Physical Therapy- Journal of the APTA, Volume 90, Issue 1 (January 2010)

January 2010  Volume 90  Number 1

Research Reports 14

Ultrasound for Soft Tissue Shoulder Pathology

26

Prognosis in Individuals With Shoulder Pain Receiving Cervicothoracic Manipulation

43

Early Measures After Unilateral Total Knee Arthroplasty

55

Effects of Dorsiflexor Muscle Functional Electrical Stimulation on Poststroke Gait

67

Strength and Stooping, Crouching, or Kneeling Difficulty in Older Adults

75

Use of Reflection in Clinical Decision Making

89

Measuring Skill in Walking of Older Adults

Case Report 100

Perspective 110

Hallux Valgus and the First Metatarsal Arch Segment

CARE V Conference Series 121

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Hospital-Based Outpatient Direct Access to Physical Therapy Services

Team Rehabilitation Care After Arthroplasty for Osteoarthritis

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Gain quick and easy access to clinical research. Get free access to full-text articles in more than 1,000 health care periodicals with APTA’s Open Door portal. Open Door also features full-text Cochrane systematic reviews, Medline, an expanded Current Research in Physical Therapy section, open access resources, and more.

Access Hooked on Evidence, APTA’s online database, which contains current research evidence on the effectiveness of physical therapy interventions. Plus, you can earn free CEUs for your contributions.

Visit Physical Therapy (PTJ) on the Web, powered by HighWire Press, which hosts more than 900 journals and the largest repository of free, full-text, peer-reviewed content, including BMJ and JAMA.

Experience the Benefits of APTA Membership! For more details about any of APTA’s exclusive member benefits, visit www.apta.org.

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at CSM 2010 Reserve These Dates and Times for PTJ Sessions at CSM 2010 Stepping Forward With Gait Rehabilitation Friday, February 19

8:00–11:00 am

0.30 CEUs

Researchers who contributed to PTJ’s Special Series on Gait share the highlights of their work and demonstrate cutting-edge and future directions in gait assessment and rehabilitation. Get a crash course in new knowledge related to theoretical frameworks; insights from a variety of gait paradigms; measurement strategies, such as accelerometry for measuring community ambulation in stroke and ambulatory self-efficacy in frail older adults; and gait applications such as virtual reality, mental practice, and body–weight supported treadmill training. You’ll also identify exciting opportunities in both research and practice. PTJ’s Special Series on Gait, to be published online ahead of print in December and in print in February 2010, honors Dr Jacquelin Perry and her many invaluable contributions to the field of gait rehabilitation overmore than 40 years. Led by Special Series Editors Janice Eng, PT, PhD, and Sara Mulroy, PT, PhD. Speakers: Diane Damiano, PT, PhD; Arthur Kuo, PhD; Francine Malouin, PT, PhD.

How to Design and Conduct RCTs: Real-World Considerations Friday, February 19

4:00–6:45 pm

0.28 CEUs

Ever wish you could consult with a group of experienced investigators who have successfully conducted randomized trials and published the results? Wish granted! At this session, you have the undivided attention of an international panel of both physical therapist and non–physical therapist researchers who will share their strategies with you. Benefit from concrete examples and small-group discussion that will focus not only on design but on some of the key issues involved in actually conducting trials. Led by Editorial Board Members Rachelle Buchbinder, MBBS(Hons), MSc, PhD, FRACP, and Christopher G. Maher, PT, PhD.

PTJ Lunch for Authors and Reviewers Saturday, February 20

12:00–2:00 pm

0.25 CEUs

If you’re an author or a reviewer, you work hard! PTJ salutes you! Take advantage of the collective expertise of PTJ’s Editorial Board; come with your questions and your appetite. Authors want to “get it right,” reduce review time, and get published; reviewers want to enhance their evaluative skills, use their time efficiently, and build their scholarly contributions. Discuss the challenges, and learn new strategies. Led by Editor-in-Chief Rebecca Craik, PT, PhD, FAPTA; Editorial Board Member Patricia Ohtake, PT, PhD; and members of PTJ’s Editorial Board.

CSM 2010

SAN DIEGO

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Feb ruary 17-20

American Physical Therapy Association’s Combined Sections Meeting

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Next month—in PTJ or online at ptjournal.org: Stepping Forward With Gait Rehabilitation Special Series in Honor of Dr. Jacquelin Perry

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Dynamic Principles of Gait

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Effects of Dual Tasking, Prioritization, Age, and Sex on Gait

Cognitive Load and Dual-Task Performance During Locomotion Poststroke

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Split-Belt and Other Locomotor Adaptation Paradigms

A Treatment for Adults With Stiff Knee Gait

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Meaningful Gait Speed Improvement Poststroke

Strength Training and Gait Kinematics

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Responsiveness to a BodyWeight–Supported Treadmill Training Program Poststroke

Parkinson Disease: EvidenceBased Physical Therapy for Gait Disorders

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Joint Kinematics and Muscle Demands in Elliptical Training and Walking

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Daily Stepping in Individuals With Motor Incomplete SCI

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Mental Practice for Relearning Locomotor Skills

“Just clicking around the site and wanted to give a huge ‘thumbs umbs up!’ PTJ…used to sit in my inbox and got quickly browsed. wsed. Now I have trouble finding time to explore all the value! Video, podcasts, tweets, applicable Journal entries entries…” —Jim m Glinn, PT, P DPT, OCS

Visit ptjournal.org for enhanced features, including articles published ahead of print! Physical Therapy (PTJ)—APTA’s peer-reviewed scholarly

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Physical Therapy Journal of the American Physical Therapy Association

Editorial Office Managing Editor / Associate Director of Publications: Jan P. Reynolds, [email protected] PTJ Online Editor / Assistant Managing Editor: Steven Glaros 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

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Editor in Chief

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

Deputy Editor in Chief

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

Rachelle Buchbinder, MBBS(Hons), MSc, PhD, FRACP, Malvern, Victoria, Australia; W. Todd Cade, PT, PhD, St. Louis, MO; James Carey, PT, PhD, Minneapolis, MN; John Childs, PT, PhD, Schertz, TX; Charles Ciccone, PT, PhD, FAPTA (Continuing Education), Ithaca, NY; Joshua Cleland, PT, DPT, PhD, OCS, FAAOMPT, Concord, NH; Janice J. Eng, PT/OT, PhD, Vancouver, BC, Canada; James C. (Cole) Galloway, PT, PhD, Newark, DE; Steven Z. George, PT, PhD, Gainesville, FL; Kathleen Gill-Body, PT, DPT, NCS, Boston, MA; Paul J.M. Helders, PT, PhD, PCS, Utrecht, The Netherlands; Maura D. Iversen, PT, ScD, MPH, 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; Kathleen Sluka, PT, PhD, Iowa City, IA; Patty Solomon, PT, PhD, Hamilton, Ont, Canada

Statistical Consultants

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Steven E. Hanna, PhD, Hamilton, Ont, Canada; John E. Hewett, PhD, Columbia, MO; Hang Lee, PhD, Boston, MA; Xiangrong Kong, PhD, Baltimore, MD; Paul Stratford, PT, MSc, Hamilton, Ont, Canada; Samuel Wu, PhD, Gainesville, FL

President / Advertising Account Manager: Jane Dees Richardson

Committee on Health Policy and Ethics

Board of Directors President: R. Scott Ward, PT, PhD Vice President: Paul A. Rockar Jr, PT, DPT, MS 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: 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, DSc, OCS; Kathleen K. Mairella, PT, DPT, MA; Stephen C.F. McDavitt, PT, DPT, MS, FAAOMPT; Lisa K. Saladin, PT, PhD; Mary C. Sinnott, PT, DPT, MEd; Nicole L. Stout, PT, MPT, CLT-LANA

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Linda Resnik, PT, PhD, OCS (Chair), Providence, RI; Janet Freburger, PT, PhD, Chapel Hill, NC; Alan Jette, PT, PhD, FAPTA, Boston, MA; Michael Johnson, PT, PhD, OCS, Philadelphia, PA; Justin Moore, PT, DPT, Alexandria, VA; Ruth Purtilo, PT, PhD, FAPTA, Boston, MA

Linking Evidence and Practice Advisory Group

Rachelle Buchbinder, MBBS(Hons), MSc, PhD, FRACP, Malvern, Victoria, Australia (Co-Chair); Diane U. Jette, PT, DSc, Burlington, VT (Co-Chair); W. Todd Cade, PT, PhD, St. Louis, MO; Christopher Maher, PT, PhD, Lidcombe, NSW, Australia; Kathleen Kline Mangione, PT, PhD, GCS, Philadelphia, PA; David Scalzitti, PT, DPT, PhD, Alexandria, VA

The Bottom Line Committee

Eric Robertson, PT, DPT, OCS; 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; Kathleen Rockefeller, PT, MPH, ScD; Michael Ross, PT, DHS, OCS; 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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Subscriptions

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 $12 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.

Members and Subscribers Send changes of address to: APTA, Attn: Membership Dept, 1111 North Fairfax St, Alexandria, VA 22314-1488. Subscription inquiries: 703/684-2782, ext 3124. PTJ is available in a special format for readers who are visually impaired. For information, contact APTA’s Membership Department at 703/684-2782, ext 3124.

Mission Statement

Physical Therapy (PTJ) engages and inspires an international readership on topics related to physical therapy. As the leading international journal for research in physical therapy and related fields, PTJ publishes innovative and highly relevant content for both clinicians and scientists and uses a variety of interactive approaches to communicate that content, with the expressed purpose of improving patient care.

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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Full-text articles are available for free at ptjournal.apta.org 12 months after the publication date. Full text also is provided through DataStar, Dialog, EBSCOHost Academic Search, Factiva, InfoTrac, ProFound, and ProQuest.

Reprints

PTJ Online at www.ptjournal.org

Readers should direct requests for reprints to the corresponding author of the article. Students and other academic customers may receive permission to reprint copyrighted material from this publication by contacting the Copyright Clearance Center Inc, 222 Rosewood Dr, Danvers, MA 01923. Authors who want reprints should contact June Billman, Cadmus Communications, at 800/4875625, or [email protected]. Nonacademic institutions needing reprint permission information should go to ptjournal.apta.org/misc/terms.dtl.

PTJ Online is available via RSS feeds. PTJ posts articles ahead of print and rapid reader responses to articles. Articles, letters to the editor, and editorials are available in full text starting with Volume 79 (1999) and in searchable PDF format starting with Volume 60 (1980). Entire issues are available online beginning with Volume 86 (2006) and include additional data, video clips, and podcasts.

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PTJ is indexed and/or abstracted by Abridged Index Medicus, Abstracts of Health Care Management Studies, AgeLine, Allied and Complementary Medicine Database (AMED), Bibliography of Developmental Medicine and Child Neurology, Current Contents, Cumulative Index to Nursing and Allied Health Literature (CINAHL), EMBASE/Exerpta Medica, Exceptional Child Education Resources, Focus on: Sports Science and Medicine, General Science Index (GSI), Health Index, Hospital and Health Administration Index, Index Medicus, Inpharma Weekly, International Nursing Index, ISR, Medical & Surgical Dermatology, MEDLINE, Neuroscience Citation Index, Personal Alert: Automatic Subject Citation Alert (ASCA), Pharmacoeconomics and Outcomes News, Physical Education Index, Reactions Weekly, RECAL Bibliographic Database, Science Citation Index (SCI), Social Sciences Citation Index (SSCI), and SportsS. Article abstracts are available online at ptjournal.apta.org (1980 through present) and via DataStar, Dialog, FirstSearch, Information Access, Ovid

January 2010

Technologies. Ingenta provides online document delivery for articles published since September 1988.

Advertisements are accepted by PTJ when they conform to the ethical standards of the American Physical Therapy Association. PTJ does not verify the accuracy of claims made in advertisements, and acceptance does not imply endorsement by PTJ or the Association. Acceptance of advertisements for professional development courses addressing advanced-level competencies in clinical specialty areas does not imply review or endorsement by the American Board of Physical Therapy Specialties.

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Editorial PTJ Helps Clinicians Link Evidence to Patient Care

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ave you ever had a patient with an unusual problem—or a typical problem that presents in an unusual way? Do patients ever ask you questions about an intervention based on information that they googled on the Internet? Do your students ask questions about the effectiveness of one treatment approach over another? If you’ve answered yes to one or more of these questions, you might have found yourself wishing that you better understood how to find and interpret evidence about the usefulness of one intervention compared to another or about the value of a particular diagnostic finding in determining the best plan of care. As a practitioner, you have to make many clinical decisions in the course of a day, often without adequate time or access to the best evidence. And even when some evidence is available, there are many factors that can affect clinical decisions, such as patient circumstances and preferences and clinician experience and education.1 What do you do when there is uncertainty about the optimal management of a patient? You might resolve to do a quick search of the literature before the patient returns for the next visit, but good searches take time, something you don’t have. Or maybe you are able to carve out time for a search and actually turn up a seemingly useful study—only to find that it doesn’t apply very well to your patient after all or that the conclusions were equivocal anyway. In a survey of physical therapists published in 2003, the majority agreed that using evidence in practice was necessary and that use of evidence improved the quality of patient care and decision making.2 At the same time, they identified insufficient time as one of the top 3 barriers to using evidence in their practice. Because evidence is cumulative—and because it is rare for a single study, no matter how well it’s conducted, to provide definitive evidence—certainty in clinical decision making may be impossible. So, one approach for the busy clinician is to rely on the results of systematic reviews to inform daily practice. Well-conducted systematic reviews critically examine and summarize the available body of evidence, usually randomized clinical trials, to identify benefits and harms of specific interventions. Other systematic reviews may identify optimal prognostic strategies or provide prognostic estimates for various disorders. By synthesizing results of individual studies, systematic reviews can save the clinician time in searching and reading individual studies, and, because systematic reviews include an assessment of the risk of bias of individual studies, they also can help the clinician judge the validity of research findings.

To comment, submit a Rapid Response to this editorial posted online at www.ptjournal.org.

Systematic reviews are, in themselves, scientific studies. They start with a clinical question; apply a detailed, methodical, and reproducible search of all available literature; and use specific criteria for selection of studies related to the question. In this way, bias is minimized. Selected studies are then critically appraised to determine the quality of their methods, and, in the case of clinical trials, a pooled estimate of the treatment benefit (and harms) may be ascertained, with an indication of the overall strength of the evidence. Systematic reviews can provide implications for clinical practice; however, in many instances, the varying level of both quality and generalizability of the studies in the review precludes definitive recommendations for practice. This is particularly frustrating for clinicians who

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Editorial may be unsure about how best to then use the information in their clinical decision making. Furthermore, treatment decisions for individual patients often require a weighing of the risks and benefits of many possible treatment choices, the preferences of the patient, and the feasibility of the interventions in a particular setting. And that’s why we’re launching Linking Evidence and Practice (page 9). This new series will offer real-life clinical scenarios, provide relevant information from Cochrane systematic reviews and other sources, and discuss the use of this evidence in practice. The Cochrane Collaboration is an international not-for-profit organization that aims to help health care providers, patients, and policy makers make well-informed decisions on health care treatments by synthesizing, maintaining, and disseminating high-quality systematic reviews.3 The collaboration includes 52 Cochrane review groups that comprise people from around the world who share an interest in developing and maintaining systematic reviews relevant to a particular health area. For example, the Cochrane Musculoskeletal Group (CMSG), one of the largest Cochrane review groups, has more than 600 active researchers, health care professionals, and consumer representatives from 26 countries (including 10 developing nations) who conduct and disseminate research on musculoskeletal conditions.4 Cochrane reviews are well known for a rigorous and systematic approach to collecting and appraising evidence, and many advances in the provision of health care have come from the efforts of Cochrane Collaboration members.* The goal of is to provide clinicians with best available evidence for various conditions in a format that is designed to streamline the application of evidence to practice. Over the coming year we will present a variety of clinical cases along with a synthesis of best available evidence for each case. Emphasis usually will be on interventions, but vignettes also may be designed with a focus on diagnosis or prognosis. The primary emphasis with all cases will be to summarize evidence in a way that is clear and accessible. We look forward to your feedback and your suggestions on how this new feature can enhance your care provision of care. Contact us at [email protected].

APTA members have access to the Cochrane Database of Systematic Reviews via Open Door at www.apta. org/OpenDoor.

Diane U. Jette, PT, DSc Rachelle Buchbinder, MBBS(Hons), MSc, PhD, FRACP Editorial Board Members References 1 Jette DU, Jette AM. Professional uncertainty and treatment choices by physical therapists. Arch Phys Med Rehabil. 1997;78:3146–3151. 2 Jette DU, Bacon K, Batty C, et al. Evidence-based practice: beliefs, attitudes, knowledge, and behaviors of physical therapists. Phys Ther. 2003;83:786–805. 3 Cochrane Collaboration. Available at: http://www.cochrane.org/docs/descrip.htm. Accessed November 17, 2009. 4 Buchbinder R, Tugwell P, Busch A, et al. Cochrane Musculoskeletal Group. Available at: http://www.mrw. interscience.wiley.com/cochrane/clabout/articles/MUSKEL/frame.html. [DOI: 10.2522/ptj.2010.90.1.6]

*

A recently updated Cochrane Handbook for Systematic Reviews of Interventions describes in detail the process of creating Cochrane systematic reviews and lists the new methodological guidelines. The Cochrane Library (http://www3.interscience.wiley.com/cgi-bin/mrwhome/106568753/HOME) contains both completed systematic reviews and outlines of those that are proposed and in preparation. The Library can be accessed for free in many countries (in the United States, however, only the state of Wyoming offers free access through public libraries).

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LINKING EVIDENCE AND PRACTICE Pulmonary Rehabilitation Following Acute Exacerbation of Chronic Obstructive Pulmonary Disease Diane U. Jette, Mary C. Bourgeois, Rachelle Buchbinder highlights the findings and application of Cochrane reviews and other evidence pertinent to the practice of physical therapy. The Cochrane Library is a respected source of reliable evidence related to health care. Cochrane systematic reviews explore the evidence for and against the effectiveness and appropriateness of interventions— medications, surgery, education, nutrition, exercise—and the evidence for and against the use of diagnostic tests for specific conditions. Cochrane reviews are designed to facilitate the decisions of clinicians, patients, and others in health care by providing a careful review and interpretation of research studies published in the scientific literature.1 Each article in this new PTJ series will summarize a Cochrane review or other scientific evidence resource on a single topic and will present clinical scenarios based on real patients to illustrate how the results of the review can be used to directly inform clinical decisions. The first article in the series focuses on a patient with chronic obstructive pulmonary disease (COPD) who has had a recent exacerbation that required medical intervention. Should this patient undergo pulmonary rehabilitation?

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he American Thoracic Society defines COPD as “a preventable and treatable disease state characterized by airflow limitation that is not fully reversible. The airflow limitation is usually progressive and is associated with an abnormal inflammatory response of the lungs to noxious particles or gases, primarily caused by cigarette smoking. Although COPD affects the lungs, it also produces significant systemic consequences.”2 Prevalence of COPD in adults who are 40 years old or older is approximately 10%.3 Chronic obstructive pulmonary disease is a leading cause of death and disability,4 and acute exacerbation is one of the main causes of hospitalization and death.5 An exacerbation of COPD is defined as “an event in the natural course of the disease characterized by a change in the patient’s baseline dyspnea, cough, and/or sputum, that is beyond normal day-to-day variations, is acute in onset and may warrant a change in medication in a patient with underlying COPD.”6(p xiv) Pulmonary rehabilitation has been shown to be effective in improving exercise capacity, physical function, and quality of life and in reducing dyspnea and fatigue in people with COPD.7 Pulmonary rehabilitation takes many forms but usually includes, at a minimum, exercise training and patient education. Other interventions may include smoking cessation strategies, ventilatory muscle training, airway clearance techniques, medication management, and psychological support. Because

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the studies included in a 2006 Cochrane systematic review only had participants without recent COPD exacerbations,7 Puhan et al8 conducted an additional Cochrane review of randomized clinical trials to determine the effect of pulmonary rehabilitation on patients with recent COPD exacerbations requiring inpatient or outpatient care. In the review, the pulmonary rehabilitation intervention had to include at least some form of exercise training beginning within 3 weeks of the COPD exacerbation. The primary outcome of interest was subsequent hospital admissions. Secondary outcomes also were examined, such as mortality, quality of life, and exercise capacity. The results of the review are outlined in the Table.

Take-Home Message The Cochrane review by Puhan et al8 indicates that pulmonary rehabilitation is effective in reducing the chance of hospitalization and mortality following an acute exacerbation of COPD. Pulmonary rehabilitation following acute COPD exacerbation also results in improvements in health-related quality of life and exercise capacity. Adverse effects of pulmonary rehabilitation following an acute exacerbation of COPD were not found in the review. Because pulmonary rehabilitation programs commonly focus on educating the patient to make such lifestyle changes as increasing physical activity, reducing smoking, and seeking care for early signs of upper respiratory infections, an advantage of pulmonary

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Case #1 Pulmonary Rehabilitation Following Acute Exacerbation of COPD Table.

Pulmonary Rehabilitation for Chronic Obstructive Pulmonary Disease (COPD): Cochrane Review Results8 ➢ Six randomized controlled trials were included in the review, with a total of 241 participants recruited following an acute exacerbation of COPD. ➢ The average ages of the participants in the included studies were between 62 and 70 years, and the average disease severity, as measured by forced expiratory volume in 1 second (FEV1), was between 36% and 40% of predicted level. ➢ Exercise program mode, duration, and frequency varied across studies. ➢ Studies compared patients receiving pulmonary rehabilitation that included at least physical exercise with patients who had conventional community care. ➢ Overall, outcomes favored the pulmonary rehabilitation intervention group. Hospitalizations

Across 3 studies, 57 people out of 100 in the control group had hospital admission over 34 weeks, compared with 14 out of 100 for the pulmonary rehabilitation group.

Mortality

Across 3 studies, 29 people out of 100 in the control group died over a mean of 107 weeks, compared with 10 out of 100 for the pulmonary rehabilitation group.

Health-related quality of life

Chronic Respiratory Disease Questionnaire9 scores favored the pulmonary rehabilitation group over the conventional therapy group in all domains (dyspnea, fatigue, emotional function, and mastery) in the 2 studies measuring this outcome (1.15 units to 1.88 units difference). Minimal important difference is 0.5 on 7-point scales.10 St George’s Respiratory Questionnaire11 scores favored the pulmonary rehabilitation group over the conventional therapy group in 2 of the 4 domains (activity limitation and impact) in the studies measuring this outcome (−9.9 units and −17.1 units difference). Minimal important difference is 4 units on 100-point scales.12

Exercise capacity

Six-minute walk13 distance favored the pulmonary rehabilitation group over the conventional therapy group in the 4 studies measuring this outcome (mean difference of 107 m). An important effect is ≥35 m.14 Shuttle-Walking test15 score favored the pulmonary rehabilitation group over the conventional therapy group in the 2 studies measuring this outcome (mean difference of 81 m). The minimal clinically important difference is 47.5 m.16

Adverse events

Two trials reported no adverse events. Four trials did not include statements of adverse event.

rehabilitation following acute exacerbation of COPD may be related to patients’ improved readiness to change following the distress of an acute episode. In addition, patients who participate in a pulmonary rehabilitation program have continuity of care in terms of reinforcing proper use of medication and attention to important symptoms. A potential disadvantage of participating in a pulmonary rehabilitation program following an acute exacerbation of COPD is that patients may have severely reduced endurance, necessitating a slower progression of exercise and a longer rehabilitation process to gain clinically important improvements. An understanding of the relative benefits and limitations of pulmonary rehabilitation after an acute exacerbation of COPD is useful when making 10 ■ Physical Therapy Volume 90 Number 1

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clinical decisions with individual patients.

Case #1: Applying Evidence to a Patient With COPD Can pulmonary rehabilitation help this patient? Ms Wilson is a 64-year-old woman with a 10-year history of COPD who had a series of 3 COPD exacerbations over a 4-month period. These exacerbations required medical intervention with antibiotic treatment and oral steroids, but she was never hospitalized. Following the third exacerbation, Ms Wilson complained of moderate exertional dyspnea and was unable to perform her usual exercise program at home. Her forced expiratory volume in 1 secJanuary 2010

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Case #1 Pulmonary Rehabilitation Following Acute Exacerbation of COPD ond (FEV1) was 35% of predicted level. Ms Wilson’s impairments included reduced exercise capacity with a 6-minute walk distance of 385 m (predicted=497 m17), impaired ventilation with an inability to properly pace breathing during activity, reduced lower-extremity muscle strength, and impaired gas exchange with desaturation to 86% on 3 L/min of supplemental oxygen during activity. Completion of the Chronic Respiratory Disease Questionnaire (CRQ) yielded the following scores: dyspnea=13/35, fatigue=18/28, emotional function=35/49, and mastery=17/28. Ms Wilson’s goals were to improve activity tolerance, avoid further COPD exacerbations, maintain oxygen saturation above 90%, and return to work. How did the results of the Cochrane systematic review apply to Ms Wilson? Based on evidence from the systematic review described in this article, Ms Wilson, her physician, and her physical therapist agreed that she would be a good candidate for an outpatient pulmonary rehabilitation program. Ms Wilson began an outpatient pulmonary rehabilitation consisting of 2-hour supervised group sessions twice per week. The program included endurance training and strength-

ening and flexibility exercises over an 18-week period. Stair climbing with instruction in paced breathing strategies was incorporated gradually. Ms Wilson completed all exercises with 3 L/min of supplemental oxygen. How well do the outcomes of the intervention provided to Ms Wilson match those suggested by the systematic review? By the end of the 18-week period, 6-minute walk distance had increased to 442 m. The CRQ score improvements included: dyspnea=20/35, fatigue=20/28, emotional function=38/49, and mastery=22/28. In addition, all muscle groups demonstrated strength improvements. Ms Wilson met her goals of returning to part-time work and restarting her home walking program. She had no hospitalizations. Can you apply the results of the systematic review to your own patients? The findings of this review apply well to patients with acute exacerbations of COPD. The review criteria allowed studies with patients requiring inpatient or outpatient care; however, the review found only studies in which participants had been hospitalized for their exacerbations, and Ms Wilson had not been hospitalized to manage her exacerbations. The health care team still considered that it was reasonable to extrapolate the findings from the review to Ms Wilson’s case. She was otherwise similar to trial participants, and there were no compelling reasons to expect

that the results would not be generalizable to patients who have exacerbations managed out of the hospital. What can be advised based on the results of this systematic review? Patients fitting the description of the participants as outlined in the Table are likely to benefit from an inpatient, outpatient, or homebased pulmonary rehabilitation program that includes endurance exercise training, strengthening exercises, and education. Similar to participants in the included studies and Ms Wilson, people engaging in a pulmonary rehabilitation program following acute exacerbation are likely to show clinically meaningful improvements in health-related quality of life and exercise capacity. Finally, patients engaging in pulmonary rehabilitation may reduce their chances for future hospitalizations and odds of death over a period of 3 months to 4 years. D.U. Jette, PT, DSc, is Professor and Chair, Department of Rehabilitation and Movement Science, University of Vermont, Burlington, Vermont. M.C. Bourgeois, PT, DPT, CCS, is Clinical Assistant Professor, Department of Physical Therapy, MGH Institute of Health Professions, Boston, Massachusetts. R. Buchbinder, PhD, is Professor, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia.

References 1

2

3

The Cochrane Library. Available at: http:// www3.interscience.wiley.com/cgi-bin/ mrwhome/106568753/HOME. Accessed December 8, 2009. COPD Guidelines, Definitions. Available at: http://www.thoracic.org/sections/ copd/for-health-professionals/definitiondiagnosis-and-staging/definitions.html. Accessed October 15, 2009. Halbert RJ, Natoli JL, Gano A, et al. Global burden of COPD: systematic review and meta-analysis. Eur Respir J. 2006;28:523–532.

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6

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Calverley PMA, Walker P. Chronic obstructive pulmonary disease. Lancet. 2003;362(9389):1053–1061. Mannino DM. COPD: epidemiology, prevalence, morbidity and mortality, and disease heterogeneity. Chest. 2002;121(5 Suppl):121S–126S. Global Initative for Chronic Obstructive Lung Disease. Global Strategy for the Diagnosis, Management and Prevention of Chronic Obstructive Lung Disease: Medical Communication Resources Inc; 2009. Available at: http:// www.goldcopd.com/Guidelineitem. asp?l1=2&l2=1&intId=2003. Accessed December 2009. Lacasse Y, Goldstein R, Lasserson TJ, Martin S. Pulmonary rehabilitation for chronic obstructive pulmonary disease. Cochrane Database Syst Rev. 2006(4):CD003793. Puhan M, Scharplatz MA, Troosters T, et al. Pulmonary rehabilitation following exacerbations of chronic obstructive pulmonary disease. Cochrane Database Syst Rev. 2009(3):CD005305.

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Guyatt G, Berman L, Townsend M, et al. A measure of quality of life for clinical trials in chronic lung disease. Thorax. 1987;42:773–778. Schünemann HJ, Puhan M, Goldstein R, et al. Measurement properties and interpretability of the Chronic Respiratory Disease Questionnaire (CRQ). COPD. 2005;2:81–89. Jones PW, Quirk FH, Baveystock CM. The St. George’s respiratory questionnaire. Respir Med. 1991;85(suppl B):25– 31. Schünemann HJ, Griffith L, Jaeschke RZ, et al. Evaluation of the minimal important difference for the feeling thermometer and the St. George’s Respiratory Questionnaire in patients with chronic airflow obstruction. J Clin Epidemiol. 2003;56:1170–1176. Butland RJA, Pang J, Gross ER, et al. Two-, six-, and twelve-minute walking tests in respiratory disease. Br Med J. 1982;284:1607–1608.

14 Puhan MA, Mador MJ, Held U, et al. Interpretation of treatment changes in six-minute walk distance in patients with COPD. Eur Respir J. 2008;32:637– 643. 15 Singh SJ, Morgan MD, Walters D, Hardman AE. Development of a shuttle walking test of disability in patients with chronic airways obstruction. Thorax. 1992;47:1019–1024. 16 Singh SJ, Jones PW, Evans R, Morgan MDL. Minimum clinically important improvement for the incremental shuttle walking test. Thorax. 2008;63:775– 777. 17 Enright PL, Sherril DL. Reference equations for the six-minute walk in healthy adults. Am J Respir Crit Care Med. 1998;158:1384–1387. [DOI: 10.2522/ptj.2010.90.1.9]

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Research Report Exposure to Low Amounts of Ultrasound Energy Does Not Improve Soft Tissue Shoulder Pathology: A Systematic Review Lisa D. Alexander, David R.D. Gilman, Derek R. Brown, Janet L. Brown, Pamela E. Houghton L.D. Alexander, MPT, is a medical student at the University of Toronto. D.R.D. Gilman, MPT, is Physiotherapist, Grand River Physiotherapy, Fergus, Ontario, Canada. D.R. Brown, MPT, is Physiotherapist, Rehab Health Inc, Brantford General Hospital, Brantford, Ontario, Canada. J.L. Brown, HBAPE, BScPT, MEd, is Lecturer, School of Physical Therapy, University of Western Ontario, London, Ontario, Canada. P.E. Houghton, HBSc, BScPT, PhD, is Associate Professor, School of Physical Therapy, University of Western Ontario, Room 1458, Elborn College, London, Ontario, Canada N6G 1H1. Address all correspondence to Dr Houghton at: [email protected]. [Alexander LD, Gilman DRD, Brown DR, et al. Exposure to low amounts of ultrasound energy does not improve soft tissue shoulder pathology: a systematic review. Phys Ther. 2010;90:14 –25.] © 2010 American Physical Therapy Association

Background. Although therapeutic ultrasound is commonly used to treat shoulder injuries, research to date on the ability of ultrasound to improve outcomes for shoulder pathologies is conflicting. Objective. This study aimed to systematically and critically review available literature to ascertain whether beneficial effects of ultrasound were associated with certain shoulder pathologies or particular ultrasound treatment protocols.

Methods. Five electronic databases were searched, and the included studies, identified through pair consensus, were randomized controlled trials (RCTs) that utilized ultrasound for soft tissue shoulder injury or pain.

Study Selection and Data Extraction. Eight studies included in this review (n⫽586 patients, median PEDro score⫽8.0/10) evaluated various parameters, including the duration of patients’ symptoms (0 –12 months), duty cycle (20% and 100%), intensity (0.1–2.0 W/cm2), treatment time per session (4.5–15.8 minutes), number of treatments (6 –39), and total energy applied per treatment (181– 8,152 J).

Data Synthesis. Inconsistent outcome measures among studies precluded metaanalysis; however, 3 RCTs showed statistically significant benefits of ultrasound, 2 of which examined calcific tendinitis. Studies that showed beneficial effects of ultrasound typically had 4 times longer total exposure times and applied much greater ultrasound energy per session (average of 4,228 J) compared with studies that showed no benefit of ultrasound (average of 2,019 J). No studies that delivered ⱕ720 J per session showed improvement in treatment groups. Limitations. Current research involving ultrasound treatment protocols that delivered low levels of ultrasound energy do not adequately address whether ultrasound can improve outcomes for shoulder disorders. Conclusion. Determining whether therapeutic ultrasound can affect soft tissue shoulder pathologies will require further research and systematic reviews that involve appropriate ultrasound treatment protocols.

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houlder pain constitutes approximately 16% of all musculoskeletal complaints,1 making it the third most common musculoskeletal disorder, next only to low back and neck disorders.2 The annual incidence of 15 new episodes of shoulder pain per 1,000 patients seen in the primary care setting3 may peak during the fourth and fifth decades of life.4 The symptoms of new episodes of shoulder pain in the primary care setting have been shown to persist for at least 1 year in 40% to 50% of patients.5,6 Shoulder pain with associated soft tissue pathology can be divided into several diagnostic categories, including subacromial impingement syndrome, tendinitis, tendinosis, bursitis, calcific deposits, and myofascial tears. The causes of such disorders can be multifactorial7 and may be associated with repetitive movements and overuse, trauma, surgical intervention, thoracic kyphosis, advancing age, acromioclavicular or glenohumeral osteophytes, decreased mobility in the cervicothoracic spine, autoimmune and inflammatory diseases, or metabolic diseases.7–11 The human shoulder complex provides a stable, yet mobile, base of support upon which coordinated movements can occur; this requirement of diametrically opposed functions also may be an underlying etiology of shoulder dysfunction. The aims of conservative treatments for shoulder complaints are to identify and ameliorate the underlying

Available With This Article at ptjournal.apta.org • Audio Abstracts Podcast This article was published ahead of print on November 12, 2009, at ptjournal.apta.org.

January 2010

etiology, when possible, and to control symptoms such as pain. Conservative treatments include, but are not limited to, analgesics, nonsteroidal anti-inflammatory drugs, steroid injections, and physical therapy; the last may include therapeutic exercise, joint mobilization and manipulation, education, and the application of physical modalities such as ultrasound.12,13 Ultrasound is widely used in the management of soft tissue injuries.14 –18 Seven systematic reviews and metaanalyses previously examined the effectiveness of ultrasound for musculoskeletal disorders.6,13,17–21 In 4 of these studies,6,13,20,21 1 of which was a Cochrane review,13 investigators reported on a wide range of physical therapy interventions for the treatment of shoulder pain or disorders. The 3 remaining reviews17–19 included studies in which only the effects of ultrasound treatment were examined but in which participants exhibited a wide range of musculoskeletal disorders (eg, chronic wounds, myofascial pain, osteoarthritis) affecting several body locations (eg, perineum, ankle, low back). In a 1999 review of the treatment of shoulder disorders, van der Heijden concluded that “there was sufficient evidence that physical modalities, including ultrasound, do not contribute to pain reduction or recovery from shoulder disorders.”6(p303) The Philadelphia Panel clinical practice guidelines on interventions for shoulder pain20 concluded that ultrasound is beneficial in the treatment of calcific tendinitis but that it has not been shown to be clinically important for nonspecific shoulder complaints, such as bursitis and tendinitis. For the most part, these conclusions are in agreement with the findings of the 2003 Cochrane review.13 However, the fact that these reviews included such a wide range of treatment interventions and heterogeneous patient populations

could have masked any specific indication for ultrasound treatment. In addition, no published review has included newer studies (published since 1999) examining the effects of ultrasound on shoulder disorders. A more focused review specifically examining the effects of ultrasound on soft tissue disorders of the shoulder is warranted. Furthermore, in published articles in which the clinical evidence for the ultrasound treatment of shoulder pathologies was reviewed, the appropriateness and rigor of the ultrasound treatment protocols used in the clinical trials were not considered. In a 2001 review of ultrasound effectiveness studies, Robertson and Baker17 were the first to calculate and compare the total amounts of ultrasound energy delivered to tissues to examine the effects of ultrasound dosages on study outcomes. However, included in that review were clinical trials involving many musculoskeletal conditions (eg, chronic wounds, carpal tunnel syndrome, osteoarthritis of the knee). Accordingly, the studies included in that review involved a wide range of ultrasound treatment protocols because many different conditions and body locations were treated with ultrasound. To calculate the ultrasound energy delivered, the authors also had to make several assumptions about transducer head size and treatment area, a fact that they suggested “was clearly a potential source of error in subsequent calculations.”17(p1345) Therefore, given the heterogeneity and limitations of previous systematic reviews, there is a need to systematically review and critically evaluate existing literature to specifically examine the potential effects of ultrasound treatment of soft tissue disorders of the shoulder. The purposes of this study were to identify relevant randomized clinical trials

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Ultrasound for Soft Tissue Shoulder Pathology (RCTs) and to evaluate ultrasound treatment protocols to determine whether certain ultrasound treatment parameters were associated with improvements in soft tissue shoulder impairments or function. The specific study protocol characteristics that were evaluated in this review included the clinical characteristics of the study populations (eg, type of pathology treated, time since symptom onset) and the ultrasound parameters (eg, duty cycle, frequency, treatment time per session, total exposure, total ultrasound energy applied both per session and over the entire duration of each study).

