.

METHODS:

A literature search was conducted to identify balance measures. Item-level content analysis was based on seven criteria related to task and environment: (i) task role, (ii) environmental variation, (iii) object interaction, (iv) obstacle negotiation, (v) external forces, (vi) dual-tasking, and (vii) moving persons/objects in the environment.

RESULTS:

26 measures were identified, containing 167 items. Task role was fairly evenly distributed, with majority of items examining gait tasks (32.3%), followed by dynamic body stability (29.9%) and static body stability (25.1%). Majority of items involved no environmental variation (58.1%), followed by variation of support surfaces (20.4%), visual conditions (13.2%), and both support and visual conditions (8.4%). Limited task role variability was seen within measures, with 73.1% of measures examining only one task role. Environmental variation was present in 65.3% of measures, primarily during static body stability tasks. Few measures involved object interaction (23.1%), obstacle negotiation (38.5%), external forces (11.5%), dual-tasking (7.7%), or moving persons/objects (0%).

LIMITATIONS:

Our classification framework was not externally validated.

CONCLUSIONS:

Existing measures focus on single-task assessment in static environments, underrepresenting postural control demands in daily-life situations involving dynamic changing environments, person-environment interactions, and multi-tasking. New items better reflecting postural control demands in daily-life situations are needed for more ecologically valid balance assessment. Individual balance measure profiles provided can help identify the most appropriate measure for a given purpose.

BACKGROUND AND PURPOSE:

The use of standardized outcome measures (OMs) can support clinicians' development of appropriate care plans, guide educators in curricular decisions, and enhance the methodological quality and generalizability of clinical trials. The purposes of this case report are to (1) describe a framework and process for assessing psychometrics and clinical utility of OMs used post-stroke, (2) describe a consensus process used to develop recommendations for stroke-related OMs in clinical practice, research and entry-level physical therapist education, (3) present examples demonstrating how the recommendations have been utilized to date, and (4) make suggestions for future efforts. CASE

DESCRIPTION:

A taskforce of 7 physical therapists with diverse clinical and research expertise in stroke rehabilitation used a 3-stage, modified Delphi consensus process to develop recommendations on OM use. An evidence-based systematic review template and a 4-point rating scheme were used to make recommendations on OM use by care setting and patient acuity, for research, and inclusion in professional education.

OUTCOMES:

An initial list of 77 OMs was developed based on input from numerous professional sources. Screening measures and duplicate measures were eliminated. 56 OMs received full review. Measures spanned the constructs of body structure/function (21), activity (28), and participation (14). Fourteen measures received a rating of "highly recommend".

DISCUSSION:

Use of highly recommended OMs may provide a common set of tools enabling comparisons across patients, interventions, settings, and studies. The use of a clearly defined, comprehensive assessment template may facilitate the pooling of data on OMs and contribute to best practice guidelines. Educational recommendations may inform curricular decisions.

<LEAP> highlights the findings and application of Cochrane reviews and other evidence pertinent to the practice of physical therapy. The Cochrane Library is a respected source of reliable evidence related to health care. Cochrane systematic reviews explore the evidence for and against the effectiveness and appropriateness of interventions-medications, surgery, education, nutrition, exercise-and the evidence for and against the use of diagnostic tests for specific conditions. Cochrane reviews are designed to facilitate the decisions of clinicians, patients, and others in health care by providing a careful review and interpretation of research studies published in the scientific literature.(1) Each article in this PTJ series summarizes a Cochrane review or other scientific evidence resource on a single topic and will present clinical scenarios based on real patients to illustrate how the results of the review can be used to directly inform clinical decisions. This article focuses on exercise for the management of osteoporosis in women postmenopause. Which, if any, approaches to exercise reduce loss of bone mineral density or reduce chance of fractures in women who are healthy postmenopause?

