Physical Therapy- Journal of the APTA- May 2009, Volume 89, Issue 5

May 2009

Volume 89

Number 5

Research Reports 409

Surplus Value of Hip Adduction in Leg-Press Exercise in Patellofemoral Pain Syndrome

474

Gait Symmetry Adaptations Following Unilateral Step Training in Hemiparesis

419

Interventions Associated With Favorable Outcomes in Adhesive Capsulitis

484

Balance Evaluation Systems Test (BESTest)

430

Clinical Reasoning in Musculoskeletal Practice

443

Upper-Extremity Exercise Training in Chronic Airway Obstruction

456

Cognitive-Behavioral Therapy for Older Adults With Chronic Pain

Case Report 499

Neuroprosthesis Peroneal Functional Electrical Stimulation

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at PT 2009 Reserve These Dates and Times for PTJ Sessions at PT 2009 PTJ Symposium: Nonpharmacologic CARE for Patients With Arthritis Thursday, June 11

2:00–5:00 pm

0.30 CEUs

This year, Physical Therapy (PTJ) will publish papers adapted from presentations at the CARE V Conference held in Oslo, Norway. In this session, a panel of authors and editors will help clinicians and researchers deal with issues ranging from ethics, to the multidisciplinary team approach, to patient perspectives. Upon completion of this course, you’ll be able to: (1) explain the primary care provider approach to arthritis management, (2) discuss recent data from European and Canadian patient advocates and the implications of the findings for US patient populations, (3) identify challenges related to the use of the ICF in developing a core set of measurements in the rehabilitation management of rheumatoid arthritis, and (4) describe state-of-the-art nonpharmacological and nonsurgical interventions for hand osteoarthritis. Speakers: G Kelley Fitzgerald, PT, PhD, OCS—Philadelphia, PA; Emalie Hurkmans, PT—The Netherlands; James J Irrgang, PT, PhD, ATC—Pittsburgh, PA; Anne Townsend, PhD—Vancouver, British Columbia

The 2009 Rothstein Debate: “Should the Physical Therapy Profession Endorse Medicare Rules and Regulations as the Standard With All Payers?” Friday, June 12

9:30–11:00 am

0.15 CEUs

Medicare regulation—some say “over-regulation”—and reimbursement cuts by all payers affect the business of physical therapy. But what are the effects on clinical practice and professionalism? Payment is different for hospitalbased versus outpatient-based practice; what might be the impact of continued payment under the Medicare Fee Schedule versus a bundled, episodic, or per-diem payment system in the outpatient setting? Under Medicare rules, and as an APTA position, the only extender of physical therapy services is the physical therapist assistant; what would be the benefits of utilizing other extenders based on patient type? The annual Rothstein Debate was established in memory of Jules Rothstein, PT, PhD, FAPTA, Editor in Chief Emeritus of PTJ. Upon completion of this course, you’ll be able to: (1) describe some of the ways in which current and potential Medicare rules and regulations might affect the health of the business enterprise across various settings, (2) explain the implications of a modification of the Medicare payment system and Medicare regulations on the practice of physical therapy, and (3) discuss the issues related to physical therapy extenders. Speakers: Anthony Delitto, PT, PhD, FAPTA—Pittsburgh, PA; Larry N Benz, PT, DPT, MBA, ECS, OCS—Louisville, KY; Stephen M Levine, PT, DPT, MSHA—Wilton Manors, FL

PTJ Breakfast—Essentials of Writing and Reviewing: Focus on Case Reports Saturday, June 13

8:00–11:00 am

0.30 CEUs

Are you an author looking to avoid common pitfalls, reduce review and revision time, and increase your chances for high-impact publication? Are you a reviewer who wants to enhance your skills? This is the session for you— regardless of which journals you write or review for! When you develop your skills as a reviewer, you also sharpen your skills as an author, and vice versa. This interactive session will discuss all manuscript types but also will include a special focus on case reports. The 3rd edition of Writing Case Reports: A How-to Manual for Clinicians will be released in June—get a sneak peek! Upon completion of this course, you’ll be able to: (1) list the top 5 essentials of high-quality research papers, (2) identify manuscript weaknesses that can bog down the review process and reduce chances of success, (3) review a manuscript using a systematic approach, and (4) describe the role of case reports and the critical elements that allow case reports to contribute to the physical therapy body of knowledge. Speakers: Rebecca L Craik, PT, PhD, FAPTA—Philadelphia, PA; Irene McEwen, PT, PhD, FAPTA—Oklahoma City, OK; G Kelley Fitzgerald, PT, PhD, OCS; Patricia J Ohtake, PT, PhD—Buffalo, NY

The Bottom Line The Bottom Line is a translation of study findings for application to clinical practice. It is not intended to substitute for a critical reading of the research article. Bottom Lines are written by invitation only. Song CY, Lin YF, Wei TC, Lin DH, Yen TY, Jan MH. Surplus Value of Hip Adduction in Leg-Press Exercise in Patients With Patellofemoral Pain Syndrome: A Randomized Controlled Trial. Phys Ther. 2009;89:409–418. Eric K Robertson EK Robertson, PT, DPT, OCS, is Assistant Professor, Department of Physical Therapy, Medical College of Georgia.

For more Bottom Lines on articles in this and other issues, visit www. ptjournal.org.

What problems did the researchers set out to study, and why? Patellofemoral pain syndrome (PFPS) is a common musculoskeletal problem of the knee. The strategies that have been proposed to manage PFPS generally emphasize selective activation of the vastus medialis oblique (VMO) muscle during quadriceps strengthening; however, little evidence to support or refute this recommendation exists. The researchers set out to examine the benefit of an exercise that some believe preferentially activates the VMO and to compare these results to a group of control subjects and to patients performing a “standard” exercise. Who participated in this study? 89 individuals examined and found to have PFPS. What new information does this study offer? The researchers determined that the addition of isometric hip adduction during leg-press exercise did not increase the therapeutic benefit observed over the control subjects. Both experimental groups significantly improved pain scores, Lysholm scale scores, and VMO cross-sectional area, but these changes were not observed in the control group. What new information does this study offer for patients? This study examined a commonly performed exercise thought to target the middle portion of the thigh muscles for patients with PFPS. When this exercise was compared to a traditional leg press, no added benefit was noted. This suggests that a simple leg-press exercise is adequate to induce a training effect in this muscle and to reduce pain and improve function for patients with PFPS. How did the researchers go about the study? The researchers randomly allocated subjects into 3 groups: (1) a group that performed a simple leg press, (2) a group that performed a leg press combined with isometric hip adduction against a 50-N force that is thought to increase the activation of the VMO, and (3) a control group that received advice but not any exercise. The test period was 8 weeks in duration and included 3 exercise sessions per week. Both the randomization and assessment portions of the trial were blinded. Outcome measures included pain scores, Lysholm scale scores, and VMO cross-sectional area that was measured via ultrasonography. How might the results be applied to physical therapist practice? The results of this trial do not support the notion that there is added benefit to performing leg-press exercises with hip adduction in the rehabilitation of patients with PFPS. Patients may be able to achieve hypertrophy of the VMO and clinically meaningful reductions in pain and improvements in function using the traditional leg-press exercise.

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Physical Therapy Volume 89 Number 5

May 2009

The Bottom Line What are the limitations of the study, and what further research is needed? Morphologic changes were measured only for the VMO, but there might have been changes in the other quadriceps muscles that contributed to clinical improvements. In addition, a 50-N adduction force might not have been enough to induce a specific training effect with this exercise. Further research is needed to investigate changes in patellar tracking and alignment with VMO hypertrophy as well as to investigate whether other modifications of the leg-press exercise may be more effective in selectively activating the VMO over a simple leg press. Beissner K, Henderson CR Jr, Papaleontiou M, Olkhovskaya Y, Wigglesworth J, Reid MC. Physical Therapists’ Use of Cognitive-Behavioral Therapy for Older Adults With Chronic Pain: A Nationwide Survey. Phys Ther. 2009;89:456–469. What problems did the researchers set out to study, and why? Chronic pain is a common and often disabling condition among older adults. Cognitive-behavioral therapy (CBT) is an evidence-supported, nonpharmacologic intervention for chronic pain. The theoretical basis for CBT is that an individual’s beliefs, attitudes, and behaviors may play a central role in their experience of pain, but few studies have described the inclusion of CBT in physical therapist practice. The researchers set out to identify the extent to which CBT is included in physical therapist practice for this patient population, as well as how often more “standard” interventions are utilized. The researchers also looked to identify physical therapist interest in, and barriers to, providing CBT for older adults with chronic pain.

Eric K Robertson EK Robertson, PT, DPT, OCS, is Assistant Professor, Department of Physical Therapy, Medical College of Georgia.

Who participated in this study? 152 physical therapists who were members of the Orthopaedic and Geriatric sections of the American Physical Therapy Association were included in a survey. What new information does this study offer? Relatively few physical therapists currently use CBT interventions as part of their treatment for older adults with chronic pain, although interest in incorporating these techniques is substantial. Commonly used CBT interventions were activity pacing and pleasurable activity scheduling. Non-CBT therapies focused on joint stability and mobility. Barriers such as lack of knowledge, skill level, and reimbursement concerns were identified. Practice type, percentage of patients with chronic pain, and educational degree of the therapist were independently associated with interest in CBT. What new information does this study offer for patients? This study provides information about how often physical therapists use techniques designed to affect the way older patients think, feel, and act in response to chronic pain. Although only a small percentage of physical therapists currently use these techniques, the interest in overcoming barriers to their use is substantial. Further research is needed to determine how to best incorporate these types of treatments and to measure their effectiveness as part of a physical therapy intervention.

May 2009

Volume 89 Number 5 Physical Therapy ■ 407

The Bottom Line How did the researchers go about the study? The research team developed a survey instrument based on a comprehensive review of the literature, including items about the aspects of CBT that best related to physical therapist practice. The survey was administered via telephone. Statistical analysis was performed using general linear models to determine associations between participant-related factors and interest in CBT. How might the results be applied to physical therapist practice? This study offers information regarding the prevalence of CBT techniques in physical therapist practice and physical therapists’ receptivity to learning more about the techniques. This information can help identify and reduce barriers to incorporating this evidencesupported intervention. What are the limitations of the study, and what further research is needed? The length of the survey did not allow analysis of the therapists’ rationale for choice of interventions, nor did it allow analysis of how much emphasis was placed on particular interventions within a treatment session. In addition, the survey focused on a general approach to treating chronic pain, whereas information related to specific pain locations or types of pain may have provided different data. Future research should investigate ways to reduce barriers to including CBT and should analyze the benefits and cost-effectiveness of CBT as part of physical therapy interventions.

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Physical Therapy Volume 89 Number 5

May 2009

Physical Therapy Journal of the American Physical Therapy Association

Editorial Office

Editor in Chief

Managing Editor / Associate Director of Publications: Jan P Reynolds, [email protected]

Rebecca L Craik, PT, PhD, FAPTA, Philadelphia, PA [email protected]

PTJ Online Editor / Assistant Managing Editor: Steven Glaros

Deputy Editor in Chief

Associate Editor: Stephen Brooks, ELS Production Manager: Liz Haberkorn Manuscripts Coordinator: Karen Darley Permissions / Reprint Coordinator: Michele Tillson Advertising Manager: Julie Hilgenberg Director of Publications: Lois Douthitt

APTA Executive Staff Senior Vice President for Communications: Felicity Feather Clancy Chief Financial Officer: Rob Batarla Chief Executive Officer: John D Barnes

Advertising Sales Ad Marketing Group, Inc 2200 Wilson Blvd, Suite 102-333 Arlington, VA 22201 703/243-9046, ext 102 President / Advertising Account Manager: Jane Dees Richardson

Board of Directors President: R Scott Ward, PT, PhD Vice President: Randy Roesch, PT, MBA, DPT Secretary: Babette S Sanders, PT, MS Treasurer: Connie D Hauser, PT, DPT, ATC Speaker of the House: Shawne E Soper, PT, DPT, MBA Vice Speaker of the House: Laurita M Hack, PT, DPT, MBA, PhD, FAPTA Directors: William D Bandy, PT, PhD, SCS, ATC; Sharon L Dunn, PT, PhD, OCS; Kevin L Hulsey, PT, DPT, MA; Dianne V Jewell, PT, DPT, PhD, CCS, FAACVPR; Aimee B Klein, PT, DPT, MS, OCS; Stephen CF McDavitt, PT, DPT, MS, FAAOMPT; Paul A Rockar Jr, PT, DPT, MS; Lisa K Saladin, PT, PhD; John G Wallace Jr, PT, MS, OCS

Daniel L Riddle, PT, PhD, FAPTA, Richmond, VA

Editor in Chief Emeritus Jules M Rothstein, PT, PhD, FAPTA (1947–2005)

Steering Committee Anthony Delitto, PT, PhD, FAPTA (Chair), Pittsburgh, PA; J Haxby Abbott, PhD, MScPT, DipGrad, FNZCP, Dunedin, New Zealand; Joanell Bohmert, PT, MS, Mahtomedi, MN; Alan M Jette, PT, PhD, FAPTA, Boston, MA; Charles Magistro, PT, FAPTA, Claremont, CA; Ruth B Purtilo, PT, PhD, FAPTA, Boston, MA; Julie Whitman, PT, DSc, OCS, Westminster, CO

Editorial Board Andrea Behrman, PT, PhD, Melrose, FL; Rachelle Buchbinder, MBBS(Hons), MSc, PhD, FRACP, Malvern, Victoria, Australia; W Todd Cade, PT, PhD, St Louis, MO; John Childs, PT, PhD, Schertz, TX; Charles Ciccone, PT, PhD, FAPTA (Continuing Education), Ithaca, NY; Joshua Cleland, PT, DPT, PhD, OCS, FAAOMPT (The Bottom Line), Concord, NH; Janice J Eng, PT/OT, PhD, Vancouver, BC, Canada; G Kelley Fitzgerald, PT, PhD, OCS, Pittsburgh, PA; James C (Cole) Galloway, PT, PhD, Newark, DE; Kathleen Gill-Body, PT, DPT, NCS, Boston, MA; Paul JM Helders, PT, PhD, PCS, Utrecht, The Netherlands; Maura D Iversen, PT, MPH, ScD, Boston, MA; Diane U Jette, PT, DSc, Burlington, VT; Christopher Maher, PT, PhD, Lidcombe, NSW, Australia; Christopher J Main, PhD, FBPsS, Keele, United Kingdom; Kathleen Kline Mangione, PT, PhD, GCS, Philadelphia, PA; Patricia Ohtake, PT, PhD, Buffalo, NY; Carolynn Patten, PT, PhD, Gainesville, FL; Linda Resnik, PT, PhD, OCS, Providence, RI; Val Robertson, PT, PhD, Copacabana, NSW, Australia; Patty Solomon, PT, PhD, Hamilton, Ont, Canada

Statistical Consultants Steven E Hanna, PhD, Hamilton, Ont, Canada; John E Hewett, PhD, Columbia, MO; Hang Lee, PhD, Boston, MA; Paul Stratford, PT, MSc, Hamilton, Ont, Canada; Samuel Wu, PhD, Gainesville, FL

The Bottom Line Committee Joanell Bohmert, PT, MS; Lara Boyd, PT, PhD; James Cavanaugh IV, PT, PhD, NCS; Todd Davenport, PT, DPT, OCS; Ann Dennison, PT, DPT, OCS; William Egan, PT, DPT, OCS; Helen Host, PT, PhD; Evan Johnson, PT, DPT, MS, OCS, MTC; M Kathleen Kelly, PT, PhD; Catherine Lang, PT, PhD; Tara Jo Manal, PT, MPT, OCS, SCS; Kristin Parlman, PT, DPT, NCS; Susan Perry, PT, DPT, NCS; Maj Nicole H Raney, PT, DSc, OCS, FAAOMPT; Rick Ritter, PT; Eric Robertson, PT, DPT; Kathleen Rockefeller, PT, MPH, ScD; Michael Ross, PT, DHS, OCS; Patty Scheets, PT, DPT, NCS; Katherine Sullivan, PT, PhD; Mary Thigpen, PT, PhD; Jamie Tomlinson, PT, MS; Brian Tovin, DPT, MMSc, SCS, ATC, FAAOMPT; Nancy White, PT, MS, OCS; Julie Whitman, PT, DSc, OCS

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Physical Therapy (PTJ) (ISSN 00319023) is published monthly by the American Physical Therapy Association (APTA), 1111 North Fairfax Street, Alexandria, VA 22314-1488, at an annual subscription rate of $15 for members, included in dues. Nonmember rates are as follows: Individual (inside USA)— $99; individual (outside USA)—$119 surface mail, $179 air mail. Institutional (inside USA)—$129; institutional (outside USA)—$149 surface mail, $209 air mail. Periodical postage is paid at Alexandria, VA, and at additional mailing offices. Postmaster: Send address changes to Physical Therapy, 1111 North Fairfax Street, Alexandria, VA 22314-1488. Single copies: $15 USA, $15 outside USA; with the exception of January 2001: $50 USA, $70 outside USA. All orders payable in US currency. No replacements for nonreceipt after a 3-month period has elapsed. Canada Post International Publications Mail Product Sales Agreement No. 0055832.

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Founded in 1921, Physical Therapy (PTJ) is the official publication of the American Physical Therapy Association (APTA) and is an international, scholarly, peer-reviewed journal. PTJ serves APTA members, other health care professionals, and patients/clients by (1) documenting basic and applied knowledge related to physical therapy, (2) providing evidence to guide clinical decision making, and (3) publishing a variety of research that is relevant to the field and diverse opinions that are based in scholarly arguments. PTJ, like the profession it serves, strives to enhance the health and well-being of all members of society.

May 2009

Readers are invited to submit manuscripts to PTJ. PTJ’s content—including editorials, commentaries, letters, and book reviews—represents the opinions of the authors and should not be attributed to PTJ or its Editorial Board. Content does not reflect the official policy of APTA or the institution with which the author is affiliated, unless expressly stated.

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Volume 89 Number 5 Physical Therapy ■ 405

Research Report Surplus Value of Hip Adduction in Leg-Press Exercise in Patients With Patellofemoral Pain Syndrome: A Randomized Controlled Trial Chen-Yi Song, Yeong-Fwu Lin, Tung-Ching Wei, Da-Hon Lin, Tzu-Yu Yen, Mei-Hwa Jan

Background. A common treatment for patients with patellofemoral pain syndrome (PFPS) is strength (force-generating capacity) training of the vastus medialis oblique muscle (VMO). Hip adduction in conjunction with knee extension is commonly used in clinical practice; however, evidence supporting the efficacy of this exercise is lacking.

Objective. The objective of this study was to determine the surplus effect of hip adduction on the VMO.

CY Song, PT, MS, is a PhD student, School and Graduate Institute of Physical Therapy, College of Medicine, National Taiwan University, Taipei, Taiwan. YF Lin, MD, PhD, is Orthopedic Surgeon, Department of Orthopedics, West Garden Hospital, Taipei, Taiwan. TC Wei, PT, MS, is Physical Therapist, Yeong-An Clinic, Taipei, Taiwan.

Design. This study was a randomized controlled trial.

Participants. Eighty-nine patients with PFPS participated.

DH Lin, MD, is Orthopedic Surgeon, Department of Orthopedics, En Chu Kong Hospital, Taipei, Taiwan.

Intervention. Participants were randomly assigned to 1 of 3 groups: hip adduc-

TY Yen, PT, MS, is Physical Therapist, Yeong-An Clinic.

Setting. The study was conducted in a kinesiology laboratory.

tion combined with leg-press exercise (LPHA group), leg-press exercise only (LP group), or no exercise (control group). Training consisted of 3 weekly sessions for 8 weeks.

Measurements. Ratings of worst pain as measured with a 100-mm visual analog scale (VAS-W), Lysholm scale scores, and measurements of VMO morphology (including cross-sectional area [CSA] and volume) were obtained before and after the intervention.

Results. Significant improvements in VAS-W ratings, Lysholm scale scores, and VMO CSA and volume were observed after the intervention in both exercise groups, but not in the control group. Significantly greater improvements for VAS-W ratings, Lysholm scale scores, and VMO volume were apparent in the LP group compared with the control group. There were no differences between the LP and LPHA groups for any measures.

MH Jan, PT, MS, is Associate Professor, School and Graduate Institute of Physical Therapy, College of Medicine, National Taiwan University, 3F, No. 17, Xuzhou Rd, Zhongzheng District, Taipei 100, Taiwan, Republic of China. Address all correspondence to Ms Jan at: [email protected]. [Song CY, Lin YF, Wei TC, et al. Surplus value of hip adduction in leg-press exercise in patients with patellofemoral pain syndrome: a randomized controlled trial. Phys Ther. 2009;89:409 – 418.] © 2009 American Physical Therapy Association

Limitations. Only the VMO was examined by ultrasonography. The resistance level for hip adduction and the length of intervention period may have been inadequate to induce a training effect.

Conclusions. Similar changes in pain reduction, functional improvement, and VMO hypertrophy were observed in both exercise groups. Incorporating hip adduction with leg-press exercise had no impact on outcome in patients with PFPS. May 2009

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Post a Rapid Response or find The Bottom Line: www.ptjournal.org Physical Therapy f

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Surplus Value of Hip Adduction in Leg-Press Exercise in PFPS

P

atellofemoral pain syndrome (PFPS) is a common musculoskeletal problem of the knee. Patients with PFPS often have retropatellar or peripatellar pain.1 This pain is aggravated by activities that increase patellofemoral compressive force, such as walking up and down stairs, squatting, running, and prolonged sitting with bent knees.2– 4 Patellofemoral pain syndrome is thought to be associated with lateral malalignment of the patella.5 Possible causes of this malalignment include hypotrophy or atrophy of the vastus medialis oblique muscle (VMO), changes that are commonly seen in patients with PFPS, and an imbalance or delay in the activation of the VMO relative to the vastus lateralis muscle (VL).5,6 Several cadaver studies have shown that the VMO fiber angle was 50 to 57 degrees off the long axis of the femur in the frontal plane, and the proximal vastus medialis muscle fiber orientation was approximately 15 degrees.7–10 Anatomically, the direction of VMO muscle pull was more horizontal. It also has been demonstrated in a cadaver study that all of the quadriceps femoris muscles, except the VMO, can extend the knee (regardless of the force applied) and that the role of the VMO is to maintain medial tracking of the patella during knee extension.11 An in vivo study12 showed that electrical stimulation of the VMO resulted in pre-

Available With This Article at www.ptjournal.org • The Bottom Line clinical summary • The Bottom Line Podcast • Audio Abstracts Podcast This article was published ahead of print on March 19, 2009, at www.ptjournal.org.

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dominantly medial patellar pull. Because the VMO plays an important role in medial stabilization of the patella,11–13 any dysfunction may lead to reduced medial stabilization of the patella against the counterforce of lateral pull exerted by the VL and other quadriceps femoris muscle components.14,15 Numerous rehabilitation protocols have been described for treating people with patellofemoral problems. Quadriceps femoris muscle strengthening (increased force-generating capacity), especially that emphasizing the VMO, is generally considered to be a conservative treatment.14,16 –19 Incorporating hip adduction with knee extension is a popular strategy for strengthening the VMO.14,16 This intervention takes into consideration the fact that the VMO is connected to the adductor magnus and longus muscles.20 Training of the adductor muscles uses this anatomical link to provide a more-stable proximal attachment and transfers physiological stretch to the VMO, thereby enhancing the contraction force.15,21 Because hip adduction exercise was found to selectively activate the VMO,22 numerous studies have examined the electrical activity of the VMO and VL with hip adduction during various knee extension exercises.15,21,23–29 Findings have been disparate. Selective recruitment of the VMO was reported in 2 studies where VMO activity was higher than VL activity following hip adduction with knee extension from a semi-squatting position in subjects who were healthy.21,28 In patients with PFPS, however, incorporation of hip adduction has been found to promote a more-balanced VMO/VL ratio29 or increased whole quadriceps femoris muscle activity.24,25 Hodges and Richardson21 and Grelsamer and McConnell30 have advocated incorporating hip adduction

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with prone-lying or squatting positions. These positions, however, are nonfunctional or weight bearing, where the tendency of increasing the dynamic Q-angle may exacerbate stress on the patellofemoral joint.31 Furthermore, some patients may not tolerate this position because the gradually increasing joint stress may aggravate the pain. Leg-press (LP) exercise, therefore, be used as a substitute to train patients in a functional position without aggravating symptoms. To date, it remains unclear as to whether the addition of hip adduction to LP exercise would facilitate VMO hypertrophy and result in a better treatment outcome. In addition to the pain and functional scales that typically are used, ultrasonography provides a further quantitative measure for assessing muscle morphology in clinical trials involving patients with PFPS. Ultrasonography is a noninvasive and low-cost technique that is now extensively used for morphological investigations in the field of rehabilitation.32 The measurement validity of ultrasound compared with the magnetic resonance imaging or computed tomography gold standards has been reported to be acceptable.33,34 Indeed, although VMO strength cannot be directly assessed in vivo, morphological changes following exercise training can be both observed and quantified via ultrasonography and, thus, muscle force and excursion capability can be determined.35 The purpose of this study was to investigate the surplus effect of hip adduction to seated LP exercise on VMO morphology, pain, and function in patients with PFPS. We hypothesized that incorporation of hip adduction with leg-press training (LPHA) would result in morebeneficial effects on VMO hypertrophy, pain, and functional improve-

May 2009

Surplus Value of Hip Adduction in Leg-Press Exercise in PFPS ment compared with LP training alone.

Method Setting and Participants A total of 123 patients with a diagnosis of PFPS were referred to our kinesiology laboratory by an orthopedic surgeon (YFL). The inclusion criteria were: (1) experience of anterior or retropatellar knee pain after performing at least 2 of the following activities: prolonged sitting, stair climbing, squatting, running, kneeling, hopping and jumping, and deep knee flexing; (2) insidious onset of symptoms unrelated to traumatic accident; (3) presence of pain for more than 1 month; and (4) age of 50 years and under (to eliminate the possibility of osteoarthritis). In addition, participants had to exhibit at least 2 of the following positive signs of anterior knee pain during the initial physical examination: (1) patellar crepitus, (2) pain following isometric quadriceps femoris muscle contraction against suprapatellar resistance with the knee in slight flexion (Clarke’s sign), (3) pain following compression of the patella against the femoral condyles with the knee in full extension (patellar grind test), (4) tenderness upon palpation of the posterior surface of the patella or surrounding structures, and (5) pain following resisted knee extension. Participants were excluded if they had: (1) self-reported clinical evidence of other knee pathology; (2) patellar tendinitis or knee plica; (3) a history of knee surgery; (4) central or peripheral neurological pathology; (5) knee radiographic abnormalities (eg, knee osteoarthritis) or lower-extremity malalignment (eg, foot pronation); (6) severe knee pain (visual analog scale [VAS] score of ⬎8); or (7) received nonsteroidal anti-inflammatory drugs, injections, or physical therapy intervention in preceding 3 months.

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Of the 123 patients initially screened, 98 met the study inclusion criteria. Nine of the 98 recruited participants declined to participate before randomization. Therefore, a total of 89 participants were enrolled in this study. Sample size was calculated using a predetermined difference between treatment groups of 1.5 cm for worst pain on a 10-cm VAS. Assuming a standard deviation of 2 cm, at least 29 participants per treatment group were required to attain 80% power. Participants were randomly allocated to 1 of 3 groups: a group that received hip adduction combined with leg-press exercise (LPHA), a group that received LP exercise only, or a group that received no exercise (control group). Ten participants later dropped out of the study due to personal factors (not knee pain) or work commitment. Seventy-nine participants completed the trial (27 in each exercise group and 25 in the control group, Fig. 1). The demographic data for the 3 study groups are presented in Table 1. There were no significant between-group differences for any of the demographic variables. None of the participants were engaged in regular sporting activities. Randomization All volunteers were enrolled after providing written informed consent. The study was performed in a blind (nondiscriminatory) manner. A single physical therapist, unaware of the purpose of the study, was responsible for randomization and interventions. Stratified allocation was carried out with regard to the number of affected sides (unilateral or bilateral) and symptom severity (Lysholm scale scores ⱖ65 or ⬍65). Participants were randomly assigned to the LP group, LPHA group, or control group in blocks of 9 (chosen through numbered opaque envelopes) and participated in 3 weekly

exercise sessions for 8 weeks. Two assessment sessions were performed by another physical therapist (blinded to each patient’s grouping) before and after the 8-week intervention. Interventions Simple LP exercise. Leg-press exercise was performed unilaterally starting from 45 degrees of knee flexion to full extension using an ENDynamic Track machine.* Exercise within the functional range was considered safe for patients with PFPS.36 A blue Thera-Band† was tied to each patient’s thigh (without resistance) to maintain consistent tactile stimulation among groups. Prior to the beginning of exercise training, the unilateral 1-repetition maximum (RM) strength of the lower extremity was determined by Odvar Holten Pyramid diagram37 with repetition-tofatigue testing. Patients were unilaterally trained at 60% of 1 RM for 5 sets of 10 repetitions. The 1 RM was re-measured every 2 weeks, and the exercise intensity was adjusted accordingly. A 60-Hz metronome was used to control the exercise pace at 2-second concentric and eccentric contractions from 45 degrees of knee flexion to full extension. There were 2-second breaks between repetitions and 2-minute breaks between sets. Limbs were alternatively trained between exercise sets. LPHA. This exercise was performed as per the LP, except that a 50-N hip abduction force was applied to the distal one third of the thigh. This force was achieved by tying a blue Thera-Band to an arm of the EN-Dynamic Track machine (Fig. 2). Therefore, this exercise was a combination of LP and 50-N isometric hip adduction.

* Enraf-Nonius BV, Vareseweg 127, 3047 AT, Rotterdam, the Netherlands. † The Hygenic Corp, 1245 Home Ave, Akron, OH 44310-2575.

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Figure 1. Flow chart demonstrating the progression of participants through the trial. LPHA⫽hip adduction with leg-press exercise, LP⫽legpress exercise.

Table 1. Demographic Data for Study Participantsa LPHA Group (nⴝ29)

Variable Sex (male:female)

8:21

Age (y) Height (cm)

162.3⫾7.2

Weight (kg)

58.3⫾9.0

Body mass index

a

38.6⫾10.8

(kg/m2)

LP Group (nⴝ30) 8:22

Control Group (nⴝ30) 4:26

P .337

40.2⫾9.9

43.9⫾9.8

.129

161.3⫾8.4

159.7⫾5.2

.370

57.4⫾6.9

.505

60.1⫾11.2

22.2⫾3.2

23.0⫾3.0

22.5⫾2.1

.498

Involved side (bilateral:unilateral)

19:10

18:12

18:12

.882

Duration of symptoms (mo)

41.8⫾36.1

38.3⫾34.2

27.7⫾41.0

.056

Data are presented as mean⫾SD. LPHA⫽hip adduction with leg-press exercise, LP⫽leg-press exercise.

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Surplus Value of Hip Adduction in Leg-Press Exercise in PFPS A hot pack was applied to the quadriceps femoris muscle for 15 minutes before exercise was commenced. After exercise completion, participants were asked to stretch the quadriceps, hamstring, iliotibial band, and calf muscle groups and were given a cold pack to apply for 10 minutes. Stretches were maintained for 30 seconds and were repeated 3 times for each muscle group. All study participants were asked not participate in any form of sport or exercise during the intervention period. Control group. Control group participants did not receive any exercise intervention, but were provided with health educational material regarding patellofemoral pain. They were advised not to perform or receive any exercise program or intervention. Neither tape nor brace was used. Exercise training was implemented after the 8-week control period. Outcome Measurements VAS pain assessment. The VAS is a reliable, well-validated, and widely used tool for assessing knee pain.38 – 41 A 100-mm VAS was used to measure the worst pain (VAS-W) experienced in the previous week. Functional evaluation. The Lysholm scale was used to measure functional ability. The scale ranges from 0 to 100 points (with a score of 100 indicating maximal function) and was originally designed to evaluate symptoms and functions pertaining to knee injury.42 There are 8 components to this assessment: stair climbing (10 points), squatting (5 points), pain (25 points), presence of a limp (5 points), locking (15 points), instability (25 points), swelling (10 points), and the requirement of support when walking (5 points). The reliability, validity, and robustness of the Lysholm scale have been well documented.42– 48 The Lysholm scale was found to correlate May 2009

Figure 2. Hip adduction with leg-press exercise (a), with a close lateral view of the setup of resisted hip adduction via Thera-Band (b).

highly with the Kujala anterior knee pain scale (r⫽.86)45 and has been used as a knee function evaluation tool in patients with patellofemoral disorders.45,49 –51 Measurement of VMO morphology. Vastus medialis oblique muscle morphology was assessed by ul-

trasonography (HDI 5000‡) with a 5- to 12-MHz broadband linear-array transducer (38 mm). The ultrasonographic measurements included VMO cross-sectional area (CSA) on the patellar-base level and VMO volume ‡ Advanced Technology Laboratories, 22100 Bothell Everett Hwy, Bothell, WA 98041-3003.

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Figure 3. Measurement of vastus medialis oblique muscle cross-sectional area on patellar-base level.

under the patellar-base level.52 All measurements were obtained while participants were lying on a bed, with both legs relaxed (feet were positioned in a frame to prevent leg rotation) and a thick padded towel placed underneath the knee to maintain resting position. The longitudinal length of the patella (in millimeters) was determined from the upper border to the lower border with calipers. The VMO volume under the patellar base was approximated from a series of VMO CSAs using the trapezoidal rule.52 To obtain a valid calculation of VMO volume from the sonographic image, a custom-made holder was used to fix the probe.52 The holder was calibrated to quantify movement of the transducer by synchronizing with a scaled hub, which was turned in a full circle to mobilize the transducer by 1 mm from the proximal patellar base toward the distal patellar apex along a line perpendicular to the horizontal representing the upper border of the patella. The first VMO 414

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CSA was taken from the line passing through the patellar-base level (Fig. 3). Serial VMO CSAs were obtained every 2 mm until the VMO image on the visual display faded. To control for any potential confounding pressure exerted by the probe holder, gel was applied to the skin such that there was no direct contact between the probe and the skin.53 The image was carefully monitored by the examiner to ensure that the VMO was not being compressed (Fig. 3). The intraclass correlation coefficients for between-day test-retest reliability of VMO CSA and volume measurements were .96 and .94, respectively. The actual day-to-day differences (X⫾SD) were 0.02⫾0.30 cm2 and 0.06⫾0.68 cm3, respectively. The standard errors of measurement were 0.29 and 0.52, respectively. Data Analysis Data obtained from the most symptomatic knee were analyzed using

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SPSS version 11.0.§ Data were subjected to an intention-to-treat analysis and included all dropouts. Descriptive statistics (X⫾SD) were used to determine participant characteristics. Prior to statistical analysis, the Kolmogorov-Smirnov test was performed to assess the normality of continuous data. Normally distributed baseline demographic variables (age, body height, body weight, and body mass index) were compared by 1-way analysis of variance (ANOVA). Non-normally distributed variables (symptom duration) were compared by KruskalWallis test with an alpha of .05. Sex and numbers of afflicted sides (bilateral versus unilateral) were compared by chi-square test with an alpha of .05. For each outcome variable measured, a 2 (preintervention and postintervention) ⫻ 3 (treatment groups: LPHA, LP, and control) 2-way mixed ANOVA was performed. When a significant 2-way interaction was detected, post hoc analysis was performed using Bonferroni adjustment (P⬍.008).

Results All exercise intervention participants except one attended all scheduled exercise sessions. One participant in the LP group completed only half of the intervention and subsequently dropped out of the study due to work commitments (Fig. 1). The remaining study participant dropouts in both exercise groups completed the exercise programs but did not attend postintervention evaluations. Results pertaining to VAS-W, Lysholm scale scores, VMO CSA, and VMO volume for the 3 groups before and after the 8-week intervention period are shown in Table 2. There were no significant baseline differences among the groups. The 2-way ANOVA for repeated measures re§

SPSS Inc, 233 S Wacker Dr, Chicago, IL 60606.

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a

Data are presented as mean⫾SD. VAS-W⫽worst pain as measured by the 100-mm visual analog scale, CSA⫽cross-sectional area, CI⫽confidence interval. Asterisk denotes significant difference between preintervention and postintervention values (P⬍.008).

0.05 .838 (⫺0.45 to 0.55) 2.82⫾1.91 2.76⫾2.01 ⬍.005* 1.06 (0.57 to 1.56) 3.38⫾2.37 3.04⫾2.18 VMO volume (cm3)

4.12⫾1.83

1.08 (0.58 to 1.59)

⬍.005*

4.45⫾2.52

⫺0.01 .962 (⫺0.38 to 0.36) 3.38⫾1.52 3.39⫾1.47 ⬍.005* 0.71 (0.34 to 1.08) 4.46⫾1.90 3.75⫾1.59 .004* 0.57 (0.22 to 0.92) 4.24⫾1.43 3.67⫾1.45 VMO CSA (cm2)

0.67 .714 (⫺2.93 to 4.27) 75.7⫾10.9 75.1⫾9.3 ⬍.005* 10.73 (7.13 to 14.33) 75.7⫾12.8 74.8⫾12.1 Lysholm scale

85.7⫾8.5

10.93 (7.27 to 14.59)

⬍.005*

86.5⫾10.4

4.81⫾2.55 4.99⫾2.18

P P

⫺2.58 ⬍.005* (⫺3.56 to ⫺1.61) 2.26⫾2.20 4.85⫾2.49 ⫺2.18 ⬍.005* (⫺3.17 to ⫺1.19)

P Variable

2.62⫾2.51

PrePostintervention intervention PrePostintervention intervention

4.80⫾2.26

Mean Difference (95% CI) PrePostintervention intervention

Control Group (nⴝ30) LP Group (nⴝ30)

Mean Difference (95% CI) Mean Difference (95% CI)

LPHA Group (nⴝ29)

Comparison Between Preintervention and Postintervention Changes of Pain, Function, and Vastus Medialis Oblique Muscle (VMO) Morphology for the Hip Adduction With Leg-Press Exercise (LPHA) Group, the Leg-Press Exercise (LP) Group, and the Control Groupa

Table 2.

The pretest-posttest effect size in the LPHA group ranged from 0.48 to 0.77 for VMO morphology and 0.76 to 1.10 for VAS-W and Lysholm scale scores, and the corresponding values for the LP group were 0.71 to 0.75 and 0.89 to 0.95, respectively. When comparing the effect between the LPHA and control groups, effect size values were 0.78 for VAS-W, 1.12 for the Lysholm scale scores, and 0.56 to 0.77 for VMO CSA and VMO volume. These effect sizes were consistently smaller than those associated with the LP group and control group comparison, where effect size values were 0.92 for VAS-W and 0.75 to 0.77 for VMO CSA and VMO volume. An exception was Lysholm scale scores (effect size⫽1.01). However, there was no significant difference in improvement for any variable between the LP and LPHA groups.

VAS-W

vealed significant interactions for VAS-W, Lysholm scale scores, VMO CSA, and VMO volume. Post hoc analyses indicated that VAS-W, Lysholm scale scores, VMO CSA, and VMO volume significantly increased following intervention in the LP and LPHA groups (P⬍.008), but not the control group (Tab. 2). Furthermore, values pertaining to the VAS-W and Lysholm scale were significantly better in both exercise groups compared with the control group after intervention (P⬍.008) (Tab. 3). The values for VMO volume were significantly higher in the LP group compared with the control group after intervention (P⬍.008), whereas the between-group difference in VMO CSA did not reach the level of adjusted significance (P⫽.012). The values for VMO CSA and VMO volume were not different between the LPHA group and the control group after intervention (P⫽.046 and P⫽.02, respectively). No differences were detected between the LP and LPHA groups (Tab. 3).

⫺0.18 .715 (⫺1.16 to 0.80)

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Surplus Value of Hip Adduction in Leg-Press Exercise in PFPS Table 3. Comparison Among Group Changes of Pain, Function, and Vastus Medialis Oblique Muscle (VMO) Morphology for the Hip Adduction With Leg-Press Exercise (LPHA) Group, the Leg-Press Exercise (LP) Group, and the Control Groupa LPHA Group vs Control Group Mean Difference (95% CI)

Variable

⫺2.19 (⫺3.44 to ⫺0.93)

VAS-W Lysholm scale

.001* ⬍.005*

9.99 (4.81 to 15.17)

P

LPHA Group vs LP Group Mean Difference (95% CI)

P

⫺2.54 (⫺3.79 to ⫺1.30)

⬍.005*

0.35 (⫺0.90 to 1.61)

.577

10.73 (5.60 to 15.87)

⬍.005*

⫺0.74 (⫺5.92 to 4.44)

.776

VMO CSA (cm )

0.86 (0.02 to 1.70)

.046

1.09 (0.25 to 1.92)

.012

⫺0.23 (⫺1.07 to 0.62)

.598

VMO volume (cm3)

1.30 (0.21 to 2.40)

.020

1.63 (0.55 to 2.71)

.004*

⫺0.33 (⫺1.42 to 0.77)

.556

2

a

P

LP Group vs Control Group Mean Difference (95% CI)

CSA⫽cross-sectional area, CI⫽confidence interval. Asterisk denotes significant difference among groups (P⬍.008).

Discussion Strengthening of the knee extensor via hip adduction is a very common therapeutic approach for treating people with patellofemoral pain.14,16 The effects of 8-week LP and LPHA exercise interventions on pain reduction, functional improvement, and VMO hypertrophy were comparable, indicating that there is no additive beneficial effect of incorporating hip adduction with LP exercise. This finding may be attributed to the fact that during simple LP exercise, the hip adductor magnus and longus muscles are simultaneously activated to stabilize hip movement.54 This is the first study, to our knowledge, that investigated the clinical effects of adding hip adduction to LP exercise for the management of PFPS. Limited knowledge might be gained if change of the training position would result in different outcomes. However, the effects of exercise training on pain reduction in the current study can be considered clinically significant based on a previous report that a VAS change of 1.5 mm in patients with PFPS is the minimal difference to be considered clinically important.38 These findings are in accordance with the results of previous studies regarding pain reduction where various quadriceps femoris muscle retraining exercise protocols were used.49,55–59 Functional performance (as indicated by Lysholm scale scores) following our exercise 416

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intervention improved by approximately 11 points. This finding is similar to those of a previous study in which Lysholm scale scores increased from 67.6⫾6.4 points to 81.1⫾9.4 points after 6 weeks of isokinetic training.49 Unlike the VAS, the minimal change in the Lysholm scale scores representing a clinically relevant improvement in functional status is yet to be determined. Out of 100 points, a score of 95 to 100 indicates excellent function, a score of 84 to 94 indicates good function, a score of 65 to 83 indicates fair function, and a score of ⬍65 indicates poor function.42 Overall, the patients in our study exhibited significant functional improvement from a level of fair to good following LP or LPHA training. Functional improvements in our study were significantly correlated with reductions in VAS-W (r⫽ ⫺.451, P⬍.005). This finding is comparable to that from a previous report (r⫽⫺.424, P⫽.009).49 It must be borne in mind that the results of intention-to-treat may even be underestimated. Because the Lysholm scale is not a PFPS-specific scale, we made a further subanalysis of the stair-climbing and squatting items. Initially, 93% and 82% of the exercise intervention participants had difficulty performing the stair-climbing and squatting tasks, respectively. After exercise intervention, 50% to 52% of the patients achieved maximal scores for

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stair climbing and squatting. Our findings of decreased pain and increased functional capacity agree with previous research demonstrating that patients with PFPS were able to perform significantly more stepups, step-downs, and squats before pain onset after quadriceps femoris muscle training.59 The relationship between quadriceps femoris muscle strength and locomotor function in patients with PFPS has been documented previously by Powers and Perry.60 Leg-press exercise training, especially in the eccentric contraction mode, is better suited for individuals with PFPS who demonstrate weaker eccentric than concentric quadriceps femoris muscle strength.61 Given the improvements in 1 RM (from 90⫾30 kg to 145⫾50 kg in the LPHA group and from 89⫾33 kg to 138⫾51 kg in the LP group), it is not surprising that both exercise groups exhibited significant improvements in the stair-climbing and squatting scores on the Lysholm scale (r⫽.347, P⬍.05). Folland and Williams62 concluded that the primary morphological adaptation after resistance exercise is related to an increase in the CSA of the whole muscle and individual muscle fibers (caused by an increase in myofibril size and number). After both LPHA and LP exercise intervention in our study, VMO hypertrophy was observed as the result of training because the amount of improvement May 2009

Surplus Value of Hip Adduction in Leg-Press Exercise in PFPS was greater than the measurement error. This is the first study using noninvasive ultrasonography to investigate changes in VMO morphology in patients with PFPS following LPHA or LP training. We speculate that this positive outcome may be partially a consequence of VMO hypertrophy. As all patients were given hot packs before exercise and were instructed to stretch and apply cold packs after exercise, it is possible that the positive outcomes may not have been due to LP exercise alone. A previous study63 demonstrated that centralization of the patella can result from VMO strengthening and stretching procedures. Further research is needed to determine whether patellar alignment or tracking is altered with VMO hypertrophy. We found that LPHA did not result in further beneficial effects compared with LP exercise alone. It is possible that hip adductor activation during LP training54 subtracted from the effect of additional isometric hip adduction. However, it also is possible that isometric hip adduction does not preferentially recruit the VMO.15,23–25,27 Further study is warranted to clarify this issue. This study had several limitations. Only the VMO was examined by ultrasonography after exercise intervention, and the VL and other components of the quadriceps femoris muscle were not assessed. Additional investigation is warranted to examine morphological changes in individual quadriceps femoris muscles. A second potential limitation was the use of 50 N as the force level for hip adduction. This force level may have been inadequate to induce a training effect. We also note that outcomes were assessed following an 8-week exercise intervention period. Determining how these outcomes change with a longer-term

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intervention period would be of interest.

Conclusion The findings suggest that an 8-week exercise program involving simple LP training (from 45° of knee flexion to full extension) and stretching can induce significant VMO hypertrophy, improve knee function, and reduce pain in patients with PFPS. We found that adding 50 N of hip adduction to LP exercise had no further beneficial effects on outcome compared with LP exercise alone after an 8-week intervention in patients with PFPS. Ms Song, Dr YF Lin, Dr DH Lin, and Ms Jan provided concept/idea/research design. Ms Song and Ms Jan provided writing. Ms Song and Mr Wei provided data collection. Ms Song and Dr DH Lin provided data analysis. Ms Jan provided project management, facilities/equipment, and institutional liaisons. Dr YF Lin and Dr DH Lin provided participants. Mr Wei and Ms Yen provided clerical support. Dr YF Lin provided consultation (including review of manuscript before submission). The study protocol was approved by the Research Ethics Committee of National Taiwan University Hospital. An oral presentation of the results of this study was given at the International Congress of the World Confederation for Physical Therapy; June 5, 2007; Vancouver, British Columbia, Canada. This article was received June 23, 2008, and was accepted February 3, 2009. DOI: 10.2522/ptj.20080195

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Surplus Value of Hip Adduction in Leg-Press Exercise in PFPS 21 Hodges PW, Richardson CA. The influence of isomeric hip adduction on quadriceps femoris activity. Scand J Rehabil Med. 1993;25:57– 62. 22 Hanten WP, Schulthies SS. Exercise effect on electromyographic activity of the vastus medialis oblique and vastus lateralis muscles. Phys Ther. 1990;70:561–565. 23 Laprade J, Culham E, Brouwer B. Comparison of five isometric exercises in the recruitment of the vastus medialis oblique in persons with and without patellofemoral pain syndrome. J Orthop Sports Phys Ther. 1998;27:197–204. 24 Cerny K. Vastus medialis oblique/vastus lateralis muscle activity ratios for selected exercises in persons with and without patellofemoral pain syndrome. Phys Ther. 1995;75:672– 683. 25 Earl JE, Schmitz RJ, Arnold BL. Activation of the VMO and VL during dynamic minisquat exercises with and without isometric hip adduction. J Electromyogr Kinesiol. 2001;11:381–386. 26 Zakaria D, Harburn KL, Kramer JF. Preferential activation of the vastus medialis oblique, vastus lateralis, and hip adductor muscles during isometric exercises in females. J Orthop Sports Phys Ther. 1997; 26:23–28. 27 Hertel J, Earl JE, Tsang KW, Miller SJ. Combining isometric knee extension exercises with hip adduction or abduction does not increase quadriceps EMG activity. Br J Sports Med. 2004;38:210 –213. 28 Miller JP, Sedory D, Croce RV. Vastus medialis oblique and vastus lateralis activity in patients with and without patellofemoral pain syndrome. J Sports Rehab. 1997; 6:1–10. 29 Coqueiro KR, Bevilaqua-Grossi D, Berzin F, et al. Analysis on the activation of the VMO and VLL muscles during semisquat exercises with and without hip adduction in individuals with patellofemoral pain syndrome. J Electromyogr Kinesiol. 2005; 15:596 – 603. 30 Grelsamer RP, McConnell J. The Patella: A Team Approach. Gaithersburg, MD: Aspen Publishers Inc; 1998:127–129. 31 Powers CM. The influence of altered lower-extremity kinematics on patellofemoral joint dysfunction: a theoretical perspective. J Orthop Sports Phys Ther. 2003;33:639 – 646. 32 Whittaker JL, Teyhen DS, Elliott JM, et al. Rehabilitative ultrasound imaging: understanding the technology and its applications. J Orthop Sports Phys Ther. 2007;37: 434 – 449. 33 Dupont AC, Sauerbrei EE, Fenton PV, et al. Real-time sonography to estimate muscle thickness: comparison with MRI and CT. J Clin Ultrasound. 2001;29:230 –236. 34 Hides JA, Richardson CA, Jull GA. Magnetic resonance imaging and ultrasonography of the lumbar multifidus muscle: comparison of two different modalities. Spine. 1995;20:54 –58.

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35 Lieber RL, Friden J. Clinical significance of skeletal muscle architecture. Clin Orthop. 2001;383:140 –151. 36 Grelsamer RP, Klein J. The biomechanics of the patellofemoral joint. J Orthop Sports Phys Ther. 1998;28:286 –297. 37 Gustavsen R, Streek R. Training Therapy: Prophylaxis and Rehabilitation. Stuttgart, Germany: Georg Thieme Verlag: 1993. 38 Crossley KM, Bennell KL, Cowan SM, Green S. Analysis of outcome measures for persons with patellofemoral pain: which are reliable and valid? Arch Phys Med Rehabil. 2004;85:815– 822. 39 Bennell KL, Bartram S, Crossley KM, Green S. Outcome measures in patellofemoral pain syndrome: test-retest reliability and interrelationships. Phys Ther Sport. 2000; 1:32–34. 40 Eng JJ, Pierrynowski MR. Evaluation of soft foot orthotics in the treatment of patellofemoral pain syndrome. Phys Ther. 1993;73:62–70. 41 Chesworth BM, Culham EG, Tata GE, et al. Validation of outcome measures in patients with patellofemoral pain syndrome. J Orthop Sports Phys Ther. 1989;17: 302–308. 42 Lysholm J, Gillquist J. Evaluation of knee ligament surgery results with special emphasis on use of a scoring scale. Am J Sports Med. 1982;10:150 –154. 43 Marx RG, Jones EC, Allen AA, et al. Reliability, validity, and responsiveness of four knee outcome scales for athletic patients. J Bone Joint Surg Am. 2001;83: 1459 –1469. 44 Kocher MS, Steadman JR, Briggs KK, et al. Reliability, validity, and responsiveness of the Lysholm knee scale for various chondral disorders of the knee. J Bone Joint Surg Am. 2004;86:1139 –1146. 45 Paxton EW, Fithian DC, Stone ML, Silva P. The reliability and validity of knee- specific and general health instruments in assessing acute patellar dislocation outcomes. Am J Sports Med. 2003;31:487– 492. 46 Irrgang JJ, Snyder-Mackler L, Wainner RS, et al. Development of a patient-reported measure of function of the knee. J Bone Joint Surg Am. 1998;80:1132–1145. 47 Bollen S, Seedhom BB. A comparison of the Lysholm and Cincinnati knee scoring questionnaires. Am J Sports Med 1991;19: 189 –190. 48 Risberg MA, Holm I, Steen H, Beynnon BD. Sensitivity to changes over time for the IKDC form, the Lysholm score, and the Cincinnati knee score. Knee Surg Sports Traumatol, Arthrosc. 1999;7:152–159. 49 Alaca R, Yilmaz B, Goktepe AS, et al. Efficacy of isokinetic exercise on functional capacity and pain in patellofemoral pain syndrome. Am J Phys Med Rehabil. 2002; 81:807– 813. 50 Lin YF, Lin JJ, Jan MH, et al. Role of the vastus medialis obliquus in repositioning the patella: a dynamic computed tomography study. Am J Sports Med. 2008;36: 741–746.