Table 1.

Method

Table 2.

Data Sources A search of 5 electronic databases (CINAHL, 1982–2008; Cochrane Central Register of Controlled Trials, 1947–2008; EMBASE, 1947–2008; MEDLINE, 1950 –2008; and PubMed, 1950 –2008) was conducted and limited by language (English), population (humans), and study type (RCT). The search included investigations published in print or electronically before April 2008. The search terms used for this process are listed in Table 1. Before the literature search was conducted, specific study inclusion and exclusion criteria were formulated (Tab. 2). To be included in the current investigation, studies had to exhibit an RCT design that involved patients who were 18 years of age or older and who exhibited soft tissue shoulder pathology or pain not attributable to hemiparesis, systemic rheumatic or autoimmune conditions, fractures, osteoarthritis, or surgical interventions. Included studies also had to report ultrasound treatment protocols in sufficient detail to enable us to calculate the power and total ultrasound energy delivered (see calculations in “Data Extraction” section below).

Study Inclusion and Exclusion Criteria

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Search Terms Used to Identify Potentially Relevant Studies Part

Search Terms

A

Ultrasound OR physical therapy OR physiotherapy OR rehabilitation OR pulsed ultrasound OR ultrasonic therapy OR continuous ultrasound OR therapeutic ultrasound OR sonic therapy OR high-frequency sound waves OR MHz OR kHz OR sound wave OR cavitation OR acoustic microstreaming

B

Shoulder tendonitis OR shoulder tendinitis OR shoulder tendinopathy OR shoulder tendinosis OR shoulder strain OR rotator cuff pathology OR rotator cuff tear OR rotator cuff injury OR rotator cuff strain OR rotator cuff tendonitis OR rotator cuff tendinitis OR rotator cuff tendinosis OR shoulder bursitis OR subdeltoid bursitis OR subacromial bursitis OR rotator cuff impingement OR supraspinatus impingement OR shoulder impingement OR calcific tendonitis OR calcific tendinitis OR acromioclavicular sprain OR coracoclavicular sprain OR rotator cuff rupture OR frozen shoulder OR adhesive capsulitis OR biceps tendonitis OR biceps tendinitis OR biceps tendinosis OR bicipital tendonitis OR bicipital tendinitis OR bicipital tendinopathy OR infraspinatus tear OR supraspinatus tear OR infraspinatus tendonitis OR infraspinatus tendinitis OR infraspinatus tendinosis OR infraspinatus tendinopathy OR bicipital strain OR biceps strain OR supraspinatus strain OR infraspinatus strain

Parameter Population

Inclusion Criteria

Exclusion Criteria

Age ⱖ18 y

Fracture

Acute or chronic condition

Dislocation

Soft tissue shoulder injury

Neurological involvement

Shoulder pain (not directly attributed to conditions listed under “exclusion criteria”)

Systemic rheumatic or autoimmune conditions (eg, multiple sclerosis, rheumatoid arthritis) Osteoarthritis Surgery Trigger points

Intervention

Therapeutic ultrasound

Diagnostic ultrasound

Pulsed or continuous ultrasound

Inability to calculate spatial average–temporal average or total energy Iontophoresis

Study design

Randomized controlled trial (RCT)

Review, meta-analysis, case study, non-RCT

Outcome measures

Pain scale

Examiner’s impression of change

Muscle strength (force-generating capacity) testing Range of motion Function, impairment, or disability measures

Study Selection Primary search part A: selection of relevant titles and abstracts. Initially, for identification of studies that met inclusion criteria, each database was searched independently by at least 2 authors of the present

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study. In part A of the search, the titles and abstracts (citations) of all studies identified in the electronic database search were assessed. For a study to be included for further assessment (part B: review of full article), a pair consensus regarding inJanuary 2010

Ultrasound for Soft Tissue Shoulder Pathology clusion was reached. In instances of doubt about whether to include a study for further assessment, the full article was retrieved. Primary search part B: identification of full articles. Full articles were obtained from the citations identified in part A of the electronic database search. Two copies of each article were randomly distributed among 3 researchers, who independently reviewed each article and determined whether the study met the inclusion criteria. Secondary search. For further identification of potentially relevant studies, a secondary search was performed. In this stage of the investigation, the authors examined the reference lists of the relevant publications, such as reviews, metaanalyses, and case studies. Any relevant articles were retrieved and assessed for inclusion independently by 2 reviewers. These articles were selected by use of the pair consensus process described above. Quality Assessment (Critical Appraisal) For each study selected for inclusion from the primary search or the secondary search, 3 reviewers independently conducted Physiotherapy Evidence Database (PEDro) assessments. The PEDro scale was chosen for this critical appraisal process because it can allow for a reliable assessment of the RCT design quality.22 No study was excluded on the basis of methodological quality. The PEDro scale ranges from 0 to 10, with 10 indicating the best possible score. Data Extraction The results of included studies were extracted and analyzed. From the extracted data, the spatial average–temporal average (SATA, W/cm2), energy density per treatment (J/cm2), total energy delivered during a single January 2010

treatment (J), and total exposure to ultrasound over the entire duration of the study (hours) were calculated. These parameters were determined with the following equations: SATA (W/cm2) ⫽

(1)

average intensity (W/ cm2) ⫻ duty cycle 共%兲 共2兲

Energy density per treatment (J/cm2) ⫽ SATA (W/cm2) ⫻ time per treatment (seconds)

共3兲

Total energy per treatment (J) ⫽ SATA (W/cm2) ⫻ transducer head size or

effective radiating area (cm2) ⫻ time per treatment (seconds) Total exposure (hours) ⫽

(4)

number of treatments ⫻ time per treatment (seconds) (5)

Total energy delivered

over entire study duration (J) ⫽ total energy per treatment (J) ⫻ number of treatments

Results As indicated in the Figure, the electronic database search yielded 727 results, with the following number of citations for each database: CINAHL (127), Cochrane Central Register of Controlled Trials (38), EMBASE (464), MEDLINE (18), and PubMed (80). Thirty full articles were identified from the search of these citations, and 697 articles were excluded. An additional 11 articles were identified from the secondary search of references cited in book chapters, reviews, and other articles. Through a pair consensus process, 33 of the 41 selected articles were excluded on the basis of the prede-

termined criteria. Eight original RCTs examining the effects of ultrasound on shoulder pathology were included in the present report.23–30 A total of 586 participants were enrolled in the 8 included studies, with 543 participants following through to completion. In 3 of the 8 studies included in the present systematic review, Shomoto et al,23 Ebenbichler et al,24 and Downing and Weinstein27 reported that ultrasound produced outcomes significantly better than those seen in control groups. In 2 of these studies, the impact of ultrasound on calcific tendinitis was specifically examined, and both Shomoto et al23 and Ebenbichler et al24 found significant reductions in pain and calcium deposits. Ebenbichler et al24 also found significant improvements in function. Assessment of the RCT design quality of the 8 included studies yielded a median PEDro scale score of 8.0 (range⫽4 –10) (Tab. 3). The following shoulder pathologies were examined in the included studies: calcific tendinitis, shoulder pain, subacromial bursitis, adhesive capsulitis, biceps tendinitis, and supraspinatus tendinitis (Tab. 4). The duration of participants’ symptoms before enrollment varied between and within the studies, ranging from 0 to greater than 12 months, with the majority of studies involving chronic shoulder disorders (ie, ⬎6 weeks since symptom onset). There was a tendency for investigators to use multiple concurrent treatments within each study; although some used only 1 concurrent treatment,24,29 others used multiple concurrent treatments, including heat, interferential current (IFC), range-of-motion exercises, and strengthening.23,25–28,30 Concurrent therapies offered to participants treated with ultrasound and control participants within a study were similar; however, none of the 8

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Figure. Flow diagram of search strategy and summary of excluded studies. PEDro⫽Physiotherapy Evidence Database, RCT⫽randomized controlled trial.

studies involved the same concurrent treatment regimens. In 2 of the studies, IFC was applied in addition to ultrasound.25,28 The results reported in 1 such study28 suggested that similar reductions in shoulder impairments occurred over time in subjects treated with ultrasound and subjects treated with IFC and that no additional benefit was observed when IFC and ultrasound were combined.

studies, a scale ranging from 0 to 3 was used (1 study rated pain during a specific resisted movement,26 another rated pain during rest and movement,25 and the third rated Table 3.

Physiotherapy Evidence Database (PEDro) Scale Scores of Included Studies

A wide array of outcome measures also were used across the studies. Several different outcome measures were used to assess quality of life, pain, and functional ability. In the 7 studies in which pain was reported as an outcome, little overlap in the measures used was observed: In 3 18

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pain during daily activities27); in the remaining 4 studies, a 10-point numeric rating scale,24 a 10-point visual analog scale,30 a 7-point Likert scale,28 or a dichotomous scale

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Study Shomoto et al

PEDro Scale Score

(2002)23

4

Ebenbichler et al (1999)24 Kurtais Gu¨rsel et al

(2004)25

Nykanen (1995)26 Downing and Weinstein

9 7 7

(1986)27

van der Heijden et al (1999)28

10 10

(1960)29

4

Ainsworth et al (2007)30

9

Median score

8.0

Roman

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January 2010 0.8

1.0

NR

0 to ⬎12 mo

⬎2 mo

Bursitis

Shoulder pain

Supraspinatus tendinosis

Roman (1960)29

van der Heijden et al (1999)28

Nykanen (1995)26

1 or 3

1.5 3.0

7b 4b

6.7c 0.5

1.0

1.5

5b

5

1.2

10

2.5

1.0–2.0

4.3b

5

Average Intensity (W/cm2)

Head Size or ERA (cm2)

Pulsed (20)

Pulsed (20)

Pulsed (20)

Continuous

Continuous

Continuous

Pulsed (20)

Continuous

Duty Cycle (%)

0.13

0.2

0.6

1.5

1.5

1.2

0.5

1.0–2.0

SATA (W/cm2)

4.5

10

5

5–8

10

6

15.0

15.8

Rx Time/ Session (min)

181

600

720

3,150–5,040

4,500

4,320

2,250

4,076–8,152

Total Energy/ Rx (J)

6

10–12

12

8.24

15

12

24

28–39

Average No. of Rxs

Therapeutic Ultrasound Treatment Parameters

0.45

1.67–2.0

1.0

0.6–1.1

2.5

1.2

6.0

7.4–10.3

Total Exposure (h)

1,085

6,000

8,640

25,956–41,529

67,500

51,840

54,000

114,128–317,928

Total Energy Over Study Duration (J)

Advice, manual therapy, exercise (home)

Heat, massage, exercise (stretching, strengthening)

NSAID, IFC, exercise (ROM, strengthening)

Heat (20 min)

Heat, IFC, exercise (ROM, stretching, strengthening)

NSAID, exercise (ROM)

Analgesics

Mobilization, exercise (stretching, strengthening)

Concurrent Treatments

No

No

No

...

No

No

Yes

Yes

Pain

...

...

...

No

...

...

Yes

Yes

Ca

...

...

No

No

No

Yes

...

...

ROM

Outcomes

No

No

No

...

No

No

Yes

...

Fn/Dis

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Total ultrasound energy delivered over study duration (J) ⫽ ultrasound energy per treatment ⫻ number of treatments

The ERA was reported. c Head size was estimated as the average value for the area used in the other 7 studies.

b

Energy per Rx (J) ⫽ SATA (W/cm2) ⫻ head size or ERA (cm2) ⫻ Rx time (s)

Total exposure (h) ⫽ number of treatments ⫻ treatment time

SATA ⫽ average intensity (W/cm2) ⫻ duty cycle

a Table is arranged in order of total ultrasound energy delivered per session. Chronicity⫽duration of participants’ symptoms before study enrollment, ERA⫽effective radiating area, SATA⫽spatial average– temporal average, Rx⫽treatment, Pain⫽statistically significant pain reduction compared with outcome in control group, Ca⫽calcium deposit reduction, ROM⫽improved range of motion, Fn/Dis⫽functional improvement or reduction in disability, ellipsis⫽not assessed, NSAID⫽nonsteroidal anti-inflammatory drug, NR⫽not reported, IFC⫽interferential current. Equations were as follows:

NR

0.87

NR

Rotator cuff tendinitis or partial rupture; biceps tendinosis

Kurtais Gu¨rsel et al (2004)25

Shoulder pain

1.0

⬍1 y

Supraspinatus tendinitis; adhesive capsulitis; subacromial bursitis

Downing and Weinstein (1986)27

Ainsworth et al (2007)30

0.89

⬎4 wk

Calcific tendinitis

Ebenbichler et al (1999)24

1.0

3.0

Frequency (MHz)

⬎3 mo

Chronicity

Calcific tendinitis

Pathologies Treated

Shomoto et al (2002)23

Study

Summary of Included Studiesa

Table 4.

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Ultrasound for Soft Tissue Shoulder Pathology Table 5. Comparison of Studies in Which Ultrasound Was Reported to Be Beneficial and Studies in Which No Statistical Difference Was Found Between Treatment and Control Groups Ultrasound Found Beneficial

Parameter No. of studies Total no. of participants Energy density, J/cm2, X៮ (range)a Total energy per session, J, X៮ (range)a

3

5

121

465

768 (432–1,422)

413 (27–900)

4,228 (2,250–6,114)

2,019 (181–4,095)

5.3 (1.2–10.3)

1.3 (0.5–2.5)

Total exposure, h, X៮ (range)a Total energy over study duration, J, X៮ (range)a

Ultrasound Found Equivalent to Control

107,289 (51,840–216,028)

20,394 (1,085–67,500)

a Values for studies in which a benefit of ultrasound was seen or in which no benefit was seen in the ultrasound group compared with the control group. Studies were considered “beneficial” when a statistically significant improvement in 1 or more of the chosen outcome measures was reported. Equations were as follows:

Energy density ⫽ spatial average – temporal average ⫻ treatment time Total energy per session ⫽ spatial average – temporal average ⫻ transducer head size ⫻ treatment time Total exposure ⫽ treatment time per session ⫻ number of sessions Total energy over study duration ⫽ total energy per session ⫻ number of sessions The treatment area sizes were considered to be the same for all of the studies because only the shoulder area was included in these studies.

(“yes” or “no”) was used.23 Quantitative outcome measures used included x-ray imaging for calcific deposits23,24 and goniometric measures of shoulder range of motion.25,27,30 Because of the wide range of outcome measures and the variety of treatment parameters used in the studies, pooling results for a metaanalysis was not possible in the present investigation. The intensity of ultrasound used varied greatly among the studies, as SATA values ranged from 0.1 to 2.0 W/cm2. In 4 of the 8 studies included in the present review, pulsed ultrasound was used (20% duty cycle),24,26,28,30 and in the other 4 studies, continuous ultrasound waves were used.23,25,27,29 The mean application time per treatment session and the number of treatment sessions were also variable, ranging from 4.5 to 15.8 minutes per treatment session and from 6 to 39 treatment sessions. The transducer head size or effective radiating area was 20

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reported in all but 1 study (Ainsworth et al30), and in most studies, similar head sizes were used (4 –5 cm2). The ultrasound machine used in the study by Downing and Weinstein27 was larger (10 cm2). The total energy delivered per session was calculated to be greater than 2,250 J in most of the studies,23–25,27,29 but it was much lower in the studies of Nykanen,26 van der Heijden et al,28 and Ainsworth et al.30 The total exposure times varied greatly among the studies, ranging from 0.45 to 10.3 hours. Calculations of the total ultrasound energy delivered over the entire duration of each study (total energy ⫻ number of treatment sessions) demonstrated the dramatic differences in the amounts of ultrasound energy to which subjects in the different studies were exposed (Tab. 4). In particular, in the recently published study of Ainsworth et al,30 the total energy delivered per session was 181 J. This low level of ultrasound energy, com-

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bined with the relatively small number of treatments administered (6 treatments), resulted in a total exposure over the study duration (1,085.4 J) that was about 1/100 of the average for the studies that were included in the present review and that noted a benefit of ultrasound (107,289 J) (Tab. 5). Calculations performed to compare and contrast the intensity and duration of ultrasound exposure in the 3 studies in which a benefit of ultrasound treatment was reported with those in studies in which no significant difference between participants receiving ultrasound treatment and control participants was reported are provided in Table 5. Average values for the ultrasound energy density, the total ultrasound energy delivered per session, and the amount of time ultrasound was applied over the entire study duration were all at least 2 times higher in studies that detected a significant improvement in subjects treated with ultrasound versus control subjects than in studies that failed to find a difference between those groups of subjects. Participants in studies in which ultrasound was not found to be beneficial received an average level of ultrasound energy for the study duration that was one fifth of that in studies in which ultrasound was found to be beneficial (Tab. 5). Unfortunately, there were fewer studies with fewer participants in which effective ultrasound treatment protocols were used.

Discussion The present systematic review of the available research on ultrasound as it relates to the treatment of soft tissue shoulder disorders and pain resulted in a total of 8 RCTs that met the inclusion criteria. Three of the 8 trials revealed statistically significant improvements in outcomes for treated participants compared with control participants. Studies that deJanuary 2010

Ultrasound for Soft Tissue Shoulder Pathology tected statistically significant improvements in patients treated with ultrasound generally involved higher levels of total ultrasound energy per treatment and provided longer exposure times than studies that failed to detect a difference between patients treated with ultrasound and control patients. Studies in which a benefit of ultrasound (relative to placebo ultrasound) was reported tended to include subjects from a well-defined patient population (such as those with calcific tendinitis). Along with identifying study protocol characteristics that have been associated with more beneficial results for ultrasound in the management of shoulder injuries, this investigation also sought to identify attributes in currently available RCTs that may have obfuscated previous assessments of the effectiveness of ultrasound in treating shoulder complaints. These issues are outlined below. Classification of Shoulder Pathology All of the studies included in the present review focused on soft tissue musculoskeletal disorders of the shoulder. Specific inclusion and exclusion criteria were applied consistently, and potential subjects were excluded if their shoulder disorders involved neurological or systemic inflammatory conditions. In 6 of the 8 included studies,23–28 subjects underwent a screening evaluation performed by an independent assessor, and diagnostic imaging was used to confirm the diagnosis in 3 of the studies.23–25 In 2 of the 8 included studies, subjects had a wide range of conditions, such as rotator cuff tendinitis and tendinosis, biceps tendinitis, subacromial bursitis, and adhesive capsulitis, in the same study populations.25,27 These disorders have been shown to vary greatly with respect to the underlying cellular processes and pathologies at January 2010

work,31–35 thereby reducing the likelihood of achieving a valid conclusion concerning the effectiveness of ultrasound. Likewise, in 2 of the 8 studies, subjects had shoulder disorders broadly categorized as causing “shoulder pain.”28,30 As indicated by Burbank et al,7 who outlined standardized diagnostic criteria for numerous categories of shoulder disorders, the diagnosis of shoulder pain falls well short of the mark for the degree of diagnostic precision that clinicians can achieve by obtaining a focused medical history and performing a careful physical examination. By categorizing study participants in this nonspecific manner, investigators risk obtaining a highly heterogeneous study population for which it could be difficult to avoid type 2 errors. Furthermore, by broadly categorizing study participants as experiencing shoulder pain, investigators risk including people who are experiencing referred pain from the cervical spine or other regions of the body and who, in fact, do not have true shoulder pathology. It is clear that in future studies of the effectiveness of ultrasound, every effort should be made to assemble a highly homogeneous study population. This goal can be greatly facilitated with the aid of diagnostic imaging. Several imaging modalities, such as radiography, ultrasonography, and magnetic resonance imaging, can be of substantial diagnostic value for conditions such as osteoarthritis, rotator cuff pathology (eg, tendinopathy, full- or partialthickness tears), and calcific tendinitis.7 The benefit of using imaging modalities to help define a focused study population may be evident in the studies (described in the present investigation) that included only participants with calcific tendinitis. In both of these trials, ultrasound (relative to placebo ultrasound) was reported to result in significant improvements.

Staging or Chronicity of Shoulder Disorders Previous RCTs examining the effects of therapeutic ultrasound on shoulder disorders also may have had a limited ability to detect changes because they included participants with a broad range of symptom durations (chronicity of the condition). Three of the 8 investigations included in the present study did not explicitly report the chronicity of participants’ conditions.25,29,30 In the remaining 5 studies,23,24,26 –28 patients’ pre-enrollment symptom durations ranged from 0 to greater than 12 months. Combining acute, possibly first-occurrence shoulder disorders with chronic, possibly recurrent disorders in a study population may be especially problematic given that the duration of patients’ symptoms has been shown to dictate the pathological state of affected tissues. For example, histopathological studies have revealed striking differences among the 3 well-documented stages of adhesive capsulitis34,36 and between acute and chronic tendinopathy31,33,37,38 (tendinitis versus tendinosis). Because acute tendinopathy has been characterized by the presence of inflammatory mediators,31 whereas chronic tendinopathy involves a disorganized collagen structure and changes consistent with hypoxia,39 it is unlikely that these disparate pathologies would respond in similar ways to a uniform set of ultrasound parameters. In fact, it is more likely that, given the differences in the proposed effects of nonthermal ultrasound and thermal ultrasound, a pulsed duty cycle and a continuous duty cycle would be most beneficial for acute and chronic injuries, respectively. Thus, the broad range in chronicity exhibited by participants within many studies, combined with the facts that all participants within a given study received the same treatment protocols and that acute and

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Ultrasound for Soft Tissue Shoulder Pathology chronic injuries were not necessarily treated with the potentially most appropriate duty cycle, may account partly for the relatively small amount of evidence supporting the utility of therapeutic ultrasound for soft tissue shoulder pathology. Future investigations need to account for the fact that the same ultrasound protocols cannot be used to treat conditions with vastly different underlying pathophysiological processes. Multiple Concurrent Treatments Unfortunately, of the 8 studies identified in the present analysis, none included a similar treatment program in the control arm of the study. Thus, it appears that there is little agreement about the standard treatment approach for soft tissue disorders of the shoulder. In 6 of the 8 studies,23,25–28,30 exercise was part of the treatment intervention; however, the type and intensity of these programs were not provided in any detail to allow an assessment for similarities. Ebenbichler et al24 used the fewest cointerventions, allowing occasional use of analgesics (but not anti-inflammatory medications) as required in both study groups. In contrast, Kurtais Gu ¨ rsel et al25 provided up to 6 concurrent treatments. Although it may be a common clinical practice to combine different types of therapies, such as exercise, medications, and modalities, to address shoulder pathologies, it is not clear why the authors elected to administer several similar concurrent modalities (such as heat, ultrasound, and IFC). This approach seems to be unjustified and very likely may have masked any potential effect of the ultrasound treatment protocol because the proposed physiological effects of ultrasound may be similar to those induced by the concurrent treatments. Although the authors did ensure that the cointerventions were similar between the comparison groups, we strongly recommend that future clinical trials testing the ther22

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apeutic benefits of ultrasound avoid the use of concurrent modalities or treatments with effects that are similar to or counterproductive to the suggested physiological effects of ultrasound. Study Design and Size of Study Population Assessment with the PEDro scale suggested that, on average, the included studies had most of the desirable methodological attributes (such as internal validity and statistical rigor) that are evaluated with this scale. The average PEDro scale score assigned by our 3 independent evaluators was 8.0, which was in keeping with the scores assigned to these clinical trials by the Centre for Evidence Based Physiotherapy (average score⫽6.75).40 We did not elect to remove any study on the basis of the PEDro scale score, partly because of contention regarding whether investigators are actually able to use effective masking strategies for ultrasound.17 A common feature of more recent RCTs is the use of prestudy calculations to establish the sample size required to detect the desired or presumed effect size of treatment. When effect sizes are thought to be relatively small, larger sample sizes are required to detect the differences between 2 groups. It is worth noting that only 1 of the 8 studies included in the present analysis conducted such calculations to ensure that an adequate sample size was used. Ainsworth et al30 suggested that a sample size of at least 200 patients was required to detect a meaningful change in their primary outcome measure (the Shoulder Disability Questionnaire). A much smaller sample size requirement of 26 participants for ultrasound studies was suggested in a review by Robertson and Baker.17 Four of the studies23,25,27,29 included in the present review failed to meet this (n⫽26) suggested sam-

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ple size. Therefore, it is possible that studies involving very small numbers of subjects25,29 may not have detected differences between groups because of reduced statistical power. Similarly, small sample sizes may partly explain the positive findings reported by Downing and Weinstein27 and Shomoto et al.23 Notably, the 2 studies involving the largest sample sizes28,30 did not find a significant difference in outcome measures between subjects treated with ultrasound and control subjects, suggesting that the inability to find a difference between the groups was not necessarily attributable to inadequate sample sizes. Future studies of therapeutic ultrasound for shoulder injuries should include sample size calculations and demonstrate that a sufficient number of participants were included to detect differences between study groups. Given the inherent difficulties with recruiting a large homogeneous population of subjects into any particular study, problems with inadequate sample size may be addressed more easily by combining results from several studies with a meta-analysis; however, this method would require a more consistent use of valid outcome measures that are known to be able to accurately assess shoulder impairments and upper-extremity function. Ultrasound Stimulus Parameters and Treatment Protocols Experimental human research studies have demonstrated that the physiological responses to ultrasound depend on ultrasound intensity and frequency. Draper and colleagues41,42 showed that the average rates of temperature increase per minute with continuous ultrasound administered at a frequency of 1 MHz were 0.04°C at 0.5 W/cm2, 0.16°C at 1.0 W/cm2, 0.33°C at 1.5 W/cm2, and 0.38°C at 2.0 W/cm2. Also, the rates of temperature inJanuary 2010

Ultrasound for Soft Tissue Shoulder Pathology crease per minute with ultrasound at a higher frequency (3 MHz) were 0.3°C at 0.5 W/cm2, 0.58°C at 1.0 W/cm2, 0.8°C at 1.5 W/cm2, and 1.4°C at 2.0 W/cm2. Although changes in tissue temperatures (thermal responses) are only part of the biological responses produced by the mechanical waves of ultrasound, these measurable changes strongly support the assertion that the amount of ultrasound energy delivered to tissues depends on the ultrasound parameters selected. Given the barely detectable temperature change occurring when lowfrequency (1-MHz) ultrasound was delivered at an intensity of 0.5 W/cm2, it is very unlikely that the ultrasound treatment used by Ainsworth et al30 would have achieved sufficient levels of the desired physiological responses to induce changes in their primary outcome measures of pain and range of motion. The low ultrasound intensity used in that study was confounded by the use of the pulsed ultrasound mode (20% duty cycle), the application of short treatments (4.5 minutes), and the limited number of treatment sessions. Collectively, these factors made the total amount of ultrasound energy delivered in that study one fifth of the average amount used in the other included studies. These arguably suboptimal ultrasound treatment parameters must be considered a key determinant that may explain the lack of effect observed in the study of Ainsworth et al.30 Of concern is the fact that the study of Ainsworth et al30 is the most recent report in the literature that has examined the effectiveness of ultrasound for soft tissue shoulder disorders. That study was a multisite investigation performed in 9 centers in the United Kingdom with 221 study participants. The ultrasound treatment regimen was not defined by the study protocol but rather by the January 2010

average ultrasound treatment parameters selected by the 28 physical therapists applying the treatments. The average ultrasound intensity was 0.5 W/cm2 (range⫽0.1–1.0 W/cm2) applied for 4.5 minutes (range⫽3–7 minutes), with 46% and 39% of therapists selecting 1 MHz and 3 MHz, respectively. These results suggest that common practice in this region of the United Kingdom is to apply ultrasound treatments that deliver extremely little sound energy to the target tissues. Of greater concern is that the practice of applying relatively low intensities of pulsed ultrasound for relatively short periods of time (5 minutes or less) is apparently being adopted more broadly across the profession of physical therapy. Although current evidence to support the use of ultrasound in the treatment of shoulder pathologies is limited, there is good evidence to suggest that the application of suboptimal ultrasound parameters like those used by Ainsworth et al30 is extremely unlikely to provide additional benefits to patients with soft tissue shoulder disorders. Calculations of total ultrasound energy revealed 2- to 5-fold-larger amounts of ultrasound energy per treatment and longer exposure times (treatment time ⫻ number of treatments) in studies in which a benefit of ultrasound was reported. Furthermore, none of the studies in which ⱕ720 J per session was applied reported an additional benefit of ultrasound. We feel that studies delivering such low doses of ultrasound energy are in effect delivering sham ultrasound and could not reasonably be expected to produce treatment effects.

Conclusions The findings of the present study reveal that favorable patient outcomes in RCTs of therapeutic ultrasound for shoulder pain and injury have been noted when ultrasound energy

of at least 2,250 J per treatment session was applied. Furthermore, when insufficient ultrasound energy (ie, ⱕ720 J per session) was provided, positive outcomes rarely occurred. Our results suggest that the effectiveness of ultrasound on soft tissue pathologies has not yet been evaluated using optimal treatment parameters, and, therefore, it is premature to conclude through systematic review of existing literature that this treatment dose “is not effective.”6,13,18 However, systematic reviews conducted to date6,13,18 have focused their evaluation of study quality on generic aspects of study design such as studies’ randomization processes, blinding, and statistical analyses. Our findings echo the general concerns reported by Robertson and Baker17 and agree with the criticisms of others43– 45 that the prohibitive conclusions of previous systematic reviews in this realm are based on weak evidence. More recent trials28,30 that used improved RCT designs with larger sample sizes have used ultrasound treatment protocols that resulted in the delivery of 1/5 to 1/20 of the average ultrasound energy per session that was used in ultrasound studies that produced beneficial results. Should these RCTs that used suboptimal ultrasound treatment protocols be included in future systematic reviews, the question of the effectiveness of ultrasound treatment for these common musculoskeletal disorders will remain an uncertainty for many years to come.

Future Directions Future primary studies must focus on selecting optimal ultrasound treatment parameters that deliver more than 720 J of ultrasound energy per session (perhaps closer to an average of 4,228 J per session) and treatment schedules that expose tissues to ultrasound for a sufficient period of time (ie, average total exposure time

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Ultrasound for Soft Tissue Shoulder Pathology of ⬎5 hours). Providing sufficient detail in future reports, such as including descriptions of the transducer head size and treatment area, is required if ultrasound treatment protocols are to be critically evaluated. Such studies must also create more homogeneous treatment groups with respect to the diagnosis and chronicity of the disorder. Future investigators should be cognizant of the histopathological state of affected target tissues before selecting the ultrasound parameters that will be used in an investigation to determine whether the thermal or nonthermal effects of ultrasound will likely be of most benefit (see Xu and Murrell,33 Sharma and Maffulli,37 and Khan et al38 for excellent reviews of tendinopathy histopathology). Although there may be ethical reasons why all concurrent therapies cannot be withheld, eliminating the application of similar modalities during a clinical trial may help to unmask some of the benefits of adding ultrasound to the treatment of patients with shoulder pathology. Standardizing the outcome measures used between studies and maintaining consistent characteristics of application are needed if studies with relatively small sample sizes are to be combined by use of meta-analytical techniques. In addition, it is critically important to this area of practice that researchers involved in future systematic reviews or meta-analyses strongly consider the appropriateness of ultrasound treatment parameters when selecting articles to be included in a review. In a recent article, Norman et al46 referred to the lessons of Cronbach and proposed that instead of examining the main effects of treatments, investigators should focus on identifying the characteristics of people that make them more or less responsive to particular treatments. Although this direction of research may not be the most scientifically 24

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rigorous, it does account for the facts that practitioners treat patients, not pathologies, and that patients may respond to their efforts in different ways. Thus, study designs other than RCTs, such as carefully designed case studies, may prove to be critical for determining which ultrasound parameters should be used for treating individual patients. All authors provided concept/idea/research design and writing. Ms Alexander, Mr Gilman, and Mr Brown provided data collection. Ms Alexander, Mr Gilman, Mr Brown, and Ms Brown provided data analysis. Dr Houghton provided project management. Ms Brown and Dr Houghton provided consultation (including review of manuscript before submission). This article was received September 4, 2008, and was accepted August 13, 2009. DOI: 10.2522/ptj.20080272

References 1 Urwin M, Symmons D, Allison T, et al. Estimating the burden of musculoskeletal disorders in the community: the comparative prevalence of symptoms at different anatomical sites, and the relation to social deprivation. Ann Rheum Dis. 1998;57: 649 – 655. 2 Bridges-Webb CH, Britt D, Miles S, et al. Treatment in general practice in Australia. Med J Aust. 1992;156(suppl):S1–S56. 3 van der Windt DA, Koes BW, de Jong BA, Bouter LM. Shoulder disorders in general practice: incidence, patient characteristics, and management. Ann Rheum Dis. 1995;54:959 –964. 4 Allander E. Prevalence, incidence, and remission rates of some common rheumatic diseases or syndromes. Scand J Rheumatol. 1974;3:145–153. 5 Brox JI. Shoulder pain. Best Pract Res Clin Rheumatol. 2003;17:33–56. 6 van der Heijden GJ. Shoulder disorders: a state-of-the-art review. Baillieres Clin Rheumatol. 1999;13:287–309. 7 Burbank KM, Stevenson JH, Czarnecki GR, Dorfman J. Chronic shoulder pain, part I: evaluation and diagnosis. Am Fam Physician. 2008;77:453– 460. 8 Smith LL, Burnet SP, McNeil JD. Musculoskeletal manifestations of diabetes mellitus. Br J Sports Med. 2003;37:30 –35. 9 Cakir M, Samanci N, Balci N, Balci MK. Musculoskeletal manifestations in patients with thyroid disease. Clin Endocrinol (Oxf). 2003;59:162–167.

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10 Norlander S, Gustavsson BA, Lindell J, Nordgren B. Reduced mobility in the cervicothoracic motion segment: a risk factor for musculoskeletal neck-shoulder pain—a two-year prospective follow-up study. Scand J Rehabil Med. 1997;29:167–174. 11 Glockner SM. Shoulder pain: a diagnostic dilemma. Am Fam Physician. 1995;51: 1677–1687, 1690 –1692. 12 Burbank KM, Stevenson JH, Czarnecki GR, Dorfman J. Chronic shoulder pain, part III: treatment. Am Fam Physician. 2008;77: 493– 497. 13 Green S, Buchbinder R, Hetrick S. Physiotherapy interventions for shoulder pain. Cochrane Database Syst Rev. 2003;(2): CD004258. 14 Wong RA, Schumann B, Townsend R, Phelps CA. A survey of therapeutic ultrasound use by physical therapists who are orthopaedic certified specialists. Phys Ther. 2007;87:986 –994, discussion 995–1001. 15 Lindsay DM, Dearness J, McGinley CC. Electrotherapy usage trends in private physiotherapy practice in Alberta. Physiother Can. 1995;47:30 –34. 16 ter Haar G, Dyson M, Oakley EM. The use of ultrasound by physiotherapists in Britain, 1985. Ultrasound Med Biol. 1985;13: 659 – 663. 17 Robertson VJ, Baker KG. A review of therapeutic ultrasound: effectiveness studies. Phys Ther. 2001;81:1339 –1350. 18 van der Windt DA, van der Heijden GJ, van den Berg SG, et al. Ultrasound therapy for musculoskeletal disorders: a systematic review. Pain. 1999;81:257–271. 19 Gam AN, Johannsen F. Ultrasound therapy in musculoskeletal disorders: a meta-analysis. Pain. 1995;63:85–91. 20 Philadelphia Panel. Philadelphia Panel Evidence-Based Clinical Practice Guidelines on Selected Rehabilitation Interventions for Shoulder Pain. Phys Ther. 2001; 81:1719 –1730. 21 van der Heijden GJ, van der Windt DA, de Winter AF. Physiotherapy for patients with soft tissue shoulder disorders: a systematic review of randomised clinical trials. BMJ. 1997;315:25–30. 22 Maher CG, Sherrington C, Herbert RD, et al. Reliability of the PEDro scale for rating quality of randomized controlled trials. Phys Ther. 2003;83:713–721. 23 Shomoto K, Katsuhiko T, Morishita S, et al. Effects of ultrasound therapy on calcified tendinitis of the shoulder. Journal of the Japanese Physical Therapy Association. 2002;5:7–11. 24 Ebenbichler GR, Erdogmus CB, Resch KL, et al. Ultrasound therapy for calcific tendinitis of the shoulder. N Engl J Med. 1999; 340:1533–1538. 25 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.