Transcutaneous electrical nerve stimulation (TENS) is a non-pharmacological treatment for control of pain. It has come under much scrutiny lately with the Center for Medicare Services rendering a recent decision stating that "TENS is not reasonable and necessary for the treatment of CLBP [chronic low back pain]".When reading and analyzing the existing literature for which systematic reviews show that TENS is inconclusive or ineffective, it is clear that a number of variables related to TENS application have not been considered. While many of the trials were designed with the highest of standards, recent evidence suggests that factors related to TENS application need to be considered in an assessment of efficacy. These factors include, dosing of TENS, negative interactions with long-term opioid use, the population and outcome assessed, timing of outcome measurement and comparison groups. The purpose of this perspective is to highlight and interpret recent evidence to help improve the design of clinical trials and the efficacy of TENS in the clinical setting.

U.S. military physical therapists have a proud history of providing medical care during operational deployments ranging from war to complex humanitarian emergencies. Regardless of environment austerity or intensity of hostility, U.S. military physical therapists serve as autonomous providers, evaluating and treating service members with and without physician referral. Our perspective is that the versatility of U.S. military physical therapist practice enables them to not only diagnose musculoskeletal injuries, but equally important to provide a wide range of definitive care and rehabilitation, reducing the need for costly evacuation. While war is not sport, the delivery of skilled musculoskeletal physical therapy services as close to the point of injury parallels the sports medicine model for on or near field practice. This model that mixes direct access with near immediate access enhances outcomes, reduces costs, and allows other healthcare team members to work at the highest levels of their licensure.

BACKGROUND:

The Department of Veterans Affairs (VA) and the Department of Defense (DoD) published evidence-based Guidelines (Guidelines) to standardize and improve rehabilitation of lower limb amputees, however no studies have examined the guideline impact.

OBJECTIVES:

To 1) describe the utilization of rehabilitative services in the acute care setting by persons who underwent major lower limb in the VA from 2005 to 2010; and 2) identify factors associated with receipt of rehabilitation services; and 3) examine impact of the Guidelines on service receipt.

DESIGN:

Cross-sectional study of 12,599 patients, who underwent major surgical amputation of the lower limb at a VA medical center from January 1, 2005 to December 31, 2010. Data were obtained from main and surgical inpatient datasets and the inpatient encounters files of the Veterans Health Administration databases.

METHODS:

Rehabilitation services were categorized as physical therapy (PT), occupational therapy (OT), and either (any therapy), before or after amputation. Separate multivariate logistic regressions examined impact of Guideline implementation, and identified factors associated with service receipt.

RESULTS:

Patients were 1.45 and 1.73 times as likely to receive pre-operative PT and OT, and 1.68 and 1.79 times as likely to receive post-operative PT and OT (p<0.0001) after Guideline implementation. Patients in the Northeast had the lowest likelihood of receiving pre-operative and post-operative rehabilitation services, while patients in the West had the highest likelihood. Other patient characteristics associated with service receipt were identified.

LIMITATIONS:

The sample included only Veterans who had surgeries at VA Medical Centers and cannot be generalized to Veterans with surgeries outside the VA or to non-Veteran patients and settings.

CONCLUSIONS:

Further quality improvement efforts are needed to standardize delivery of rehabilitation services for Veterans with amputations in the acute care setting.

BACKGROUND:

The Affordable Care Act of 2010 establishes American Health Benefit Exchanges. The benefit design of insurance plans in the state health insurance exchanges will be based on the structure of existing small employer sponsored plans.

OBJECTIVE:

The purpose of this study was to describe the structure of the physical therapy benefit in a typical BCBS preferred provider organization (PPO) health insurance plan available in the individual insurance market in 2011.

DESIGN:

Cross-sectional survey design.

METHODS:

Using a standard patient with a standard budget, the physical therapy benefit within 39 Blue Cross Blue Shield (BCBS) preferred provider organization plans in 2011 was studied. We first determined if physical therapy was a benefit in the plan. If so, the structure of the benefit was then described i.e., whether it was a stand-alone benefit or a part of a combined discipline benefit and if a visit or financial limit was placed on the physical therapy benefit.

RESULTS:

Physical therapy was included in all BCBS plans that were studied. Ninety-three percent of plans combined physical therapy with other disciplines into a benefit. Two in three plans placed a limit on the number of visits covered by the plan.