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51 Natri A, Kannus P, Ja¨rvinen M. Which factors predict the long-term outcome in chronic patellofemoral pain syndrome? A 7-year prospective follow-up study. Med Sci Sports Exerc. 1998;30:1572–1577. 52 Lin YF, Lin JJ, Cheng CK, et al. Association between sonographic morphology of vastus medialis obliquus and patellar alignment in patients with patellofemoral pain syndrome. J Orthop Sports Phys Ther. 2008;38:196 –202. 53 Jan MH, Chai HM, Wang CL, et al. Effects of repetitive shortwave diathermy for reducing synovitis in patients with knee osteoarthritis: an ultrasonographic study. Phys Ther. 2006;86:236 –244. 54 Enocson AG, Berg HE, Vargas R, et al. Signal intensity of MR-images of thigh muscles following acute open- and closedchain kinetic knee extensor exercise: index of muscle use. Eur J Appl Physiol. 2005;94:357–363. 55 Witvrouw E, Lysens R, Bellemans J, et al. Open versus closed kinetic chain exercises for patellofemoral pain. Am J Sports Med. 2000;28:687– 694. 56 Herrington L, Al-Sherhi A. A controlled trial of weight-bearing versus non-weightbearing exercises for patellofemoral pain. J Orthop Sports Phys Ther. 2007;37: 155–160. 57 Hazneci B, Yildiz Y, Sekir U, et al. Efficacy of isokinetic exercise on joint position sense and muscle strength in patellofemoral pain syndrome. Am J Phys Med Rehabil. 2005;84:521–527. 58 Clark DI, Downing N, Mitchell J, et al. Physiotherapy for anterior knee pain: a randomized controlled trial. Ann Rheum Dis. 2000;59:700 –704. 59 Crossley KM, Bennell KL, Green S, et al. Physical therapy for patellofemoral pain: a randomized, double-blinded, placebocontrolled trial. Am J Sports Med. 2002; 30:857– 865. 60 Powers CM, Perry J. Are patellofemoral pain and quadriceps strength associated with locomotor function? Phys Ther. 1997;77:1063–1074. 61 Werner S. An evaluation of knee extensor and flexor torques and EMGs in patients with PFPS in comparison with matched controls. Knee Surg Sports Traumatol Arthrosc. 1995;3:89 –94. 62 Folland JP, Williams AG. The adaptations to strength training: morphological and neurological contributions to increased strength. Sports Med. 2007;37:145–168. 63 Doucette SA, Goble EM. The effect of exercise on patellar tracking in lateral patellar compression syndrome. Am J Sports Med. 1992;20:434 – 440.

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Research Report Interventions Associated With an Increased or Decreased Likelihood of Pain Reduction and Improved Function in Patients With Adhesive Capsulitis: A Retrospective Cohort Study Dianne V Jewell, Daniel L Riddle, Leroy R Thacker

Background and Purpose. The purpose of this study was to determine whether physical therapy interventions predicted meaningful short-term improvement in 4 measures of physical health, pain, and function for patients diagnosed with adhesive capsulitis.

Participants. Data were examined from 2,370 patients (mean age⫽55.3 years, SD⫽12.4; 65% female, 35% male) classified into ICD-9 code 726.0 who had completed an episode of outpatient physical therapy.

Methods. Principal components factor analysis was used to define intervention categories from specific treatments applied during the episode of care. A nested logistic regression model was used to identify intervention categories that predicted a 50% or greater change in Physical Component Summary-12 (PCS-12), physical function (PF), bodily pain (BP), and hybrid function (HF) scores.

Results. None of the patients achieved a 50% or greater improvement in PCS-12 scores. Improvement in BP scores was more likely in patients who received joint mobility interventions (odds ratio⫽1.35, 95% confidence interval⫽1.10 –1.65). Improvement in HF scores was more likely in patients who received exercise interventions (odds ratio⫽1.50, 95% confidence interval⫽1.03–2.17). Use of iontophoresis, phonophoresis, ultrasound, or massage reduced the likelihood of improvement in these 3 outcome measures by 19% to 32%.

DV Jewell, PT, DPT, PhD, CCS, is Assistant Professor, Department of Physical Therapy, Virginia Commonwealth University, 1200 E Broad St, Suite 100, PO Box 980224, Richmond, VA 232980224 (USA). Address all correspondence to Dr Jewell at: [email protected]. DL Riddle, PT, PhD, FAPTA, is Otto D. Payton Professor, Department of Physical Therapy, Virginia Commonwealth University. LR Thacker, PhD, is Assistant Professor, Department of Biostatistics, Virginia Commonwealth University. [Jewell DV, Riddle DL, Thacker LR. Interventions associated with an increased or decreased likelihood of pain reduction and improved function in patients with adhesive capsulitis: a retrospective cohort study. Phys Ther. 2009;89:419 – 429.] © 2009 American Physical Therapy Association

Limitations. The authors relied on clinician-identified ICD-9 coding for the diagnosis. Impairment measures were not available to support the diagnosis, and some interventions were excluded because of infrequent use by participating therapists.

Discussion and Conclusions. These results are consistent with findings from randomized clinical trials that demonstrated the effectiveness of joint mobilization and exercise for patients with adhesive capsulitis. Ultrasound, massage, iontophoresis, and phonophoresis reduced the likelihood of a favorable outcome, which suggests that use of these modalities should be discouraged.

Post a Rapid Response or find The Bottom Line: www.ptjournal.org May 2009

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Interventions Associated With Favorable Outcomes in Adhesive Capsulitis

A

dhesive capsulitis, or “frozen shoulder,” is a soft tissue disorder that results in pain, stiffness, and progressive loss of active and passive range of motion (AROM and PROM) in the glenohumeral joint.1,2 The patient frequently has difficulty dressing, grooming, and performing overhead reaching activities for a period of several months to several years.3 The disorder predominantly affects women aged 40 to 60 years and occurs in roughly 2% to 4% of the adult population.1,4 – 6 In addition to age and sex, risk factors commonly identified include diabetes, cervical disk disease, immobilization of the shoulder, shoulder trauma, cardiovascular and pulmonary disease, hyperthyroidism, and autoimmune diseases.2,4,7 Three distinct clinical stages with overlapping timelines have been proposed: (1) an acute stage, with painful shoulder motion and sleep interruption; (2) a frozen stage, characterized by stiffness, reduced pain, and loss of joint motion, and; (3) a thawing stage, with resolution of pain and gradual recovery of joint Available With This Article at www.ptjournal.org • eTable 1: Percentage of Patients Receiving Individual Treatment Options • eTable 2: FOTO Training Manual Definitions of Physical Therapy Interventions • eTable 3: Physical Therapy Intervention Categories for Patients With Adhesive Capsulitis • The Bottom Line clinical summary • The Bottom Line Podcast • Audio Abstracts Podcast This article was published ahead of print on March 6, 2009, at www.ptjournal.org.

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motion.8 Left untreated, adhesive capsulitis appears to be a selflimiting, but frequently disabling, disorder that lasts an average of 3 years. The economic impact of this protracted condition has been estimated in randomized controlled trials (RCTs) in Europe and Australia.9,10 When converted to US dollars, the total combined annual health care and non– health care costs are approximately $7,000 to 8,000 per episode. Despite the individual and societal burden associated with adhesive capsulitis, relatively little is known about which nonsurgical interventions increase or decrease the likelihood of a successful outcome. Management options for adhesive capsulitis include oral corticosteroids or glenohumeral joint corticosteroid injection,6,11–18 manipulation under anesthesia,1 arthroscopic capsular release,19 and a variety of interventions provided by physical therapists. Physical therapy interventions most commonly described include therapeutic exercise, manual therapy techniques such as joint mobilization and manipulation, electrotherapeutic modalities, and thermal modalities.10,11,13–17,20 –22 Green and colleagues’ meta-analysis of clinical trials evaluating the effectiveness of physical therapy interventions for shoulder pain revealed beneficial effects from laser therapy for patients with adhesive capsulitis or rotator cuff pathology.23 Exercise also produced positive outcomes in patients with “mixed shoulder disorders.” Ultrasound, however, provided no additional benefit, and there was insufficient evidence to support or refute the effectiveness of physical therapy alone for adhesive capsulitis. Most of the studies included in the review were methodologically weak, had small sample sizes, and did not investigate combinations of interventions. The variability in diagnostic classification across studies also made it difficult to isolate treatment effects for

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patients with confirmed adhesive capsulitis. Four RCTs published since Green and colleagues’ systematic review23 examined different combinations of physical therapy interventions in people with adhesive capsulitis. Guler-Uysal and Kozanoglu20 randomly assigned 40 patients with idiopathic adhesive capsulitis (35% painful stage, 65% frozen stage) to a deep friction massage and Cyriax mobilization group or a heat modality and therapeutic exercise group. Ninety-five percent of the participants who received manual therapy techniques achieved 80% of normal PROM and greater pain reduction after 2 weeks of treatment compared with 65% of those who received modalities and exercise. The authors did not assess functional change and did not repeat the outcome measures beyond the 2-week treatment period. Buchbinder et al10 evaluated the effectiveness of a combination of manual therapy techniques and exercise compared with sham ultrasound (placebo) in 144 patients who had adhesive capsulitis for an average of 6 months. Both groups received 8 treatment sessions over 6 weeks following arthrographic glenohumeral joint distension. The experimental group achieved a statistically significant improvement in AROM (ie, an increase in active shoulder abduction of 10.6°, P⫽.006) and patientperceived improvement (relative risk⫽1.4, 95% confidence interval [CI]⫽1.1–1.7) that were sustained over the 6-month follow-up period. However, no differences were detected between the groups with respect to pain, function, or quality of life at 6, 12, and 26 weeks. Two RCTs21,22 compared the effectiveness of specific joint mobilization techniques in patients with adhesive capsulitis who had documented PROM deficits. Both studies showed May 2009

Interventions Associated With Favorable Outcomes in Adhesive Capsulitis improvements in PROM for either Maitland grade III or IV procedures (ie, an increase of 36.3°-46.3° of passive abduction)21 or with posteriorly directed Kaltenborn grade III procedures (ie, an increase of 31.3° of passive external rotation).22 However, subsequent changes in pain and function were comparable to those of the respective comparison groups. In addition, the improvement in functional outcomes in Vermeulen and colleagues’ subjects occurred months after treatment concluded.21 The 4 RCTs10,21–22 examined different types and combinations of treatments over different time periods and used a variety of self-report instruments to assess pain, function, and quality of life. Two of the studies used small samples with a wide range of symptom duration. As a result, it is unclear which interventions may be most effective for patients with adhesive capsulitis. In addition, we found no cohort studies evaluating outcomes of physical therapy interventions for this disorder in large samples of subjects. Longitudinal outcome studies have limitations but can provide insight into the usefulness of interventions delivered in “real-world” clinical conditions, the influences of which are purposefully constrained in RCTs. Large sample cohort studies also have the advantage of comparing outcomes for many combinations of interventions, unlike RCTs, which typically compare a limited number of interventions. Predictive models using large cohorts may identify convincing relationships between specific interventions and patient outcomes and help narrow the focus of future effectiveness and efficacy studies. Therefore, the purpose of our study was to determine whether physical therapy interventions, either in isolation or in combination, predicted meaningful short-term change in pain and physical health for a large May 2009

cohort of patients diagnosed with adhesive capsulitis of the shoulder.

Method Design Overview Focus On Therapeutic Outcomes Inc (FOTO),* a private rehabilitation outcomes management company, provided data for this study. Clinics contracting with FOTO during the study used standardized questionnaires24 with several demographic and disorder-related questions as well as the Physical Component Summary-12 (PCS-12).25 The PCS-12 is a 12-item generic health measure derived from the Physical Component Summary of the Medical Outcomes Study 36-Item Short-Form Health Survey questionnaire (SF-36). Transformed scores on the PCS-12 range from 0 to 100, with 50 representing the mean score for the population of adults in the United States. Higher scores indicate less physical disability.26 Physical function (PF) and bodily pain (BP) subscale scores also can be calculated from this survey. Several authors have examined the usefulness of self-report health status instruments in patients with shoulder disorders. Gartsman et al27 compared the SF-36 scores of 100 patients diagnosed with adhesive capsulitis. The average Physical Component Summary (PCS) score was 37.6 (SD⫽8.8), and the mean PF and BP subscale scores were 67.2 (SD⫽22.4) and 37.6 (SD⫽20.6). However, the authors did not evaluate responsiveness to change of the composite or subscale scores in this patient group. Beacon and Richards28 found the SF-36 PCS and PF subscale scores to be less responsive to change compared with shoulderspecific health status instruments in 99 patients undergoing total shoulder arthroplasty or rotator cuff sur* Focus on Therapeutic Outcomes Inc, PO Box 11444, Knoxville, TN 37939-1444.

gery. The BP subscale, however, demonstrated a standardized response mean comparable to those of the other surveys. Schmitt and Di Fabio29 reported comparable findings regarding the responsiveness of the PCS-12 in 58 patients with a variety of “proximal UE [upperextremity] musculoskeletal disorders.” Taken together, these studies27–29 suggest that generic measures such as the 36-Item Short-Form Health Survey questionnaire (SF-12) or SF-36 may require supplementation by region-specific measures in order to detect change in health status in patients with adhesive capsulitis. Setting and Participants The initial sample consisted of 3,383 patients who received outpatient physical therapy services for signs and symptoms that were classified by ICD-9 code 726.0 as adhesive capsulitis30 between January 1, 1998, and December 31, 2000. All patients were at least 18 years of age and did not have secondary diagnostic or procedural ICD-9 codes related to the shoulder. These criteria were selected to ensure that our sample consisted of adults in whom we could confirm that the interventions provided were only for adhesive capsulitis. Consenting patients completed the FOTO questionnaires at intake and at discharge from physical therapy. Therapists were not informed of their patients’ initial or discharge PCS-12 scores. Patients were excluded if they did not complete their episode of care (n⫽832), if outcome scores were missing (n⫽101), or if categorical or ordinal variables were coded with scores not included among the survey options (n⫽80). All FOTO data were masked to prevent recognition of individual patients, clinicians, or clinics. FOTO’s research oversight committee approved the use of these data following review of the study proposal.

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Interventions Associated With Favorable Outcomes in Adhesive Capsulitis Table 1. Comparison Between Patients Included In and Excluded From Analysisa Included (nⴝ2,370)

Excluded (nⴝ1,013)

P

55.3 (12.4)

53.6 (12.8)

⬍.001

39.6 (9.2)

39.3 (9.3)

.462

b

69.1 (22.3)

68.9 (22.5)

.879

Intake BP scoreb

43.1 (17.7)

42.6 (18.9)

.452

Characteristic Age (y)

b

Intake PCS-12 scoreb,c Intake PF score

Intake MCS-12 score

b,d

⬍.001

46.8 (9.4)

52.9 (9.8)

Sex (female)

65%

64%

.409

Employed (yes)

53%

58%

.007

Onset of condition (⬍90 d)

41%

39%

.357

Medications for condition (yes)

52%

50%

Visitsb

11.6 (7.6)

9.2 (7.2)

⬍.001

Discharge PCS-12 scoreb,c

45.7 (9.5)

N/A

N/A

Discharge PF scoreb

78.8 (20.8)

N/A

N/A

b

65.1 (20.6)

N/A

N/A

Discharge BP score

.260

a

PCS-12⫽Physical Component Summary-12, MCS-12⫽Mental Component Summary-12, PF⫽physical function subscale, BP⫽bodily pain subscale, N/A⫽not applicable. b Mean (standard deviation). c Mean (SD) PCS-12 score for general US population⫽50.12 (9.45). d Mean (SD) MCS-12 score for general US population⫽50.04 (9.59).

Table 2. Characteristics of Participating Physical Therapists and Clinics Characteristic

Mean (SD) or Percentage

Physical therapists (n⫽1,175) Sex (female) Degree

53%

a

BSPTb

50%

b

17.4%

DPTb

0.3%

MPT

Specialist (yes)

3.1%

Years in patient care

8.6 (6.9)

Patient visits per week

50.3 (21.5)

Clinics (n⫽424) Not for profit

60%

Full-time-equivalent physical therapists

5.0 (3.5)

Full-time-equivalent physical therapist assistants

1.2 (2.3)

Full-time-equivalent certified athletic trainers

0.69 (1.2)

Full-time-equivalent physical therapy aides

3.1 (4.4)

% in Northeast

14.2%

% in Midwest

33.6%

% in South

34%

% in West

18.5%

a

Percentages do not add up to 100 because of missing data. BSPT⫽Bachelor of Science in Physical Therapy, MPT⫽Master of Physical Therapy, DPT⫽Doctor of Physical Therapy. b

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The subjects were 2,370 patients coded as having adhesive capsulitis who received outpatient physical therapy services from a specific admission date to a specific discharge date within the study time frame. The majority of the patients were female (65.4%), with a mean age of 55.3 years (SD⫽12.4). Information regarding patient race or ethnicity was not available in the database. On admission, the mean PCS-12 score was 39.6 (SD⫽9.2), the mean PF score was 69.1 (SD⫽22.3), and the mean BP score was 43.1 (SD⫽17.7). These scores are comparable to those reported by Gartsman et al27 using the SF-36. Patients included in the analysis were slightly older, averaged 2 more visits, were less likely to be working, and had slightly lower overall mental health scores (Mental Component Summary-12 [MCS-12]) than those excluded according the study criteria (Tab. 1). A total of 1,175 physical therapists with an average of 8.6 years (SD⫽6.9) of clinical experience participated in the study (Tab. 2). Three percent of the therapists reported that they were clinical specialists in orthopedic physical therapy, as defined by the American Board of Physical Therapy Specialties, or specialists in manual therapy, as defined by the American Academy of Orthopaedic Manual Physical Therapists. Interventions When a patient was discharged, the physical therapist completed a form that indicated the interventions provided over the episode of care. The therapist checked relevant items from a list of 60 treatment options. Definitions for each treatment are provided in the FOTO training manual.31 We included 21 interventions that were provided to at least 5% of the patients in the study (eTab. 1 available at www.ptjournal.org). We reasoned that interventions provided less frequently would not be May 2009

Interventions Associated With Favorable Outcomes in Adhesive Capsulitis represented adequately in the data set in order to estimate their relationship to outcomes with any precision. Therapists used an average of 7.88 (SD⫽2.8) different interventions over an episode of care. We used factor analysis to group interventions to more accurately reflect the multidimensional nature of the plan of care. We have described this analytic approach in previous work using FOTO data for patients with sciatica.32 Seven factors explaining 48% of the common variance were extracted in the factor analysis. Factors 1 through 6 each contained at least 2 interventions that met the ⱖ0.500 inclusion criterion recommended by Sharma.33 We applied the following category labels based on the definitions of the interventions (eTab. 2 available at www.ptjournal.org) in each of the groups: “postural correction and stabilization,” “joint mobilization and mobility,” “ultrasound and massage,” “exercise,” “ice and electrical stimulation,” and “iontophoresis and phonophoresis.” Factor 7 was defined by only 1 intervention (moist heat) and was labeled accordingly. These treatment groups are similar to those previously reported and appear to describe combinations of interventions with clinically sensible bases. Five of the 21 interventions did not meet the ⱖ0.500 criterion and, therefore, were excluded from the analysis: closed-chain exercises (⫺0.376), endurance exercises (0.471), flexibility exercises (0.494), pain modulation (0.470), and myofascial release (0.429). The intervention categories and relevant factor loading scores obtained in the analysis are summarized in eTable 3 (available at www.ptjournal.org). Dependent and Independent Variables We evaluated change in 4 dependent variables: PCS-12 score, PF score, BP score, and a hybrid function score May 2009

Table 3. Factor Analysis Results Used to Create Hybrid Function (HF) Score Standardized Factor Loading

% Variance Explained

Vigorous activities, such as running, lifting heavy objects, participating in strenuous sports (vigorous)

0.671

54.1

Moderate activities, such as moving a table, pushing a vacuum cleaner, bowling, or playing golf (moderate)

0.819

Lifting or carrying groceries (lift groceries)

0.796

Bathing or dressing yourself (bathing)

0.649

Lifting overhead to a cabinet (lift overhead)

0.727

FOTO Survey Items How much does your health now limit you in these activities?

HF score equation⫽0.671 (vigorous score) ⫹ 0.819 (moderate score) ⫹ 0.796 (lift groceries score) ⫹ 0.649 (bathing score) ⫹ 0.727 (lift overhead score) Minimum score⫽3.662 Maximum score⫽10.986

(HF). We used the composite physical health score (PCS-12) because Gartsman et al27 demonstrated that patients with adhesive capsulitis have reduced PCS-36 scores relative to the adult population. We included the 2 subscale scores (PF and BP) because we could not determine the stage of patients’ adhesive capsulitis and, therefore, did not know whether primary impairments for individual patients were related to pain, loss of range of motion (ROM), or both. We reasoned that the PF and BP scores may be more responsive to change for patients in the “frozen” and “painful” stages, respectively. The HF score was created for this study to provide an additional measure of functional status that was theoretically more sensitive to change than the PCS-12 or PF scores. We developed this score using exploratory factor analysis of FOTO physical health survey items that we hypothesized were most related to shoulder function (Tab. 3). We anticipated that this hybrid score might be sensitive to change because it more specifically focused on upperextremity function similar to shoulderspecific self-report instruments evaluated by other authors.28,29 We defined clinically meaningful improvement as an increase of 50% or

more in a dependent variable. We chose this criterion over other options such as the minimum detectable change (MDC) or minimal clinically important difference (MCID) because these thresholds have not been established for the PCS-12 and related subscales in patients with adhesive capsulitis. Schmitt and Di Fabio29 calculated MDC and MCID thresholds for PCS-12 scores in patients with proximal UE conditions, and these thresholds were smaller than our 50% improvement criterion; therefore, we acknowledge that our selection of a 50% threshold may be too conservative. Some of the patients in our study may have changed by less than 50% but still had clinically meaningful improvement. However, given the protracted nature of adhesive capsulitis, we feel confident that a 50% improvement reflects meaningful change in individuals with the disorder. Data in our study were coded as “0” when less than 50% improvement was found and “1” when 50% or greater improvement was found. The primary independent variables in our study were the 7 intervention groups derived from the factor analysis (eTab. 3). We scored the factor as present when a patient received 50% or more of the interventions represented by the factor. Each fac-

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Interventions Associated With Favorable Outcomes in Adhesive Capsulitis Table 4. Logistic Regression Model Predicting Meaningful Improvement in Physical Function Variable

P

Odds Ratio

95% Confidence Interval

Iontophoresis and phonopheresis

.020

0.76

0.60–0.96

Ultrasound and massage

.003

0.77

0.65–0.92

⬍.001

0.98

0.97–0.99

Patient sex (female)

.073

0.85

0.71–1.02

Patient working (yes)

.017

1.27

1.04–1.55

Onset of condition (⬍90 d)

.292

1.10

0.92–1.31

Prescription medications for condition (yes)

.906

0.99

0.83–1.18

Visits

.673

1.0

0.99–1.01

⬍.001

0.99

0.98–0.99

.091

0.99

0.98–1.00

Patient age

Physical function (PF) score on admission Mental Component Summary-12 (MCS-12) score on admission

⬍.001

Constant

Table 5. Logistic Regression Model Predicting Meaningful Improvement in Bodily Pain Variable

P

Odds Ratio

95% Confidence Interval

Iontophoresis and phonopheresis

.003

0.68

0.53–0.88

Joint mobilization and mobility

.004

1.34

1.10–1.65

Ultrasound and massage

.010

0.79

0.66–0.94

Patient age

.003

0.98

0.98–0.99

Patient sex (female)

.664

1.04

0.87–1.26

Patient working (yes)

.012

1.30

1.06–1.59

Onset of condition (⬍90 d)

.061

1.19

0.99–1.42

Prescription medications for condition (yes)

.449

0.93

0.78–1.12

Visits

.903

1.00

0.99–1.01

⬍.001

0.98

0.98–0.99

Mental Component Summary-12 (MCS-12) score on admission

.002

0.98

0.97–0.99

Constant

.002

Bodily pain (BP) score on admission

tor was scored as absent if a patient received less than 50% of the interventions represented by the factor. We reasoned that when at least half of the interventions for a factor were provided to a patient, the factor was adequately represented. Data Analysis Potential collinearity among the demographic variables was assessed using Pearson product moment and Phi statistics. Analysis of the intake scores for the dependent variables in424

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dicated that a proportion of patients (PF⫽53.5%, HF⫽48%, BP⫽10.3%, PCS-12⫽0%) were too close to the upper limit of the scale (“no disability”) to demonstrate a 50% or greater improvement in scores. We eliminated this ceiling effect by transforming the intake and discharge scores for all of the dependent variables so that the lowest value on the scale equaled “no disability” and the highest value on the scale equaled “maximum disability.” A meaningful improvement, therefore, was redefined

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as a 50% or greater decrease in each of the disability scores. We used multiple logistic regression to identify the treatment variables that independently predicted meaningful clinical improvement. In order to account for variance from multiple levels of data, we used a model that nested patient data within therapists. We were unable to perform a 3-level analysis because the majority of clinics had only one physical therapist. To protect against violation of assumptions of the model, we used a robust variance estimation method.34 The calculated intra-cluster correlations for this study ranged from .0578 to .1414; these values represent the proportion of total variation in meaningful improvement in the dependent variables that can be attributed to the differences among therapists. The probabilities for entry of the intervention variables into and removal from the model were set at .20 and .10, respectively. A P value ⱕ.05 for the Wald test was used to determine the statistical significance of the predictor variables. To adjust for confounders, patient age and sex, length of time since onset of condition (⬍90 days), employment status (working), use of prescription medications for the condition, number of visits, intake mental health composite (MCS-12) score, and scores on admission for physical therapy for each of the dependent variables were forced into each model. We tested for all 2-way interactions of any independent variables included in the final models. Initial descriptive and correlational statistical analyses were conducted using SPSS 16.0 software for Windows.† Logistic regression analysis was generated using SAS 9.1.3,‡ a statistical software program de† SPSS Inc, 233 S Wacker Dr, Chicago, IL 60606. ‡ SAS Institute Inc, SAS Campus Dr, Cary, NC 27513.

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Interventions Associated With Favorable Outcomes in Adhesive Capsulitis signed to analyze cluster-correlated data like that used in this study.

Table 6. Logistic Regression Model Predicting Meaningful Improvement in Hybrid Function

Results All but one pair of subject demographic characteristics were weakly correlated to one another, with coefficients ranging from .000 to .102. Patient age and working status demonstrated a statistically significant relationship (point biserial coefficient⫽⫺.493, P⬍.01). Although this value represents a moderate correlation, we decided to enter both variables into the analysis because we anticipated that they potentially would influence outcomes differently. The following proportions of patients achieved clinically meaningful improvement in the dependent variables: PCS-12⫽0%, PF⫽43.8% (n⫽ 1,037), BP⫽37.8% (n⫽895), and HF⫽40.4% (n⫽958). We eliminated the PCS-12 score from further analysis as a result of these findings. Two independent variables reduced the odds of meaningful improvement in PF score: “iontophoresis and phonophoresis” (odds ratio [OR]⫽ 0.76, 95% confidence interval [CI]⫽ 0.60 – 0.96) and “ultrasound and massage” (OR⫽0.77, 95% CI⫽0.65– 0.91). None of the intervention categories increased the odds of meaningful improvement in this measure (Tab. 4).

Variable

P

Similar results occurred with respect to the “iontophoresis and phonophoresis” and “ultrasound and massage” intervention categories in the May 2009

95% Confidence Interval

Iontophoresis and phonopheresis

.015

0.74

0.58, 0.94

Ultrasound and massage

.016

0.81

0.68, 0.96

Exercise

.034

1.50

1.03, 2.17

⬍.001

0.99

0.98, 0.99

Patient sex (female)

.062

0.84

0.70, 1.01

Patient working (yes)

.000

1.43

1.17, 1.74

Patient age

Onset of condition (⬍90 d)

.748

0.97

0.82, 1.16

Prescription medications for condition (yes)

.980

1.00

0.84, 1.19

Visits

.663

1.00

0.99, 1.01

Hybrid function (HF) Score on Admission

.031

1.06

1.01, 1.12

⬍.001

0.98

0.97, 0.99

Mental Component Summary-12 (MCS-12) score on admission Constant

.050

model for predicting meaningful improvement in the HF score. However, application of the “exercise” intervention category increased the odds of improvement in this measure by 50% (OR⫽1.50, 95% CI⫽1.03–2.17) (Tab. 6). We did not identify statistically significant interactions among independent variables in any of the models. Model fit using the likelihood ratio test indicated that the models with covariates fit the data better than the models with the intercept only (P⬍.0001).

Discussion Application of “iontophoresis and phonophoresis” and “ultrasound and massage” interventions also reduced the odds of meaningful improvement in the BP score. The use of “joint mobilization and mobility” interventions, however, increased the odds of meaningful improvement in this measure (OR⫽1.35, 95% CI⫽1.10 –1.65) (Tab. 5).

Odds Ratio

Two intervention categories—“iontophoresis and phonophoresis” and “ultrasound and massage”—remained in all 3 regression models (P⬍.05) after adjusting for patient demographic and clinical characteristics. Odds ratios indicated that the use of these types of intervention reduced the likelihood of improvement in the dependent variables by 19% to 32%. Alternatively, the presence of 2 intervention categories— “joint mobilization and mobility” and “exercise”—increased the odds of a successful outcome in the BP and HF

models, respectively. For example, after adjusting for confounders, the odds of a meaningful change in BP score were 34% higher in patients who received joint mobility interventions compared with patients who did not receive these interventions. The odds of a comparable change in HF score also were 50% greater in patients who received exercise interventions compared with those who did not receive these interventions. We conducted a post hoc chi-square analysis to determine whether a difference in intervention use existed between subjects who demonstrated meaningful improvement in outcomes and subjects who did not demonstrate improvement. Fewer subjects with improved PF scores received “ultrasound and massage” interventions compared with those whose PF scores did not meet the threshold for improvement (48.4% vs 55.8%, P⬍.001). A greater proportion of subjects whose BP scores improved received “joint mobilization and mobility” interventions (73.5% vs 68.8%, P⫽.018). Fewer of these subjects, however, received “iontophoresis and phonophoresis” inter-

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Interventions Associated With Favorable Outcomes in Adhesive Capsulitis ventions (13.5% vs 17.4%, P⫽.015). Finally, more subjects with improved HF scores received “exercise” intervention (95.1% vs 92.9%, P⫽.037), whereas fewer of these subjects received “ultrasound and massage” interventions compared with subjects who did not achieve meaningful improvement (49.2% vs 54.8%, P⫽.006). Our study suggests that the use of physical therapy interventions to administer anti-inflammatory or other agents across the skin (eg, iontophoresis and phonophoresis) decreases the likelihood of meaningful clinical improvement in pain or physical health in patients with adhesive capsulitis. We found 2 RCTs that examined the effectiveness of iontophoresis in patients with calcific tendinitis of the shoulder.35,36 Both studies demonstrated no added benefit compared with a placebo treatment in terms of pain, disability, or size of the calcium deposits. We found no studies that investigated the effectiveness of phonophoresis for any disorders of the shoulder. Our results extend the implications of this limited work by suggesting that application of these passive modalities may actually hinder recovery when emphasized over other treatment options such as joint mobilization and mobility. The application of therapeutic ultrasound or massage also reduced the odds of meaningful improvement in pain or physical function. Dogru et al37 randomly assigned 49 patients with adhesive capsulitis of 5 to 6 months’ duration (range⫽3–12) to an ultrasound group or a sham ultrasound group. Both groups also received moist hot packs along with stretching and AROM exercises. These authors found that both groups improved similarly over time on the visual analog scale (VAS) for pain, the Shoulder Pain and Disability Index (SPADI), and the SF-36. 426

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Lack of effectiveness of therapeutic ultrasound also has been demonstrated in RCTs enrolling patients with other disorders of the shoulder.38,39 Studies evaluating the benefits of massage are limited in size and quality and provide conflicting results in mixed populations with general cervical or shoulder pain.40,41 Time spent using these interventions in patients with adhesive capsulitis may delay meaningful improvement in symptoms and functional abilities. We identified 2 treatment categories that increased the likelihood of meaningful improvement in patients with adhesive capsulitis. The “joint mobilization and mobility” intervention category consists of manual joint mobilization techniques as well as activities the patient performs to improve joint mobility. Our findings are consistent with those of studies examining the effectiveness of interventions focusing on improving joint movement in this patient population. Vermeulen et al21 found that patients with adhesive capsulitis who received “high-grade” or “lowgrade” Maitland joint mobilization techniques reported reductions in VAS pain scores at rest, with movement, and during sleep. Unlike our findings, these subjects also demonstrated a 13- to 14-point improvement in their PCS-36 scores following treatment. However, the experimental group averaged 18.6 treatment sessions, and the comparison group averaged 21.5 treatment sessions. Our subjects averaged only 11 treatment sessions. Although 71% of our sample received this intervention category (eTab. 3), it is impossible to determine whether mobilization or joint mobility was applied during every session. Johnson et al22 demonstrated comparable reductions in pain and mixed success with physical function following 6 treatment sessions of anterior or posterior glide joint mobilization techniques for patients with this

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condition. Our results, in conjunction with these findings, suggest that the effect of joint mobility techniques on physical function in people with adhesive capsulitis may be dependent upon the number of times these interventions are applied. The results of this study also indicate that exercise interventions improve the likelihood of a meaningful clinical improvement in physical health, as measured by the HF score (OR⫽1.5). The “exercise” category consisted of strengthening, stretching, and home programs. None of the RCTs we found evaluated the effectiveness of exercise techniques alone in patients with adhesive capsulitis. Two studies examined the impact of physical therapy interventions that included exercise on selfreport measures of pain and disability comparable to those used in our study. Buchbinder et al10 found that patients who received 8 sessions of passive stretching and active strength and coordination exercises, along with shoulder and spine mobilization techniques, demonstrated improvement over time similar to the comparison group in pain and disability, as measured by the VAS pain scale, the SF-36, and the SPADI. These results suggest that the combination of physical therapy interventions did not provide additional benefit beyond the capsular distension technique for these 3 self-report measures. Carette et al16 randomly assigned 93 patients with adhesive capsulitis to 1 of 4 groups: corticosteroid injection plus physical therapy, corticosteroid injection alone, physical therapy plus saline injection, or saline injection alone (placebo). Physical therapy interventions consisted of electrical or thermal modalities, AROM and PROM exercises, joint mobilization techniques, and a home program. After 12 sessions, the patients in the corticosteroid injection May 2009

Interventions Associated With Favorable Outcomes in Adhesive Capsulitis plus physical therapy group and the corticosteroid injection alone group demonstrated a statistically significant improvement in their SPADI composite, pain, and disability scores compared with patients in the physical therapy plus saline injection and placebo groups. The corticosteroid injection plus physical therapy group also achieved greater improvement in joint AROM and PROM compared with the other 3 groups. Contrary to Buchbinder and colleagues’ findings,10 these results indicate that a combination of physical therapy interventions may provide additional benefit when applied along with a corticosteroid injection. However, the effect of the exercise interventions in either study cannot be isolated. We used 4 self-report outcome measures in this study because we anticipated that they might differ in their abilities to detect clinically meaningful change. The consistency of results regarding the role of passive modalities that may not address the most impaired tissues is particularly compelling. The finding that different intervention categories improved the odds of meaningful improvement in pain compared with function is an important consideration for future effectiveness studies. None of our sample, however, achieved a 50% or greater change score on the PCS-12. One potential explanation for this result is that this composite score consists of items related to lower-extremity function and general health, neither of which may be affected by adhesive capsulitis.26 Another explanation is that our threshold for meaningful improvement was too high. However, when we reduced the value to 33% or greater improvement, we found that only 66 patients (2.8% of the sample) had this result. Our mean intake PCS-12 score was 39.6 (Tab. 1), which may not be low enough for significant change to be measured. May 2009

Limitations The ability to generalize the findings from this study is constrained by sample selection and composition. First, the patients were chosen in a nonrandomized fashion from a single outcomes management company that does not have a uniform distribution of clients across the United States. Selection bias within the FOTO data set also is suggested by the statistically significant differences in age, employment status, and intake MCS-12 scores between patients included in the study versus those excluded from the study (Tab. 1). Despite these differences, both groups had similar PCS-12, PF, BP, and HF scores, suggesting that these attributes had a limited influence on the impairments and functional limitations of these individuals. Commitment to job or better mental health, however, may explain why so many patients in the excluded group did not complete their episodes of care and may have influenced our findings. Second, we were unable to confirm the diagnosis recorded by the physical therapists or the methods by which the physical therapists selected individual diagnostic labels. Most of the RCTs evaluating treatment effects in patients with adhesive capsulitis used a limitation in one or more planes of glenohumeral joint PROM as an inclusion criterion.6,10,11,13,14,16,17,20 –22 The FOTO data set does not include quantitative impairment measures; therefore, the potential lack of reliability and validity of the ICD-9 codes themselves also should be considered.42 Coding and interpretation of treatment options pose another challenge in this study. For example, we cannot determine the specific interventions that were provided as part of the “joint mobility” intervention. FOTO defines joint mobility in the therapist training manual31 as “self-

explanatory,” implying to us that therapists had to judge for themselves whether the interventions they applied were designed to affect joint mobility. In the absence of professional consensus on the operational definitions of all physical therapy interventions, joint mobility exercises may vary considerably. Details from actual patient records would be required to identify the specific techniques attributed to this label. To our knowledge, this is the first study to use statistically created intervention categories to evaluate the effectiveness of various physical therapy interventions for people with adhesive capsulitis. Our approach provides an objective method for reducing a wide variety of interventions into sensible groups of related techniques. However, we may have missed some important categories because of the criteria we used to include and exclude specific types of treatments. Additional research is needed to confirm the stability of these intervention categories in additional samples of patients with this disorder. A related issue is the inability to assess the timing or sequence of interventions applied over the episode of care. Physical therapists identified all interventions provided when the patients were discharged. We were unable to identify what role, if any, the timing or sequence of interventions may have played in patient outcomes. In addition, our factor analysis explained only 48% of the variance in treatment categories used by physical therapists in this study. The substantial portion of unexplained variance may be attributable to those interventions we excluded because of weak factor loading or infrequent representation in the data set. Future research should address the impact of the interven-

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Interventions Associated With Favorable Outcomes in Adhesive Capsulitis tions that were excluded from our analysis.

Conclusions Therapists should consider increasing their use of joint mobility and exercise interventions as defined in this study for patients with adhesive capsulitis. Ultrasound, massage, iontophoresis, and phonophoresis reduce the odds of improved outcomes in these patients. Future RCTs are needed to clarify treatment dosage for the more-effective interventions for people with adhesive capsulitis. Specifically, studies of the frequency with which joint mobility interventions should be applied in isolation or in combination with exercise are needed in order to optimize physical therapy care. Dr Jewell and Dr Riddle provided concept/ idea/research design and writing. Dr Jewell provided data collection. Dr Jewell and Dr Thacker provided data analysis. Dr Riddle provided consultation (including review of manuscript before submission). The authors acknowledge Dennis L Hart, PT, PhD, Director of Research and Consulting Services, Focus On Therapeutic Outcomes Inc, for his assistance on this project. The Virginia Commonwealth University Institutional Review Board approved this study according to expedited review criteria. This article was received August 14, 2008, and was accepted January 14, 2009. DOI: 10.2522/ptj.20080250

References 1 Dias R, Cutts S, Massoud S. Frozen shoulder. BMJ. 2005;331:1453–1456. 2 Griggs SM, Ahn A, Green A. Idiopathic adhesive capsulitis: a prospective functional outcome study of nonoperative treatment. J Bone Joint Surg Am. 2000;82:1398 –1407. 3 Shaffer B, Tibone JE, Kerlan RK. Frozen shoulder: a long-term follow-up. J Bone Joint Surg Am. 1992;74:738 –746. 4 Vad VB, Hannafin JA. Frozen shoulder in women: evaluation and management. J Musculoskel Med. 2000;17:13–28. 5 Nevasier RJ, Nevasier TJ. The frozen shoulder diagnosis and management. Clini Orthop Rel Res. 1987;223:59 – 64.

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6 Buchbinder R, Hoving JL, Green S, Hall S, et al. Short course prednisolone for adhesive capsulitis (frozen shoulder or stiff painful shoulder): a randomised, double blind, placebo controlled trial. Ann Rheum Dis. 2004;63:1460 –1469. 7 Boyle-Walker K, Gabard DL, Bietsch E, et al. A profile of patients with adhesive capsulitis. J Hand Ther. 1997;10:222–228. 8 Reeves B. The natural history of frozen shoulder syndrome. Scand J Rheumatol. 1975;4:193–196. 9 Van den Hout WB, Vermeulen HM, Rozing PM, Vlieland TMPV. Impact of adhesive capsulitis and economic evaluation of high-grade and low-grade mobilisation techniques. Aust J Physiother. 2005;51: 141–149. 10 Buchbinder R, Youd JM, Green S, et al. Efficacy and cost-effectiveness of physiotherapy following glenohumeral joint distension for adhesive capsulitis: a randomized trial. Arthritis Rheum. 2007;57: 1027–1037. 11 Bulgen DY, Binder AI, Hazleman BL, et al. Frozen shoulder: prospective clinical study with an evaluation of three treatment regimens. Ann Rheum Dis. 1984;43:353–360. 12 Winters JC, Sobel JS, Groenier KH, et al. Comparison of physiotherapy, manipulation, and corticosteroid injection for treating shoulder complaints in general practice: randomised, single blind study. BMJ. 1997;314:1320 –1325. 13 Van der Windt DAWM, Koes BW, Deville W, et al. Effectiveness of corticosteroid injections versus physiotherapy for the treatment of painful stiff shoulder in primary care: randomised trial. BMJ. 1998;317: 1292–1296. 14 Arslan S, Celiker R. Comparison of the efficacy of local corticosteroid injection and physical therapy for the treatment of adhesive capsulitis. Rheumatol Int. 2001;21: 20 –23. 15 Hay EM, Thomas E, Paterson SM, et al. A pragmatic randomised controlled trial of local corticosteroid injection and physiotherapy for the treatment of new episodes of unilateral shoulder pain in primary care. Ann Rheum Dis. 2003;62:394 –399. 16 Carette S, Moffet H, Tardif J, et al. Intraarticular corticosteroids, supervised physiotherapy, or a combination of the two in the treatment of adhesive capsulitis of the shoulder: a placebo controlled trial. Arthritis Rheum. 2003;48:829 – 838. 17 Ryans I, Montgomery A, Glaway R, et al. A randomized controlled trial of intraarticular triamcinolone and/or physiotherapy in shoulder capsulitis. Rheumatology. 2005;44:529 –535. 18 James M, Stokes EA, Thomas E, et al. A cost consequences analysis of local corticosteroid injection and physiotherapy for the treatment of new episodes of unilateral shoulder pain in primary care. Rheumatology. 2005;44:1447–1451. 19 Diwan DB, Murrell GAC. An evaluation of the effects of the extent of capsular release and of postoperative therapy on temporal outcomes of adhesive capsulitis. Arthroscopy. 2005;21:1105–1113.

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20 Guler-Uysal F, Kozanoglu E. Comparison of the early response to two methods of rehabilitation in adhesive capsulitis. Swiss Med Wkly. 2004;134:353–358. 21 Vermeulen HM, Rozing PM, Obermann WR, et al. Comparison of high-grade and low-grade mobilization techniques in the management of adhesive capsulitis of the shoulder: randomized controlled trial. Phys Ther. 2006;86:355–368. 22 Johnson AL, Godges JJ, Zimmerman GJ, Ounanian LL. The effect of anterior versus posterior glide join mobilization on external rotation range of motion in patients with shoulder adhesive capsulitis. J Orthop Sports Phys Ther. 2007;37:88 –99. 23 Green S, Buchbinder R, Hetrick SE. Physiotherapy interventions for shoulder pain. Cochrane Database Syst Rev. 2003;2: CD004258. 24 Hart DL. Test-retest reliability of an abbreviated self-report overall health status measure. J Orthop Sports Phys Ther. 2003;33: 734 –742. 25 Ware JE Jr, Kosinski M, Keller SD. A 12Item Short-Form Health Survey: construction of scales and preliminary tests of reliability and validity. Med Care. 1996;34: 220 –233. 26 Ware JE Jr, Kosinski M, Keller SD. SF-12: How to Score the SF-12 Physical and Mental Health Summary Scales. 2nd ed. Boston, MA: The Health Institute, New England Medical Center; 1995. 27 Gartsman GM, Brinker MR, Khan M, Karahn M. Self-assessment of general health status in patients with five common shoulder conditions. J Shoulder Elbow Surg. 1998;7:228 –237. 28 Beacon D, Richards RR. Assessing the reliability and responsiveness of 5 shoulder questionnaires. J Shoulder Elbow Surg. 1998;7:565–572. 29 Schmitt JS, Di Fabio RP. Reliable change and minimum important difference (MID) proportions facilitated group responsiveness comparisons using individual threshold criteria. J Clin Epidemiol. 2004;57: 1008 –1018. 30 Hart AC, Hopkins CA, eds. ICD-9-CM Expert for Physicians. Volumes 1 and 2. Reston, VA: Ingeniz; 2003. 31 FOTO Outcomes Measurement System Training Manual. Knoxville, TN: Focus On Therapeutic Outcomes, Inc; 2001. 32 Jewell DV, Riddle DL. Interventions that increase or decrease the likelihood of a meaningful improvement in physical health in patients with sciatica. Phys Ther. 2005;85:1139 –1150. 33 Sharma S. Applied Multivariate Techniques. New York, NY: John Wiley & Sons Inc; 1996. 34 Binder DA. On the variances of asymptotically normal estimators from complex surveys. International Statistical Review. 1983;51:279 –292. 35 Leduc BE, Caya J, Tremblay S, et al. Treatment of calcifying tendinitis of the shoulder by acetic acid iontophoresis: a doubleblind randomized controlled trial. Arch Phys Med Rehabil. 2003;84:1523–1527.

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Interventions Associated With Favorable Outcomes in Adhesive Capsulitis 36 Perron M, Malouin F. Acetic acid iontophoresis and ultrasound for the treatment of calcifying tendinitis of the shoulder: a randomized control trial. Arch Phys Med Rehabil. 1997;78:379 –384. 37 Dogru H, Basaran S, Sarpel T. Effectiveness of therapeutic ultrasound in adhesive capsulitis. Joint Bone Spine. 2008;75: 445– 450.

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38 Ainsworth R, Dziedzic K, Hiller L, et al. A prospective double-blind placebo-controlled randomized trial of ultrasound in the physiotherapy treatment of shoulder pain. Rheumatology. 2007;46:815– 820. 39 Kurtais Gu ¨ rsel Y, Ulus Y, Bilgic¸ A, et al. Adding ultrasound in the management of soft tissue disorders of the shoulder: a randomized placebo-controlled trial. Phys Ther. 2004;84:336 –343. 40 Van den Dolder PA, Roberts DL. A trial into the effectiveness of soft tissue massage in the treatment of shoulder pain. Aust J Physiother. 2003;49:183–188.

41 Verhagen AP, Karels C, Bierma-Zeinstra SM, et al. Ergonomic and physiotherapeutic interventions for treating work-related complaints of the arm, neck or shoulder in adults: a Cochrane Systematic Review. Eura Medicophys. 2007;43:391– 405. 42 Deyo RA, Taylor VM, Diehr P, et al. Analysis of automated administrative and survey databases to study patterns and outcomes of care. Spine. 1994;19: 2083S–2091S.

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Research Report

Clinical Reasoning in Musculoskeletal Practice: Students’ Conceptualizations Paul Hendrick, Carol Bond, Elizabeth Duncan, Leigh Hale P Hendrick, BSc(Hons), GradDipPhty, PGDMPhty, MMPhty, MNZSP, is Professional Practice Fellow, Centre for Physiotherapy Research, School of Physiotherapy, University of Otago, PO Box 56, Dunedin, New Zealand. Address all correspondence to Mr Hendrick at: paul. [email protected] or [email protected]. C Bond, PhD, MCSP, is Academic Director, Student Learning Centre, and Senior Lecturer, The Higher Education Development Centre, University of Otago. E Duncan, PhD, BSc(Hons), is Research Assistant, School of Physiotherapy, University of Otago. L Hale, PhD, MSc(Physio), BSc(Physio), FNZCP, is Senior Lecturer, Centre for Physiotherapy Research, School of Physiotherapy, University of Otago. [Hendrick P, Bond C, Duncan E, Hale L. Clinical reasoning in musculoskeletal practice: students’ conceptualizations. Phys Ther. 2009;89:430 – 442.] © 2009 American Physical Therapy Association

Background. Qualitative research on physical therapist students’ conceptualizations of clinical reasoning (CR) is sparse.

Objectives. The purpose of this study was to explore CR from students’ perspectives.

Design. For this study, a qualitative, cross-sectional design was used. Methods. Thirty-one students were randomly selected from years 2, 3, and 4 of an undergraduate physical therapist program in New Zealand. Students were interviewed about their understanding of CR and how they used it in practice in a recent musculoskeletal placement. Interviews were recorded and transcribed verbatim. A 3-stage analysis included the categorization of students’ conceptualizations on the basis of the meaning and the structure of each experience and the identification of cross-category themes.

Results. Five qualitatively different categories were identified: A—applying knowledge and experience to the problem, patient, or situation; B—analyzing and reanalyzing to deduce the problem and treatment; C—rationalizing or justifying what and why; D— combining knowledge to reach a conclusion; and E—problem solving and pattern building. Cross-category analysis revealed 5 general themes: forms of CR, spatiotemporal aspects, the degree of focus on the patient, attributions of confidence, and the role of clinical experience. Conclusions. Categories formed a continuum of CR from less to more sophistication and complexity. Students were distributed evenly across categories, except for category E, which included only students from years 3 and 4. Each category comprised a logical, coherent experiential field. The general themes as critical dimensions suggest a new way of exploring CR and suggest a possible pathway of development, but further research is required. These findings have implications for teaching and the development of physical therapy curricula.

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Clinical Reasoning in Musculoskeletal Practice

C

linical reasoning (CR) is the thinking and decision-making process used by practitioners.1 Research on CR in the health sciences has evolved over 3 distinct, but overlapping, phases, in which the shifts in focus have been accompanied by differences in how CR was understood and explained.2 The first phase (1950s–1970s), which focused on the psychometric aspects of reasoning and the development of measurement tools, continues to be evident in tools used to assess CR skills.

The second phase was more cognitive and process oriented, concerned with specifying knowledge structures and strategies,3 analyzing behaviors, and eliciting steps in problem solving.4,5 Clinical reasoning was understood predominantly as hypothetical deductive reasoning (HDR), comprising the generation of hypotheses on the basis of prior knowledge and clinical data, inductive reasoning to generate hypotheses, and the deductive reasoning necessary for the testing of hypotheses. Four components of HDR were identified: cue acquisition, hypothesis generation, cue interpretation, and hypothesis evaluation.6 Much of this research originated in occupational therapy7 and was adopted and expanded by recent work in physical therapy.8,9 Research in the third phase was more hermeneutic. It emphasized situated cognition and phenomenological approaches,10 focused on understanding practitioners’ lived experiences, and reflected the emerging movement toward patientcentered care.11 Clinical knowledge and CR were interdependent; effective CR required depth and organization of knowledge.12 Clinical reasoning was understood predominantly as pattern formation and recognition,13,14 a process of perceiving and storing related information to be reMay 2009

called and used as a prototype when a suitable stimulus was presented. Patterns were constantly revised and reformulated,13 making CR a more transformative spiral model15 reflecting a cyclical, developmental process. Each loop of the spiral incorporated data input, interpretation, and problem formulation to achieve a broader and deeper understanding of the clinical problem; this model better matched the definition of CR as a process of integrating knowledge, cognition, and metacognition.16,17 In contrast to CR in previous phases, CR in the third phase was a process that applied throughout the interaction with the patient.7 For this contemporary, multidimensional view of CR18 to be explained and understood, morecomplex integrated models had to be developed.19 Teaching and assessment of CR skills are key objectives of physical therapy education worldwide.20 Currently, a range of tools are used to assess students’ CR skills.21–27 Each tool tests different decisions regarding diagnostic hypotheses, investigative actions, or treatment options, thus focusing on analyzing and measuring the processes used by the students rather than their understanding of CR.21,25,27,28 Missing are studies that focus on the students’ own experiences, that is, the ways in which they conceptualize CR. Knowledge of variations in students’ conceptualizations of subject matter is important for teaching. Marton et al29 argued that teaching becomes a rational activity only when the instructor understands what and how students discern or conceptualize the phenomenon being taught. From a phenomenographic perspective,30 –32 a large body of research shows that students’ conceptions of learning influence the way in which they learn.33 Students who understand learning as repetitive memori-

zation tend to use simple strategies and achieve a limited conceptualization of the topic. In contrast, students who learn in order to understand a topic are likely to engage in activities that promote understanding and achieve a more sophisticated conceptualization. Given this research, it follows that students’ conceptualizations of CR are likely to influence the way in which they reason in the clinical setting. The current study was prompted by musculoskeletal (MS) clinical teachers’ concerns about the extent of variability in physical therapist students’ CR skills across the curriculum and most evident in the fourth year of study. The aim of this research was to explore students’ conceptualizations of CR in the MS component of the physical therapy curriculum across the years to help inform teaching of this complex skill.

Method Study Context The study was located in a physical therapy school at a university in New Zealand. The physical therapist program offered a 4-year undergraduate degree and comprised a curriculum approved by the physical therapy regulatory body in New Zealand—the New Zealand Physiotherapy Board. Year 1 of the program was a common science foundation program for all students intending to enter health professions. Years 2 to 4 were dedicated to physical therapy education.

Available With This Article at www.ptjournal.org • Audio Abstracts Podcast This article was published ahead of print on March 27, 2009, at www.ptjournal.org.

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Clinical Reasoning in Musculoskeletal Practice guage or who had not completed an MS clinical placement were excluded from the groups. A stratified purposeful sampling approach by year of study was used. Although this approach reduced sample size, it allowed sampling to cover a range of characteristics that better defined the phenomenon under study.35 Students were selected randomly from each group at a ratio of women to men reflecting the actual sex distribution of the class. The final sample consisted of 31 students (20 women and 11 men): 11 from year 2 and 10 each from years 3 and 4 (Tab. 1).