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Ultrasound for Soft Tissue Shoulder Pathology 26 Nykanen M. Pulsed ultrasound treatment of the painful shoulder: a randomized, double-blind, placebo-controlled study. Scand J Rehabil Med. 1995;27:105–108. 27 Downing DS, Weinstein A. Ultrasound therapy of subacromial bursitis: a doubleblind trial. Phys Ther. 1986;66:194 –199. 28 van der Heijden GJ, Leffers P, Wolters PJ, et al. No effect of bipolar interferential electrotherapy and pulsed ultrasound for soft tissue shoulder disorders: a randomised controlled trial. Ann Rheum Dis. 1999;58:530 –540. 29 Roman MP. A clinical evaluation of ultrasound by use of a placebo technic. Phys Ther Rev. 1960;40:649 – 652. 30 Ainsworth R, Dziedzic K, Hiller L, et al. A prospective double blind placebocontrolled randomized trial of ultrasound in the physiotherapy treatment of shoulder pain. Rheumatology (Oxford). 2007; 46:815– 820. 31 Puddu G, Ippolito E, Postacchini F. A classification of Achilles tendon disease. Am J Sports Med. 1976;4:145–150. 32 Enwemeka CS. Inflammation, cellularity, and fibrillogenesis in regenerating tendon: implications for tendon rehabilitation. Phys Ther. 1989;69:816 – 825.

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33 Xu Y, Murrell GA. The basic science of tendinopathy. Clin Orthop Relat Res. 2008;466:1528 –1538. 34 Hand GC, Athanasou NA, Matthews T, Carr AJ. The pathology of frozen shoulder. J Bone Joint Surg Br. 2007;89:928 –932. 35 Hyvo ¨ nen P, Melkko J, Lehto VP, Jalovaara P. Involvement of the subacromial bursa in impingement syndrome of the shoulder as judged by expression of tenascin-C and histopathology. J Bone Joint Surg Br. 2003;85:299 –305. 36 Dias R, Cutts S, Massoud S. Frozen shoulder. BMJ. 2005;331:1453–1456. 37 Sharma P, Maffulli N. Biology of tendon injury: healing, modeling and remodeling. J Musculoskelet Neuronal Interact. 2006; 6:181–190. 38 Khan KM, Cook JL, Bonar F, et al. Histopathology of common tendinopathies: update and implications for clinical management. Sports Med. 1999;27:393– 408. 39 Kannus P, Jozsa L. Histopathological changes preceding spontaneous rupture of a tendon: a controlled study of 891 patients. J Bone Joint Surg Am. 1991;73: 1507–1525. 40 Centre for Evidence Based Physiotherapy. www.cebp.nl. Accessed September 25, 2009.

41 Draper DO, Castel JC, Castel D. Rate of temperature increase in human muscle during 1 MHz and 3 MHz continuous ultrasound. J Orthop Sports Phys Ther. 1995;22:142–150. 42 Draper DO, Ricard MD. Rate of temperature decay in human muscle following 3 MHz ultrasound: the stretching window revealed. J Athl Train. 1995;30:304 –307. 43 Draper DO. Don’t disregard ultrasound yet—the jury is still out [letter to the editor]. Phys Ther. 2002;82:190 –191. 44 Brockow T, Franke A, Resch KL. Physiotherapy for soft tissue shoulder disorders: conclusion that therapeutic ultrasound is ineffective was based on weak evidence [comment]. BMJ. 1998;316:555, author reply 556. 45 Amusat NT. On “A survey of therapeutic ultrasound . . .” Wong et al. Phys Ther. 2007;87:986 –994 [letter]. Phys Ther. 2007;87:1558 –1559, author reply 1559. 46 Norman GR, Stratford PW, Regehr G. Methodological problems in the retrospective computation of responsiveness to change: the lesson of Cronbach. J Clin Epidemiol. 1997;50:869 – 879.

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Research Report P.E. Mintken, PT, DPT, OCS, FAAOMPT, is Assistant Professor, Department of Physical Therapy, School of Medicine, University of Colorado Denver, 13121 E 17th Ave, Mailstop C244, Aurora, CO 80045 (USA); and Lead Clinician, Wardenburg Health Center, University of Colorado at Boulder, Boulder, Colorado. Address all correspondence to Dr Mintken at: [email protected].

Some Factors Predict Successful Short-Term Outcomes in Individuals With Shoulder Pain Receiving Cervicothoracic Manipulation: A Single-Arm Trial

J.A. Cleland, PT, PhD, is Professor, Department of Physical Therapy, Franklin Pierce University, Concord, New Hampshire; Physical Therapist, Rehabilitation Services, Concord Hospital, Concord, New Hampshire; and Faculty, Manual Physical Therapy Fellowship Program, Regis University, Denver, Colorado.

Paul E. Mintken, Joshua A. Cleland, Kristin J. Carpenter, Melanie L. Bieniek, Mike Keirns, Julie M. Whitman

K.J. Carpenter, PT, DPT, is Physical Therapist, Waldron’s Peak Physical Therapy PC, Boulder, Colorado. Dr Carpenter was a student in the Department of Physical Therapy, School of Medicine, University of Colorado Denver, at the time of this study. M.L. Bieniek, PT, DPT, is Rehabilitation Manager and Physical Therapist, Concord Hospital. M. Keirns, PT, PhD, is Associate Professor, School of Physical Therapy, Regis University, and Clinical Director, Physiotherapy Associates, Greenwood Athletic Club, Greenwood Village, Colorado. J.M. Whitman, PT, DSc, is Director, Evidence In Motion’s Orthopedic Manual Physical Therapy Program, Louisville, Kentucky, and Assistant Professor, School of Physical Therapy, Regis University. [Mintken PE, Cleland JA, Carpenter KJ, et al. Some factors predict successful short-term outcomes in individuals with shoulder pain receiving cervicothoracic manipulation: a single-arm trial. Phys Ther. 2010;90:26 – 42.] © 2010 American Physical Therapy Association

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Background. It has been reported that manipulative therapy directed at the cervical and thoracic spine may improve outcomes in patients with shoulder pain. To date, limited data are available to help physical therapists determine which patients with shoulder pain may experience changes in pain and disability following the application of these interventions. Objective. The purpose of this study was to identify prognostic factors from the history and physical examination in individuals with shoulder pain who are likely to experience rapid improvement in pain and disability following cervical and thoracic spine manipulation.

Design. This was a prospective single-arm trial. Setting. This study was conducted in outpatient physical therapy clinics. Participants. The participants were individuals who were seen by physical therapists for a primary complaint of shoulder pain. Intervention and Measurements. Participants underwent a standardized examination and then a series of thrust and nonthrust manipulations directed toward the cervicothoracic spine. Individuals were classified as having achieved a successful outcome at the second and third sessions based on their perceived recovery. Potential prognostic variables were entered into a stepwise logistic regression model to determine the most accurate set of variables for prediction of treatment success.

Results. Data for 80 individuals were included in the data analysis, of which 49 had a successful outcome. Five prognostic variables were retained in the final regression model. If 3 of the 5 variables were present, the chance of achieving a successful outcome improved from 61% to 89% (positive likelihood ratio⫽5.3).

Limitations. A prospective single-arm trial lacking a control group does not allow for inferences to be made regarding cause and effect. The statistical procedures used may result in “overfitting” of the model, which can result in low precision of the prediction accuracy, and the bivariate analysis may have resulted in the rejection of some important variables. Conclusions. The identified prognostic variables will allow clinicians to make an a priori identification of individuals with shoulder pain who are likely to experience short-term improvement with cervical and thoracic spine manipulation. Future studies are necessary to validate these findings.

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Prognosis in Individuals With Shoulder Pain Receiving Cervicothoracic Manipulation

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houlder pain can present a diagnostic challenge. One study on nonspecific shoulder pain showed rotator cuff tendinopathy in 85% of patients, but 77% were diagnosed with more than one shoulder problem.1 The most common causes of shoulder pain, namely rotator cuff pathology and adhesive capsulitis, may present similar findings but have a different set of outcomes and responses to specific treatments.2 Although specific diagnoses can be made in some patients with shoulder pain,3 de Winter et al4 reported only moderate agreement on the classification of shoulder disorders and concluded that differentiation among shoulder disorders is complicated. Dinant et al5 argued that we need a shift from diagnostic to prognostic research, as health care providers frequently see patients with conditions such as shoulder pain and low back pain that are difficult to accurately diagnose.

The prevalence of shoulder symptoms has been reported to range from 20% to 33%,6 and the incidence of shoulder complaints in the general population is increasing.7 Furthermore, several authors have reported low rates of perceived recovery for individuals with a new episode of shoulder pain.8 –11 The prognosis generally is poor, with re-

Available With This Article at ptjournal.apta.org • eTable 1: Categorical Variables From the Baseline Clinical Examination • eTable 2: Continuous Variables From the Baseline Clinical Examination • Audio Abstracts Podcast This article was published ahead of print on December 3, 2009, at ptjournal.apta.org.

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covery rates of only 49% to 59% at the time of an 18-month followup.9,11 Additionally, Rekola et al12 reported that 25% of individuals with shoulder or neck pain experienced at least one episode of recurrence within 12 months, suggesting that shoulder pain can be recurrent and frequently progresses to the chronic stage. This is important, as the direct costs for the treatment of people with shoulder dysfunction in the United States in 2000 totaled $7 billion.13 Furthermore, Kuijpers et al14 reported that patients with persistent shoulder pain generated 74% of the total costs. Regional interdependence is defined as “the concept that seemingly unrelated impairments in a remote anatomical region may contribute to, or be associated with, the patient’s primary complaint.”15(p658) This concept of examining and treating impairments away from the primary source of pain is gaining popularity in orthopedic manual therapy.15 Patients with primary reports of shoulder pain often have impairments of the shoulder girdle, including the cervicothoracic spine and the adjacent ribs, and these impairments can negatively affect patient outcomes.16 –21 For example, Sobel et al19 found that more than 40% of patients with shoulder complaints had impairments of the cervicothoracic spine and the adjacent ribs. They concluded that impairments in the cervicothoracic spine and adjoining ribs represent an integral part of the intrinsic causes of shoulder complaints. Additionally, Norlander and colleagues16 –18 investigated the correlation between mobility in the cervicothoracic junction in patients with musculoskeletal neck and shoulder pain and found a significant association between decreased mobility in the thoracic spine and the presence of patient-reported complaints associated with neck and shoulder pain. Impairments of the

cervicothoracic spine and adjacent ribs have been shown to predict a poor outcome and triple the risk for developing shoulder disorders.16 –19,22 Finally, Crosbie et al23 demonstrated in 32 women who were healthy that thoracic motion was present in both bilateral and unilateral shoulder elevation, and they concluded that a key link exists between the thoracic spine and arm elevation. Current evidence suggests that inclusion of manipulative interventions (both thrust and nonthrust techniques) indeed may be helpful in the treatment of individuals with shoulder pain.22,24 –27 Some studies have included cervicothoracic manipulative interventions in addition to other interventions in the management of shoulder pain.24 –26 To date, 2 studies have investigated the effectiveness of treatment directed solely at the cervicothoracic spine and ribs in individuals with shoulder pain.22,24 Boyles et al24 found that individuals with impingement syndrome who received thoracic spine thrust manipulation demonstrated significant improvements in pain and disability 48 hours after treatment. Bergman et al22 randomly assigned individuals with a primary report of shoulder pain to receive either usual medical care (UMC) for their shoulder symptoms from their primary care physicians or usual care plus manipulative therapy (UMC⫹MT) directed at the cervicothoracic spine and rib cage. Although there were no between-group differences identified at the 6-week follow-up, the UMC⫹MT group demonstrated significantly higher rates of “full recovery,” as well as more improvement in the severity of main complaints and disability at 12, 26, and 52 weeks.22 These findings suggest that a subgroup of individuals with shoulder pain may exist who will respond dramatically to these interventions.

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Prognosis in Individuals With Shoulder Pain Receiving Cervicothoracic Manipulation Recently, there have been multiple studies identifying prognostic variables to guide physical therapy interventions.28 –30 It would be useful for physical therapists to have guidance in selecting which patients with shoulder pain may experience improved outcomes following manipulative interventions targeted at the cervicothoracic spine. Thus, the purpose of this project was to identify prognostic factors for individuals with shoulder pain likely to experience improvements in pain and disability following the application of cervicothoracic spine thrust and nonthrust manipulation.

Materials and Method We conducted a prospective singlearm trial of consecutive individuals with a primary complaint of shoulder pain who were seen for physical therapy at 1 of 7 outpatient physical therapy clinics (Wardenburg Health Center, University of Colorado Boulder, Boulder, Colorado; the faculty practice at the University of Colorado Denver, Aurora, Colorado; Physiotherapy Associates, Greenwood Village, Colorado; Rehabilitation Services of Concord Hospital, Concord, New Hampshire; Groves Physical Therapy, St Paul, Minnesota; Newton Wellesley Hospital, Newton, Massachusetts; and Southwest Physical Therapy, Yuma, Arizona). Inclusion criteria required participants to be between the ages of 18 and 65 years, with a primary report of shoulder pain and a baseline Shoulder Pain and Disability Index (SPADI) score of 20% or greater. The SPADI is a self-administered questionnaire consisting of pain and disability subscales, where the means of the 2 subscales are combined to produce a total score ranging from 0 (best) to 100 (worst).31 The SPADI has excellent reliability, validity, and responsiveness.31,32 Exclusion criteria included any medical “red flags” suggestive of a nonmusculoskeletal etiology of symptoms, acute frac28

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tures in the shoulder region, acute severe trauma in the cervical or thoracic region in the previous 6 weeks, a diagnosis of cervical spinal stenosis or bilateral upper-extremity symptoms, osteoporosis, prior surgery to the cervical or thoracic region, evidence of central nervous system involvement, insufficient Englishlanguage skills to complete the questionnaires, or signs consistent with nerve root compression (defined as impairment in at least 2 of the following: myotomal strength, sensation, or reflexes). “Red flags” were ruled out by a combination of a medical screening questionnaire, a neurological examination, and a patient history.33 All participants reviewed and signed a consent form approved by one of the following institutional review boards: the University of Colorado at Boulder, Boulder, Colorado; the University of Colorado Denver, Denver, Colorado; Regis University, Denver, Colorado; Newton-Wellesley Hospital, Newton, Massachusetts; or Concord Hospital, Concord, New Hampshire. Physical Therapists Nine physical therapists participated in the examination and treatment of participants in this study. All therapists underwent a standardized training regimen, which included studying a manual of standard procedures with the operational definitions for each examination and treatment procedure used in this study. All participating therapists then underwent a 1-hour training session in which they practiced all study procedures to ensure they were performed in a standardized fashion. Participating therapists had a mean of 11.6 years (SD⫽10.2, range⫽0 –29) of clinical experience. Five of the 9 therapists were board certified in orthopedics and had received fellowship training in manual therapy.

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Examination Procedures Participants provided demographic information and completed a variety of standardized self-report measures,34 followed by a standardized history and physical examination at baseline. Self-report measures included a body diagram to assess the distribution of symptoms,35 a numeric pain rating scale (NPRS),36 the SPADI,31 the Modified FearAvoidance Beliefs Questionnaire (FABQ),37 and the Tampa Scale for Kinesiophobia (TSK). The body diagram was used to record the location and nature of a patient’s shoulder symptoms.38 The body diagram has been shown to be a reliable tool to localize a patient’s symptoms.39 The 11-point NPRS (range⫽0 –10) was used to measure pain intensity. The scale is anchored on the left with the phrase “no pain” and on the right with the phrase “worst imaginable pain.” The NPRS was used to rate the participants’ current level of pain and their worst and least amount of pain in the previous 24 hours. The average of the 3 ratings was used to represent each participant’s level of pain. Numeric pain scales have been shown to be reliable and valid.36,40,41 The FABQ is a 16-item questionnaire that was designed to quantify fear and avoidance beliefs in individuals with low back pain (LBP).37 The FABQ has 2 subscales: a 7-item scale to measure fear-avoidance beliefs about work and a 4-item scale to measure fear-avoidance beliefs about physical activity. Higher scores represent an increase in fear-avoidance beliefs. We modified the FABQ by changing the word “back” to “shoulder” on the questionnaire. We used the 11-item TSK that assesses fear of movement or of injury or reinjury.42 Individuals rate each item on a 4-point Likert scale, with scoring alternatives ranging from “strongly disagree” to “strongly agree.” TestJanuary 2010

Prognosis in Individuals With Shoulder Pain Receiving Cervicothoracic Manipulation retest reliability is high.42 The SPADI is a 13-item questionnaire consisting of a pain domain with 5 questions and a disability domain with 8 questions. Each section is scored from 0% to 100%, with higher scores indicating higher levels of pain and disability. Beaton and Richards43 reported that the individual-level reliability of measurements obtained with the SPADI had an intraclass correlation coefficient of .91. The minimal clinically important difference (MCID) is 10 points. The historical examination included questions about age, sex, employment status, past medical history, expectations for treatment, mode of onset, location and nature of the patient’s symptoms, number of days since onset, aggravating and relieving factors, number of previous episodes of shoulder pain, and treatment for previous episodes. The physical examination began with a neurological screen,44 followed by an assessment of posture as described previously.28,45 GriegelMorris et al46 examined the reliability of postural assessment using a plumb line and reported a high degree of reliability (kappa⫽.83). The therapist then measured painfree active shoulder flexion47 and administered a battery of 3 functional tests described by Yang and Lin48: hand to neck, hand to scapula and hand to opposite shoulder movements. A soft tape measure was used to measure the resting position of the scapula from the midpoint of the sternal notch (SN) to the medial aspect of the coracoid process (CP) and the horizontal distance from the posterolateral angle of the acromion (PLA) to the thoracic spine (TS).49 The Scapula Index was calculated using the equation: [(SN to CP/PLA to TS) ⫻ 100].49 The lateral slide test was used to evaluate 3 different positions of the scapula as described by

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Kibler.50 Scapular dyskinesis was assessed as described by Kibler et al.51 The therapist then performed a battery of special pathoanatomic tests for the shoulder. These tests were selected based on their psychometric properties, including high sensitivity or specificity, identified during our literature review. As included participants had a primary complaint of shoulder pain, we wanted the tests to cover the spectrum of potential pathoanatomic conditions involving the shoulder. The tests included the load and shift test and the sulcus sign,52 the apprehension/relocation test,52 the Paxinos test and acromioclavicular joint palpation,53 the active compression test,54 the anterior slide test,55 the Hawkins-Kennedy impingement test,56 –58 the Neer impingement test,56 –58 the empty can and full can test,59 the drop sign,60 and the Speed test.61 Next, cervical range of motion (ROM) and symptom response were assessed using an inclinometer for flexion, extension, and side bending and a long-arm goniometer for rotation.62– 64 These measurements have been shown to have moderate intertester reliability.62,63,65 Active rotation of the thoracic spine was assessed visually, and any symptom provocation was recorded.65 We acknowledge that thoracic spine ROM is very difficult to measure accurately. The following tests were used to screen for cervical radiculopathy66: the Spurling test, the Upper Limb Tension Test, the distraction test, and cervical rotation active ROM. First rib mobility testing was performed in a sitting position67; the therapist palpated the first rib and assessed symmetry during quiet breathing and passive downward springing. The cervical rotation lateral flexion test also was performed in a sitting position.68

Passive ROM of the shoulder was measured as described by Norkin and White.69 Cross-chest adduction was measured in a supine position with the shoulder flexed to 90 degrees with 0 degrees of adduction to assess for posterior shoulder tightness.70 Passive accessory joint mobility as described by Maitland71 was assessed at the following joints: glenohumeral (anterior, posterior, and inferior glides, as well as distraction), acromioclavicular, and sternoclavicular. Based on comparison with the opposite shoulder, each motion was judged to be hypomobile, normal, or hypermobile. Finally, the therapist assessed the length72 and strength (forcegenerating capacity)45 of the muscles of the upper quarter and endurance of the deep neck flexor muscles.73 Spring testing of the cervical and thoracic spine (C2–T9) and ribs (1–9)74 and segmental mobility of the cervical spine72 were assessed for mobility and symptom response. Of the 80 participants who were enrolled in the study, 18 underwent a second examination by an additional therapist who was blind to the findings of the first clinician. The 18 participants who underwent a second evaluation were selected based on the availability of a second clinician to perform the examination. The reliability analysis was performed to evaluate the intertester reliability of data obtained for the identified potential prognostic variables. Treatment As treatment outcome served as the reference criterion,75 all participants received the same standardized treatment regardless of the results of the clinical examination. Treating clinicians were not permitted to adjust the intervention based on individual clinical decision-making processes.34 During each session, the participants received 1 nonthrust mobilization

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Prognosis in Individuals With Shoulder Pain Receiving Cervicothoracic Manipulation technique directed at the lower cervical spine and 5 different thrust manipulation techniques directed at the thoracic spine. We used a large number of techniques targeting the cervical and thoracic regions, as it has been reported that patients with shoulder pain may have impairments from the cervicothoracic junction to the lower thoracic spine.16 –20,22,23,46,49 We wanted to be sure that we addressed any impairments that might be present in this region in order to maximize our chances for success. All techniques took less than 10 to 15 minutes to perform and are described below using the standardized terminology proposed by Mintken et al76: • A high-velocity, mid-range distraction force to the midthoracic spine on the lower thoracic spine in a sitting position (Appendix 1). • A low-velocity, end-range, left and right lateral translational force to the lower cervical spine on the upper thoracic spine in a supine position in “neutral” and slight cervical flexion (Appendix 1). • A high-velocity, end-range, anteriorposterior force through the elbows to the cervicothoracic junction on the upper thoracic spine in a supine position (Appendix 1). • A high-velocity, end-range, anteriorposterior force through the elbows to the upper thoracic spine on the midthoracic spine in a supine position in cervicothoracic flexion (Appendix 1). • A high-velocity, end-range, anteriorposterior force through the elbows to the middle thoracic spine on the lower thoracic spine in a supine position in cervicothoracic flexion (Appendix 1). • A high-velocity, mid-range, posteriorto-anterior force to the midthoracic spine on the upper thoracic spine in a prone position (Appendix 1).

Each nonthrust manipulation was performed for 30 seconds at each 30

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cervical level (C5–7) in neutral and slight cervical flexion (for a total of 6 bouts of oscillations to the left and 6 bouts of oscillations to the right). In order to maximize each patient’s opportunity for improvement, each individual received each thrust technique twice, for a total of 10 thrust manipulations per treatment session. Following the manual therapy interventions, all participants were instructed in 2 general spinal mobility exercises. The first was a general cervical mobility exercise called the “3finger ROM exercise” (Appendix 2).77 The second was a general thoracic mobility exercise performed in a supine position (Appendix 2).72 Individuals performed both exercises for 10 repetitions, 3 to 4 times per day, while participating in the study. Participants also received instruction to maintain their usual activity level within the limits of pain. The first treatment session always was performed on the day of the initial examination, and the participant was scheduled for a follow-up visit within 2 to 4 days. The 15-point Global Rating of Change (GROC) described by Jaeschke et al78 was used as the reference criterion for establishing a successful outcome. This decision was based on the fact that the GROC is considered to be a valid reference standard for identifying clinically important change.78 The scale ranges from ⫺7 (“a very great deal worse”) to 0 (“about the same”) to ⫹7 (“a very great deal better”). Intermittent descriptors of worsening or improving are assigned values from – 6 to ⫹6, respectively. Scores of ⫹4 and ⫹5 are reported to indicate moderate changes in patient status, and scores of ⫹6 and ⫹7 indicate large changes in patient status.78 Individuals who rated their perceived recovery on the GROC as “a very great deal better,” “a great deal better,” “quite a bit better,” or “moderately

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better” (ie, a score of ⫹4 or greater) at follow-up were categorized as having a successful outcome. We set ⫹4 as the threshold for success because this score represents clinically meaningful improvements and, due to the short duration of this study, it would be likely that the clinical outcome would be attributable to the intervention rather than the passage of time.78 We chose not to use the SPADI, as it may not adequately capture low levels of disability.79 At the beginning of the second session, the participants completed the GROC and the other outcome measures. If their score on the GROC did not exceed the ⫹4 cutoff at the second session, they received the same intervention program again and were scheduled for a follow-up within 2 to 4 days. Participants again completed the GROC along with the other outcome measures. If they scored ⫹4 or better on the GROC, they were categorized as having a successful outcome; if they scored below ⫹4, they were categorized as not having a successful outcome. At this point, their participation in the study was complete, and the therapist could administer further treatment as needed. Data Analysis We used SPSS version 16.0* to analyze the data. Individuals were dichotomized as having or not having a successful outcome based on the treatment response, as indicated on the GROC (⫺7 to ⫹3⫽nonsuccessful outcome, ⫹4 to ⫹7⫽successful outcome). The mean NPRS and SPADI change scores (and 95% confidence intervals [CIs]) were calculated for the success and nonsuccess groups and were analyzed using an independent t test to determine whether any differences existed between groups. Individual variables * SPSS Inc, 233 S Wacker Dr, Chicago, IL 60606.

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Prognosis in Individuals With Shoulder Pain Receiving Cervicothoracic Manipulation from self-report measures, the history, and the physical examination were tested for univariate relationship with the GROC reference criterion using independent-samples t tests for continuous variables and chi-square tests for categorical variables. Variables with a significance level of P⬍.10 were retained as potential prognostic variables.80 A liberal significance level was selected to increase the likelihood that no potential prognostic variables would be overlooked. For continuous variables with a significant univariate relationship, sensitivity and specificity values were calculated for all possible cutoff points and then plotted as a receiver operator characteristic (ROC) curve.81 The point on the curve nearest the upper left-hand corner represented the value with the best diagnostic accuracy, and this point was selected as the cutoff defining a positive test.81 Sensitivity, specificity, and positive and negative likelihood ratios (⫹LR and ⫺LR) were calculated for potential prognostic variables. Potential prognostic variables were entered into a stepwise logistic regression model to determine the most accurate set of variables for prediction of treatment success. A significance level of P⬍.10 was set to increase the likelihood that no potential prognostic variables would be overlooked.80 The Hosmer-Lemeshow goodness-of-fit statistic was used to assess if the model fit the data.82 Variables retained in the regression model were factors that might predict which individuals with shoulder pain are likely to benefit rapidly and dramatically from manual therapy interventions directed at the cervicothoracic spine. Cohen kappa (␬)83 was used to calculate the interrater reliability of categorical data for identified prognostic variables from the patient history and clinical examination. Intraclass January 2010

correlation coefficients (2,1) and the 95% CIs were calculated to determine the interrater reliability for continuous variables identified as potential prognostic variables.84 Role of the Funding Source This study was supported by a grant from the American Academy of Orthopaedic Manual Physical Therapists.

Results Between October 2006 and December 2008, 131 individuals with a primary report of shoulder pain who were seen for physical therapy were screened for eligibility criteria. Eighty individuals (61%) satisfied the criteria for the study and agreed to participate. The total number of participants screened and reasons for ineligibility are shown in Figure 1. Patient demographics and initial baseline scores for self-report measures are shown in Table 1. Clinical examination variables for the entire sample and both the success and nonsuccess groups, as well as the reliability values, are shown in eTable 1 (available at ptjournal. apta.org) for categorical variables and eTable 2 (available at ptjournal. apta.org) for continuous variables. Of the 80 individuals who enrolled in the study, a total of 49 (61%) experienced a successful outcome. Thirty-one individuals (63% of those who experienced a successful outcome) experienced a successful outcome at the time of the second visit. The remaining 18 individuals reported a successful outcome at the third visit (following 2 treatment sessions). No adverse events were reported during the study. Data for individual therapists were analyzed separately, and there was no heterogeneity among therapists’ average outcomes. Specifically, the percentage of successful patients per therapist was analyzed using chisquare tests, and the results were not

significant (P⫽.425). Additionally, changes on the SPADI and the NPRS were analyzed using an analysis of variance (ANOVA), and there was no significant difference among therapists for these outcomes (P⫽.44 and .113, respectively). Baseline scores, final scores, and change scores with 95% CIs for all outcomes scales for the success and nonsuccess groups are reported in Tables 2 and 3. Differences in change scores for the SPADI for the success group were significantly better than for the nonsuccess group (P⬍.001), with a mean difference between groups of 12.9 (95% CI⫽7.3, 18.5). The mean SPADI score for the success group decreased by more than 50% (from 38.1 to 18.4), whereas the mean SPADI score for the nonsuccess group decreased by 18% (from 37.9 to 30.4) (Fig. 2A). Additionally, analysis of NPRS change scores revealed the success group experienced significantly greater improvements compared with the nonsuccess group, with a mean difference between-group change of 1.7 (95% CI⫽1.1, 2.3) (Fig. 2B). The success group exceeded the MCID for both the SPADI79 and the NPRS85 (19.7 and 2.2, respectively). The participants’ ability to flex the shoulder without pain also improved significantly in both groups (P⬍.001). Differences in change scores for pain-free shoulder flexion were significantly better for the success group than for the nonsuccess group, both immediately after treatment (P⫽.017) and at the final visit (P⬍.001), with mean differences between groups of 7.5 degrees (95% CI⫽1.4°, 13.7°) and 13.8 degrees (95% CI⫽6.2°, 21.4°), respectively (Tab. 3, Fig. 3). The 14 potential prognostic variables (Tab. 4) that exhibited a significance level of less than .10 were

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Prognosis in Individuals With Shoulder Pain Receiving Cervicothoracic Manipulation

Figure 1. Flow diagram showing participant recruitment and retention. CNS⫽central nervous system, UE⫽upper extremity, SPADI⫽Shoulder Pain and Disability Index, GROC⫽Global Rating of Change.

entered into the logistic regression. The cutoff values determined by the ROC curve analysis were 90 days since the onset of symptoms and pain-free shoulder flexion of ⬍127 degrees. We dichotomized duration of symptoms to greater or less than 90 days. Accuracy statistics for all 14 32

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variables (and 95% CIs) are shown in Table 4. The ⫹LRs ranged from 1.1 to 3.0. Of the 14 variables that were entered into the regression model, 5 were retained as the most parsimonious group of prognostic variables for identifying individuals with shoulder pain likely to benefit rap-

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idly and dramatically from manual therapy interventions targeting the cervicothoracic region (Nagelkerke R2⫽.56). The Hosmer-Lemeshow goodness-of-fit statistic indicated the model fit the data (P⫽.90).

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Prognosis in Individuals With Shoulder Pain Receiving Cervicothoracic Manipulation Table 1. Demographics, Baseline Self-Report Variables, and Baseline Characteristics of Participantsa Success Group (nⴝ49)

Variable

Nonsuccess Group (nⴝ31)

P

Age (y)

40.4 (13.5)

42.5 (12.8)

.51b

Sex: female, n (%)

29 (59%)

19 (61%)

.52c

Duration of symptoms (d), mean (SD), median

482.39 (1,635.5), 99

555.84 (1,289.5), 225

.15d

4.0 (1.7)

4.3 (1.8)

.42b

SPADI score (0–100)

38.1 (13.9)

37.9 (13.1)

.93b

FABQ-PA score (0–24)

13.1 (4.8)

12.7 (6.4)

.80b

FABQ-W score (0–42)

10.7 (8.8)

TSK score (0–55)

22.7 (4.4)

21.9 (6.0)

.53b

BMI (kg/m )

24.5 (4.2)

26.4 (5.9)

.11b

Prior history of shoulder pain, n (%)

24 (49%)

18 (58%)

.50c

Traumatic injury, n (%)

13 (27%)

11 (35%)

.45c

Symptoms distal to the shoulder

11

17

.004c

Taking medications, n (%)

30 (61%)

25 (81%)

.07c

NPRS score

2

8.9 (10.3)

.41b

a

Data are mean (SD) unless otherwise indicated. NPRS⫽numeric pain rating scale, SPADI⫽Shoulder Pain and Disability Index, FABQ-PA⫽Fear-Avoidance Beliefs Questionnaire–physical activity subscale, FABQ-W⫽Fear-Avoidance Beliefs Questionnaire–work subscale, TSK⫽Tampa Scale of Kinesiophobia, BMI⫽body mass index. b Independent-samples t test. c Chi-square test. d Mann-Whitney U test.

The pretest probability for the likelihood of success with manual therapy and general mobility exercises for this study was 61% (49 out of 80 participants). If the patient exhibited 4 or 5 out of the 5 variables, the diagnostic accuracy was maximized (⫹LR was infinity), with a posttest probability of success at 100% (Tab. 5). The accuracy of predicting success when 3 out of 5 variables were present (⫹LR⫽5.3, 95% CI⫽1.7, 16.0) was 89%. The accuracy decreased to 78% if only 2 out of

5 variables were present. Reliability data for all variables are presented in eTables 1 and 2 (available at ptjournal.apta.org).

Discussion We have identified several prognostic factors that can potentially identify, a priori, individuals with shoulder pain who are likely to experience a rapid and dramatic response to manual therapy and ROM directed to the cervicothoracic spine. This information may be use-

ful for guiding clinical decision making for individual patients. The results of our study suggest that 61% of individuals with shoulder pain are likely to experience a successful outcome with this intervention program. If 3 out of 5 variables were present (⫹LR⫽5.3, 95% CI⫽1.7, 16.0), the likelihood of success increased to 89%. All individuals who met 4 or 5 of the variables had a positive outcome (⫹LR⫽⬁, posttest probability⫽100%). According to the criteria described by Landis and

Table 2. Baseline, Final, and Change Scores for Outcome Measures Baseline Mean (SD)

Final Mean (SD)

Success group

38.1 (13.9)

18.4 (12.0)

19.7 (15.5, 20.0)

Nonsuccess group

37.9 (13.1)

30.4 (13.7)

6.9 (4.6, 9.1)

Outcome Measure

Within-Group Change Score (95% CIa)

Between-Group Change Scores (95% CI)

Shoulder Pain and Disability Index (0–100) 12.9 (7.3, 18.5) P⬍.001

Numeric pain rating scale (0–10)

a

Success group

4.0 (1.7)

1.8 (1.1)

2.2 (1.9, 2.6)

Nonsuccess group

4.3 (1.8)

3.9 (1.5)

0.50 (⫺0.08, 0.90)

1.7 (1.1, 2.3) P⬍.001

CI⫽confidence interval.

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Prognosis in Individuals With Shoulder Pain Receiving Cervicothoracic Manipulation Table 3. Baseline, Immediate Posttreatment, and Final Session Degrees of Pain-Free Shoulder Flexion Baseline Mean (SD)

Final Mean (SD)

Within-Group Change Scores (95% CIa)

Between-Group Change Scores (95% CI)

Success group

118.6 (31.0)

142.0 (29.8)

23.1 (19.1, 27.2)

Nonsuccess group

134.7 (24.4)

150.1 (20.6)

15.6 (11.1, 20.1)

7.5 (1.4, 13.7) P⫽.017

Success group

118.6 (31.0)

149.3 (25.1)

30.4 (25.1, 35.7)

Nonsuccess group

134.7 (24.4)

151.1 (19.1)

16.6 (11.9, 21.3)

Variable Pain-free shoulder flexion, pretreatment to immediate posttreatment

Pain-free shoulder flexion, pretreatment to final visit

a

13.8 (6.2, 21.4) P⬍.001

CI⫽confidence interval.

Koch,86 all prognostic variables exhibited moderate to substantial reliability. We consider these reliability coefficients acceptable to guide clinical decision making in the treatment of individuals with shoulder pain. The 5 prognostic variables that were retained in the regression model

were: pain-free shoulder flexion of ⬍127 degrees, shoulder internal rotation of ⬍53 degrees, a negative Neer test, not taking medications of any kind for shoulder pain, and duration of symptoms of ⬍90 days. Two variables from the patient history provided an indication that this subgroup is more likely to experi-

Figure 2. (A) Line graph for Shoulder Pain and Disability Index (SPADI) scores of intervention time (P⬍.001 for both groups). (B) Line graph for numeric pain rating scale (NPRS) scores of intervention time (P⬍.001 for success group).