LIMITATIONS:

The results of the study are limited to one standard patient, one association of insurance companies, one form of insurance (a PPO) and one PPO plan in each of the 39 states that were studied.

CONCLUSIONS:

Physical therapy is a covered benefit in a typical BCBS preferred provider organization health plan. Physical therapy is most often combined with other therapy disciplines and in two-thirds of plans has a limit on the number of covered visits.

BACKGROUND:

Workplace injuries from patient handling are prevalent. with the adoption of no-lift policies, sit-to-stand transfer devices have emerged as one tool to combat injuries. However, the therapeutic value associated with sit-to-stand transfers using an assistive apparatus cannot be determined due to a lack of evidence-based data.

OBJECTIVE:

The aim of this study was to compare clinician-assisted, device-assisted, and the combination of clinician- and device-assisted sit-to-stand transfers in individuals who recently experienced a stroke.

DESIGN:

Cross-sectional, controlled laboratory study that used a repeated measures design.

METHODS:

The duration, joint kinematics and muscle activity of four sit-to-stand transfer conditions were compared for 10 stroke patients. Each patient performed four randomized sit-to-stand transfer conditions: clinician-assisted (CA), device-assisted with no patient effort (D-NE), device-assisted with patient's best effort (D-BE), and device- and clinician-assisted (D-CA).

RESULTS:

Device-assisted transfers took nearly twice as long as clinician-assisted transfers. Hip and knee joint movement patterns were similar across all conditions. Forward trunk flexion was lacking and ankle motion was restrained during device-assisted transfers. Encouragement and guidance from the clinician during device-assisted transfers led to increased lower extremity muscle activation levels.

LIMITATIONS:

One lifting device and one clinician were evaluated. Clinician effort could not be controlled.

CONCLUSIONS:

Lack of forward trunk flexion and restrained ankle movement during device-assisted transfers may dissuade clinicians from selecting this device for use as a dedicated rehabilitation tool. However, with clinician encouragement, muscle activation increased, suggesting that it is possible to safely practice transfers while challenging key leg muscles essential for standing. Future sit-to-stand devices should not only promote safety for the patient and clinician, but also encourage a movement pattern that more closely mimics normal sit-to-stand biomechanics.

BACKGROUND:

Evaluation of walking capacity and risk of falls in people with multiple sclerosis (PwMS) are often performed in rehabilitation. The Dynamic Gait Index (DGI) evaluates walking during different tasks, but the feasibility in identifying persons at risk of falls needs to be further investigated.

OBJECTIVE:

1) investigate construct validity of the DGI: known-groups, convergent, discriminant; 2) the accuracy of predicting falls and establishing a cut-off point to identify fallers.

DESIGN:

A multi-centre, cross-sectional study.

METHODS:

A convenience sample of 81 PwMS with subjective gait and balance impairment but still able to walk 100 meters (comparable with EDSS 1-6). Mean age was 49 years, 76% were women. The 25-foot Timed Walk test, Timed Up and Go test, Four Square Step Test, Timed sit-to-stand test, MS Walking scale, Multiple Sclerosis Impact Scale (MSIS), and self-reported falls during the previous two months were used for validation, establishing cut-off point for identifying fallers and to investigate predictive values.

RESULTS:

Significantly lower DGI scores (p≤0.001) was found for participants reporting falls (n=31). High sensitivity (87%) in identifying fallers was found with cut-off score ≤19. The positive predictive value was 50% and the negative predictive value 87%. The convergent validity was moderate to strong (rho=0.58-0.80), with the highest correlation coefficient found for the 25-foot Timed Walk test. Discriminant validity was shown with low correlation for the psychological subscale of the MSIS.

LIMITATIONS:

The sample included ambulatory persons participating in a randomized controlled trial investigating balance training.

CONCLUSIONS:

The DGI is a valid measure of dynamic balance during walking for ambulatory persons with MS. With the cut-off point of ≤19, sensitivity was high in identifying persons at risk of falls.