Figure 1. Analytical framework for students’ conceptualizations of clinical reasoning (CR).32

Years 2 and 3 focused predominantly on principles and techniques, taught mainly through lectures and practical sessions; CR was embedded as a key objective and learning outcome in each topic of the 3 core disciplines (MS, neurorehabilitation, and cardiorespiratory). In the MS component of the curriculum, CR was specifically taught using HDR and pattern recognition through three 1-hour lectures and 3 practical sessions in year 2 and two 1-hour lectures and 2 practical sessions in year 3. A “problem-based” learning approach was used, with integration of CR models into case-based scenarios throughout the MS practical sessions. In years 2 and 3, students undertook 162 hours of clinical practice, during which clinical instructors facilitated and reinforced the CR process. Year 4 comprised entirely clinical practice, and the teaching of CR was integrated experientially into the students’ clinical training. A qualitative, interpretive approach based on principles of phenomenography, such as a second-order perspective, internal relationship, and the structure of experience,32 was used in this research. In the secondorder perspective, category meanings were defined by students’ expla432

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nations of their conceptualizations of CR rather than being based on definitions derived from previous research (ie, first-order or researchers’ perspectives).32 Each student’s conceptualization of CR was treated as a holistic experiential field in which aspects such as beliefs about physical therapy and patients, learning, reasoning, understanding, and knowledge were understood to both define and internally relate one to the other and define the whole experience.34 Access to the meaning and structure of the students’ conceptualizations was gained through questions about what was understood about each aspect and how it was understood (Fig. 1). Design and Sampling The study population comprised 360 physical therapist students, 120 enrolled in each of years 2, 3, and 4, in order to gain an understanding of students’ CR processes across the curriculum. Students were informed of the research in lectures at the beginning of the teaching year, assured that nonparticipation would have no effect on their assessment results, and asked to volunteer. A total of 56 volunteers were grouped by year of study and sex. Students for whom English was a second lan-

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Procedure Students participated individually in an audiotaped, semistructured, indepth interview at the midpoint of the year, when all lectures and practical sessions involving CR were completed. Interviews were scheduled to take place within 3 weeks of the completion of the participant’s MS clinical placement (range⫽2–18 days). Interviews, ranging from 30 to 60 minutes, were conducted by the first and second authors. The first author taught CR in the MS component of the curriculum but was not involved in the assessment of the study participants. Participants were assured that their responses would have no influence on their grades. The second author was previously a physical therapist educator and coordinator of student learning development at The Higher Education Development Centre and is currently Academic Director of the Student Learning Centre at the University of Otago. The third author was a PhD research student with a background in science. To ensure procedural reliability, the first and second authors shared the task of conducting several interviews at the beginning of and later in the process. Interviews focused on what the students understood and how they went about their practice. ParticiMay 2009

Clinical Reasoning in Musculoskeletal Practice pants were asked to describe examples of their practice and to talk about their understanding of CR, clinical knowledge or information, and learning and how they achieved that understanding (Appendix). The audiotapes were transcribed verbatim. The transcripts were checked against the audiotapes by the third author.

Table 1. Allocation of the 31 Participants to Categories by Age, Sex, and Year in Program Research Pseudonym

Data Analysis The first and second authors undertook analyses separately to ensure unbiased category development. The third author audited the evolving themes and categories by checking them at regular intervals against the raw data to ensure validity. At each stage of analysis (see below), researchers separately explored the data in a search for evidence that would disconfirm evolving themes and categories.36 Regular research meetings in which each author’s assumptions about evolving themes and categories were reported, challenged, debated, and clarified were used as one strategy to ensure trustworthy representation of the data.

Age (y)a

Sex

Year in Program

Conceptualization of Clinical Reasoningb

Lesley

20

Female

2

A

Malcolm

21

Male

2

A

Melvyn

24

Male

2

A

Shauna

22

Female

3

A

Hazel

22

Female

3

A

Patrick

21

Male

3

A

Kaley

21

Female

4

A

Kane

25

Male

4

A

Aiden

21

Male

2

B

Shayla

22

Female

2

B

Reagan

21

Male

3

B

Sinead

27

Female

3

B

Bevan

22

Male

4

B

Danelea

22

Female

4

B

Aeryn

23

Female

2

C

Ailsa

20

Female

2

C

Betha

20

Female

2

C

Maegan

19

Female

2

C

Annie

22

Female

3

C

Enya

23

Female

3

C

Genevieve

24

Female

3

C

Gallagher

25

Female

4

C

Kristen

22

Female

2

D

The base unit of analysis was a student’s whole transcript. Analysis comprised 3 iterative stages:

James

19

Male

2

D

1. A crude initial reading and sorting, in which individual transcripts were read and grouped according to their similarities and differences, provided easier access to the large amount of complex data.

Alana

21

Female

4

D

Monaghan

38

Male

4

D

2. In a refined categorization, transcripts in each group were subjected to a detailed analysis. Different aspects of a student’s conceptual field were noted and compared with other aspects to establish the meanings that the student associated with CR, practice, patient care, learning, and knowledge. This analysis focused on what the student understood May 2009

Norah

23

Female

3

D

Ardara

24

Female

4

D

Sabrina

23

Female

3

E

Callahan

31

Male

4

E

Trevor

24

Male

4

E

a

The average age of the participants was 23 years. The numbers (percentages) for the whole sample were as follows: category A, 8 (26); category B, 6 (19); category C, 8 (26); category D, 6 (19); and category E, 3 (10). b

as CR, that is, the meaning ascribed to both parts and whole; the structure of each aspect, that is, how the experience was described; and the possible rationale or logic for the relationship between aspects, that is, why the student understood the experience in the way in which he or Volume 89

she described it. Intracategory and transcategory similarities and differences were identified and compared. Emerging categories were continually revisited and adjusted to take into account the data by use of the disconfirmation process outlined above. Detailed descriptions of each category Number 5

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Clinical Reasoning in Musculoskeletal Practice were prepared. Criteria for allocation to categories were identified, and an individual’s experiences were checked against the category descriptions and criteria. 3. Completed category descriptions were subjected to a meta-analysis to identify general themes that were evident in different forms across categories. Credibility and Verification Several strategies (shared interviews, audit trails, and disconfirmation) were used to ensure the credibility and robustness of the research process and data analyses. Category descriptions were subjected to peer review and audit in 2 seminars, one with 25 physical therapist faculty staff members at the location where the research was conducted and the other with 20 university academic staff members. Feedback was invited from the audiences, noted, and incorporated into the research. In a separate process, the fourth author (not involved in the original research) verified the conceptualizations of CR and the cross-category themes on the basis of her experiences of CR in the physical therapy curriculum. She reviewed the audit trails through regular discussions with the first 2 authors and step-bystep interrogation of the research process and associated documents. Ethics and the Role of the Funding Source This study was approved by the Human Ethics Committee at the University of Otago and was funded by a Research Into University Teaching grant.

Results The results are presented in 2 parts: conceptualizations of CR as descriptive categories and cross-category thematic variations.

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Conceptualizations of CR Analysis of the data in stages 1 and 2 revealed 5 qualitatively different conceptualizations of CR: category A—applying knowledge and experience to the problem, patient, or situation; category B—analyzing and reanalyzing to deduce the problem and treatment; category C—rationalizing or justifying what and why; category D— combining knowledge to reach a conclusion; and category E—problem solving and pattern building. Category descriptions include the meaning (what) participants attributed to CR and how they thought (the structural aspects). Quotations (identified by pseudonyms and the student’s year of enrollment, eg, “Hazel, 3”) illustrate each category. Table 1 shows the distribution of participants by age, sex, year in program, and category. Category A—applying knowledge and experience to the problem, patient, or situation. In this category, participants conceptualized CR in very general terms. Their focus was applying or relating what had been learned (knowledge, experience, evidence from examination of the patient, or a combination of these) to a problem, patient, or situation. Applying was described as follows: “the application of the treatment procedures” or “doing it” (Hazel, 3), “you’ve got to try and . . . relate . . . what you know . . . to your patient” (Shauna, 3), or “. . . everything you’ve learned in the classroom, [seen and] used in the clinical setting, . . . you apply it to the patient (Patrick, 3). A therapist-centered view of both physical therapy and CR was evident throughout the data. The main concern was finding a technique that “worked” and was the “right thing to do” (Hazel, 3). Figure 2A shows a linear experiential structure. The di-

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rection of application of knowledge was from the student to the object of application: the patient or the problem. Feedback from the patient indicated “how effective the treatment has been” (Patrick, 3). However, there was little evidence to show how the feedback was used, hence, the dotted line in Figure 2A. Category B—analyzing and reanalyzing to deduce the problem and treatment. In category A, students conceptualized CR predominantly as a linear trial-and-error process. In contrast, category B was a much more cyclical analytical process (Fig. 2B). Students spoke of analyzing and reanalyzing to deduce the problem and treatment relating to the patient. They used all of the information available to them to determine possible scenarios, which then were continually narrowed down. The focus was on the process rather than the outcome. Clinical reasoning was exemplified as follows: . . . just figuring it out . . . basically, it’s getting all the information . . . and trying to come up, first with a hypothesis, then testing that and . . . , hopefully, determining whether you’re on the right track and narrowing down that hypothesis to try and come to a treatment process. . . . And . . . then every other session doing all that again in a . . . smaller way . . . reanalyzing and reassessing and determining whether . . . for that patient (Sinead, 3).

Clinical reasoning continued to be mainly therapist centered and tended to emphasize diagnosis. However, information about the patient informed hypothesis formation and assessment. The direction of application of knowledge continued to be from the student but focused more specifically on the patient and the condition (Fig. 2B).

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Figure 2. Diagrammatic representation of the structural aspects of students’ experiences with clinical reasoning.

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Clinical Reasoning in Musculoskeletal Practice Category C—rationalizing or justifying what and why. Clinical reasoning was conceptualized as justification: “explaining why” (Annie, 3), “rationalizing what you’re doing . . . using treatments and techniques for a specific purpose based on your knowledge and experience” (Genevieve, 3), “the thinking behind the thinking . . . the reasons for why you do things” (Betha, 2), and: . . . being able to justify [to yourself and to the patient] what you do, what you see, and what you think is going on. . . . You might interpret what’s going on and then apply [a] certain technique for a certain reason. I think it’s taking the information, evaluating it, and then responding to it in an appropriate way . . . it’s the whole process of going through that (Gallagher, 4).

There was a focus for “why you . . . use techniques” (Enya, 3), “to see . . . the underlying cause of injury” (Aeryn, 2), and “using evidence to suggest a certain outcome” (Annie, 3). Structurally, the experience appeared circular (Fig. 2C). Students referred to the importance of recognition and related their growing confidence to bringing together their own knowledge and experience with their knowledge of the patient. They spoke of using their developing experience of reasoning in new situations. Unlike in categories A and B, in category C the patient was more integral to the experience: . . . it’s their goals and their body . . . you might want to fix their ankle, but they want to be able to play basketball or something . . . so it’s combining it . . . [to] try and get that holistic approach. . .you’re treating the whole person rather than a sprained ankle (Gallagher, 4).

Category D— combining knowledge to reach a conclusion. Clinical reasoning emphasized the endpoint of the process (Fig. 2D). 436

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Clinical reasoning was exemplified as combining knowledge to arrive at a conclusion, a decision, or a diagnosis or to solve a problem: “. . . you just combine things and eventually come up with a conclusion” (Alana, 4) and: . . . what you get from the patient, the subjective and objective, . . . you put that together with what you know, what other people tell you, and . . . clinical experience. You use all that together to make a decision . . . using all your resources, putting them together to make a decision about a patient (Norah, 3).

This kind of combining differed from the concept of bringing knowledge together described for category C above. Students were aware of a range of possibilities and used a flexible approach that required an open mind: . . . you’re really trying to keep an open mind and anything they tell you . . . [you’re] trying to decipher if it’s relevant . . . you’re initially trying to arrive at a diagnosis, so you’re trying to think of . . . a list of possible diagnoses, and the more they tell you [the] more you’re trying to narrow it down to 1 or 2 possible suspects (Ardara, 4). I think you’ve just got to keep an open mind and . . . if you decide to do something and you realize that you’re going along the wrong track, then you need to be able to change that and do something else (Norah, 3).

When asked about HDR, students showed a preference for forms of simple pattern recognition: “I don’t go through it [HDR]. . . . I rely on my experience . . . pattern recognition” (Monaghan, 4), “I don’t really go through the whole . . . [HDR process]” (Ardara, 4); rather, conclusions were based on “gut feeling” (Alana, 4) or a “leap of faith” (Monaghan, 4). Alana (4) talked about different cases with similar signs and symptoms:

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. . . as soon as you see them you get a feeling . . . of what it’s most likely going to be . . . I’d say it’s some form of pattern recognition, but I haven’t seen many patients to get a pattern going, but just from cases I heard about recognizing signs and symptoms that are similar. . . . Each person will be slightly different, but there will be 2 or 3 things that come up time and time again.

Category E—problem solving and pattern building. Clinical reasoning was exemplified as problem solving and picture or pattern building (Fig. 2E), interrelated metacognition processes that were not evident in previous conceptions. Problem solving, which tended to focus on the student’s experiences with individual patients, was perceived as a continuous, spiral process of planning, doing, and reflecting. Picture or pattern building was a more temporally extended, visual process concerned with individual patients, previous clinical experience, and the growth of knowledge and expertise. Both processes involved more focus on the patient than previous experiences: . . . it’s problem solving, really . . . each patient . . . gives you a set of clues, and then you . . . look . . . at your objective measures and . . . what they tell you and then try and build a pattern of what’s gone wrong and see how that relates to a structure (Trevor, 4). It’s not so much about the diagnosis . . . [although] it has a part to do with it, it’s how you get there . . . it’s what you’re given, what you see, what you probe for, what you test, . . . you’re . . . thinking, “OK, is this adding to [the] picture?” If it isn’t, get rid of it . . . carry on until you’re happy in your own mind that you have come to a conclusion based on evidence . . . [and] experience (Callahan, 4).

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Clinical Reasoning in Musculoskeletal Practice Is there a fit?” Trevor (4) indicated, “There’s always the possibility that it’s going to be other things, so I still went through all the different tests.” Callahan (4) described his approach to a patient as follows:

can apply a lot of the time. So, the next time someone comes in and says, “I do this and I’ve done that and this hurts,” then you can go, “Well, I think it’s that because of. . . ,” . . . you’ve seen the pattern before in so many different other people (Sabrina, 3).

. . . when a patient says “shoulder pain,” . . . you go through all the possibles . . . [suprascapular nerve damage is] not a very common thing at all . . . [we considered it because] she had weakness. . . . I still went through my structured objective exam, but as I’m going through [it] I’m always thinking what [it] could be, given what the patient was saying; what could be at fault? . . . that’s what I do with every patient, . . . they say something and I think . . . to myself, it could be this, could be this, could be this, but not discount them all until I’ve had a good check (Callahan, 4).

The therapist-patient relationship was a 2-way “linking [of] the theory to the actual” (Sabrina, 3). Students’ reasoning appeared to start with the patient: “Every person’s different, so you link all the different ideas together . . . with the person” (Sabrina, 3). There was evidence that students intentionally set about building their experience, and they emphasized the ongoing improvement of their clinical practice.

Students emphasized process because it allowed them to “know what they need to do next” (Sabrina, 4). Yet, they also “deviate[d] from the process knowing that when you’ve exhausted the deviation . . . you can get back on track again because you know . . . you’ve done it a number of times” (Callahan, 4). Trevor (4) argued:

Cross-Category Themes Cross-category analysis (stage 3) revealed evidence of 5 general themes: (1) focus of CR, (2) spatiotemporal characteristics of CR, (3) differences in the degree of focus on the patient, (4) variations in meaning and attribution of confidence, and (5) role of clinical experience in CR. These general themes are summarized in Table 2.

. . . having a logical sequence that you can stick to each time so that as a pattern develops, you can recognize it . . . you can’t do exactly the same with every patient but . . . in my assessment, I try to make sure that I’ve got clear what I want to work out—a logical sequence so you can build a good picture of the problem.

Sequence appeared to be the key to more general pattern building: . . . the more you deal with . . . patients . . . you actually start to build up ideas of how things happen and you check it out, and after you’ve done about 5 different patients with a similar thing, you actually start to see a pattern forming with . . . their symptoms or their signs or the way things worked, and those patterns actually

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Focus of CR. With the exception of category A, in which a trial-anderror approach predominated, some features of HDR were recognizable across all categories. In category B, there was evidence of analysis, testing of hypotheses, reassessment of the patient’s response, interpretation and evaluation of information, and decision making using an active, albeit simple, feedback loop. However, there was little reflection on the process, and the narrow focus lacked the full breadth and depth of HDR. In category C, CR was a deeper, more-complex process based on the rationalization of evidence. Categories D and E showed more evidence of the stages of HDR,37 including combining and

weighing information to rationalize decision making6 and recognition of the importance of experience in practice.38 Category D was concerned with both process and outcome, and students showed an increased awareness of their limitations and the implications of CR. They talked about combining knowledge to reach a conclusion but also made reference to their use of intuition and the recognition of clinical patterns in the decision-making process. They acknowledged that pattern recognition was gained through experience and practice. They realized that their application of knowledge and skills in the clinical environment had changed and developed, but they quite often struggled to articulate how decision making took place and were aware that reliance on a particular process could sometimes hinder their reasoning. There was evidence of a strong feedback loop for incorporating knowledge and skills from a range of sources to inform practice. Category E differed significantly from the other categories. As with category D, students described pictures and clinical patterns. However, their focus extended beyond simple recognition to an active and intentional development of such patterns by combining and weighing the information against previous knowledge and experience. Clinical information and knowledge were used to build a “mental picture” to inform current management of the patient’s condition and future practice. Students also talked about reflection in action and about action as a means to build experience and inform practice. Spatiotemporal characteristics of CR. The spatiotemporal characteristics of CR changed across categories (Tab. 2). “Spatio” is defined as the boundary of the experience or “the space” it occupies. “Temporal”

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Clinical Reasoning in Musculoskeletal Practice Table 2. Summary of Cross-Category Themes and Variations Associated With Each Category Conceptualization of Clinical Reasoning (CR)

Spatiotemporal Aspects

Forms of CR

Degree of Focus on the Patient

Characteristic to Which Confidence Was Attributed

Role of Clinical Experience in CR

A: Applying knowledge and experience to the problem, patient, or situation

Simple trial and error

Immediate: the problem, the situation, or the effectiveness of a technique

Little or none: therapist centered

The ability to perform a particular technique

Prior experience with the technique or problem

B: Analyzing and reanalyzing to deduce the problem and treatment

Analysis, testing of hypotheses, and reassessment of the patient’s response; use of a simple feedback loop

Immediate: the diagnosis

Therapist centered: you must be able to explain it to the patient

The ability to figure it out

Prior experience with the condition

C: Rationalizing or justifying what and why

More-complex process involving a form of hypothetical deductive reasoning based on the rationalization of evidence

The treatment period and projection to new situations

The patient is a source of information

An awareness of personal ability: how you put it together

Prior experience is required for effective CR

D: Combining knowledge to reach a conclusion

Combining and weighing information to rationalize both process and outcome decisions; acknowledging recognized patterns

The whole treatment program, from decision to conclusion

Focus on the patient’s goals

Experience, practice, and seeing similar situations

Prior experience is crucial for pattern recognition

E: Problem solving and pattern building

Extending recognition of clinical patterns to active involvement in pattern development, including reflection and action

Past experience, current situation, and future practice, with a broad focus on improving practice

Broadly patient focused

The ability to be professional and base decisions on evidence

Prior experience is crucial for pattern recognition

is defined in terms of the student’s focus in time. In each conception, space and time are integrally linked and are described together. In categories A and B, participants dealt only with current time and the immediate task space. In category A, the student’s focus was the immediate problem, situation, or application or effectiveness of a technique, and in category B, it was the immediate diagnosis. In category C, the temporal focus included a single treatment period and possible new situations, and the experiential boundary was extended to include the management of the patient’s condition during treatment. In category D, the temporal focus was the whole treatment period from diagnosis to conclusion, and the experiential boundary was the student’s practice. In category E, the temporal focus was very broad, extending from past experience to the current situation and to future practice, and the experiential boundary was both the stu438

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dent’s practice and the improvement of practice. Differences in the degree of focus on the patient. Students’ conceptualizations of the role of the patient in the clinical encounter changed across categories from therapist centered to a greater focus on the patient (Tab. 2). In category A, there was little or no reference to the patient, and in category B, the reference was limited to the student’s capacity to provide explanations to the patient. In category C, the patient was recognized as an important source of information, and students focused on their ability to provide care to the patient rather than the problem. In category D, the patient was central to the reasoning process, and students focused on the patient’s goals. In category E, there was a broader focus on the patient.

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Variations in meaning and attribution of confidence. Confidence was mentioned in all categories, but its meaning and attribution differed across categories. In category A, having confidence was associated with the effective performance of a technique. In category B, confidence was related to students’ knowledge of a situation and its analysis. In category C, confidence was related to students’ ability to use their current knowledge to rationalize the management of the patient’s condition. In category D, confidence was based on whether students had experience with the condition or had seen the situation before. Students also showed an increased awareness of their limitations and the implications of CR. In category E, confidence assumed a much broader focus on professionalism and decision making on the basis of best practice.

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Clinical Reasoning in Musculoskeletal Practice Role of clinical experience in CR. Conceptions of the role of clinical experience in CR differed across categories. In categories A and B, previous clinical experience was necessary for the successful completion of a technique (A) or effective diagnosis (B). However, in categories C, D, and E, the emphasis changed. In category C, students perceived the accumulation of clinical experience to be an important contributing factor to CR, and in categories D and E, it was crucial to pattern recognition.

Discussion This study was undertaken because of the belief that good teaching depends on an understanding of students’ conceptualizations of the phenomenon being taught.29 Students conceptualized CR in 5 qualitatively different ways across the 3 years of the undergraduate program, and conceptualizations ranged from very simple to more complex. Moreover, students’ conceptualizations and descriptions of their approaches to CR appeared to be internally related in ways that resembled research on conceptions and approaches to subject material.33 Therefore, in category A, a student who understood CR as an application or a way to make something work used simple, linear trial and error in practice, that is, applying a technique or aspect of knowledge to the patient. Educational research on conceptions of learning has often reported categories of conceptions as a hierarchy from simple to increasingly complex sophistication.33 The categories of CR reported above showed a similar pattern. Moreover, across categories, shifts in emphasis from aspects of HDR, task focus, and therapistcentered practice to embryonic forms of pattern recognition, process orientation, and more patientfocused practice resembled those described in research on novices and experts.4,39,40 However, none of the May 2009

category descriptions resembled a particular model of CR described in earlier literature. Rather, the categories represented a continuum from relatively simple to increasingly complex, but mixed, forms of reasoning. The development of a continuum is further supported by the changes within the cross-category themes. Table 2 shows how each theme assumed a particular meaning in association with the other aspects of its respective category. Yet, across categories, each theme increased in breadth, depth, and sophistication from categories A to E. On the basis of these results and previous literature, it may be argued that such themes represent key dimensions of CR development. For example, the shift from therapist- to patientfocused care is well documented,37,41 and the development of patient-focused care is often a concern for clinical teachers. The characteristics and themes of CR suggest a developmental trend that resembles the development of expertise reported in the literature.11–14 In particular, category E showed evidence of a more cyclical and dynamic reasoning process,40 including a much broader focus and critical self-reflection, recognized as part of the evolutionary process toward independent practice42 and expert practitioner status.37,43 The categories showing more development revealed CR to be a combination of problem solving and pattern recognition, and some of the characteristics of the spiral models of thinking and reasoning11,44 were evident in category E. The latter categories showed signs of students’ increasing ability to manipulate knowledge.14 It was also interesting that variations in experiences mirrored, to some extent, the changing views of CR in the literature.

The sample included students from 3 consecutive years of study. With year of study as an indicator, it would be expected that increasing expertise in CR would be evident as students proceeded through their clinical program. However, this was not the case. Although year 4 students were associated with a more sophisticated and holistic experience of CR than year 2 students, two thirds of the sample experienced CR predominantly in terms of categories A to C, in which the focus was immediate practice, that is, diagnosis, treatment, or both (Tab. 1). Application to Teaching Students’ conceptions of and approaches to learning are related to the context (curriculum organization, teaching, and assessment) in which they learn.45,46 The curriculum was organized so that clinical experience was concentrated predominantly in the fourth year. The variations in our results supported the clinical teachers’ observations that students’ capacity for CR varied substantially in year 4. This variation may be attributable to several factors, including the possible influences of other parts of the curriculum, the quality of clinical supervision, the context of the MS clinical placements,47 the clinical and theoretical balance in the curriculum, and the appropriateness of the assessment. The results suggest a need to examine the relationship between the development of CR and clinical exposure as well as the alignment of course objectives and assessment within the curriculum.48 Dimensions of CR could be used to identify where students are located on the continuum and, therefore, could contribute to the development of teaching, learning, and assessment strategies in the curriculum. For instance, students can be located on the continuum by the language they use, their degree of focus on the

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Clinical Reasoning in Musculoskeletal Practice patient, their spatiotemporal characterizations of CR, and the ways in which they attribute confidence to their practice. Students also could make use of such a tool as a reflective device to aid in learning. The results of this study emphasize the need for clinical educators to explore students’ conceptions and understanding of reasoning in teaching and assessment. Teaching strategies focusing on, for example, particular views of CR could be used to help improve student learning, and generic strategies could be used to improve students’ understanding of CR. These generic strategies might include using open-ended questioning to extend students’ boundaries of thinking and focus; encouraging students to think beyond the textbook, for example, to explore their previous experience; enabling students to trust their observations; and using metacognition strategies to help guide critical reflection. Limitations and Further Research These results may inform undergraduate physical therapist programs in Australasia and Europe, but their application to doctoral programs must be made with some caution. However, it is worth noting that 12 of the 31 therapists (39%) in our sample entered the physical therapist program as graduates, yet this cohort exhibited the same variations in conceptualization. Interestingly, all 3 students who conceptualized CR as category E were graduate entrants. Although students’ conceptualizations of CR in graduate programs may differ, arguably the thematic dimensions will remain the same in that they reflect existing literature. The cross-sectional design and constraints imposed by single-school sampling make it impossible to do more than suggest a developmental trend. Clinical reasoning development and its influences can be inves440

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tigated only through longitudinal studies that track individual students’ progression in various physical therapist programs. The generalizability of results to other physical therapy disciplines, such as neurorehabilitation, and to other programs requires further research. It also is acknowledged that volunteer bias (ie, the majority of students did not agree to take part in the research) and student recall bias may have influenced students’ responses to patient-related questions and, therefore, may have influenced the distribution of conceptualizations of CR; however, these factors are unlikely to have changed the range of conceptualizations of CR found in this study.

Conclusion Previously, CR was not explored qualitatively using students’ direct experience as data. Further research of this kind, in particular, longitudinal studies, may provide a new way of exploring CR and an insight into its development, teaching, and assessment. The continuum reported above for CR has the potential to provide a method of assessing students’ understanding at a particular time in their study. Such knowledge would be extremely useful to teachers and students in the advancement of student learning. Mr Hendrick, Dr Bond, and Dr Duncan provided concept/idea/research design, data collection, and consultation (including review of manuscript before submission). All authors provided writing and data analysis. Mr Hendrick and Dr Bond provided project management and fund procurement. Mr Hendrick provided participants, facilities/ equipment, and institutional liaisons. Dr Duncan provided clerical support. Linda Robertson assisted in checking and editing the manuscript before submission. This study was approved by the Human Ethics Committee at the University of Otago. This study was funded by a Research Into University Teaching grant.

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This research was presented at a research seminar series at The Higher Education Development Centre, University of Otago; September 28, 2006; Dunedin, New Zealand. This article was received May 20, 2008, and was accepted February 2, 2009. DOI: 10.2522/ptj.20080150

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Clinical Reasoning in Musculoskeletal Practice 15 Higgs J, Jones MA. Clinical reasoning in the health professions. In: Higgs J, Jones MA, eds. Clinical Reasoning in the Health Professions. 2nd ed. Oxford, United Kingdom: Butterworth-Heinemann; 2000. 16 Jones M, Jensen G, Edwards I. Clinical reasoning in physiotherapy. In: Higgs J, Jones MA, eds. Clinical Reasoning in the Health Professions. 2nd ed. Oxford, United Kingdom: Butterworth-Heinemann; 2000. 17 Jones MA. Clinical reasoning in manual therapy. Phys Ther. 1992;72:875– 884. 18 Smart K, Doody C. The clinical reasoning of pain by experienced musculoskeletal physiotherapists. Man Ther. 2007;12: 40 – 49. 19 Nikopoulou-Smyrni P, Nikopoulos CK. A new integrated model of clinical reasoning: development, description and preliminary assessment in patients with stroke. Disabil Rehabil. 2007;29:1129 –1138. 20 Rivett D, Higgs J. Experience and expertise in clinical reasoning. NZ J Physiother. 1995;23:16 –21. 21 Babyar SR, Rosen E, Sliwinski MM, et al. Physical therapy students’ self-reports of development of clinical reasoning: a preliminary study. J Allied Health. 2003;32: 227–239. 22 Groves M, O’Rourke P, Alexander H. The association between student characteristics and the development of clinical reasoning in a graduate-entry, PBL medical programme. Med Teach. 2003;25:626 – 631. 23 Norton BJ, Strube MJ. The influence of experience with a set of simulated patients on diagnosis of simulated patients not previously diagnosed. Phys Ther. 1998;78:375–385. 24 Ladyshewsky RK. A quasi-experimental study of the differences in performance and clinical reasoning using individual learning versus reciprocal peer coaching. Physiother Theory Pract. 2002;18:17–31. 25 Haffer AG, Raingruber BJ. Discovering confidence in clinical reasoning and critical thinking development in baccalaureate nursing students. J Nurs Educ. 1998;37: 61–70.

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26 Chapman JA, Westmorland MG, Norman GR, et al. The structured oral self-directed learning evaluation: one method of evaluating the clinical reasoning skills of occupational therapy and physiotherapy students. Med Teach. 1993;15:223–236. 27 Larin H, Wessel J, Al-Shamlan A. Reflections of physiotherapy students in the United Arab Emirates during their clinical placements: a qualitative study. BMC Med Educ. 2005:20:3. 28 Gadamer HG. Truth and Method. 2nd rev ed. Weinsheimer J, Marshall DG, trans. London, United Kingdom: Sheed & Ward; 1989. 29 Marton F, Runesson U, Tsui ABM. The space of learning. In: Marton F, Tsui ABM, eds. Classroom Discourse and the Space of Learning. Mahwah, NJ: Lawrence Erlbaum Associates; 2004:3– 40. 30 Marton F. Phenomenography: describing conceptions of the world around us. Instrumental Science. 1981;10:177–200. 31 Marton F. Phenomenography: a research approach to investigating different understandings of reality. J Thought. 1986;21: 28 – 49. 32 Marton F, Booth S. Learning and Awareness. Mahwah, NJ: Lawrence Erlbaum Associates; 1997. 33 Prosser M, Trigwell K. Understanding Learning and Teaching: The Experience in Higher Education. Buckingham, United Kingdom: Open University Press; 1999. 34 Bond C, Madill B, Ross E. The development of tertiary teachers’ experiences of teaching. Paper presented at; Annual Conference of Improving University Teaching (IUT); July 3– 6, 2006; Dunedin, New Zealand. http://iutconference.org/2006/ sessionIII.htm. Accessed March 14, 2008. 35 Patton, MQ. Qualitative Research and Evaluation Methods. 2nd ed. Thousand Oaks, CA: Sage Publications; 2001. 36 Creswell JW, Miller DL. Determining validity in qualitative inquiry. Theor Pract. 2000;39:124 –130.

37 Jensen GM, Gwyer J, Shepard KF. Expert practice in physical therapy. Phys Ther. 2000;80:28 – 43. 38 Norman G. The role of experience in the development of clinical reasoning. Int J Ther Rehabil. 2003;10:488. 39 Embrey DG, Guthrie MR, White OR, Dietz J. Clinical decision making by experienced and inexperienced pediatric physical therapists for children with diplegic cerebral palsy. Phys Ther. 1996;76:20 –33. 40 Rivett DA, Higgs J. Hypothesis generation in the clinical reasoning behaviour of manual therapists. J Phys Ther Educ. 1997;11: 40 – 45. 41 Doody C, McAteer M. Clinical reasoning of expert and novice physiotherapists in an outpatient orthopaedic setting. Physiotherapy. 2002;88:258 –268. 42 Jensen GM, Paschal KA. Habits of mind: student transition toward virtuous practice. J Phys Ther Educ. 2000;14:42– 47. 43 Rikers R, Winkel WT, Loyens S, Schmidt H. Clinical case processing by medical experts and subexperts. J Psychol. 2003; 137:213–223. 44 Stockhausen L. The clinical learning spiral: a model to develop reflective practitioners. Nurse Educ Today. 1994;14: 363–371. 45 Ramsden P. Student learning and perceptions of the academic environment. Higher Education. 1979;8:411– 428. 46 Ramsden P. Learning to Teach in Higher Education. 2nd ed. New York, NY: Routledge Falmer; 2003. 47 Ajjawi R, Higgs J. Learning to reason: a journey of professional socialisation. Adv Health Sci Educ. 2008;13:133–150. 48 Anderson LW. Objectives, evaluation, and the improvement of education. Studies in Educational Evaluation. 2005;31:102–113.

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Clinical Reasoning in Musculoskeletal Practice Appendix. Interview Schedule

1. Let’s start with a question about you. Can you tell me a little about yourself? Age? Where you come from? What made you choose to do physical therapy? (For mature students) What did you do before you enrolled? 2. You’ve completed a musculoskeletal module. I’d like you to think about the placement and choose a particular patient with a musculoskeletal problem that you feel comfortable talking about. Possible probes, depending on response: Tell me about them. What was the patient’s problem? Why did you choose this patient to talk about? What did you think when you first saw. . . ? What did you do? Why did you do that? What conclusions did you draw? Why did you come to those conclusions? Can you talk through the process you used to reach those conclusions? 3. What does the term “clinical reasoning” mean to you? Possible probes: Can you tell me more about. . . ? What do you mean by. . . ? Why do you think that? 4. Can you provide another example of your own clinical reasoning in practice? Tell me about the situation; what happened then. . . ? How did that come about? Why did you think that? 5. Where does the patient fit into clinical reasoning? 6. How do you think you have developed this idea of clinical reasoning? Can you tell me more about. . .? What affected that development? What changed it? How has it changed? What was the effect of the physical therapy curriculum? 7. What is clinical information or clinical knowledge? 8. How do you learn in the clinical area? 9. What is learning for you—in the clinical area? More generally? 10. Do you have any other comments or questions?

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Research Report Short-term Efficacy of UpperExtremity Exercise Training in Patients With Chronic Airway Obstruction: A Systematic Review Stefania Costi, Mauro Di Bari, Paolo Pillastrini, Roberto D’Amico, Ernesto Crisafulli, Cinzia Arletti, Leonardo M Fabbri, Enrico M Clini

Background, Objectives, and Measurements. Patients with chronic airway obstruction (CAO) frequently experience dyspnea and fatigue during activities performed by accessory muscles of ventilation, which competitively participate in arm elevation. This systematic review of randomized controlled trials (RCTs) concerning patients with CAO addresses the effects of upper-extremity exercise training (UEET), added to lower-extremity training or comprehensive pulmonary rehabilitation, on the following patient-centered outcomes: exercise capacity, symptoms, ability to perform daily activities, and health-related quality of life.

Methods. Studies were retrieved using comprehensive database and hand-search

S Costi, PT, MSc, is Physical Therapist, Section of Respiratory Disease, Department of Oncology, Haematology, and Respiratory Disease, University of Modena and Reggio Emilia, Via del Pozzo 74, 41100 Modena, Italy. Address all correspondence to Ms Costi at: [email protected]. M Di Bari, MD, is Doctor, Department of Critical Care Medicine and Surgery, Unit of Gerontology and Geriatrics, University of Florence and Azienda OspedalieroUniversitaria Careggi, Florence, Italy. P Pillastrini, PT, MSc, is Physical Therapist, Department of Neurological Sciences, Occupational Medicine Unit, S Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy. R D’Amico, PhD, is Statistician, Section of Respiratory Disease, Department of Oncology, Haematology, and Respiratory Disease, University of Modena and Reggio Emilia.

strategies. Two independent reviewers determined study eligibility based on inclusion criteria. A detailed description of treatments was mandatory. Reviewers rated study quality and extracted information on study methods, design, intervention, and results.

E Crisafulli, MD, is Doctor, Department of Pulmonary Rehabilitation, Ospedale Villa Pineta, Pavullo, Modena, Italy.

Results. Forty publications were evaluated. Four RCTs met the inclusion criteria

C Arletti, PT, BSc, Physical Therapist, Anni Azzurri, Ducale 1, 2, 3, Modena, Italy.

but had serious methodological limitations, which introduce possible biases that reduce their internal validity. The outcomes measured were heterogeneous, and the results were inconsistent regarding maximal exercise capacity, dyspnea, and healthrelated quality of life. No effect of UEET was demonstrated for measures of arm fatigue.

Limitations and Conclusions. The limited methodological quality of the studies retrieved prevented us from performing a meta-analysis, the results of which could be misleading. This systematic review shows that there is limited evidence examining UEET and that the evidence available is of poor quality. Therefore, a recommendation for the inclusion or exclusion of UEET in pulmonary rehabilitation programs for individuals with CAO is not possible. Further research is needed to definitively ascertain the effects of this training modality on patient-centered outcomes.

LM Fabbri, MD, is Doctor, Section of Respiratory Disease, Department of Oncology, Haematology, and Respiratory Disease, University of Modena and Reggio Emilia. EM Clini, MD, FCCP, is Doctor, Section of Respiratory Disease, Department of Oncology, Haematology, and Respiratory Disease, University of Modena and Reggio Emilia, and Department of Pulmonary Rehabilitation, Ospedale Villa Pineta. [Costi S, Di Bari M, Pillastrini P, et al. Short-term efficacy of upperextremity exercise training in patients with chronic airway obstruction: a systematic review. Phys Ther. 2009;89:443– 455.] © 2009 American Physical Therapy Association Post a Rapid Response or find The Bottom Line: www.ptjournal.org

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Upper-Extremity Exercise Training in Chronic Airway Obstruction

T

he upper extremities (UEs) play an important role in performing many activities of daily living (ADL), both in the domain of basic self-care and in everyday jobs. Patients with chronic airway obstruction (CAO) frequently experience marked dyspnea and fatigue when performing these tasks,1,2 which commonly require unsupported arm work and, therefore, pose a unique challenge to these individuals, whose upper-limb muscles are frequently recruited as accessory inspiratory muscles.3–5 During unsupported arm exercise, the participation of these muscles in ventilation decreases, and there is a shift of respiratory work to the diaphragm, which is commonly weakened and has a reduced functional capacity in these patients.6 This shift is associated with thoracic-abdominal desynchronization, severe dyspnea, and premature termination of exercise.1,7,8 The effectiveness of pulmonary rehabilitation (PR) programs has been well documented in patients with CAO, with consistent and clinically significant improvements in exercise capacity, symptoms, and healthrelated quality of life (HRQoL).9 However, such programs primarily focus on lower-extremity (LE) exercise training.10,11 Because training effects are specific to the limb trained, it seems reasonable to assume— but it so far remains unproven—that, in

Available With This Article at www.ptjournal.org • The Bottom Line clinical summary • The Bottom Line Podcast • Audio Abstracts Podcast This article was published ahead of print on March 12, 2009, at www.ptjournal.org.

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patients with CAO, upper-extremity exercise training (UEET) may improve functional status and reduce symptoms while performing ADL. Recent guidelines from the American College of Chest Physicians11 recommend the introduction of unsupported endurance training of the UEs in PR programs. We think that this recommendation relies on limited evidence available from both randomized12–17 and nonrandomized18 –20 studies conducted over recent decades. However, to our knowledge, no systematic review has ever been conducted on this topic. We undertook this systematic review of randomized controlled trials (RCTs) to clarify the effect of UEET, implemented over and above standard treatment or lower-extremity exercise training (LEET), on patient-centered outcomes, such as exercise capacity, symptoms, ability to perform ADL, and HRQoL in patients with CAO.

Method Data Sources and Searches We performed a computer-based search, querying Ovid MEDLINE (1950 to March 2007), CINAHL (Cumulative Index to Nursing and Allied Health, 1982 to March 2007), EMBASE (1980 to March 2007), PEDro (Physiotherapy Evidence Database), and the Cochrane Central Register of Controlled Trials for original research articles published in English, Italian, and Spanish. Search terms and strategies were as follows: (chronic airway obstruction OR pulmonary diseases chronic obstructive) AND (exercise therapy OR exercise OR rehabilitation OR physical therapy OR physiotherapy OR training) AND (arm OR upper extremities). In addition, reference lists of relevant research articles were reviewed for pertinent studies. Abstracts pre-

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sented at international meetings (American Thoracic Society, 2001– 2007, European Respiratory Society, 2001–2007) also were hand-searched, and the authors of appropriate abstracts were contacted to obtain from them complete, unpublished data. Finally, PR experts were contacted to locate any further, unpublished material. Study Selection The following criteria were used to select trials for inclusion in the review. Design. We considered for inclusion RCTs only. Target population. Trials were considered when they enrolled patients with a diagnosis of moderate, severe, or very severe CAO. The criteria used for this purpose were the best recorded ratio of forced expiratory volume in 1 second (FEV1) to forced vital capacity (FVC) of less than 0.7, associated with the best recorded FEV1 of less than 80% of the predicted value,21 and a clinical diagnosis of CAO. Intervention. As recommended by the major scientific societies in this field,10 we selected any inpatient, outpatient, or home-based PR programs that included at least 20 sessions for a minimum frequency of 3 times a week. Both supervised and unsupervised home sessions were considered acceptable. The program had to include supported or unsupported UEET as the experimental intervention. A detailed description of the experimental intervention was mandatory. Control. Randomized controlled trials were included only when they compared UEET with treatments not specifically aimed at improving UE exercise capacity. The control group could receive standard training consisting of comprehensive inpatient, May 2009

Upper-Extremity Exercise Training in Chronic Airway Obstruction outpatient, or home-based PR programs, or it could be a training program targeting only LE exercise capacity. Again, the program had to include at least 20 regular sessions for a minimum frequency of 3 times a week; both supervised and unsupervised home sessions were acceptable. A detailed description of the control treatment was mandatory. Outcome measures. These measures could be arm exercise capacity (maximal exercise capacity, functional exercise capacity, or endurance time). The UE maximal exercise capacity was defined as the peak exercise capacity measured by an incremental exercise stress test. Functional exercise capacity was defined as the maximum number of UE elevations performed in 6 minutes, and arm endurance was defined as the duration of a constantload, symptom-limited exercise, performed using an arm ergometer. Outcome measures also could be the symptoms of dyspnea or arm fatigue on exertion, which had to be quantified by specific, validated questionnaires as scores achieved during exercises requiring exerting the UEs; the ability to perform ADL tasks that involve the arms, using reliable measures; or the HRQoL, as assessed by data collected by specific questionnaires. Data Extraction and Quality Assessment To assess eligibility, 2 investigators (SC and EC) independently retrieved and examined the titles and abstracts of the studies in order to achieve higher accuracy in this process; a third investigator (RD) was consulted in case of disagreement to improve accuracy. The 2 investigators extracted the data from the studies selected for inclusion and requested important data missing from these reports from their authors. Finally, the 2 investigators independently rated the quality of the May 2009

Figure. Flow chart of screened, excluded, and eventually analyzed reports. Research articles included in more than one of the databases consulted (overlap) are not represented. RCT⫽randomized controlled trial, UEET⫽upper-extremity exercise training.

studies selected using the Consolidated Standards of Reporting Trials (CONSORT) statement.22

Results Bibliographic Search Results Forty publications were retrieved with combined computerized and hand search, including 2 abstracts and 1 reference (Figure). After a first review of the titles and abstracts, 13 studies remained potentially eligible. Efforts to obtain the full-length articles, or the data, directly from the authors of the reference and the 2 abstracts, presented at international meetings, were unsuccessful: in 2 cases, the authors did not answer our multiple attempts to contact them,20,23 and in the third case, the authors were unable to provide the information requested.24 The 10 eligible full-text studies were independently reviewed as previously described. Agreement was reached to include 4 studies and to exclude 5 studies from the systematic review, using the Cohen coefficient of association (K⫽.8). One other study25 was excluded after consulting the third investigator. Summarizing, 6 research articles were excluded because they did not

satisfy inclusion criteria for intervention or control. Two trials did not focus on UEET as the experimental intervention,25,26 and a third article was excluded because the intervention lasted less than 20 sessions,27 thus not satisfying the evidencebased criteria for duration of PR as stated by the American Thoracic Society/European Respiratory Society10 and because it included patients with diseases other than CAO. Two trials were excluded because the control groups did not perform comprehensive PR or LEET,14,15 and the sixth trial was excluded because it compared 2 different modes of UEET, thus not allowing for control.13 One trial selected for this review16 included 2 intervention groups, both satisfying our inclusion criteria, that were similar in the amount of training but different in the training modalities used. Both groups were separately considered for comparison with the control group. Another selected trial12 included 4 groups for multiple comparisons. We checked them for inclusion criteria and considered the group that performed LEET only for comparison with the group that performed UEET plus LEET.

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28

13

28

At Completion

22

Not reported

7

9

8

Allocated to Intervention Group

6

8

8

8

Follow-up (wk)

Intervention Group

69.4 (6.6)

63.0 (9.4)

71.8 (3.3)

66.6 (8.4)

66.07 (9.2)

66.3 (6.8)

Not reported

Control Group

Age (y), mean (SD)

10/6

12/2

6/0

Intervention Group

14/8

11/3

4/3

Not reported

Control Group

Male/Female Ratio

PR (including LEET) ⫹ placebo

LEET

LEET

PR (including LEET)

Control

UEET ⫹ LEET

UEET ⫹ LEET

UEET ⫹ LEET

UEET (PNF) ⫹ GPT

UEET (GRT) ⫹ GPT

Intervention

Treatment

Number 5

b

a

24

30

Sivori et al, 199828

Holland et al, 200417 6

8

8

6

Program Duration (wk)

Unsupported UEET: Unsupported arm exercises aimed at increasing tolerance to effort and consisting of 3 min of weight lifting with an initial resistance of 500 g. The resistance is incremented by 0.5 kg in order to maintain the muscular effort between a grade of 12 to 14 and a dyspnea grade of at least 3 on the modified Borg self-administered scale. Outpatientb/ home based

Supported and unsupported UEET: 10 min of warm-up followed by supported and unsupported arm exercises consisting of 20 min of circuit training (arm ergometer with variable resistance, ball throwing with horizontal arms, passing a beanbag overhead, tug of war linked to a pulley, dexterity exercises) followed by 10 min of cooling off.

Outpatientb

b

Unsupported UEET (GRT): Unsupported arm exercises in coordination with respiration to increase the endurance of the muscles of the arms and shoulders. Several repetitions against gravity only and against minimal resistance (1–5 lb). Unsupported UEET (PNF): Unsupported arm exercises in coordination with respiration against a progressive resistance on the basis of the PNF technique.

Characteristics of Training

Unsupported UEET: A total of 20 min of training consisting of unsupported arm exercises in coordination with respiration. The sequence comprises the following 4 exercises: lifting a ball or a sandbag in front of the chest up to the head while maintaining the arms extended, lifting a wooden pole with the same technique, passing the ball from one hand to the other overhead, and passing the sandbag from one hand to the other with the same technique. Each exercise is repeated for 45 s, followed by 15 s of rest, until reaching 5 min of training. Increments are allowed on the basis of the patient’s tolerance.

Outpatient

Outpatient

b

Setting

GRT⫽gravity-resistance training, PNF⫽proprioceptive neuromuscular facilitation, UEET⫽upper-extremity exercise training. Day hospital or outpatient visit.

24

28 (PNF)

55 (GRT)

Lake et al, 199012

Ries et al, 198816

Study

No. of Sessions

Characteristics of the Experimental Intervention in the Trials Included in the Reviewa

Table 2.

a PR⫽comprehensive pulmonary rehabilitation, LEET⫽lower-extremity exercise training, UEET⫽upper-extremity exercise training, GRT⫽gravity-resistance training, GPT⫽general physical therapy, PNF⫽proprioceptive neuromuscular facilitation.

40

43

Sivori et al, 199828

Holland et al, 200417

13

45

Randomized

Lake et al, 199012

Ries et al, 198816

Study

No. of Participants

Characteristics of the Patient Samples and Study Designs of Trials That Fulfilled Eligibility Criteriaa

Table 1.

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Upper-Extremity Exercise Training in Chronic Airway Obstruction Table 3. Outcome Measures Used in the Trials Included in the Reviewa Upper-Extremity Exercise Capacity Study

Maximal

Ries, 198816

⻫

Lake, 199012

⻫

Functional

Holland,

200417

⻫

⻫

Sivori, 199828 ⻫

Endurance Time

Dyspnea on Exertion

Arm Fatigue on Exertion

⻫ Borg-m

⻫ Borg-m

⻫

⻫ Borg

⻫ Borg

ADL

HRQoL

⻫ ⻫ Bandura scale ⻫ CRDQ

⻫ Borg-m

⻫ Borg

⻫ CRDQ

a

ADL⫽activities of daily living, Borg⫽Borg dyspnea scale, Borg-m⫽modified Borg dyspnea scale (range⫽0 –10), CRDQ⫽Chronic Respiratory Disease Questionnaire, HRQoL⫽health-related quality of life.

Characteristics of the Samples Table 1 shows baseline demographic characteristics of participants in the studies, as well as study design features of the 4 RCTs that fulfilled all of the eligibility criteria. The sample size was small in all of the trials (13– 45 participants); altogether, 141 participants were randomized, and 107 participants completed the trials (76% of those who had been randomized). Among the patients who completed the trials, 60 were allocated to the intervention group and 47 were allocated to the control group.

Both the intervention and the control treatments were performed in an outpatient setting, although, in the study by Holland and co-workers,17 an unsupervised, daily home exercise program integrated the twiceweekly, outpatient, supervised sessions. Upper-extremity training was conducted as unsupported arm exercises against gravity and progressive resistance as the major component in all of the trials. A combination of unsupported and supported UEET, using an arm ergometer, was used in one trial.12

Participants were elderly and had severe or very severe CAO.21 The main exclusion criteria in the selected trials were ischemic heart disease, heart failure, intermittent claudication, disabling musculoskeletal disorders, need for home oxygen treatment, hypercapnia, and medical conditions (other than CAO) severely limiting exercise tolerance.

Outcome Measures Table 3 summarizes the outcome measures used to assess the treatment effects. Arm exercise capacity (maximal exercise tolerance, functional exercise tolerance, or arm endurance time) was measured in all of the trials. An incremental stress test, with either supported UEs12,16 or unsupported UEs,17 was performed in 3 trials to assess the maximal exercise capacity, whereas 1 trial28 measured functional exercise capacity using a nonstandardized field test based on the number of arm elevations performed in 6 minutes. Finally, 1 trial16 measured the duration of a constant load exercise, sustained by patients on the arm cycle, at a work level one step below their previously determined maximum. We did not consider the submaximal test performed on an arm ergometer in the trial by

Characteristics of the Training Programs All of the selected trials included a detailed and complete description of the control and the intervention treatments (Tab. 2). Overall, UEET programs lasted 6 weeks16,17 to 8 weeks12,28 and included from 24 sessions12,28 to 55 sessions.16 In each study design, a short-term follow-up was planned, within 2 weeks from the end of the treatment.

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Lake and co-workers12 because they did not report the endurance time. Three trials16,17,28 measured dyspnea on exertion, and 3 trials12,16,17 measured arm fatigue on exertion, using different authorized versions of the Borg scale.29,30 One trial12 measured dyspnea with an unidentified scale; because the authors did not answer our request for clarification, the findings from this study are not reported for this specific outcome. The participants’ ability to perform several ADL tasks, predominantly involving the arms, was measured in 1 trial only,16 using a nonvalidated simulation field test. Three trials12,17,28 evaluated HRQoL, using self-administered questionnaires.31,32 Methodological Quality of the Included Trials Quality of reporting of the studies selected was assessed by means of the CONSORT statement,22 which recently has been extended to cover reporting of nonpharmacological treatments such as physical therapy. It is a guideline designed to improve the reporting of RCTs. It consists of a checklist and a flow diagram that address the reporting of patient enrollment, allocation to treatments, follow-up, and data analysis. The CONSORT statement is widely used, and it is proven that the use of this evidence-based guideline is associated with improved quality of reporting of RCTs.33

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yes

yes

Sivori et al, 199828

Holland et al, 200417

no

no

yes

Lake et al, 199012

Sivori et al, 199828

Holland et al, 200417 NO

NO

YES

YES

Implementation of Intervention

yes

yes

yes

NO

yes

yes

yes

yes

no

YES

no

no

Results

YES

YES

YES

YES

yes

yes

yes

NO

no

no

no

no

yes

NO

NO

no

Section

NO

NO

NO

NO

no

YES

YES

YES

Method

NA

NA

NA

NA

Ancillary Analysis

NO

yes

NO

NO

Randomization Sequence Generation

Outcomes and Estimation

Outcomes

No. Analyzed

Objectives

Baseline Data

Interventions

Recruitment

Participants

Sample Size

Section

YES

YES

YES

YES

Adverse Events

NO

NO

NO

NO

NO

NO

NO

NO

no

NO

NO

NO

NO

NO

yes

yes

Generalizability

yes

NO

NO

NO

Blinding

Discussion

Randomization Implementation

Interpretation

Randomization Allocation Concealment

YES

YES

YES

YES

Overall Evidence

yes

yes

yes

yes

Statistical Methods

a NA⫽not applicable, no⫽criterion is satisfied for less than 50% of its components, NO⫽criterion is totally not satisfied, yes⫽criterion is satisfied for more than 50% of its components, YES⫽criterion is totally satisfied.

no

Ries et al, 198816

Study

Continued

YES

YES

YES

YES

Introduction and Background

Participant Flow

YES

Lake et al, 199012

Table 4.

yes

Ries et al, 198816

Study

Title and Abstract

Methodological Quality of the Trials Included in This Reviewa

Table 4.