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ence improvement if they are not taking medications and have a shorter duration of symptoms. Brox and Brevik87 reported that not taking medications was a prognostic factor for success in individuals with rotator cuff tendinosis. A longer duration of symptoms frequently has been shown to be associated with a poorer prognosis.88 –90 Two studies have shown that a duration of symptoms of ⬎3 months predict persistent shoulder symptoms and increased sick leave.88 –90 Although a duration of symptoms of ⱕ90 days was one of the strongest predictors of successful outcome, we used a high threshold for defining success on the GROC78 to attempt to distinguish between patients who improved significantly with manipulation and those who were improving over time due to natural history of the disorder. Finally, the magnitude of the difference in change scores for both the SPADI and the NPRS substantiates that an important clinical change occurred in the success group. Two of the prognostic variables included limitations in shoulder motion: pain-free shoulder flexion of ⬍127 degrees and shoulder internal rotation of ⬍53 degrees. These limitations in shoulder motion could be linked to restricted spine and rib

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Prognosis in Individuals With Shoulder Pain Receiving Cervicothoracic Manipulation Winters et al25 found that subjects with purely shoulder girdle disorders (pain or limited motion in the cervical spine, the thoracic spine, or the adjoining ribs) had better outcomes when randomized to receive manipulation (including manipulation of the cervical spine, upper thoracic spine, upper ribs, acromioclavicular joint, and glenohumeral joint) versus conventional physical therapy. As the Neer test has been shown to be sensitive and not specific,56,58 perhaps it serves as a good test to rule out structures that are mechanically painful around the glenohumeral joint and may cue the clinician to focus on the cervicothoracic spine and ribs.

Figure 3. (A) Line graph for changes in pain-free shoulder flexion immediately posttreatment (P⬍.001 for both groups). (B) Line graph for changes in pain-free shoulder flexion from initial visit to final visit (P⬍.001 for both groups).

cage ROM. Decreased thoracic spine ROM has been associated with a functional restriction of arm movement.91,92 Crosbie et al23 found that there is significant movement in the thoracic spine with unilateral and bilateral arm elevation. Sobel et al26 reported that impaired cervicothoracic mobility may be an intrinsic cause of shoulder pain. Painful shoulder elevation may be caused by restricted cervicothoracic spine motion.16 –18,46 Interestingly, both groups in our study improved significantly (P⬍.001) in the degree of pain-free shoulder flexion following the manipulative interventions. Additionally, it is possible that the changes we observed were due to a neurophysiological effect of manipulation that may be unrelated to any biomechanical effects or changes. There is a significant body of literaJanuary 2010

ture demonstrating that spinal manipulation affects the flow of sensory information to the central nervous system, evokes paraspinal muscle reflexes, alters motoneuron excitability, and increases pain tolerance or its threshold.93–96 We were surprised that a negative Neer test was predictive of success. The trials by Boyles et al24 and Bang and Deyle27 required that subjects have either a positive Neer test or a positive Hawkin-Kennedy test. However, it has been reported that many individuals with shoulder pain have no significant impairments in the glenohumeral structures.20,25 Sobel et al20 and Winters et al25 reported that up to a third of subjects with shoulder pain had no identifiable shoulder “synovial impairments” beyond impaired cervicothoracic mobility.

This study successfully developed a set of prognostic factors that may help identify individuals with shoulder pain who are likely to experience meaningful changes in pain, disability, and ROM following cervicothoracic manipulation and general mobility exercises. We believe that these results are generalizable to individuals with a primary report of shoulder pain seeking physical therapy care, as data were collected by 9 physical therapists at 7 outpatient clinics across the country. There were no differences in outcomes among clinicians with varying levels of experience; therefore, it is unlikely that any potential clustering effect based on an individual therapist would have biased the results. It should be noted that this is only the first step in the process of identifying prognostic variables.97 Future studies will be necessary to validate the predictive value of the prognostic factors in a randomized controlled trial with a comparison group and a longer-term follow-up. Ultimately, if these variables do turn out to be useful guides to clinical decision making, an impact analysis should be performed to determine the effects on economic factors, clinical practice patterns, and patient outcomes.

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Prognosis in Individuals With Shoulder Pain Receiving Cervicothoracic Manipulation Table 4. Accuracy Statistics with 95% Confidence Intervals (CIs) for Individual Predictor Variablesa Sensitivity (95% CI)

Specificity (95% CI)

Positive Likelihood Ratio (95% CI)

Posttest Probability (%)

Symptoms ⬍90 d

.47 (.33, .62)

.84 (.66, .94)

2.9 (1.2, 6.6)

81.9

Pain-free shoulder flexion ⬍127°

.59 (.44, .73)

.74 (.55, .87)

2.3 (1.2, 4.4)

78.3

Variable

a

Shoulder internal rotation ⬍53° at 90° of abduction

.78 (.63, .88)

.53 (.35, .71)

1.7 (1.1, 2.5)

72.7

Scapula Index greater than 66.5

.57 (.42, .71)

.67 (.47, .82)

1.7 (0.98, 3.0)

72.7

Pain with cervical range of motion

.55 (.40, .69)

.67 (.47, .82)

1.7 (0.99, 2.9)

72.7

Hypomobility of either first rib

.94 (.82, .98)

.23 (.10, .43)

1.2 (0.99, 1.5)

65.2

Weak middle trapezius muscle

.65 (.49, .77)

.6 (.41, .77)

1.6 (0.99, 2.6)

71.5

No deltoid muscle weakness

.77 (.62, .87)

.52 (.31, .71)

1.1 (1.1, 2.4)

63.2

No symptoms distal to shoulder

.77 (.62, .87)

.57 (.38, .74)

1.8 (1.1, 2.8)

71.8

Scapular symptoms

.71 (.57, .83)

.65 (.45, .80)

2.0 (1.2, 3.3)

75.8

Painful arc with flexion

.29 (.17, .43)

.90 (.73, .97)

3.0 (0.92, 9.4)

82.4

Negative active compression test

.73 (.59, .85)

.47 (.29, .65)

1.3 (0.95, 2.0)

67

Negative Neer test

.50 (.35, .65)

.73 (.54, .87)

1.9 (0.97, 3.6)

74.8

Not taking medications

.38 (.24, .53)

.83 (.65, .94)

2.3 (0.93, 5.4)

78.3

Pretest probability of success⫽61%.

There are limitations to the current study that should be recognized. First, a prospective single-arm design lacking a comparison group does not allow for inferences to be made regarding cause and effect. Weeks98 stated that single-arm studies are the most vulnerable to a regression effect, as the absence of a control

group makes it impossible to determine the amount of change due to regression. The regression effect is defined as a statistical phenomenon in which a finding that may seem significant on first analysis will tend to be closer to the mean of a group on a subsequent measurement.98 It is possible that the statistical proce-

dures used may have resulted in overfitting of the model, which may have resulted in low precision of the prediction accuracy.99 Therefore, the values for sensitivity, specificity, and LRs presented here may be higher than they actually were. Furthermore, it is possible that the prognostic variables were not reliably se-

Table 5. Clinical Prediction Rule Criteria Identified in the Logistic Regression Analysis and Their Accuracy Statistics Clinical Prediction Rule Criteria Identified in Logistic Regression Analysis Pain-free shoulder flexion ⬍127° Shoulder internal rotation ⬍53° at 90° of abduction Negative Neer test Not taking medications for their shoulder pain Symptoms less than 90 d Probability of Success (%)a

.04 (.01, .15)

1.0 (.86, 1.0)

⬁

100

2

0

.27 (.15, .41)

1.0 (.86, 1.0)

⬁

100

13

0

Patients Who Satisfied:

Sensitivity

Met all 5 Met at least 4 Met at least 3

.51 (.37, .65)

.90 (.73, .97)

5.3 (1.7, 16.0)

89

25

3

Met at least 2

.90 (.77, .96)

.61 (.42, .78)

2.3 (1.5, 3.6)

78

44

12

.19 (.08, .38)

1.0 (1.2, 1.5)

61

49

25

Met at least 1 a

Specificity

Positive Likelihood Ratio

No. of Predictor Variables Present

1.0 (.90, 1.0)

Success

Nonsuccess

The probability of success is calculated using the positive likelihood ratios and assumes a pretest probability of 61%.

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Prognosis in Individuals With Shoulder Pain Receiving Cervicothoracic Manipulation lected and that they may represent spurious findings rather than true prognostic variables. It also is possible that the initial screening process using bivariate analysis may have caused the rejection of some variables that actually have prediction accuracy.100 However, as is the case with all statistical modeling, the results presented here will require validation to protect against potential problems and limitations. Such validation could include performing the study on an independent sample of patients.99 It is possible that one or more of the prognostic variables simply identify individuals who have a favorable natural history rather than a response to the manual therapy and general mobility exercises. Although this may be the case, our sample included participants with relatively longstanding symptoms (65% had symptoms for greater than 90 days). We chose not to limit the duration of symptoms, as research indicates that 50% of individuals with a new onset of shoulder pain will continue to have symptoms at 6 months, and 40% still have symptoms at 1 year.11,89 In this study, the median duration of symptoms was 99 days for the success group and 225 days in the nonsuccess group. The individuals in our study with acute symptoms seemed to respond more favorably than those with chronic symptoms. The proportion of individuals with a duration of symptoms of ⬎90 days was the same for both the success group (n⫽26, 32.5%) and the nonsuccess group (n⫽26, 32.5%). The proportion of individuals with a duration of symptoms of ⬍90 days was significantly different (P⫽.005) between the success group (n⫽23, 29%) and the nonsuccess group (n⫽5, 6%). It also is possible that we did not capture every possible variable that could be a potential predictor during January 2010

the examination. We did not standardize the number of treatments, which could have affected the results. It is possible that the small sample size and the number of variables entered into the logistic regression may have resulted in overfitting of the model, which may have led to spurious findings.99 However, in order to not introduce bias into the analysis, we included all potential predictor variables, and any variable that identified as a predictor should be re-examined in future studies.99 As we collected only data for shortterm outcomes on these individuals, we do not know whether the individuals who were classified as having a successful outcome were still doing well at a longer-term follow-up. Finally, although there is a percentage of individuals with shoulder pain for whom a specific diagnosis can be made, we chose to not separate out any specific diagnoses, which potentially confounded our results. Dr Mintken, Dr Cleland, Dr Keirns, and Dr Whitman provided concept/idea/research design, writing, and fund procurement. Dr Mintken, Dr Carpenter, Dr Keirns, and Dr Bieniek provided data collection, participants, facilities/equipment, and clerical support. Dr Cleland provided data analysis. Dr Mintken provided project management. All authors provided consultation (including review of manuscript before submission). The authors thank Scott Burns, Amy Garrigues, Paul Glynn, John Groves, Tim Mondale, and Louie Puentedura for their assistance with data collection. They also thank David Weil for his production of the photographs for the figures. The study was approved by the institutional review boards at the University of Colorado at Boulder, the University of Colorado Denver, Regis University, Newton Wellesley Hospital, and Concord Hospital. This study was supported by a grant from the American Academy of Orthopaedic Manual Physical Therapists. This study is registered at www.clinicaltrials. gov: Identifier: NCT00835302.

This article was received March 20, 2009, and was accepted August 28, 2009. DOI: 10.2522/ptj.20090095

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Prognosis in Individuals With Shoulder Pain Receiving Cervicothoracic Manipulation 15 Wainner RS, Whitman JM, Cleland JA, Flynn TW. Regional interdependence: a musculoskeletal examination model whose time has come. J Orthop Sports Phys Ther. 2007;37:658 – 660. 16 Norlander S, Aste-Norlander U, Nordgren B, Sahlstedt B. Mobility in the cervicothoracic motion segment: an indicative factor of musculo-skeletal neck-shoulder pain. Scand J Rehabil Med. 1996;28: 183–192. 17 Norlander S, Gustavsson BA, Lindell J, Nordgren B. Reduced mobility in the cervico-thoracic motion segment—a risk factor for musculoskeletal neck-shoulder pain: a two-year prospective follow-up study. Scand J Rehabil Med. 1997;29: 167–174. 18 Norlander S, Nordgren B. Clinical symptoms related to musculoskeletal neckshoulder pain and mobility in the cervico-thoracic spine. Scand J Rehabil Med. 1998;30:243–251. 19 Sobel JS, Kremer I, Winters JC, et al. The influence of the mobility in the cervicothoracic spine and the upper ribs (shoulder girdle) on the mobility of the scapulohumeral joint. J Manipulative Physiol Ther. 1996;19:469 – 474. 20 Sobel JS, Winters JC, Groenier K, et al. Physical examination of the cervical spine and shoulder girdle in patients with shoulder complaints. J Manipulative Physiol Ther. 1997;20:257–262. 21 Picavet HSJ, Schouten JSAG. Musculoskeletal pain in the Netherlands: prevalences, consequences and risk groups, the DMC(3) study. Pain. 2003;102:167– 178. 22 Bergman GJD, Winters JC, Groenier KH, et al. Manipulative therapy in addition to usual medical care for patients with shoulder dysfunction and pain: a randomized, controlled trial. Ann Intern Med. 2004;141:432– 439. 23 Crosbie J, Kilbreath SL, Hollmann L, York S. Scapulohumeral rhythm and associated spinal motion. Clin Biomech. 2008; 23:184 –192. 24 Boyles RE, Ritland BM, Miracle BM, et al. The short-term effects of thoracic spine thrust manipulation on patients with shoulder impingement syndrome. Man Ther. 2009;14:375–380. 25 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(7090):1320 –1325. 26 Bergman G, Winters J, Groenier K, et al. Manipulative therapy in addition to usual medical care for patients with shoulder dysfunction and pain: a randomized, controlled trial. Ann Intern Med. 2004;141: 432– 439. 27 Bang MD, Deyle GD. Comparison of supervised exercise with and without manual physical therapy for patients with shoulder impingement syndrome. J Orthop Sports Phys Ther. 2000;30:126 –137.

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28 Cleland JA, Childs JD, Fritz JM, et al. Development of a clinical prediction rule for guiding treatment of a subgroup of patients with neck pain: use of thoracic spine manipulation, exercise, and patient education. Phys Ther. 2007;87:9 –23. 29 Flynn T, Fritz J, Whitman J, et al. A clinical prediction rule for classifying patients with low back pain who demonstrate short-term improvement with spinal manipulation. Spine. 2002;27: 2835–2843. 30 Hicks GE, Fritz JM, Delitto A, McGill SM. Preliminary development of a clinical prediction rule for determining which patients with low back pain will respond to a stabilization exercise program. Arch Phys Med Rehabil. 2005;86:1753–1762. 31 Roach KE, Budiman-Mak E, Songsiridej N, Lertratanakul Y. Development of a shoulder pain and disability index. Arthritis Care Res. 1991;4:143–149. 32 Heald SL, Riddle DL, Lamb RL. The Shoulder Pain and Disability Index: the construct validity and responsiveness of a region-specific disability measure. Phys Ther. 1997;77:1079 –1089. 33 McCarthy CJ, Gittins M, Roberts C, Oldham JA. The reliability of the clinical tests and questions recommended in international guidelines for low back pain. Spine. 2007;32:921–926. 34 Beneciuk JM, Bishop MD, George SZ. Clinical prediction rules for physical therapy interventions: a systematic review. Phys Ther. 2009;89:114 –124. 35 Werneke MW, Hart DL, Cook D. A descriptive study of the centralization phenomenon: a prospective analysis. Spine. 1999;24:676 – 683. 36 Jensen MP, Turner JA, Romano JM. What is the maximum number of levels needed in pain intensity measurement? Pain. 1994;58:387–392. 37 Waddell G, Newton M, Henderson I, et al. A Fear-Avoidance Beliefs Questionnaire (FABQ) and the role of fearavoidance beliefs in chronic low back pain and disability. Pain. 1993;52:157–168. 38 Uden A, Astrom M, Bergenudd H. Pain drawings in chronic back pain. Spine. 1988;13:389 –392. 39 Werneke MW, Harris DE, Lichter RL. Clinical effectiveness of behavioral signs for screening chronic low-back pain patients in a work-oriented physical rehabilitation program. Spine. 1993;18: 2412–2418. 40 Downie WW, Leatham PA, Rhind VM, et al. Studies with pain rating scales. Ann Rheum Dis. 1978;37:378 –381. 41 Katz J, Melzack R. Measurement of pain. Surg Clin North Am. 1999;79:231–252. 42 Woby SR, Roach NK, Urmston M, Watson PJ. Psychometric properties of the TSK11: a shortened version of the Tampa Scale for Kinesiophobia. Pain. 2005;117: 137–144. 43 Beaton D, Richards RR. Assessing the reliability and responsiveness of 5 shoulder questionnaires. J Shoulder Elbow Surg. 1998;7:565–572.

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44 Viikari-Juntura E. Interexaminer reliability of observations in physical examinations of the neck. Phys Ther. 1987;67: 1526 –1532. 45 Kendall FP, McCreary EK, Provance PG. Muscles: Testing and Function. 4th ed. Baltimore, MD: Williams & Wilkins; 1993. 46 Griegel-Morris P, Larson K, Mueller-Klaus K, Oatis CA. Incidence of common postural abnormalities in the cervical, shoulder, and thoracic regions and their association with pain in two age groups of healthy subjects. Phys Ther. 1992;72: 425– 431. 47 Magee DJ. Orthopedic Physical Assessment. 4th ed. Philadelphia, PA: Saunders; 2002. 48 Yang J-l, Lin J-J. Reliability of functionrelated tests in patients with shoulder pathologies. J Orthop Sports Phys Ther. 2006;36:572–576. 49 Borstad JD. Resting position variables at the shoulder: evidence to support a posture-impairment association. Phys Ther. 2006;86:549 –557. 50 Kibler WB. The role of the scapula in athletic shoulder function. Am J Sports Med. 1998;26:325–337. 51 Kibler WB, Uhl TL, Maddux JW, et al. Qualitative clinical evaluation of scapular dysfunction: a reliability study. J Shoulder Elbow Surg. 2002;11:550 –556. 52 Tzannes A, Paxinos A, Callanan M, Murrell GAC. An assessment of the interexaminer reliability of tests for shoulder instability. J Shoulder Elbow Surg. 2004; 13:18 –23. 53 Walton J, Mahajan S, Paxinos A, et al. Diagnostic values of tests for acromioclavicular joint pain. J Bone Joint Surg Am. 2004;86:807– 812. 54 O’Brien SJ, Pagnani MJ, Fealy S, et al. The active compression test: a new and effective test for diagnosing labral tears and acromioclavicular joint abnormality. Am J Sports Med. 1998;26:610 – 613. 55 Kibler WB. Specificity and sensitivity of the anterior slide test in throwing athletes with superior glenoid labral tears. Arthroscopy. 1995;11:296 –300. 56 Calis M, Akgun K, Birtane M, et al. Diagnostic values of clinical diagnostic tests in subacromial impingement syndrome. Ann Rheum Dis. 2000;59:44 – 47. 57 Leroux JL, Thomas E, Bonnel F, Blotman F. Diagnostic value of clinical tests for shoulder impingement syndrome. Rev Rhum Engl Ed. 1995;62:423– 428. 58 MacDonald PB, Clark P, Sutherland K. An analysis of the diagnostic accuracy of the Hawkins and Neer subacromial impingement signs. J Shoulder Elbow Surg. 2000;9:299 –301. 59 Itoi E, Kido T, Sano A, et al. Which is more useful, the “full can test” or the “empty can test,” in detecting the torn supraspinatus tendon? Am J Sports Med. 1999;27:65– 68.

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73 Harris KD, Heer DM, Roy TC, et al. Reliability of a measurement of neck flexor muscle endurance. Phys Ther. 2005;85: 1349 –1355. 74 Maitland G, Hengeveld E, Banks K, English K. Maitland’s Vertebral Manipulation. 6th ed. Oxford, United Kingdom: Butterworth-Heinemann; 2001. 75 Jaeschke R, Guyatt GH, Sackett DL; the Evidence-Based Medicine Working Group. Users’ guides to the medical literature, III: how to use an article about a diagnostic test, B. What are the results and will they help me in caring for my patients? JAMA. 1994;271:703–707. 76 Mintken PE, DeRosa C, Little T, Smith B. A model for standardizing manipulation terminology in physical therapy practice. J Orthop Sports Phys Ther. 2008;38(3): A1–A6. 77 Erhard RE. The Spinal Exercise Handbook: A Home Exercise Manual for a Managed Care Environment. Pittsburgh, PA: Laurel Concepts; 1998. 78 Jaeschke R, Singer J, Guyatt GH. Measurement of health status: ascertaining the minimal clinically important difference. Control Clin Trials. 1989;10:407– 415. 79 Williams JW Jr, Holleman DR Jr, Simel DL. Measuring shoulder function with the Shoulder Pain and Disability Index. J Rheumatol. 1995;22:727–732. 80 Freedman D. A note on screening regression equations. American Statistician. 1983;37:152–155. 81 Deyo RA, Centor RM. Assessing the responsiveness of functional scales to clinical change: an analogy to diagnostic test performance. J Chronic Dis. 1986;39: 897–906. 82 Field A. Discovering Statistics Using SPSS for Windows. London, United Kingdom: Sage Publications; 2002. 83 Cohen J. A coefficient of agreement for nominal scales. Educ Psychol Meas. 1960; 20:37– 46. 84 Shrout PE, Fleiss JL. Intraclass correlations: uses in assessing rater reliability. Psychol Bull. 1979;86:420 – 426. 85 Childs JD, Piva SR, Fritz JM. Responsiveness of the numeric pain rating scale in patients with low back pain. Spine. 2005; 30:1331–1334. 86 Landis JR, Koch CG. The measurement of observer agreement for categorical data. Biometrics. 1977;33:159 –174. 87 Brox JI, Brevik JI. Prognostic factors in patients with rotator tendinosis (stage II impingement syndrome) of the shoulder. Scand J Primary Health Care. 1996;14: 100 –105.

88 Kuijpers T, van der Windt DAWM, Boeke AJP, et al. Clinical prediction rules for the prognosis of shoulder pain in general practice. Pain. 2006;120:276 –285. 89 Kuijpers T, van der Windt DAWM, van der Heijden GJMG, Bouter LM. Systematic review of prognostic cohort studies on shoulder disorders. Pain. 2004;109: 420 – 431. 90 Borg K, Hensing G, Alexanderson K. Risk factors for disability pension over 11 years in a cohort of young persons initially sick-listed with low back, neck, or shoulder diagnoses. Scand J Public Health. 2004;32:272–278. 91 Crawford HJ, Jull GA. The influence of thoracic posture and movement on range of arm elevation. Physiother Theory Pract. 1993;9:143–148. 92 Stewart S, Jull GA, Ng JK-F, Willems JM. An initial analysis of thoracic spine movement during unilateral arm elevation. J Man Manip Ther. 1995;3:15–20. 93 George SZ, Bishop MD, Bialosky JE, et al. Immediate effects of spinal manipulation on thermal pain sensitivity: an experimental study. BMC Musculoskelet Disord. 2006;7:68. 94 Pickar JG. Neurophysiological effects of spinal manipulation. Spine J. 2002;2: 357–371. 95 Wright A. Hypoalgesia post-manipulative therapy: a review of a potential neurophysiological mechanism. Man Ther. 1995;1:11–16. 96 Vicenzino B, Collins D, Benson H, Wright A. An investigation of the interrelationship between manipulative therapyinduced hypoalgesia and sympathoexcitation. J Manipulative Physiol Ther. 1998;21:448 – 453. 97 McGinn TG, Guyatt GH, Wyer PC, et al; Evidence-Based Medicine Working Group. Users’ guides to the medical literature, XXII: how to use articles about clinical decision rules. JAMA. 2000;284:79 – 84. 98 Weeks DL. The regression effect as a neglected source of bias in nonrandomized intervention trials and systematic reviews of observational studies. Evaluation and the Health Professions. 2007; 30:254 –265. 99 Concato J, Feinstein A, Holford T. The risk of determining risk with multivariable models. Ann Intern Med. 1993;118: 201–210. 100 Sun GW, Shook TL, Kay GL. Inappropriate use of bivariable analysis to screen risk factors for use in multivariable analysis. J Clin Epidemiol. 1996;49:907–916.

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Prognosis in Individuals With Shoulder Pain Receiving Cervicothoracic Manipulation Appendix 1. Manual Therapy Interventions

Seated thoracic spine thrust manipulation. The therapist uses his sternum as a fulcrum on the individual’s middle thoracic spine and applies a high-velocity distraction thrust in an upward direction.

The treating therapist cradles the individual’s head and neck and performs a lateral translation (Maitland grades III and IV) to the right and left in neutral and flexion, 3 bouts of 30 seconds from C5 to C7.

Supine cervicothoracic thrust manipulation technique. The therapist uses his body to push down through the individual’s elbows to perform a high-velocity, low-amplitude thrust directed toward moving C7 on T1.

(Continued)

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Prognosis in Individuals With Shoulder Pain Receiving Cervicothoracic Manipulation Appendix 1. Continued

Supine upper thoracic spine thrust manipulation technique. The therapist uses his body to push down through the individual’s arms to perform a high-velocity, lowamplitude thrust directed in the direction of the arrow toward T1 through T4.

Supine middle thoracic spine thrust manipulation technique. The therapist uses his body to push down through the individual’s arms to perform a high-velocity, lowamplitude thrust directed in the direction of the arrow toward T5 through T8.

Prone middle to lower thoracic spine thrust manipulation technique. The therapist achieves a “skin lock” with the pisiforms of each hand over the transverse processes of the target vertebra pushing caudal with one hand and cephalad with the other. The therapist then uses his body to push down through his arms to perform a high-velocity, low-amplitude posterior to anterior thrust.

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Prognosis in Individuals With Shoulder Pain Receiving Cervicothoracic Manipulation Appendix 2. General Spinal Mobility Exercises

Active-range-of-motion (AROM) exercises performed by participants in the study: 3-finger cervical AROM and supine thoracic extension over a towel.

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Research Report Early Postoperative Measures Predict 1- and 2-Year Outcomes After Unilateral Total Knee Arthroplasty: Importance of Contralateral Limb Strength Joseph A. Zeni Jr, Lynn Snyder-Mackler

Background. Total knee arthroplasty (TKA) has been shown to be an effective surgical intervention for people with end-stage knee osteoarthritis. However, recovery of function is variable, and not all people have successful outcomes. Objective. The aim of this study was to discern which early postoperative functional measures could predict functional ability at 1 year and 2 years after surgery.

Design and Methods. One hundred fifty-five people who underwent unilateral TKA participated in the prospective longitudinal study. Functional evaluations were performed at the initial outpatient physical therapy appointment and at 1 and 2 years after surgery. Evaluations consisted of measurements of height, weight, quadriceps muscle strength (force-generating capacity), and knee range of motion; the Timed “Up & Go” Test (TUG); the stair-climbing task (SCT); and the Knee Outcome Survey (KOS) questionnaire. The ability to predict 1- and 2-year outcomes on the basis of early postoperative measures was analyzed with a hierarchical regression. Differences in functional scores were evaluated with a repeated-measures analysis of variance. Results. The TUG, SCT, and KOS scores at 1 and 2 years showed significant improvements over the scores at the initial evaluation (P⬍.001). A weaker quadriceps muscle in the limb that did not undergo surgery (“nonoperated limb”) was related to poorer 1- and 2-year outcomes even after the influence of the other early postoperative measures was accounted for in the regression. Older participants with higher body masses also had poorer outcomes at 1 and 2 years. Postoperative measures were better predictors of TUG and SCT times than of KOS scores.

J.A. Zeni Jr, PT, PhD, is Research Assistant Professor, Department of Physical Therapy, University of Delaware, 301 McKinly Laboratory, Newark, DE 19716 (USA). Address all correspondence to Dr Zeni at: [email protected]. L. Snyder-Mackler, PT, ScD, FAPTA, is Alumni Distinguished Professor, Department of Physical Therapy, and Academic Director, Graduate Program in Biomechanics and Movement Science, University of Delaware. [Zeni JA Jr, Snyder-Mackler L. Early postoperative measures predict 1and 2-year outcomes after unilateral total knee arthroplasty: importance of contralateral limb strength. Phys Ther. 2010;90: 43–54.] © 2010 American Physical Therapy Association

Conclusions. Rehabilitation regimens after TKA should include exercises to improve the strength of the nonoperated limb as well as to treat the deficits imposed by the surgery. Emphasis on treating age-related impairments and reducing body mass also might improve long-term outcomes.

Post a Rapid Response or find The Bottom Line: www.ptjournal.org January 2010

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Early Measures After Unilateral Total Knee Arthroplasty

T

otal knee arthroplasty (TKA) has been proven to be an effective and cost-efficient intervention for end-stage knee osteoarthritis (OA). Most people who undergo TKA show marked improvements in function and reductions in pain compared with their preoperative condition.1,2 However, recovery of functional ability is variable, and not all patients experience significant improvements.3,4 The ability to predict which patients will have successful recoveries relies on the ability to identify factors that result in different functional outcomes. Preoperative measures that predict postsurgical functional status were examined in many previous investigations. Lower levels of preoperative quadriceps muscle strength (forcegenerating capacity) and selfperceived functional ability and a larger number of comorbidities have been shown to predict decreased functional ability 6 to 24 months after TKA.4 – 6 In the short term, greater preoperative knee pain and less preoperative range of motion (ROM) are related to reduced walking ability 2 months after surgery.7 Other factors, such as a high body mass index (BMI), female sex, and older age, have been implicated as factors that predict poor short-term outcomes, higher per-patient costs, or higher postoperative complication rates.8,9 Although preoperative predictors may aid in the identification of people at risk for postoperative difficulties, it also is important to recognize

Available With This Article at ptjournal.apta.org • Audio Abstracts Podcast This article was published ahead of print on December 3, 2009, at ptjournal.apta.org.

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early postoperative factors that may predict poor long-term outcomes. Van den Akker-Scheek et al10 found that early postoperative evaluations of self-efficacy were better predictors of long-term outcomes than preoperative evaluations. This finding is important because most people receive outpatient physical therapy services after TKA, but preoperative therapeutic interventions are not as common. Physical therapists, therefore, can tailor rehabilitation regimens to maximize early postoperative self-efficacy, whereas increasing preoperative self-efficacy is not always feasible. No studies have evaluated the ability to predict long-term functional outcomes on the basis of early postoperative measures. The purpose of this study was to discern whether age, BMI, pain, knee ROM, and knee strength measured at an initial physical therapy evaluation could predict functional ability at 1 year and 2 years after surgery. We hypothesized that certain factors would best predict long-term outcomes. Identification of these factors will aid in the creation of targeted therapeutic interventions to maximize postoperative functional ability.

Method One hundred and fifty-five people who underwent primary unilateral TKA for end-stage knee OA participated in the study (Tab. 1). Before surgery, participants were excluded if they reported symptomatic OA in the contralateral limb, as measured by maximal pain of greater than 4 on a scale of 1 to 10 in that limb during daily activities. All participants signed an informed consent form approved by the Human Subjects Review Board of the University of Delaware. Participants were treated 2 or 3 times per week for 6 weeks in the same outpatient physical therapy clinic. Outpatient physical therapy began shortly after they concluded

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home-based therapy (under direct physical therapist supervision) and had their staples removed. The physical therapy regimen consisted of progressive lower-extremity strengthening exercises, modalities to control pain and inflammation, electrical stimulation to improve quadriceps muscle function, and manual therapy to improve ROM (Appendix). Quantitative clinical measurements were obtained at the initial evaluation and at 1 and 2 years after surgery. These measurements included age, height, weight, bilateral quadriceps muscle strength, knee flexion and extension ROM, the Timed “Up & Go” Test (TUG), and a stairclimbing task (SCT). Two subsets of the Knee Outcome Survey (KOS), the activities of daily living subset (KOS-ADLS) and the pain subset (KOS-Pain), also were used. Quadriceps Muscle Strength Quadriceps muscle strength was defined in this study as the volitional isometric force created by the quadriceps muscle. It was measured with the participants seated with their knees flexed to 75 degrees and their hips flexed to 85 degrees on a KinCom dynamometer.* Knee flexion of 75 degrees was chosen to ensure consistency between time points and participants. After surgery, it was likely that a percentage of the participants would not be able to achieve knee flexion of greater than 75 degrees. Seventy-five degrees of knee flexion during isometric knee extension also results in the greatest force output of the quadriceps muscle after TKA.11 Participants were given verbal encouragement to kick “as hard as possible” for 3 seconds. Three trials were completed, and the average of these trials was recorded. The raw force measured by the dy* Isokinetic International, 6426 Morning Glory Dr, Harrison, TN 37341.

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Early Measures After Unilateral Total Knee Arthroplasty namometer, in newtons, was normalized to each participant’s BMI (N/ BMI), and this value was used as quadriceps muscle strength.

Table 1. Participant Demographics at Initial Evaluation, 1 Year, and 2 Yearsa

Characteristicb

Knee ROM Active knee flexion ROM was measured with participants in the supine position. The axis of the goniometer was aligned over the lateral epicondyle of the femur. The distal arm was aligned with the lateral malleolus of the fibula, and the proximal arm was aligned with the long axis of the shaft of the femur and directed toward the greater trochanter. Participants were instructed to maximally bend their knees by flexing their hips and sliding their heels toward their buttocks. No overpressure was applied by the therapist during knee flexion. Three trials were performed, and the average knee flexion angle was recorded. All measurements were obtained with respect to full extension of the knee being 0 degrees and increasing knee flexion being recorded as positive values. Goniometric measurements in people with knee OA have been shown to be highly reliable.12 TUG The TUG is a functional test that has been used extensively to examine functional outcomes in people with knee OA and after TKA.5,13,14 The test begins with a participant seated in a chair with both feet touching the floor. When instructed to “go,” the participant rises from the chair, walks 3 m, turns around, returns to the chair, and sits down. Participants were instructed to complete the task as quickly as possible. They performed 2 trials, and the average time to complete the task was recorded. They were permitted to use the arms of the chair during standing and returning to a seated position. This test has excellent interrater and intrarater reliability in older adults and is responsive to changes after TKA.15,16 January 2010

Age, y

64.9 (8.7)

Sex, % of men/women

57/43

Height, m

2 Years (nⴝ125)

1.72 (0.10) 89.1 (17.0)

91.2 (17.5)

94.1 (18.6)

BMI, kg/m2

30.2 (4.9)

31.0 (5.2)

31.8 (5.7)

6.3 (4.1)

0.4 (2.8)

0.3 (2.9)

97.1 (15.0)

120.1 (10.4)

120.2 (11.3)

9.9 (4.1)

20.7 (8.5)

20.6 (8.8)

Nonoperated quadriceps muscle strength, N/BMI

24.0 (8.7)

22.7 (9.4)

21.0 (9.3)

Days since surgery

27.7 (3.7)

Flexion AROM, ° Operated quadriceps muscle strength, N/BMI

b

1 Year (nⴝ155)

Weight, kg

Extension AROM, °

a

Initial Evaluation (nⴝ155)

Values are reported as mean (SD) unless otherwise indicated. BMI⫽body mass index, AROM⫽active range of motion.

SCT The SCT is a measure of a participant’s ability to ascend and descend a flight of 12 steps as quickly as possible in a safe manner. Participants began at the bottom of the stairs and, at the investigator’s instruction, ascended the steps, turned around, and descended the steps as quickly as possible with the use of the handrail only if needed for balance. Participants performed 1 practice trial and then 2 timed trials, the average of which was recorded. This test has been used to successfully measure recovery after TKA.5,15,17 KOS For the purpose of this study, we used 2 subsets of the KOS, the KOSADLS and the KOS-Pain. The KOSADLS consists of 14 questions pertaining to a participant’s ability to perform activities of daily living. The KOS-ADLS is represented as a percentage score, with higher scores indicating higher levels of selfperceived functional ability. With the KOS-Pain, participants rate their pain on a 6-point scale, in which 0 represents no pain and 5 represents pain that prevents daily activities.

The KOS has been shown to have high reliability and validity in people with knee pathology.18,19 Data Analysis A hierarchical regression model was created to predict the TUG, SCT, and KOS-ADLS scores at 1 and 2 years after TKA. Baseline test scores and then participant age, BMI, KOS-Pain score, flexion ROM, quadriceps muscle strength of the limb that underwent TKA (“operated limb”), and quadriceps muscle strength of the limb that did not undergo TKA (“nonoperated limb”), all obtained at the initial physical therapy evaluation, were entered into the hierarchical regression model as independent variables, in that order. The order of the variables was chosen on the basis of their clinical relevance, and the baseline test scores were entered first to account for changes in each variable over time. Preoperative quadriceps muscle strength and knee ROM are predictors of postoperative outcomes and often are directly addressed during postoperative physical therapy.5,7 For this reason, the order of the regression was designed to determine whether

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Figure 1. Significant improvements in results of the Timed “Up & Go” Test (TUG) and stairclimbing task (SCT) and in scores on the activities of daily living subset of the Knee Outcome Survey (KOS-ADLS) at 1-year follow-up and 2-year follow-up (asterisk indicates P⬍.001). Error bars represent 95% confidence intervals.

knee strength and ROM would significantly improve the predictive ability of the model, even when the influence of age, BMI, knee pain, and baseline test scores was accounted for. A change in the F score from each step of the model to the next (the addition of each variable) was analyzed for significance (Pⱕ.05). An analysis of variance with 1 repeated measure (time) was used to determine differences in the TUG, SCT, and KOS-ADLS scores at the initial evaluation and those at 1 and 2 years after TKA.

Results Participants reported to outpatient physical therapy an average (median) of 28 days after TKA. The median number of physical therapy treatments was 17, with 90% of the participants receiving 16 to 18 treatments. No participants reported any major neurological or cardiovascular events after surgery. The Mauchley test of sphericity was significant, suggesting unequal variances between the time points. When the Green46

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house–Geisser correction was used, a significant effect of time on all of the outcome measures was revealed. The TUG, SCT, and KOS scores at 1 and 2 years showed significant improvements over the scores at the initial evaluation (P⬍.001) (Fig. 1). The TUG and SCT showed 34% and 53% reductions in the times needed to complete the tasks at the initial evaluation and at 1 year, respectively. The KOS-ADLS score increased by 52% between the initial evaluation and 1 year. Post hoc testing revealed no significant differences between 1 and 2 years (P⬎.43). For descriptive purposes, the TUG, SCT, and KOS-ADLS scores at 3 months after TKA (near the time of discharge from physical therapy) were 8.23 seconds (SD⫽1.87 seconds), 13.63 seconds (SD⫽4.76 seconds), and 78.6% (SD⫽12%), respectively. Early postoperative values were predictive of the TUG, SCT, and KOS scores at 1 year after TKA (Tabs. 2, 3, and 4). After the other variables in the regression were accounted for,

Number 1

the quadriceps muscle strength of the nonoperated limb significantly improved the predictive ability of the model with respect to the TUG, SCT, and KOS-ADLS scores. Increased force production in the nonoperated limb was related to improved scores on the TUG, SCT, and KOS (Fig. 2). Age also improved the predictive ability of the model for the TUG and SCT times, and BMI improved the predictive ability for the SCT time. A younger age and a lower BMI predicted better functional outcomes in terms of faster times to complete the TUG and SCT. The KOS-Pain and strength of the involved limb did not predict scores for outcomes. The BMI was the most significant predictor of the KOSADLS score (P⫽.023), with a higher postoperative BMI predicting a lower KOS-ADLS score at 1 year after TKA. A stronger quadriceps muscle in the nonoperated limb also significantly contributed to the prediction of an improved KOS-ADLS score, whereas age, the KOS-Pain, knee flexion ROM, and quadriceps muscle strength of the operated limb did not. One hundred twenty-five participants returned for the 2-year followup. The remaining 30 participants either failed to return for the 2-year follow-up or had undergone TKA less than 2 years earlier. Similar to the 1-year results, the quadriceps muscle strength of the nonoperated limb significantly improved the ability of the model to predict the TUG and SCT times at 2 years after TKA, even when the other variables were accounted for (Pⱕ.011) (Tabs. 2 and 3). Age also significantly added to the predictive ability of the model for the TUG and SCT times, whereas the BMI, KOS-Pain, knee flexion ROM, and quadriceps muscle strength of the operated limb did not. The trends were the same as those at 1 year, with a stronger quadriceps muscle and a younger age predicting January 2010

Early Measures After Unilateral Total Knee Arthroplasty Table 2. Timed “Up & Go” Test Results Modela

Year 1

2

R

R2

R2 Change

F Change

Significance of F Changeb

TUG

.587

.345

.345

80.581

<.001

TUG ⫹ age

.657

.432

.087

23.264

<.001

TUG ⫹ age ⫹ BMI

.663

.440

.008

2.126

.147

TUG ⫹ age ⫹ BMI ⫹ KOS-Pain

.664

.441

.001

0.278

.599

TUG ⫹ age ⫹ BMI ⫹ KOS-Pain ⫹ ROM

.671

.451

.010

2.720

.101

TUG ⫹ age ⫹ BMI ⫹ KOS-Pain ⫹ ROM ⫹ op quad muscle strength

.672

.451

.000

0.065

.799

TUG ⫹ age ⫹ BMI ⫹ KOS-Pain ⫹ ROM ⫹ op quad muscle strength ⫹ nonop quad muscle strength

.704

.495

.044

12.891

<.001

TUG

.596

.355

.355

64.979

<.001

TUG ⫹ age

.633

.401

.046

8.974

.003

TUG ⫹ age ⫹ BMI

.645

.416

.015

3.061

.083

TUG ⫹ age ⫹ BMI ⫹ KOS-Pain

.648

.419

.003

0.561

.456

TUG ⫹ age ⫹ BMI ⫹ KOS-Pain ⫹ ROM

.650

.423

.004

0.735

.393

TUG ⫹ age ⫹ BMI ⫹ KOS-Pain ⫹ ROM ⫹ op quad muscle strength

.654

.428

.005

1.018

.315

TUG ⫹ age ⫹ BMI ⫹ KOS-Pain ⫹ ROM ⫹ op quad muscle strength ⫹ nonop quad muscle strength

.678

.460

.032

6.671

.011

a TUG⫽Timed “Up & Go” Test, BMI⫽body mass index, KOS-Pain⫽pain subset of the Knee Outcome Survey, ROM⫽range of motion, op quad⫽operated quadriceps, nonop quad⫽nonoperated quadriceps. b Values in bold type were significant at P⬍.05.

Table 3. Stair-Climbing Task Results Modela

Year 1

2

R

R2

R2 Change

F Change

Significance of F Changeb

SCT

.656

.430

.430

115.510

<.001

SCT ⫹ age

.694

.481

.051

15.008

<.001

SCT ⫹ age ⫹ BMI

.704

.495

.014

4.128

.044

SCT ⫹ age ⫹ BMI ⫹ KOS-Pain

.707

.500

.004

1.327

.251

SCT ⫹ age ⫹ BMI ⫹ KOS-Pain ⫹ ROM

.721

.520

.021

6.405

.012

SCT ⫹ age ⫹ BMI ⫹ KOS-Pain ⫹ ROM ⫹ op quad muscle strength

.721

.520

.000

0.000

.996

SCT ⫹ age ⫹ BMI ⫹ KOS-Pain ⫹ ROM ⫹ op quad muscle strength ⫹ nonop quad muscle strength

.758

.574

.054

18.728

<.001

SCT

.647

.419

.419

85.167

<.001

SCT ⫹ age

.675

.455

.036

7.711

.006

SCT ⫹ age ⫹ BMI

.685

.470

.014

3.162

.078

SCT ⫹ age ⫹ BMI ⫹ KOS-Pain

.688

.474

.004

0.928

.337

SCT ⫹ age ⫹ BMI ⫹ KOS-Pain ⫹ ROM

.697

.485

.012

2.556

.113

SCT ⫹ age ⫹ BMI ⫹ KOS-Pain ⫹ ROM ⫹ op quad muscle strength

.699

.488

.003

0.650

.422

SCT ⫹ age ⫹ BMI ⫹ KOS-Pain ⫹ ROM ⫹ op quad muscle strength ⫹ nonop quad muscle strength

.743

.552

.064

15.888

<.001

a SCT⫽stair-climbing task, BMI⫽body mass index, KOS-Pain⫽pain subset of the Knee Outcome Survey, ROM⫽range of motion, op quad⫽operated quadriceps, nonop quad⫽nonoperated quadriceps. b Values in bold type were significant at P⬍.05.

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Early Measures After Unilateral Total Knee Arthroplasty Table 4. Knee Outcome Survey Results R

R2

R2 Change

F Change

Significance of F Changeb

KOS-ADLS

.315

.099

.099

15.924

<.001

KOS-ADLS ⫹ age

.316

.100

.001

0.180

.672

Modela

Year 1

2

KOS-ADLS ⫹ age ⫹ BMI

.363

.132

.032

5.248

.023

KOS-ADLS ⫹ age ⫹ BMI ⫹ KOS-Pain

.377

.142

.010

1.655

.200

KOS-ADLS ⫹ age ⫹ BMI ⫹ KOS-Pain ⫹ ROM

.377

.142

.001

0.087

.768

KOS-ADLS ⫹ age ⫹ BMI ⫹ KOS-Pain ⫹ ROM ⫹ op quad muscle strength

.397

.158

.015

2.526

.114

KOS-ADLS ⫹ age ⫹ BMI ⫹ KOS-Pain ⫹ ROM ⫹ op quad muscle strength ⫹ nonop quad muscle strength

.440

.194

.036

6.230

.014

KOS-ADLS

.283

.080

.080

10.381

.002

KOS-ADLS ⫹ age

.289

.083

.003

0.404

.526

KOS-ADLS ⫹ age ⫹ BMI

.380

.144

.061

8.327

.005

KOS-ADLS ⫹ age ⫹ BMI ⫹ KOS-Pain

.394

.155

.011

1.528

.219

KOS-ADLS ⫹ age ⫹ BMI ⫹ KOS-Pain ⫹ ROM

.399

.159

.004

0.522

.472

KOS-ADLS ⫹ age ⫹ BMI ⫹ KOS-Pain ⫹ ROM ⫹ op quad muscle strength

.399

.159

.000

0.013

.909

KOS-ADLS ⫹ age ⫹ BMI ⫹ KOS-Pain ⫹ ROM ⫹ op quad muscle strength ⫹ nonop quad muscle strength

.409

.167

.008

1.100

.296

a KOS-DLS⫽activities of daily living subset of the Knee Outcome Survey, BMI⫽body mass index, KOS-Pain⫽pain subset of the Knee Outcome Survey, ROM⫽range of motion, op quad⫽operated quadriceps, nonop quad⫽nonoperated quadriceps. b Values in bold type were significant at P⬍.05.

better functional outcomes at 2 years (Fig. 3). Similar to the 1-year results, BMI was the strongest predictor of the KOS-ADLS score at 2 years after TKA (P⫽.005) (Tab. 4); a lower BMI was related to a higher KOS-ADLS score at 2 years. The KOS-Pain and strength of the involved limb did not contribute significantly to any of the models. The R2 values for the TUG and SCT were more than twice the R2 values for the KOS-ADLS at 1 and 2 years (Tabs. 2, 3, and 4).

Discussion The participants showed significant and clinically meaningful improvements in the first year after TKA. The recovery of function appeared to be nearly complete by this time because no improvements were seen between the 1- and 2-year time points. 48

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As hypothesized, postoperative variables predicted scores on the TUG, SCT, and KOS-ADLS. A stronger quadriceps muscle on the nonoperated side and a younger age were the main variables related to improved 1and 2-year outcomes for the TUG and SCT. A lower BMI was important for maximizing self-reported measures of function at 1 and 2 years. Interestingly, these variables are not typically addressed during postoperative physical therapy. As expected, the participants in the present study showed dramatic increases in function at 1 year after TKA. This finding supports the general consensus that TKA is an effective intervention for restoring quantitative and self-perceived functional abilities.2,17,20,21 No improvements in the TUG, SCT, or KOS scores were seen between 1 and 2 years, suggest-

Number 1

ing that the majority of functional recovery occurs within the first year after surgery. Other investigators examining multiyear outcomes have reported similar results.4,22 The early postoperative variables considered in the present study were better at predicting the scores of the quantitative functional measures at 1 and 2 years than at predicting the KOS-ADLS scores. The TUG and SCT had much higher R2 values than the KOS-ADLS at 1 and 2 years after TKA (Tabs. 2, 3, and 4). This inconsistency may be explained by the discrepancy between functional measures and self-reported measures of function.23,24 Quadriceps muscle strength and knee ROM are quantitative functional measures. An older age and a higher BMI also affected clinical measures and resulted in reduced strength, a lower freely choJanuary 2010

Early Measures After Unilateral Total Knee Arthroplasty sen walking speed, and impaired stair-climbing ability.25,26 Because most of the predictor variables are, or affect, quantitative measures, their predictive ability may have been oriented toward performancebased outcome measures rather than self-perceived functional ability. Many investigators have examined preoperative predictors of postoperative status in people who have undergone TKA; they concluded that greater preoperative knee flexion ROM and quadriceps muscle strength on the operated side or a higher level of self-perceived functional ability predicted improved outcomes.4,5,27,28 These variables often are addressed during physical therapy. The postoperative predictors noted in the present study were impairments that might not or cannot be addressed during physical therapy. Maximizing patients’ outcomes in minimal time is often the emphasis of physical therapy interventions. For this reason, clinicians focus on the most obvious functional deficits, such as knee ROM and strength of the operated limb. People who have undergone TKA show marked improvements in the quadriceps muscle strength of the operated limb after a course of physical therapy.17 However, in the present study, the strength of the nonoperated limb accounted for most of the variability in functional outcomes, with reduced strength predicting poorer outcomes. Rehabilitation regimens should also focus on improving the strength of the nonoperated limb because quadriceps muscle strength is strongly correlated with functional ability.29 If left untreated, weakness in the nonoperated limb may continue to impede functional ability and result in poorer 1- and 2-year functional outcomes. Although the inclusion of these variables may be vital to maximizing outcomes, knee flexion ROM and

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Figure 2. Significant relationship between the quadriceps muscle strength of the nonoperated limb at initial evaluation and quantitative functional measures at 1 year. BMI⫽body mass index, SCT⫽stair-climbing task, TUG⫽Timed “Up & Go” Test.

strength on the involved side should not be overlooked. It also is possible that the quadriceps muscle strength of the nonoperated limb represents disease progression on the nonoperated side.30 –32 People undergoing unilateral TKA often have bilateral joint disease.33 The more involved joint is typically replaced first, with the hope that improved functional ability will reduce the symptoms on the nonoperated side. However, the incidence of replacement of the cognate joint is relatively high, at 37%, by 10 years.33 It has been shown that the status of the nonoperated limb at 3 years after surgery best predicts the functional ability of the operated limb at that time point.34 Those data support our finding that reduced quadriceps muscle strength of the nonoperated limb predicted poorer long-term functional outcomes. If we can assume

that quadriceps muscle weakness is related to disease progression, then people with more advanced OA in the nonoperated limb after TKA may expect poorer outcomes at 1 and 2 years after TKA. Although age is a variable that cannot be addressed by rehabilitation, age-related impairments, such as poor balance and strength, can be treated with rehabilitation.35,36 In addition to treating the deficits imposed by the surgery, physical therapists should focus on improving balance and generalized lowerextremity strength in older participants. Although further research is warranted, a rehabilitation regimen that incorporates training to treat age-related functional deficits may lead to improved functional outcomes. The older participants in the present study may have had a greater risk for poorer outcomes secondary

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Early Measures After Unilateral Total Knee Arthroplasty participants tended to have shorter TUG and SCT times. Although some participants with a quadriceps muscle strength of less than 30 N/BMI did have quick TUG and SCT times, others did not. This finding was clinically meaningful and suggested that if the quadriceps muscle strength of the nonoperated limb at the initial evaluation was greater than 30 N/BMI, then participants would likely achieve nearly normal TUG and SCT scores at 1 and 2 years after surgery. A quadriceps muscle strength of less than 30 N/BMI might not result in similar satisfactory outcomes.

Figure 3. Significant relationship between the quadriceps muscle strength of the nonoperated limb at initial evaluation and quantitative functional measures at 2 years. BMI⫽body mass index, SCT⫽stair-climbing task, TUG⫽Timed “Up & Go” Test.

to delayed recovery of muscle function after surgery; this notion provides support to the suggestion that undergoing TKA earlier in the course of OA or earlier in a patient’s life may improve functional outcomes.3,37 A higher BMI also was found to predict poorer outcomes, particularly those described by self-reported measures. This interesting finding suggests that having a high body mass or being overweight may skew how people view their functional capacity, even if there are no quantitative changes in function. Providing patients with access to nutrition and weight loss services is essential to reducing body mass after TKA because TKA alone does not facilitate weight loss.38 Clinicians and patients should treat high body mass as a separate concern that will not be resolved merely through improved 50

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functional ability after TKA. Rehabilitation programs should include a cardiovascular component for patients with a high body mass after surgery. Although the TUG and SCT are measures that validly and reliably quantify functional ability, they do have a ceiling effect. However, these tests are still sensitive enough to measure differences between people with and without knee pathology39 (Figs. 2 and 3). The strength of the relationship between the quadriceps muscle strength of the nonoperated limb at the initial evaluation and the functional measures varied depending on the quadriceps muscle strength. When the quadriceps muscle strength was less than 30 N/BMI, there was much more variability in the data, whereas above 30 N/BMI, the relationship was less variable and

Number 1

Despite the ceiling effect and the fact that the TUG and SCT scores reached a plateau within 1 year after surgery,29 we chose to include these measures to capture dysfunction that might have been associated with disease progression in the nonoperated limb. Functional ability, as determined with outcome measures, declines with time since surgery,40 possibly because of complications related to advanced age or deterioration of the cognate joint. We wanted to use a consistent set of measurement variables throughout the study, and although we did not expect to see much further improvement after 1 year, we wanted to ensure that we would be able to identify functional deficits if they occurred. The present study had a few limitations. First, the KOS-ADLS has been used to extensively evaluate people with knee pathology, although the instrument has not yet been validated for people with TKA. However, it is not likely that this instrument would be any less valid than similar measures of functional ability. Second, radiographs were not evaluated for disease progression in the contralateral limb, although correlations of radiographic disease progression and functional ability are weak.31,41 Finally, the determination January 2010

Early Measures After Unilateral Total Knee Arthroplasty of 30 N/BMI of quadriceps muscle strength as a cutoff for success with the TUG and SCT was based on a qualitative analysis of the data, and this value did not represent a statistical cutoff value. Traditional statistical methods of determining cutoff values rely on a dichotomous variable that represents success or failure. With the data and methodology used in the present study, no such dichotomous outcome variables were defined. Future investigations should be performed to evaluate disease progression on the contralateral side in relation to long-term functional ability. Additionally, future studies should be done to determine clinically and statistically meaningful cutoff values for variables that predict success or failure after TKA, such as quadriceps muscle strength. Because a portion of the variability was not explained by the variables selected in the present study, future work also should incorporate different predictor variables that might account for a portion of the unexplained variability. Of the variables selected, the strength of the nonoperated limb, age, and BMI explained most of the variability in functional outcomes at 1 and 2 years after TKA. The weakness of the nonoperated limb, older age, and higher BMI at the initial evaluation predicted poorer functional outcomes. Treatment regimens after TKA should focus on improving the strength of the nonoperated limb in addition to treating the deficits imposed by the surgery. People with more advanced disease progression on the nonoperated side may also experience poorer functional outcomes after TKA. Future research should focus on evaluating the effects of tailored rehabilitation protocols that incorporate bilateral quadriceps muscle strengthening, cardiovascular and weight loss regimens, and exercises

January 2010

to reduce age-related impairments on long-term functional outcomes. Both authors provided concept/idea/research design, writing, and data analysis. Dr Snyder-Mackler provided project management, fund procurement, and facilities/ equipment. This study was approved by the Human Subjects Review Board of the University of Delaware. An abstract based on the data was presented at the 2009 World Congress of the Osteoarthritis Research Society International; September 10 –13, 2009; Montreal, Quebec, Canada. Funding for the study was provided by National Institutes of Health grants R01HD041055 (NICHD) and P20RR016458 (NCRR). This research also was funded by the National Center for Research Resources of the National Institutes of Health. This article was received March 17, 2009, and was accepted August 13, 2009. DOI: 10.2522/ptj.20090089

References 1 Cushnaghan J, Bennett J, Reading I, et al. Long-term outcome following total knee arthroplasty: a controlled longitudinal study. Ann Rheum Dis. 2009;68:642– 647. 2 Hawker G, Wright J, Coyte P, et al. Healthrelated quality of life after knee replacement. J Bone Joint Surg Am. 1998;80:163–173. 3 Fortin PR, Penrod JR, Clarke AE, et al. Timing of total joint replacement affects clinical outcomes among patients with osteoarthritis of the hip or knee. Arthritis Rheum. 2002;46:3327–3330. 4 Lingard EA, Katz JN, Wright EA, Sledge CB. Predicting the outcome of total knee arthroplasty. J Bone Joint Surg Am. 2004; 86:2179 –2186. 5 Mizner RL, Petterson SC, Stevens JE, et al. Preoperative quadriceps strength predicts functional ability one year after total knee arthroplasty. J Rheumatol. 2005;32:1533– 1539. 6 Jones CA, Voaklander DC, Suarez-Alma ME. Determinants of function after total knee arthroplasty. Phys Ther. 2003;83: 696 –706. 7 Parent E, Moffet H. Preoperative predictors of locomotor ability two months after total knee arthroplasty for severe osteoarthritis. Arthritis Rheum. 2003;49:36 –50. 8 Kreder HJ, Grosso P, Williams JI, et al. Provider volume and other predictors of outcome after total knee arthroplasty: a population study in Ontario. Can J Surg. 2003; 46:15–22.

9 Vincent HK, Vincent KR. Obesity and inpatient rehabilitation outcomes following knee arthroplasty: a multicenter study. Obesity (Silver Spring). 2008;16:130 – 136. 10 van den Akker-Scheek I, Stevens M, Groothoff JW, et al. Preoperative or postoperative self-efficacy: which is a better predictor of outcome after total hip or knee arthroplasty? Patient Educ Couns. 2007;66:92–99. 11 Silva M, Shepherd EF, Jackson WO, et al. Knee strength after total knee arthroplasty. J Arthroplasty. 2003;18:605– 611. 12 Cibere J, Bellamy N, Thorne A, et al. Reliability of the knee examination in osteoarthritis: effect of standardization. Arthritis Rheum. 2004;50:458 – 468. 13 Maly MR, Costigan PA, Olney SJ. Contribution of psychosocial and mechanical variables to physical performance measures in knee osteoarthritis. Phys Ther. 2005;85: 1318 –1328. 14 Ouellet D, Moffet H. Locomotor deficits before and two months after knee arthroplasty. Arthritis Rheum. 2002;47:484 – 493. 15 Kennedy DM, Stratford PW, Wessel J, et al. Assessing stability and change of four performance measures: a longitudinal study evaluating outcome following total hip and knee arthroplasty. BMC Musculoskelet Disord. 2005;6:3. 16 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. 17 Yoshida Y, Mizner RL, Ramsey DK, SnyderMackler L. Examining outcomes from total knee arthroplasty and the relationship between quadriceps strength and knee function over time. Clin Biomech. 2008;23: 320 –328. 18 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. 19 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. 20 National Institutes of Health. NIH Consensus Statement on total knee replacement. NIH Consens State Sci Statements. 2003; 20:1–34. 21 Fitzgerald JD, Orav EJ, Lee TH, et al. Patient quality of life during the 12 months following joint replacement surgery. Arthritis Rheum. 2004;51:100 –109. 22 Ritter MA, Wing JT, Berend ME, et al. The clinical effect of gender on outcome of total knee arthroplasty. J Arthroplasty. 2008;23:331–336. 23 Hidding A, van Santen M, De Klerk E, et al. Comparison between self-report measures and clinical observations of functional disability in ankylosing spondylitis, rheumatoid arthritis and fibromyalgia. J Rheumatol. 1994;21:818 – 823. 24 Wittink H, Rogers W, Sukiennik A, Carr DB. Physical functioning: self-report and performance measures are related but distinct. Spine. 2003;28:2407–2413.

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Early Measures After Unilateral Total Knee Arthroplasty 25 Al-Abdulwahab SS. The effects of aging on muscle strength and functional ability of healthy Saudi Arabian males. Ann Saudi Med. 1999;19:211–215. 26 Menz HB, Lord SR, Fitzpatrick RC. Agerelated differences in walking stability. Age Ageing. 2003;32:137–142. 27 Gandhi R, de Beer J, Leone J, et al. Predictive risk factors for stiff knees in total knee arthroplasty. J Arthroplasty. 2006;21: 46 –52. 28 Fortin PR, Clarke AE, Joseph L, et al. Outcomes of total hip and knee replacement: preoperative functional status predicts outcomes at six months after surgery. Arthritis Rheum. 1999;42:1722–1728. 29 Mizner RL, Petterson SC, Snyder-Mackler L. Quadriceps strength and the time course of functional recovery after total knee arthroplasty. J Orthop Sports Phys Ther. 2005;35:424 – 436. 30 Liikavainio T, Lyytinen T, Tyrvainen E, et al. Physical function and properties of quadriceps femoris muscle in men with knee osteoarthritis. Arch Phys Med Rehabil. 2008;89:2185–2194.

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31 McAlindon TE, Cooper C, Kirwan JR, Dieppe PA. Determinants of disability in osteoarthritis of the knee. Ann Rheum Dis. 1993;52:258 –262. 32 Slemenda C, Brandt KD, Heilman DK, et al. Quadriceps weakness and osteoarthritis of the knee. Ann Intern Med. 1997; 127:97–104. 33 Ritter MA, Carr KD, Keating EM, Faris PM. Long-term outcomes of contralateral knees after unilateral total knee arthroplasty for osteoarthritis. J Arthroplasty. 1994;9:347–349. 34 Farquhar S, Snyder-Mackler L. The Chitranjan Ranawat Award: the nonoperated knee predicts function 3 years after unilateral total knee arthroplasty [published online ahead of print May 27, 2009]. Clin Orthop Relat Res. doi:10.1007/s11999-0090892-9. 35 Taaffe DR, Duret C, Wheeler S, Marcus R. Once-weekly resistance exercise improves muscle strength and neuromuscular performance in older adults. J Am Geriatr Soc. 1999;47:1208 –1214. 36 Nichols JF, Hitzelberger LM, Sherman J, Patterson P. Effects of resistance training on muscular strength and functional abilities of community-dwelling older adults. J Aging Phys Act. 1995;3:238 –250.

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37 Tanaka T, Kariya Y, Hoshino Y. Histochemical study on the changes in muscle fibers in relation to the effects of aging on recovery from muscular atrophy caused by disuse in rats. J Orthop Sci. 2004;9: 76 – 85. 38 Donovan J, Dingwall I, McChesney S. Weight change 1 year following total knee or hip arthroplasty. ANZ J Surg. 2006;76: 222–225. 39 Petterson SC, Raisis L, Bodenstab A, Snyder-Mackler L. Disease-specific gender differences among total knee arthroplasty candidates. J Bone Joint Surg Am. 2007; 89:2327–2333. 40 Benjamin J, Johnson R, Porter S. Knee scores change with length of follow-up after total knee arthroplasty. J Arthroplasty. 2003;18:867– 871. 41 Creamer P, Lethbridge-Cejku M, Hochberg MC. Factors associated with functional impairment in symptomatic knee osteoarthritis. Rheumatology (Oxford). 2000;39: 490 – 496.

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Early Measures After Unilateral Total Knee Arthroplasty Appendix. Physical Therapy Treatment Regimen–Aggressive Strengthening Protocol

All exercises were incorporated into treatment in the clinic and were advanced as described below. Direct physical therapist guidance and assistance were provided for all exercises until participants became self-sufficient and completed the exercises with proper form. Participants also performed stretching and strengthening exercises at home on days on which they did not receive physical therapy in the clinic. I. Warm-up exercise a. Five to 10 minutes of riding an exercise bicycle II. Range of motion (for participants with less than 120 degrees of knee flexion or with knee flexion contracture) a. Patellar mobilization (if indicated) 1. Three sets of 10 repetitions with knee in full extension 2. Active superior patellar glides b. Incision mobility 1. Soft-tissue mobilization of the entire length of the incision 2. Greater emphasis on the distal third c. Knee extension stretch 1. Manual overpressure on the knee d. Standing knee flexion stretch 1. The participant stands at the bottom of a flight of stairs with the foot of the operated side placed on the third step. While holding the rail, the participant leans forward, sits down to bend the knee to the end range, and holds the position for 30 seconds. The participant repeats the exercise 3 times. 2. Supine active assisted wall slides e. Manual stretching of hamstring muscle, quadriceps muscle, gastrocnemius muscle, and joint capsule as needed III. Strengthening a. Weight should be 70% of participant’s 1-repetition maximum b. Three sets of 8 repetitions for all exercises c. One to 2 minutes of rest between sets d. Exercises are advanced when the participant can complete the exercises and maintain control through 3 sets of 8 repetitions e. Exercises (initial) 1. Straight leg raises (without quadriceps muscle lag) ● The participant lies supine with the hip and knee on the nonoperated side flexed and the foot placed flat on an exercise table. The participant first isometrically contracts the quadriceps muscle and then lifts the leg to about 45 degrees of hip flexion while keeping the knee extended. The participant lowers the leg slowly to the starting position. 2. Hip abduction (side-lying position) ● The participant is in the side-lying position on the nonoperated side. The participant flexes the bottom leg for balance and then lifts the top leg until 45 degrees of hip abduction is reached. The participant lowers the abducted leg slowly to the starting position. The participant should not externally rotate the hip during abduction. 3. Standing terminal knee extension with resistance band ● The participant stands with a rubber band resisting knee extension. The participant flexes the knee to 45 degrees and straightens the leg against the resistance to full extension. 4. Lateral step-ups ● The exercise begins with a 5.08-cm (2-in) block and advances to a 10.16-cm (4-in) block and then a 15.24-cm (6-in) block. The participant should step to the side with slow, controlled movements during ascent and descent. 5. Hamstring muscle curls ● Standing with hands on a table or counter for support, the participant flexes the knee maximally. (Continued)

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Early Measures After Unilateral Total Knee Arthroplasty Appendix. Continued

f. Exercises (additional) 1. Seated knee extension (90°–0°) ● The participant sits on a knee exercise machine with the knee bent to 90 degrees and the tibial pad placed at a 2-finger width proximal to the lateral malleolus. The participant extends the knee to full extension and then slowly lowers it to the starting position. 2. Terminal knee extension (45°–0°) ● With the participant in the long sitting position, a bolster is placed under the operated knee to keep it in a flexed position (45°). The participant extends the knee to full extension and then slowly lowers it to the starting position. 3. Heel-raises ● In the standing position, the participant raises the heel as far as possible and then slowly lowers it to the starting position. Bilateral heel-raises are used if the participant is unable to perform 15 repetitions of the unilateral heel-raise. Unilateral heel-raises are used if the participant is able to perform more than 15 repetitions of the unilateral heel-raise. A weighted backpack is used to increase the challenge once the participant is able to perform 3 sets of 10 repetitions of unilateral heel-raises. 4. Wall slides ● Standing with the back against the wall, the participant flexes the hips and knees, slides the back down until reaching 45 degrees of knee flexion, and then slides the back up to return to the starting position. The exercise is advanced by increasing the degree of knee flexion up to 90 degrees. 5. Front lunges ● Standing with hands on hips, the participant puts the involved leg forward and lunges until the forward knee reaches 45 to 90 degrees, depending on the level of progression. IV. Quadriceps femoris neuromuscular electrical stimulation a. The participant is seated on a Kin-Com dynamometer with the involved knee flexed to 60 degrees, and a portable stimulator (Empi 300pv)a is used for stimulation. The participant performs 1 submaximal warm-up and then 2 maximum voluntary isometric contractions (MVICs). The average of the 2 MVICs is considered to be the participant’s daily MVIC. b. Parameters 1. On time: 12 seconds; off time: 50 seconds 2. Symmetrical waveform at 50 pulses per second 3. Two-second ramp time 4. Pulse width of 400 microseconds 5. Amplitude to maximum tolerable (at least 30% of the MVIC) c. Ten contractions per session d. Three sessions per week until the quadriceps muscle MVIC is 80% of that of the uninvolved limb V. Management of pain and swelling a. Ice and elevation after exercises b. Compression as needed VI. Functional retraining a. Gait training with emphasis on heel-strike and push-off at toe-off and on normal knee joint excursions b. Stair ascending and descending 1. Step-over-step pattern 2. Training should be performed when the unilateral stance is steady and not painful a

Empi, 599 Cardigan Rd, St Paul, MN 55126-4099.

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Research Report Novel Patterns of Functional Electrical Stimulation Have an Immediate Effect on Dorsiflexor Muscle Function During Gait for People Poststroke Trisha M. Kesar, Ramu Perumal, Angela Jancosko, Darcy S. Reisman, Katherine S. Rudolph, Jill S. Higginson, Stuart A. Binder-Macleod

Background. Foot drop is a common gait impairment after stroke. Functional electrical stimulation (FES) of the ankle dorsiflexor muscles during the swing phase of gait can help correct foot drop. Compared with constant-frequency trains (CFTs), which typically are used during FES, novel stimulation patterns called variablefrequency trains (VFTs) have been shown to enhance isometric and nonisometric muscle performance. However, VFTs have never been used for FES during gait. Objective. The purpose of this study was to compare knee and ankle kinematics during the swing phase of gait when FES was delivered to the ankle dorsiflexor muscles using VFTs versus CFTs.

Design. A repeated-measures design was used in this study. Participants. Thirteen individuals with hemiparesis following stroke (9 men, 4 women; age⫽46 –72 years) participated in the study.

Methods. Participants completed 20- to 40-second bouts of walking at their self-selected walking speeds. Three walking conditions were compared: walking without FES, walking with dorsiflexor muscle FES using CFTs, and walking with dorsiflexor FES using VFTs.

Results. Functional electrical stimulation using both CFTs and VFTs improved ankle dorsiflexion angles during the swing phase of gait compared with walking without FES (X⫾SE⫽⫺2.9°⫾1.2°). Greater ankle dorsiflexion in the swing phase was generated during walking with FES using VFTs (X⫾SE⫽2.1°⫾1.5°) versus CFTs (X⫾SE⫽0.3⫾1.3°). Surprisingly, dorsiflexor FES resulted in reduced knee flexion during the swing phase and reduced ankle plantar flexion at toe-off.

Conclusions. The findings suggest that novel FES systems capable of delivering VFTs during gait can produce enhanced correction of foot drop compared with traditional FES systems that deliver CFTs. The results also suggest that the timing of delivery of FES during gait is critical and merits further investigation.

T.M. Kesar, PT, PhD, is PostDoctoral Researcher, Department of Physical Therapy, University of Delaware, Newark, Delaware. She was a doctoral student in the Biomechanics and Movement Science Program, University of Delaware, during the completion of this study. R. Perumal, PhD, is Research Scientist, Department of Physical Therapy, University of Delaware. A. Jancosko, PT, NCS, is Physical Therapist, Magee Rehabilitation Hospital, Philadelphia, Pennsylvania. D.S. Reisman, PT, PhD, is Assistant Professor, Department of Physical Therapy, University of Delaware. K.S. Rudolph, PT, PhD, is Associate Professor, Department of Physical Therapy, University of Delaware. J.S. Higginson, PhD, is Assistant Professor, Department of Mechanical Engineering, University of Delaware. S.A. Binder-Macleod, PT, PhD, FAPTA, is Edward L. Ratledge Professor and Chair, Department of Physical Therapy, University of Delaware, Newark, DE 19716 (USA). Address all correspondence to Dr Binder-Macleod at: [email protected]. [Kesar KM, Perumal R, Jancosko A, et al. Novel patterns of functional electrical stimulation have an immediate effect on dorsiflexor muscle function during gait for people poststroke. Phys Ther. 2010; 90:55– 66.] © 2010 American Physical Therapy Association

Post a Rapid Response or find The Bottom Line: www.ptjournal.org January 2010

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Effects of Dorsiflexor Muscle Functional Electrical Stimulation on Poststroke Gait

S

troke is a leading cause of longterm adult disability.1 Regaining walking function is one of the primary concerns for individuals who experience stroke.2 Even after rehabilitation, residual gait deficits are prevalent in individuals with stroke.2 Foot drop is a common poststroke gait impairment estimated to affect 20% of survivors of stroke.3 Foot drop is caused by total or partial paresis of ankle dorsiflexor muscles,4 makes ground clearance difficult during swing, and can lead to inefficient gait compensations such as circumduction and hip hiking (increased hip abduction in the unaffected limb during stance, with simultaneous elevation of the affected side of the pelvis during swing).5,6 Residual gait deficits such as foot drop contribute to increased energy expenditure during gait, decreased endurance, and an increased incidence of falls.2,5– 8 Ankle-foot orthoses (AFOs) are widely prescribed for the management of foot drop.9,10 Functional electrical stimulation (FES) is another intervention that is used to deliver electrical stimulation to the ankle dorsiflexor muscles during the swing phase of gait to correct foot drop.11–14 In contrast to AFOs, FES promotes active muscle contractions, can help improve muscle strength (force-generating capacity),15–18 prevents disuse atrophy,19 –21 reduces muscle tone (velocitydependent resistance to stretch) and spasms,22 produces a more energyefficient use of proximal limb muscles,23 and aids in motor relearning.24

Available With This Article at ptjournal.apta.org • Audio Abstracts Podcast This article was published ahead of print on November 19, 2009, at ptjournal.apta.org.

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Figure 1. (A) Example of the ankle angle, footswitch, and vertical ground reaction force (GRF) data from the paretic lower extremity of one representative participant. Data shown are for one complete gait cycle (ie, first initial contact [IC] to toe-off [TO] to second IC for the same leg, as determined using the vertical GRFs). Initial contact and toe-off, as determined by the footswitches, are depicted by FSwIC and FSwTO. Dorsiflexor stimulation was delivered during the swing phase of the paretic limb (ie, from FSwTO to FswIC). (B) A schematic depicting the 2 types of stimulation train patterns used for functional electrical stimulation in this study: constant-frequency trains (CFTs) and variable-frequency trains (VFTs). The CFTs consisted of single pulses (300-microsecond pulse duration) separated by 33-millisecond interpulse intervals. The VFTs consisted of a 200-Hz high-frequency burst at the start of a CFT with 33-millisecond interpulse intervals.