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Upper-Extremity Exercise Training in Chronic Airway Obstruction The selected trials completely satisfied a minimum of 417 and a maximum of 712 of the 23 evaluation criteria included (Tab. 4). In all cases, an accurate explanation of the rationale and hypothesis of the study was given, as well as precise details of the treatments provided and the statistical methods used. Furthermore, the results were always interpreted in the context of current evidence. However, a number of criteria were only partially met or not at all satisfied, introducing the possibility of systematic errors that reduce the internal validity of trials.34 More specifically, in the trial of Ries and co-workers,16 eligibility criteria for patients were not specified, clear definitions of primary and secondary outcome measures were not provided, and there was not a clear description of the flow of participants through each stage of the trial. Furthermore, their results were weakened by the high number of patients who dropped out and whose data were not collected at follow-up. Similarly, the trials by Lake et al12 and Sivori et al28 did not provide clear definitions of primary and secondary outcome measures, did not describe the flow of participants through each stage of the trial, did not provide the number of participants included in each analysis for each group, and did not specify whether the statistical analysis followed an intention-to-treat approach. Also in the trial by Sivori and co-workers,28 there was a large number of patients who dropped out and, therefore, were not reassessed at follow-up. Although Holland and co-workers17 provided a clear description of eligibility criteria for their patients, clarified the primary and secondary outcome measures, provided a blinded assessment of the outcome measured, described the flow of participants through each phase of the trial, and followed an intention-to-treat approach, they did not provide an estiMay 2009

mate of the effect size with its precision (eg, 95% confidence interval) for any of the outcomes measured. As a whole, none of the selected trials specified how sample size was determined or the methods used to generate and implement the random allocation sequence. In 3 trials,12,16,28 there was a complete lack of blinding for participants and the physical therapists administering the treatments and assessing the outcomes. One study17 added a placebo treatment to the PR performed by the control group to disguise their allocation to this group. The placebo treatment consisted of finger dexterity exercises performed in a sitting position with arm supported and, therefore, was not expected to improve arm exercise capacity. Furthermore, we would like to point out that 3 trials12,17,28 reported inequality in the male participant to female participant ratios, which might reduce the generalizability of their findings to the population of interest. The fourth trial16 did not report these data. Because of the poor methodological quality of the 4 RCTs included, we decided not to perform a metaanalysis, the results of which could be misleading given the low internal validity of the trials. However, we based the conclusions of our review on the results of the between-group comparisons made in each of the selected studies, and we always considered their limits. Effects of UEET The effects of UEET, compared with conventional PR or LEET, are summarized in Tables 5 and 6. Maximal exercise capacity was measured in 3 trials, and data were obtained from 79 participants with severe or very severe CAO. In 2 trials,12,16 maximal exercise capacity was measured using an arm ergometer. In the third trial,17 maximal exercise capacity

was quantified as the duration of a standardized field test,35 consisting of asking participants to raise their unsupported arms repeatedly, keeping an external pace, while the height of the target and the resistance were increased. Among the 3 trials mentioned, only 1 trial17 detected a statistically significant increment of the maximal exercise capacity in favor of the intervention (change score⫽55.3 seconds, 95% confidence interval [CI]⫽8.25 to 102.35, P⬍.02). One trial28 measured functional exercise capacity with a field test that satisfied our criteria. This outcome was collected in 28 individuals and documented a strong benefit in favor of the intervention group compared with the control group (change score⫽108, 95% CI⫽63.87 to 152.13, P⬍.0001), represented by an increased number of arm elevations per time unit. One trial16 measured endurance time by registering the duration of a constant-load, symptom-limited exercise performed using an arm ergometer, and it did not show any statistically significant difference between groups. Data regarding muscle effort of the UEs consistently showed no differences between intervention and control groups. Performance of ADL was measured in 28 patients with severe CAO enrolled in one trial.16 This measurement was collected with a nonstandardized field test, simulating 3 common ADL tasks that involve the UEs and are usually considered to be fatiguing in this population. No statistically significant difference was detected between groups in this domain, either in terms of the time required to perform activities or as perceived symptoms. With regard to symptoms during exertion, 3 trials16,17,28 measured dyspnea and 3 trials12,16,17 measured the effort of the UE muscles. Altogether, data regarding dyspnea were collected in 94 patients, and 79 patients

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Upper-Extremity Exercise Training in Chronic Airway Obstruction Table 5. Effects of Upper-Extremity Exercise Training Plus Standard Training on Maximal and Functional Exercise Capacity, Endurance of the Upper Extremities, and Ability to Perform Activities of Daily Living (ADL) Involving the Upper Extremitiesa Arm Exercise Capacity and Ability to Perform ADL Maximal exercise capacity: peak exercise capacity measured in watts,16 Kpm/min,12 or seconds17 by incremental test

Ries, 198816

Before

Mean Difference (CI) for Before-After Comparison

After

P Value

Mean Difference (CI) for Between-Group Comparison

Control

16 (8)

20 (10)

4 (⫺3.57 to 11.57)

Not significant

Intervention-GR

16 (13)

17 (10)

1 (⫺10.37 to 12.37)

Not significant

⫺3.00 (⫺12.11 to 6.11)

Intervention-PNF

13 (9)

12 (9)

Lake, 199012

Before

⫺1 (⫺9.32 to 7.32)

After

Not significant

⫺8.00 (⫺16.34 to 0.34)

Mean Difference (CI) for Before-After Comparison

P Value

Mean Difference (CI) for Between-Group Comparison

Control

27.0 (7.9)

27.1 (8.6)

0.10 (⫺9.24 to 9.44)

Not significant

Intervention

24.0 (11.1)

30.3 (9.7)

6.30 (⫺4.62 to 17.22)

P⬍.04

3.20 (⫺6.75 to 13.15)

Before

After

Mean Difference (CI) for Before-After Comparison

Control

Not reported

Not reported

Not estimated

Not reported

Intervention

Not reported

Not reported

Not estimated

Not reported

Holland, 200417

P Value

P Value Both comparisons not significant

P Value Not significant

Mean Difference (CI) for Between-Group Comparison

P Value

55.3 (8.25 to 102.35)

P⬍.02

Functional exercise capacity: maximum number of upper-extremity elevations performed in 6 min

Sivori, 199828

Before

After

Control

166.93 (58.38)

166.57 (58.24)

Intervention

139.21 (45.64)

274.57 (60.86)

Mean Difference (CI) for Before-After Comparison

P Value

⫺0.36 (⫺39.78 to 39.06)

Not significant

135.36 (98.21 to 172.5)

Mean Difference (CI) for Between-Group Comparison 108 (63.87 to 152.13)

P Value P⬍.0001

P⬍.0001

Endurance: duration in seconds of a constant-load, symptom-limited exercise, performed using an arm ergometer

Ries, 198816

Before

Mean Difference (CI) for Before-After Comparison

After

P Value

Mean Difference (CI) for Between-Group Comparison

Control

185 (72)

181 (75)

⫺4 (⫺65.44 to 57.44)

Not significant

Intervention-GRT

215 (172)

195 (72)

⫺20 (⫺149.21 to 109.21)

Not significant

14 (⫺52.74 to 80.74)

Intervention-PNF

135 (56)

144 (27)

9 (⫺31.62 to 49.62)

Not significant

⫺37 (⫺84.70 to 10.70)

P Value Both comparisons not significant

ADL: ability to perform ADL measured by the number of seconds needed to complete 3 tasks

Ries, 198816

Before

Mean Difference (CI) for Before-After Comparison

After

P Value

Control

529 (86)

548 (96)

19 (⫺57.17 to 95.17)

Not significant

Intervention-GRT

665 (142)

663 (125)

⫺2 (⫺133.09 to 129.09)

Not significant

Intervention-PNF

786 (361)

636 (234)

⫺150 (⫺431.07 to 131.07)

Not significant

Mean Difference (CI) for Between-Group Comparison

115 (11.45 to 218.55)

P Value Both comparisons not significant

88 (⫺75.07 to 251.07)

a

Results of comparisons within and between study groups for variables measured in the trials. Data are reported as mean (SD) or as mean (95% confidence interval [CI]). GRT⫽gravity-resistance training, PNF⫽proprioceptive neuromuscular facilitation, Kpm/min⫽kiloweight⫻meters/minute.

were assessed at follow-up for muscle effort. Although symptoms perceived during exertion always improved in both the intervention and control groups, a statistically significant difference in the dyspnea score, favoring the intervention group, was 450

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detected only in 1 trial28 (change score⫽⫺1.07, 95% CI⫽⫺1.87 to ⫺0.27, P⬍.01). Two trials detected no benefits in favor of either group. Health-related quality of life was measured in 3 trials12,17,28 for a total of 79

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participants, using the Chronic Respiratory Disease Questionnaire31 in 2 studies and the Bandura scale32 in the third trial. Overall, the HRQoL improved for the intervention and control groups in all studies at the end of the treatment, but none of the studies May 2009

Upper-Extremity Exercise Training in Chronic Airway Obstruction Table 6. Effects of Upper-Extremity Exercise Training Plus Standard Training on the Symptoms of Dyspnea and Arm Fatigue During Activities Involving the Upper Extremities and on Health-Related Quality of Life (HRQoL)a Symptoms and HRQoL Dyspnea: score achieved during exercise exerting the upper extremities, as measured by the Borg scale28 or the modified Borg scale16,17

Ries et al, 198816

Mean Difference (CI) for Before-After Comparison

Before

After

P Value

Control

5.5 (2.9)

4.1 (1.8)

⫺1.40 (⫺3.42 to 0.62)

P⬍.05

Intervention-GRT

4.9 (2.0)

3.3 (0.8)

⫺1.60 (⫺3.09 to ⫺0.11)

P⬍.05

Intervention-PNF

4.9 (2.0)

4.1 (1.4)

⫺0.80 (⫺2.39 to 0.79)

P⬍.05

⌬ Before-After

Mean Difference (CI) for Before-After Comparison

Control

⌬ ⫺2.9 (0.78)

⫺2.90 (⫺3.28 to ⫺2.52)

Not reported

Intervention

⌬ ⫺4.0 (0.84)

⫺4.00 (⫺11.72 to 3.72)

Not reported

Holland et al, 200417

Sivori et al, 199828

Mean Difference (CI) for Before-After Comparison

Before

After

Control

2.21 (1.76)

1.86 (1.17)

⫺0.35 (⫺1.32 to 0.62)

Intervention

2.50 (1.79)

0.79 (0.97)

⫺1.71 (⫺2.61 to ⫺0.81)

P Value

Mean Difference (CI) for Between-Group Comparison

⫺0.80 (⫺2.0 to 0.4)

P Value

P⬍.001

Both comparisons not significant

0.00 (⫺1.4 to 1.4) Mean Difference (CI) for Between-Group Comparison Not estimated

Not significant

P value

P Value Not significant

Mean Difference (CI) for Between-Group Comparison

P value

⫺1.07 (⫺1.87 to ⫺0.27)

P⬍.01

Arm fatigue: score achieved during exercise exerting the upper extremities, as measured by the Borg scale12,17 or the modified Borg scale16

Ries et al, 198816

Mean Difference (CI) for Before-After Comparison

Before

After

Control

5.5 (2.4)

5.1 (2.2)

⫺0.40 (⫺2.32 to 1.52)

Not significant

Intervention-GRT

4.6 (2.4)

4.2 (2.1)

⫺0.40 (⫺2.61 to 1.81)

Not significant

⫺0.90 (⫺2.85 to 1.05)

Intervention-PNF

4.3 (1.8)

3.6 (1.3)

⫺0.70 (⫺2.15 to 0.75)

Not significant

⫺1.50 (⫺3.05 to 0.05)

Lake et al, 199012

Before

After

P Value

Mean Difference (CI) for Between-Group Comparison

Mean Difference (CI) for Before-After Comparison

P Value

Control

12.7 (0.5)

13.2 (1.1)

0.50 (⫺0.47 to 1.47)

Not significant

Intervention

12.1 (0.8)

12.0 (1.4)

⫺0.10 (⫺1.29 to 1.09)

Not significant

Before

After

Mean Difference (CI) for Before-After Comparison

Control

Not reported

Not reported

Not estimated

Not reported

Intervention

Not reported

Not reported

Not estimated

Not reported

Holland et al, 200417

P Value

Mean Difference (CI) for Between-Group Comparison ⫺1.20 (⫺2.56 to 0.16) Mean Difference (CI) for Between-Group Comparison Not estimated

P Value Both comparisons not significant

P Value Not significant

P Value Not significant* (continued)

revealed a statistically significant improvement in the intervention group compared with the control group.

Discussion and Conclusions This systematic review demonstrates that there is insufficient evidence to support the inclusion of UEET in PR programs for patients with severe and very severe CAO. Although the May 2009

results of 2 trials included,17,28 when considered separately, may suggest some advantages when UEET is incorporated into standard PR programs, the same results, when taken together, are strongly contradictory and, therefore, inadequate to recommend this activity.

Due to numerous shortcomings existing in the 4 RCTs included, the overall quality of the evidence collected in this systematic review was low for any of the outcomes studied. By examining the influence of key components of study quality for each trial reviewed, we found that potential sources of selection bias might exist in all of the selected trials. Se-

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Upper-Extremity Exercise Training in Chronic Airway Obstruction Table 6. Continued HRQoL: score achieved by specific, validated questionnaires

Lake et al, 199012

⌬ Before-After

Mean Difference (CI) for Before-After Comparison

P Value

Control

⌬ ⫹7%

Not estimated

Not reported

Intervention

⌬ ⫹24%

Not estimated

P⬍.005*

Holland et al, 200417

Before

After

Mean Difference (CI) for Before-After Comparison

P Value

Control

Not reported

Not reported

Not estimated

Not reported

Intervention

Not reported

Not reported

Not estimated

Not reported

Before

After

Mean Difference (CI) for Before-After Comparison

P Value

Control

87.57 (29.81)

111.79 (17.29)

24.22 (8.58 to 39.86)

P⬍.0001

Intervention

75.14 (24.74)

107.5 (16.96)

32.3 (18.73 to 45.99)

P⬍.0001

Sivori et al, 199828

Mean Difference (CI) for Between-Group Comparison

P Value

Not estimated

Not significant*

Mean Difference (CI) for Between-Group Comparison

P Value

Not estimated

Not significant*

Mean Difference (CI) for Between-Group Comparison

P Value

⫺4.29 (⫺16.98 to 8.40)

Not significant

a Results of comparisons within and between study groups for variables measured in the trials. Data are reported as mean (SD) or as mean (95% confidence interval [CI]), GRT⫽gravity-resistance training, PNF⫽proprioceptive neuromuscular facilitation, ⌬⫽difference between means. Asterisk indicates as reported by the authors in the text.

quence of allocation to treatments was not concealed in any of the RCTs, although it is well known that investigators’ knowledge of the sequence of allocation may cause selective enrollment of patients on the basis of prognostic factors34 and, consequently, may lead to inflated treatment effects.34 Performance bias and detection bias arise when the lack of doubleblinding influences additional treatments that might be offered preferentially to one group or the assessment of the outcomes, respectively. Again, such biases may inflate treatment effects to a different degree, depending on the outcome assessed. This possibility is strongly reduced by the blinding of those administering the treatment, which is almost impossible in the field of physical therapy, and the blinding of patients and those assessing outcomes, which was accomplished by 1 trial17 among the 4 trials selected. The same trial was the only one that minimized the sources of attrition bias by making every effort to reduce the number of data lost to follow-up (1%) 452

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and using an intention-to-treat approach. Conversely, reporting of 3 trials12,16,28 was unclear regarding the approach followed in the data analysis, and in 2 trials16,28 the participant dropout rate was higher than 30%, thus reducing the validity of the findings. Moreover, not even one of the studies selected stated the intended sample size, and some trials needed multiple comparisons because they included more than one intervention group16,12 or control group,12 thus reducing the power of the analysis. If UEET did indeed result in improvements, these changes may not have been able to be identified for several reasons, including the lack of sample power in all of these trials. Additionally, all of the trials implemented UEET specifically targeted at submaximal performance levels, whereas the testing procedures measured maximal performance. Finally, the benefit of UEET in the experimental group on the outcomes of HRQoL, dyspnea, and arm fatigue may have been masked by the concomitant participation in a PR program, which is known to improve

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these measures and would have done so in both experimental and control groups. Thus, the overall quality of the trials included in this review is very low in 3 cases12,16,28 and unsatisfactory in the fourth case.17 Taking all of these weaknesses into consideration, the findings of this review cannot support the inclusion of UEET in PR programs for patients with CAO, and even the inconsistent advantages shown individually by some of the trials included12,17,28 may be overestimated.34 Notwithstanding these findings, the most recent guidelines for PR10,11 strongly recommend the introduction of unsupported UEET of sufficient duration (ie, 20 sessions) in PR programs. This was the main reason why we decided to include trials with at least 20 sessions of UEET in our review analysis, thus excluding other studies of different duration. Despite the belief that the longer the program, the greater the benefit,10 we cannot deny that significant benefits of UEET may occur in trials of May 2009

Upper-Extremity Exercise Training in Chronic Airway Obstruction shorter duration, such as in the study by Porta et al27; however, that particular study was performed in a very different population. The rationale that supports the inclusion of specific training directed at the UEs in patients with CAO in PR programs relies on data from 6 randomized studies12–17 (3 included in this review) and 3 nonrandomized studies.18 –20 The underlying principle is that an improvement in arm exercise capacity might be particularly important in these patients, whose UE muscles are competitively involved in both arm elevation and accessory ventilation. The same guidelines11 postulate that the mechanisms for improvement in UE function from such training include desensitization to dyspnea, better muscular coordination, and metabolic adaptation to exercise. Numerous patients with stable, moderate to severe CAO complain of dyspnea during activities involving the UEs. These patients often show a characteristic association of dyspnea, dyssynchronous breathing,1 and inefficient metabolic and ventilatory response.1,36,37 A possible explanation of these phenomena is that, in patients with CAO who have hyperinflation, the diaphragm is less effective in performing inspiration.6 Consequently, during unsupported arm activities, these patients, compared with people who are healthy, must rely more on the accessory inspiratory muscles, which are involved in the competitive demands of ventilation and arm elevation. This fact poses greater demands on the accessory inspiratory muscle function, thus sustaining the hypothesis that these multifunctional muscles might benefit from specific training.38 However, the symptom of dyspnea was assessed in 3 trials16,17,28 based on unsupported UEET, and a statistically and clinically39 significant benefit in favor of the intervenMay 2009

tion was detected in only 1 trial.28 Taken together, the results reported in this review cannot support or refute the hypothesis that arm exercise may improve dyspnea. The ultimate scope of rehabilitation is to improve the patient’s autonomy in daily life. Pulmonary rehabilitation and exercise training, in particular, contribute in a decisive way to this process. Any accomplishment in this domain should be demonstrated by an increase in the patient’s ability to perform ADL in his or her own environment. Unfortunately, the RCTs included in this review did not investigate these areas, and the trial16 that assessed the ability to perform ADL with a nonstandardized field test was unable to detect any favorable effects of UEET. Furthermore, arm fatigue was unchanged by the addition of UEET to a standard PR program. Interestingly, one trial screened and excluded from this review15 showed that, when UEET was administered independent of standard PR, it failed to provide any benefit compared with a control treatment. This finding suggests that UEET alone is not sufficient to improve clinically important outcomes for patients with CAO. However, when implemented in the unsupported modality, UEET may add additional benefit to the established results of standard PR programs in terms of maximal and functional exercise capacity of the UEs. Indeed, Sivori and colleagues28 demonstrated a 100% improvement in functional exercise capacity of the arm, which was associated with a decrease in dyspnea but no change in HRQoL. Similarly, when a higher peak of exercise capacity was documented due to the effect of UEET, it did not translate to a reduction of dyspnea or arm fatigue, nor did it lead to a better HRQoL. Therefore, the effect of UEET on maximal exercise capacity is equivocal; findings in favor of UEET detected by individual

trials are difficult to interpret and would exclude that desensitization to dyspnea and metabolic adaptation to exercise are possible mechanisms of improvement in UE exercise capacity, as recently postulated.11 This review did not demonstrate any additional improvement in HRQoL for patients who underwent UEET. In fact, among 3 trials12,17,28 that measured HRQoL, none showed a significant difference in favor of the intervention group. However, the trial by Lake and colleagues12 showed a trend favoring the intervention group in comparison with the control group (24% versus 7%). This benefit could be due to the Hawthorne effect, because in this trial patients were not blinded to treatment group allocation and no other improvement was detected in the other outcomes measured to substantiate this finding. To our knowledge, this is the first systematic review examining the effectiveness of UEET in patients with CAO that has been performed using a rigorous, yet broad, search in different languages. The available evidence is limited, and the outcome measures examined varied considerably. Furthermore, the possibility that the samples were heterogeneous, coupled with the diverse UEET training protocols, limits the aggregation of the data. Finally, the relatively poor methodological quality of the included studies compromised both internal validity and generalizability of the results. These factors prevented us from conducting a meta-analysis, which might have been useful in clarifying the efficacy of UEET in patients with CAO. In summary, the available evidence from RCTs appears inadequate to recommend in favor of or against the inclusion of UEET in PR programs for individuals with CAO. Further research should be conducted by

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Upper-Extremity Exercise Training in Chronic Airway Obstruction means of well-designed and adequately powered trials, based on validated outcome measures addressed to clinically meaningful end points. The development of standardized and quantitative tests to assess the ability of patients with CAO to perform ADL also would be helpful to obtain a deeper understanding of clinically important achievements from the patients’ perspectives. Other important related research questions should be whether patients with different CAO severity or levels of disability might benefit differently from UEET and whether unsupported versus supported arm exercise might provide greater, or more selective, benefits. Ms Costi, Dr Di Bari, Dr Crisafulli, Dr Fabbri, and Dr Clini provided concept/idea/research design. Ms Costi, Dr Di Bari, Mr Pillastrini, and Dr Clini provided writing. Ms Costi, Dr Di Bari, Dr Crisafulli, and Ms Arletti provided data collection. Ms Costi, Dr Di Bari, Dr D’Amico, and Ms Arletti provided data analysis. Ms Costi, Dr Di Bari, Mr Pillastrini, and Dr Crisafulli provided project management. Ms Costi, Dr Fabbri, and Dr Clini provided fund procurement, facilities/equipment, and institutional liaisons. Ms Costi, Dr D’Amico, and Dr Clini provided participants. The authors thank Mrs Jessie Cross for her helpful editorial advice and linguistic review of the manuscript. This article was received December 16, 2007, and was accepted January 29, 2009. DOI: 10.2522/ptj.20070368

References 1 Celli BR, Rassulo J, Make BJ. Dyssynchronous breathing during arm but not leg exercise in patients with chronic airflow obstruction. N Engl J Med. 1986;314: 1485–1490. 2 Criner GJ, Celli BR. Effect of unsupported arm exercise on ventilatory muscle recruitment in patients with severe chronic airflow obstruction. Am Rev Respir Dis. 1988;138:856 – 861. 3 Martinez FJ, Strawderman RL, Flaherty KR, et al. Respiratory response during arm elevation in isolated diaphragm weakness. Am J Respir Crit Care Med. 1999;160: 480 – 486.

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4 Sharp JT, Danon J, Druz WS, et al. Respiratory muscle function in patients with chronic obstructive pulmonary disease: its relationship to disability and to respiratory therapy. Am Rev Respir Dis. 1974;110: 154 –167. 5 Celli BR. The clinical use of upper extremity exercise. Clin Chest Med. 1994;15: 339 –349. 6 Polkey MI, Kyroussis D, Hamnegard CH, et al. Diaphragm strength in chronic obstructive pulmonary disease. Am J Respir Crit Care Med. 1996;154:1310 –1317. 7 Hamilton AL, Killian KJ, Summers E, et al. Muscle strength, symptom intensity and exercise capacity in patients with cardiorespiratory disorders. Am J Respir Crit Care Med. 1995;152:2021–2031 8 O’Donnell DE, Bertley JC, Chau LK, et al. Qualitative aspects of exertional breathlessness in chronic airflow limitation: pathophysiologic mechanisms. Am J Respir Crit Care Med. 1997;155:109 –115. 9 Lacasse Y, Brosseau L, Milne S, et al. Pulmonary rehabilitation for chronic obstructive pulmonary disease. Cochrane Database Syst Rev. 2002;3:CD003793. 10 Nici L, Donner C, Wouters E, et al. American Thoracic Society/European Respiratory Society statement on pulmonary rehabilitation. Am J Respir Crit Care Med. 2006;173:1390 – 413. 11 Ries AL, Bauldoff GS, Carlin BW, et al. Pulmonary Rehabilitation: Joint ACCP/ AACVPR Evidence-Based Clinical Practice Guidelines. Chest. 2007;131:4S– 42S 12 Lake F, Henderson K, Briffa T, et al. Upper limb and lower limb exercise training in patients with chronic airflow obstruction. Chest. 1990;97:1077–1082. 13 Martinez FJ, Vogel PD, Dupont DN, et al. Supported arm exercise vs unsupported arm exercise in the rehabilitation of patients with severe chronic airflow obstruction. Chest. 1993;103:1397–1402. 14 Epstein S, Celli BR, Martinez FJ, et al. Arm training reduces the VO2 and VE cost of unsupported arm exercise and elevation in chronic obstructive pulmonary disease. J Cardiopulmonary Rehabil. 1997;17: 171–177. 15 Bauldoff GS, Hoffman L, Sciurba F, et al. Home-based, upper arm exercise training for patients with chronic obstructive pulmonary disease. Heart Lung. 1996;25: 288 –294. 16 Ries AL, Ellis B, Hawkins RW. Upper extremity exercise training in chronic obstructive pulmonary disease. Chest. 1988; 93:688 – 692. 17 Holland AE, Hill CJ, Nehez E, et al. Does unsupported upper limb exercise training improve symptoms and quality of life for patients with chronic obstructive pulmonary disease? J Cardiopulmonary Rehabil. 2004;24:422– 427. 18 Franssen FM, Wouters EF, Baarends EM, et al. Arm mechanical efficiency and arm exercise capacity are relatively preserved in chronic obstructive pulmonary disease. Med Sci Sports Exerc. 2002;34: 1570 –1576.

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19 Couser JI Jr, Martinez FJ, Celli BR. Pulmonary rehabilitation that includes arm exercise reduces metabolic and ventilatory requirements for simple arm elevation. Chest. 1993;103:37– 41. 20 O’Hara WJ, Lasachuk KE, Matheson PC, et al. Weight training and backpacking in COPD. Respir Care. 1984;29:1202–1210. 21 Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease: NHLBI/WHO Global Initiative for Chronic Obstructive Lung Disease (GOLD) Workshop Summary. Am J Respir Crit Care Med. 2001;163: 1256 –1276. 22 Boutron I, Moher D, Altman DG, Schulz KF, Ravaud P; CONSORT Group. Extending the CONSORT statement to randomized trials of nonpharmacologic treatment: explanation and elaboration. Ann Intern Med. 2008;148:295–309. 23 Shu MF, Kao CH, Kuo HP. Upper arm exercise improves exercise tolerance and dyspnea sensation in patients with chronic obstructive airway disease (COAD) [abstract]. Eur Respir J. 1998;12(suppl):406S. 24 Baarends BM, Crautzherg EC, Janssen PP, et al. Functional effects of unsupported arm exercise training in addition to nutritional therapy in depleted patients with chronic obstructive pulmonary disease (COPD) participating in a pulmonary rehabilitation program [abstract]. Eur Respir J. 1999;13(suppl):211S. 25 Normandin EA, McCusker C, Connors M, et al. An evaluation of two approaches to exercise conditioning in pulmonary rehabilitation. Chest. 2002;121:1085–1091. 26 Bauldoff G, Rittinger M, Nelson T, et al. Feasibility of distractive auditory stimuli on upper extremity training in persons with chronic obstructive pulmonary disease. J Cardiopulmonary Rehabil. 2005; 25:50 –55. 27 Porta R, Vitacca M, Gile` LS, et al. Supported arm training in patients recently weaned from mechanical ventilation. Chest. 2005;128:2511–2520. 28 Sivori M, Rhodius E, Kaplan P, et al. Exercise training in chronic obstructive pulmonary disease. Medicina (B Aires). 1998;58: 717–727. 29 Borg GA. Perceived exertion. Exerc Sport Sci Rev. 1974;2:131–153. 30 Borg GA. Psychophysical bases of perceived exertion. Med Sci Sports Exerc. 1982;14;377–381. 31 Guyatt GH, Berman LB, Townsend M, et al. A measure of quality of life for clinical trials in chronic lung disease. Thorax. 1987;42:773–778. 32 Bandura A, Adam NE. Analysis of selfefficacy theory of behavioural change. Cognit Ther Res. 1977;1:287–310. 33 Plint AC, Moher D, Morrison A, et al. Does the CONSORT checklist improve the quality of reports of randomised controlled trials? A systematic review. Med J Aust. 2006;185:263–267.

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Upper-Extremity Exercise Training in Chronic Airway Obstruction 34 Juni P, Altman DG, Egger M. Assessing the quality of controlled clinical trials. BMJ. 2001;323:42– 46. 35 Takahashi T, Jenkins SC, Strauss GR, et al. A new unsupported upper limb exercise test for patients with chronic obstructive pulmonary disease. J Cardiopulm Rehabil. 2003;23:430 – 437.

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36 Couser JI, Martinez FJ, Celli BR. Respiratory response and ventilatory muscle recruitment during arm elevation in normal subjects. Chest. 1992;101:336 –340. 37 Dolmage TE, Avendano MA, Goldstein RS. The ventilatory response to arm elevation of patients with chronic obstructive pulmonary disease. Chest. 1993;1047: 1097–1100.

38 Gigliotti F, Coli C, Bianchi R, et al. Arm exercise and hyperinflation in patients with COPD: effect of arm training. Chest. 2005;128:1225–1232. 39 Ries AL. Minimally clinically important difference for the UCSD Shortness of Breath Questionnaire, Borg Scale, and Visual Analog Scale. COPD. 2005;2:105–110.

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Research Report Physical Therapists’ Use of Cognitive-Behavioral Therapy for Older Adults With Chronic Pain: A Nationwide Survey Katherine Beissner, Charles R Henderson Jr, Maria Papaleontiou, Yelena Olkhovskaya, Janet Wigglesworth, MC Reid K Beissner, PT, PhD, is Professor, Department of Physical Therapy, Ithaca College, 953 Danby Rd, Ithaca, NY 14850 (USA). Address all correspondence to Dr Beissner at: [email protected]. CR Henderson Jr, PhD, is Senior Research Associate, Cornell University, Ithaca, New York. M Papaleontiou, MD, is Physician, Department of Medicine, Saint Peter’s University Hospital, New Brunswick, New Jersey.

Background. Increasing evidence supports the use of cognitive-behavioral therapy (CBT) for patients with chronic pain.

Objective. This study determined whether physical therapists incorporate CBT techniques (eg, relaxation, activity pacing) when treating older patients with chronic pain, ascertained their interest in and barriers to using CBT, and identified participantrelated factors associated with interest in CBT.

Design. This cross-sectional study used a telephone survey. Methods. One hundred fifty-two members of the Geriatrics and Orthopaedics

Y Olkhovskaya, MD, PhD, is Physician, Department of Medicine, Weill Cornell Medical College, New York, New York.

sections of the American Physical Therapy Association completed the survey. Associations between participant-related factors and interest in CBT were assessed in statistical general linear models.

J Wigglesworth, PhD, is Interim Assistant Provost, Ithaca College.

Results. Commonly used CBT interventions included activity pacing and pleasurable activity scheduling, frequently used by 81% and 30% of the respondents, respectively. Non-CBT treatments included exercises focusing on joint stability (94%) and mobility (94%), and strengthening and stretching programs (91%). Respondents’ overall interest in CBT techniques was 12.70 (SD⫽3.4, scale range⫽5–20). Barriers to use of CBT included lack of knowledge of and skill in the techniques, reimbursement concerns, and time constraints. Practice type and the interaction of percentage of patients with pain and educational degree of the physical therapist were independently associated with provider interest in CBT in a general linear model that also included 6 other variables specified a priori.

MC Reid, MD, PhD, is Associate Professor, Department of Medicine, Weill Cornell Medical College. [Beissner K, Henderson CR Jr, Papaleontiou M, et al. Physical therapists’ use of cognitive-behavioral therapy for older adults with chronic pain: a nationwide survey. Phys Ther. 2009;89:456 – 469.] © 2009 American Physical Therapy Association

Limitations. Data are based on self-report without regard to treatment emphasis. Conclusions. Although only a minority of physical therapists reported use of some CBT techniques when treating older patients with chronic pain, their interest in incorporating these techniques into practice is substantial. Concerns with their skill level using the techniques, time constraints, and reimbursement constitute barriers to use of the interventions.

Post a Rapid Response or find The Bottom Line: www.ptjournal.org 456

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hronic pain is a highly prevalent and often disabling condition among older adults.1–3 Prior research has demonstrated strong associations between chronic pain and substantial morbidity, including depression and functional disability,4 – 8 as well as increased health care utilization.9 –11 Given the prevalence of chronic pain, its impact on health, and its costs, which approach $100 billion annually,12 chronic pain represents a public health issue of major importance.13–15

The most commonly administered treatment for chronic pain is analgesic medication (eg, acetaminophen, nonsteroidal anti-inflammatory drugs, opioids).16,17 Analgesic medications also constitute the most frequently endorsed treatment by older patients.16,18 Although many older people derive benefits from analgesic medications, the costs and side effects associated with many of these drugs and the potential for drug-drug interactions pose significant limitations to this treatment approach.19 –21 In addition, many older adults continue to report substantial pain despite regular use of analgesic medications.16 These limitations have led to a call for effective nonpharmacological interventions to manage chronic pain.22 Aside from physical therapy, other nonpharmacological approaches to pain management include cognitivebehavioral therapy (CBT), hypnosis, and individual psychotherapy.23,24 Of particular interest in the present study is the use of CBT because this treatment approach has demonstrated efficacy for a wide range of chronic pain disorders.25–28 Cognitivebehavioral therapy is an intervention that seeks to enhance patients’ control over pain using diverse psychological techniques.29 Underlying this therapy is the notion that a person’s beliefs, attitudes, and behaviors play

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a central role in determining his or her overall experience of pain.23,30 Standard CBT pain protocols seek to: (1) teach patients specific cognitive and behavioral skills to better manage pain; (2) inform patients regarding the effects that specific cognitions (thoughts, beliefs, attitudes), emotions (fear of pain), and behaviors (activity avoidance due to fear of pain) can have on pain; and (3) emphasize the primary role that patients can play in controlling their own pain as well as adaptations to pain. Cognitive-behavioral therapy has proven efficacy for reducing pain and disability levels among middle-aged people with diverse chronic pain disorders.25–28 Prior research also has demonstrated that older adults can benefit from a CBT program directed toward pain management.29,31,32 Although numerous efficacy studies have demonstrated the benefits of this particular therapy, few older adults use CBT techniques for managing pain.25,33 In a recent study of older primary care patients with chronic pain, only 4% reported using cognitive methods for managing pain,34 and a non– clinic-based study of older adults with chronic pain showed that only 3% cited the use of cognitive methods for managing pain.16 Access to psychological treatments such as CBT often is gained through multidisciplinary pain management programs. However, older patients are less frequently referred to this type of program,35 leaving them with less access to these interventions. These data, coupled with the findings of a recent study showing that older adults with chronic pain are highly receptive to trying cognitive methods as a means of managing pain,34 provide additional support for efforts to teach CBT techniques to people with chronic pain in conventional health care settings.

We propose that CBT is consistent with physical therapy intervention in that both promote adoption of selfmanagement strategies and use some similar techniques such as graded activity pacing and relaxation training. Other CBT techniques used by physical therapists include cognitive restructuring to identify counterproductive thought patterns36,37 as well as the use of imagery to enhance goal achievement.38 – 41 Instructing patients with chronic pain in the use of specific coping skills such as these may help to reduce activity avoidance associated with chronic pain and may enhance exercise program adherence and functional recovery.42 Given the under-referral of older adults to multidisciplinary programs,35 the importance of integrating psychological treatments for pain management into standard care,43 and the concordance of physical therapy and CBT philosophies, it seems important to investigate the potential for incorporating CBT into physical therapy for the treatment of older adults with chronic pain. Accordingly, the primary purpose of this study was to identify the extent to which physical therapists currently use CBT techniques when

Available With This Article at www.ptjournal.org • Invited Commentary from Kathleen A Sluka and Dennis C Turk and the Author Response • The Bottom Line clinical summary • The Bottom Line Podcast • Audio Abstracts Podcast This article was published ahead of print on March 6, 2009, at www.ptjournal.org.

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Cognitive-Behavioral Therapy for Older Adults With Chronic Pain treating older patients with chronic pain and ascertain their interest in, and barriers to, incorporating CBT into their treatments. We also sought to determine the specific types of more-conventional physical therapy interventions used in the treatment of this patient population. Finally, in related analyses, we sought to determine whether specific participant characteristics (eg, years in practice, practice setting) were independently associated with level of interest in CBT.

Method Sample The membership directory of the American Physical Therapy Association (APTA) served as the sampling roster for this study. Names were randomly chosen from the Orthopaedics and Geriatrics sections, with 14,891 and 4,401 listed members, respectively, in approximately equal numbers to reach the target goal of 150 participants. These sections were selected for sampling due to their relevance to the diagnosis (chronic pain) and population (older adults) of interest. Participants were selected from all 50 states, proportionate to the number of section members in each state. Eligibility criteria included a valid mailing address, a telephone number, and current practice with the patient population of interest. The target sample of 150 was selected for practical purposes based on the resources available for data collection. Because this study was predominantly descriptive in nature and no prior research addresses this area of practice (there are no data on the variance of the outcome variable), no formal power calculations were carried out. The sample of 150 was judged to be of sufficient size to gain an understanding of physical therapists’ current use of CBT and to ascertain their overall interest in and barriers to using CBT techniques.

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Prospective participants first were contacted by letter, informing them as to the nature of the study. We then placed telephone calls to prospective participants 2 weeks, on average, after each letter was mailed. Verbal consent for participation was obtained at the time of the call. Thirty-eight physical therapists could not be contacted because of an incorrect telephone number or mailing address, and 25 therapists were ineligible (the most common reasons were retirement and not being involved in the care of older adults or patients with chronic pain). Of the 173 eligible physical therapists contacted, 21 declined to participate and 152 (88%) completed the survey. All 50 states were represented in the sample, and all participants answered every question in the survey instrument. Instrument Development The telephone survey instrument (Appendix) was designed by a multidisciplinary team comprising a physical therapist, 2 physicians, and 1 health psychologist with expertise in pain management. Collectively, the team has more than 40 years of experience delivering nonpharmacologic pain therapies to older adults. The initial draft of the survey instrument was reviewed by 2 physical therapists outside the research team, each with more than 15 years of physical therapy experience. Both worked in outpatient orthopedic settings, 1 as a manager. The second reviewer also worked in home health. The therapists were asked to review the draft survey instrument to ensure that the list of potential physical therapy interventions was sufficiently inclusive, recommend items for exclusion, consider whether the items were worded clearly, and identify potential barriers to implementation. In addition, student physical therapists were asked to read the survey instrument

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aloud to another student and to time the interview. Based on therapist input and length of interviews, items regarding physical therapy interventions were consolidated, wording was altered, and 2 new barriers to CBT were incorporated. After these revisions, the therapists reviewed the instrument again to ensure that their concerns were addressed and to review changes made due to input of the other reviewer. The main section of the survey instrument was designed to determine how frequently physical therapists used CBT interventions for treatment of older patients with chronic pain and the frequency of use of other physical therapy interventions for this patient population. The list of CBT interventions included in the instrument was drawn from a comprehensive review of the literature regarding CBT for pain management in older adults.29,32,44 Based on research team and physical therapist input, those CBT interventions deemed most unrelated to physical therapist practice were deleted from the survey (ie, anger management, sleep habits). To determine the other types of treatments used in the care of this population, a list of potential interventions was generated by the research team and reviewed by outside physical therapists, then crosschecked with the Guide for Physical Therapist Practice45 to ensure representation from major categories of interventions. Because the focus of the study was on chronic pain management, no integumentary interventions were included. Furthermore, items related to the use of devices and equipment were excluded from the survey instrument in an effort to focus on treatments associated with pain management, rather than other pathologies or impairments. In keeping with the telephone survey format, the research team determined that the instrument needed to be brief and, therefore, limited the inMay 2009

Cognitive-Behavioral Therapy for Older Adults With Chronic Pain terventions surveyed to broad categories (eg, physical agents), rather than specific techniques (eg, cold packs, ultrasound). The final version of the survey instrument queried respondents regarding their frequency of use of 14 interventions: physical agents, electrotherapy, exercises to increase joint stability, exercises to increase joint mobility, general conditioning exercises, soft tissue techniques, joint mobilization or manipulation, injury prevention education, relaxation, distraction, visualization and imagery, cognitive restructuring, pleasurable activity scheduling, and activity pacing. Response choices were: “always” (80% or more of the time), “frequently” (between 50% and 79% of the time), “sometimes” (between 25% and 49% of the time), and “rarely” (less than 25% of the time). The next portion of the survey instrument addressed the extent of therapists’ interest in 5 interventions classified as CBT (relaxation, distraction, visualization and imagery, cognitive restructuring, and activity pacing and pleasurable activity scheduling). Respondents were asked to indicate their level of interest in the 5 techniques using the following response categories: “not interested,” “interested,” “very interested,” or “already using technique.” Potential barriers to implementation of CBT into physical therapist practice were generated by the research team based on their clinical experience and a review of the literature, with additional barriers identified by the outside therapists. A list of 6 potential barriers was identified, and an option to identify “other” barriers was included. Statements were worded as facts (eg, “the techniques are not part of physical therapist practice”), and respondents were asked to indicate whether each statement was true or not true. May 2009

Items related to demographic characteristics of respondents included percentage of practice focused on patients 65 years or older with chronic pain, years of physical therapist practice, racial or ethnic group, sex, hours per week in patient care, highest academic degree, practice setting, size of practice community (ie, large metropolitan area, small city, suburban, or rural), and any specialist certification. Data Analysis Descriptive statistics (frequency for categorical data, mean and standard deviation for continuous data) were computed to address the primary purpose of identifying the extent to which physical therapists currently use CBT techniques and other physical therapy interventions and ascertaining their interest in using CBT treatments and barriers to using CBT. The secondary purpose of the analysis was to determine whether particular therapist characteristics were associated with interest in CBT. A composite variable indicating overall “interest” in CBT was created by summing participants’ answers to each of the 5 items assessing interest in CBT techniques: “not interested” was coded as 1, “interested” as 2, “very interested” as 3, and “already using technique” as 4. Scores for each participant could range from a low of 5 (no interest) to 20 (maximal interest). The variable shows good normal characteristics in a normal probability plot. Skewness is less than twice the standard error of skewness, and kurtosis is less than twice the standard error of kurtosis, so problems do not exist on either account at a conventional level of significance. Nine independent variables were included in the statistical models a priori based on the research team’s subject-area knowledge. These variables were practice setting (outpa-

tient, hospital, home care, or skilled nursing facility), percentage of patients with pain (ⱕ50%, ⬎50%), highest degree (Bachelor’s or certificate versus Master’s or higher), practice location (large metropolitan, small city, suburban, or rural), part-time or full-time practice (⬍35 hours per week versus ⱖ35 hours per week), race or ethnicity (nonHispanic Caucasian versus other), sex, APTA section (Orthopaedics versus Geriatrics), and years in practice (0 –5 years, 6 –15 years, ⬎15 years). All 9 variables are categorical and were included as classification factors in the models. An examination of 2-way and 3-way interactions was carried out, focusing on the variables significant or within range of significance in a main effects model. A final model was specified that included the percentage of patients with pain, degree, interaction between these 2 variables, and the main effects for the other 7 variables. A number of other models were examined to verify that the final model presented in this report correctly represented the results. These other models included a mixed model in which the individual components of the composite variable were levels of a repeated-measures classification factor (CBT domain), and therapists were included in the model as levels of a random classification factor. Statistical analysis was by general linear model methods. Analyses were carried out with SAS 9.1 software.*

Results Descriptive Results of Study Sample Table 1 shows that most participants were white (84%), worked full time (65%), had practiced physical therapy for more than 15 years (55%), and were currently employed in the outpatient setting (57%). Approxi* SAS Institute Inc, 100 SAS Campus Dr, Cary, NC 27513-2414.

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Cognitive-Behavioral Therapy for Older Adults With Chronic Pain Table 1. Sample Characteristics Variable

Frequency

%

Male

78

51

Female

74

49

Sex

Race/ethnicity Non-Hispanic Caucasian

128

84

24

16

Full time (ⱖ35 h/wk)

98

65

Part time (⬍35 h/wk)

54

36

0–5

18

12

6–15

50

33

⬎15

84

55

Bachelor’s or certificate

63

41

Master’s

71

47

Doctorate

18

12

Other Employment

Years in practice

Almost 70% of the participants reported that they frequently or always used physical agents (eg, heat, cold), whereas joint mobilization or manipulation was frequently or always used by only 42%. With respect to CBT techniques, 81% of the sample reported that they either frequently or always used activity pacing when treating older patients with chronic pain, and 39% said they frequently or always addressed pleasurable activity scheduling. Infrequently used CBT techniques included cognitive restructuring (77%⫽rarely or never used), relaxation training (84%), and use of visual imagery or distraction (88%).

Highest academic degree

Practice setting Outpatient

87

57

Skilled nursing facility

33

22

Hospital

20

13

Home care

12

8

Large metropolitan

52

34

Rural

37

24

Suburban

32

21

Small city

31

20

0–20

63

41

21–50

46

30

⬎50

43

28

Orthopaedic

78

51

Geriatrics

74

49

Practice location

Percentage of older patients with chronic pain

Section

mately 1 in 4 participants reported that more than 50% of their patients were older adults who report chronic pain as a major complaint. Frequency of Use of Physical Therapy and CBT Interventions The proportion of participants who reported use of physical therapy in460

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terventions when treating older patients with chronic pain is shown in Table 2. The vast majority (ⱖ91%) reported that they frequently or always used active exercise in their plan of care for these patients, including general exercises, joint mobility, and stability exercises, and 90% included prevention education.

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Therapists’ Interest in CBT Techniques The Figure shows the relative proportions of the sample who reported current use of CBT techniques in their treatment of older patients with chronic pain, interest in incorporating the techniques in their respective practices, or no interest. A substantial majority indicated interest in incorporating each of the techniques. Barriers to Using CBT The most commonly endorsed barrier to incorporating CBT techniques into practice, noted by 59% of the sample, was insufficient knowledge of the CBT modalities (Tab. 3). Fewer participants endorsed problems with reimbursement (31%), inadequate time to incorporate the techniques into practice (27%), and reluctance of patients to engage in these types of treatments (21%) as potential barriers. Of note, 21% endorsed no barriers to incorporating CBT into their practice. Factors Associated With Interest in CBT A related purpose of this study was to identify factors independently associated with physical therapists’ May 2009

Cognitive-Behavioral Therapy for Older Adults With Chronic Pain level of interest in incorporating CBT into practice. These factors were examined using the composite interest variable as the outcome. Therapists’ mean interest in CBT techniques was 12.70 (SD⫽3.40). Table 4 presents the final model. It includes each line of the analysis, raw means and least squares means for each level of each effect, and, for practice setting, single-degree of freedom tests for a priori contrasts of each of the other settings versus home care. The model R2 is .222, and the test of the 15-degree of freedom model fit had an F value of 2.59 (P⫽.002). Practice type was significant (P⫽.041), with the overall significance a result of home care having a significantly lower score on the outcome scale than each of the other 3 practice types (outpatient, hospi-

Table 2. Frequency (%) of Use for Each Intervention (N⫽152) Technique

Always

Frequently

Sometimes

Rarely

Activity pacing

47

34

18

1

Pleasurable activity scheduling

14

25

35

26

9

15

34

43

Cognitive techniques

Cognitive restructuring Relaxation training

3

13

33

51

Imagery or visualization

2

10

25

63

Distraction

2

7

37

55

Joint stability

68

26

5

1

Joint mobility

63

31

5

1

Other

Prevention education

62

28

8

2

General exercise

61

30

7

3

Physical agents

21

48

17

14

Soft tissue techniques

12

44

28

16

Joint mobilization/manipulation

11

31

31

28

7

39

24

30

Electrical stimulation

Figure. Level of interest in specific cognitive-behavioral therapy interventions.

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Cognitive-Behavioral Therapy for Older Adults With Chronic Pain Table 3. Barriers to Using Cognitive-Behavioral Therapy (CBT) (N⫽152) Barrier

Frequency

%

Clinician has insufficient knowledge about CBT techniques

90

59

CBT techniques are difficult to reimburse

47

31

No time to incorporate CBT into treatment

41

27

Patients are not open to CBT techniques

32

21

Patients have cognitive

impairmentsa

14

9

11

7

CBT techniques are not appropriate for clinician’s patient populationa

6

4

Environment is not conducive to CBT–too loud/opena

4

3

CBT techniques are not useful

3

2

Have never considered using CBT techniquesa

3

2

3

2

2

1

1

1

1

1

1

1

1

1

CBT techniques are not part of physical therapy

Other disciplines provide this

servicea

Limited evidence of CBT effectivenessa Need for consistency among

therapistsa

Lack of management supporta Patient/therapist language

barriersa

Legal/ethical issuesa a

Response was provided by respondents within the category of “Other.”

tal, and skilled nursing facility). The interaction of percentage of patients with pain and level of training was highly significant (P⫽.005). The least squares means in Table 1 show the pattern of the interaction. Interest in CBT was highest for physical therapists with advanced degrees and practices with lower numbers of patients with pain. None of the other variables was significant.

Discussion The results of this nationwide telephone survey demonstrate that a minority of physical therapists report using some CBT components when treating older adults with chronic pain. Notably, the techniques most related to enhancing activity levels were the most-frequently incorporated CBT treatments. Teaching patients to pace their activities and encouraging them to engage in pleasurable activities were the most commonly used interventions. These techniques may be helpful in encouraging patients to remain active and, 462

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therefore, decrease the potential for deconditioning associated with activity avoidance. Other CBT techniques, such as distraction and imagery, were reported as being used infrequently, and the participants reported the least interest in using these strategies. Prior reports of using imagery in physical therapy focused on mental practice of motor tasks for patients with sport injuries39 or neurological diagnoses.38,40 Imagery techniques used for pain management differ in that patients assume a relaxed state and focus attention away from the pain to the mental construction of detailed scenes. Cognitive restructuring also was used relatively infrequently, yet the participants expressed strong interest in using this strategy for patients with chronic pain. In prior studies incorporating cognitive restructuring strategies into physical therapy, the focus of the intervention was

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on increasing patient activity levels. Cognitive restructuring techniques were incorporated into the Strong for Life Program to enhance exercise adherence36 and into a rehabilitation program focused on increasing activity levels for patients with chronic neck pain.46 When focused on increasing activity, cognitive restructuring can be viewed as being similar to the activity pacing and pleasurable activity participation that are currently reported to be the most commonly used CBT interventions. Although we did not investigate therapists’ rationale for using particular interventions, it appears that interventions geared toward increasing movement or mobility are preferred by physical therapists over those that are more passively directed toward decreasing pain levels. This pattern is reflected in the other physical therapy interventions addressed in the survey. Participants indicated greater use of active exercises aimed at increasing joint stability and mobility, with less-frequent use of more-passive interventions such as physical agents, joint mobilization, and electrical stimulation. These results are consistent with a prior investigation of physical therapy for older patients. Miller and colleagues47 found that “therapeutic exercise” was the most frequently used intervention with older adults without regard to diagnostic classification and that physical agents and electrotherapeutic modalities were the least-frequently used. This use of active exercise is supported by research demonstrating its effectiveness in improving function and reducing pain levels for patients with chronic neck or low back pain48 –51 and in decreasing pain associated with osteoarthritis.52–55 Participants reported less-frequent use of morepassive techniques such as physical agents, electrical stimulation, and manual therapy.