Functional electrical stimulation also has been shown to reduce the energy cost of walking poststroke.17 Although FES offers many advantages compared with AFOs, it has been well documented that stimulation parameters traditionally used during FES can contribute to limitations such as imprecise control of Number 1

force and rapid muscle fatigue and prevent FES from gaining widespread clinical application.25–30 Stimulation frequency (number of pulses per second) and intensity (amplitude or duration of individual pulses) are the 2 primary parameters that are modulated to control movements during FES. The stimulation pattern, or the arrangement of pulses within January 2010

Effects of Dorsiflexor Muscle Functional Electrical Stimulation on Poststroke Gait a stimulation train, is another parameter that can be varied during FES27,31 (Fig. 1). However, typically, FES applications use only one type of stimulation pattern: stimulation trains consisting of stimulation pulses separated by constant interpulse intervals (constant-frequency trains [CFTs]).32,33 Our laboratory27,28,31,34 and others35–37 have shown that novel stimulation patterns known as variable-frequency trains (VFTs) have several advantages compared with traditional CFTs.31 Variable-frequency trains can take advantage of the catchlike property of human muscles.38 The catchlike property of skeletal muscle, first discovered in 1970 in mammalian motor units, is the force augmentation produced when an initial, brief, highfrequency burst of 2 to 4 pulses is included at the onset of a subtetanic low-frequency stimulation train.31,38 Variable-frequency trains have been shown to enhance isometric31,34 and nonisometric39 – 41 muscle performance in healthy human quadriceps femoris muscles compared with CFTs of similar frequency, especially when muscles are fatigued. Variablefrequency trains also have been shown to produce greater knee joint excursions using fewer pulses than CFTs in healthy human quadriceps femoris muscles.41 In addition to providing enhanced skeletal muscle performance, VFTs are a more physiologically based stimulation pattern compared with CFTs.42 Highfrequency doublets and triplets, such as those included at the onset of VFTs, have been reported to occur during animal and human muscle contractions.38,42 Interestingly, no previous study has systematically compared the effects of delivering VFTs versus CFTs during FES to correct foot drop in individuals poststroke. Global measures of walking performance, such as walking speed and January 2010

physiological cost, typically are used as outcome measures in FES studies.3,13,43– 45 Although important to justify inclusion of FES in rehabilitation protocols, such measures do not provide a detailed biomechanical understanding of how specific aspects of gait are modified during walking with FES. There is a dearth of data in the literature about the immediate effects of FES on gait kinematics, kinetics, and gait compensations.4,46 We posit that using instrumented gait analysis to study the immediate effects of FES on poststroke gait patterns can help develop better FES strategies to maximize the immediate (orthotic) effects of FES, which can enable the design of better neuroprostheses and potentially help to increase therapeutic benefits to patients. Thus, the purpose of this study was to compare the immediate effects of dorsiflexor FES using CFTs versus VFTs on gait kinematics in individuals who display gait impairments as a result of stroke.

sure outside of the range of 90/60 to 170/90 mm Hg, substantial cognitive deficits (Mini-Mental State Exam score⫽22), inability to communicate with the investigators (severe aphasia), orthopedic conditions or pain in lower limbs or spine, cerebellar involvement (eg, ataxic hemiparesis), neglect (as assessed with the Star Cancellation Test), hemianopia, and absence of sensation on the skin of the calf or leg of the paretic limb.

Method

Design Overview Electrical stimulation. Surface electrical stimulation electrodes (5.08 ⫻ 5.08 cm [2 ⫻2 in])* were attached to the ankle dorsiflexor muscles. A Grass S8800 stimulator† in combination with a Grass Model SIU8TB stimulus isolation unit was used to deliver electrical stimulation. With participants seated and the foot hanging freely in a plantar-flexed position, the stimulation amplitude was set by gradually increasing the amplitude of a 300-millisecond-long, 30-Hz train with a pulse duration of 300 microseconds until a neutral ankle joint position (0°), or at least to 5 degrees of plantar flexion in participants with deficits of range of motion, was achieved. Electrode placement was adjusted to minimize ankle

Setting and Participants Thirteen individuals (9 men, 4 women; age⫽46 –72 years) with poststroke hemiparesis participated in this study (Table). All participants had experienced a stroke involving cerebral cortical regions more than 6 months previously, were able to walk continuously for 5 minutes at their self-selected speed, and had sufficient passive ankle dorsiflexion range of motion to enable their paretic ankle joint to reach at least 5 degrees of plantar flexion with the knee flexed. Exclusion criteria included evidence of moderate to severe chronic white matter disease on magnetic resonance imaging, more than one previous stroke, congestive heart failure, peripheral artery disease with claudication, uncontrolled diabetes, shortness of breath without exertion, unstable angina, resting heart rate outside of the range of 40 to 100 bpm, resting blood pres-

Participants completed an initial clinical evaluation conducted by a licensed physical therapist comprising clinical tests for characterizing deficits following a stroke, including the lower-extremity portion of the Fugl-Meyer Assessment of Motor Recovery47 (Table). Each participant’s self-selected overground walking speeds was determined using the 6-meter walk test. All subjects signed informed consent forms approved by the Human Subjects Review Board of the University of Delaware.

* TENS Products Inc, PO Box 2089, Grand Lake, CO 80447. † Grass Technologies, Div of Astro-Med Inc, 600 E Greenwich Ave, Warwick, RI 02893.

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Effects of Dorsiflexor Muscle Functional Electrical Stimulation on Poststroke Gait Table. Participant Demographic and Clinical Informationa Participant No.

Sex

Age (y)

Side of Hemiparesis

Gait Speed (m/s)

Fugl-Meyer Score (Maximum Scoreⴝ34)

1

M

66

2.4

L

0.9

24

2

M

52

6.3

L

0.6

20

3

F

58

21.3

L

0.2

23

4

F

51

1.9

L

0.3

20

5

M

49

9.3

R

0.9

28

6

M

72

6.1

R

0.5

18

7

M

57

2.7

R

0.7

22

8

M

58

9.9

R

0.7

21

9

M

60

5.8

R

0.8

25

10

M

74

4.7

R

0.7

31

11

M

56

9.8

R

1.2

25

12

F

46

2.2

L

0.9

23

13

F

66

1.4

R

0.3

18

58.8

6.4

0.7

23

8.6

5.4

0.3

Average SD a

Time Since Stroke (y)

3.8

Data for participant 13 were not included in the results due to technical problems during data collection. M⫽male, F⫽female, L⫽left, R⫽right.

eversion and dorsiflexion.

inversion

during

Two compression-closing footswitches (25-mm diameter MA-153)‡ attached bilaterally to the soles of each shoe, one on the forefoot under the fifth metatarsal head and the other on the hindfoot under the lateral portion of the heel, were used to control the timing of FES during gait. Timing of FES during gait. A customized, real-time FES system (CompactRIO)§ consisting of a real-time controller (NI cRIO-9004),§ analog input module (NI 9210),§ and digital input/output module (NI9401)§ was used to deliver stimulation during gait.48 The FES system delivered FES to the paretic ankle dorsiflexor muscles during the swing phase of each gait cycle, as detected by the footswitches (ie, from the time when the forefoot footswitch was off the ‡ Motion Lab Systems Inc, 15045 Old Hammond Hwy, Baton Rouge, LA 70816. § National Instruments Inc, 11500 N Mopac Expwy, Austin, TX 78759.

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ground to the time when the hindfoot footswitch contacted the ground) (Fig. 1). For FES using CFTs, a 30-Hz constant-frequency train was delivered. For FES using VFTs, a highfrequency (200-Hz) 3-pulse burst was delivered followed by a lowerfrequency (30-Hz) CFT (Fig. 1B). All stimulation parameters for the VFTs and CFTs were identical except that the 200-Hz 3-pulse burst was included at the onset of the VFTs. Marker placement. Retroreflective markers (14-mm diameter) placed bilaterally over the iliac crests, greater trochanters, lateral and medial femoral condyles, lateral and medial malleoli, and fifth metatarsal heads were used to define the joint centers of the lower limb. Elastic bands (SuperWrap)㛳 were tightly wrapped around the bilateral thigh and shank segments. Four-marker clusters attached to rigid thermoplastic shells were affixed to the elastic 㛳

Fabrifoam, 900 Springdale Dr, Exton, PA 19341.

Number 1

wraps and used to track the bilateral thigh and shank segments. A 3-marker cluster on the sacrum and 3 additional markers on the shoe were used to track pelvis and foot movements, respectively. Gait analysis. During gait analysis, participants walked on a split-belt treadmill# instrumented with two 6-degree-of-freedom force platforms. Participants held on to a handrail during walking. All participants wore a harness that was attached to an overhead support for safety. No body weight was supported by the harness. Marker data were collected using an 8-camera motion analysis system (Vicon 5.2).** Video data were sampled at 100 Hz, and analog data (force platforms, footswitches, and stimulation channel) were sampled at 2,000 Hz.

# Advanced Mechanical Technology Inc, 176 Waltham St, Watertown, MA 02472-4800. ** Vicon, 14 Minus Business Park, West Way, Oxford, United Kingdom OX2 OJB.

January 2010

Effects of Dorsiflexor Muscle Functional Electrical Stimulation on Poststroke Gait The data presented are a subset of the data collected during one testing session. The complete testing session comprised ⬃18 trials, and each trial was 20 to 40 seconds in duration. Rest intervals of 5 to 10 minutes were provided between consecutive trials (Fig. 2). In this article, we report data for 3 walking trials or conditions: (1) walking without FES (noFES), (2) walking with dorsiflexor muscle FES using CFTs (FES-CFT), and (3) walking with dorsiflexor muscle FES using VFTs (FES-VFT). The noFES data presented in this article were collected during the beginning (1st trial), middle (8th trial), and end (17th trial) of the session (Fig. 2). Data for different types of walking trials with FES of the ankle muscles at 2 different gait speeds were collected either during the 2nd through 7th walking trials (first block) or the 9th through 15th walking trials (second block) (Fig. 2). Within any one trial, the gait speed and the stimulation condition were kept constant. The 2 FES conditions presented in this study (ie, FES-CFT and FES-VFT) were randomly distributed across the first and second blocks within the testing session. All 3 walking conditions presented in this study were tested at the participants’ self-selected overground walking speed, determined during a separate clinical testing session. Data Processing Marker trajectories and ground reaction force data were low-pass filtered (Butterworth fourth-order, phase lag) at 6 and 30 Hz, respectively, using commercial software (Visual 3D).†† Lower-limb kinematics were calculated using rigid-body analysis and Euler angles using Visual 3D software. Vertical GRFs were used to identify initial contact and toe-off for the gait data, using a force threshold ††

C-Motion Inc, 15819 Crabbs Branch Way #A, Rockville, MD 20855.

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Figure 2. Schematic showing the walking trials conducted as part of the experimental protocol. Each trial comprised 20 to 40 seconds of treadmill walking with a 5- to 10-minute rest provided between consecutive trials. The data for walking without functional electrical stimulation (noFES) used to compare with the data for walking with dorsiflexor muscle functional electrical stimulation using constant-frequency trains (FES-CFT) and walking with dorsiflexor muscle functional electrical stimulation using variable-frequency trains (FES-VFT) were obtained by averaging the noFES data obtained from the walking trials at the beginning, middle, and end of the session.

of 20 N. Strides were time normalized to 100% of the gait cycle and averaged across trials for each participant and walking condition. The noFES data were obtained by averaging the 3 noFES trials from the beginning, middle, and end of the session. For each of the 3 walking conditions, all outcome variables were computed using Visual 3D software for each stride and averaged across strides using a custom-written program.§

phase. Circumduction was defined as the maximum distance between the heel marker position during stance and the greatest lateral position of the heel marker during the subsequent swing phase.49,50 Based on an exploratory analysis of the data, we included ankle dorsiflexion angle at toe-off as a secondary outcome variable to capture the interesting and surprising decrease in ankle plantar-flexion angle observed at the stance-to-swing transition.

Outcome Variables The 2 primary outcome measures for the effectiveness of FES during gait were peak ankle dorsiflexion angle during swing and ankle dorsiflexion angle at initial contact. Three secondary outcome measures were computed: peak flexion of the paretic knee during the swing phase, circumduction, and dorsiflexion angle of the paretic ankle at toe-off. Circumduction refers to a compensatory strategy during the swing phase that involves hip abduction and lateral (external) rotation and often is accompanied by pelvic hiking on the paretic side during the swing

Data Analysis One-way analyses of variance (ANOVAs) for repeated measures were performed for each dependent variable to test for overall differences across the 3 walking conditions tested (noFES, FES-CFT, and FESVFT). Post hoc pair-wise comparisons were performed to detect differences between noFES versus FESCFT, noFES versus FES-VFT, and FESCFT versus FES-VFT conditions. Based on our directional hypotheses, we planned to perform one-tailed paired t tests for ankle angle during swing and ankle angle at initial contact. Two-tailed paired t tests were

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Effects of Dorsiflexor Muscle Functional Electrical Stimulation on Poststroke Gait W911NF-05-1-0097. Part of the funding came from the University of Delaware Dissertation Fellowship awarded to Dr Kesar.

Results Of the 13 participants tested in this study, one participant’s data (participant 13) were excluded from the analyses due to technical problems encountered during the testing session. Results are presented for the remaining 12 participants (Table). For each condition, data for each outcome variable represent the mean of the first 6 consecutive gait cycles for which accurate forceplate data could be analyzed.

Figure 3. Average (n⫽12) stride-by-stride values of the 2 primary outcome variables: (A) peak swing phase ankle angle and (B) ankle angle at initial contact for the 3 walking conditions tested (walking without functional electrical stimulation [noFES], walking with dorsiflexor muscle functional electrical stimulation using constant-frequency trains [FES-CFT], and walking with dorsiflexor muscle functional electrical stimulation using variable-frequency trains [FES-VFT]). Data shown are for the first 6 consecutive strides. Positive standard error bars are shown. Positive angles represent dorsiflexion. IC⫽initial contact.

planned for circumduction, peak swing phase knee flexion, and ankle angles at toe-off. In addition, we compared the peak ankle angles during swing and ankle angle at initial contact measured during the noFES walking condition at the beginning, middle, and end of the session using a one-way ANOVA for repeated measures to assess the presence of either muscle fatigue or potentiation. A decrease in ankle dorsiflexion angles during swing or initial contact would signify the presence of fatigue within the testing session. A post hoc 2-tailed pair-wise comparison was performed to check for differences between noFES data at the beginning versus the end of 60

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the session. The alpha level was set at .05. The Shapiro-Wilk test was used to test for normal distribution of data for each of the outcome variables. All statistical analyses were performed using SPSS version 16.0.‡‡ Role of the Funding Source This study was supported by National Institute of Nursing Research grant RO1 NR010786 awarded to Dr Binder-Macleod. This funding source did not bias the outcome of this investigation. Funding for the laboratory instrumentation was provided by NIH Shared Instrumentation grant S10 RR022396-01 and DOD grant ‡‡

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

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A qualitative analysis of stride-bystride data showed that FES using VFTs consistently produced greater ankle dorsiflexion during swing and at initial contact compared with FES using CFTs and that FES using CFTs produced greater ankle angles compared with noFES for each of the 6 gait strides included in the analyses (Fig. 3). The ensemble gait data for the 12 participants’ sagittal-plane ankle angles throughout the gait cycle showed that FES-CFT and FES-VFT shifted the ankle angle toward greater dorsiflexion during swing, at initial contact, and at toe-off (Fig. 4A). The descriptive statistics presented in the text are means⫾ standard errors. Primary Outcome Variables Peak ankle angle during swing. Without FES, participants walked with their paretic ankle joints in a slightly plantar-flexed position (ankle angle⫽⫺2.9°⫾1.2°) during swing (Figs. 4A and 5A). The repeated-measures ANOVA detected significant differences in swing phase ankle angles among the 3 walking conditions tested (F⫽14.73, Pⱕ.01). Dorsiflexor FES using either CFTs or VFTs produced significant improvements in ankle dorsiflexion during swing compared with noFES January 2010

Effects of Dorsiflexor Muscle Functional Electrical Stimulation on Poststroke Gait (both Pⱕ.01). Functional electrical stimulation using CFTs brought the paretic ankle joint to an approximately neutral position during swing (0.3°⫾1.3°), and FES using VFTs produced significantly greater ankle dorsiflexion (2.1°⫾1.5°) compared with FES using CFTs (Pⱕ.05). The peak swing phase ankle angles for the nonparetic extremities were 5.2⫾2.0 degrees. Ankle angle at initial contact. Overall, there were differences in ankle angle at initial contact among the 3 walking conditions tested (F⫽16.92, Pⱕ.01) (Figs. 4A and 5B). Our participants were in a markedly plantar-flexed position at initial contact (⫺8.5°⫾1.6°) when walking without FES. Functional electrical stimulation using either CFTs (⫺3°⫾1.4°) or VFTs (⫺1°⫾1.7°) significantly reduced the amount of ankle plantar flexion at initial contact compared with walking without FES (both Pⱕ.01). The post hoc pair-wise comparison detected a trend toward significantly improved dorsiflexion using VFTs versus CFTs (P⫽.07). The ankle angles at initial contact for the nonparetic extremities were 2.8⫾2.2 degrees. Secondary Outcome Variables Although FES was delivered only to the muscles crossing the paretic ankle joint, there were significant differences in the peak knee flexion attained by the paretic leg during the swing phase among the 3 walking conditions (F⫽13.9, Pⱕ.01) (Figs. 4B and 6). Two-tailed pair-wise comparisons showed that participants demonstrated significantly reduced knee flexion during walking with FES using CFTs (42.6°⫾4.3°) or VFTs (40.8°⫾4.2°) compared with walking without FES (44.1°⫾4.2°) (both Pⱕ.05) (Fig. 6A). In addition, FES using VFTs produced a greater decrease in knee flexion compared with FES using CFTs (Pⱕ.05). The peak swing phase knee flexion anJanuary 2010

Figure 4. Ensemble plots showing the average time normalized (0% to 100%⫽initial contact to initial contact) ankle (A) and knee (B) angles for 12 participants. Ankle dorsiflexion and knee flexion are positive. The 3 lines in each graph denote the 3 walking conditions tested: walking without functional electrical stimulation (noFES), walking with dorsiflexor muscle functional electrical stimulation using constant-frequency trains (FESCFT), and walking with dorsiflexor muscle functional electrical stimulation using variable-frequency trains (FES-VFT). Vertical dashed line represents toe-off.

gles for the nonparetic extremity were 68.3⫾2.0 degrees. Participants demonstrated no differences in the amount of circumduction among the 3 walking conditions (F⫽0.473, P⫽.63). Average circumduction was 4.0⫾0.8 cm for noFES, 3.8⫾0.8 cm for FES-CFT, and 3.7⫾0.7 cm for FES-VFT. The circumduction values for the nonparetic extremities were 1.62⫾0.39 cm.

There were significant differences in the position of the paretic ankle angle at the stance-to-swing transition (F⫽16.92, Pⱕ.01) among the 3 walking conditions (Fig. 6B). The position of the paretic ankle angle at toeoff changed from a more plantarflexed position during walking without FES (⫺9.1°⫾1.2°) to significantly less plantar flexion during walking with FES using CFTs (⫺5.2°⫾1.2°; Pⱕ.01) or VFTs

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Effects of Dorsiflexor Muscle Functional Electrical Stimulation on Poststroke Gait CFTs. Surprisingly, we also found that dorsiflexor FES decreased ankle plantar flexion at toe-off and decreased knee flexion during the swing phase, and these effects were enhanced by the use of VFTs versus CFTs. Although peak ankle dorsiflexion during swing improved with FES, there were no changes in circumduction during walking with FES. Additionally, analysis of the noFES data suggested that despite the rest intervals provided to the participants and the short (20- to 40-second) durations of the walking trials, the ankle dorsiflexor muscles may have experienced fatigue within one testing session.

Figure 5. Graphs showing average values and standard error bars for (A) peak ankle angles during swing and (B) ankle angles at initial contact for the 12 participants tested in our study. Three walking conditions shown are: walking without functional electrical stimulation (noFES), walking with dorsiflexor muscle functional electrical stimulation using constant-frequency trains (FES-CFT), and walking with dorsiflexor muscle functional electrical stimulation using variable-frequency trains (FES-VFT). *Significant difference from noFES (Pⱕ.05). †Significant difference from FES-CFT (Pⱕ.05). #Trend for difference from FES-CFT (P⫽.07).

(⫺3.1°⫾1.5°; Pⱕ.01). Functional electrical stimulation using VFTs produced lesser plantar flexion at toe-off compared with FES using CFTs (Pⱕ.01). The ankle angles at toe-off for the nonparetic extremities were ⫺13.4⫾2.1 degrees. Analysis of No FES Data There were significant differences in peak ankle angles during swing among the 3 noFES walking trials at the beginning, middle, and end of the testing session (F⫽5.13, Pⱕ.05). Participants demonstrated significantly reduced peak swing phase ankle angles (Pⱕ.05) during the noFES walking trial at the end 62

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(⫺3.8°⫾1.3°) versus the beginning of the session (⫺2.2°⫾1.1°). Similarly, there were significant differences in ankle angles at initial contact among the noFES walk trials collected at the beginning, middle, and end of the session (F⫽9.04, Pⱕ.01). There was significantly less ankle dorsiflexion at initial contact during the noFES walking trials at the end (⫺9.5°⫾1.6°) versus the beginning (⫺7°⫾1.8°) of the session.

Discussion Our results showed that during dorsiflexor FES, VFTs produced greater increases in ankle dorsiflexion during the swing phase compared with

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This was the first study to compare the effects of using traditional (CFTs) versus novel (VFTs) stimulation patterns for dorsiflexor FES on poststroke gait. Interestingly, dorsiflexor FES using VFTs produced greater peak dorsiflexion angles during the paretic swing phase compared with FES using CFTs. Previous dynamometric studies on human and animal muscles showed greater rates of rise of force in response to VFTs versus CFTs during isometric contractions in nonfatigued muscle.33,34,51 Furthermore, in fatigued muscles, VFTs have consistently been shown to generate greater rates of rise of force, peak forces, and force-time integrals during isometric contractions51 and greater joint excursions and power during dynamic contractions.31,40 Our testing session was designed with 5- to 10-minute rest breaks between brief (20- to 40-second) walking trials to minimize fatigue. Nevertheless, our noFES walking data showed a significant decrement in ankle dorsiflexor angles from the beginning to the end of the session. The presence of fatigue in the dorsiflexor muscles could partly explain the enhanced ankle dorsiflexion seen with VFTs versus CFTs,51 along January 2010

Effects of Dorsiflexor Muscle Functional Electrical Stimulation on Poststroke Gait with the enhanced rates of rise of force produced by the VFTs.31 The observed muscle fatigue may be an important factor limiting gait performance during prolonged walking with FES.29,30 These results pave the way for future studies investigating the use of VFTs during prolonged bouts of walking to test whether VFTs can help generate repeated foot drop correction for a greater number of steps compared with CFTs. We also found a trend (P⫽.07) toward greater dorsiflexion at initial contact (at the end of the swing phase) during FES using VFTs, despite the fact that the high-frequency burst that differentiated the VFTs from the CFTs occurred at the beginning of the swing phase. Evidently, the force enhancement produced by the high-frequency burst at the onset of the VFTs lasted long enough to generate some enhancement in ankle dorsiflexion throughout the paretic swing phase, further supporting the advantages of VFTs for FES applications. Typically, CFTs are delivered during dorsiflexor FES, but there is a dearth of data in the literature quantifying the immediate effects of FES using CFTs on poststroke gait. In our study, as expected, we observed that delivering FES to the paretic ankle dorsiflexor muscles during the swing phase produced greater ankle dorsiflexion angles during the swing phase and at initial contact compared with walking without FES. Increased dorsiflexion during the swing phase and at initial contact with FES using traditional stimulation patterns (CFTs) are not surprising and have been shown previously.52,53 However, in this study, we also presented an analysis of the effects of FES using CFTs on knee kinematics and circumduction. An interesting and novel finding of this study was the reduction in swing phase knee flexion during dorsiJanuary 2010

Figure 6. Graph showing average and standard error bars for (A) peak knee flexion during swing and (B) ankle angle at toe-off for the paretic leg for 12 participants. Three walking conditions shown are: walking without functional electrical stimulation (noFES), walking with dorsiflexor muscle functional electrical stimulation using constant-frequency trains (FES-CFT), and walking with dorsiflexor muscle functional electrical stimulation using variable-frequency trains (FES-VFT). *Significant difference from noFES (Pⱕ.05). † Significant difference from FES-CFT (Pⱕ.05).

flexor FES. In their randomized controlled trial assessing the Odstock Drop Foot Stimulator, Burridge and colleagues anecdotally noted that the immediate effect of FES on the tibialis anterior and peroneal muscles was “to bring the ankle into greater dorsiflexion as the foot left the ground and facilitate a flexor withdrawal response in which flexion occurred at both hip and knee joints.”3(pp208 –209) In the present study, we did not have a directional hypothesis about the change in knee flexion with FES. As stated by Burridge and colleagues, it can be argued that swing phase knee flexion might increase during FES because of the flexion withdrawal reflex and the prevalence of flexion synergy in peo-

ple poststroke. We were surprised to find a decrease in swing phase knee flexion during walking with dorsiflexor FES versus walking without FES. The decrease in knee flexion with dorsiflexor FES is particularly important in individuals poststroke because they show a decreased swing phase knee flexion in the paretic leg compared with the nonparetic leg and compared with control subjects without neurological impairment walking at matched speeds.5,50 Thus, dorsiflexor FES seems to enhance a typical poststroke gait impairment that can negatively influence foot clearance during swing. To our knowledge, decreased knee flexion as an immediate effect of dor-

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Effects of Dorsiflexor Muscle Functional Electrical Stimulation on Poststroke Gait siflexor FES has not been reported previously in the literature. We believe that the decreased swing phase knee flexion observed in our study was related to the decreased plantar flexion that we observed at toe-off. The decreased plantar-flexion angles could result in decreased push-off forces at the ankle during the stanceto-swing transition. Forwarddynamic simulations of healthy gait suggest that ankle plantar-flexor force generation during terminal stance helps increase the knee flexion velocity at toe-off, which is a critical contributor to swing phase knee flexion.54 Interestingly, consistent with our findings, preliminary results from our laboratory of forwarddynamic gait simulations of poststroke gait have predicted that enhanced excitation of ankle dorsiflexor muscles would result in reduced swing knee flexion.55 We posit that the timing of dorsiflexor FES during gait could be a factor contributing to decreased plantar flexion at toe-off and decreased knee flexion during the swing phase. Because we triggered the FES using footswitches, dorsiflexor stimulation began before actual toe-off (Fig. 1). Thus, the forces generated by the dorsiflexor muscles at toe-off could have reduced the net plantar-flexor moment at toe-off, potentially resulting in the observed decreased ankle plantar flexion at toe-off, reduced push-off force generation during terminal stance, and reduced knee flexion during swing. The timing of delivery of dorsiflexor FES needs to be systematically manipulated and studied to test this hypothesis further. In addition, the effects of delivering FES to the ankle plantar-flexor muscles to increase force generation during push-off needs to be investigated. An ideal FES intervention for management of foot drop poststroke would increase dorsiflexion during the swing phase and at initial contact 64

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and increase plantar flexion at toeoff. However, we found that although FES helped produce greater dorsiflexion during swing and initial contact, it worsened the already reduced plantar flexion at toe-off prevalent in the paretic leg. Similar to the onset of dorsiflexor FES in our study, previous FES studies have shown that onset of dorsiflexor FES was between heel-off and toe-off and that dorsiflexion increased at toe-off during dorsiflexor FES,52,53 suggesting that this issue is prevalent in other FES systems and needs to be addressed in future studies. We did not detect differences in circumduction among the 3 walking conditions tested in this study. The average values of circumduction demonstrated by the individuals tested in our study during walking without FES (X⫾SD⫽4.0⫾2.9 cm) were similar to the amount of circumduction shown in individuals with poststroke hemiparesis by Chen and colleagues (4.6⫾3.2 cm).50 Because circumduction is a learned compensatory gait strategy, it is understandable that the amount of circumduction did not change as an immediate effect of FES, even though our participants were achieving greater ankle dorsiflexion during the swing phase and, therefore, may not have required circumduction to clear the foot. Perhaps correction of gait compensations such as circumduction could occur if FES is used in conjunction with other interventions during gait retraining under the guidance of a physical therapist to help individuals with poststroke hemiparesis to “unlearn” the compensatory strategies they have developed over time. Nevertheless, a better understanding of the immediate and therapeutic effects (or the lack of effects) of FES on gait compensations, such as circumduction, may help to modify FES-based gait interventions to enable prevention and

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correction of gait compensations poststroke. Our findings suggest that novel FES systems capable of delivering VFTs during gait48,56 can produce enhanced correction of foot drop compared with traditional FES systems that deliver CFTs. The use of VFTs for dorsiflexor FES during poststroke gait, as presented for the first time in our study, is an example of the successful translation of research evidence from animal studies34,38 to isometric human studies27,31,33,51 and, finally, in the current study, to a clinical application. The present study also brings forward several interesting issues, such as the reduced swing-phase knee flexion and reduced ankle plantar flexion at toe-off with dorsiflexor FES and the need for more precise timing of dorsiflexor FES, that merit future investigation. One limitation of the present study is that we did not restrict handrail hold during testing. The use of handrails may affect kinematics and kinetics during gait57,58 and must be investigated adequately in future studies. There also is a need to investigate the effects of delivering FES to multiple muscles to address the many multijoint deficits in poststroke gait. Finally, future studies are needed to investigate whether the use of VFTs during FES can enable the generation of targeted gait performance for a greater number of walking strides. All authors provided concept/idea/research design. Dr Kesar, Dr Perumal, and Ms Angela Jancosko provided data collection. Dr Perumal provided hardware and software design for the functional electrical stimulation aspect of the data collection. Dr Reisman, Ms Jancosko, and Dr Rudolph assisted with data processing. Dr Kesar provided data analysis and manuscript writing. Dr Binder-Macleod, Dr Perumal, Ms Jancosko, Dr Reisman, and Dr Rudolph provided reviews of the manuscript before submission. The authors thank Ms Margie Roos, PT, NCS, for clinical testing and participant recruitment and Ms Leigh Shrewsbury for scheduling and recruitment. They also thank Dr Andrew Fuglevand for

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Effects of Dorsiflexor Muscle Functional Electrical Stimulation on Poststroke Gait providing helpful reviews of previous drafts of the manuscript. This study was approved by the Human Subjects Review Board of the University of Delaware. An oral presentation of some of the results was given at the 12th Annual International Functional Electrical Stimulation Society Conference; November 10 –14, 2007; Philadelphia, Pennsylvania. These results also were presented at the annual meeting of the American Society of Biomechanics; August 26 –29, 2009; University Park, Pennsylvania. This study was supported by National Institute of Nursing Research grant R01 NR010786 awarded to Dr Binder-Macleod. Funding for the laboratory instrumentation was provided by NIH Shared Instrumentation grant S10 RR022396 – 01 and DOD grant W911NF-05–1-0097. Part of the funding came from the University of Delaware Dissertation Fellowship awarded to Dr Kesar. This article was received April 29, 2009, and was accepted August 11, 2009. DOI: 10.2522/ptj.20090140

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Effects of Dorsiflexor Muscle Functional Electrical Stimulation on Poststroke Gait 40 Lee SC, Binder-Macleod SA. Effects of activation frequency on dynamic performance of human fresh and fatigued muscles. J Appl Physiol. 2000;88:2166 –2175. 41 Maladen RD, Perumal R, Wexler AS, Binder-Macleod SA. Effects of activation pattern on nonisometric human skeletal muscle performance. J Appl Physiol. 2007;102:1985–1991. 42 Garland SJ, Griffin L. Motor unit double discharges: statistical anomaly or functional entity? Can J Appl Physiol. 1999;24:113–130. 43 Kottink AI, Hermens HJ, Nene AV, et al. A randomized controlled trial of an implantable 2-channel peroneal nerve stimulator on walking speed and activity in poststroke hemiplegia. Arch Phys Med Rehabil. 2007;88:971–978. 44 Bogataj U, Gros N, Kljajic M, et al. The rehabilitation of gait in patients with hemiplegia: a comparison between conventional therapy and multichannel functional electrical stimulation therapy. Phys Ther. 1995;75:490 –502. 45 Stein RB, Chong S, Everaert DG, et al. A multicenter trial of a footdrop stimulator controlled by a tilt sensor. Neurorehabil Neural Repair. 2006;20:371–379. 46 Pomeroy VM, King L, Pollock A, et al. Electrostimulation for promoting recovery of movement or functional ability after stroke. Cochrane Database Syst Rev. 2006:CD003241.

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47 Fugl-Meyer AR, Jaasko L, Leyman I, et al. The post-stroke hemiplegic patient, 1: a method for evaluation of physical performance. Scand J Rehabil Med. 1975;7: 13–31. 48 Perumal R, Kesar TM, Wexler AS, BinderMacleod SA. Novel FES system to stimulate both dorsi- and plantar-flexor muscles during stroke gait. Paper presented at: 12th Annual Conference of the International Functional Electrical Stimulation Society; November 10 –14, 2007; Philadelphia, Pennsylvania. 49 Roth HR, Moore JL, Lewek MD, et al. Development and validation of circumduction assessment scale for individuals with hemiplegia. Paper presented at: Combined Sections Meeting of the American Physical Therapy Association; February 1–5, 2006; San Diego, California. 50 Chen G, Patten C, Kothari DH, Zajac FE. Gait differences between individuals with post-stroke hemiparesis and non-disabled controls at matched speeds. Gait Posture. 2005;22:51–56. 51 Binder-Macleod SA, Lee SC, Fritz AD, Kucharski LJ. New look at force-frequency relationship of human skeletal muscle: effects of fatigue. J Neurophysiol. 1998;79: 1858 –1868. 52 Voigt M, Sinkjaer T. Kinematic and kinetic analysis of the walking pattern in hemiplegic patients with foot-drop using a peroneal nerve stimulator. Clin Biomech (Bristol, Avon). 2000;15:340 –351.

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53 Preuss R, Stein RB, Fung J. Gait kinematics after forty weeks of use of the Walkaide 2: a case study. Paper presented at: 10th Annual Conference of the International Functional Electrical Stimulation Society; July 5– 8, 2005; Montreal, Quebec, Canada. 54 Anderson FC, Goldberg SR, Pandy MG, Delp SL. Contributions of muscle forces and toe-off kinematics to peak knee flexion during the swing phase of normal gait: an induced position analysis. J Biomech. 2004;37:731–737. 55 Higginson JS, Kesar TM, Perumal R, Binder-Macleod SA. Simulation-guided stimulation for paretic ankle muscles during stroke gait. Paper presented at: ASME Summer Bioengineering Conference; June 20 –24, 2007; Keystone, Colorado. 56 Hart DJ, Taylor PN, Chappell PH, Wood DE. A microcontroller system for investigating the catch effect: functional electrical stimulation of the common peroneal nerve. Med Eng Phys. 2006;28:438 – 448. 57 Chen G, Patten C, Kothari DH, Zajac FE. Gait deviations associated with post-stroke hemiparesis: improvement during treadmill walking using weight support, speed, support stiffness, and handrail hold. Gait Posture. 2005;22:57– 62. 58 Siler WL, Jorgensen AL, Norris RA. Grasping the handrails during treadmill walking does not alter sagittal plane kinematics of walking. Arch Phys Med Rehabil. 1997;78: 393–398.

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Research Report

Decreased Muscle Strength Relates to Self-Reported Stooping, Crouching, or Kneeling Difficulty in Older Adults Manuel E. Hernandez, Allon Goldberg, Neil B. Alexander

Background. Bending down and kneeling are fundamental tasks of daily living, yet nearly a quarter of older adults report having difficulty performing or being unable to perform these movements. Older adults with stooping, crouching, or kneeling (SCK) difficulty have demonstrated an increased fall risk. Strength (force-generating capacity) measures may be useful for determining both SCK difficulty and fall risk. Objective. The purposes of this study were: (1) to examine muscle strength differences in older adults with and without SCK difficulty and (2) to examine the relative contributions of trunk and leg muscle strength to SCK difficulty.

Design. This was a cross-sectional observational study. Methods. Community-dwelling older adults (age [X⫾SD]⫽75.5⫾6.0 years) with SCK difficulty (n⫽27) or without SCK difficulty (n⫽21) were tested for leg and trunk strength and functional mobility. Isometric strength at the trunk, hip, knee, and ankle also was normalized by body weight and height. Results. Compared with older adults with no SCK difficulty, those with SCK difficulty had significant decreases in normalized trunk extensor, knee extensor, and ankle dorsiflexor and plantar-flexor strength. In 2 separate multivariate analyses, raw ankle plantar-flexor strength (odds ratio [OR]⫽0.97, 95% confidence interval [CI]⫽0.95– 0.99) and normalized knee extensor strength (OR⫽0.61, 95% CI⫽0.44 – 0.82) were significantly associated with SCK difficulty. Stooping, crouching, and kneeling difficulty also correlated with measures of functional balance and falls.

Limitations. Although muscle groups that were key to rising from SCK were examined, there are other muscle groups that may contribute to safe SCK performance.

Conclusions. Decreased muscle strength, particularly when normalized for body size, predicts SCK difficulty. These data emphasize the importance of strength measurement at multiple levels in predicting self-reported functional impairment.

M.E. Hernandez, MS, is a PhD candidate in the Department of Biomedical Engineering, Mobility Research Center, University of Michigan, 2025 Traverwood Dr, Suite E, Ann Arbor, MI 48105 (USA). Address all correspondence to Mr Hernandez at: manueleh@ umich.edu. A. Goldberg, PT, PhD, is Assistant Professor, Department of Health Care Sciences, Program in Physical Therapy, Mobility Research Laboratory, Wayne State University; Faculty Fellow, Institute of Gerontology, Wayne State University; and Adjunct Assistant Professor, Department of Internal Medicine, School of Medicine, Wayne State University, Detroit, Michigan. At the time of the study, Dr Goldberg was a postdoctoral fellow at the Institute of Gerontology, University of Michigan. N.B. Alexander, MD, is Professor, Department of Internal Medicine, Division of Geriatric Medicine, Mobility Research Center; Research Professor, Institute of Gerontology, University of Michigan; and Director, VA Ann Arbor Health Care System Geriatric Research, Education and Clinical Center, Ann Arbor, Michigan. [Hernandez ME, Goldberg A, Alexander NB. Decreased muscle strength relates to self-reported stooping, crouching, or kneeling difficulty in older adults. Phys Ther. 2010;90:67–74.] © 2010 American Physical Therapy Association Post a Rapid Response or find The Bottom Line: www.ptjournal.org

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tooping, crouching (ie, bending down), and kneeling movements are an integral component of many common activities, including gardening, shopping, and cleaning. Limitations in stooping, crouching, or kneeling (SCK) are associated with an increased likelihood of limitations in other lowerbody functional tasks such as lifting and prolonged standing1 and also are associated with fall risk.2 As with standing up from a chair, SCK movements require coordination of the whole-body center of mass over a wide range of postures in order to prevent a loss of balance or fall. Moving from stance into crouching and kneeling involves significant ankle, knee, and hip range of motion, whereas stooping movements are characterized by a reduction of knee movement.3 In addition to mobility requirements, SCK movements can constitute a significant challenge to the balance and strength (forcegenerating capacity) capacities of older adults, which may explain why “bending down” tasks are included in clinical assessments such as the Physical Performance Test4 and Berg Balance Scale5 that are thought to predict fall risk. However, even though SCK difficulty may be a significant indicator of mobility and independence in older adults, few data exist regarding the determinants of SCK difficulty and its association with fall risk. The prevention of falls in older adults is the focus of much research effort. A

Available With This Article at ptjournal.apta.org • Discussion Podcast: Participants to be determined.

key component of avoiding falls is the motor system’s ability to produce joint torques to counteract perturbations that would lead to losses of balance.6 The neuromuscular system invokes a series of response strategies involving extremity and trunk musculature7–10 to produce joint torques at various body segments in order to maintain the center of mass over the base of support or return the center of mass rapidly to within the base of support when external perturbations have altered its position. Muscle weakness contributes to both falls and selfreported SCK difficulty in older adults, but the relative contribution of different muscle groups, such as proximal (trunk and hip) versus distal (ankle) muscle strength, is not entirely clear.11,12 The association of reduced lowerextremity muscle forces, particularly ankle strength, with falls is well established.13–15 Leg strength also has been associated with functional performance such as gait speed and chair rises.16,17 Ankle dorsiflexor and ankle plantar-flexor strength measures predict performance on some (Timed “Up & Go” Test [TUG] and Berg Balance Scale)15 but not all (unipedal stance time [UST])18 common clinical balance tests that are thought to predict falls in older adults. Although knee extensor strength is associated with static and dynamic capabilities as well as functional ability in older adults,19,20 the role of more proximal trunk and hip muscles in determining functional performance has not been well characterized. Given that control of the flexing trunk is critical to avoiding falls when losses of balance occur,9 it is important to determine the relative contributions of both trunk and lower-extremity strength to functional tasks such as SCK.

• Audio Abstracts Podcast This article was published ahead of print on November 26, 2009, at ptjournal.apta.org.

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The purposes of this study were: (1) to examine trunk and lowerextremity muscle strength differences in older adults with and withNumber 1

out SCK difficulty and (2) to examine the relative contributions of trunk and leg muscle strength to SCK difficulty that may predict falls in older adults with a range of balance impairments. Of particular interest are the relative contributions of muscle strengths that have not been well studied in older adults, including strength at the trunk and hip. These data will advance the understanding of the contribution of strength measures, particularly of the proximal lower extremity and trunk, to selfreported functional performance and may allow a more thoughtful approach to the use of strength training in improving balance and thereby reducing falls. Given the previous data on the importance of ankle function in balance performance and fall risk, we hypothesized that lowerextremity strength would be significantly decreased in older adults with SCK difficulty and that distal strength measures would be the main predictors of SCK difficulty.

Method Participants Functionally independent, communitydwelling older adults were recruited largely from a database maintained by the University of Michigan Older Americans Independence Center Human Subjects and Assessment Core. Inclusion criteria for the study were age over 65 years, ability to speak and understand English, and ability to stand for 5 minutes without an assistive device. A nurse practitioner performed a screening medical history and physical examination and excluded those whose medical conditions precluded the ability to complete the test battery, such as those individuals who: (1) were medically unstable (eg, chest pain upon exertion, dyspnea, acute infection), (2) reported severe and frequent back or lower-extremity pain, or (3) reported severe neurologically induced impairments that might affect balance (eg, history of cerebrovascular acciJanuary 2010

Strength and Stooping, Crouching, or Kneeling Difficulty in Older Adults dent, Parkinson disease). Out of 50 recruited individuals, 2 were excluded due to severe osteoporosis and severe and frequent back pain. During screening, participants rated their ability to stoop, crouch, or kneel, according to a 5-point difficulty scale, based on a single question on the Established Populations for Epidemiologic Studies of the Elderly (EPESE) questionnaire21: no difficulty (n⫽21), a little (n⫽13), some (n⫽9), a lot (n⫽2), or unable to do (n⫽3). Participants were categorized into 1 of 2 groups: a no SCK difficulty group (n⫽21), if they reported no difficulty, or an SCK difficulty group (n⫽27) if they reported any SCK difficulty. Participants signed a written informed consent form approved by the University of Michigan Medical School Institutional Review Board. Based on previous work,12 power analysis22 revealed that a sample size of 21 for each group was required to achieve a power of 0.80 with an alpha level of .05 in detecting strength differences between older adults with and without SCK difficulty. Instrumentation and Measures Self-report health measures. The nurse practitioner used self-report (interview-based) health measures to obtain patient data at the medical screening. The total number of chronic medical conditions was ascertained by asking participants if they had a previous history of osteoarthritis, rheumatoid arthritis, osteoporosis, myocardial infarction, stroke, joint replacement, Parkinson disease, or peripheral neuropathy. Dizziness was determined by asking participants if they had a current episode of lightheadedness or vertigo. Self-reported leg joint limitations were determined by the report of joint range-ofmotion limitations due to pain or stiffness in the hip, knee, or ankle. Clinical balance measures. The 3 clinical balance measures that were January 2010

examined were the UST, the TUG, and the maximum step length (MSL). The UST is a commonly used clinical balance measure. Deficits in UST, defined as the inability to stand unsupported on one leg for more than 5 seconds, is a strong predictor of injurious falls.23 Participants stood on their preferred leg while their arms were folded. The foot of the remaining leg was lifted and held approximately 5.08 cm (2 in) from the medial malleolus of the stance leg. Participants performed a practice trial followed by 2 experimental trials. The best time (maximum 30 seconds) was recorded as the UST. The UST has excellent interrater reliability (intraclass correlation coefficient [ICC]⫽.99).24 The TUG is a reliable measure of functional mobility and dynamic balance in older adults (intrarater ICC⫽.99, interrater ICC⫽.99).25 Participants sat in a chair and, on command, stood up and walked 9.84 ft (3 m) at their “comfortable and safe pace” before turning around and returning to the seated position. The time to complete this task is the person’s TUG score. Scores exceeding 14 seconds have been associated with increased fall risk in older adults.26 Participants performed a practice trial, followed by 3 experimental trials. The TUG was recorded as the mean time (in seconds) of the 3 trials. The MSL test is a reliable test of stepping ability, which correlates with standard balance measures (eg, unipedal stance, tandem stance, tandem walk), functional mobility measures, (eg, TUG, Performance-Oriented Mobility Assessment, Six-Minute Walk Test) and fall history (intrarater ICC⫽.91).27–29 Standing with arms folded and feet together, participants stepped forward maximally with their dominant leg and returned to the original starting position. Leg dominance was ascertained using a simple screening question, namely the preferred foot used to kick a soc-

cer ball. Participants performed a practice trial followed by 5 experimental trials, and MSL was recorded as the mean distance stepped over the 5 trials. To account for individual anthropometric differences, the MSL was normalized as a percentage of body height (% height). Strength measures. Isometric peak torque of the trunk, hip, and knee extensors, as well as of the ankle plantar flexors and dorsiflexors of the dominant lower extremity, was evaluated using the Biodex multijoint isokinetic dynamometer.* After a practice trial, participants exerted a maximal contraction for 2 trials of 3 seconds each. Participants received approximately 45 seconds of rest between trials, the best of which was recorded as the peak torque. If the 2 torque measurements differed by more than 15%, an additional trial was performed to achieve consistency. Trunk extensor isometric strength was evaluated using a back attachment* affixed to the multijoint isokinetic dynamometer. Participants were supported and stabilized in the seated position via chest, pelvic, and thigh straps, with the arms folded and the trunk and lower extremities configured at approximately 90 degrees to each other. Participants exerted a maximal trunk extensor contraction against a pad located at the interscapular region. Hip extensor isometric strength was evaluated in the functional standing position as previously described.30 Briefly, this measure required the participants to stand supported and stabilized upright in a standing frame with the lower extremity straight and the hip flexed 15 degrees in the sagittal plane. Participants exerted a maximal hip extensor contraction by pushing * Biodex Medical Systems Inc, 20 Ramsey Rd, Shirley, NY 11967.

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Strength and Stooping, Crouching, or Kneeling Difficulty in Older Adults against a pad located immediately distal to the popliteal fossa. Knee extensor isometric strength was evaluated in the seated position with the knee flexed to 90 degrees and chest and thigh straps providing support and stabilization. With the arms folded, participants exerted a maximal knee extension contraction against a pad located at the anterior distal tibia. Isometric strength of the ankle plantar flexors and dorsiflexors was evaluated with the participants in a semireclined position with the tibia parallel to the floor, the foot and tibia at 90 degrees to each other, and the knee and hip at approximately 30 and 60 degrees of flexion, respectively. The lower leg was supported with a pad and straps, and with arms folded, participants either pushed maximally into (plantar flexors) or pulled away from (dorsiflexors) a footplate in which the foot was tightly secured with straps. Peak torque values are expressed as raw strength (in N 䡠 m) or as normalized strength, as a percentage of the product of body weight (BW) (newtons) and body height (BH) (meters). as done in previous studies (% BW ⫻ BH).12,29 Reliability of isometric strength testing using the Biodex multijoint dynamometer system has been demonstrated previously in measurements of knee strength for older men (intrarater ICC⫽.90).31 Fall-related measures. Data for fall-related measures were obtained during the medical screening by asking participants whether they had fallen within the past year. In the event that a fall was reported, the number of falls incurred and whether medical treatment was sought for their injuries (ie, injurious falls) were ascertained. For analysis, the number of falls and number of injurious falls 70

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within the past year were dichotomized (ie, falls ⱖ2 and injurious falls ⱖ1). Data Analysis All statistical analyses were carried out in SPSS 16.0 for Windows.† To test for normality in continuous variables, the Kolmogorov-Smirnov test was used. Group comparisons for continuous participant description, self-reported health, clinical balance, and strength data in older adults with and without SCK difficulty were evaluated using an independent-samples t test when data were normally distributed and a Mann-Whitney U test when data were not normally distributed (eg, number of chronic medical conditions, UST, trunk extensor strength). To determine group differences in dichotomous variables, either the Pearson chi-square test (eg, sex, dizziness, self-reported leg joint limitations) or the Fisher exact test (eg, fall-related measures) was performed. Relationships among strength, clinical balance measures, and SCK difficulty were evaluated using Spearman correlation coefficients, using the full 5-point scale of SCK difficulty. A forward stepwise binary logistic regression analysis included all the strength variables with a significant correlation (P⬍.05) to determine which measurements were important predictors of selfreported SCK difficulty. A log transformation resulted in a normal distribution for UST and trunk strength measures. Statistical analyses were carried out with and without the log transformation to the UST and trunk strength measurements, but yielded similar results. Thus, for ease of interpretation, the untransformed variables are presented in this article. Two separate logistic regression models, one for normalized strength and one for raw strength, are presented. We performed an analysis of † SPSS Inc, 233 S Wacker Dr, Chicago, IL 60606.

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multicollinearity among the variables. Even with all strength measures entered into a linear regression model, we found no evidence of collinearity, as the variance inflation factor was not greater than 10 for any raw or normalized strength measure.32 A significance level of .05 was used for all correlational and regression analyses, and a Bonferroni correction was used for multiple SCK group comparisons of strength (.05/5). Role of the Funding Source This work was funded, in part, by the National Institute on Aging; the Department of Veterans Affairs Office of Research and Development, Clinical Science and Rehabilitation Research and Development Services; and the Dorothy and Herman Miller Fund for Mobility Research in Older Adults.

Results Participant Characteristics and Strength Measures Forty-eight older adults (62.5% women, 37.5% men) participated in the study. Participant characteristics (demographic, self-reported health, clinical balance, strength, and fallrelated data) are presented for the entire sample in Table 1. Compared with older adults without SCK difficulty, older adults with SCK difficulty were older and had increased self-reported leg joint limitations, decreased UST, increased TUG scores, and decreased MSL. The incidence of 2 or more falls within the previous year (P⫽.096) tended to be higher in older adults with SCK difficulty. Compared with older adults without SCK difficulty, mean (SD) raw ankle plantar-flexor strength was significantly lower in those with SCK difficulty (76.4⫾25.6 N䡠m versus 53.9⫾29.8 N䡠m, respectively) (Tab. 1). Raw ankle dorsiflexor and knee extensor strength were decreased in older adults with SCK difJanuary 2010

Strength and Stooping, Crouching, or Kneeling Difficulty in Older Adults Table 1. Characteristics of Older Adults With and Without Stooping, Crouching, or Kneeling (SCK) Difficulty

Characteristic

a

No SCK Difficulty (nⴝ21)

SCK Difficulty (nⴝ27)

X (SD) or (%)

X (SD) or (%)

P

Participant description Age (y) Height (cm)

73.5 (5.4)

77.1 (6.1)

.037

165.3 (9.6)

166.5 (10.7)

.675

Weight (kg)

70.6 (11.2)

77.3 (18.0)

.121

Body mass index (kg/m2)

25.8 (3.7)

27.6 (4.4)

.145

62

63

.940

0.6 (0.6)

0.9 (0.7)

.141

19

26

.733

5

41

.004

Sex, female (%) Self-reported health Chronic medical conditions (n) Dizziness (%) Self-reported leg joint limitation (%) Clinical balance measures UST (s)

22.0 (8.8)

9.5 (9.9)

⬍.001

TUG (s)

9.6 (1.5)

11.5 (2.5)

.004

48.0 (8.6)

40.1 (8.6)

.003

Ankle dorsiflexor strength (N䡠m)

27.7 (11.9)

20.1 (8.4)

.013

Ankle plantar-flexor strength (N䡠m)

76.4 (25.6)

53.9 (29.8)

.008

MSL (% height) Raw strength measures

Knee extensor strength (N䡠m)

128.0 (37.9)

95.9 (46.3)

.013

Hip extensor strength (N䡠m)

81.6 (26.1)

72.8 (29.4)

.284

Trunk extensor strength (N䡠m)

72.4 (45.2)

53.1 (33.8)

.053

Fall-related ⱖ2 falls (%) ⱖ1 injurious falls (%)

5

22

.096

10

22

.220

a Means (SD) are presented for continuous variables, and proportions are presented for categorical variables. For determining group differences, continuous measures were evaluated using either an independent-samples t test or a Mann-Whitney U test, and dichotomous measures were evaluated using a Pearson chi-square test or Fisher exact test. SCK⫽stooping, crouching, or kneeling; UST⫽unipedal stance time; TUG⫽Timed “Up & Go” Test; MSL⫽maximum step length.

ficulty versus those without SCK difficulty, but when the Bonferroni correction was applied, the difference was not statistically significant. After normalization of strength data to account for body size (eg, body height and weight), mean normalized strength was higher in older adults without SCK difficulty compared with those with SCK difficulty in ankle dorsiflexors (2.4⫾0.9 % BW ⫻ BH versus 1.6⫾0.6 % BW ⫻ BH, respectively), ankle plantar flexors (6.8⫾2.4 % BW ⫻ BH versus 4.3⫾2.3 % BW ⫻ BH, respectively), knee extensors (11.1⫾2.2 % BW ⫻ January 2010

BH versus 7.6⫾3.0 % BW ⫻ BH, respectively), and trunk extensors (6.3⫾3.7 % BW ⫻ BH versus 4.3⫾2.3 % BW ⫻ BH, respectively) (P⬍.01) (Figure). There were tendencies toward greater normalized hip extensor strength in participants without SCK difficulty compared with those with SCK difficulty (7.1⫾2.0 % BW ⫻ BH versus 5.8⫾2.0 % BW ⫻ BH, respectively), but this observation was not significant after correcting for multiple comparisons. Correlations With SCK Difficulty Considering the full 5-point ordinal scale of SCK difficulty, SCK difficulty

was associated with raw knee extensor (r⫽⫺.43) and ankle plantarflexor (r⫽⫺.39) strength (P⬍.01), and to a lesser degree with ankle dorsiflexor strength (r⫽⫺.31, P⬍.05). However, no significant correlations between SCK difficulty and raw hip or trunk extensor strength were observed. Normalization of strength variables led to strong associations between all strength measures and SCK difficulty, such that decreased strength was associated with SCK difficulty (r⫽⫺.37 to ⫺.58, P⬍.01) (Tab. 2). Stooping, crouching, or kneeling difficulty also was strongly correlated with func-

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Figure. Mean normalized isometric peak torque (% body weight ⫻ body height) for all muscle groups tested in older adults with and without stooping, crouching, or kneeling (SCK) difficulty. Error bars show 1 standard deviation (* indicates P⬍.01). ADF⫽ankle dorsiflexors, APF⫽ankle plantar flexors, KE⫽knee extensors, HE⫽hip extensors, TE⫽trunk extensors.

Table 2. Correlations Between Stooping, Crouching, or Kneeling (SCK) Difficulty and Both Normalized Strength and Clinical Balance Measuresa SCK Difficulty

Measure Ankle dorsiflexor strength

⫺.44b

Ankle plantar-flexor strength

⫺.48

Knee extensor strength

⫺.58b

Hip extensor strength

⫺.38c

Trunk extensor strength

⫺.37c

UST

⫺.62b

TUG

.47b

MSL

⫺.46b

b

a Values are Spearman correlation coefficient (r). SCK difficulty was scored on a 5-point ordinal scale. Strength measures were normalized for body size (height ⫻ weight), and MSL was normalized for body height prior to computation of r. UST⫽unipedal stance time, TUG⫽Timed “Up & Go” Test; MSL⫽maximum step length. b Significant at P⬍.005. c Significant at P⬍.01.

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tional mobility in all 3 clinical balance tests (P⬍.005), particularly with UST (r⫽⫺.62). Strength as Predictor of SCK Difficulty Based on findings from the primary analyses, raw ankle and knee strength values were entered in a forward stepwise binary logistic regression. The model showed that ankle plantarflexor strength (odds ratio [OR]⫽0.97, 95% confidence interval [CI]⫽0.95– 0.99) was significantly associated with SCK difficulty (P⫽.014), but explained only 11% of the variance. Considering the primary analyses of normalized strength, all 5 strength measures were entered into a forward stepwise binary logistic regression model. The model showed that the most significant predictor for SCK difficulty was normalized knee extensor strength (OR⫽0.61, 95% CI⫽0.44 – 0.82, P⫽.001), which explained 26% of the variance in SCK difficulty (Tab. 3).

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The results of this study highlight the significant association between strength and self-reported SCK difficulty. We hypothesized that lowerextremity strength would be significantly decreased in older adults with SCK difficulty and that distal strength measures would be the main predictors in SCK difficulty. Results from the primary analyses of raw and normalized strength are mostly in agreement with our hypothesis, as leg strength, particularly after normalization, was significantly decreased in older adults with SCK difficulty. Two novel findings of this study were: (1) the significant correlation between SCK difficulty and both normalized strength and functional balance measures, and (2) that among a broad sample of leg and trunk muscle strengths, those having the greatest association with SCK difficulty were raw ankle plantar-flexor and normalized knee extensor strengths. Overall, these findings suggest that in older adults, the major strength determinant of SCK difficulty is strength of the distal leg musculature, thereby providing a common link with functional tests of balance. This is the first study to examine the differences in trunk and lowerextremity muscle strength in older adults with SCK difficulty. Although ankle plantarflexor strength was found to be a significant predictor of SCK difficulty, normalization of strength measures to account for differences in body size demonstrated that normalized knee extensor strength is a more significant predictor of SCK difficulty as evaluated by the percentage of variance explained (26% for the knee versus 11% for the ankle). As in the present study, decreased lowerextremity strength has been found to be associated with SCK limitations12,33 and limited functional performance in daily activities such as rising from a chair, walking, or stair ascent or descent.34 –36 Similarly, frequent fallers January 2010

Strength and Stooping, Crouching, or Kneeling Difficulty in Older Adults Table 3. Results of Logistic Regression Analyses of Muscle Strength Measurements as Predictors of Stooping, Crouching, or Kneeling Difficultya Variable Model 1 Model 2

Ankle plantar flexorb Normalized knee extensor

c

P

Odds Ratio

95% Confidence Interval

.014

0.97

0.95–0.99

.001

0.61

0.44–0.82

a

Stooping, crouching, or kneeling difficulty was scored as a dichotomous measure. b 2 R ⫽.11 (Hosmer and Lemeshow). Raw muscle strength model ␹2(1)⫽7.23. c 2 R ⫽.26 (Hosmer and Lemeshow). Normalized muscle strength model ␹2(1)⫽17.22.

have reported decreased lowerextremity strength,37 and older adults with a high fall risk have been best identified by maximum isometric push-off force in a leg press apparatus.38 The significant correlations found between SCK difficulty and functional balance tests such as UST, TUG, and MSL extend the results of other investigators who found an increased risk of falls in older adults who reported trouble bending down to the floor.2 Distal strength consistently had stronger correlations to SCK difficulty than proximal strength measures and may provide a common link between SCK difficulty and functional balance tests. Adequate ankle dorsiflexor and plantarflexor strength may be required to generate corrective torques about the ankle to maintain equilibrium by moving the center of mass forward or backward during stooping movements, due to the limited range of motion at the knee and hip. Knee extensor strength would be expected to play a significant role in the recovery to an upright stance after crouching or kneeling. Similarly to SCK movements, lower-extremity strength is of primary importance to the performance of functional tests such as the UST, TUG, and MSL.16 –18,39 Even though fall-related measures such as the incidence of more than 2 falls or an injurious fall were not found to be significantly different between older adults with and without SCK difficulty, this might have been due to the overall January 2010

health of this study cohort or limitations in sample size. After normalization of strength measures, hip extensor and trunk extensor isometric strength were found to correlate with SCK difficulty. These muscle groups would be expected to play a role in performing stooping tasks and recovery of the trunk after bending down to the ground, but appear to be of less significance to distal musculature as seen in the multivariate analysis. A possible explanation for the lack of significance of hip and trunk extensors is that additional muscle groups, such as lateral hip muscles (eg, hip abductors), may be playing a role in the stabilization of the torso during the large motions undertaken while stooping, crouching, or kneeling. The results of this study have important implications for clinicians working to reduce fall risk in older adults. Rehabilitation or intervention programs aimed at addressing deficits in self-reported SCK performance should focus on improving distal strength. Although reduced strength is a significant contributor to SCK difficulty, older adults with SCK difficulty also may benefit from more comprehensive programs that address balance confidence, coordination, leg joint limitations such as stiffness and pain, and sensory capacities. A limitation of this study is that although we included participants with a wide range of SCK difficulty and balance capabilities, some of whom may be at risk for a fall, the

participants were all communitydwelling volunteers and generally active. Therefore, it is undetermined whether similar results would be seen in a frailer cohort of older adults. Future studies should include older adults who are regular fallers to understand the strength determinants of SCK difficulty and clinical measures of balance and trunk control in those having the highest risk for falls. Finally, a further limitation of this study is that although it focused on muscle groups that were key to rising from SCK, there are other muscle groups, such as hip abductors, that may contribute to safe SCK performance, particularly as the older adult lowers himself or herself.

Conclusions Decreased muscle strength, particularly when normalized for body size, predicts SCK difficulty. These data emphasize the importance of strength measurement at multiple levels in predicting self-reported functional impairment. Further studies are needed to determine whether rehabilitation programs with a focus on training specific muscle groups are effective in improving self-reported functional performance and whether improvements in self-reported functional performance are associated with fewer falls in older adults. All authors provided concept/idea/research design, writing, and data collection and analysis. Dr Goldberg and Dr Alexander provided project management, participants, and consultation (including review of manuscript before submission). Dr Alexander provided fund

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Strength and Stooping, Crouching, or Kneeling Difficulty in Older Adults procurement, facilities/equipment, institutional liaisons, and clerical support. The authors thank Diane Scarpace, Brad Grincewicz, Ravi Goswami, and Eric Pear for assistance with participant screening and data collection. This study was approved by the University of Michigan Medical School Institutional Review Board. This work was funded, in part, by grant F31AG02468 from the National Institute on Aging (NIA) (National Research Service Award to Mr Hernandez); grant AG08808 from the Claude D. Pepper Older Americans Independence Center, University of Michigan; NIA grant AG10542; and NIA Institutional Training Grant T32 AG00114 (Multidisciplinary Research Training in Aging). This work also was supported by the Department of Veterans Affairs Office of Research and Development, Clinical Science and Rehabilitation Research and Development Services, and the Dorothy and Herman Miller Fund for Mobility Research in Older Adults. Dr Alexander is a recipient of the K24 Mid-Career Investigator Award in Patient-Oriented Research (grant AG109675) from NIA. Dr. Goldberg is the recipient of the 2004 Fellowship for Geriatric Research Award from the Section on Geriatrics of the American Physical Therapy Association. This article was received February 6, 2009, and was accepted September 2, 2009. DOI: 10.2522/ptj.20090035

References 1 Long JS, Pavalko EK. The life course of activity limitations: exploring indicators of functional limitations over time. J Aging Health. 2004;16:490 –516. 2 O’Loughlin JL, Robitaille Y, Boivin JF, Suissa S. Incidence of and risk factors for falls and injurious falls among the community-dwelling elderly. Am J Epidemiol. 1993;137:342–354. 3 Burgess-Limerick R, Shemmell J, Barry BK, et al. Spontaneous transitions in the coordination of a whole body task. Hum Mov Sci. 2001;20:549 –562. 4 Reuben DB, Siu AL. An objective measure of physical function of elderly outpatients: the Physical Performance Test. J Am Geriatr Soc. 1990;38:1105–1112. 5 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. 6 Hall CD, Woollacott MH, Jensen JL. Agerelated changes in rate and magnitude of ankle torque development: implications for balance control. J Gerontol A Biol Sci Med Sci. 1999;54:M507–M513. 7 Horak FB, Nashner LM. Central programming of postural movements: adaptation to altered support-surface configurations. J Neurophysiol. 1986;55:1369 –1381.

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8 Alexander NB, Shepard N, Gu MJ, Schultz A. Postural control in young and elderly adults when stance is perturbed: kinematics. J Gerontol. 1992;47:M79 –M87. 9 Grabiner MD, Koh TJ, Lundin TM, Jahnigen DW. Kinematics of recovery from a stumble. J Gerontol. 1993;48:M97–M102. 10 Marigold DS, Bethune AJ, Patla AE. Role of the unperturbed limb and arms in the reactive recovery response to an unexpected slip during locomotion. J Neurophysiol. 2003;89:1727–1737. 11 Moreland JD, Richardson JA, Goldsmith CH, Clase CM. Muscle weakness and falls in older adults: a systematic review and metaanalysis. J Am Geriatr Soc. 2004;52:1121– 1129. 12 Hernandez ME, Murphy SL, Alexander NB. Characteristics of older adults with selfreported stooping, crouching, or kneeling difficulty. J Gerontol A Biol Sci Med Sci. 2008;63:759 –763. 13 Whipple RH, Wolfson LI, Amerman PM. The relationship of knee and ankle weakness to falls in nursing home residents: an isokinetic study. J Am Geriatr Soc. 1987;35:13–20. 14 Studenski SA, Duncan PW, Chandler J. Postural responses and effector factors in persons with unexplained falls: results and methodologic issues. J Am Geriatr Soc. 1991;39:229 –234. 15 Daubney ME, Culham EG. Lowerextremity muscle force and balance performance in adults aged 65 years and older. Phys Ther. 1999;79:1177–1185. 16 Brown M, Sinacore DR, Host HH. The relationship of strength to function in the older adult. J Gerontol A Biol Sci Med Sci. 1995;50 Spec No:55–59. 17 Bean JF, Kiely DK, Herman S, et al. The relationship between leg power and physical performance in mobility-limited older people. J Am Geriatr Soc. 2002;50:461– 467. 18 Ringsberg K, Gerdhem P, Johansson J, Obrant KJ. Is there a relationship between balance, gait performance and muscular strength in 75-year-old women? Age Ageing. 1999;28:289 –293. 19 Carter ND, Khan KM, Mallinson A, et al. Knee extension strength is a significant determinant of static and dynamic balance as well as quality of life in older community-dwelling women with osteoporosis. Gerontology. 2002;48:360 –368. 20 Avlund K, Schroll M, Davidsen M, et al. Maximal isometric muscle strength and functional ability in daily activities among 75-year-old men and women. Scand J Med Sci Sports. 1994;4:32– 40. 21 Smith LA, Branch LG, Scherr PA, et al. Short-term variability of measures of physical function in older people. J Am Geriatr Soc. 1990;38:993–998. 22 Faul F, Erdfelder E, Lang AG, Buchner A. G*Power 3: a flexible statistical power analysis program for the social, behavioral, and biomedical sciences. Behav Res Methods. 2007;39:175–191. 23 Vellas BJ, Wayne SJ, Romero L, et al. Oneleg balance is an important predictor of injurious falls in older persons. J Am Geriatr Soc. 1997;45:735–738.

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24 Franchignoni F, Tesio L, Martino MT, Ricupero C. Reliability of four simple, quantitative tests of balance and mobility in healthy elderly females. Aging (Milano). 1998;10:26 –31. 25 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. 26 Shumway-Cook A, Brauer S, Woollacott M. Predicting the probability for falls in community-dwelling older adults using the Timed Up & Go Test. Phys Ther. 2000; 80:896 –903. 27 Medell JL, Alexander NB. A clinical measure of maximal and rapid stepping in older women. J Gerontol A Biol Sci Med Sci. 2000;55:M429 –M433. 28 Cho BL, Scarpace D, Alexander NB. Tests of stepping as indicators of mobility, balance, and fall risk in balance-impaired older adults. J Am Geriatr Soc. 2004;52: 1168 –1173. 29 Schulz BW, Ashton-Miller JA, Alexander NB. Maximum step length: relationships to age and knee and hip extensor capacities. Clin Biomech (Bristol, Avon). 2007;22:689–696. 30 Dean JC, Kuo AD, Alexander NB. Agerelated changes in maximal hip strength and movement speed. J Gerontol A Biol Sci Med Sci. 2004;59:286 –292. 31 Symons TB, Vandervoort AA, Rice CL, et al. Reliability of a single-session isokinetic and isometric strength measurement protocol in older men. J Gerontol A Biol Sci Med Sci. 2005;60:114 –119. 32 Myers RH. Classical and Modern Regression With Applications. 2nd ed. Boston, MA: Duxbury Press; 1990. 33 Janssen I, Heymsfield SB, Ross R. Low relative skeletal muscle mass (sarcopenia) in older persons is associated with functional impairment and physical disability. J Am Geriatr Soc. 2002;50:889 – 896. 34 Moxley Scarborough D, Krebs DE, Harris BA. Quadriceps muscle strength and dynamic stability in elderly persons. Gait Posture. 1999;10:10 –20. 35 Buchner DM, Larson EB, Wagner EH, et al. Evidence for a non-linear relationship between leg strength and gait speed. Age Ageing. 1996;25:386 –391. 36 Hurley MV, Rees J, Newham DJ. Quadriceps function, proprioceptive acuity and functional performance in healthy young, middle-aged and elderly subjects. Age Ageing. 1998;27:55– 62. 37 Tinetti ME, Williams TF, Mayewski R. Fall risk index for elderly patients based on number of chronic disabilities. Am J Med. 1986;80:429 – 434. 38 Pijnappels M, van der Burg PJ, Reeves ND, van Diee¨n JH. Identification of elderly fallers by muscle strength measures. Eur J Appl Physiol. 2008;102:585–592. 39 Riemann BL, Myers JB, Lephart SM. Comparison of the ankle, knee, hip, and trunk corrective action shown during single-leg stance on firm, foam, and multiaxial surfaces. Arch Phys Med Rehabil. 2003;84:90 –95.

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Research Report Novice and Experienced Physical Therapist Clinicians: A Comparison of How Reflection Is Used to Inform the Clinical Decision-Making Process Susan Flannery Wainwright, Katherine F. Shepard, Laurinda B. Harman, James Stephens

Background. Prior experience informs clinical decision making and shapes how reflection is used by novice and experienced physical therapist clinicians. Objectives. The aims of this research were: (1) to determine the types and extent of reflection that informs the clinical decision-making process and (2) to compare the use of reflection to direct and assess clinical decisions made by novice and experienced physical therapists.

Design. Qualitative research methods using grounded theory were used to gain insight into how physical therapists use reflection to inform clinical decision making.

Methods. Three participant pairs (each pair consisting of one novice and one experienced physical therapist) were purposively selected from 3 inpatient rehabilitation settings. Case summaries of each participant provided the basis for within- and across-case analysis. Credibility of these results was established through member check of the case summaries, presentation of low-inference data, and triangulation across multiple data sources and within and across the participant groups.

Results. Although all participants engaged in reflection-on-action, the experienced participants did so with greater frequency. The experienced participants were distinguished by their use of reflection-in-action and self-assessment during therapistpatient interactions. An intermediate effect beyond novice practice was observed.

Conclusions. The results of this study may be used by educators and employers to develop and structure learning experiences and mentoring opportunities to facilitate clinical decision-making abilities and the development of the skills necessary for reflection in students and novice practitioners.

S.F. Wainwright, PT, PhD, is Assistant Professor, Department of Physical Therapy, University of the Sciences in Philadelphia, 600 South 43rd St, Philadelphia, PA 19104 (USA). Address all correspondence to Dr Wainwright at: [email protected]. K.F. Shepard, PT, PhD, FAPTA, is Professor Emeritus, Department of Physical Therapy, Temple University, Philadelphia, Pennsylvania. L.B. Harman, PhD, RHIA, is Associate Professor and Chair, Department of Health Information Management, Temple University. J. Stephens, PT, PhD, CFP, is Senior Physical Therapist, Movement Learning and Rehab, Havertown, Pennsylvania. [Wainwright SF, Shepard KF, Harman LB, Stephens J. Novice and experienced physical therapist clinicians: a comparison of how reflection is used to inform the clinical decision-making process. Phys Ther. 2010;90:75– 88.] © 2010 American Physical Therapy Association

Post a Rapid Response or find The Bottom Line: www.ptjournal.org January 2010

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Use of Reflection in Clinical Decision Making

H

ealth care providers face many challenges in the current health care environment. These challenges include an expanding body of medical knowledge, an explosion of technology, an aging population facing diverse health problems in large numbers, and shrinking financial resources for medical care. Within physical therapy, the scope of practice has evolved toward autonomous practice with legislation in 44 states that allows independent physical therapist practice.1 These trends require that practitioners demonstrate a higher degree of independent clinical decision making specific to patient/client management.