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Cognitive-Behavioral Therapy for Older Adults With Chronic Pain Table 4. Association of Therapist Characteristics With Level of Interest in Cognitive-Behavioral Therapy in the Final Model (N⫽152) Raw Means

Least Squares Meansb

Single-Degree of Freedom Testsc

12.97

12.05

OP vs HC (P⫽.042)

Hospital (H)

13.95

13.23

H vs HC (P⫽.005)

Home care (HC)

10.58

9.82

12.42

12.18

ⱕ50%

13.21

12.35

⬎50%

11.72

11.28

11.79

11.33

13.49

12.31

ⱕ50% Bachelor’s/certificate

11.55

11.00

ⱕ50% Master’s/doctorate

14.17

13.70

⬎50% Bachelor’s/certificate

12.22

11.65

⬎50% Master’s/doctorate

11.15

10.91

Large metropolitan

12.77

11.85

Small city

11.68

10.97

Suburban

13.50

12.33

13.14

12.12

Part time (⬍35 h/wk)

12.46

11.56

Full time (ⱖ35 h/wk)

12.97

12.05

12.90

12.06

12.21

11.58

Male

12.88

11.59

Female

12.69

12.05

13.19

11.75

12.36

11.89

0–5

13.22

11.92

6–15

13.12

11.70

⬎15

12.50

11.84

Variablea Practice setting

df

Mean Square

F

P

3

28.20

2.82

.041

Outpatient (OP)

Skilled nursing facility (SN) Chronic pain case loadd

Highest degree

1

1

27.73

23.70

2.78

2.37

.126

Bachelor’s or certificate Master’s or doctorate Case load by degree

Practice location

1

3

82.43

10.45

8.25

1.05

.005

.374

Rural Employment

Race/ethnicity

1

1

7.40

4.26

0.74

0.43

.391

.515

Non-Hispanic Caucasian Other Sex

Section

1

1

6.44

0.38

0.64

0.04

.424

.845

Orthopaedics Geriatrics Years of experience as a physical therapist

2

0.41

0.04

SN vs HC (P⫽.031)

.098

.960

a

This column includes effects in the final model—the main effects for 9 classification factors and one interaction—and under each effect its levels. The least squares means for each level of factors and interactions are given in this column. For practice setting, tests of 3 a priori single-degree of freedom contrasts are shown in this column (contrasts of each of the other levels versus home care). d Represents participants’ estimate of the average proportion of patients seen who are aged 65 years or older with chronic pain. b c

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Cognitive-Behavioral Therapy for Older Adults With Chronic Pain Although the results show a relatively low current use of CBT techniques, they provide strong evidence that therapists are interested in incorporating these techniques into practice. Only 14% and 16% of the participants were “not interested” in distraction and imagery techniques, respectively, the least popular of the CBT techniques. However, 57% were “very interested” in learning how to instruct patients in or were “already using” activity pacing and pleasurable activity scheduling, whereas 44% were similarly inclined toward the use of cognitive restructuring. With this high level of interest in using CBT, the most commonly noted barrier to implementing these techniques into practice was lack of knowledge about the techniques. Concern regarding reimbursement was another frequently endorsed potential barrier, a concern echoed in the medical community regarding all forms of treatment,56 –58 and cited here by almost 1 in 3 participants. Coupled with the concerns regarding time constraints as a factor limiting integration of CBT into physical therapist practice, research into the cost-effectiveness and efficiency of the combined treatment approach is warranted. An additional purpose of the study was to determine whether participant characteristics were associated with level of interest in using CBT. Ascertaining level of interest could help to focus educational intervention efforts (eg, targeting groups of physical therapists most likely to incorporate CBT into practice). Of the 9 variables considered, practice setting, percentage of patients with pain, and physical therapy degree were the variables most strongly associated with interest in CBT. Respondents working in home care reported lower levels of interest in using CBT than respondents from any other practice setting. One pos464

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sible explanation for this finding is that that therapists working in home care perceive greater challenges for implementing CBT than therapists working in other settings. Only one interaction was found to be significant (ie, between case load and therapist educational level). Therapists with higher academic degrees and a lower caseload of older patients with chronic pain had the highest level of interest in using CBT techniques. Although this finding is interesting, possible reasons for the observed difference remain unclear. Perhaps given the relatively lower day-to-day experience in working with older patients with chronic pain, these therapists have a lower level of comfort in their current treatment methods, thereby making them more amenable to different approaches. While this study provides new and useful information concerning physical therapists’ level of receptivity regarding the use of CBT techniques for the treatment of older patients with chronic pain and sheds light on other techniques used by physical therapists when treating this patient population, the research has several important limitations that warrant consideration. As a telephone survey, the number of items was kept to a minimum so that the survey could be conducted in a brief time period, thereby enhancing participation. The brevity of our survey did not allow us to examine therapists’ rationale for use of some techniques over others, only their perception of how frequently they use specific treatments. We also did not gather data about the amount of time they spend using each technique, nor the emphasis placed on one treatment versus others. This type of information would be helpful in better clarifying the importance therapists place on the different techniques used. Finally, the survey focused on general approaches to treating older patients with chronic pain, regardless of the

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source or location of that pain. It is possible that our results might have been different had we focused on a particular disorder, such as fibromyalgia, or a specific body region, such as the lower back.

Conclusions Physical therapists currently use some CBT interventions in the care of older patients with chronic pain, especially those interventions associated with increasing patients’ activity levels through activity pacing and counseling on scheduling pleasurable activities. Physical therapists indicate interest in incorporating CBT techniques into practice, with strongest interest in cognitive restructuring. Barriers that limit the current use of CBT include lack of knowledge in the use of the techniques, concerns with reimbursement, and treatment time constraints. Examining a wider array of physical therapy treatments, the most frequently used interventions involve active exercise, with fewer therapists reporting use of more-passive techniques such as physical agents and manual therapy. Future research into the use of CBT by physical therapists should address methods to reduce the barriers to incorporating CBT into practice and examine the effectiveness of a combined physical therapy-CBT approach to the management of chronic pain. Dr Beissner and Dr Reid provided concept/ idea/research design and fund procurement. Dr Beissner, Dr Papaleontiou, and Dr Olkhovskaya provided data collection. All authors provided writing. Dr Henderson and Dr Wigglesworth provided data analysis. Dr He´le`ne Larin and Dr Michael Buck provided consultation. The Ithaca College Institutional Review Board approved the study. This work was previously presented at the Combined Sections Meeting of the American Physical Therapy; February 6 –9, 2008; Nashville, Tennessee.

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Cognitive-Behavioral Therapy for Older Adults With Chronic Pain This research was supported, in part, by a Summer Research Grant through the Office of the Provost, Ithaca College. This work also was supported by the John A. Hartford Foundation (Hartford Center of Excellence in Geriatric Medicine Award to Weill Cornell Medical College) and the Cornell Institute for Translational Research on Aging: An Edward R. Royball Center for Research on Translational Aging Research (P30 AG22845– 01). This article was received June 5, 2008, and was accepted January 21, 2009. DOI: 10.2522/ptj.20080163

References 1 Miro ´ J, Paredes S, Rull M, et al. Pain in older adults: a prevalence study in the Mediterranean region of Catalonia. Eur J Pain. 2007;11:83–92. 2 Edwards RR. Age differences in the correlates of physical functioning in patients with chronic pain. J Aging Health. 2006; 18:56 – 69. 3 Weiner DK, Sakamoto S, Perera S, et al. Chronic low back pain in older adults: prevalence, reliability, and validity of physical examination findings. J Am Geriatr Soc. 2006;54:11–20. 4 Leong IY, Farrell MJ, Helme RD, et al. The relationship between medical comorbidity and self-rated pain, mood disturbance, and function in older people with chronic pain. J Gerontol A Biol Sci Med Sci. 2007; 62:550 –555. 5 Tripp DA, Van Den Kerkhof EG, McAlister M. Prevalence and determinants of pain and pain-related disability in urban and rural settings in southeastern Ontario. Pain Res Manag. 2006;11:225–233. 6 Arnow BA, Hunkeler EM, Blasey CM, et al. Comorbid depression, chronic pain, and disability in primary care. Psychosom Med. 2006;68:262–268. 7 Reid MC, Williams CS, Gill TM. The relationship between psychological factors and disabling musculoskeletal pain in community-dwelling older persons. J Am Geriatr Soc. 2003;51:1092–1098. 8 Reid MC, Guo Z, Towle VR, et al. Painrelated disability among older male veterans receiving primary care. J Gerontol A Biol Sci Med Sci. 2002;57:M727–M732. 9 Blyth FM, March LM, Brnabic AJM, et al. Chronic pain and frequent use of health care. Pain. 2004;111:51–58. 10 Turk DC. Clinical effectiveness and costeffectiveness of treatments for patients with chronic pain. Clin J Pain. 2002;18: 355–365. 11 Hopman-Rock M, de Bock GH, Bijlsma JW, et al. The pattern of health care utilization of elderly people with arthritic pain in the hip or knee. Int J Qual Health Care. 1997;9:129 –137.

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12 Knab J, Wallace M, Wagner R, et al. The use of a computer-based decision support system facilitates primary care physicians’ management of chronic pain. Anesth Analg. 2001;93:712–720. 13 Gallagher RM. Chronic pain: a public health problem? Clin J Pain. 1998;14: 277–279. 14 Gallagher RM, Verma S. Managing pain and comorbid depression: a public health challenge. Semin Clin Neuropsychiatry. 1999;4:203–220. 15 Burgoyne DS. Prevalence and economic implications of chronic pain. Manag Care. 2007;16:2– 4. 16 Barry LC, Gill TM, Kerns RD, et al. Identification of pain-reduction strategies used by community-dwelling older persons. J Gerontol A Biol Sci Med Sci. 2005;60: 1569 –1575. 17 Barry LC, Kerns RD, Guo Z, et al. Identification of strategies used to cope with chronic pain in older persons receiving primary care from a Veterans Affairs Medical Center. J Am Geriatr Soc. 2004;52: 950 –956. 18 Jakobsson U, Rahm Hallberg I, Westergren A. Pain management in elderly persons who require assistance with activities of daily living: a comparison of those living at home with those in special accommodations. Eur J Pain. 2004;8:335–344. 19 Bell GM, Schnitzer TJ. Cox-2 inhibitors and other nonsteroidal anti-inflammatory drugs in the treatment of pain in the elderly. Clin Geriatr Med. 2001;17:489. 20 Blumstein H, Gorevic PD. Rheumatologic illnesses: treatment strategies for older adults. Geriatrics. 2005;60:28 –35. 21 Gloth FM III. Geriatric pain: factors that limit pain relief and increase complications. Geriatrics. 2000;55:46. 22 Bergman S. Management of musculoskeletal pain. Best Pract Res Clin Rheumatol. 2007; 21:153–166. 23 Osborne TL, Raichle KA, Jensen MP. Psychologic interventions for chronic pain. Phys Med Rehabil Clin North Am. 2006;17:415– 433. 24 Thorn BE, Cross TH, Walker BB. Metaanalyses and systematic reviews of psychological treatments for chronic pain: relevance to an evidence-based practice. Health Psychol. 2007;26:10 –12. 25 Morley S, Eccleston C, Williams A. Systematic review and meta-analysis of randomized controlled trials of cognitive behaviour therapy and behaviour therapy for chronic pain in adults, excluding headache. Pain. 1999;80:1–13. 26 Williams DA, Cary MA, Groner KH, et al. Improving physical functional status in patients with fibromyalgia: a brief cognitive behavioral intervention. J Rheumatol. 2002;29:1280 –1286. 27 McCracken LM, MacKichan F, Eccleston C. Contextual cognitive-behavioral therapy for severely disabled chronic pain sufferers: effectiveness and clinically significant change. Eur J Pain. 2007;11: 314 –322.

28 McCracken LM, Turk DC. Behavioral and cognitive-behavioral treatment for chronic pain: outcome, predictors of outcome, and treatment process. Spine. 2002;27: 2564 –2573. 29 Kerns RD, Otis JD, Marcus KS. Cognitivebehavioral therapy for chronic pain in the elderly. Clin Geriatr Med. 2001;17:503. 30 Gatchel RJ, Peng YB, Peters ML, et al. The biopsychosocial approach to chronic pain: scientific advances and future directions. Psychol Bull. 2007;133:581– 624. 31 Cook AJ. Cognitive-behavioral pain management for elderly nursing home residents. J Gerontol B Psychol Sci Soc Sci. 1998;53:P51–P59. 32 Reid MC, Otis J, Barry LC, et al. Cognitivebehavioral therapy for chronic low back pain in older persons: a preliminary study. Pain Med. 2003;4:223–230. 33 Astin JA. Mind-body therapies for the management of pain. Clin J Pain. 2004;20: 27–32. 34 Austrian JS, Kerns RD, Reid MC. Perceived barriers to trying self-management approaches for chronic pain in older persons. J Am Geriatr Soc. 2005;53:856 – 861. 35 Kee WG, Middaugh SJ, Redpath S, et al. Age as a factor in admission to chronic pain rehabilitation. Clin J Pain. 1998;14: 121–128. 36 Jette A, Lachman M, Giorgetti M, et al. Exercise—it’s never too late: the Strong-forLife Program. Am J Public Health. 1999; 89:66 –72. 37 Herning M, Schneider J. Cognitive behavioral therapy to promote exercise behavior in older adults: implications for physical therapists. J Geriatr Phys Ther. 2005; 28:34 –38. 38 Fell N. Case in point: mental imagery and mental practice for an individual with multiple sclerosis and balance dysfunction, including commentary by Zabolitzki F. Phys Ther Case Rep. 2000;3:3–10. 39 Sardoni C, Hall C, Forwell L. The use of imagery by athletes during injury rehabilitation. J Sport Rehabil. 2000;9:329 –338. 40 Van Leeuwen R, Inglis J. Mental practice and imagery: a potential role in stroke rehabilitation, including commentary by Ravey. J Phys Ther Rev. 1998;3:47–54. 41 Decety J. Should motor imagery be used in physiotherapy? Recent advances in cognitive neurosciences. Physiother Theory Pract. 1993;9:193–203. 42 Keefe FJ, Kashikar-Zuck S, Opiteck J, et al. Pain in arthritis and musculoskeletal disorders: the role of coping skills training and exercise interventions. J Orthop Sports Phys Ther. 1996;24:279 –290. 43 Keefe FJ, Abernethy AP, Campbell LC. Psychological approaches to understanding and treating disease-related pain. Ann Rev Psychol. 2005;56:601– 630. 44 Rudy TE, Hanlon RB, Markham JR. Psychosocial issues and cognitive behavioral therapy: from theory to practice. In: Weiner DK, Herr K, Rudy TE, eds. Persistent Pain in Older Adults: An Interdisciplinary Guide for Treatment. New York, NY: Springer Publishing Co; 2002:58 –94.

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Cognitive-Behavioral Therapy for Older Adults With Chronic Pain 45 Guide to Physical Therapist Practice. 2nd ed. Phys Ther. 2001;81:9 –746. 46 Sullivan MJL, Adams H, Rhodenizer T, et al. A psychosocial risk factor: targeted intervention for the prevention of chronic pain and disability following whiplash injury. Phys Ther. 2006;86:8 –18. 47 Miller EW, Ross K, Grant S, et al. Geriatric referral patterns for physical therapy: a descriptive analysis. J Geriatr Phys Ther. 2005;28:20 –27. 48 Hayden JA, van Tulder MW, Malmivaara A, et al. Exercise therapy for treatment of non-specific low back pain. Cochrane Database Syst Rev. 2005:CD000335. 49 Hayden JA, van Tulder MW, Malmivaara AV, et al. Meta-analysis: exercise therapy for nonspecific low back pain. Ann Intern Med. 2005;142:765–775.

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50 Chiu TTW, Hui-Chan CWY, Chein G. A randomized clinical trial of TENS and exercise for patients with chronic neck pain. Clin Rehabil. 2005;19:850 – 860. 51 Chiu TTW, Lam T-H, Hedley AJ. A randomized controlled trial on the efficacy of exercise for patients with chronic neck pain. Spine. 2005;30:E1–E7. 52 Schilke JM, Johnson GO, Housh TJ, et al. Effects of muscle-strength training on the functional status of patients with osteoarthritis of the knee joint. Nurs Res. 1996; 45:68 –72. 53 Mangione KK, McCully K, Gloviak A, et al. The effects of high-intensity and lowintensity cycle ergometry in older adults with knee osteoarthritis. J Gerontol A Biol Sci Med Sci. 1999;54:M184 –M190. 54 Mangani I, Cesari M, Kritchevsky SB, et al. Physical exercise and comorbidity: results from the Fitness and Arthritis in Seniors Trial (FAST). Aging Clin Exp Res. 2006;18:374 –380.

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55 Kolasinski SL, Garfinkel M, Tsai AG, et al. Iyengar yoga for treating symptoms of osteoarthritis of the knees: a pilot study. J Altern Complement Med. 2005;11: 689 – 693. 56 Manchikanti L. Medicare in interventional pain management: a critical analysis. Pain Physician. 2006;9:171–197. 57 Jost TS. Medicare and Medicaid financing of pain management. J Pain. 2000;1: 183–194. 58 Stieg RL, Lippe P, Shepard TA. Roadblocks to effective pain treatment. Med Clin North Am. 1999;83:809.

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Cognitive-Behavioral Therapy for Older Adults With Chronic Pain Appendix. Survey Script

For all of these questions, consider the patient population you have treated over the past 2 months. First, can you please estimate the percentage of patients you see who are aged 65 years and over who have chronic pain (pain for greater than 6 months) as a major complaint? 0%–20% 21%–50% 51%–75% ⬎75% How frequently do you use the following techniques in the treatment of these patients? Response choices are: ●

Always (more than 80% of the time)

●

Frequently (between 50% and 79% of the time)

●

Sometimes (between 25% and 49% of the time)

●

Rarely (0%–24% of the time) Physical agents (eg, heat, cold) Electrotherapy (eg, transcutaneous electrical nerve stimulation) Active exercise focused on joint stability Exercises to restore joint mobility General exercises (eg, walking, swimming, general stretching/strengthening) Soft tissue techniques (eg, massage, myofascial release, connective tissue mobilization) Joint mobilization or manipulation techniques Injury prevention education Deep muscle relaxation (eg, progressive muscle relaxation) Training in the use of distraction techniques Visualization or imagery Cognitive restructuring; teaching different ways to think about pain Education/counseling on scheduling pleasurable activities Activity pacing to avoid relapse or flare-ups (Continued)

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Cognitive-Behavioral Therapy for Older Adults With Chronic Pain Appendix. Continued

The last few items in this list (relaxation, visualization, pleasurable activity scheduling) are sometimes referred to as cognitive-behavioral therapy techniques. Recent research has indicated that these techniques can be effective in managing pain in patients with chronic conditions. Please indicate your level of interest in potentially incorporating these techniques into your practice. Response choices are: ●

Already using

●

Very interested

●

Interested

●

Not interested Deep muscle relaxation (eg, progressive muscle relaxation) Education on distraction techniques Using visual imagery to decrease pain focus Cognitive restructuring Education/counseling on pacing activities and scheduling pleasurable activities

One more item along these lines. We would like to know the barriers to incorporating cognitive-behavioral techniques into physical therapist practice. Please indicate whether each of the following is True or Not True for you. No barriers, these techniques are used regularly You do not believe the techniques are useful The techniques are not part of physical therapist practice The patients you see in your practice would not be open to using these techniques You have no time to incorporate these techniques into practice You do not know how to use the technique You have concerns with reimbursement Other: Now I would like to finish with a few questions about you and your practice. For how many years have you been practicing physical therapy? 0 –5 6 –10 11–15 ⬎15 What is your racial or ethnic group? Non-Hispanic Caucasian African American or black Hispanic or Latino Asian Native American or Hawaiian Other (Continued)

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Cognitive-Behavioral Therapy for Older Adults With Chronic Pain Appendix. Continued

At this time, about how many hours per week do you spend in patient care? What is your highest academic degree? Bachelor’s degree Master’s degree Clinical doctorate Academic doctorate (EdD, PhD) In what type of practice do you currently work (as your primary job)? Privately owned outpatient clinic Corporately owned (for-profit) outpatient clinic Not-for-profit outpatient clinic Hospital Home care Other Is this practice in a: Large metropolitan area (ⱖ1 million people)? Small city (250,000 –999,999 people)? Suburban setting (100,000 –249,999 people)? Rural area (ⱕ99,999 people)? Do you hold any clinical specialist certifications? Yes/No If “Yes,” in what area? Would you like to make any comments regarding how you care for older adults with chronic pain?

Thank you very much for your time and for your participation in this research study.

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Cognitive-Behavioral Therapy for Older Adults With Chronic Pain

Invited Commentary

Kathleen A Sluka and Dennis C Turk

“Cognitive-behavioral therapy” (CBT) has become a generic term that includes a range of cognitive and behavioral techniques such as cognitive restructuring, problem solving, communication skills training, and operant conditioning (ie, contingent reward for activity and withdrawal of positive reinforcement for avoidance and withdrawal of activity). The survey article by Beissner and colleagues1 describes the current usage of cognitive and behavioral techniques in physical therapist management of older adults with chronic pain that would be considered part of a CBT program, such as pleasurable activity scheduling and activity pacing. However, CBT is much more than a set of techniques, and it is easy to become seduced by the details of the techniques and lose sight of the conceptual perspective and objectives for which the techniques are being used.2

The cognitive-behavioral perspective can be incorporated into interactions with patients by a variety of clinicians, including physical therapists. This will assist patients in making positive changes in their thought processes and changes in maladaptive pain behaviors (inactivity) to well behaviors (exercise). The various cognitive and behavioral techniques are less important than the set of principles outlined. The techniques themselves are all designed to help patients self-manage their symptoms and their lives. The objectives and the change in behavior being targeted are the essential components; how the changes in behavior are brought about, the techniques, much less so. The assumptions underlying the cognitive-behavioral perspective are helpful in guiding interactions between any health care provider and his or her patients and are not the specific purview of psychologists.

The cognitive-behavioral perspective is predicated on a set of assumptions about people. Specifically: (1) patients are active processors of information and not passive reactors; (2) thoughts (eg, appraisals, expectancies, beliefs) can elicit and influence mood, affect physiological processes, have social consequences, and serve as an impetus for behavior; conversely, mood, physiology, environmental factors, and behavior can influence the nature and content of thought processes; (3) behavior is reciprocally determined by both the individual and environmental factors; (4) patients can learn more adaptive ways of thinking, feeling, and behaving; and (5) patients should be active collaborative agents in changing their thoughts, feelings, behavior, and physiology.

To summarize, CBT has 4 key components that can be adapted for use in physical therapist practice: (1) education, (2) skills acquisition, (3) skills consolidation, and (4) generalization and maintenance.2,3 The educational component focuses on helping patients identify and challenge their maladaptive beliefs and expectations about activity, their abilities, and their negative expectations about the future. It also attempts to manage pain by making patients aware of the role that thoughts and emotions play in potentiating and maintaining stress and physical symptoms (ie, cognitive restructuring). Cognitive restructuring includes identifying and challenging maladaptive thoughts, feelings, and behaviors; introduction and practice of coping thoughts and behaviors; shifting from self-defeating to coping thoughts; and practice of positive

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thoughts including home practice and follow-up. The main goal of the education component is to shift the patient’s repertoire from well-established, habitual, and automatic, but ineffective, responses toward systematic problem solving, control of affect, or disengagement from self-defeating situations. For example, as a physical therapist, it is important to examine and challenge the patient’s perception about exercise and physical activity: the erroneous and often-inhibiting thought that “hurt” is equivalent to “harm” and, therefore, if exercise hurts, it should be avoided to prevent damage. Physical therapists should emphasize that in patients with chronic pain, exercise and physical activity will not make the injury worse, but rather, if continued regularly, will increase flexibility, endurance, and strength and eventually decrease pain, as well as improve the ability to perform other activities. Avoidance of activity or premature termination will prevent patients from obtaining corrective feedback. That is, they may not learn that they, indeed, can perform activities that they may have feared, without further damage and with improvements in functioning. Skills acquisition and consolidation help people learn and practice new pain management behaviors through a variety of techniques that include relaxation, problem solving, distraction methods, activity pacing, and communication. Psychologists utilize a variety of methods to teach these pain management behaviors: education, didactic instruction, Socratic questioning, observational learning, and role playing. The overall goal of the skills acquisition and consolidation components is to teach the patient self-management strategies

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Cognitive-Behavioral Therapy for Older Adults With Chronic Pain using various techniques. Importantly, patients learn from observing outcomes of their own efforts and those of others. Often CBT is carried out in a group context where the psychologist can use the support of other patients and have patients interact with each other to assist in providing alternative ways of thinking and behaving. In such groups, patients can observe others making improvements without aversive consequences that may have been anticipated by the patients. Observational learning is thus a valuable tool that can easily be incorporated into physical therapist practice through group exercise therapy, where patients view others with similar physical limitations performing exercises that might be threatening without anticipated negative consequences. As a physical therapist, the use of activity pacing also is common and consistent with the therapist’s understanding of exercise and functional activities. Thus, incorporating cognitive and behavioral techniques into physical therapist practice can easily be accomplished and serve to enhance standard physical therapy treatments. Finally, generalization and maintenance are geared toward consolidating skills and preventing relapse. Importantly, psychologists utilize homework in CBT to solidify the skills learned. Initially, patients have been taught and have practiced selfmanagement skills within the therapeutic environment. After this, it is essential that the patients practice their skills in the home environment, where the therapist is not present to guide and support them. Difficulties that arise when the skills are attempted at home are important topics for discussion and to teach further problem solving, including flare management. In this phase, psychologists assist patients to anticipate future problems and high-risk situations so that they can think May 2009

about and practice the behavioral responses that may be necessary for adaptive coping. This is a critical phase for long-term success of the patients in managing their pain. In terms of physical therapist practice, implementation of behaviors longterm, especially with exercise, is quite difficult. Understanding and emphasizing home programs of exercise for the patient, outside the clinical setting, is an important factor. This may require encouraging participation in a local gym, setting up home exercise equipment, or assisting with setting up a daily exercise routine with the patient. Thus, translating the principles taught in the clinic to a continued successful program will take guidance from the therapist to strategize and adapt to the home program. There is good evidence, from randomized controlled trials and systematic reviews, that the cognitive-behavioral perspective, when integrated within a comprehensive rehabilitation program, reduces pain and disability and restores function in people with chronic pain.4 –7 We have only highlighted some aspects of CBT, but it should be obvious that the approach is much more complex then simply teaching patients a set of skills such as pleasurable activity scheduling and activity pacing. Considerable clinical sensitivity and expertise are required to develop an integrated program for patients with chronic pain. (For detailed treatments of CBT as a perspective and techniques applied to chronic pain, see Turk8 and Turk and Meichenbaum.9) Although understanding the principles of CBT for the management of pain and incorporating these into physical therapy interactions with patients are important, it is equally important to recognize when to refer a patient to a psychologist specializing in pain management. Some cognitive and behavioral techniques

(eg, activity pacing, relaxation exercises) can be incorporated into physical therapist practice, whereas some techniques (eg, cognitive restructuring, communications skills training) require specialized training in CBT and remain outside the domain of physical therapist practice. Many patients with chronic pain would benefit from psychological interventions; thus, patients in need of specific CBT skills training should be referred to a psychologist specializing in pain management. Furthermore, those individuals who are in most critical need of referral for psychological interventions include those with a high level of fear of pain and reinjury, those with a high level of catastrophizing (negative thoughts about themselves, their abilities, and the future), those with a strong affective (emotional) component to their pain, and those with suspected underlying psychological diseases (eg, anxiety, depression). Adequate treatment of these variables may require multiple psychological approaches and, when used in combination with physical therapy approaches in a team environment, will result in an enhanced efficacy of treatment. KA Sluka, PT, PhD, is Professor, Physical Therapy and Rehabilitation Science, University of Iowa, Iowa City, IA 52242 (USA). Address all correspondence to Dr Sluka at: [email protected]. DC Turk, PhD, is Professor, Department of Anesthesiology, University of Washington, Seattle, Washington. DOI: 10.2522/ptj.20080163.ic

References 1 Beissner K, Henderson CR Jr, Papaleontiou M, et al. Physical therapists’ use of cognitive-behavioral therapy for older adults with chronic pain: a nationwide survey. Phys Ther. 2009;89:456 – 469. 2 Turk DC. Cognitive-behavioral approach to the treatment of chronic pain patients. Reg Anesth Pain Med. 2003;28:573–579.

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Cognitive-Behavioral Therapy for Older Adults With Chronic Pain 3 Turk DC, Wilson HD, Psychological approaches in pain management. In: Sluka KA, ed. Mechanisms and Management of Pain for the Physical Therapist. Seattle, WA: IASP Press. In press. 4 Guzman J, Esmail R, Karjalinen K, et al. Multidisciplinary rehabilitation for chronic low back pain: systematic review. Br Med J. 2001;322:1511–1516. 5 McCracken LM, Turk DC. Behavioral and cognitive-behavioral treatment for chronic pain: outcome, predictors of outcome, and treatment process. Spine. 2002;27: 2564 –2573.

Author Response

Although we were pleased to see that a significant minority of therapists in our sample already use many of these techniques, our study documents substantial barriers to incorporating these techniques into customary practice. We hypothesize that incorporating cognitive and behavioral techniques into physical therapist practice may provide additive (and possibly synergistic) benefit for older patients with chronic pain problems; however, we are not

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8 Turk DC. A cognitive-behavioral perspective on the treatment of chronic pain patients. In: Turk DC, Gatchel RJ. eds. Psychological Approaches to Pain Management: A Practitioner’s Handbook. New York, NY: Guilford Press; 2002:138 –158. 9 Turk DC, Meichenbaum D, Geneat M. Pain and Behavioral Medicine: A CognitiveBehavioral Perspective. New York, NY: Guilford Press; 1983.

Katherine Beissner and MC Reid

We thank Sluka and Turk for their commentary1 on our article.2 Their commentary illustrates key differences among a cognitive-behavioral perspective, cognitive-behavioral techniques, and cognitive-behavioral programs for pain. We fully agree that a cognitivebehavioral perspective can be used successfully by diverse health care providers, including physical therapists. Although we did not measure the extent to which respondents incorporate this type of perspective into their respective practices, our results suggest that a substantial number of physical therapists use this approach when addressing patients’ maladaptive pain behaviors. Sluka and Turk further note that certain cognitive and behavioral techniques can be readily translated into physical therapist practice and lead to positive patient outcomes.

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6 Morley S, Eccleston C, Williams A. Systematic review and meta-analysis of randomized controlled trials of cognitive behaviour therapy and behaviour therapy for chronic pain in adults, excluding headache. Pain. 1999;80:1–13. 7 Friedrich M, Gittler G, Arendasy M, Friedrich KM. Long-term effect of a combined exercise and motivational program on the level of disability of patients with chronic low back pain. Spine. 2005; 30:995–1000.

aware of any current evidence that supports this claim. Furthermore, Sluka and Turk make the distinction that certain cognitive and behavioral techniques (eg, activity pacing, relaxation) are readily amenable for use by physical therapists, whereas other cognitive and behavioral techniques (eg, cognitive restructuring, communication skills training) are not. We are not clear why the commentators believe certain cognitivebehavioral techniques are beyond the scope of physical therapist practice. Cognitive restructuring and communication skills training are core components of many selfmanagement programs that have been successfully taught by trained laypeople for well over 30 years and that, when taught along with other self-management techniques, have led to positive outcomes (the Arthritis Foundation’s Self-Help Program3 is just one example). We agree with the commentators that many patients with chronic pain would benefit from work with a psychologist specializing in pain management. However, one of the critical problems with accessing such care is the shortage of qualified practitioners. According to the US Department of Health and Human Resources,4 there are 3,059 health professional shortage areas for men-

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tal health professionals, and 87% of these shortage areas are in nonmetropolitan counties. This increases the likelihood that older adults in many rural (and some suburban) areas will not have access to a mental health professional at all, much less one skilled in using cognitive-behavioral therapy (CBT) for the management of chronic pain. Because these statistics do not differentiate by specialty area of health care professionals, we believe that they likely underestimate the problem of accessing psychologists specializing in pain management. In fact, the lack of clinicians trained in CBT is cited as one of the barriers leading to the development of minimal-contact and Web-based administration of CBT for adolescents with chronic pain.5 Given the efficacy of CBT for pain management and the scarcity of mental health providers prepared to deliver this treatment, ultimately the issue of importance is one of translating the research into practice settings that help to maximize the reach of the intervention. We maintain that physical therapist practice is an ideal venue in which to translate this particular evidence. Glasgow and Emmons6 highlighted the many difficulties that often arise when attempting to translate research on effective in-

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Cognitive-Behavioral Therapy for Older Adults With Chronic Pain 3 Turk DC, Wilson HD, Psychological approaches in pain management. In: Sluka KA, ed. Mechanisms and Management of Pain for the Physical Therapist. Seattle, WA: IASP Press. In press. 4 Guzman J, Esmail R, Karjalinen K, et al. Multidisciplinary rehabilitation for chronic low back pain: systematic review. Br Med J. 2001;322:1511–1516. 5 McCracken LM, Turk DC. Behavioral and cognitive-behavioral treatment for chronic pain: outcome, predictors of outcome, and treatment process. Spine. 2002;27: 2564 –2573.

Author Response

Although we were pleased to see that a significant minority of therapists in our sample already use many of these techniques, our study documents substantial barriers to incorporating these techniques into customary practice. We hypothesize that incorporating cognitive and behavioral techniques into physical therapist practice may provide additive (and possibly synergistic) benefit for older patients with chronic pain problems; however, we are not

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8 Turk DC. A cognitive-behavioral perspective on the treatment of chronic pain patients. In: Turk DC, Gatchel RJ. eds. Psychological Approaches to Pain Management: A Practitioner’s Handbook. New York, NY: Guilford Press; 2002:138 –158. 9 Turk DC, Meichenbaum D, Geneat M. Pain and Behavioral Medicine: A CognitiveBehavioral Perspective. New York, NY: Guilford Press; 1983.

Katherine Beissner and MC Reid

We thank Sluka and Turk for their commentary1 on our article.2 Their commentary illustrates key differences among a cognitive-behavioral perspective, cognitive-behavioral techniques, and cognitive-behavioral programs for pain. We fully agree that a cognitivebehavioral perspective can be used successfully by diverse health care providers, including physical therapists. Although we did not measure the extent to which respondents incorporate this type of perspective into their respective practices, our results suggest that a substantial number of physical therapists use this approach when addressing patients’ maladaptive pain behaviors. Sluka and Turk further note that certain cognitive and behavioral techniques can be readily translated into physical therapist practice and lead to positive patient outcomes.

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6 Morley S, Eccleston C, Williams A. Systematic review and meta-analysis of randomized controlled trials of cognitive behaviour therapy and behaviour therapy for chronic pain in adults, excluding headache. Pain. 1999;80:1–13. 7 Friedrich M, Gittler G, Arendasy M, Friedrich KM. Long-term effect of a combined exercise and motivational program on the level of disability of patients with chronic low back pain. Spine. 2005; 30:995–1000.

aware of any current evidence that supports this claim. Furthermore, Sluka and Turk make the distinction that certain cognitive and behavioral techniques (eg, activity pacing, relaxation) are readily amenable for use by physical therapists, whereas other cognitive and behavioral techniques (eg, cognitive restructuring, communication skills training) are not. We are not clear why the commentators believe certain cognitivebehavioral techniques are beyond the scope of physical therapist practice. Cognitive restructuring and communication skills training are core components of many selfmanagement programs that have been successfully taught by trained laypeople for well over 30 years and that, when taught along with other self-management techniques, have led to positive outcomes (the Arthritis Foundation’s Self-Help Program3 is just one example). We agree with the commentators that many patients with chronic pain would benefit from work with a psychologist specializing in pain management. However, one of the critical problems with accessing such care is the shortage of qualified practitioners. According to the US Department of Health and Human Resources,4 there are 3,059 health professional shortage areas for men-

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tal health professionals, and 87% of these shortage areas are in nonmetropolitan counties. This increases the likelihood that older adults in many rural (and some suburban) areas will not have access to a mental health professional at all, much less one skilled in using cognitive-behavioral therapy (CBT) for the management of chronic pain. Because these statistics do not differentiate by specialty area of health care professionals, we believe that they likely underestimate the problem of accessing psychologists specializing in pain management. In fact, the lack of clinicians trained in CBT is cited as one of the barriers leading to the development of minimal-contact and Web-based administration of CBT for adolescents with chronic pain.5 Given the efficacy of CBT for pain management and the scarcity of mental health providers prepared to deliver this treatment, ultimately the issue of importance is one of translating the research into practice settings that help to maximize the reach of the intervention. We maintain that physical therapist practice is an ideal venue in which to translate this particular evidence. Glasgow and Emmons6 highlighted the many difficulties that often arise when attempting to translate research on effective in-

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Cognitive-Behavioral Therapy for Older Adults With Chronic Pain terventions into practice. Among these, intervention characteristics (including high cost, high level of staff expertise, and time intensity of treatments) and target-setting issues (including limited human resources for delivery of the intervention) are particularly relevant when attempting to deliver CBT for older adults with chronic pain. Thus, timeintensive programs requiring special expertise may be effective but will have limited reach. We submit that cognitive-behavioral programs for pain constitute an example of such a problem. Glasgow and Emmons further suggested there is a real need to develop interventions that translate evidence into practice in a manner that incorporates the “minimal intensity needed for change.” Although the effect size of such interventions will no doubt be smaller than the original program, the overall impact at the population level is likely to be greater, as long as the minimally intensive intervention reaches larger segments of the population. We propose that incorporating cognitive-behavioral techniques with traditional physical therapy interventions provides an approach that can measurably enhance patients’ selfmanagement strategies, including the adoption of positive coping

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skills. Teaching patients specific stretching, strengthening, and conditioning exercises provides a context for practicing adaptive pain coping skills. Likewise, instructing patients in the use of specific coping skills may help to reduce their levels of activity avoidance and thereby enhance incorporation of the exercises into their daily routines. Having patients practice coping skills while exercising also may help them successfully complete the exercises should pain or discomfort occur. Finally, an individualized, graded exercise program provides an appropriate context for learning both goal-setting and self-reinforcement skills, which are core CBT components. Because self-management programs that incorporate cognitive-behavioral techniques have been delivered by laypeople with advantageous results for patients with various chronic health problems (eg, arthritis, heart disease, lung disease),7 it seems reasonable to investigate whether physical therapists can be trained to incorporate similar approaches into physical therapist practice. Given the congruency of the physical therapy and CBT perspectives, we argue that it is logical to examine whether physical therapists can successfully deliver cognitivebehavioral techniques in the context

of delivering customary care and whether patients receive additive benefit as a consequence. This type of translational research initiative can help to move evidence into real-world practice and ultimately lead to improved patient outcomes. DOI: 10.2522/ptj.20080163.ar

References 1 Sluka KA, Turk DC. Invited commentary on “Physical therapists’ use of cognitivebehavioral therapy for older adults with chronic pain: a nationwide survey.” Phys Ther. 2009;89:470 – 472. 2 Beissner K, Henderson CR Jr, Papaleontiou M, et al. Physical therapists’ use of cognitivebehavioral therapy for older adults with chronic pain: a nationwide survey. Phys Ther. 2009;89:456 – 469. 3 Arthritis Foundation Self-Help Program. Available at: http://www.arthritis.org/selfhelp-program.php. 4 US Department of Health and Human Services. Shortage Designation: HPSAs, MUAs & MUPs. 2008. Available at: http://bhpr. hrsa.gov/shortage/. Accessed February 18, 2009. 5 Long AC, Palermo TM. Brief report: Webbased management of adolescent chronic pain: development and usability testing of an online family cognitive behavioral therapy program. J Pediatr Psychol. 2008 Jul 31 [Epub ahead of print]. 6 Glasgow RE, Emmons KM. How can we increase translation of research into practice? types of evidence needed. Annu Rev Public Health. 2007;28:413– 433. 7 Bruce B, Lorig K, Laurent D. Participation in patient self-management programs. Arthritis Rheum. 2007;57:851– 854.

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Research Report Rapid and Long-term Adaptations in Gait Symmetry Following Unilateral Step Training in People With Hemiparesis Jennifer H Kahn, T George Hornby JH Kahn, PT, DPT, NCS, is Research Physical Therapist, Sensory Motor Performance Program, Rehabilitation Institute of Chicago, Chicago, Illinois. TG Hornby, PT, PhD, is Assistant Professor, Department of Physical Therapy, University of Illinois at Chicago, 1919 W Taylor St, Chicago, IL 60612 (USA), and Research Scientist, Sensory Motor Performance Program, Rehabilitation Institute of Chicago. Address all correspondence to Dr Hornby at: [email protected]. [Kahn JH, Hornby TG. Rapid and long-term adaptations in gait symmetry following unilateral step training in people with hemiparesis. Phys Ther. 2009;89:474 – 483.] © 2009 American Physical Therapy Association

Background and Objective. Evidence for specific physical interventions that improve walking symmetry in individuals with hemiparesis poststroke is limited. The aim of this study was to investigate the rapid and prolonged effects of unilateral step training (UST) on step length asymmetry (SLA) in people with hemiparesis. Subjects and Design. Eighteen individuals with chronic hemiparesis and substantial SLA during overground walking participated in a single-group, pretestposttest study. The study consisted of 2 phases, with 10 subjects participating in each phase; 2 subjects participated in both phases.

Interventions and Measurements. To investigate rapid effects of UST, the participants completed a 20-minute session of UST on a treadmill with their unimpaired limb, with the impaired limb held stationary off the treadmill. Data for spatiotemporal gait parameters during overground walking at self-selected and fastest speeds were collected prior to and following UST, with follow-up measurements at 1 day and 1 week. To investigate the prolonged effects, the participants completed ten 20-minute sessions of UST. Data for spatiotemporal gait parameters were collected prior to training as well as after every third session, with follow-up measurements at 1 and 2 weeks. Results. Immediately following UST, SLA tested during fast-paced overground walking improved by up to 13% (49% reduced to a 36% SLA), with changes retained for up to 24 hours. Following 10 sessions of UST, SLA improved significantly, with changes retained for up to 2 weeks. Limitations. Despite repeated baseline measurements, the absence of a control group was a limitation. Furthermore, stepping characteristics during UST were not quantified. Conclusion. Unilateral step training may improve spatiotemporal patterns in people with substantial gait asymmetry poststroke. Repeated training may be necessary for maintenance of adaptations.

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D

espite substantial recovery of independent ambulation in individuals following unilateral stroke, persistent gait abnormalities are observed in a large percentage of these individuals and are a priority for rehabilitation interventions.1,2 In addition to decreased gait speed,3 asymmetrical gait patterns are commonly observed4 –7 and appear unrelated to walking speed.8 Gait asymmetries often are characterized by decreased duration of single-leg stance on the impaired limb9 –11 and differences in step length,9,10,12 primarily decreased step length of the unimpaired limb versus the impaired limb10,13,14 (however, Kim and Eng15). The presence of step length asymmetry (SLA) is thought to be correlated with propulsive forces of the paretic limb and hemiparetic severity,13 with some evidence to suggest that spastic plantar-flexor activity also may contribute.12

Despite recent insight into potential factors underlying SLA poststroke, there is little evidence to indicate these behaviors can be modified with physical rehabilitation. For example, locomotor training using bodyweight support (BWS) on a motorized treadmill has been shown to facilitate recovery of independent walking function poststroke,16 with improvements in postural control, gait speed, and endurance.17,18 There is, however, little emphasis on potential alterations in gait symmetry following such training,19,20 with recent data indicating little change in spatial symmetry.21 A previous investigation22 attempted to alter step timing symmetry using a standing biofeedback paradigm to augment paretic-limb weight bearing, although changes in gait symmetry were not different from those of a control group that did not receive such feedback training. No studies using conventional physical therapy approaches have shown substantial changes in SLA. May 2009

A long-standing body of literature has demonstrated the capacity of the locomotor system to adapt rapidly in response to experimental perturbations and, depending on the magnitude and duration of perturbing stimuli, retain such adaptations (ie, demonstrate aftereffects) following removal of the stimulus.23–25 To investigate adaptations in interlimb coordination during walking, Reisman and colleagues26 utilized a splitbelt training paradigm in which a belt under each limb was controlled separately. In their paradigm, subjects walked on a split-belt treadmill with 2- to 4-fold differences in individual belt speeds while data for kinematic gait parameters were collected. During 10 minutes of splitbelt walking, rapid changes in intralimb parameters (ie, stride length and percentage of stance time) were observed, but the changes were not maintained during normal treadmill walking when the belts were tied together. In contrast, interlimb parameters (ie, step length and percentage of double support time) changed gradually throughout the training paradigm, with significant adaptations following return to normal treadmill conditions. Such adaptations were characterized by longer step lengths on the perturbed (fast-trained) limb, with a gradual reversion to symmetrical walking patterns. Recent data indicate that similar adaptations in spatiotemporal gait parameters are evident in people with hemiparesis poststroke following split-belt walking.26,27 More precisely, gait symmetry improved following split-belt walking when the limb with shorter step lengths was trained at the faster speed; however, changes returned to baseline within the 6-minute post-adaptation period. Evidence of rapid alterations in spatiotemporal gait parameters in individuals with gait asymmetry poststroke is appealing in that repeated

exposure to such perturbations may induce lasting alterations in walking characteristics.28 Preliminary evidence indicates the transfer of locomotor adaptations during overground walking,29 although these adaptations persist for a brief duration. Unfortunately, minimal access to split-belt treadmills also may limit the clinical application of this training. The purpose of this study was to investigate the potential adaptations in spatiotemporal gait parameters in individuals poststroke following unilateral step training (UST). Subjects with marked SLA were trained using a simple stepping paradigm in which they were required to step with their unimpaired limb on the treadmill while their impaired limb was held stationary off the treadmill. The study consisted of 2 phases: phase 1 assessed the rapid changes in gait symmetry following a single session of UST, and phase 2 determined long-term alterations in SLA with repeated UST. We hypothesized that UST would decrease SLA during overground walking in people with chronic hemiparesis poststroke on both rapid and prolonged time courses. Alterations in spatiotemporal gait patterns following UST may further demonstrate the adaptive capacity of locomotor behaviors in people with damage to supraspinal pathways and reveal a clinical strategy to enhance gait symmetry.

Available With This Article at www.ptjournal.org • The Bottom Line clinical summary • The Bottom Line Podcast • Audio Abstracts Podcast This article was published ahead of print on March 12, 2009, at www.ptjournal.org.

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Gait Symmetry Adaptations Following Unilateral Step Training in Hemiparesis Table. Subject Demographics Subject No.

Age (y)

Duration Poststroke (y)

Side of Paresis

Self-selected Walking Speed (m/s)

1

68

4

Right

0.27

2

56

14

Right

0.53

3

47

5

Right

0.86

4

55

7

Left

0.14

5

74

10

Left

0.19

6

63

7

Left

0.50

7

58

2

Right

0.10

8

60

2

Left

0.18

9

60

2

Left

0.38

10

51

1

Right

0.60

11

49

2

Left

0.49

12

53

0.5

Left

0.39

13

49

2

Right

0.28

14

35

8

Right

0.69

15

43

1

Right

0.08

16

46

3

Left

0.54

17

38

3

Left

0.46

18

70

10

Right

0.72

Method Setting and Participants Ten subjects with a history of unilateral hemiparesis of ⱖ6 months duration following stroke and clinical presentation of hemiparesis completed both phase 1 and phase 2. Preliminary power analysis estimated effect sizes of changes in SLA to be greater than 1.0 using paired comparisons of pretraining versus posttraining data. Therefore, 10 subjects were recruited for each phase. Two subjects participated in both phases, for a total of 18 subjects. All subjects ambulated without physical assistance at speeds of less than 1.0 m/s, but they were permitted to use an assistive device or orthosis below the knee, as needed. Specific criteria included the presence of substantial SLA, defined as an unimpaired step length at least 20% less than that of the impaired limb during overground walking at a self-selected pace. 476

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line measures in phase 1. A preliminary screening examination was performed to determine eligibility. Spatiotemporal gait characteristics were determined using the Gait Mat II,* for which concurrent validity30 and reliability31 have been demonstrated. For both phases, data for spatiotemporal gait parameters were collected and averaged over 2 to 3 walking trials on the Gait Mat II at both self-selected and fastest speeds with specific instructions to “walk at your normal, comfortable pace” and “walk as fast as you safely can,” respectively.

Additional exclusion criteria included: presence of severe lower-extremity contractures or orthopedic injuries limiting range of motion or mobility; uncontrolled hypertension; cardiac arrhythmias; uncontrolled diabetes; bilateral, brain-stem, or cerebellar stroke; presence of unhealed decubiti; and significant cognitive impairments that would limit the subject’s ability to understand the study procedures (Folstein Mini Mental Status Examination scores ⬎22/30). All subjects provided written informed consent. The intent to investigate walking patterns following UST was explained to the subjects, but they were not given specific information on the primary hypothesis. Individual subject characteristics are provided in the Table.

For UST, subjects were escorted to a motorized treadmill† and fitted with a safety harness attached to a counterweight system. Body-weight support was provided only as necessary to minimize buckling of the impaired limb (phase 1: mean⫽8 kg, 95% confidence interval [CI]⫽2 to 14; phase 2: mean⫽0 kg, 95% CI⫽0). Subjects were permitted to hold on to a support bar placed at waist height across the treadmill, but they were discouraged from substantial upperextremity weight bearing and encouraged to ambulate without upperextremity support whenever possible. Subjects were permitted to rest, as needed, with vital signs obtained prior to, during, and following training and maintained within American College of Sports Medicine guidelines for individuals with known cardiovascular disease.32 In both phases, UST was performed for 20 minutes (1 session for phase 1 and 10 sessions for phase 2) with the stepping (unimpaired) limb positioned on the treadmill belt and the nonstepping (impaired) limb off the belt at the same height. Subjects were instructed to step continuously

Design Overview and Interventions Both phases consisted of a pretestposttest design, with repeated base-

* EQ Inc, PO Box 16, Chalfont, PA 189140016. † Woodway GmbH, Steinackerstrasse 20, D79576 Weil am Rhein, Germany.

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Figure 1. Description of phase 1 and phase 2 unilateral step training (UST) protocols. (A) Pretest followed by 20 minutes of training, followed by posttraining same-day assessments (10, 20, and 30 minutes posttraining) and follow-up testing at 1 day and 1 week. (B) Pretest followed by posttraining assessments (recorded prior to sessions 4, 7, and 10) and follow-up testing at 1 and 2 weeks.

with their unimpaired limb, while the impaired limb was to remain stationary (ie, in stance). Visual or verbal cues were provided only as necessary at initial training sessions to facilitate continuous stepping, maintain upright posture, and minimize upper-extremity support. Phase 1. Following the screening examination, subjects attended one 20-minute session of UST (Fig. 1A) and 2 follow-up testing sessions. Initial treadmill speed was determined by the average overground walking speed at subjects’ self-selected pace, recorded immediately prior to training, with walking speed gradually increased by 25% every 5 minutes. Following 20 minutes of UST, subjects were removed from the treadmill using a wheelchair and were not permitted to walk between testing intervals. Spatiotemporal data were May 2009

collected over 2 to 3 trials at selfselected and fastest-possible speeds at 10, 20, and 30 minutes following UST, with similar instructions provided as in the initial evaluation. Follow-up evaluations for spatiotemporal gait patterns were performed approximately 24 hours following the single UST session and at 1 week posttraining. Phase 2. Subjects attended 10 sessions of 20 minutes of UST (as described above) over a 2- to 3-week period. Stepping conditions on the first 2 days of repeated UST were identical to those described above for phase 1. With continued training (training sessions 3–10), the starting speed was increased by 25% every 2 sessions, with increments of 25% every 5 minutes. Maximum possible start speeds during the final UST sessions (9 –10) were 100% greater

than (ie, double) each subject’s mean self-selected speed obtained at pretesting. Spatiotemporal data were collected over 2 to 3 trials at pretraining, prior to sessions 4, 7, and 10, and then again for follow-up at 1 and 2 weeks posttraining. Outcomes and Statistical Analysis Spatiotemporal data collected during self-selected and fast walking speeds were averaged within each testing period, with specific parameters (step and stride lengths and stance and swing durations) analyzed using the Gait Mat II software. The primary dependent variable was SLA, calculated by the following equation:

100 ⫺

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unimpaired step length ⫻ 100 , impaired step length

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Gait Symmetry Adaptations Following Unilateral Step Training in Hemiparesis where subjects with values greater than 20% were eligible to participate and values of 0% indicated no asymmetry. Secondary analyses were limited to changes in step timing asymmetry (STA) and gait speed. Step timing asymmetry was calculated similarly, using single-limb support times of the nonparetic limb versus the paretic limb. Data across subjects were pooled, and spatiotemporal data were described as the mean (CI) unless stated otherwise. All statistical analysis was performed using StatView (version 5.0.1),‡ with ␣⫽.05. To assess for improvements in gait patterns due to familiarity of the testing apparatus, paired t tests were performed between data collected at the screening examination and data collected during testing immediately prior to unilateral stepping, indicating no significant differences in any gait parameter. Specifically, SLA at self-selected speed changed slightly (mean⫽43%, 95% CI⫽27% to 59%, to mean⫽46%, 95% CI⫽29% to 63%; P⫽.09) with repeated baseline testing. Pearson correlation coefficients were calculated to assess the strength of associations between baseline gait asymmetry (SLA and STA) measures during both self-selected and fastest walking conditions and gait speed to compare data with those previously published.8,13 Data were tested for normality using the Kolmogorov-Smirnov test, and, following determination of normality, parametric testing was done. The statistical analysis focused on the primary outcome of differences in SLA calculated immediately prior to UST and during subsequent testing sessions. For phases 1 and 2, separate one-way, repeated-measures analyses of variance were used to calculate differences in SLA during both ‡ SAS Institute Inc, PO Box 8000, Cary, NC 27513.

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overground walking speeds, with post hoc Tukey-Kramer tests as necessary, emphasizing changes in gait parameters prior to versus following UST. Conditions tested in phase 1 were: pretraining; 10, 20, and 30 minutes posttraining; 1-day followup; and 1-week follow-up. Conditions compared for phase 2 were: pr-training; SLA prior to sessions 4, 7, and 10; and follow-up assessments at 1 and 2 weeks posttraining. Additional analyses were directed toward secondary outcomes, including changes in individuals’ step lengths and changes in STA and gait speed. Pearson correlation analyses were completed to further describe potential relationships between changes in SLA and changes in STA and gait speed at each testing interval posttraining (ie, pretraining values compared with values in all subsequent testing conditions).

phase 2, and the correlation between SLA and gait speed approached significance in phase 1 (r⫽.61, P⫽.06; also see Balasubramanian et al13), with no other associations observed.

Role of the Funding Sources This study was supported by the Taylor Fellowship, Rehabilitation Institute of Chicago, and the National Institutes of Disability Rehabilitation Research, Rehabilitation Research Training Center (grant #H133B031127). Funding sources had no role in study design or reporting.

In contrast, significant changes in SLA following UST (ie, adaptations) during walking at fast speed were observed (P⬍.001). Immediately following UST, step length asymmetry improved by 9% to 13% throughout same-day testing sessions, with a smaller but significant difference (mean⫽4%, 95% CI⫽⫺13% to 21%)] maintained up to 24 hours after testing (Fig. 2C). Changes in SLA during walking at fast speed were characterized by 19% (0.04-m) to 29% (0.05-m) increases in step length of the unimpaired limb, with a 19% difference (95% CI⫽⫺1% to 39%) observed 24 hours following training. There were minimal changes in step length of the impaired limb (eg, all values changed ⬍4% compared with pretraining conditions). There was no relationship between initial SLA and amount of improvement of SLA.

Results Baseline Characteristics The average SLA and STA of subjects during overground walking at selfselected speed were 46% and 69%, respectively, for phase 1 and 43% and 100%, respectively, for phase 2, with similar values obtained for fastest-possible speed. A paired comparison revealed no significant differences between subjects’ SLA at selfselected speed and their SLA at the fastest-possible speed. Pearson correlational analyses revealed no significant correlations between baseline SLA and STA at self-selected and fastest-possible paces. At the fastest walking speed, SLA was correlated with gait speed (r⫽.76, P⬍.05) in

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Phase 1 Alterations in SLA. Measurements for spatiotemporal gait parameters were collected prior to and following a single 20-minute session of UST with the unimpaired limb. Following UST, changes in SLA at selfselected and fast speeds were altered differentially. Changes in SLA during self-selected speed approached significance (improved by 9% at 10 minutes posttraining, P⫽.05). Differences were characterized by a nearly 20% (0.04-m) increase in step length in the unimpaired limb, but also an approximately 9% (0.04-m) increase in the impaired (untrained) limb (Fig. 2).

Alterations in STA and gait speed. Alterations in selected temporal aspects of gait also were assessed following UST to determine their potential association with SLA. At selfMay 2009

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Figure 2. Phase 1 changes in step length symmetry (SLA) and step length during self-selected walking speed (A–B) and during fastest-possible walking speed (C–D). (A–B) No significant change in SLA at self-selected walking speed, with significant increases in step length indicated by asterisks (P⬍.01). (C–D) Asterisks indicate significant decreases in SLA and increases in step length at fast speed (P⬍.01) at all posttesting sessions ⱕ1 day. Error bars indicate 95% confidence intervals.

selected walking speed, there were no changes in STA from pretraining values. During fast walking, however, improvements in STA were observed following UST, with significant differences at 30 minutes (mean⫽20%, 95% CI⫽⫺2% to 42%; P⬍.05), although no significant differences were observed at other testing periods. Adaptations in STA were characterized by an improvement in single-limb stance time of the impaired limb (⬃12%), without alterations in stance time of the unaffected limb. There were no significant correlations between changes in SLA and STA at either overground walking speed.

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Gait speed at self-selected walking speed tested following UST increased from pretraining values, with significant differences at 30 minutes posttraining (16% [0.05-m/s] increase, 95% CI⫽3% to 29%) and at 1 day posttraining (15% [0.03-m/s] increase, 95% CI⫽0% to 30%). There was no significant increase in fastest-possible speed. Increases in gait speed were not correlated with changes in SLA at either self-selected or fastest-possible walking speed. Phase 2 Alterations in SLA. Measurements for spatiotemporal gait parameters were collected prior to and inter-

mittently throughout 10 sessions of UST with the unimpaired limb. Following training, SLA during both selfselected walking speed (P⫽.01) and fastest walking speed (P⬍.01) increased only slightly following the first 3 UST sessions (range⫽4%–5%), with significant differences of up to 12% observed at the follow-up sessions. Changes in SLA were characterized by increased step length of the unimpaired limb observed before session 7 and at 1 and 2 weeks posttraining, with the greatest change at 1 week posttraining for self-selected pace (32% [0.04-m] increase, 95% CI⫽24% to 40%) and at 2 weeks posttraining for fast walking

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Figure 3. Phase 2 changes in step length symmetry (SLA) and step length during self-selected walking speed (A–B) and during fast walking speed (C–D). (A–B) Asterisks indicate significant decrease in SLA maintained at 2 weeks posttraining, (P⬍.01). (C–D) Asterisks indicate significant decreases in SLA at 1 and 2 weeks posttraining and increases in step length following 6 sessions of unilateral step training maintained at 1 and 2 weeks posttraining at fast walking speed (P⬍.01). Blue bars indicate impaired limb, white bars indicate unimpaired limb. Error bars indicate 95% confidence intervals.

(24% [0.04-m] increase, 95% CI⫽20% to 28%) (Fig. 3). Initial SLA was correlated with the amount of improvement in SLA (r⫽.64, P⬍.05).

and STA at self-selected pace. A low correlation, however, was revealed between changes in STA and SLA during fast walking (r⫽.41, P⬍.01).

Alterations in STA and gait speed. Alterations in selected temporal aspects of gait were assessed following UST to determine their potential association with SLA. There were no significant changes in STA or percentage of single-limb support for either self-selected walking speed or fastest-possible walking speed following UST, with no significant relationship between changes in SLA

Changes in gait speed were analyzed to determine potential association with alterations in gait symmetry parameters. Overground gait speed at self-selected pace increased throughout testing, with the largest increase at 1 week posttraining (18% [0.06m/s] increase, 95% CI⫽15% to 21%), with a moderate correlation with changes in SLA (r⫽.50, P⬍.001). There were no significant changes in

gait speed for the fastest-possible walking condition, despite large changes in SLA.

Discussion and Conclusions

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This study investigated the rapid and prolonged adaptations of UST in individuals with hemiparesis poststroke and substantially smaller step lengths in their unimpaired limb versus their impaired limb. Significant improvements in spatial symmetry were observed primarily following a single 20-minute session of UST, with differences retained up to 24 hours posttraining, but not at 1 week May 2009

Gait Symmetry Adaptations Following Unilateral Step Training in Hemiparesis posttraining. Following 10 sessions of UST, significant differences were observed after 6 sessions and up to 2 weeks posttraining. Secondary analyses revealed smaller changes in STA, although only following a single session of UST, which were not correlated with changes in SLA. In contrast to previous investigations of gait asymmetry poststroke,27,33 selected spatiotemporal characteristics of walking were observed over ground and maintained with repeated exposure to UST in the current study. Previous studies using bilateral locomotor training and a treadmill in individuals poststroke have demonstrated very little change in SLA.17,34 In addition, recalculation of our own previously published data21 for subjects with substantial SLA (ie, ⬎20%, n⫽9) following locomotor training did not show significant improvements in SLA. Patterson and colleagues19 recently demonstrated increases in step length of the paretic and nonparetic limbs following 6 months of treadmill exercise, although no changes in interlimb symmetry were observed. The present data are consistent with previous evidence demonstrating adaptations in stepping behaviors following locomotor perturbations in people who were neurologically intact and in people with impairments. For example, in subjects without impairments who were asked to jog either forward or backward on a treadmill, Anstis23 demonstrated inadvertent forward or backward motion, respectively, when the subjects were asked to jog in place without visual guidance immediately following the treadmill stimuli. Patients with Parkinson disease35 or spinal cord injury36 also demonstrated rapid increases in gait speed following brief bouts of fast treadmill walking. Alterations in locomotor trajectory were observed following stepping on a circular treadmill, in which subjects May 2009

both with and without neurological injury demonstrated curved trajectories of stepping or walking in the opposite direction of the rotation of the treadmill.24,25,37 More pertinent to the present study, alterations in intralimb coordination38 and interlimb coordination26,27 have been observed following exposure to specific locomotor stimuli (ie, split-belt walking) as described previously. Such changes appear dependent on cerebellar structures,39,40 although patients with other neurological diagnoses, including stroke,27 can demonstrate such adaptations and aftereffects. Consistent with these studies, the present investigation revealed significant locomotor adaptations consistent with the demands of the experimental task. Specifically, subjects were required to step only with their unimpaired limb at progressively faster speeds. Although gait kinematic data were not collected during the training period (also see Earhart et al,24 Hong et al,25 and Weber et al37), a likely reason for the observed changes in SLA may be that subjects were taking longer steps on the unimpaired limb to keep pace with the treadmill speed, consistent with the changes observed following single or repeated sessions of UST. These adaptations are consistent with previous data27 and indicate that positive changes in gait symmetry are possible in subjects with damage to supraspinal centers. Of additional interest was the general lack of improvement in STA following repeated sessions of UST. Specifically, substantial loading of the impaired limb occurs during UST with the unimpaired limb, and intuitively we would expect STA to improve accordingly. The lack of significant findings may be due to the inclusion criteria used for this study, which focused only on SLA in our potential population, and resulted in

substantial variability in our STA measurements. Specific limitations of the present study warrant further discussion. Despite the perturbation applied to the subjects, they were initially given verbal instruction for continuous stepping, at least in the first session to facilitate accommodation to the novel stepping paradigm. Often, this was necessary only to ensure subjects continued to maintain their position on the treadmill. Despite data indicating a potential for auditory cueing to facilitate symmetry during treadmill walking in subjects with hemiparesis following stroke,41,42 verbal cueing was minimal, did not occur with all subjects, and was not directed for subjects to increase their step length on their impaired limb. It is unlikely, therefore, that minimal cueing contributed to the results. In this protocol, we increased treadmill speed during UST to increase practice (ie, number of steps) during the allotted training paradigm. Changes in spatiotemporal patterns observed following training could potentially be due to increased speed, as indicated by a moderate correlation between changes in self-selected gait speed and changes in SLA in phase 213 (however, see Roth et al8). However, lack of significant differences in subjects’ pretest SLA at either speed may argue against this possibility. Specifically, subjects walked with similar asymmetrical patterns at baseline assessments at their self-selected or fastest-possible walking speed. Additionally, in the fastest overground walking conditions for phases 1 and 2, there were no changes in gait speed; however, there were significant changes in SLA, further indicating that the 2 variables may not be dependent on each other. Finally, in this pilot study, we did not quantify the stepping characteristics

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Gait Symmetry Adaptations Following Unilateral Step Training in Hemiparesis during the intervention, but rather collected data only on the spatiotemporal gait characteristics during overground walking prior to and following training. Future studies should include quantification of kinetics13 and kinematics26,27 during and following the stepping perturbations to understand potential mechanisms underlying the observed changes in SLA, influenced primarily by changes in step length of the unimpaired limb. For example, other authors have indicated that paretic propulsion13 or spastic plantar-flexor activity10 may be related to stepping asymmetries in people with hemiparesis after stroke, although neither of these variables was assessed. Following bilateral locomotor training, however, changes in ankle spasticity (hypertonicity) are inconsistent, with either small changes43 or negligible changes44 observed. In contrast, the degree of SLA and gait speed are both correlated with paretic propulsive forces and may have been a contributing factor to our present results, although the contribution of propulsion to our current results is unknown and further investigation is needed. Although targeting asymmetrical walking is certainly a goal of both patients1 and therapists18 in rehabilitation, the clinical and functional significance of the present results warrant further consideration. For example, Perera et al45 recently attempted to describe clinically significant changes in gait performance related to walking speed or distance, although there are no studies that identify what a clinically significant change is for gait symmetry. Following repeated training, our current data represent a relatively large (28%) reduction in asymmetry compared with baseline conditions (mean SLA change⫽12% versus mean baseline SLA⫽43%).

although both SLA and gait speed increased following UST, the small potential relationship between changes in these variables brings into question whether gait symmetry may provide a functional benefit beyond improved gait cosmesis. One potential positive aspect of improved symmetry may be increased gait efficiency. Although the energetic costs of asymmetrical gait in people with hemiparesis has not been established, previous studies46,47 indicate that alterations in step length may increase the metabolic requirements of ambulation. Despite the limitations described, the observed changes in spatiotemporal parameters indicate the potential capacity for immediate improvements in gait symmetry in people with hemiparesis following specific stimuli, with repeated exposure required for persistence of adaptations. Unilateral step training may have the potential to be used as an adjunct treatment to improve gait symmetry in people with chronic hemiparesis and can be applied readily in the clinical setting. Future studies to determine alterations in gait symmetry between UST and other physical interventions are warranted. Both authors provided concept/idea/ research design, writing, data collection and analysis, fund procurement, and participants. Dr Kahn provided project management. Dr Hornby provided facilities/equipment and consultation (including review of manuscript before submission). The authors thank the following individuals for assistance with data collection: Donielle Campbell, PTA, Tobey DeMott, PT, Jennifer Moore, PT, NCS, and Heidi Roth, PT, NCS. This study was approved by the Institutional Review Board of Northwestern University. Poster presentations of this research were give at the Combined Sections Meetings of the American Physical Therapy Association; February 1–5, 2006; San Diego, California; and February 9 –12, 2009; Las Vegas, Nevada.

Whether such changes are functionally important is unclear. Specifically, 482

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This study was supported by the Taylor Fellowship, Rehabilitation Institute of Chicago, and the National Institutes of Disability Rehabilitation Research, Rehabilitation Research Training Center (grant #H133B031127). This article was received August 6, 2008, and was accepted January 30, 2009. DOI: 10.2522/ptj.20080237

References 1 Bohannon RW, Andrews AW, Smith M. Rehabilitation goals of patients with hemiplegia. Int J Rehabil Res. 1988;11:181–182. 2 Bohannon RW, Horton M, Wikholm J. Importance of 4 variables of gait to patients with stroke. Int J Rehabil Res. 1991;14: 246 –250. 3 Perry J, Garret M, Gronley JK, Mulroy SJ. Classification of walking handicap in the stroke population. Stroke. 1995;26: 982–999. 4 Brandstater ME, de Bruin H, Gowland C, Clark BM. Hemiplegic gait: analysis of temporal variables. Arch Phys Med Rehabil. 1983;64:583–587. 5 Ekaterina B, Titianova E, Tarkka I. Asymmetry of walking performance and postural sway in patients with chronic unilateral cerebral infarction. J Rehabil Res Dev. 1995;32:236 –244. 6 von Shroeder H, Coutts R, Lyden P, et al. Gait parameters following stroke: a practical assessment. J Rehabil Res Dev. 1995; 32:583–587. 7 Wall J, Turnbull G. Gait asymmetries in residual hemiplegia. Arch Phys Med Rehabil. 1986;67:550 –553. 8 Roth EJ, Merbitz C, Mroczek K, et al. Hemiplegic gait: relationships between walking speed and other temporal parameters. Am J Phys Med Rehabil. 1997; 76:128 –133. 9 Chen G, Patten C, Kothari D, Zajac F. Gait differences between individuals with poststroke hemiparesis and non disabled controls at matched speeds. Gait Posture. 2005;22:51–56. 10 Hsu A, Tang P, Jan M. Analysis of impairments influencing gait velocity and asymmetry of hemiplegic patients after mild to moderate stroke. Arch Phys Med Rehabil. 2003;8:1185–1193. 11 Lehmann J, Condon S, Price R, de Lateur B. Gait abnormalities in hemiplegia: their correction by ankle foot orthoses. Arch Phys Med Rehabil. 1987;68:763–771. 12 Lin PY, Yang YR, Cheng SJ, Wang RY. The relation between ankle impairments and gait velocity and symmetry in people with stroke. Arch Phys Med Rehabil. 2006; 87:562–568. 13 Balasubramanian CK, Bowden MG, Neptune RR, Kautz SA. Relationship between step length asymmetry and walking performance in subjects with chronic hemiparesis. Arch Phys Med Rehabil. 2007; 88:43– 49.

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Gait Symmetry Adaptations Following Unilateral Step Training in Hemiparesis 14 Dettmann MA, Linder MT, Sepic SB. Relationships among walking performance, postural stability, and functional assessments of the hemiplegic patient. Am J Phys Med. 1987;66:77–90. 15 Kim CM, Eng JJ. Symmetry in vertical ground reaction force is accompanied by symmetry in temporal but not distance variables of gait in persons with stroke. Gait Posture. 2003;18:23–28. 16 Hesse S, Bertelt C, Jahnke MT, et al. Treadmill training with partial body weight support compared with physiotherapy in nonambulatory hemiparetic patients. Stroke. 1995;26:976 –981. 17 Plummer P, Behrman AL, Duncan PW, et al. Effects of stroke severity and training duration on locomotor recovery after stroke: a pilot study. Neurorehabil Neural Repair. 2007;21:137–151. 18 Sullivan KJ, Knowlton BJ, Dobkin BH. Step training with body weight support: effect of treadmill speed and practice paradigms on poststroke locomotor recovery. Arch Phys Med Rehabil. 2002;83:683– 691. 19 Patterson SL, Rodgers MM, Macko RF, Forrester LW. Effect of treadmill exercise training on spatial and temporal gait parameters in subjects with chronic stroke: a preliminary report. J Rehabil Res Dev. 2008;45:221–228. 20 Silver KH, Macko RF, Forrester LW, et al. Effects of aerobic treadmill training on gait velocity, cadence, and gait symmetry in chronic hemiparetic stroke: a preliminary report. Neurorehabil Neural Repair. 2000;14:65–71. 21 Hornby TG, Campbell DD, Kahn JH, et al. Enhanced gait-related improvements after therapist- versus robotic-assisted locomotor training in subjects with chronic stroke: a randomized controlled study. Stroke. 2008;39:1786 –1792. 22 Winstein CJ, Gardner ER, McNeal DR, et al. Standing balance training: effect on balance and locomotion in hemiparetic adults. Arch Phys Med Rehabil. 1989; 70:755–762. 23 Anstis S. Aftereffects from jogging. Exp Brain Res. 1995;103:476 – 478. 24 Earhart GM, Jones GM, Horak FB, et al. Podokinetic after-rotation following unilateral and bilateral podokinetic stimulation. J Neurophysiol. 2002;87:1138 –1141. 25 Hong M, Perlmutter JS, Earhart GM. Podokinetic after-rotation in Parkinson disease. Brain Res. 2007;1128:99 –106.

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26 Reisman DS, Block HJ, Bastian AJ. Interlimb coordination during locomotion: what can be adapted and stored? J Neurophysiol. 2005;94:2403–2415. 27 Reisman DS, Wityk R, Silver K, Bastian AJ. Locomotor adaptation on a split-belt treadmill can improve walking symmetry poststroke. Brain. 2007;130(Pt 7):1861–1872. 28 Schmidt R, Lee T. Motor Control and Learning: A Behavioral Emphasis. 3rd ed. Champaign, IL: Human Kinetics Inc; 1999. 29 Reisman DS, Wityk R, Silver K, Bastian AJ. Does Split-Belt Treadmill Walking Adaptation Transfer to Overground Walking Post-Stroke? Atlanta, GA: Society of Neuroscience; 2006. 30 Brach JS, Berthold R, Craik RL, et al. Gait variability in community-dwelling older adults. J Am Geriatr Soc. 2001;49: 1646 –1650. 31 Pomeroy VM, Chambers SH, Giakas G, Bland M. Reliability of measurement of tempo-spatial parameters of gait after stroke using GaitMat II. Clin Rehabil. 2004;18:222–227. 32 Mahler D, Froelicher V, Miller N, York T. ACSM’s Guidelines for Exercise Testing and Prescription. 5th ed. Baltimore, MD: Williams & Wilkins; 1995. 33 Hassid E, Rose D, Commisarow J, et al. Improved gait symmetry in hemiparetic stroke patients induced during body weight supported treadmill stepping. J Neurol Rehabil. 1997;26:976 –981. 34 Ada L, Dean CM, Hall JM, et al. A treadmill and overground walking program improves walking in persons residing in the community after stroke: a placebocontrolled, randomized trial. Arch Phys Med Rehabil. 2003;84:1486 –1491. 35 Miyai I, Fujimoto Y, Yamamoto H, et al. Long-term effect of body weight-supported treadmill training in Parkinson’s disease: a randomized controlled trial. Arch Phys Med Rehabil. 2002;83:1370 –1373. 36 Trimble MH, Behrman AL, Flynn SM, et al. Acute effects of locomotor training on overground walking speed and H-reflex modulation in individuals with incomplete spinal cord injury. J Spinal Cord Med. 2001;24:74 – 80. 37 Weber KD, Fletcher WA, Gordon CR, et al. Motor learning in the “podokinetic” system and its role in spatial orientation during locomotion. Exp Brain Res. 1998;120: 377–385.

38 Lam T, Wolstenholme C, Yang JF. How do infants adapt to loading of the limb during the swing phase of stepping? J Neurophysiol. 2003;89:1920 –1928. 39 Morton SM, Bastian AJ. Cerebellar contributions to locomotor adaptations during split belt treadmill walking. J Neurosci. 2006;26:9107–9116. 40 Earhart GM, Fletcher WA, Horak FB, et al. Does the cerebellum play a role in podokinetic adaptation? Exp Brain Res. 2002; 146:538 –542. 41 Schauer M, Mauritz KH. Musical motor feedback (MMF) in walking hemiparetic stroke patients: randomized trials of gait improvement. Clin Rehabil. 2003;17: 713–722. 42 Thaut MH, McIntosh GC, Rice RR. Rhythmic facilitation of gait training in hemiparetic stroke rehabilitation. J Neurol Sci. 1997;151:207–212. 43 Smith GV, Silver KH, Goldberg AP, Macko RF. “Task-oriented” exercise improves hamstring strength and spastic reflexes in chronic stroke patients. Stroke. 1999;30: 2112–2118. 44 Werner C, Von Frankenberg S, Treig T, et al. Treadmill training with partial body weight support and an electromechanical gait trainer for restoration of gait in subacute stroke patients: a randomized crossover study. Stroke. 2002;33:2895–2901. 45 Perera S, Mody SH, Woodman RC, Studenski SA. Meaningful change and responsiveness in common physical performance measures in older adults. J Am Geriatr Soc. 2006;54:743–749. 46 Donelan JM, Kram R, Kuo AD. Mechanical work for step-to-step transitions is a major determinant of the metabolic cost of human walking. J Exp Biol. 2002;205(Pt 23): 3717–3727. 47 Kuo AD. A simple model of bipedal walking predicts the preferred speed-step length relationship. J Biomech Eng. 2001; 123:264 –269.

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Research Report

The Balance Evaluation Systems Test (BESTest) to Differentiate Balance Deficits Fay B Horak, Diane M Wrisley, James Frank FB Horak, PT, PhD, is Research Professor of Neurology and Adjunct Professor of Physiology and Biomedical Engineering, Department of Neurology, Oregon Health and Sciences University, West Campus, Building 1, 505 NW 185th Ave, Beaverton, OR 97006-3499 (USA). Address all correspondence to Dr Horak at: [email protected]. DM Wrisley, PT, PhD, NCS, is Assistant Professor, Department of Rehabilitation Science, University at Buffalo, Buffalo, New York. J Frank, PhD, is Dean of Graduate Studies, Department of Kinesiology, University of Windsor, Windsor, Ontario, Canada. [Horak FB, Wrisley DM, Frank J. The Balance Evaluation Systems Test (BESTest) to differentiate balance deficits. Phys Ther. 2009;89: 484 – 498.] © 2009 American Physical Therapy Association

Background. Current clinical balance assessment tools do not aim to help therapists identify the underlying postural control systems responsible for poor functional balance. By identifying the disordered systems underlying balance control, therapists can direct specific types of intervention for different types of balance problems.

Objective. The goal of this study was to develop a clinical balance assessment tool that aims to target 6 different balance control systems so that specific rehabilitation approaches can be designed for different balance deficits. This article presents the theoretical framework, interrater reliability, and preliminary concurrent validity for this new instrument, the Balance Evaluation Systems Test (BESTest).

Design. The BESTest consists of 36 items, grouped into 6 systems: “Biomechanical Constraints,” “Stability Limits/Verticality,” “Anticipatory Postural Adjustments,” “Postural Responses,” “Sensory Orientation,” and “Stability in Gait.” Methods. In 2 interrater trials, 22 subjects with and without balance disorders, ranging in age from 50 to 88 years, were rated concurrently on the BESTest by 19 therapists, students, and balance researchers. Concurrent validity was measured by correlation between the BESTest and balance confidence, as assessed with the Activities-specific Balance Confidence (ABC) Scale.

Results. Consistent with our theoretical framework, subjects with different diagnoses scored poorly on different sections of the BESTest. The intraclass correlation coefficient (ICC) for interrater reliability for the test as a whole was .91, with the 6 section ICCs ranging from .79 to .96. The Kendall coefficient of concordance among raters ranged from .46 to 1.00 for the 36 individual items. Concurrent validity of the correlation between the BESTest and the ABC Scale was r⫽.636, P⬍.01. Limitations. Further testing is needed to determine whether: (1) the sections of the BESTest actually detect independent balance deficits, (2) other systems important for balance control should be added, and (3) a shorter version of the test is possible by eliminating redundant or insensitive items. Conclusions. The BESTest is easy to learn to administer, with excellent reliability

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and very good validity. It is unique in allowing clinicians to determine the type of balance problems to direct specific treatments for their patients. By organizing clinical balance test items already in use, combined with new items not currently available, the BESTest is the most comprehensive clinical balance tool available and warrants further development.

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B

alance deficits are one of the most common problems treated by physical therapists. Therapists need to identify who has a balance problem and then decide the best approach to rehabilitation. Current standardized clinical balance assessment tools are directed at screening for balance problems and predicting fall risk, particularly in elderly people.1–7 These tools identify which patients may benefit from balance retraining, but they do not help therapists decide how to treat the underlying balance problems. Besides not being aimed at guiding treatment, the current balance assessment tools were developed specifically for older adults with balance problems. This article presents a new balance assessment tool developed to help physical therapists identify the underlying postural control systems that may be responsible for poor functional balance so that treatments can be directed specifically at the abnormal underlying systems.

Although many clinical tests are designed to test a single “balance system,” balance control is very complex and involves many different underlying systems.8 –11 Whereas previous motor control models assumed postural control consisted of heirarchical righting and equilibrium reflexes, we wanted to develop a clinical test of balance control based on Bernstein’s concept that postural control results from a set of interacting systems.11–16 Consistent with this “systems model of motor control,” recent research in our laboratory and others has demonstrated how constraints, or deficits, in different underlying systems can impair balance.10,11,13,15,17–20 Constraints on the biomechanical system, such as ankle or hip weakness and flexed postural alignment, limit the ability of frail elderly people and patients with Parkinson disease May 2009

(PD) to use an ankle strategy or compensatory steps for postural recovery.21,22 Constraints on the limits of stability (that is, how far the body’s center of mass can be moved over its base of support) and on verticality (that is, representation of gravitational upright), affected by sensory deficits or by stroke in the parietal cortex, may result in inflexible postural alignment or precarious body tilt.23,24 Constraints on anticipatory postural adjustments prior to voluntary movements depend on interaction of supplementary motor areas with the basal ganglia and brain-stem areas and result in instability during step initiation or during rapid arm movements while standing.25,26 Constraints on short, medium, and long proprioceptive feedback loops responsible for automatic postural responses to slips, trips, and pushes include late responses in patients with sensory neuropathy or multiple sclerosis, weak responses in patients with PD, and hypermetric responses in patients with cerebellar ataxia.27–31 Constraints on sensory integration for spatial orientation result in disorientation and instability in patients with deficits in pathways involving the vestibular system and sensory integrative areas of the temporoparietal cortex when the support surface or visual environments are moving.27,32,33 Constraints on dynamic balance during gait result from impaired coordination between spinal locomotor and brain-stem postural sensorimotor programs when the falling body’s center of mass must be caught by a changing base of foot support.34 In addition, cognitive constraints on executive or attentional systems can compound constraints in the other systems because each underlying neural control system for balance control requires cortical attention.12

Figure 1 shows the 6 interacting systems underlying control of balance that are targeted in our new Balance Evaluation Systems Test (BESTest). Each system consists of the neurophysiological mechanisms that control a particular aspect of postural control. Many of these systems are independent from each other in that different neural circuitry is involved, such that different pathologies may involve damage to different systems. For example, people with PD may have an abnormal system for stepping in response to an external perturbations but a normal sensory orientation system, which allows them to stand with eyes closed on an unstable surface by relying upon vestibular information.27,35 In contrast, people with loss of peripheral vestibular inputs may have abnormal sensory orientation with eyes closed on an unstable surface but normal postural responses to external perturbations.36,37 In current practice, computerized, dynamic posturography is based on the concept that the sensory orientation and postural motor reactions systems underlying balance can be separately measured and represent separate systems underlying control of balance.38 Thus, each patient with balance problems is likely to fall because of deficits in different underlying systems and may consequently fall in different environments and while performing different tasks. Therapists need to be able to differentiate the underlying systems’ contribution to bal-

Available With This Article at www.ptjournal.org • eAppendix: Balance Evaluation Systems Test (BESTest) • Audio Abstracts Podcast This article was published ahead of print on March 27, 2009, at www.ptjournal.org.

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Balance Evaluation Systems Test (BESTest) necessarily be correlated with how far a person can lean the body’s center of mass when not reaching.43,44 III. Anticipatory Postural Adjustments: This system includes tasks that require an active movement of the body’s center of mass in anticipation of a postural transition from one body position to another. For example, we include the transitions from a sitting to a standing position45 (item 9), from normal stance to stance on toes45 (item 10), and from 2-legged- to 1-legged stance46 (item 11). Item 12 involves repetitive weight shifting from leg to leg in anticipation of tapping a forefoot on a stool, and item 13 involves anticipatory postural adjustments prior to rapid, bilateral arm raises with a weight.47,48

Figure 1. Model summarizing systems underlying postural control corresponding to sections of the Balance Evaluation Systems Test (BESTest).

ance problems and fall risk in their patients in order to appropriately direct intervention. Table 1 summarizes the performance tasks grouped under each postural system for the BESTest. The entire BEStest with scoring, examiner, and patient instructions is presented in the eAppendix (available at: www. ptjournal.org). The performance tasks are grouped to reveal function or dysfunction of a particular system underlying balance control (see reviews by Horak and colleagues8 –11). Here, we briefly summarize the role of these systems in balance control and how each task item is related to its system: I. Biomechanical Constraints: Biomechanical constraints for standing balance include the quality of the base of foot support (item 1), geometric postural alignment (item 2), 486

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functional ankle and hip strength (force-generating capacity) for standing (items 3 and 4), and ability to rise from the floor to a standing position (item 5).39 II. Stability Limits/Verticality: This system includes items for an internal representation of how far the body can move over its base of support before changing the support or losing balance, as well as an internal perception of postural vertical.40,41 The ability to lean as far as possible in a sitting position with eyes closed (item 6) provides a measure of lateral limits of stability in a sitting posture, and the ability to realign the trunk and head back to perceived vertical (item 6) provides a measure of internal representation of gravity. The ability to reach maximally forward and laterally while standing (items 7 and 8) represents the functional limits of stability, although this may not

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IV. Postural Responses: Reactive postural responses include both inplace and compensatory stepping responses to an external perturbation induced by the examiner’s hands using the unique “push and release” technique.49 To induce an automatic postural response with the patient’s feet in place (ankle or hip strategy), the tester pushes isometrically against either the front (item 14) or back (item 15) of the patient’s shoulders until either the toes or the heels just begin to raise without changing the initial position of the body’s center of mass over the feet before suddenly letting go of the push. To induce compensatory stepping responses, the tester requires a forward (item 16) or backward (item 17) or lateral (item 18) lean of the patient’s center of mass over the base of foot support prior to release of pressure, requiring a fast, automatic step to recover equilibrium.49,50 V. Sensory Orientation: This system identifies any increase in body sway during stance associated with altering visual or surface somatosensory information for control of standing May 2009

Balance Evaluation Systems Test (BESTest) Table 1. Summary of Balance Evaluation Systems Test (BESTest) Items Under Each System Categorya III. Anticipatory Postural Adjustments

I. Biomechanical Constraints

II. Stability Limits/Verticality

1. Base of support

6. Sitting verticality (left and right) and lateral lean (left and right)

2. CoM alignment

7. Functional reach forward

10. Rise to toes

15. In-place response, backward

3. Ankle strength and ROM

8. Functional reach lateral (left and right)

11. Stand on one leg (left and right)

16. Compensatory stepping correction, forward

4. Hip/trunk lateral strength

12. Alternate stair touching

17. Compensatory stepping correction, backward

5. Sit on floor and stand up

13. Standing arm raise

18. Compensatory stepping correction, lateral (left and right)

9. Sit to stand

IV. Postural Responses

V. Sensory Orientation

14. In-place response, forward

19. Sensory integration for balance (modified CTSIB) Stance on firm surface, EO Stance on firm surface,EC Stance on foam, EO Stance on foam, EC

VI. Stability in Gait 21. Gait, level surface

22. Change in gait speed 23. Walk with head turns, horizontal

20. Incline, EC

24. Walk with pivot turns

25. Step over obstacles

26. Timed “Get Up & Go” Test 27. Timed “Get Up & Go” Test with dual task a

CoM⫽center of mass, ROM⫽range of motion, CTSIB⫽Clinical Test of Sensory Integration for Balance, EO⫽eyes open, EC⫽eyes closed.

balance. Item 19 is the modified Clinical Test of Sensory Integration for Balance51 (CITSIB), and item 20 involves standing on a 10-degree, toes-up incline with eyes closed. VI. Stability in Gait: This system includes evaluation of balance during gait (item 21) and when balance is challenged during gait by changing gait speed52 (item 22), by head rotations53 (item 23), by pivot turns (item 24), and by stepping over obstacles54 (item 25). This section also includes the Timed “Get Up & Go” Test, which evaluates how fast a patient can sequence rising from a chair, walking 3 m, turning, and sitting back down again without (item 26) and with (item 27) a secondary cognitive task to challenge the patient’s attention.55 Although several separate neural systems underlie control of balance, May 2009

each task may involve more than one system that interacts with others. For example, the task of tapping alternate feet onto a stair (item 12) is placed in the “Anticipatory Postural Adjustments” system because it requires adequate anticipatory postural weight shifting from one leg to the other. However, it also requires an adequate base of support and strength in the hip abductors (“Biomechanical Constraints” system). Interactions among systems can be seen by how a single pathology, such as abnormal vestibular function, will likely affect several tasks, such as the ability to stand on foam with eyes closed (item 19 in the “Sensory Orientation” system) and the ability to rotate the head while walking (item 23 in the “Stability in Gait” system). Future studies are needed to determine the extent to which postural system problems cluster, such that

disorders in each system can be differentiated in the clinic. The purpose of this article is to present the BESTest, with its theoretical framework and its first interrater reliability and concurrent validity analysis. This is the first step in maximizing the psychometric properties of this new balance assessment tool.

Method Development of the BESTest The conceptual framework for developing a balance assessment tool that separates control of balance into its underlying systems is based on the scientific literature about laboratory measures of postural disorders in elderly people and in people with neurological disorders.8 –11 The principle of having physical therapists evaluate 6 subcomponent systems underlying balance function initially was suggested as a qualitative assess-

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Balance Evaluation Systems Test (BESTest) Table 2. Balance Tasks in the Balance Evaluation Systems Test (BESTest) That Have Been Borrowed From Existing Clinical Testsa Clinical Test

BESTest Item

Functional Reach Test

Fregly Single-Limb Stance Test

Berg Balance Scale

7. Functional reach forward

11. Stand on one leg, right

12. Alternate stair touching

8. Functional reach lateral, right

11. Stand on one leg, left

8. Functional reach lateral, left

CTSIB

Dynamic Gait Index

19. Sensory integration for balance, stance on firm surface, EO

21. Gait, level surface

19. Sensory integration for balance, stance on firm surface, EC

22. Change in gait speed

19. Sensory integration for balance, stance on foam, EO

23. Walk with head turns, horizontal

19. Sensory integration for balance, stance on foam, EC

24. Walk with pivot turns

Timed “Up & Go” Test 26. Timed “Get Up & Go” Test

25. Step over obstacles a

CTSIB⫽Clinical Test of Sensory Interaction on Balance, EO⫽eyes open, EC⫽eyes closed.

ment by Horak and Shumway-Cook in their continuing medical education courses between 1990 and 1999.15–17,19,56,57 After Horak and Frank developed the BESTest, thousands of experienced physical therapy clinicians contributed to continued development of the BESTest by providing feedback about clarity, sensitivity, and practicality of items across 38 continuing education workshops delivered by Horak between 1999 and 2005. Following 2 days of didactic and observational training in the test, therapists in the workshops practiced performance of the test on each other and provided critical feedback to improve the clarity and specificity of instructions to patients and therapists. Some of the balance tasks in the test have been borrowed from current assessment tools, although they are now placed within our theoretical framework and the therapist and patient instructions, and most of the rating scales have been modified to improve consistency and reliability (Tab. 2). This is the first balance assessment tool to include a clinical method for assessing postural responses to external perturbations (section IV) and verticality (section II).

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The BESTest consists of 27 tasks, with some items consisting of 2 of 4 subitems (eg, for left and right sides), for a total of 36 items. Each item is scored on a 4-level, ordinal scale from 0 (worst performance) to 3 (best performance). Scores for the total test, as well as for each section, are provided as a percentage of total points. Specific patient and rating instructions and stopwatch and ruler values are used to improve reliability (see the eAppendix for the full test). Session 1: Raters and Subjects To evaluate the interrater reliability and internal consistency of the original version of the BESTest (current sections II–VI), we recruited 12 ambulatory adults with a wide range of balance function. Subjects were recruited as a sample of convenience from individuals who previously had participated in research studies on balance and postural control. No subjects had completed the BESTest prior to the first session. However, subjects may have completed specific items that were adapted from other clinical tests such as the Dynamic Gait Index. For this session, we included 3 subjects with PD, 5 subjects with vestibular dysfunction

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(3 with bilateral loss, 2 with unilateral loss), 1 subject with peripheral neuropathy and a total hip arthroplasty, and 3 subjects who were healthy (controls) (Tab. 3). All subjects met the following inclusion criteria: (1) ability to follow 3-step commands, (2) ability to provide informed consent, (3) ability to ambulate 6 m (20 ft) without human assistance, and (4) ability to tolerate the balance tasks without excessive fatigue. Subjects were provided short rest breaks as needed. The subjects (5 female, 7 male) ranged in age from 50 to 80 years (X⫽63, SD⫽10). Descriptive information for the subjects who completed the BESTest is listed in Table 3. None of the subjects used an assistive device during the testing. The 9 raters consisted of a convenience sample of 6 physical therapists from various practice settings and 3 Doctor of Physical Therapy students from Pacific University (mean age⫽33.1 years, SD⫽4.7; 3 male, 6 female; Tab. 3). Physical therapists were included if they had a valid Oregon physical therapist license, and physical therapist students were included if they had completed the relevant course work in

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Balance Evaluation Systems Test (BESTest) Table 3. Descriptive Information on the Raters and Subjectsa Descriptive information on the Raters Using the BESTest

Session 1: BESTest Sections II–VI

Session 2: BESTest Section I and Revised Section VI

Rater No.

Years of Practice

1

0

2 3 *

Clinical Setting

Orthopedic Experience

Balance Experience

Neurologic Experience

Student

0

0

0

0

Student

0

0

0

0

Student

0

0

0

4

4

Research

1

0

4

5

4

OP orthopedics

4

0

0

6

5

IP acute care

5

0

0

7

12

OP neurology

0

12

12

8

13

Faculty

0

10

10

9 *

19

Research

3

13

19

1

0

Research

0

0

0

2

0

Research

0

0

0

3 *

1

OP neurology

0

1

1

4

4

Research

0

4

4

5

14

Home care

6

19

OP orthopedics

7*

20

8

22

0

11

11

16

15

15

Faculty

3

14

20

OP neurology

5

14

18

9

22

Faculty

1

15

22

10

28

OP neurology

1

25

25 (Continued)

relation to the evaluation and treatment of balance disorders. Session 2: Raters and Subjects After initial analysis of the first reliability data, a second testing session 18 months later evaluated the interrater reliability of a newly developed section I (“Biomechanical Constraints”) and a revised section VI (“Stability in Gait”). Section VI was revised due to a low intraclass correlation coefficient (ICC [2,1]⫽.54) obtained in the first session. The goals of this second testing session were to improve the reliability of section VI by modifying the criteria for scoring and requiring raters to view subjects from the front or back while walking and to add section I on biomechanical constraints affecting postural control. Testing session 2 involved 11 raters, including 3 raters May 2009

from the first session (denoted by asterisks in Tab. 3). No students were included, although 2 raters were PhD researchers in human balance disorders without any physical therapy training or experience (Tab. 3). Eleven subjects, including 4 subjects from the first session, were administered 2 sections of the BESTest. As in the first session, subjects were a sample of convenience recruited from individuals who had previously participated in laboratory studies but who had no experience with the BESTest. Subjects in session 2 met the same inclusion criteria as in session 1. The subjects consisted of 6 subjects who were healthy (controls), 1 subject with unilateral vestibular loss, 1 subject with bilateral vestibular loss, 2 subjects with PD, and 1 subject with both peripheral neuropathy and bilateral hip arthro-

plasty. The subjects (5 female, 6 male) ranged in age from 67 to 88 years (X⫽75, SD⫽7.6). The data and analysis from sections I through IV (current sections II–V) of session I and the new section I and revised section VI from session 2 are presented in this article. For both sessions, each subject completed an informed consent statement according to the Declaration of Helsinki. Procedure All raters were provided with the BESTest and written instructions for administering the test approximately 1 week prior to the session. On the day of the study, the raters participated in a 45-minute training session with one of the developers of the BESTest (FBH). For training raters, each item of the BESTest was dem-

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Balance Evaluation Systems Test (BESTest) Table 3 Continued Descriptive Information on the Subjects Completing the BESTest

Session 1: BESTest Sections I–VI

Session 2: BESTest Section I and Revised Section VI

Subject No.

Age (y)

Sex

ABC Scale

Falls

BESTest Total Score

1

56

F

Control

99

0

95.83

2*

64

3*

77

M

Control

99

0

86.46

M

Control

95

0

89.58

4 5

56

F

UVL

66

0

79.17

80

M

UVL

78

0

61.46

6

50

F

BVL

55

0

71.88

7

57

F

BVL

64

1

83.33

8

64

M

BVL

72

0

88.54

9

62

M

PD

57

0

68.75

10*

65

M

PD

70

0

78.13

11

75

M

PD

53

0

63.54

Diagnosis

12*

75

F

PNP, THA

73

0

76.04

1

53

M

UVL

94

0

NA

2

66

F

Control

100

0

NA

3*

67

M

Control

93

0

NA

4

73

F

Control

97

0

NA

5*

79

M

Control

93

0

NA

6

81

F

Control

91

0

NA

7

83

M

Control

93

0

NA

8

88

F

BVL

57

1

NA

9*

68

M

PD

73

0

NA

10

69

M

PD

83

0

NA

11*

77

F

PNP, THA

74

0

NA

a

BESTest⫽Balance Evaluation Systems Test. ABC Scale⫽Activities-specific Balance Confidence Scale, OP⫽outpatient, IP⫽inpatient, F⫽female, M⫽male, UVL⫽unilateral vestibular loss, BVL⫽bilateral vestibular loss, PD⫽Parkinson disease, PNP⫽peripheral neuropathy, THA⫽total hip arthroplasty, NA⫽not applicable. Asterisk indicates participation in both sessions.

onstrated on a subject who did not participate in the reliability study, and the rating criteria were discussed. The raters were allowed to ask questions regarding the scoring of the test. However, the raters were instructed to rate each outcome with no assistance or discussion with the other raters. The BESTest took 20 to 30 minutes to administer. During the experimental sessions, the raters were asked to concurrently rate each of the subjects. In both sessions 1 and 2, one of the authors (FBH), who was not one of the raters, administered the BESTest 490

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once for each subject while the raters observed. The raters were allowed to position themselves around the area where the subjects were performing the test and to move about as needed in order to optimally view the subjects’ performance for recording the outcome. Only one opportunity was provided to view the performance of each test item. If a rater missed the performance of an item, the item was repeated (3 items for session 1 and 1 item for session 2), and all of the raters scored the second performance for consistency. Raters were provided with separate scoring sheets

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for each subject and did not discuss scoring among subjects. The raters were instructed to rate each outcome independently, with no assistance from or discussion with the other raters. The diagnoses of the subjects who completed the BESTest were masked from the raters. To begin to describe concurrent validity, subjects completed the Activities-specific Balance Confidence (ABC) Scale.58 The ABC Scale quantifies how confident a person feels that he or she will not lose balance while performing 16 activities of daily living. The ABC Scale has demMay 2009

Balance Evaluation Systems Test (BESTest) onstrated test-retest reliability (r⫽.92).59 Scores on the ABC Scale range from 0, indicating no confidence, to 100, indicating complete confidence in the person’s ability to perform the task without losing balance. Scores on the ABC Scale have been correlated with ratings of older adults’ level of community function.60 Data Analysis Interrater agreement for individual BESTest items was determined using the Kendall coefficient of concordance for ordinal data.61 Concurrent validity was assessed by analyzing the correlation of the BESTest total and subsection scores of the rater with the most exposure to the BESTest (DMW) with the ABC Scale scores using the Spearman correlation coefficient. Coefficients of .00 to .25 were interpreted to indicate little to no relationship, .25 to .50 as a fair relationship, .50 to .75 as a moderate to good relationship, and above .75 as a strong relationship.1,2,4,5,62 A Mann-Whitney U test was used on the ranking of BESTest total scores (of the rater with the most exposure to the BESTest) among subjects to determine whether the 3 controls scored better than the 7 subjects with balance problems.

Results Interrater Reliability Interrater reliability statistics for BESTest total and subsection scores are presented in Table 4. The interrater reliability of the BESTest total scores was excellent, with an ICC (2,1) of .91. Subsection ICCs ranged from .79 to .96, and Kendall coefficients ranged from .79 to .95, indicating good to excellent reliability. Reliability statistics for individual BESTest items are presented in Figure 2. Individual items demonstrated Kendall coefficients ranging from .46 to 1.00. Items based on stopwatch time, such as items in section V (“Sensory Orientation”), tended to May 2009

Table 4. Interrater Reliability Statistics for Balance Evaluation Systems Test (BESTest) Section and Total Scoresa

BESTest Section

a

ICC, Mean (95% CI)

Kendall Coefficient of Concordance for Ordinal Measures, Mean (95% CI)

Section I. Biomechanical Constraints

.80 (.63–.93)

.79 (.73–.85)

Section II. Stability Limits/Verticality

.79 (.63–.92)

.86 (.84–.88)

Section III. Anticipatory Postural Adjustments

.92 (.85–.97)

.92 (.91–.93)

Section IV. Postural Responses

.92 (.85–.97)

.91 (.90–.92)

Section V. Sensory Orientation

.96 (.92–.99)

.95 (.947–.953)

Section VI. Stability Gait

.88 (.76–.96)

.93 (.90–.96)

Total

.91 (.83–.97)

ICC⫽intraclass correlation coefficient, CI⫽confidence interval.

show the highest concordance, whereas judgments of alignment, ankle strength, and sitting limits of stability and verticality tended to show the lowest concordance. Only 3 items could not have concordance measured accurately because of limited variability among subjects (denoted by asterisks in Fig. 2). All raters scored all subjects as excellent (score of 3) on standing arm raise, and they scored the majority of subjects as excellent on the alternate stair touch (92%) and stance with eyes open (98%). The ICCs for the BESTest total scores were .94 among the 3 students and .87 among the 6 therapists. The ICCs for each item within section VI (“Stability in Gait”) improved for the second interrater testing session compared with the first session, by instructing raters to view the subjects’ gait from the front or back rather than from the side. The ICCs for the BESTest total scores for items in section VI increased from .54 to .88, with the range of Kendall coefficients for individual items of .51 to .72 for the first interrater testing session increasing to a range of .62 to .90 for the second interrater testing session.

Test Performance The subjects showed a wide range of variability on their performance of the test (Fig. 3). Figure 3 presents the median and interquartile ranges of BESTest total scores (expressed as percentages) across diagnostic categories. Median scores of all subjects ranged from 65% to 95%, with control subjects clustered at the high end and subjects with PD clustered at the low end. The Mann-Whitney U test showed that control subjects scored significantly higher (better) than the subjects with balance problems (P⫽.036). Consistent with our theoretical construct, the scores for each BESTest section by diagnostic subgroup (Tab. 5) show that the subjects with unilateral vestibular loss scored the worst in section V (“Sensory Orientation”) (60%), whereas the subjects with PD scored the worst in section IV (“Postural Responses”) (50%). The 1 subject with neuropathy scored the worst on section III (“Anticipatory Postural Adjustments”). Although this score was similar to that of the subjects with unilateral vestibular loss (67% versus 69%), the subject with neuropathy could be distinguished by a much higher

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Figure 2. Kendall coefficient of concordance scores for individual items of the Balance Evaluation Systems Test (BESTest). Error bars indicate 95% confidence interval. Asterisk indicates Kendall coefficient of concordance unable to be calculated accurately due to lack of variance in the data. EO⫽eyes open, EC⫽eyes closed.

score on section V (“Sensory Orientation”) (93% versus 60%) and a higher BESTest total score (79% versus 73%). The most difficult items for our subjects were: single-limb stance, stance on foam with eyes closed, Timed “Get Up & Go” Test with a cognitive task, walk with horizontal head turns, backward in-place postural responses, and standing hip strength. In one item (standing arm raise), all subjects had perfect scores; the other least-difficult items included stance with eyes open, alternate stair touch, sitting verticality and leans, and stance with eyes closed. Sorted by difficulty, the mean score (SD) 492

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and the frequency of how often a score was given for an individual item are summarized in Table 6. Variability among subjects and raters provided a wide range of scores across BESTest items.

best correlation with the ABC Scale scores (r⫽.78), and Section III (“Anticipatory Postural Adjustments”) scores had the worst correlation (r⫽.41).

Discussion and Conclusions Concurrent Validity With ABC Scale The BESTest total scores correlated significantly with each subject’s balance confidence, as measured by the subject’s average ABC Scale score (r⫽.685, r2⫽.47, P⬍.05; Fig. 4). The ABC Scale scores demonstrated moderate correlation with the BESTest section scores of the BESTest (r⫽.41–.78). Section II (“Stability Limits/Verticality”) scores had the

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This study presents a new clinical balance assessment tool that is the first tool aimed at distinguishing the underlying systems that may be contributing to balance problems in individual patients. By distinguishing which systems underlying balance control are affected, this is the first clinical balance assessment tool to help direct rehabilitation of people with balance disorders. The most important contribution of the BESTest May 2009

Balance Evaluation Systems Test (BESTest) is to provide a conceptual framework around which to evaluate and treat patients with different types of balance problems. Most existing clinical balance tests are directed at predicting fall risk or whether a balance problem exists, rather than what type of balance problem exists.1– 6 Although these tests have proven valid in predicting the likelihood of future falls, with sensitivity and specificity values of 80% to 90%, the test results do not help therapists direct treatment.63– 65 Lord et al1 developed a different type of test, directed at identifying physiological impairments that could affect balance, such as impaired proprioception, visual function, or reaction time delays. Although the test is helpful for understanding the physiological reasons for balance problems, it is not apparent how to translate many of the impairments into specific balance exercise programs. Identification of impairments may help to identify the pathology, such as peripheral neuropathy or vestibular loss, that may be responsible for the balance problem. However, therapeutic exercise is not best designed based on pathology, because the functional ability of each patient is multifactorial and depends not only on the patient’s pathology but also on the patient’s compensation, experience, motivation, prior and concurrent pathologies, age, and so on. It is especially critical, however, to stop conceptualizing balance as a single system so that treatment can be more specific than generalized “balance training” for a generalized “balance problem.” There is little evidence of carryover from learning one motor task to a different motor task, so practicing grapevine stepping in balance training is unlikely to improve functional limits of stability, postural responses to perturbations, or the ability to use vestibular inMay 2009

Figure 3. Median and interquartile range of Balance Evaluation Systems Test (BESTest) total scores across diagnostic categories for sections II through VI in testing session 1. Note the variation in scores among subjects tested. UVL⫽unilateral vestibular loss, BVL⫽bilateral vestibular loss, PD⫽Parkinson disease, PNP⫽peripheral neuropathy.

formation for balance. If a patient shows difficulty on a particular section of the BESTest, the therapist should not limit therapy to practicing the specific tasks that were difficult for the patient but should aim therapy at the underlying system deficit.66 If the BESTest is valid in supporting the conceptual framework that bal-

ance function can be divided into separate underlying systems, we would expect some patients to perform poorly in different subcategories compared with other patients. Even with our small sample of subjects, the 3 subjects with PD tended to perform poorly on items in section IV (“Postural Responses”), whereas the 3 subjects with vestibular loss performed poorly on items

Table 5. Percentage Score in Each Balance Evaluation Systems Test (BESTest) Section and Total Score in Session 1 by Diagnostic Group Diagnostic Group

Section II

Section III

Section IV

Section V

Section VI

Total

Control (n⫽3)

100

81

88

91

89

94

BVL (n⫽3)

83

76

83

78

84

85

PNP (n⫽1)

71

67

78

93

76

79

UVL (n⫽2)

75

69

69

60

74

73

PD (n⫽3)

76

72

50

71

78

73

a BVL⫽bilateral vestibular loss, PNP⫽peripheral neuropathy, UVL⫽unilateral vestibular loss, PD⫽Parkinson disease.

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Balance Evaluation Systems Test (BESTest) Table 6. Means, Standard Deviations, and Distribution of Balance Evaluation Systems Test (BESTest) Scores Within Each Balance Item Listed by Item Difficultya Frequency Section

Item

Mean

SD

0

1

2

3

Total

III

11. Stand on one leg, right

1.13

0.98

29

51

11

17

108

III

11. Stand on one leg, left

1.18

1.01

29

52

9

18

108

V

19. Stance on foam, EC

1.30

1.01

18

63

3

24

108

VI

27. Timed “Get Up & Go” Test with dual task

1.33

1.06

31

29

31

18

109

VI

23. Walk with head turns, horizontal

1.40

1.03

21

48

17

24

110

IV

15. In-place response, backward

1.57

0.79

9

37

54

8

108

I

4. Hip/trunk lateral strength

1.59

1.17

31

13

36

30

110

VI

25. Step over obstacles

1.87

1.24

28

8

24

50

110

VI

24. Walk with pivot turns

1.95

0.95

2

46

18

44

110

I

3. Ankle strength and ROM

1.99

1.09

11

32

14

53

110

IV

17. Compensatory stepping correction, backward

2.18

0.62

2

7

68

31

108

I

5. Sit on floor and stand up

2.19

1.25

21

10

2

72

105

II

8. Functional reach lateral, left

2.22

0.41

0

0

84

24

108

IV

14. In-place response forward

2.26

0.66

1

8

65

34

108

V

19. Stance on foam, EO

2.26

1.03

9

19

15

65

108

III

10. Rise to toes

2.32

0.72

0

17

42

49

108

IV

16. Compensatory stepping correction, forward

2.32

0.71

2

8

52

46

108

II

8. Functional reach lateral, right

2.38

0.49

0

0

67

41

108

VI

21. Gait, level surface

2.39

0.78

2

14

33

61

110

IV

18. Compensatory stepping correction, lateral (left)

2.40

0.75

0

16

31

60

107

IV

18. Compensatory stepping correction, lateral (right)

2.43

0.86

0

27

9

72

108

I

1. Base of support

2.48

0.86

4

14

17

74

109

I

2. CoM alignment

2.49

0.81

4

10

24

72

110

V

20. Incline, EC

2.53

0.70

1

8

29

70

108

II

7. Functional reach forward

2.56

0.50

0

0

48

60

108

VI

26. Timed “Get Up & Go” Test

2.56

0.78

2

13

16

77

108

VI

22. Change in gait speed

2.60

0.79

0

21

2

87

110

II

6. Sitting lateral lean, right

2.61

0.61

0

7

24

77

108

II

6. Sitting lateral lean, left

2.65

0.50

0

1

32

75

108

II

6. Sitting verticality, left

2.66

0.51

0

2

29

77

108

V

19. Stance on firm surface, EC

2.66

0.75

0

18

1

89

108

III

9. Sit to stand

2.73

0.69

0

13

0

94

107

II

6. Sitting verticality, right

2.85

1.84

0

3

29

76

108

III

12. Alternate stair touching

2.92

0.28

0

0

9

99

108

V

19. Stance on firm surface, EO

2.98

0.13

0

0

1

107

108

III

13. Standing arm raise

3.00

0.00

0

0

0

108

108

a

Frequency⫽how often each rating was provided for an individual item. Total⫽total number of ratings for each item (items have different totals due to missing data). Means, standard deviations, and frequency for items 6 –20 reported for session 1 and frequency for items 1–5 and 21–27 reported for session 2. EO⫽eyes open, EC⫽eyes closed, ROM⫽range of motion, CoM⫽center of mass.

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Balance Evaluation Systems Test (BESTest) in section V (“Sensory Orientation”). Laboratory studies of postural responses and the ability to maintain equilibrium in stance under different sensory conditions in patients with PD, unilateral vestibular loss, or bilateral vestibular loss support these trends in our study.67– 69 In contrast to the subjects with PD and vestibular loss, the one subject with peripheral neuropathy combined with bilateral total hip arthroplasty scored worst on items in section III (“Anticipatory Postural Adjustments”). Based on these differential results, therapists would direct the patients with PD to practice compensatory stepping in response to perturbations,70 the patients with unilateral vestibular loss to practice balancing in conditions requiring use of the remaining vestibular information,66 and the patient with peripheral neuropathy to practice moving from one stable posture to another.62 Of course, other patients with these same pathologies may show different profiles in the BESTest, depending on their compensation strategies, which may affect their ability to overcome limitations from physiological constraints to perform a task using an alternative strategy. Although the categories of systems in the BESTest were selected from current, scientific understanding of neurophysiological systems underlying postural control, the systems are quite interdependent. For example, constraints on the base of foot support (item 1) will necessarily affect the forward limits of postural stability in standing (item 7), and difficulty using vestibular information to stand on foam with eyes closed (item 19D) may make it difficult to perform head turns during gait (item 23). Furthermore, the tasks selected to reveal function of each of the 6 postural systems may not be ideal; some tasks are likely too easy to be discriminatory. For example, the standing arm raise to look for anticipatory postural May 2009

Figure 4. Correlation between subjects’ Activities-specific Balance Confidence (ABC) Scale mean scores and their Balance Evaluation Systems Test (BESTest) total scores (from testing session 1 raters’ median scores).

adjustments (item 13) and stance with eyes open to examine postural sway (item 19) may only be sensitive in a laboratory, where surface reactive forces or body kinematics can be measured to detect physiologically significant, but not clinically apparent, changes in postural control. All of our subjects also scored a perfect 3 on alternate stair touch (item 12), adapted from the Berg Balance Scale,62 but this may be a problem with the excessively long time criteria (within 20 seconds) for doing only 8 steps, so we recommend increasing the number of steps to 15 in order to determine the number of steps completed per second. Further psychometric testing on large groups of patients with a variety of

balance problems will reveal which items naturally group together and may suggest that some items should be moved or eliminated or altered, or even that a new system category should be added (ie, cognitive interference with balance performance). With an ICC of .91 for BESTest total scores, the interrater reliability for the BESTest is excellent71 and just as good, or better than, the current, shorter balance assessment batteries (Berg Balance Scale: ICC⫽ .9872; Tinetti Mobility Assessment: ICC⫽.75–1.042). Subsections of the BESTest adapted from established tests in the literature also show reliability similar to or better than that previously reported: Functional Reach Test

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Balance Evaluation Systems Test (BESTest) ICC⫽.9873 compared with BESTest section II ICC⫽.79; CTSIB ICC⫽ .7474 compared with BESTest section V ICC⫽.96; Dynamic Gait Index kappa⫽.642 and Timed “Get Up & Go” Test ICC⫽.997 compared with BESTest section VI ICC⫽.88. The interrater reliability of each section of the BESTest is sufficiently strong to allow therapists to use an individual section if they are short on time or want to direct a balance test at a specific postural system.75 An abbreviated test would be helpful because the BESTest takes about 30 minutes to carry out, even by an experienced therapist. Future studies are needed to identify redundant and insensitive items and to eliminate unnecessary items that do not add value to the test. Inexperienced raters, without physical therapy experience, were able to learn how to score the BESTest with prior review and 45 minutes of instruction with demonstration. This unfamiliarity may have caused raters to be unsure of how to score a particular item or to make an error when recording a score. The reliability of Peabody Motor Developmental Scales-2 scores has been shown to increase as familiarity with the test increased.76 Because some of the items are novel and required specific hand positions and instructions, actual demonstration and training may be necessary for excellent interrater reliability, as well as for safety. Specifically, the push and release technique to elicit automatic postural responses by suddenly releasing the subjects’ leans requires observation and practice with at least video demonstration. Because the compensatory stepping postural responses necessarily required to move the body’s center of mass beyond the limits of the base of foot support, these items also are the most dangerous to test in patients with balance disorders and, therefore, require special training. In some cases, subjects 496

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who are judged to be prone to a fall if attempting these items should automatically receive a score of 0 or not be tested in order to avoid a fall. Some scores, such as those for section IV (“Postural Responses”), may have been even more reliable if the raters also were physically performing the BESTest, although other scores, such as those for functional reach (items 7–9), were likely better because subjects could be viewed from a distance, without standby assistance for safety in our study. In this study, we found that it is important for raters to stand in front or in back of subjects, rather than parallel with them, while they are walking in items for section VI (“Stability in Gait”) in order to view potential lateral postural instability during gait. To improve reliability, we have since developed an educational DVD to train therapists how to administer and score the BESTest.* The strong agreement between the BESTest total score and subjects’ rating of their balance confidence in the ABC Scale suggests that the BESTest measures aspects of balance functionally relevant to patients. The ABC Scale has been shown to be related to patients’ actual unwillingness to engage in activities in the community due fear of falling.59 However, treatments cannot be designed based solely on the ABC Scale, and a current study is investigating the relationship between the BESTest and the Berg Balance Scale and prospective falls in patients with a wide range of pathologies and abilities. Limitations This study had several limitations. It is possible that other systems impor* The BESTest Training DVD is distributed through Oregon Health and Science University’s Technology and Research Collaborations Office and is available via a nonexclusive license. See: http://www.ohsu.edu/tech-transfer/ portal/technology.php?technology_id⫽217191.

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tant for balance control are missing from the test and only the last item is related to cognitive constraints on balance, and this may be inadequate. Whether or not the sections of the BESTest accurately detect dissociable balance deficits remains to be investigated to establish its construct validity. How well section III (“Postural Responses”) and section IV (“Sensory Orientation”) are related to similar measures using computerized posturography is unknown. Sections I and II should be revised to improve their test-retest reliability. In addition, the test is quite long, such that future clinimetric studies need to identify redundant, insensitive items for a more efficient clinical tool. We also do not know how sensitive the BESTest is to change with intervention. Further psychometric testing is warranted for the BESTest to establish its construct and concurrent validity, sensitivity and specificity, and ability to direct effective treatment for people with balance disorders. The scale is quantitative, and scoring is reproducible both for the test as a whole and for its subsections, as demonstrated by agreement among raters with varying experience. The BESTest appears to be testing functionally relevant aspects of balance control as seen by the agreement with subjects’ self-reported balance confidence. However, success of the BESTest will depend on how useful it is in assisting therapists to organize their systematic assessment of balance disorders to develop specific treatments based on each individual’s balance constraints. All authors provided concept/idea/project design and writing. Dr Horak and Dr Wrisley provided data collection and analysis, project management, fund procurement, and subjects. Dr Horak provided facilities/ equipment, institutional liaisons, and clerical support. Dr Horak and Dr Frank provided

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Balance Evaluation Systems Test (BESTest) consultation (including review of manuscript before submission). The authors thank Larry Meyer and Trent Thompkins for collecting data on the first interrater reliability study as part of their Doctor of Physical Therapy thesis, as well as all of the subjects and raters who participated in this study. The authors also are indebted to the physical therapists who provided helpful criticisms of early versions of the test in continuing education workshops by Dr Horak. Statistical support from Dr George Knafl and Dawn Peters also is appreciated. This work was supported by the National Institute on Aging grant R0-1 AG006457. Poster presentations of this research were given at the Combined Sections Meetings of the American Physical Therapy Association; February 4 – 8, 2004; Nashville, Tennessee; and February 23–27, 2005; New Orleans, Louisiana. This article was received March 10, 2008, and was accepted January 30, 2009. DOI: 10.2522/ptj.20080071

References 1 Lord SR, Clark RD, Webster IW. Physiological factors associated with falls in an elderly population. J Am Geriatr Soc. 1991; 39:1194 –1200. 2 Podsiadlo D, Richardson S. The timed “Up & Go”: a test of basic functional mobility for frail elderly persons. J Am Geriatr Soc. 1991;39:142–148. 3 Berg KO, Maki BE, Williams JI, et al. Clinical and laboratory measures of postural balance in an elderly population. Arch Phys Med Rehabil. 1992;73:1073–1080. 4 Shumway-Cook A, Baldwin M, Polissar NL, Gruber W. Predicting the probability for falls in community-dwelling older adults. Phys Ther. 1997;77:812– 819. 5 Shumway-Cook A, Brauer S, Woollacott MH. Predicting the probability for falls in community-dwelling older adults using the Timed “Up & Go” Test. Phys Ther. 2000;80:896 –903. 6 Tinetti ME, Baker DI, McAvay G, et al. A multifactorial intervention to reduce the risk of falling among elderly people living in the community. N Engl J Med. 1994; 331:821– 827. 7 Whitney SL, Poole J, Cass S. A review of balance instruments for older adults. Am J Occup Ther. 1998;52:666 – 671. 8 Horak FB. Postural orientation and equilibrium: what do we need to know about neural control of balance to prevent falls? Age Ageing. 2006;35(Suppl 2):ii7–ii11.

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9 Horak FB, Macpherson JM. Postural orientation and equilibrium. In: Smith JL, ed. Handbook of Physiology: Section 12— Exercise: Regulation and Integration of Multiple Systems. New York, NY: Oxford University Press; 1996:255–292. 10 Macpherson J, Horak FB. Neural control of posture. In: Kandel E, Schwartz J, Jessell T, eds. Principles of Neural Science. 5th ed. New York, NY: Elsevier; in press. 11 Horak FB, Shupert CL, Mirka A. Components of postural dyscontrol in the elderly: a review. Neurobiol Aging. 1989;10: 727–738. 12 Woollacott MH, Shumway-Cook A. Attention and the control of posture and gait: a review of an emerging area of research. Gait Posture. 2002;16:1–14. 13 Nutt J, Horak FB. Gait and balance disorders. In: Asbury AK, McKhann GM, McDonald WI, et al, eds. Diseases of the Nervous System: Clinical Neuroscience and Therapeutic Principles. 3rd ed. Cambridge, United Kingdom: Cambridge University Press; 2002:581–591. 14 Bernstein NA. The Co-ordination and Regulation of Movements. Oxford, NY: Pergamon Press; 1967. 15 Horak FB, Shumway-Cook A. Clinical implications of posture control research. In: Duncan P, ed. Balance: Proceedings of the APTA Forum. Alexandria, VA: American Physical Therapy Association; 1990: 105–111. 16 Horak FB. Effects of neurological disorders on postural movement strategies in the elderly. In: Vellas B, Toupet M, Rubenstein L, et al, eds. Falls, Balance, and Gait Disorders in the Elderly. Paris, France: Elsevier Science Publishers; 1992:137–151. 17 Horak FB. Clinical measurement of postural control in adults. Phys Ther. 1987; 67:1881–1885. 18 Horak FB, Henry SM, Shumway-Cook A. Postural perturbations: new insights for treatment of balance disorders. Phys Ther. 1997;77:517–533. 19 Horak FB. Clinical assessment of balance disorders Gait Posture. 1997;6:76 – 84. 20 Horak FB, Frank J. Three separate postural systems affected in parkinsonism. In: Stuart DG, Gurfunkel VS, Wiesendanger M, eds. Motor Control VII. Tucson, AZ: Motor Control Press; 1996:343–346. 21 Robinovitch SN, Heller B, Lui A, Cortez J. Effect of strength and speed of torque development on balance recovery with the ankle strategy. J Neurophysiol. 2002;88: 613– 620. 22 Jacobs JV, Dimitrova DM, Nutt JG, Horak FB. Can stooped posture explain multidirectional postural instability in patients with Parkinson’s disease? Exp Brain Res. 2005;166:78 – 88. 23 Mancini M, Rocchi L, Horak FB, Chiari L. Effects of Parkinson’s disease and levodopa on functional limits of stability. Clin Biomech (Bristol, Avon). 2008;23: 450 – 458.

24 Bisdorff AR, Anastasopoulos D, Bronstein AM, Gresty MA. Subjective postural vertical in peripheral and central vestibular disorders. Acta Otolaryngol Suppl. 1995; 520(Pt 1):68 –71. 25 Burleigh-Jacobs A, Horak FB, Nutt JG, Obeso JA. Step initiation in Parkinson’s disease: influence of levodopa and external sensory triggers. Mov Disord. 1997;12: 206 –215. 26 Horak FB, Esselman P, Anderson ME, Lynch MK. The effects of movement velocity, mass displaced, and task certainty on associated postural adjustments made by normal and hemiplegic individuals. J Neurol Neurosurg Psychiatry. 1984;47: 1020 –1028. 27 Jacobs JV, Horak FB. Cortical control of postural responses. J Neural Transm. 2007;114:1339 –1348. 28 Horak FB, Diener HC. Cerebellar control of postural scaling and central set in stance. J Neurophysiol. 1994;72:479 – 493. 29 Cameron MH, Horak FB, Herndon RR, Bourdette D. Imbalance in multiple sclerosis: a result of slowed spinal somatosensory conduction. Somatosens Mot Res. 2008;25:113–122. 30 Inglis JT, Horak FB, Shupert CL, JonesRycewicz C. The importance of somatosensory information in triggering and scaling automatic postural responses in humans. Exp Brain Res. 1994;101: 159 –164. 31 Horak FB. Adaptation of automatic postural responses. In: Bloedel J, Ebner TJ, Wise SP, eds. Acquisition of Motor Behavior in Vertebrates. Cambridge, MA: MIT Press; 1996:57– 85. 32 Peterka RJ, Loughlin PJ. Dynamic regulation of sensorimotor integration in human postural control. J Neurophysiol. 2004;91: 410 – 423. 33 Speers RA, Kuo AD, Horak FB. Contributions of altered sensation and feedback responses to changes in coordination of postural control due to aging. Gait Posture. 2002;16:20 –30. 34 Yang JF, Winter DA, Wells RP. Postural dynamics of walking in humans. Biol Cybern. 1990;62:321–330. 35 King LA, Horak FB. Lateral stepping for postural correction in Parkinson’s disease. Arch Phys Med Rehabil. 2008;89:492– 499. 36 Nashner LM, Black FO, Wall C III. Adaptation to altered support and visual conditions during stance: patients with vestibular deficits. J Neurosci. 1982;2:536 –544. 37 Horak FB. Role of the vestibular system in postural control. In: Herdman SJ, ed. Vestibular Rehabilitation. 3rd ed. Philadelphia, PA: FA Davis Co; 2007:25–51. 38 O’Sullivan SB. Assessment of motor function. In: O’Sullivan SB, Schmitz TJ, eds. Physical Rehabilitation: Assessment and Treatment. 4th ed. Philadelphia, PA: FA Davis Co; 2001:191–197. 39 Hayes KC. Biomechanics of postural control. Exerc Sport Sci Rev. 1982;10:363–391. 40 McCollum G, Leen TL. Form and exploration of mechanical stability limits in erect stance. J Mot Behav. 1989;21:225–244.

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Balance Evaluation Systems Test (BESTest) 41 Bisdorff AR, Wolsley CJ, Anastasopoulos D, et al. The perception of body verticality (subject postural vertical) in peripheral and central vestibular disorders. Brain. 1996;119:1523–1534. 42 Duncan PW, Weiner DK, Chandler J, Studenski S. Functional reach: a new clinical measure of balance. J Gerontol. 1990;45: M192–M197. 43 Newton RA. Validity of the Multidirectional Reach Test: a practical measure for limits of stability in older adults. J Gerantol A Biol Sci Med Sci. 2001; 56:M248 –M252. 44 Jonsson E, Henriksson M, Hirschfeld H. Does the functional reach test reflect stability limits in elderly people? J Rehabil Med. 2002;35:26 –30. 45 Crenna P, Frigo C. A motor programme for the initiation of forward-oriented movements in humans. J Physiol. 1991;437: 635– 653. 46 Rogers MW, Hedman LD, Pai Y-C. Kinetic analysis of dynamic transitions in stance support accompanying voluntary leg flexion movements in hemiparetic adults. Arch Phys Med Rehabil. 1993;74:19 –25. 47 Horak FB, Anderson M. Preparatory postural activity associated with movement [abstract]. Phys Ther. 1980;60:580. 48 Massion J, Woollacott MH. Posture and equilibrium. In: Bronstein AM, Brandt T, Woollacott MH, eds. Clinical Disorders of Balance, Posture and Gait. London, United Kingdom: Arnold; 1996:1–18. 49 Horak FB, Jacobs JV, Tran VK, Nutt JG. The push and release test: an improved clinical postural stability test for patients with Parkinson’s disease [abstract]. Mov Disord. 2004;19(Suppl 9):S170. 50 Maki BE, McIlroy WE. The role of limb movements in maintaining upright stance: The “change-in-support” strategy. Phys Ther. 1997;77:488 –507. 51 Shumway-Cook A, Horak FB. Assessing the influence of sensory interaction on balance: suggestion from the field. Phys Ther. 1986;66:1548 –1550. 52 Huxham FE, Goldie PA, Patla AE. Theoretical considerations in balance assessment. Aust J Physiother. 2001;47:89 –100. 53 Paquette C, Paquet N, Fung J. Aging affects coordination of rapid head motions with trunk and pelvis movements during standing and walking. Gait Posture. 2006;24: 62– 69.

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54 Shumway-Cook A, Woollacott MH. Motor Control: Theory and Practical Applications. Baltimore, MD: Williams & Wilkins; 2001. 55 Mathias S, Nayak USL, Isaacs B. Balance in elderly patients: the “get-up and go” test. Arch Phys Med Rehabil. 1986;67: 387–389. 56 Shumway-Cook A, Horak FB. Vestibular rehabilitation: an exercise approach to managing symptoms of vestibular dysfunction. Semin Hearing. 1989;10:196 –208. 57 Shumway-Cook A, Horak FB. Rehabilitation strategies for patients with vestibular deficits. Neurol Clin. 1990;8:441– 457. 58 Powell LE, Myers AM. The Activitiesspecific Balance Confidence (ABC) Scale. J Gerontol A Biol Sci Med Sci. 1995;50: M28 –M34. 59 Myers AM, Fletcher PC, Myers AH, Sherk W. Discriminative and evaluative properties of the Activities-specific Balance Confidence (ABC) Scale. J Gerontol. 1998;53: M287–M294. 60 Shrout PE, Fleiss JL. Interclass correlation: uses in assessing rater reliability. Psychol Bull. 1979;86:420 – 428. 61 Portney LG, Watkins MP. Foundations of Clinical Research: Applications to Practice. Upper Saddle River, NJ: Prentice Hall Health; 2000. 62 Berg KO, Wood-Dauphine´e SL, Williams JI, Maki B. Measuring balance in the elderly: validation of an instrument. Can J Public Health. 1992;83(Suppl 2):S7–S11. 63 Tinetti ME, Mendes de Leon CF, Doucette JT, Baker DI. Fear of falling and fall-related efficacy in relationship to functioning among community-living elders. J Gerontol. 1994;49:140 –147. 64 Close JC, Lord SL, Menz HB, Sherrington C. What is the role of falls? Best Pract Res Clin Rheumatol. 2005;19:913–935. 65 Lord SR, Menz HB, Tiedemann A. A physiological profile approach to falls risk assessment and prevention. Phys Ther. 2003;83:237–252. 66 Woollacott MH, Shumway-Cook A. Motor Control: Translating Research Into Clinical Practice. Philadelphia, PA: Lippincott Williams & Wilkins; 2007. 67 Runge CF, Shupert CL, Horak FB, Zajac F. Role of vestibular information in initiation of rapid postural responses. Exp Brain Res. 1998;122:403– 412.

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68 Shupert CL, Horak FB. Effects of vestibular loss on head stabilization in response to head and body perturbations. J Vestib Res. 1996;6:423– 437. 69 Jobges M, Heuschkel G, Pretzel C, et al. Repetitive training of compensatory steps: a therapeutic approach for postural instability in Parkinson’s disease. J Neurol Neurosurg Psychiatry. 2003;75:1682–1687. 70 Shumway-Cook A, Horak FB, Yardley L, Bronstein AM. Rehabilitation of balance disorders in the patient with vestibular pathology. In: Bronstein AM, Brandt T, Woollacott MH, eds. Clinical Disorders of Balance, Posture, and Gait. London, United Kingdom: Arnold, Div of Hodder Headline PLC; 1996:213–220. 71 Berg KO, Wood-Dauphine´e S, Williams JI. The Balance Scale: reliability assessment with elderly residents and patients with an acute stroke. Scand J Rehabil Med. 1995; 27:27–36. 72 Cipriany-Dacko LM, Innerst D, et al. Interrater reliability of the Tinetti Balance Scores in novice and experienced physical therapy clinicians. Arch Phys Med Rehabil. 1997;78:1160 –1164. 73 Anacker SL, Di Fabio RP. Influence of sensory inputs on standing balance in community-dwelling elders with a recent history of falling. Phys Ther. 1992;72:575– 581; discussion 581–574. 74 Wrisley DM, Walker ML, Echternach JL, Strasnick B. Reliability of the Dynamic Gait Index in people with vestibular disorders. Arch Phys Med Rehabil. 2003;84: 1528 –1533. 75 Folio R, Fewell RP. Peabody Developmental Motor Scales, Second Edition (PDMS2). Los Angeles, CA: Western Psychological Services; 2000. 76 Wang HH, Liao HF, Hsieh CL. Reliability, sensitivity to change, and responsiveness of the Peabody Developmental Motor Scales—Second Edition for children with cerebral palsy. Phys Ther. 2006;86:1351– 1359.

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Case Report Neuroprosthesis Peroneal Functional Electrical Stimulation in the Acute Inpatient Rehabilitation Setting: A Case Series Kari Dunning, Kristy Black, Andrea Harrison, Keith McBride, Susan Israel

Background and Purpose. Studies have suggested that peroneal nerve functional electrical stimulation (peroneal FES) during walking improves gait in patients with chronic stroke. The effect of peroneal FES during the acute stages of stroke recovery is not known. The purposes of this case report are: (1) to describe differences between walking with and without a neuroprosthesis during the first few weeks after stroke, (2) to offer a clinical perspective on decision making for the use of peroneal FES during acute rehabilitation, and (3) to determine the feasibility of rehabilitation with peroneal FES neuroprostheses during the acute phases of stroke recovery.

Case Description. This case report describes 2 patients with different clinical presentations but both receiving inpatient rehabilitation less than 2 weeks after stroke. Each patient received peroneal FES via a neuroprothesis as tolerated while gait training in therapy. Outcomes. One patient immediately increased gait speed (128%) and decreased time to perform the Timed “Up & Go” Test (40%) using the neuroprothesis. Both patients immediately increased the 6-Minute Walk Test distance using the neuroprothesis (121% and 101%). The patient who underwent testing with the instrumented walking system also demonstrated improved gait symmetry. After 1 to 3 weeks of using the neuroprothesis, the difference between outcomes with and without the neuroprothesis decreased. Discussion. It is possible that peroneal FES delivered through a neuroprosthesis during acute stroke recovery may improve gait outcomes. Research is needed to determine proper duration and timing.

K Dunning, PT, PhD, is Assistant Professor, Department of Rehabilitation Sciences, College of Allied Health Sciences, University of Cincinnati Academic Medical Center, and Director of Clinical Research, Drake Center Rehabilitation, Cincinnati, Ohio. Mailing address: Department of Rehabilitation Sciences, University of Cincinnati, 3202 Eden Ave, Cincinnati, OH 45220-0394 (USA). Address all correspondence to Dr Dunning at: [email protected]. K Black, PT, is Physical Therapist, Drake Center Rehabilitation. A Harrison, PT, was Team Leader for inpatient physical therapy, Drake Center Rehabilitation, at the time this case report was written. K McBride, PT, is Physical Therapist and Director of Clinical Support and Education, Bioness Inc, Valencia, California, and Assistant Professor, Department of Physical Therapy and Rehabilitation Science, University of Maryland School of Medicine, Baltimore, Maryland. S Israel, PT, MSPT, is Physical Therapist and a doctoral student, Department of Neuroscience, University of Cincinnati School of Medicine, Cincinnati, Ohio. [Dunning K, Black K, Harrison A, et al. Neuroprosthesis peroneal functional electrical stimulation in the acute inpatient rehabilitation setting: a case series. Phys Ther. 2009;89:499 –506.] © 2009 American Physical Therapy Association Post a Rapid Response or find The Bottom Line: www.ptjournal.org

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tudies have suggested that peroneal nerve functional electrical stimulation (peroneal FES) during walking increases gait speed and facilitates normal tibialis anterior muscle electromyographic (EMG) activity among people with stroke.1–5 However, these studies involved people with chronic stroke (⬎6 months). One reason for this is that previously available peroneal FES systems were not feasible to operate in inpatient settings where clinicians have limited time (eg, due to complicated programming, wires, reliability of reapplying electrodes). New, easy-touse technologies (neuroprostheses) provide a feasible method of using peroneal FES in the inpatient setting, but the effectiveness of peroneal FES during the acute phase of stroke recovery is not known. There have been a limited number of studies regarding FES in the inpatient rehabilitation setting after stroke. A recent study by Yan et al6 using multiple surface electrodes an average of 8 days after first stroke among rehabilitation inpatients suggested increased strength (forcegenerating capacity) and improved walking ability. The multiple surface electrodes were placed on the quadriceps, hamstring, medial gastrocrocnemius, and tibialis anterior muscles of the affected leg.6 This multiple electrode system is not available in most clinics and is not feasible for busy clinicians due to complicated and time-consuming donning and doffing. Additionally,

Available With This Article at www.ptjournal.org • Patient Demonstration Video • Audio Abstracts Podcast This article was published ahead of print on March 6, 2009, at www.ptjournal.org.

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the subjects who received electrical stimulation in the study by Yan and colleagues did not use it in the context of function (ie, walking). There have been no studies conducted during acute stroke recovery using peroneal FES neuroprotheses that have recently become available. The purposes of this case series report are: (1) to describe differences between walking with and without a neuroprosthesis during the first few weeks after stroke, (2) to offer a clinical perspective on decision making for the use of peroneal FES during inpatient rehabilitation, and (3) to determine the feasibility of rehabilitation with peroneal FES neuroprostheses during the acute phases of stroke recovery.

Patient History and Review of Systems In recruiting for patients for this case series, our inclusion criteria were: (1) inability to perform enough ankle dorsiflexion to clear the foot during swing-through; (2) first stroke experienced less than 2 weeks prior to intervention; (3) ankle dorsiflexion range of motion (ROM) in the affected lower leg of at least neutral with peroneal FES stimulation; (4) history of independent function prior to stroke, including walking without an assistive device; (5) adequate cognition and communication abilities (ⱖ21/30 on the Modified Mini Mental Status Examination7; (6) age 30 to 70 years; (7) ability to walk 5 m with minimum to moderate assistance (with or without assistive device); and (8) tolerance to peroneal FES stimulation. Exclusion criteria were: (1) excessive pain in the affected leg (ⱖ5 on a 10-point visual analog scale); (2) participating in any experimental rehabilitation or drug studies; (3) implants such as a cardiac pacemaker or vagal nerve stimulator or implants that generate electrical signals or

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have moving metal parts; (4) lower motor neuron disease or injury with inadequate response to stimulation; (5) significant swelling in the affected leg extending up to the knee; (6) diseases that would limit wearing of the neuroprosthesis, such as venous stasis, or a history of lowerextremity ulcers, chronic skin conditions, or peripheral neuropathy; (7) pregnancy; and (8) a pre-existing orthopedic condition or history of pain that could limit ambulatory progress (eg, total hip or knee replacement, limited lower-extremity ROM, arthritis). Using these criteria, inpatient physical therapists briefly described the intervention to eligible patients and asked for verbal permission for the treating therapists to contact them. Both patients described below were chosen for the intervention, and, consequently, this case series report, because they met the inclusion criteria. Prior to participating in the intervention, both patients signed an informed consent statement approved by the local institutional review board. The first patient was a 50-year-old African American man who was 10 days poststroke. He had a history of cocaine abuse, hypertension, and schizophrenia. His hemorrhagic stroke was located in the left thalamus, extending into the left corona radiata with mass effect in the third ventricle, resulting in right-side hemiplegia. The second patient was a 66-year-old Caucasian woman who was 9 days poststroke. She had a history of hypertension and peripheral vascular disease. Her hemorrhagic stroke was located in the left brain stem, resulting in right-side hemiplegia. Clinical Impression These 2 patients were appropriate for peroneal FES due to their inability May 2009

Neuroprosthesis Peroneal Functional Electrical Stimulation to dorsiflex the affected foot during swing-through. In addition, they met the criteria established to ensure safe and successful participation by the patient, effectiveness of the device, and in consideration of contraindications for use of the device.

Examination At initial testing, patient 1 had right ankle dorsiflexion strength of 4/5 with heel support on the floor and 2/5 without heel support. Other lower-extremity strength was normal except: 4⫹ for right hip flexion, 3⫺ for right hip extension, 3⫹ for left hip extension, 4⫹ for right knee extension, and 4 for right knee flexion. Right ankle dorsiflexion passive range of motion (PROM) was 0 degrees in sitting with knees flexed at 90 degrees. Otherwise, bilateral lower-extremity PROM was normal. At enrollment, the patient was walking during therapy with a singlepoint cane and minimum assistance, demonstrating consistent foot drop with swing-through. As he was unable to clear his foot during swingthrough, the therapist had been wrapping his foot into dorsiflexion with an elastic bandage during gait training. At initial testing, patient 2 had 0/5 right ankle strength. Otherwise, right lower-extremity strength was: 3 for hip flexion, 2 for hip extension, 2⫹ for hip abduction, 2 for hip adduction, 1 for knee extension, and 1 for knee flexion. Left lower-extremity strength was normal, and bilateral lower-extremity PROM was normal. Outcomes measured without and with the L300 neuroprosthesis were the 5-Meter Walk Test (5MWT), the Timed “Up & Go” Test (TUG), and the 6-Minute Walk Test (6MWT). The 5MWT has been recommended as a responsive outcome measure during the first 5 weeks after stroke,8 and gait speed has been shown to be a reliable outcome measure for peoMay 2009

ple undergoing inpatient rehabilitation after stroke.9 The TUG is a timed task in which the patients stood up from a chair, walked 3 m, turned around, and sat down. The amount of time that it takes to perform the TUG has been shown to be a reliable and valid outcome measure for people with stroke.10,11 The 6MWT is a reliable outcome measure for people with stroke that measures the distance walked in 6 minutes.11 Both patients were allowed to rest, as needed, during that 6-minute time. Additional testing for patient 1 included use of the GAITRite system* to obtain data for gait spatiotemporal parameters, including step length, stride length, and single- and double-leg support time. Patient 2 did not have enough endurance to do GAITRite testing. The coefficient of variation, an output of the GAITRite system that demonstrates gait parameter variation between gait cycles, was used to measure gait cycle consistency. The reliability and validity of data obtained with the GAITRite system have been demonstrated in previous research.12,13 In our facility, the GAITRite is located in the outpatient therapy gym, involving a 5-minute transport by wheelchair from the inpatient unit. After baseline testing, the patients were fitted for the neuroprosthesis and practiced walking for 5 to 10 minutes prior to testing with the neuroprosthesis. Follow-up outcome testing was repeated weekly. However, due to impaired endurance, patient 2 was unable to finish all 3 tests (5MWT, TUG, and 6MWT) with and without the neuroprosthesis in the same day. Therefore, the 6MWT was performed at baseline, the TUG and 5MWT were performed after 1 week of using the neuroprosthesis, and the tests were alternated thereafter, * CIR Systems Inc, 60 Garlor Dr, Havertown, PA 19083.

During follow-up testing, outcomes first were measured without the L300 neuroprosthesis. Outcomes were measured by a licensed and trained physical therapist who was not masked to treatment. For patient 1, all testing was done using a single-point cane and assistance, as needed, for safety (contact guard to minimum assistance for loss of balance). For patient 2, all testing was done using a large-base quad cane and minimum assistance for loss of balance and to advance the affected leg, as needed. Due to ankle instability during stance, patient 2 also wore a Velcro ankle support† to prevent inversion. To determine user satisfaction, the patients were asked the following questions at each testing session: (1) “Did the stimulation help walking or make it more difficult?” (2) “Did you like the stimulation during walking?” (3) “If you liked the stimulation, why?” and (4) “If you did not like the stimulation, why?” The therapist also was asked questions regarding the feasibility of using this neuroprosthesis in the inpatient rehabilitation setting. Clinical Impression Based on examination data, both patients were determined to be appropriate for peroneal FES during gait training, including neutral ankle dorsiflexion, adequate hip and knee strength, and ability to walk with minimal assistance. We expected that they would demonstrate increased gait speed, normalized gait parameters, decreased TUG time, and increased 6MWT distance when walking with the neuroprosthesis compared with walking without the prosthesis.

† Velcro USA Inc, PO Box 5218, 406 Brown Ave, Manchester, NH 03103.

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Figure. Ness L300 neuroprosthesis used for peroneal functional electrical stimulation during gait training.

Intervention The Ness L300 neuroprosthesis‡ (Figure) was used daily, Monday through Friday, during gait training. The L300 consists of an in-shoe pressure sensor, a control unit, and an orthotic cuff that holds 2 stimulating surface electrodes (Figure). The 2 surface electrodes are positioned to produce dorsiflexion with slight eversion to provide adequate foot and toe clearance and safe initial contact and loading. One electrode is placed in the origin of the tibialis anterior muscle, and the other electrode is placed over the common peroneal nerve, posterior and proximal to the fibular head. Once the optimal position is established, the orthotic cuff holds the electrodes in place for future treatments, thus increasing the reliability of optimum electrode placement and eliminating the need for daily placement fitting. The pressure sensor, through detect-

ing heel-off and initial contact, activates the system to stimulate ankle dorsiflexion and eversion during the swing phase of gait and terminates stimulation during early stance. This system uses wireless communication. At the initial fitting of the device, frequency, waveform, delays, and ramp up and down times were set to elicit the most-effective contraction during ambulation. A video demonstrating the use of the Ness L300 neuroprosthesis for peroneal functional electrical stimulation during gait training is available at www.ptjournal.org. Therapists were trained in donning and doffing the device. A physical therapist with experience in L300 neuroprosthesis administration performed the initial fitting session and was available for consultation. The duration of daily L300 sessions was dictated by how much the patient walked during therapy.

‡ Bioness Inc, 25103 Rye Canyon Loop, Valencia, CA 91355.

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At baseline, patient 1 demonstrated immediate improved outcomes using the L300 neuroprosthesis compared with not using the neuroprosthesis. Gait speed more than doubled (from 13.4 cm/s without the L300 to 42.2 cm/s with the L300), and the 6MWT distance increased 121% (from 13.4 m without the L300 to 30.5 m with the L300) (Tab. 1). Time to perform the TUG decreased 39.5% (from 48.4 seconds without the L300 to 29.3 seconds with the L300) (Tab. 1). Table 2 shows that step length increased for both the left and right legs (158% and 78%, respectively), and the coefficient of variation decreased. Other gait parameters, including increased stride length and percentage of gait cycle spent in single-leg support, also improved. Patient 1 used the L300 neuroprosthesis while walking during therapy, an average of 40 minutes (434 steps) per day for 7 days, with no observable muscle fatigue. Daily duration of L300 stimulation with walking varied from 13 minutes (the first day) to 2 hours 8 minutes. Daily contraction was consistent, and the device and electrodes did not need to be adjusted after the initial fitting. After 7 days of walking with the L300 neuroprosthesis during therapy, patient 1 demonstrated less foot drop without the device, and the differences between outcomes with and without the device were less dramatic (Tabs. 1 and 2). Thus, it was decided to stop using the neuroprosthesis to further challenge him to actively dorsiflex during swingthrough. He was discharged home 25 days poststroke (17 days after starting use of the L300 neuroprosthesis) walking with a single-point cane and no ankle support. The majority of the time his foot cleared during swing-through, but he re-

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Neuroprosthesis Peroneal Functional Electrical Stimulation Table 1. Gait Speed, Timed “Up & Go” Test (TUG), and 6-Minute Walk Test (6MWT) Measurements Without and With the L300 Neuroprosthesis for Patients 1 and 2 Baselinea (Day 1)

Week 1

Week 2

Without L300

With L300

Without L300

With L300

Gait speed (cm/s)

13.8

42.2

45.3

54.1

TUG (s)

48.4

29.3

22.6

26.4

6MWT distance (m)

13.8

30.5

119.3

145.5

6MWT speed (cm/s)

3.8

8.5

33.1

40.4

3.4

. . .c

Outcome Measures

Without L300

Week 3 With L300

Without L300

Week 4 With L300

Without L300

With L300

Patient 1b

Patient 2 Gait speed (cm/s)

327d

TUG (s)

...

...

...

12.8

11.2

130

6.9

111

7.2

...

...

60

8.3

56

8.9

71

72

6MWT distance (m)

9.7

19.5

...

...

22.6

24.2

...

...

37.9

41.6

6MWT speed (cm/s)

2.7

5.4

...

...

6.3

6.7

...

...

10.5

11.6

a

On day 1, measurements were obtained first without the L300 neuroprosthesis. After the patient was fitted for the L300 neuroprosthesis and practiced with the device for 10 minutes, measurements were repeated. b Patient 1 wore the L300 for 1 week only; measurements were not obtained during weeks 2 to 4. c Ellipsis indicates that due to fatigue, measurements were not obtained. d At baseline, patient 2 required minimal assistance for the sit-to-stand task and minimal assistance using a pyramid cane for turning during the TUG.

Table 2. Gait Parameters for Patient 1 Without and With the L300 Neuroprosthesis Baselinea (Day 1) b

Week 1

Without L300

With L300

Without L300

With L300

Left

18.8 (90)

48.5 (3)

39.1 (21)

46.4 (5)

Right

26.5 (91)

47.2 (10)

52.5 (13)

51.3 (6)

Left

0.55 (89), 15.8

0.77 (7), 34.0

0.71 (24), 34.2

0.71 (5), 38.8

Right

0.61 (12), 16.3

0.65 (5), 28.3

0.59 (8), 29.2

0.55 (2), 29.7

Left

2.72 (41), 79.0

0.83 (10), 36.6

0.73 (12), 35.2

0.58 (6), 32.1

Right

2.71 (21), 72.4

0.86 (12), 37.6

0.70 (5), 34.7

0.59 (6), 32.1

Gait Parameter

Step length, cm (%CV)

Single-leg support time, s (%CV), %GC

Double-leg support time, s (%CV), %GC

a

On day 1, measurements were obtained first without the L300 neuroprosthesis. After the patient was fitted for the L300 neuroprosthesis and practiced with the device for 10 minutes, measurements were repeated. b %CV⫽percentage of coefficient of variation, %GC⫽percentage of gait cycle.

quired standby assistance to walk due to loss of balance. After the first L300 neuroprosthesis session, patient 1 stated he liked the stimulation because it helped him walk by keeping his foot up instead of dragging. The therapist found the neuroprosthesis easy to use and reported that gait training was easier, May 2009

requiring her to provide less physical assistance for balance and to advance the patient’s right leg. At baseline (day 1), patient 2 demonstrated a 101% increase in 6MWT distance (from 9.7 m without the L300 to 19.5 m with the L300) (Tab. 1). At 2 and 4 weeks, using the neuroprosthesis still resulted in increased

6MWT distance; however, the differences were less dramatic. As shown in Table 1, after 1 week of using the neuroprosthesis during gait training, gait speed was similar (4%) between walking with and without the device (7.2 and 6.9 cm/s, respectively). After 1 week of using the neuroprosthesis, the patient was able to complete the TUG 14.6% faster with the

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Neuroprosthesis Peroneal Functional Electrical Stimulation device than without it (111 and 130 seconds, respectively). By the fourth week, there was little difference in TUG time without and with the neuroprosthesis. During the first 2 weeks, patient 2 used the L300 neuroprosthesis during gait training an average of 30 minutes (270 steps) per day. Daily duration of L300 stimulation with walking varied from 15 to 42 minutes. After 1 week of using the neuroprosthesis, she began to experience difficulties achieving a dorsiflexion contraction with the device. Although her ankle active dorsiflexion was returning, it fatigued quickly and she demonstrated continued drop foot during gait. Therefore, we felt she could still benefit from peroneal FES and continued to try to use the L300 neuroprosthesis during therapy for 3 more weeks until discharge. Throughout these 3 weeks, the patient demonstrated inconsistent responses using the neuroprosthesis, sometimes showing a good dorsiflexion contraction and other times demonstrating no contraction. Patient 2 was discharged from inpatient rehabilitation to a skilled nursing unit 5 weeks poststroke (4 weeks after starting use of the L300 neuroprosthesis). At that time, she was walking with a small-base quad cane, an air cast for right ankle support, and contact guard assistance due to loss of balance. She had ankle dorsiflexion strength of 3⫺, but the movement caused rapid fatigue and still required wrapping with an elastic bandage during gait training. Prior to trying the L300 neuroprosthesis, patient 2 was afraid of the electrical stimulation, but after the first session walking with the device, she liked it and said it helped her walk. Throughout the next 3 weeks, however, she sometimes said the neuroprosthesis helped and at other times said it did not make a differ504

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ence. The therapist reported that gait training with the L300 neuroprosthesis was easier, requiring less physical assistance to advance the patient’s right leg, but that she was frustrated with the inconsistent contraction after the first week.

Discussion Central nervous system plasticity and motor learning principles emphasize the importance of task-specific, repetitive practice using close-tonormal movements after stroke.14,15 Research16 –20 suggests that earlier intervention may improve outcomes after stroke. Peroneal FES via the L300 neuroprosthesis allowed our 2 patients to experience a more-normal gait 10 days poststroke. There have been a limited number of studies focusing solely on peroneal FES for people during the acute rehabilitation phase. Yan and colleagues6 tested a 4-channel FES system (not a neuroprosthesis) for inpatients used in a side-lying position within 2 weeks poststroke. By the end of the 3-week treatment, the 13 participants who received FES showed greater increases in EMG ankle dorsiflexion torque and decreases in EMG co-contraction ratios compared with the 15 participants who received placebo FES (P⬍.05). Although there was never any statistical difference in time to perform the TUG between groups, 76.9% of the FES group was ambulating compared with 50.0% of the placebo group after 3 weeks of training (P⬍.05). There have been no studies investigating the effect of peroneal FES via a neuroprosthesis during the acute stages of stroke rehabilitation. A recent study using the L300 neuroprosthesis showed immediate increases in gait speed and symmetry among 24 people with foot drop due to chronic hemplegia.21 After 8 weeks of wearing the neuroprosthesis daily,

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participants continued to experience increased gait speed (P⬍.001) and symmetry (P⬍.001). For people with chronic stroke, typical neuroprosthetic protocols involve gradually increasing the amount of stimulation weekly to avoid fatigue and minimize adverse skin reaction to electrodes. The patients in this case report used the device as tolerated while walking. For patient 1, duration of walking with L300 neuroprosthesis stimulation varied from 13 minutes to 2 hours 8 minutes, with no evidence of fatigue. For patient 2, duration of walking with L300 neuroprosthesis stimulation varied from 15 to 42 minutes. After 1 week of using the L300 neuroprosthesis, patient 2 began to experience problems achieving a sufficient contraction for toe clearance. This variability could explain her outcome performance with the neuroprosthesis after the first week. At approximately the same time, she began to demonstrate return of active ankle dorsiflexion. Ankle dorsiflexion PROM remained normal throughout her inpatient stay. In addition, although not formally tested using a standardized spasticity (hypertonicity) tool, the therapist observed no resistance to ankle PROM. Patient 2 also had no observable swelling in the affected lower leg. We tried different electrode placements, different frequencies, and increasing intensity without success in achieving a consistent stimulated contraction during walking. All other factors being negative (eg, no lower-extremity swelling or ankle spasticity or tightness), it may be that patient 2 was having difficulty incorporating her newly acquired active ankle movement with the stimulation during walking. Another reason for the inconsistent contraction for patient 2 may have been tibialis anterior muscle fatigue. Although the potential mechanisms May 2009

Neuroprosthesis Peroneal Functional Electrical Stimulation of fatigue induced by electrical stimulation have been studied,22,23 to our knowledge, the susceptibility of the muscle to fatigue from electrical stimulation during acute stroke recovery is not known. To avoid fatigue, Ness protocols recommend performing 15 minutes of cyclic stimulation (referred to as “training” mode) twice daily during the first week and 20 minutes twice daily during the second and third weeks of using the L300 neuroprosthesis in addition to walking. We did not use cyclic stimulation because our objective was to determine changes with peroneal FES when used during walking. It is possible that patient 2 could have benefited from a controlled dosage progression to avoid fatigue. It is unknown which type of patients would benefit from peroneal cyclic stimulation versus FES with walking versus a combined approach during acute recovery. There have been no studies to determine optimal timing and duration of stimulation per day during acute recovery after stroke. Animal studies have suggested that early, intense therapy may be harmful, potentially causing delayed increases in cortex lesions due to high glutamate release.20 Preliminary results from the first study of humans to investigate this concept of dosing during acute rehabilitation suggest a higher dose (3 hours) of upper-extremity constraint-induced therapy per day was associated with less motor recovery compared with 2 hours per day.24 This concept is controversial, however, as some animal studies have shown that enriched environments early after injury improved outcomes.20 None of these studies tested electrical stimulation. More studies are needed to determine appropriate dosing of peroneal FES during the acute stages of stroke recovery.

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Some authors25 have suggested that neuromuscular stimulation can facilitate motor relearning in hemiplegia, especially in the early phases after stroke. The immediate and dramatic improvement in gait symmetry and speed may have facilitated motor relearning for patient 1. It may be beneficial to introduce peroneal FES as early as possible, considering the most-rapid recovery occurs during the first month after stroke.26,27 However, there have been no studies investigating timing of electrical stimulation after stroke. For example, electrical stimulation early after stroke may be beneficial to facilitate neuromuscular education, maintain or increase strength, and decrease spasticity. If peroneal FES normalizes gait during acute stroke recovery, it may help to decrease impairments that become “habits” in chronic stroke, such as hip circumduction and walking with a stiff leg. Alternatively, it is possible that peroneal FES delivered early after stroke may interfere with motor recovery of the ankle during the gait cycle. Early electrical stimulation following stroke has shown positive outcomes in some upper-extremity studies,28 –31 although the majority of these studies utilized cyclic activation, with only one study integrating the stimulation with function.31 More studies are needed to determine appropriate timing and method of delivery of electrical stimulation intervention for the lower limb after acute stroke. Limitations of this case series should be considered. The outcome tester was not masked to treatment. It is not known whether the patients would have experienced the same improvements if they had not used the L300 neuroprosthesis. Both patients had experienced hemorrhagic stroke. It is possible that people with different types of strokes would respond differently. The physical therapists also suggested that when the patients used the L300 neuropros-

thesis for gait training, they demonstrated improved balance, but this was not one of our outcomes tested. A final limitation is the lack of anklespecific outcomes that would have been helpful in determining possible mechanisms for improvements (eg, ankle active range of motion [AROM], spasticity, and EMG muscle activity and timing during the gait cycle). To our knowledge, these ankle-specific outcomes have not been shown to be reliable or valid for patients with acute stroke. In our experience with patient 2, ankle dorsiflexion AROM varied by day and her fatigue level. The purpose of this case series was to determine clinical rehabilitation feasibility. However, future studies are needed for evidence-based practice. Therefore, we will briefly address issues related to research feasibility learned from this case series. Outcome testing procedures need to account for the possibility of limited endurance. Incorporating a masked rater is challenging considering inpatient schedules. In addition, a masked rater would not be familiar with physical and cognitive limitations of the individuals tested, which may present safety concerns. Finally, reliability of ankle-specific measures during the acute phase of recovery after stroke, including strength, AROM, and EMG activity, need to be studied. For example, factors such as time of day, time since last gait training session, and lower-extremity swelling may influence the accuracy of these measures. These factors should be considered in future studies. Future studies also should include randomized controls and longer-term follow-up after discharge.

Conclusion This case series describes 2 patients with different clinical presentations during acute inpatient rehabilitation. Both patients showed immediate im-

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Neuroprosthesis Peroneal Functional Electrical Stimulation provement in function and gait with the L300 neuroprosthesis, but their progression of treatment differed. There is limited evidence regarding duration and timing of peroneal FES during acute stroke recovery. Dr Dunning, Ms Black, Ms Harrison, and Mr McBride provided concept/idea/project design. Dr Dunning and Ms Israel provided writing. Dr Dunning and Ms Black provided data collection. Dr Dunning provided data analysis, project management, fund procurement, institutional liaisons, and clerical support. Dr Dunning, Ms Black, and Ms Harrison provided patients. Dr Dunning and Ms Harrison provided facilities/equipment. Dr Dunning, Ms Black, Mr McBride, and Ms Israel provided consultation (including review of manuscript before submission). Mr McBride is employed by Bioness Inc, the manufacturer of the Ness L300 neuroprosthesis, and had no role in data collection and analysis or project management. This work was conducted at the Drake Center and was funded by a University of Cincinnati Research Council Grant. This work was presented at the Combined Sections Meeting of the American Physical Therapy Association; February 6 –12, 2009; Las Vegas, Nevada. This article was received August 7, 2008, and was accepted January 21, 2009. DOI: 10.2522/ptj.20080241

References 1 Burridge JH, Taylor PN, Hagan SA, et al. The effects of common peroneal stimulation on the effort and speed of walking: a randomized control trial with chronic hemiplegic patients. Clin Rehabil. 1997; 11:201–210. 2 Taylor PN, Burridge JH, Dunkerley AL, et al. Clinical use of the Odstock dropped foot stimulator: its effect on the speed and effort of walking. Arch Phys Med Rehabil. 1999;80:1577–1583. 3 Kottick AIR, Oostendorp LJM, Buurke JH, et al. The orthotic effect of functional electrical stimulation on the improvement of walking in stroke patients with a dropped foot: a systematic review. Artif Org. 2004; 28:577–586.

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4 Kottick AIR, Hermens HJ, Nene AV, et al. Therapeutic effect of an implantable peroneal nerve stimulator in subjects with chronic stroke and footdrop: a randomized control trial. Phys Ther. 2008;88: 437– 448. 5 Robbins SM, Houghton PE, Woodbury MG, Brown JL. The therapeutic effect of functional and transcutaneous electric stimulation on improving gait speed in stroke patients: a meta-analysis. Arch Phys Med Rehabil. 2006;87:853– 859. 6 Yan T, Hui-Chan CWY, Li LSW. Functional electrical stimulation improves motor recovery of the lower extremity and walking ability of subjects with first acute stroke. Stroke 2005;36:80 – 85. 7 Teng EL, Chui HC. The Modified MiniMental State Exam. J Clin Psychiatry. 1987;48:314 –318. 8 Salbach NM, Mayo NE, Higgins J, et al. Responsiveness and predictability of gait speed and other disability measures in acute stroke. Arch Phys Med Rehabil. 2001;82:1204 –1212. 9 Fulk GD, Echternach JL. Test-retest reliability and minimal detectable change of gait speed in individuals undergoing rehabilitation after stroke. J Neurol Phys Ther. 2008;32:8 –13. 10 Ng SS, Hui-Chan CW. The Timed Up & Go test: its reliability and association with lower-limb impairments and locomotor capacities in people with chronic stroke. Arch Phys Med Rehabil. 2005;86:1641–1647. 11 Flansbjer UB, Holmback AM, Downham D, et al. Reliability of gait performance tests in men and women with hemiparesis after stroke. J Rehabil Med. 2005;37:75– 82. 12 Bilney B, Morris M, Webster, K. Concurrent related validity of the GAITRite walkway system for quantification of the spatial and temporal parameters of gait. Gait Posture. 2003;17:68 –74. 13 Cutlip RG, Mancinelli C, Huber F, DiPasquale J. Evaluation of an instrumented walkway for measurement of the kinematic parameters of gait. Gait Posture. 2000;12:134 –138. 14 Nudo RJ. Functional and structural plasticity in motor cortex: implications for stroke recovery. Phys Med Rehabil Clin North Am. 2003;14:S57–S76. 15 Daly JJ, Ruff RL. Construction of efficacious gait and upper limb functional interventions based on brain plasticity evidence and model-based measures for stroke patients. Scientific World Journal. 2007;7:2031–2045. 16 Ottenbacher KJ, Jannell S. The results of clinical trials in stroke rehabilitation research. Arch Neurol. 1993;50:37– 44. 17 Horn SD, DeJong G, Smout R, et al. Stroke rehabilitation patients, practice, and outcomes: Is earlier and more aggressive therapy better? Arch Phys Med Rehabil. 2005; 86(Suppl 2):S101–S114.

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18 Kwakkel G, Wagenaar RC, Koelman TW, et al. Effects of intensity of rehabilitation after stroke. Stroke. 1997;28:1150 –1156. 19 Kwakkel G, van Peppen R, Wagenaar RC, et al. Effects of augmented exercise therapy time after stroke: a meta-analysis. Stroke. 2004;35:2529 –2536. 20 Teasell R, Bitensky J, Salter K, Bayona NA. The role of timing and intensity of rehabilitation therapies. Top Stroke Rehabil. 2005;12:46 –57. 21 Hausdorff JM, Ring H. Effects of a new radio frequency-controlled neuroprothesis on gait symmetry and rhythmicity in patients with chronic hemiparesis. Am J Phys Med Rehabil. 2008;87:4 –13. 22 Binder-Macleod SA, Snyder-Mackler L. Muscle fatigue: clinical implications for fatigue assessment and neuromuscular electrical stimulation. Phys Ther. 1993;73:902–910. 23 Siatras T, Poumarat G, Boucher JP, Le Flohic JC. Normal and paralyzed muscle force and fatigability induced by electrical stimulation. J Manipulative Physiol Ther. 1994;17:321–328. 24 Dromerick AW, Lang CE, Powers WJ, et al. Very Early Constraint-Induced Movement Therapy (VECTORS): phase II trial results. Stroke. 2007;38:465. 25 Chae J, Yu D. Neuromuscular stimulation for motor relearning in hemiplegia. Crit Rev Phys Med Rehabil. 1999;11:279 –297. 26 Duncan P, Goldstein L, Matchar D, et al. Measurement of motor recovery after stroke: outcome assessment and sample size requirements. Stroke. 1992;23:1084 –1089. 27 Jorgnesen H, Nakayama H, Raaschowu H, et al. Outcome and time course of recovery in stroke, II: time course of recovery. the Copenhagen Study. Arch Phys Med Rehabil. 1995;76:406 – 412. 28 Chae J, Bethoux F, Bohine T, et al. Neuromuscular stimulation for upper extremity motor and functional recovery in acute hemiplegia. Stroke. 1998;29:975–979. 29 Linn SL, Granat MH, Lees KR. Prevention of shoulder subluxation after stroke with electrical stimulation. Stroke. 1999;30: 963–968. 30 Chantraine A, Baribeault A, Uebelhart D, Gremion G. Shoulder pain and dysfunction in hemiplegia: effects of functional electrical stimulation. Arch Phys Med Rehabil. 1999;80:328 –331. 31 Alon G, Levitt AF, McCarthy PA. Functional electrical stimulation enhancement of upper extremity functional recovery during stroke rehabilitation: a pilot study. Neurorehabil Neural Repair. 2007;21: 207–215.

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Letters to the Editor On “Ilial anterior rotation…” Vaughn HT, Nitsch W. Phys Ther. 2008;88:1578–1590. I was surprised by the content of the article by Vaughn and Nitsch1 and the inductive and often contradictory logic used throughout the case report. The current evidencebased literature on low back pain is leaning heavily toward a treatment-based classification system, with an active treatment paradigm.2,3 This article seems to fly in the face of this evidence and proposes a structural-based diagnostic classification based on poor tests and passive treatment, namely bed rest, transcutaneous electrical nerve stimulation, ice, ultrasound, massage, and taping.4–8 The active treatment provided to the patient appears to be based on inductive reasoning to address the pseudodiagnostic category arrived at by a series of nonvalid tests, proposed by the authors, and poorly supported by the evidence and anecdotal reference to opinionbased papers. In the introduction, the authors do review the current evidencebased literature and outline that most testing procedures for the sacroiliac (SI) complex have poor validity, yet proceed to ignore this and use the nonvalid tests to support a pathology-based treatment paradigm. The authors quote Laslett’s research9 and suggest that the positive likelihood ratio (LR) of 3 or more positive SI joint provocative tests is 4.27; however, if they read the article closely they would discover that the positive LR is 6.97 for 3 positive tests, when patients who centralized during the mechanical evaluation were excluded.

May 2009

It would have been nice to include a body chart for the patient’s original pain pattern because the authors state that the patient has right-sided low back pain. Young and Laslett10 clearly identified that “sacroiliac joint pain was related to three or more positive pain provocation tests, pain when rising from sitting, unilateral pain and absence of lumbar pain.” This would preclude the patient from having an SI joint problem based on the lumbar spine pain. I am not sure why the authors, after quoting Laslett, failed to utilize his recommendations and perform a mechanical assessment (McKenzie Method) and provocative testing of the SI joint.7 The Gillet test was used as the main test to determine the positional fault diagnosis. The Gillet test has a positive LR of 1.2 in the study by Dreyfuss.11 Assuming that the prevalence of SI joint pain is 24%, then the posttest odds of having SI joint pain after the Gillet test is only around 29%. Is this enough basis to form a diagnosis and build a 6-month treatment plan around? The authors even state, “Palpationbased methods of the pelvis, when used alone, have demonstrated poor diagnostic value in patients with long-term nonspecific low back pain.”1(p1581) Yet they proceed to use tests that have been shown to have little, if any, validity to assess, diagnose, and track as outcome measures of improvement and recovery. A recent review on the validity of SI joint tests by Cattley et al12 stated, “Gillet’s test, FABER, sacral thrust and compression were considered invalid and unreliable.” These findings are not restricted to Cattley’s review; Stuber13 has recently published a paper on the

sensitivity and specificity of SI joint tests, and his conclusion was that “practitioners may consider using the distraction test, compression test, thigh thrust/posterior shear, sacral thrust, and resisted hip abduction as these were the only tests to have specificity and sensitivity greater than 60% in at least one study.” This is in agreement with Laslett and colleagues’ findings.9 I would suggest that because of the use of inductive logic and nonvalid testing to reach a diagnostic conclusion, the treatment applied has limited justification or value. This case report also lacks valid outcome measures. It would have been better to use valid outcome tools such as the Oswestry Disability Index, Fear-Avoidance Beliefs Questionnaire, SF-36, or other valid outcome tools outlined in the evidence-based literature.14,15 There seems to be a lack of understanding and screening for red and yellow flags, one of the key elements described in most low back pain guidelines.16 I also suggest that the authors seek understanding of the term “regression to the mean,” which may account for some of the patient’s outcomes.17 My question to the authors is: Why did a simple acute low back pain episode under your care become a 6-month chronic recurrent episode? The very nature of the interventions would lead to illness behaviors and kinesiophobia.18 The authors need to consider the evidence-based guidelines for low back pain, suggesting advice to patients that includes reassuring the patient of a favorable prognosis, encouraging the patient to stay active, and discouraging bed rest.16

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Letters to the Editor This patient would probably fit the clinical prediction rule for the lumbar spine, based on the description of her condition.19,20 I believe that the case report was therapist-centered, while trying to suggest some sort of patientcentered approach. I propose that the mantra “Offer patients solutions to their current problems, not more problems” is something the authors should ponder. David C Poulter DC Poulter, PT, is a physical therapist, Coon Rapids, Minnesota. This letter was posted as a Rapid Response on November 6, 2008, at www.ptjournal.org.

References 1 Vaughn HT, Nitsch W. Ilial anterior rotation hypermobility in a female collegiate tennis player. Phys Ther. 2008;88:1578– 1590. 2 Fritz JM, George S. The use of a classification approach to identify subgroups of patients with acute low back pain: interrater reliability and short-term treatment outcomes. Spine. 2000;25:106–114. 3 Fritz JM, Cleland JA, Brennan GP. Does adherence to the guideline recommendation for active treatments improve the quality of care for patients with acute low back pain delivered by physical therapists? Med Care. 2007;45:973–980. 4 Malmivaara A, Häkkinen U, Aro T, et al. The treatment of acute low back pain— bed rest, exercises, or ordinary activity? N Engl J Med. 1995;332:351–355. 5 Hagen KB, Hilde G, Jamtvedt G, Winnem M. Bed rest for acute low-back pain and sciatica. Cochrane Database Syst Rev. 2004;4:CD001254. 6 Philadelphia Panel. Philadelphia Panel Evidence-Based Clinical Practice Guidelines on Selected Rehabilitation Interventions for Low Back Pain. Phys Ther. 2001;81:1641–1674. 7 Deyo RA, Walsh NE, Martin DC, et al. A controlled trial of transcutaneous electrical nerve stimulation (TENS) and exercise for chronic low back pain. N Engl J Med. 1990;322:1627–1634. 8 Khadilkar A, Odebiyi DO, Brosseau L, Wells GA. Transcutaneous electrical nerve stimulation (TENS) versus placebo for chronic low-back pain. Cochrane Database Syst Rev. 2008;4:CD003008.

9 Laslett M, Young SB, Aprill CN, McDonald B. Diagnosing painful sacroiliac joints: a validity study of a McKenzie evaluation and sacroiliac provocation tests. Aust J Physiother. 2003;49:89–97. 10 Young S, Aprill C, Laslett M. Correlation of clinical examination characteristics with three sources of chronic low back pain. Spine. 2003;3:460–465. 11 Dreyfuss P, Michaelsen M, Pauza K, et al. The value of medical history and physical examination in diagnosing sacroiliac joint pain. Spine. 1996;21:2594–2602. 12 Cattley P, Winyard J, Trevaskis J, Eaton S. Validity and reliability of clinical tests for the sacroiliac joint: a review of the literature. Australas Chiropr Osteopathy. 2002;10(2):73–80. 13 Stuber KJ. Specificity, sensitivity, and predictive values of clinical tests of the sacroiliac joint: a systematic review of the literature. JCCA J Can Chiropr Assoc. 2007;51(1):30–41. 14 Bombardier C. Outcome assessments in the evaluation of treatment of spinal disorders: summary and general recommendations. Spine. 2000;25:3100–3103. 15 Taylor SJ, Taylor AE, Foy MA, Fogg AJ. Responsiveness of common outcome measures for patients with low back pain. Spine. 1999;24:1805–1812. 16 Koes BW, van Tulder MW, Ostelo R, et al. Clinical guidelines for the management of low back pain in primary care: an international comparison. Spine. 2001;26:2504–2513. 17 Whitney CW, Von Korff M. Regression to the mean in treated versus untreated chronic pain. Pain. 1992;50:281–285. 18 Picavet HS, Vlaeyen JW, Schouten JS. Pain catastrophizing and kinesiophobia: predictors of chronic low back pain. Am J Epidemiol. 2002;156:1028–1034. 19 Childs JD, Cleland JA. Development and application of clinical prediction rules to improve decision making in physical therapist practice. Phys Ther. 2000;86:122–131. 20 Childs JD, Fritz JM, Flynn TW, et al. A clinical prediction rule to identify patients with low back pain most likely to benefit from spinal manipulation: a validation study. Ann Intern Med. 2004;141:920– 928. [DOI: 10.2522/ptj.2009.89.5.507]

I was pleased to find the article about sacroiliac joint dysfunction (SIJD) by Vaughn and Nitsch1 in the December 2008 issue of PTJ. Reading the paper gave me some thoughts on how evidence is being interpreted and used in the clinic. Current evidence suggests that the

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diagnosis of sacroiliac joint syndrome (SIJS) is difficult because of the paucity of tests with good measurement properties. Thus, I agree with Vaughn and Nitsch’s statement that “there is a lack of sensitive and specific tests to diagnose SIJ [sacroiliac joint] pain, which is commonly referred to as ‘sacroiliac joint syndrome’ (SIJS).”1(p1579) However, a few paragraphs later the authors state, “Accurate diagnosis of the type of SIJD [sacroiliac dysfunction] is essential in determining the appropriate therapeutic intervention.”1(p1579) How do we interpret the apparent contradiction between not having the evidence and yet needing this evidence to make an accurate diagnosis? How do you make an accurate diagnosis with tests that lack sensitivity or specificity? The apparent contradiction in the introduction surely does not lend itself to trusting the diagnosis. I believe there is more evidence about the SIJ that often is overlooked by clinicians. How do we make sure that published evidence is being used in the clinic? After reading the description of this patient who was missing significant right hip medial (internal) rotation, I could not help wonder why the authors did not include previously published evidence. Prior research has shown that limited hip medial rotation is related to a unilateral posterior tilt of their innominate.2 This evidence either was not examined by Vaughn and Nitsch or was not included in their case report because it did not agree with their findings. How do we use evidence that may be contrary to our findings? Do we disregard it, or do we use just the evidence that agrees with our own beliefs? Or, how do we ensure that all evidence that is out there is considered? As far as I know, we do not have a software program that can help us look May 2009

Letters to the Editor This patient would probably fit the clinical prediction rule for the lumbar spine, based on the description of her condition.19,20 I believe that the case report was therapist-centered, while trying to suggest some sort of patientcentered approach. I propose that the mantra “Offer patients solutions to their current problems, not more problems” is something the authors should ponder. David C Poulter DC Poulter, PT, is a physical therapist, Coon Rapids, Minnesota. This letter was posted as a Rapid Response on November 6, 2008, at www.ptjournal.org.

References 1 Vaughn HT, Nitsch W. Ilial anterior rotation hypermobility in a female collegiate tennis player. Phys Ther. 2008;88:1578– 1590. 2 Fritz JM, George S. The use of a classification approach to identify subgroups of patients with acute low back pain: interrater reliability and short-term treatment outcomes. Spine. 2000;25:106–114. 3 Fritz JM, Cleland JA, Brennan GP. Does adherence to the guideline recommendation for active treatments improve the quality of care for patients with acute low back pain delivered by physical therapists? Med Care. 2007;45:973–980. 4 Malmivaara A, Häkkinen U, Aro T, et al. The treatment of acute low back pain— bed rest, exercises, or ordinary activity? N Engl J Med. 1995;332:351–355. 5 Hagen KB, Hilde G, Jamtvedt G, Winnem M. Bed rest for acute low-back pain and sciatica. Cochrane Database Syst Rev. 2004;4:CD001254. 6 Philadelphia Panel. Philadelphia Panel Evidence-Based Clinical Practice Guidelines on Selected Rehabilitation Interventions for Low Back Pain. Phys Ther. 2001;81:1641–1674. 7 Deyo RA, Walsh NE, Martin DC, et al. A controlled trial of transcutaneous electrical nerve stimulation (TENS) and exercise for chronic low back pain. N Engl J Med. 1990;322:1627–1634. 8 Khadilkar A, Odebiyi DO, Brosseau L, Wells GA. Transcutaneous electrical nerve stimulation (TENS) versus placebo for chronic low-back pain. Cochrane Database Syst Rev. 2008;4:CD003008.

9 Laslett M, Young SB, Aprill CN, McDonald B. Diagnosing painful sacroiliac joints: a validity study of a McKenzie evaluation and sacroiliac provocation tests. Aust J Physiother. 2003;49:89–97. 10 Young S, Aprill C, Laslett M. Correlation of clinical examination characteristics with three sources of chronic low back pain. Spine. 2003;3:460–465. 11 Dreyfuss P, Michaelsen M, Pauza K, et al. The value of medical history and physical examination in diagnosing sacroiliac joint pain. Spine. 1996;21:2594–2602. 12 Cattley P, Winyard J, Trevaskis J, Eaton S. Validity and reliability of clinical tests for the sacroiliac joint: a review of the literature. Australas Chiropr Osteopathy. 2002;10(2):73–80. 13 Stuber KJ. Specificity, sensitivity, and predictive values of clinical tests of the sacroiliac joint: a systematic review of the literature. JCCA J Can Chiropr Assoc. 2007;51(1):30–41. 14 Bombardier C. Outcome assessments in the evaluation of treatment of spinal disorders: summary and general recommendations. Spine. 2000;25:3100–3103. 15 Taylor SJ, Taylor AE, Foy MA, Fogg AJ. Responsiveness of common outcome measures for patients with low back pain. Spine. 1999;24:1805–1812. 16 Koes BW, van Tulder MW, Ostelo R, et al. Clinical guidelines for the management of low back pain in primary care: an international comparison. Spine. 2001;26:2504–2513. 17 Whitney CW, Von Korff M. Regression to the mean in treated versus untreated chronic pain. Pain. 1992;50:281–285. 18 Picavet HS, Vlaeyen JW, Schouten JS. Pain catastrophizing and kinesiophobia: predictors of chronic low back pain. Am J Epidemiol. 2002;156:1028–1034. 19 Childs JD, Cleland JA. Development and application of clinical prediction rules to improve decision making in physical therapist practice. Phys Ther. 2000;86:122–131. 20 Childs JD, Fritz JM, Flynn TW, et al. A clinical prediction rule to identify patients with low back pain most likely to benefit from spinal manipulation: a validation study. Ann Intern Med. 2004;141:920– 928. [DOI: 10.2522/ptj.2009.89.5.507]

I was pleased to find the article about sacroiliac joint dysfunction (SIJD) by Vaughn and Nitsch1 in the December 2008 issue of PTJ. Reading the paper gave me some thoughts on how evidence is being interpreted and used in the clinic. Current evidence suggests that the

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diagnosis of sacroiliac joint syndrome (SIJS) is difficult because of the paucity of tests with good measurement properties. Thus, I agree with Vaughn and Nitsch’s statement that “there is a lack of sensitive and specific tests to diagnose SIJ [sacroiliac joint] pain, which is commonly referred to as ‘sacroiliac joint syndrome’ (SIJS).”1(p1579) However, a few paragraphs later the authors state, “Accurate diagnosis of the type of SIJD [sacroiliac dysfunction] is essential in determining the appropriate therapeutic intervention.”1(p1579) How do we interpret the apparent contradiction between not having the evidence and yet needing this evidence to make an accurate diagnosis? How do you make an accurate diagnosis with tests that lack sensitivity or specificity? The apparent contradiction in the introduction surely does not lend itself to trusting the diagnosis. I believe there is more evidence about the SIJ that often is overlooked by clinicians. How do we make sure that published evidence is being used in the clinic? After reading the description of this patient who was missing significant right hip medial (internal) rotation, I could not help wonder why the authors did not include previously published evidence. Prior research has shown that limited hip medial rotation is related to a unilateral posterior tilt of their innominate.2 This evidence either was not examined by Vaughn and Nitsch or was not included in their case report because it did not agree with their findings. How do we use evidence that may be contrary to our findings? Do we disregard it, or do we use just the evidence that agrees with our own beliefs? Or, how do we ensure that all evidence that is out there is considered? As far as I know, we do not have a software program that can help us look May 2009

Letters to the Editor through all of the related evidence for our papers. This, no doubt, is a daunting task for most. Perhaps one will be developed soon. When is evidence not really evidence? In other words, do the published papers we use to support our important factual points have enough credible evidence? For example, the authors state, “Sacroiliac joint dysfunction manifests as a mobility impairment that is identified based on the type of motion dysfunction (hypomobility or hypermobility) and the direction of the abnormal movement.”1(p1579) This sentence, which clearly sets the tone for the rest of the paper, cites 3 different references supporting their view of SIJ mobility. The first citation is a review paper, the second citation is course notes, and the third citation is a textbook. The publications cited for support do not include any original research, nor do they contain any substantive or credible research that supports the belief that SIJD manifests itself as a mobility impairment. This lack of evidence lends itself to confusion and surely does not help us in our quest to understand the SIJ. Throughout the article there are numerous examples of “jargon.” Jargon is best described as using specialized terms that are ambiguous and ill-defined. For example: “Displacement (positional faults) occur when the hypermobile joint overrides the articular prominence.”1(p1579) Jargon usually occurs when we do not have operational definitions that are clearly defined. Lamentably, jargon appears all too common when discussing the SIJ; in fact, it may be the most-abused joint when it comes to our use of jargon. The terms “upslips,” “downslips,” “shears,” “torsion,” “outflares,” “inflares,” and so on continue to show up in our literature and undoubtedly bewilder

May 2009

any new physical therapist student who is trying to learn how to evaluate and treat this joint. I also believe that our customary and continued use of jargon can hurt our credibility as health care professionals. As we continue on our journey to learn more about the SIJ, we first must clearly define what we mean before we can move forward. I believe that the SIJ continues to be a very misunderstood joint and will remain that way unless we provide the evidence that can help us understand it better. Michael T Cibulka MT Cibulka, PT, DPT, MHS, OCS, is a Assistant Professor of Physical Therapy at Maryville University. This letter was posted as a Rapid Response on December 30, 2008, at www.ptjournal.org.

References 1 Vaughn HT, Nitsch W. Ilial anterior rotation hypermobility in a female collegiate tennis player. Phys Ther. 2008;88:1578–1590.

2 Cibulka MT, Sinacore DR, Cromer GS, Delitto A. Unilateral hip rotation range of motion asymmetry in patients with sacroiliac joint regional pain. Spine. 1998;23:1009– 1015. [DOI: 10.2522/ptj.2009.89.5.508]

This case report on right anterior ilial rotation hypermobility (RAIRH) presented a successful outcome with a comprehensive approach in 33 visits.1 It was particularly inspiring to read of the use of film, which clearly identified a problem with the patient’s tennis stroke. After resolving RAIRH, the client’s tennis stroke was retrained to address prevention of recurrence. The authors were thorough in their literature review, revealing some research that could discourage evaluation and treatment of RAIRH, while providing a good rationale for including treatment of RAIRH as part of a comprehensive approach. There were many insightful statements within the article, and my copy is well highlighted. I would like to share some general thoughts and observations I have made regarding the topic.

THE STRENGTH TO HEAL

As a physical therapist and Officer in the U.S. Army Reserve, you’ll be able to help our Soldiers resume an active life. No one deserves it more. You’ll be able to prescribe treatment and see the results. You’ll even be able to write a limited number of prescriptions. Perhaps best of all, you’ll be able to continue to practice in your community and serve when needed. To learn more about the U.S. Army Reserve Health Care Team, call 888-509-6706, or visit healthcare.goarmy.com/info/c395. ©2008. Paid for by the United States Army. All rights reserved.

Volume 89 Number 5 Physical Therapy ■ 509

Letters to the Editor through all of the related evidence for our papers. This, no doubt, is a daunting task for most. Perhaps one will be developed soon. When is evidence not really evidence? In other words, do the published papers we use to support our important factual points have enough credible evidence? For example, the authors state, “Sacroiliac joint dysfunction manifests as a mobility impairment that is identified based on the type of motion dysfunction (hypomobility or hypermobility) and the direction of the abnormal movement.”1(p1579) This sentence, which clearly sets the tone for the rest of the paper, cites 3 different references supporting their view of SIJ mobility. The first citation is a review paper, the second citation is course notes, and the third citation is a textbook. The publications cited for support do not include any original research, nor do they contain any substantive or credible research that supports the belief that SIJD manifests itself as a mobility impairment. This lack of evidence lends itself to confusion and surely does not help us in our quest to understand the SIJ. Throughout the article there are numerous examples of “jargon.” Jargon is best described as using specialized terms that are ambiguous and ill-defined. For example: “Displacement (positional faults) occur when the hypermobile joint overrides the articular prominence.”1(p1579) Jargon usually occurs when we do not have operational definitions that are clearly defined. Lamentably, jargon appears all too common when discussing the SIJ; in fact, it may be the most-abused joint when it comes to our use of jargon. The terms “upslips,” “downslips,” “shears,” “torsion,” “outflares,” “inflares,” and so on continue to show up in our literature and undoubtedly bewilder

May 2009

any new physical therapist student who is trying to learn how to evaluate and treat this joint. I also believe that our customary and continued use of jargon can hurt our credibility as health care professionals. As we continue on our journey to learn more about the SIJ, we first must clearly define what we mean before we can move forward. I believe that the SIJ continues to be a very misunderstood joint and will remain that way unless we provide the evidence that can help us understand it better. Michael T Cibulka MT Cibulka, PT, DPT, MHS, OCS, is a Assistant Professor of Physical Therapy at Maryville University. This letter was posted as a Rapid Response on December 30, 2008, at www.ptjournal.org.

References 1 Vaughn HT, Nitsch W. Ilial anterior rotation hypermobility in a female collegiate tennis player. Phys Ther. 2008;88:1578–1590.

2 Cibulka MT, Sinacore DR, Cromer GS, Delitto A. Unilateral hip rotation range of motion asymmetry in patients with sacroiliac joint regional pain. Spine. 1998;23:1009– 1015. [DOI: 10.2522/ptj.2009.89.5.508]

This case report on right anterior ilial rotation hypermobility (RAIRH) presented a successful outcome with a comprehensive approach in 33 visits.1 It was particularly inspiring to read of the use of film, which clearly identified a problem with the patient’s tennis stroke. After resolving RAIRH, the client’s tennis stroke was retrained to address prevention of recurrence. The authors were thorough in their literature review, revealing some research that could discourage evaluation and treatment of RAIRH, while providing a good rationale for including treatment of RAIRH as part of a comprehensive approach. There were many insightful statements within the article, and my copy is well highlighted. I would like to share some general thoughts and observations I have made regarding the topic.

THE STRENGTH TO HEAL

As a physical therapist and Officer in the U.S. Army Reserve, you’ll be able to help our Soldiers resume an active life. No one deserves it more. You’ll be able to prescribe treatment and see the results. You’ll even be able to write a limited number of prescriptions. Perhaps best of all, you’ll be able to continue to practice in your community and serve when needed. To learn more about the U.S. Army Reserve Health Care Team, call 888-509-6706, or visit healthcare.goarmy.com/info/c395. ©2008. Paid for by the United States Army. All rights reserved.

Volume 89 Number 5 Physical Therapy ■ 509

Letters to the Editor In the case report,1 the term “altered function of the pelvis” was part of the definition of sacroiliac joint dysfunction (SIJD). This is very appropriate, as research and opinion have been presented indicating that asymmetrical pelvic position and movement (and its testing and treatment) do not necessarily imply actual position and movement dysfunction intrinsic to the SIJ.2–4 However, it seems reasonable that extrinsic restrictions, such as pelvic asymmetry, could change the direction of forces going to and through the SIJ and even reduce SIJ mobility and shock attenuation, as the authors stated, referencing Nyberg.5 Also relevant is a study showing that SIJ manipulation does not alter the joint itself.4 The authors1 clearly stated that other extra-articular proximal tissues often become symptomatic and dysfunctional, which does not always imply intraarticular position and movement dysfunction or pain. For the remainder of this letter, any empirical reference I make regarding intrinsic SIJD (ie, ilium moving on sacrum) also implies the alternate possibility of position and movement dysfunction of the pelvis (ie, the entire pelvis moves as a unit). The clinical reality, perhaps, is that at times these may be mutually exclusive entities and at other times they may be a combination of both. The authors1 utilized hip flexion (in the sagittal plane) as a corrective exercise for RAIRH. As RAIRH is a triplane phenomenon, I believe that this could be enhanced by adding abduction and lateral (external) rotation of the hip, as described by DonTigny.6 The direction of force would essentially be parallel to the SIJ and might encourage anterior gapping. The corrective force would occur primarily in the sagittal plane, less so in the frontal plane, and only slightly in the transverse plane. 510■Physical Therapy Volume 89 Number 5

In the “Discussion” section, the authors1 mentioned the possibility of the innominate slipping vertically on the sacrum, which is named “upslip.”7,8 I suggest that in the prone position, the client could be screened for upslip position and movement dysfunction. A superior spring to the ischial tuberosity and an inferior spring to the posterior iliac shelf would both be blocked with upslip. I define the posterior iliac shelf as the flat portion that is in the midline, at the top of the posterior portion of the ilium. As upslip is a nonphysiological motion dysfunction, both spring tests would reveal blocked mobility, as the ilium is stuck at end range. In contradistinction, a physiological motion dysfunction, such as RAIRH, can go further in the direction of dysfunction and is blocked from moving out of dysfunction, as the authors noted with passive testing.

tion of the hip joint is at least 7.5 cm below the transverse axis of the SIJ (S2). Therefore, I believe that it would primarily induce anterior rotation of the ilium, rather than pure posterior glide.

Much of the literature addresses passive motion as a pain provocation test. I encounter more clients with nonsymptomatic SIJ/pelvic position and movement dysfunction than I do clients with symptomatic SIJ/pelvic dysfunction.9,10 In my opinion, treating clients who have asymptomatic SIJ/pelvic dysfunction seems appropriate from the perspective of prevention and reducing the suboptimal biomechanical influence on proximal and distal structures.

2 Sturesson B, Uden A, Vleeming A. A radiostereometric analysis of movements of the sacroiliac joints during the standing hip flexion test. Spine. 2000;25:364–368.

The Ostgaard test is a special test (provocative), which was described in the article.1 The test is performed with the client positioned supine. The therapist stabilizes the sacrum and imparts a posterior glide to the pelvis through the flexed hip (90º), which is reported by Ostgaard11 and the authors1 to induce a posterior glide of the ilium. I agree that the force induced with this test is a posterior glide. However, the mid por-

I again congratulate the authors on a very thorough and successful case study. Thank you for the opportunity to share some general thoughts, opinions, and empiricism on the subject. Jerry Hesch J Hesch, PT, MHS, is Manager, Hesch Seminars and Physical Therapy LLC, Henderson, Nevada. This letter was posted as a Rapid Response on February 23, 2009, at www.ptjournal.org.

References 1 Vaughn HT, Nitsch W. Ilial anterior rotation hypermobility in a female collegiate tennis player. Phys Ther. 2008;88:1578– 1590.

3 Sturesson B, Selvik G, Uden A. Movements of the sacroiliac joints: a roentgen stereophotogrammetric analysis. Spine. 1989;14:162–165. 4 Tullberg T, Blomberg S, Branth B, Johnsson R. Manipulation does not alter the position of the sacroiliac joint: a roentgen stereophotogrammetric analysis. Spine. 1998;23:1124–1128; discussion 1129. 5 Nyberg R. S4 Course Notes: Functional Analysis and Management of the Lumbopelvic Hip Complex. St Augustine, FL: Institute Press; 1997. 6 DonTigny R. Function and pathomechanics of the sacroiliac joint: a review. Phys Ther. 1985;65:35–44. 7 Nyberg R. Pelvic girdle. In: Payton O, Di Fabio RP, Paris SV, et al. Manual of Physical Therapy. New York, NY: Churchill Livingstone Inc; 1989:378–380. 8 Greenman P. Principles of diagnosis and treatment of pelvic girdle dysfunction. In: Greenman P. Principles of Manual Medicine. Baltimore, MD: Williams & Wilkins; 1989:257. 9 Hesch J, Aisenbrey J, Guarino J. The pitfalls associated with traditional evaluation of sacroiliac dysfunction and their proposed solution. Presented at the Annual Conference of the American Physical Therapy Association; June 25, 1990; Anaheim, California. May 2009

Letters to the Editor 10 Hesch J. Evaluating sacroiliac joint play with spring tests. Journal of Obstetric and Gynecologic Physical Therapy. 1996;20(3):4–7. 11 Ostgaard HC, Zetherström G, RoosHansson E, Svanberg B. Reduction of back and posterior pelvic pain in pregnancy. Spine. 1994;19:894–900. [DOI: 10.2522/ptj.2009.89.5.509]

Author Response I would like to thank Poulter,1 Cibulka,2 and Hesch3 for their responses to the case report titled “Ilial Anterior Rotation Hypermobility in a Female Collegiate Tennis Player.”4 I appreciate their professional input regarding the case report and admire their commitment to holding the physical therapy profession accountable for fostering evidencebased practice. Several criticisms were made; some I feel are justified, whereas others warrant a response. I will address each of the responses separately. Poulter states: The current evidence-based literature on low back pain is leaning heavily toward a treatment-based classification system, with an active treatment paradigm. This article seems to fly in the face of this evidence and proposes a structural-based diagnostic classification based on poor tests and passive treatment, namely bed rest, transcutaneous electrical nerve stimulation, ice, ultrasound, massage, and taping.1(p507)

A treatment-based classification system identifies a heterogenous group of patients and places them into subgroups based on the examination data. The classification of the patient in each subgroup guides the treatment plan.5 The assumption of this type of classification system is that all patients will fall into a particular subgroup. Each patient is unique and may have multiple impairments that require a multitreatment approach. Based on exMay 2009

amination data, my patient would need to be classified in both the mobilization and immobilization treatment subgroups, as proposed by Fritz and George.5 Currently, there is only a treatment-based classification system for classifying patients with acute low back pain to treatment subgroups.5 I propose that a treatment-based classification system be developed for patients with sacroiliac joint dysfunction (SIJD). I recognize the deficiency of valid tests associated with the sacroiliac region, specifically, those tests related to SIJD where pain patterns are related to extra-articular structures. With the lack of a treatment-based classification system and valid tests, accurate diagnosis and subsequent treatment of SIJD should be based on a combination of historic clues, palpatory findings, segmental and regional motion testing, overall functional biomechanical examination, and appropriate diagnostic testing.6 I certainly could have classified my patient as having general low back pain and ignored the patient’s mechanism of injury and the impairments identified in the examination. This approach was used by the athletic trainer for 2 weeks after the patient’s first onset of pain. The athletic trainer had the patient continue this active treatment paradigm until she no longer could play tennis, walk with a normal gait pattern, or sit with normal posture. Poulter suggests that a body chart and valid outcome measures should have been utilized in the case report. I agree that a body chart would have increased clarity of the location of the patient’s pain. The patient reported right low back pain as a general descriptor; her pain was palpated inferior to the posterior-superior iliac spine (long dorsal sacroiliac ligament). I also

agree that the Oswestry Disability Index7 could have been used with this patient. However, it was apparent that, based on the patient’s goals, returning to competitive tennis was the true measure of attaining her functional outcome. Poulter asks, “Why did a simple acute low back pain episode under your care become a 6-month chronic recurrent episode?”1(p507) Based on the history, examination, and mechanism of injury, I believed the patient developed right ilial anterior rotation hypermobility secondary to excessive stress to her long dorsal sacroiliac ligament (LDL). The LDL restrains anterior ilial rotation and was susceptible to sprain secondary to performing repetitive 2-hand backhands. The literature suggests that ligaments can regain 50% of their normal tensile strength by 6 months after injury, 80% after 1 year, and 100% after 1 to 3 years.8–10 The subsequent treatment program was designed to stress the LDL gradually over time, being careful not to exceed its tensile strength during the remodeling phase. The sacroiliac belt and taping technique were necessary at 6 months during tennis play secondary to the high pelvic rotational forces and the LDL having approximately only 50% of its tensile strength. The patient was reexamined 1 year later and was found to have no impairments or functional limitations. We hypothesized at 1 year that the ligament had regained its tensile strength and, therefore, the sacroiliac belt and taping technique no longer were necessary for tennis. I do not understand the basis for Poulter’s comment suggesting that I contributed to the patient’s 6-month chronic episode. Furthermore, I believe that I was able to offer the patient a solution to her complex problem.

Volume 89 Number 5 Physical Therapy ■ 511

Letters to the Editor 10 Hesch J. Evaluating sacroiliac joint play with spring tests. Journal of Obstetric and Gynecologic Physical Therapy. 1996;20(3):4–7. 11 Ostgaard HC, Zetherström G, RoosHansson E, Svanberg B. Reduction of back and posterior pelvic pain in pregnancy. Spine. 1994;19:894–900. [DOI: 10.2522/ptj.2009.89.5.509]

Author Response I would like to thank Poulter,1 Cibulka,2 and Hesch3 for their responses to the case report titled “Ilial Anterior Rotation Hypermobility in a Female Collegiate Tennis Player.”4 I appreciate their professional input regarding the case report and admire their commitment to holding the physical therapy profession accountable for fostering evidencebased practice. Several criticisms were made; some I feel are justified, whereas others warrant a response. I will address each of the responses separately. Poulter states: The current evidence-based literature on low back pain is leaning heavily toward a treatment-based classification system, with an active treatment paradigm. This article seems to fly in the face of this evidence and proposes a structural-based diagnostic classification based on poor tests and passive treatment, namely bed rest, transcutaneous electrical nerve stimulation, ice, ultrasound, massage, and taping.1(p507)

A treatment-based classification system identifies a heterogenous group of patients and places them into subgroups based on the examination data. The classification of the patient in each subgroup guides the treatment plan.5 The assumption of this type of classification system is that all patients will fall into a particular subgroup. Each patient is unique and may have multiple impairments that require a multitreatment approach. Based on exMay 2009

amination data, my patient would need to be classified in both the mobilization and immobilization treatment subgroups, as proposed by Fritz and George.5 Currently, there is only a treatment-based classification system for classifying patients with acute low back pain to treatment subgroups.5 I propose that a treatment-based classification system be developed for patients with sacroiliac joint dysfunction (SIJD). I recognize the deficiency of valid tests associated with the sacroiliac region, specifically, those tests related to SIJD where pain patterns are related to extra-articular structures. With the lack of a treatment-based classification system and valid tests, accurate diagnosis and subsequent treatment of SIJD should be based on a combination of historic clues, palpatory findings, segmental and regional motion testing, overall functional biomechanical examination, and appropriate diagnostic testing.6 I certainly could have classified my patient as having general low back pain and ignored the patient’s mechanism of injury and the impairments identified in the examination. This approach was used by the athletic trainer for 2 weeks after the patient’s first onset of pain. The athletic trainer had the patient continue this active treatment paradigm until she no longer could play tennis, walk with a normal gait pattern, or sit with normal posture. Poulter suggests that a body chart and valid outcome measures should have been utilized in the case report. I agree that a body chart would have increased clarity of the location of the patient’s pain. The patient reported right low back pain as a general descriptor; her pain was palpated inferior to the posterior-superior iliac spine (long dorsal sacroiliac ligament). I also

agree that the Oswestry Disability Index7 could have been used with this patient. However, it was apparent that, based on the patient’s goals, returning to competitive tennis was the true measure of attaining her functional outcome. Poulter asks, “Why did a simple acute low back pain episode under your care become a 6-month chronic recurrent episode?”1(p507) Based on the history, examination, and mechanism of injury, I believed the patient developed right ilial anterior rotation hypermobility secondary to excessive stress to her long dorsal sacroiliac ligament (LDL). The LDL restrains anterior ilial rotation and was susceptible to sprain secondary to performing repetitive 2-hand backhands. The literature suggests that ligaments can regain 50% of their normal tensile strength by 6 months after injury, 80% after 1 year, and 100% after 1 to 3 years.8–10 The subsequent treatment program was designed to stress the LDL gradually over time, being careful not to exceed its tensile strength during the remodeling phase. The sacroiliac belt and taping technique were necessary at 6 months during tennis play secondary to the high pelvic rotational forces and the LDL having approximately only 50% of its tensile strength. The patient was reexamined 1 year later and was found to have no impairments or functional limitations. We hypothesized at 1 year that the ligament had regained its tensile strength and, therefore, the sacroiliac belt and taping technique no longer were necessary for tennis. I do not understand the basis for Poulter’s comment suggesting that I contributed to the patient’s 6-month chronic episode. Furthermore, I believe that I was able to offer the patient a solution to her complex problem.

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Letters to the Editor Cibulka states, “How do we interpret the apparent contradiction between not having the evidence and yet needing this evidence to make an accurate diagnosis? How do you make an accurate diagnosis with tests that lack sensitivity or specificity?”2(p508) I recognize the deficiency of valid tests associated with the sacroiliac region, specifically, those tests related to SIJD, where pain patterns are related to extra-articular structures. With the lack of a treatment-based classification system and valid tests, accurate diagnosis and subsequent treatment of SIJD should be based on a combination of historic clues, palpatory findings, segmental and regional motion testing, overall functional biomechanical examination, and appropriate diagnostic testing.9

I apologize to Cibulka for not citing his article titled “Unilateral Hip Rotation Range of Motion Asymmetry in Patients With Sacroiliac Joint Regional Pain”11 in my literature review. Its omission was not intentional, and the article should have been included. I also agree that the terms used to describe the SIJ need to be operationally defined. There is too much “jargon” that leads to confusion when discussing the sacroiliac joint. Hesch discussed several interesting points in his response. I agree that the corrective exercise for the right ilial anterior rotation hypermobility could have been enhanced by adding abduction and lateral (external) rotation of the hip. The “upslip” of the innominate should

Incorporate functional progressions into rehabilitation programs

Todd S. Ellenbecker, DPT, Mark DeCarlo, MS, MHA, and Carl DeRosa, PhD ©2009 • Paperback 248 pp Print: ISBN 978-0-7360-6381-4 $39.00 ($48.95 CDN) E-Book: ISBN 978-0-7360-8593-9 $22.00 ($27.95 CDN)

H Todd Vaughn HT Vaughn, PT, DPT, OCS, MTC, is Senior Lecturer, Physical Therapist Assistant Program, Southern Illinois University at Carbondale, Illinois. This letter was posted as a Rapid Response on March 27, 2009, at www.ptjournal.org.

References 1 Poulter DC. On “Ilial anterior rotation...” Phys Ther. 2009;89:507–508. 2 Cibulka MT. On “Ilial anterior rotation...” Phys Ther. 2009;89:508–509. 3 Hesch J. On “Ilial anterior rotation...” Phys Ther. 2009;89:509–511. 4 Vaughn HT, Nitsch W. Ilial anterior rotation hypermobility in a female collegiate tennis player. Phys Ther. 2008;88:1578– 1590.

One of the most challenging tasks for a sports medicine clinician is rehabilitating an injured athlete for a successful return to competition. Effective Functional Progressions in Sport Rehabilitation provides clinicians with the strategies and tools they need to prepare their clients for the physical demands required by their sport.

5 Fritz JM, George S. The use of a classification approach to identify subgroups of patients with acute low back pain: interrater reliability and short-term treatment outcomes. Spine. 2000:25;106–114.

In this complete reference, clinicians will find evidencebased, functional tests and learn how to interpret and use the test results to develop specific rehabilitation programs. The text also features an online component that allows users access to every image from the text to create takehome instruction sheets for their clients or to create a PowerPoint presentation. The images and sample templates are available at www.HumanKinetics.com/ EffectiveFunctionalProgressionsinSportRehabilitation.

7 Fairbank JC, Pynsent PB. The Oswestry Disability Index. Spine. 2000;25:2940– 2952.

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8 Vailas AC, Tipton CM, Mathes RD, Gart M. Physical activity and its influence on the repair process of medial collateral ligaments. Connect Tissue Res. 1981;9:25–31. 9 Tipton CM, Matthes RD, Maynard JA, Carey RA. The influence of physical activity on ligaments and tendons. Med Sci Sports. 1975;7:165–175. 10 Tipton CM, James SL, Mergner W, Tcheng TK. Influence of exercise in strength of medial collateral knee ligaments of dogs. Am J Physiol. 1970;218:894–902.

[DOI: 10.2522/ptj.2009.89.5.511]

HUMAN KINETICS The Information Leader in Physical Activity *Prices subject to change

6 Brolinson PG, Kozar AJ, Cibor G. Sacroiliac dysfunction in athletes. Curr Sports Med Rep. 2003;2:47–56.

11 Cibulka MT, Sinacore DR, Cromer GS, Delitto A. Unilateral hip rotation range of motion asymmetry in patients with sacroiliac joint regional pain. Spine. 1998;23:1009–1015.

For a complete description or to order, call:   53s  #$.s  )NTERNATIONAL Or visit www.HumanKinetics.com!

Q002

have been examined with passive mobility testing in the prone position, as Hesch suggested. Hesch also brings up an interesting point that the Ostgaard test theoretically could induce anterior rotation of the ilium. Extensive research is needed to validate tests related to the diagnosis of SIJD.

3/09

May 2009

Scholarships, Fellowships, and Grants News from the Foundation for Physical Therapy Celebrating 30 Years of Research Success This year, the Foundation for Physical Therapy celebrates 30 years of advancing physical therapy through research, doctoral scholarships, and fellowships. This timeline lists just a few of the many highlights as the Foundation funding programs grew, one by one. The visionary volunteers who devoted countless hours to building the Foundation and the thousands of generous donors made these achievements possible. The Foundation invites you to appreciate the past and to continue your commitment to the future of physical therapy through research. For a more complete timeline, visit www.FoundationForPhysical Therapy.org. 1979 • Foundation for Physical Therapy is incorporated as a charitable organization, dedicated to advancing physical therapy through clinical research, doctoral scholarships, and fellowships. • First research grants were awarded for a total $10,356.

1981 • Foundation awards 6 scholarships totaling $10,000.

1986 • Foundation launches Endowment Fund Campaign to raise funds for research and scholarship.

1987 • A total of $218,008 in research grants have been awarded since Foundation’s inception.

May 2009

• Foundation co-sponsors 2-part video conference series with the American Rehabilitation Educational Network: “PT Biomechanical Analysis & Treatment of Foot & Ankle Dysfunction” and “TMJ–Craniomandibular Complex: PT Management.” • Orthopaedic Section establishes the Steven J Rose Orthopaedic Physical Therapy Research & Education Endowment Fund with $500,000.

1988 • Marquette University conducts its first Challenge, and students at 14 schools raise $7,400.

1991 • Foundation funds its first Clinical Research Center at the University of Iowa with $200,000 over 3 years to develop the processes and methods necessary to support the physical therapy profession’s drive to document the clinical effectiveness of its interventions.

1995 • APTA establishes the Section on Geriatrics Fund.

1996 • University of Pittsburgh is awarded a 3-year grant for a Clinical Research Center for work-related low-back injuries.

1998 • The Marquette Challenge, co-sponsored by the University of Pittsburgh, surpasses $1 million raised by students over 20 years. Funds underwrite an annual research grant and, when more than $80,000 is raised, a doctoral scholarship. • McMillan Doctoral Scholarships established to award $5,000 to students accepted into a doctoral program and beginning their first semester.

• Two scholarships established: Promotion of Doctoral Studies (PODS) I, which provides up to $7,500 for doctoral coursework prior to candidacy; PODS II, which provides up to $15,000 after candidacy.

1999 • APTA establishes the Pediatrics Section Research Grant Fund.

2001 • APTA establishes an endowment fund with the Foundation for the Patricia Leahy Scholarship and Marylou Barnes Scholarship for doctoral studies in physical therapy.

2002 • Foundation awards its largest grant, $1.5 million, to establish a 3-year, multi-site Clinical Research Network to study 4 areas: PEDALS (Pediatric Endurance Development and Limb Strengthening), MUSSEL (MuscleSpecific Strengthening Effectiveness Post-Lumbar Microdiscectomy), STOMPS (Strengthening and Optimal Movements for Painful Shoulders in Chronic Spinal Cord Injury), and STEPS (Strength Training Effectiveness Post-Stroke). Principal Investigator: Carolee Winstein, PT, PhD.

2004 • 25th Anniversary: More than 400 physical therapist researchers have received $10 million in Foundation funding since 1979. • Magistro Family Endowment Fund established through a generous gift from the Foundation’s first chairman, Charles Magistro, and his family to fund up to 2 research grants each year.

2006 • APTA creates the Cardiovascular & Pulmonary Health Endowment Fund.

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Scholarships, Fellowships, and Grants 2007 • Endowment funds are established by the Orthopaedic Section and the Education Section. • APTA establishes a research fund for the Private Practice Section. • Foundation renames its annual $5,000 award to first-year doctoral students as the Florence P Kendall Doctoral Scholarship. The awards are funded by the Henry O and Florence P Kendall Endowment Fund, established in 1980.

2008 • The major gift campaign, “Destination: Research Excellence—Roadmap for the Future of Physical Therapy,” concludes with more than $5 million in pledges for physical therapy research from sections, chapters, physical therapy leaders, and APTA. • Endowment funds are established through the major gifts campaign: Jayne L Snyder Endowment Fund; Marilyn Moffat Endowment Fund for Geriatric Research; Robert and Susan Deusinger Family Endowment Fund.

2009 • 30th Anniversary: More than 500 researchers have received more than $12 million in Foundation funding and leveraged that to attain more than $100 million in grants from other institutions.

Nominations for Scientific Review Committee The Foundation is seeking recommendations for individuals to serve on its Scientific Review Committee (SRC). Well-qualified physical therapist researchers will review doctoral, fellowship, and research grant applications received by the Foundation. Three appointments will be made for terms that begin January 2010. To be considered, individuals must meet the criteria for SRC membership posted at www. FoundationforPhysicalTherapy. org. Self-nominations are welcome. Please e-mail your recommendations to [email protected].

Applications Opening for 2009 Florence P Kendall Doctoral Scholarships and 2010 Research Grant Opportunities Applications for the Foundation for Physical Therapy’s 2009 Florence P Kendall doctoral scholarships and 2010 research grants will be opening shortly. Go to www.Foundation forPhysicalTherapy.org, and click on “Program Information” to obtain the guidelines and instructions. The anticipated closing date for these applications will be late August. For additional information, contact Eva Donley, Scientific Program Administrator, at 800/875-1378, ext 8505, or [email protected]. [DOI: 10.2522/ptj.2009.89.5.513]

Foundation Dinner Dance at PT 2009— Celebrating 30 Years of Research Join the Celebration on June 11 during APTA’s Annual Conference in Baltimore, Maryland. Individual tickets are $150 ($100 for students). Tables of 8 are $1,600 and include a listing of your name, company, or organization in the program. Contact Barbara Malm at 800/875-1378, ext 8502, for more information. You also may purchase your tickets by contacting the APTA Service Center at 800/9992782, ext 3395. Dinner Dance tickets will not be available in Baltimore. New this year, the Georgia State– Marquette Challenge Awards will be announced during the reception at 7:00 pm. The complimentary reception is open to all attendees. Dinner will be served at 7:30 pm followed by the program and dancing until midnight. In addition to celebrating 30 years of research, the Foundation will present its 2009 Service Awards. The Spirit of Philanthropy Award will be presented to Rep Jim Langevin (DRhode Island) in recognition of his

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tireless advocacy for rehabilitation, health insurance, stem cell research, power mobility, and other healthrelated issues. The Charles M Magistro Distinguished Service Award will be presented to Stanley Paris, PT, PhD, FAPTA, in recognition of his outstanding personal commitment to raise awareness and funds for the Foundation through his attempt to swim the English Channel in 2008. Brad Thuringer, PTA, will be awarded the Robert C Bartlett Innovation in Fundraising Award for demonstrating leadership, creativity, and initiative to develop, coordinate, and execute an innovative fundraising activity to benefit the Foundation. Preferred Therapy Providers Inc will be honored as the Foundation’s Premier Partner in Research for 2009. Special thanks to HPSO/CNA, Dinner Dance title sponsor for the 9th consecutive year.

May 2009