Figure 1. Scho¨n’s model of reflective practice.2

Theories of Reflection Scho ¨ n2 identified 3 elements of reflection: active engagement in intellectual processes, exploration of problems or experiences, and a subsequent changed perspective or new insights. At the highest level of cognitive analysis, reflection integrates theory and practice, which is necessary to achieve a changed conceptual perspective.3 Scho ¨ n’s stages of the reflection process (Fig. 1) represent component abilities that are necessary for lifelong learning and professional growth.4 This process begins with the knowledge and skills (knowledge-in-action [KIA]) that a professional possesses and uses within a given context. Surprise occurs when an unexpected or novel problem is encountered, and experimentation arises when a solution to a problem is attempted. Within this

Available With This Article at ptjournal.apta.org • Audio Abstracts Podcast This article was published ahead of print on November 19, 2009, at ptjournal.apta.org.

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model, reflection guides and informs the clinical decision-making process. Reflection-in-action (RIA) is the ongoing meta-cognition about what is occurring during patient-therapist interaction and often informs the process of experimentation. Reflectionon-action (ROA) occurs as an individual looks back on what occurred and often results in a broadened or revised clinical decisionmaking framework. Progression through the 5 stages of this model may depend upon an individual’s level of expertise, as well as the novelty of the clinical experience. For example, the stages of surprise and experimentation are most evident with novice learners.5 As learners gain more experience, they are less likely to be surprised by novel situations because they have a greater breadth of prior experiences that provides an associative frame of reference. Thus, they have less need for experimentation and are surprised less frequently. Conversely, novel experiences cause surprise, uncertainty and experimentation in experienced as well as novice clinicians.5,6

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There are skills that are necessary for effective reflection (Tab. 1).7 These skills represent a progression from the foundation of self-awareness upon which critical analysis of information supports the ability to make value judgments. Differences in characteristics of novice and experienced clinicians influence how professionals engage in reflection and are likely related to their varied skill levels. Novices often start their reflection at the level of calculative rather than contemplative thinking.8 Furthermore, the type of thinking that directs decisions may be related to the phase of a person’s professional development.9 This is evidenced in novice clinicians, who are prone to make errors in clinical decision making and have limited knowledge and decreased ability to recall what they have learned compared with expert clinicians.10 Over time, there is a transition away from the hypothetico-deductive reasoning processes used by novices to the forward reasoning processes evidenced by expert clinicians. “Expert” knowledge is characterized by the development of causal networks of knowledge that evolve into illness scripts January 2010

Use of Reflection in Clinical Decision Making Table 1. Skills Needed for Reflection7 Skill

Description

Self-awareness

The ability to assess how the situation has affected the person and how the person has affected the situation.

Description

The ability to recognize and recall salient events.

Critical analysis

The ability to examine, identify, challenge assumptions, and imagine and explore alternatives.

Synthesis

The ability to integrate new knowledge with existing knowledge and to use knowledge to solve problems and make predictions.

Evaluation

The ability to make judgments about the value of something.

that guide clinical decision making as clinicians gain more experience.11,12

and affective attributes of expert clinicians.18,19,27,28

Relationship Between Clinical Decision Making and Reflection

Although “reflection” is not a term included in clinical decision-making definitions, it is integral to the thought processes of experts.30 Just as effective clinical reasoning is seen to be central to professional autonomy, reflection is a necessary component of developing reasoning skills consistent with expert practice. Insight into how the skills necessary for effective clinical decision making and reflection evolve as individuals develop professionally provides insight into this crucial link between the 2 processes.

Clinical decision making is defined at the most basic level as “reasoning that results in action.”13(p10) Three important premises are assumed about clinical decision making: (1) thought leading to action requires deliberation about an appropriate course of action and occurs within a specific context, and there is an anticipated outcome; (2) the nature of the thought, as well as the subsequent action, is tied to prior personal and professional experiences of the learner; and (3) prior experiences provide the framework against which an appropriate plan of action is developed. Clinical reasoning models incorporate these premises by explicating the cognitive processes and activities that are used to arrive at an appropriate medical diagnosis11 or engage in the patient/client management.14 How individuals within the health care professions develop the attributes of expert practice has been studied.9 –12,15–32 Research on clinical decision making in medicine has focused on reasoning processes used by practitioners,10,12 studies within the nursing field have focused on quantifying the use of clinical decision making,21–26 and studies within the field of physical therapy have focused on defining behaviors January 2010

Development of Clinician Decision Making and Reflection Clinical decision-making skills evolve along a continuum as practitioners gain experience. The literature has identified clinical decision-making skills and abilities,9 –12 as well as the attributes of practitioners,27,28 consistent with expert practice. Although previous studies have described attributes and performance levels across novice, experienced, and expert practitioners, there is limited insight into how expertise is developed. Within the field of medicine, the development of expertise has been tied to experience rather than the attainment of domain-specific knowledge11 and is likely driven by noncognitive factors such as the nature of the knowledge domain, prior experience, and the

acquisition of established group norms.10 The process of evolving expertise is theorized to occur in stages that are characterized by distinct knowledge and skills possessed by individuals with similar experience.9,10 Progression from one stage to another (novice 3 intermediate 3 expert) occurs with experience as the knowledge and skills necessary to advance decision-making abilities are developed. This stage theory provides a framework to explain the differences observed between novice and expert practitioners. Steinberg31 suggested that skills are components of abilities and that these abilities are the building blocks of expert practice. Furthermore, he proposed that study of abilities and achievements may prove to be an effective measure of developing expertise. These differences in abilities has been established in the study of novice and expert physical therapist clinicians.27,28,32

Attributes of Reflective Practice The attributes of self-assessment and autonomous behaviors exemplified by expert physical therapist clinicians illustrate the importance of reflection in clinical decision making. Expert physical therapists use more of their treatment time to engage in direct patient treatment, handle environmental interruptions without disrupting treatment, use social interaction as a means of eliciting information from the patient as well as providing information, and provide

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Use of Reflection in Clinical Decision Making Table 2. Novice and Experienced Participant Characteristicsa

Pseudonym

a

Age (y)

Sex

Galway

26–30

Male

Years of Experience as a Physical Therapist

Other Physical Therapy Employment

EntryLevel Education

⬍1

No

DPT

No

Post–Entry-Level Education

Cavan

26–30

Female

⬍1

Yes

DPT

No

Kerry

26–30

Female

⬍1

No

DPT

No

Mayo

31–35

Male

8

No

MPT

No

Dara

31–35

Female

8

Yes

MPT

No

Cork

36–40

Male

8

Yes

MPT

t-DPT

MPT⫽master of physical therapy, DPT⫽doctor of physical therapy, t-DPT⫽transitional doctor of physical therapy.

more frequent and integrated cues and encouragement.27,28 They also engage in “dialectical reasoning,” characterized by the use and integration of a variety of knowledge paradigms to arrive at a clinical decision.33 This higher level of reasoning is consistent with the illness scripts5 and biomedical knowledge propositions10 identified in the medical literature. Although the clinical decisionmaking abilities of individuals at a given point on the continuum of clinical practice have been studied, there is a gap in the understanding of how clinical decision-making abilities evolve as an individual transitions from novice toward expert clinical practice. The underlying assumption that guides this research study is that reflection informs the clinical decision-making processes of health care professionals. The constructs of reflection described in Scho ¨ n’s model defined the elements, as well as bounded this study.34 There were 2 primary research aims. The first aim was to determine the types of reflection and to what extent reflection informs the clinical decision-making process of physical therapist clinicians. The second aim was to determine how reflection is used to direct and assess the clinical decisions made by novice

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clinicians compared with experienced clinicians.

Method Grounded theory method35,36 and data collection from the clinician’s perspective37 within the phenomenologic philosophy were central to meeting the research aims of this study. The primary researcher (S.F.W.) gained insight into participants’ KIA and RIA and how they subsequently dealt with “surprise” and “experimentation” through observation of evaluation and treatment sessions. Insight into the participants’ use of ROA and selfawareness of their use of RIA was gained through semi-structured participant interviews. Participants Purposive sampling techniques37,38 were used to elicit participation from 3 clinician pairs, consisting of 1 novice (⬍1 year of experience) and 1 experienced physical therapist (⬎8 years of experience),20 from 3 inpatient acute rehabilitation centers (Tab. 2). These 3 participant pairs met the following inclusion criteria: currently treated patients following a cerebrovascular accident (CVA) and had primary clinical experiences in neurologic physical therapy in an inpatient rehabilitation setting. Fifteen clinical sites across 3 states were

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contacted to yield 3 participant pairs meeting the inclusion criteria. Inpatient acute neurologic rehabilitation settings were selected for 2 reasons. First, less work is done on the development of expertise in these settings.20 Second, the researcher’s primary clinical experience was with patients with CVA in these clinical settings. This shared knowledge facilitated insight into the participants’ clinical decision-making process. Selecting one pair from each clinical site served to minimize the effects of varied prior experience, while recruiting from 3 different clinical sites provided opportunity for observation across a breadth of clinical environments. Each clinical site afforded the participant pair unique clinical experiences, supervision structures, and mentorship opportunities. Data Collection and Management Informed consent and permission to videotape were obtained from each therapist and patient, and additional permission to audiotape was obtained from the therapists. The sources of data and the sequence of the data collection process are detailed in Figure 2. The data collection process is detailed in Appendix 1. Two separate sessions, one evaluation and one treatment, between

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Use of Reflection in Clinical Decision Making

Figure 2. Flow diagram of the elements of data collection process.

each therapist and patient after CVA were videotaped. Prior to each interview, the researcher used field notes to select portions of the videotape to view with each participant in separate audiotaped, semi-structured interviews (Appendix 2).39 Videotaped segments included activities with which each participant began the session and transitions that occurred throughout each session. For example, each videotape review of an evaluation began with the patient January 2010

interview to prompt discussion of each participant’s approach to evaluation. Subsequent preselected video clips were representative of impairments and functional limitations examined. Occasionally, comments made by the participants during the interview directed review of videotape segments not selected for review by the researcher, which affirmed that decision making from the participants’ perspectives was recognized. A re´sume´ sort was com-

pleted in a third audiotaped, semistructured interview (Appendix 3). All 3 audiotaped interviews were transcribed verbatim. Interview data were triangulated with artifact data (medical records and participant re´sume´) and the researcher’s field notes and reflective memos. Data Analysis An iterative process of coding a subset of the data and discussion between the researcher and a peer ex-

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Use of Reflection in Clinical Decision Making Table 3. Axial Code Category “Reflection,” Corresponding Open Codes, Definitions, and Sample Quotes Open Code

Definition

Sample Quotes

Reflection-in-action (RIA)

Analyzing the effectiveness of one’s own cues, handling as well as patient performance and behaviors; decisions are made and interventions may be modified.

• “Even when I do it, I’m thinking, ‘What am I doing?’” • “In order to reflect, you have to appropriately observe the activity.”

Reflection-on-specific action (ROSA)

Thinking about clinician-patient interaction and performance once the treatment session is over. Affirm plan of care or modify it based on the assessment made.

• “And then asking ‘Did this work? Did this not work? What should I try next time?’” • “So when I do an activity, I ask myself, ‘Why did that happen?’”

Reflection-on-professional experience (ROPE)

Thinking about prior experiences that lead to ways of thinking about clinical decision making and professional practice that is broader than one-on-one practice

• “A Fay Horak course . . . and it was just one of those mind-bending experiences. . . . I had a bunch of patients . . . I went on Friday and came back on Monday and treated them totally differently.”

pert resulted in development and refinement of a coding scheme representative of the participants’ views. All subsequent data were read and coded line by line. Qualitative data management software (NVivo 6)* was used during the process of open and axial coding. Through this iterative process of coding, themes representative of the types of reflection that participants applied to their clinical decision-making process emerged from the data. A case summary that integrated portions of the 3 interviews with demographic and artifact data, field notes, and reflective memos was developed for each participant. These case summaries provided the basis for thematic analysis and for within- and across-case analysis between the novice and experienced groups. Establishing Scientific Rigor Reliability of this coding scheme was confirmed by percentage of agreement among researchers of 86.4%, with a kappa value of .85, which represents excellent agreement.35 Trustworthiness of the data was ensured through member checks of the case summaries and presentation of low-inference data.37,38,40 Each participant reviewed his or her case * QSR International Pty Ltd, 2nd Floor, 651 Doncaster Rd, Doncaster, Victoria 3108, Australia.

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summary and affirmed that the researcher accurately represented his or her thoughts and words. Credibility of the data was ensured through ongoing peer assessment by an experienced qualitative researcher during all phases of the research study. Strategies to reduce researcher bias included reflexive bracketing and maintenance of a log that included memos, field notes, and a reflective journal.37,38

Results The data presented here are part of a larger study of the differences in clinical decision-making abilities between novice and experienced clinicians.41 These data illustrate the theme of reflection as it is used to inform the clinical decision-making process (Tab. 3). The participants described and engaged in 3 different types of reflection. Participants expressed ROA 2 different ways. Reflection-on-specific action (ROSA) included thinking back upon interaction with a specific patient for the purpose of affirming the plan of care or modifying it based on the assessment made. Reflection-on-professional experience (ROPE) encompassed broad comments about prior experiences that informed clinical decision making and professional practice. Although there were differences between novice and experienced clini-

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cians, all participants demonstrated ROPE and ROSA. In contrast, all of the experienced participants and only one of the novice participants engaged in RIA in a manner consistent with Scho ¨ n’s model. Reflection-on-Specific Action This type of reflection demonstrated the highest degree of consistency across the novice and experienced practitioners. When asked to define reflection, all participants gave definitions that were consistent with ROSA. Novice and experienced participants described using reflection to gain insight into their actions and thoughts. This reflection occurred away from the patient-therapist interaction and included assessment of their own performance (or thought process), as well as assessment of the patient’s performance. Their insights often were used to refine future actions or thought processes. The following excerpts illustrate how novice and experienced participants defined reflection: Reflection would be after the fact, looking back on either your treatment sessions or your interactions with the patient, with co-workers . . . . Anything that you could have done differently to make your next session better. (Novice participant—Galway 3:20 –24)

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Use of Reflection in Clinical Decision Making Reflection to me is looking back at what just happened, or may have happened a long time ago. In order to reflect, you have to appropriately observe the activity. I think that comes with experience. You have to be a critical observer and know what you saw to be able to look back on it later while you’re not currently looking at it. (Experienced participant—Mayo 3:43– 47)

Across both groups, the participants’ use of ROSA informed their clinical decision making. The examples below illustrate how both novice and experienced participants used these think-aloud processes with reference to the specific tasks observed on videotape during the interviews to assess, evaluate, and redirect their clinical decision making. Cavan exemplified the novices’ use of ROSA within the context of specific therapeutic procedures as she described an ambulation activity: I guess if I say “Step,” I tried to move her hip if she wasn’t moving her right leg forward. I kind of started backing off of the cues and just let her think, because I think it distracts her too much—the more you cue her, and then she doesn’t always get it. And then she just wants to do her own thing anyway. So I’ve really backed off on it (verbal cues) unless it’s really necessary. (Novice participant—Cavan 2:196 –201)

Dara demonstrated how the experienced participants engaged in ROSA to explain treatment activities within the broader context of physical therapy goals: Because her mobility was so limited and our goals are improving transfers and potentially getting standing a little more functional, she needs tons of repetition to get it. So I think that’s why for her I did a lot of repetition and the same sequence of things so she knows what to expect. We may vary one thing, but we don’t vary 6 things so that she can anticipate what is going to happen and that way not

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be so frightened by 17 new things versus just one new thing that I add each time. (Experienced participant—Dara 2:79 –91)

Reflection-on-Professional Experience Although both the novice and experienced groups reflected on their prior experiences and professional development, the experienced practitioners discussed this 3 or 4 times more often compared with their novice counterparts. During the semistructured interviews, all participants engaged in meta-cognitive thinking beyond their reflection on patient/client management issues. The novice participants described their professional growth within the context of their evolving clinical decision-making abilities and hands-on skills. Novice reflections on professional growth are characterized by Kerry’s and Galway’s statements below: I think maybe in a sense to have confidence in myself and that I’ve experienced a lot in the 6 months that I’ve been here. And I do think that there is a certain point where patients do plateau and . . . unfortunately not everybody is there with cognitive insight into what’s what. But you still have to give it your best shot and go with your gut and just do the best you can. (Novice participant—Kerry 3:278 –285) I think that’s one of our biggest jobs as physical therapists—to facilitate the patients learning it and figuring out differences in their gait or whatever functional test they’re doing rather than giving them the answer every time. And I like to start to do that early on because if you start giving them answers right off the bat, then people are going to become dependent on that. That’s my belief. (Novice participant—Galway 1:156 –165)

As these 3 novice clinicians reflected on their own clinical practice, they provided a candid self-evaluation of their abilities as autonomous practi-

tioners. Kerry’s comment exemplifies these novice views: I think it’s funny because when I first started, I felt like I was still a student because I had only started . . . 3 weeks after I was done with my last internship. And then when my mentor wasn’t here any more, it was like, “Oh my gosh. I’m responsible for these patients now.” I realize that I have to be responsible for my own learning. I can’t just ask people for help all the time. It’s more of a giveand-take. (Novice participant—Kerry 2:62– 67)

The experienced participants reflected upon how they have evolved as clinicians and developed their clinical philosophy and approach in working with their patients. The experienced participants’ reflections on practice included thoughts on their goals for interactions with patients and their philosophy about patient management, as detailed below: I think that I develop a relationship with them [patients] once I meet them. I think you gain their confidence in you. I think once they’re comfortable with you, they feel confident to move in front of you. It’s like a friendly relationship. Then we talk about what we’re going to do. It’s sort of natural, actually. You just jump in there. I guess my main concern is to try to instill confidence in them, their confidence in me and my skills. Then, they’ll be willing to take a chance. Once you establish that level of confidence, then no matter what you ask them to do or how you challenge them, they know they’re going to be safe with you. (Experienced participant—Dara 1:16 –28) I like to repeat the same thing with the same patient because then I can see progress. The same order, the same exercises. Now some people say you should vary your treatment sessions. And I do agree with that to some extent. But for me to evaluate progress, it’s really nice to do the same things. And also to be able

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Use of Reflection in Clinical Decision Making to . . . know when they’re going to be safe. (Experienced participant—Mayo 2:434 – 444)

Reflection-in-Action The use of RIA was a discriminator between novice and experienced participants. Although all 3 experienced participants demonstrated RIA, only one novice participant (Galway) demonstrated RIA during the therapist-patient interactions. There were differences in how this novice participant used RIA compared with the experienced participants. Galway used RIA to assess a patient’s performance relative to his expectations about the patient’s abilities. The excerpt below illustrates Galway’s think-aloud analysis of his thoughts during the therapistpatient interaction about the patient’s need for an assistive device during ambulation. Because I am taking the information that I got originally and use that to decide “Okay, I want to use the hemiwalker.” Let’s start off with that, and (the patient) presents a certain way with that. And I think to myself, “He’s doing well. Let’s see how he does with his original assistive device and see if there is any difference.” And, if you recall, there wasn’t much of a difference. (Novice participant—Galway 3:38 – 43)

The excerpt below from an experienced clinician illustrates similarities with Galway’s use of RIA when addressing patient performance and direction of the treatment session: Ambulation for her, as you saw, is not functional. In a sense, if you just saw that, even when I do it, I’m thinking “What am I doing?” sometimes. But it’s motivating to her. So I almost do it as a way to provide some encouragement. (Experienced participant— Dara 1:213–216)

The experienced participants used RIA not only to assess their patient’s performance as the novice partici82

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pant did but also to assess their own thought processes and actions. These assessments were ongoing throughout the treatment session and effected change in the therapistpatient interaction as necessary. During an interview, Mayo described these thought processes as being very “fluid . . . not something that I was consciously thinking about.” (Field note 2IE.) The following excerpts illustrate how RIA was used by experienced participants in ongoing self-assessment of their performance during interactions with patients: And I just didn’t understand why. Why was I not able to get him (the patient) to verbally do it? And show him. What wasn’t I doing that would enable him to do the activity that I wanted him to do? There had to be something in the way I was saying it or the way I was showing it that was confusing him. I think that I tried to simplify it, but I’m not sure. I tried some different verbal and tactile commands. (Experienced participant— Mayo 2:123–128) You know, the first time I see someone like her, maybe I would switch up every session and go “Wow, why am I getting nowhere?” . . . and let me think “If I keep these 7 things the same, will I get more carryover? (Experienced participant—Dara 2:101–104) There was a point what I felt what I thought was clonus, but I wasn’t sure that that was what I felt because I tested it and it was there, and then I tested it again and it wasn’t. It was just a weird 2-beat sort of resistance. And then I also felt it on the left. So that might have been my “Huh.” I wasn’t expecting it, and I certainly wasn’t expecting it on both sides. (Experienced participant—Cork 1 and 2:95–100)

Discussion Scho ¨ n’s model of the reflective process2 was the framework used to study the attributes and behaviors of the participants. Across-case analysis between the novice and experi-

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enced groups identified similarities and differences in how these participants used reflection throughout the clinical decision-making process. Novice and experienced participants provided exemplar definitions that described activities that occurred away from the therapist-patient interaction and that affirmed or clarified a course of action. These exemplars were consistent with ROA activity and existing definitions of reflection.2,15 Furthermore, these definitions were consistent with the attributes of moral imagination42 and mindfulness43 that are integral to the reflective process. What did emerge from the data was a differentiation between the types of ROA in which these participants engaged: ROSA and ROPE. Thus, these data support a more discrete delineation of ROA as described in Scho ¨ n’s model. The factor of ROPE emerged from the remarks made by the participants about their professional development and abilities as clinicians. This factor and the participants’ comments are consistent with Resnick and Jensen’s definition of “reflection on practice.”29 Again, differences were noted between the novice and experienced groups. The novice participants’ reflections were specific to themselves and their performance with patients. In addition to echoing the novice participants’ comments, the experienced participants also were reflective about their abilities within the scope of contemporary clinical practice. The experienced participants demonstrated the ability to integrate and use information from multiple sources. The differences between the 2 groups about how they reflect on their professional experience are shaped by the depth and breadth of their prior experiences. The most notable difference between the 2 groups was the use of RIA during the clinical decisionJanuary 2010

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Figure 3. Evolution of initial conceptual framework to revised conceptual framework: the use of reflection to inform the clinical decision-making process within the patient/client management model.

making process. The experienced participants’ use of RIA to assess their own performance is consistent with the results of a previous study19 in which experienced pediatric physical therapists used selfmonitoring twice as often as the novice therapists studied. Although the frequency of use of RIA by the novice participants in the current study did not equal that of the novice participants in previous study, the observed phenomenon is parallel. Despite the fact that the purposive sampling techniques did not attempt to select physical therapists that were identified as experts, the experienced participants demonstrated some abilities consistent with expert practice.9,19,25–28 Galway, the only novice participant who engaged in RIA, demonstrated abilities that were more consistent with intermediate practice.10,30 Galway’s use of RIA is likely related to the nature and depth of his professional experience. Galway was employed in a physical therapist practice for 2 years prior to beginning his physical therapy education. He identified positive mentoring experiences and the length of time he spent in these clinical environments as essential to the development of his decision-making and reflective abilities (re´sume´ sort, inJanuary 2010

terview 3). The other novice participants did not have the depth or breadth of such prior experiences. Although this does not indicate that the novice participants are not reflective during treatment sessions, it may indicate that they are not using ongoing, simultaneous reflective activities to evaluate their decision making during the therapist-patient interaction. The evolution from the initial to the revised conceptual framework is illustrated in Figure 3. Throughout this study, the initial conceptual framework was revised to illustrate the different types of reflection used to inform clinical decision making across the spectrum of prior experience to achieve the outcomes of effective patient management. Although it is beyond the scope of this article to detail the prior experiences of these participants, the role that these experiences have on developing both reflective and clinical decision-making abilities is depicted. These reflective activities inform decision making with the outcome of each participant working toward achieving his or her perceived optimal patient outcomes through effective patient management.

The common thread in the differences between the types of reflection used by the novice and experienced participants is the depth and breadth of experiences in which each participant has had the opportunity to be engaged. At the most basic level, it is necessary to have sufficient time to engage in reflective activities.44 The novice participants’ experiences with mentorship seemed to have provided them with this opportunity. All of the novice participants benefited from mentorship on clinical affiliation or with their employment. These mentoring activities provided them with the opportunity to engage in ROA activities with their mentors. Cavan described her experience with mentoring in the following way: No, I still need help. I still miss things. That’s why I need Meath [Clinical Supervisor] and Monaghan [Clinical Specialist], to bounce ideas off of them . . . and maturing is a big part of it. (Novice participant—Cavan 2:229 –231)

Insight into how clinicians use reflection is important because reflection is central the development of clinical decision-making skills consistent with expert practice. It has been recognized that the overemphasis on

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Use of Reflection in Clinical Decision Making knowledge and skill acquisition in curricula occurs at the expense of the development of the abilities and attributes consistent with reflective practice.45,46 The development of these skills of reflection is necessary to take assessment and decision making in the clinical setting beyond textbook knowledge to patient management that recognizes the values, ethics, and preferences of the participants. Thus, there is a need for the development of attributes consistent with “indeterminate zones of practice,”10,12 as well as those processes used by expert clinicians.2,9,28 These data allude to the importance of experience to develop the skills necessary for intermediate and, ultimately, expert practice. The participants all demonstrated skills consistent with Goodman and Boud.7 The experienced participants were observed to use all of these skills during their interactions with patients. They applied these skills during think-aloud activities while observing themselves interacting with patients. In contrast, the novice participants are continuing to develop but have not yet mastered these skills. For example, when providing description about what they observe in their interactions with a patient, the novice participants often attend to one particular event rather than all of the salient events, or when evaluating a clinical problem, their limited experience may result in uncertainty about the judgments they make that affect patient care. The skill that most clearly differentiates the novice from the experienced participants is self-assessment. It is only through effective self-assessment that clinicians can effect change in their approach to patient management. The results of this study and earlier studies16,19,25,28,29 reveal that reflection affects patient outcome. Steinberg31 suggested that abilities, such as those necessary for reflec84

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tion, can be taught. Furthermore, Atkins and Murphy3 concluded that these skills and abilities should be taught so that reflection can be used as a learning tool during the education process. The opportunity and responsibility to provide the necessary experiences to develop these attributes lie with academic and clinical faculty involved in professional (entry-level) DPT education. There are several factors that should be integrated into the education of students and the professional development of novice practitioners. First, curricula should establish explicit goals for decision-making processes and the practice of reflection and develop intentional instructional and assessment activities to meet these goals. Such instructional activities should incorporate metacognition through think-aloud processes modeled by faculty and put into practice by students.47 Providing intentional learning opportunities in these skills may assist novice learners in mastering strategies for clinical decision making consistent with the strategies used by experts. Because reflection requires active participation and commitment from the individual engaged in the activity, time is the second factor necessary for success.44,48 The need to take time to reflect should be made explicit and modeled for novices. Too often traditional classroom and clinical settings do not afford the time necessary for the consideration of thoughts or feelings in the clinical decision-making process.45 Allowing students the opportunity to develop these abilities and attributes while expanding their knowledge base may facilitate their effectiveness in patient/client management. Third, benchmark performance should be assessed relative to established academic or clinical course objectives49 or curriculum out-

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comes. Finally, academic and clinical faculty should engage in their own professional development to prepare to teach these skills and model the appropriate behaviors.50 This study has provided a deeper understanding of how novice and experienced physical therapists use reflection to inform the clinical decision-making process. Although the research design afforded the opportunity to observe each participant with one patient over 2 physical therapy sessions, doing so may have narrowed the breadth of the participants’ perspectives on clinical decision making, as the interviews were grounded in the participants’ observations and think-aloud processes specific to the videotaped session. Observation and data collection in one type of clinical setting increased the likelihood of similar clinical experiences among the participants, but may have limited the extent to which these results may be applied to clinicians in other clinical settings. These limitations are not of a nature that prevent using the results of this study to lay the groundwork for further study of the use of reflection as it informs the clinical decision-making process. Consistent with qualitative research methods, purposive sampling criteria for type and length of experience within this clinical setting were applied to recruit these 3 pairs of clinicians. Although in-depth study of their clinical practice revealed consistent themes between the experienced and novice groups, the generalizability of these results for clinicians of similar experience levels in other clinical settings must be determined by the reader. Insight into the differences in abilities and the varied depth and breadth of experiences between the novice and experienced groups provides a framework to develop learnJanuary 2010

Use of Reflection in Clinical Decision Making ing experiences and opportunities for students and novice clinicians. This research provides information to educators, novice clinicians, and the clinicians who mentor these novices that may facilitate the development of mature clinical decisionmaking abilities. All authors provided concept/idea/research design. Dr Wainwright, Dr Harman, and Dr Stephens provided writing. Dr Wainwright provided data collection and project management. Dr Wainwright and Dr Shepard provided data analysis. Dr Shepard, Dr Harman, and Dr Stephens provided consultation (including review of manuscript before submission). This work was conducted in partial fulfillment of the requirements for Dr Wainwright’s doctoral dissertation. Institutional review board approval was obtained from Temple University, the academic institution at which the research was conducted; from the University of the Sciences in Philadelphia, the academic institution where the primary researcher was employed; and from one of the clinical sites, which required its own institutional review board approval. A platform presentation of portions of this work was given at the Combined Sections Meeting of the American Physical Therapy Association; February 14 –18, 2007; Boston, Massachusetts. This article was received March 5, 2009, and was accepted August 15, 2009. DOI: 10.2522/ptj.20090077

References 1 Frequently asked questions on physical therapists’ services provided without referral. Available at: http://www.apta. org/AM/Template.cfm?Section⫽Home& TEMPLATE⫽/CM/ContentDisplay.cfm& CONTENTID⫽43257. Accessed March 5, 2009. 2 Scho ¨ n D. The Reflective Practitioner: How Professionals Think in Action. San Francisco, CA: Jossey-Bass Inc Publishers; 1983. 3 Atkins S, Murphy K. Reflection: a review of the literature. J Adv Nurs. 1993;18: 1188 –1192. 4 Scho ¨ n D. Educating the Reflective Practitioner. San Francisco, CA: Jossey-Bass Inc Publishers; 1987. 5 West AF, West RR. Clinical decision-making: coping with uncertainty. Postgrad Med J. 2002;78:319 –321.

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6 Rikers RM, Schmidt HG, Boshuizen HP, et al. The robustness of medical expertise: clinical case processing by medical expert and subexperts. Am J Psychol. 2002;115: 609 – 629. 7 Boud D, Keogh R, Walker D. Promoting reflection in learning: a model. In: Boud D, Keogh R, Walker D, eds. Reflection: Turning Experience Into Learning. London, United Kingdom: Kegan Page; 1985:18 – 40. 8 Heidegger M. Discourse on Thinking. New York, NY: Harper & Row; 1966. 9 Schmidt HG, Norman GR, Boshuizen HPA. A cognitive perspective in medical expertise: theory and implications. Acad Med. 1990;65:611– 621. 10 Patel VL, Groen GJ. Developmental accounts in the transition from medical student to doctor: some problems and suggestions. Med Educ. 1991;25:526 –535. 11 Elstein AS, Shulman LS, Sprafka SA. Medical problem solving. Eval Health Prof. 1990;13:5–36. 12 Boshuizen HPA, Schmidt HG. On the role of biomedical knowledge in clinical reasoning by experts, intermediates and novices. Cogn Sci. 1992;16:153–184. 13 Mattingly C, Fleming MH. Clinical Reasoning: Forms of Inquiry in a Therapeutic Practice. Philadelphia, PA: FA Davis Co; 1994. 14 Guide to Physical Therapist Practice. 2nd ed. Phys Ther. 2001;81:9 –746. 15 Boud D, Keogh R, Walker D, eds. Reflection: Turning Experience Into Learning. London, United Kingdom: Kegan Page; 1985. 16 Burnard P. Nurse educators’ perceptions of reflection and reflective practice: a report of a descriptive study. J Adv Nurs. 1995;21:1167–1174. 17 Dowie J, Elstein AS. Professional Judgment: A Reader in Clinical Decision Making. New York, NY: Cambridge University Press; 1988. 18 Payton O. Clinical reasoning process in physical therapy. Phys Ther. 1985;65: 924 –928. 19 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. 20 Jensen GM, Gwyer J, Hack LM, Shepard KF. Expertise in Physical Therapy. 2nd ed. St Louis, MO: Saunders Elsevier; 2007. 21 Martin C. The theory of critical thinking of nursing. Nurs Educ Perspect. 2002;23: 243–247. 22 Thompson C, McCaughan D, Cullum N, et al. Research information in nurses’ clinical decision making: what is useful? J Adv Nurs. 2001:36:376 –388. 23 Seymour B, Kinn S, Sutherland N. Valuing both critical and creative thinking in clinical practice: narrowing the research gap? J Adv Nurs. 2003;42;288 –296.

24 Hoffman K, Donoghue J, Duffield C. Decision making in clinical nursing: investigating contributing factors. J Adv Nurs. 2004; 5:53– 62. 25 Powell J. The reflective practitioner in nursing. J Adv Nurs. 1989;14:824 – 832. 26 Benner P, Tanner C, Chesla C. Expertise in Nursing Practice: Caring, Clinical Judgment and Ethics. New York, NY: Springer Publishing Co; 1996. 27 Jensen GM, Shepard KF, Hack LM. The novice versus the experienced clinician: insights into the work of the physical therapist. Phys Ther. 1990;70:314 –323. 28 Jensen GM, Gwyer J, Hack LM, Shepard KF. Attribute dimensions that distinguish master and novice physical therapy clinicians in orthopedic settings. Phys Ther. 1992;72:711–722. 29 Resnick L, Jensen GM. Using clinical outcomes to explore the theory of expert practice in physical therapy. Phys Ther. 2003;83:1090 –1106. 30 Elstein AS, Shulman LA, Sprafka SA. Medical Problem Solving: An Analysis of Clinical Reasoning. Cambridge, MA: Harvard University Press; 1978. 31 Steinberg R. Abilities are forms of developing expertise. Educational Researcher. 1998;27:11–19. 32 Riolo L. Skill differences in novice and expert clinicians in neurologic physical therapy. Neurol Rep. 1996;20:60 – 63. 33 Edwards I, Jones M, Carr J, et al. Clinical reasoning strategies in physical therapy. Phys Ther. 2004;84:312–335. 34 Miles MB, Huberman M. Qualitative Data Analysis. 2nd ed. Thousand Oaks, CA: Sage Publications; 1994. 35 Chenitz WC, Swanson JM. From Practice to Grounded Theory. Reading, MA: Addison-Wesley Publishers; 1986. 36 Shepard KF, Jensen GM, Schmoll BJ, et al. Alternative approaches to research in physical therapy: positivism and phenomenology. Phys Ther. 1993;73:88 –101. 37 Patton MQ. Qualitative Evaluation and Research Methods. 2nd ed. Thousand Oaks, CA: Sage Publications; 1990. 38 Morse JM, ed. Critical Issues in Qualitative Research. Thousand Oaks, CA: Sage Publications; 1994. 39 Rubin HJ, Rubin IS. Qualitative Interviewing: The Art of Hearing Data. Thousand Oaks, CA: Sage Publications; 1995. 40 Merriam SB. Case Study Research in Education. San Francisco, CA: Jossey-Bass Inc Publishers; 1988. 41 Wainwright SF. Novice and Experienced Physical Therapists: A Comparison of Clinical Decision Making Abilities [dissertation]. Ann Arbor, MI: ProQuest, UMI Dissertations Publishing; 2006. 42 Coles R. The moral education of medical students. Acad Med. 1999;8:55–57. 43 Epstein R. Mindful practice. JAMA. 1999; 282:833– 839. 44 Saylor CR. Reflection and professional education: art, science and competency. Nurse Educ. 1990;15:8 –11.

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Use of Reflection in Clinical Decision Making 45 Shepard KF, Jensen GM. Physical therapy curricula for the 1990s: educating the reflective practitioner. Phys Ther. 1990;70: 566 –577. 46 Pierson W. Reflection and nursing education. J Adv Nurs. 1998:27:165–170. 47 Musolino G, Mostrom E. Reflection and the scholarship of teaching, learning, and assessment. J Phys Ther Educ. 2005;19(3): 52– 66.

48 Blunden R. Reflective teaching and the beginning teacher: morality and methodology. Research & Reflection: A Journal of the Educational Praxis. 1997;1:1–19. 49 Santasier AM, Plack MM. Assessing professional behaviors using qualitative data analysis. J Phys Ther Educ. 2007;21(3): 29 –39.

50 Crandall S. How expert clinicians teach what they know. J Contin Educ Health Prof. 1993;13:85–98.

Appendix 1. Data Collection: Process and Sources Data Source

Description

Observation

The researcher observed and videotaped 2 interactions (one evaluation and one treatment session) between each physical therapist participant and one patient who had a diagnosis of cerebrovascular accident.

Interviews

Three semi-structured interviews were completed with each participant. Interviews were audiotaped and transcribed. Videotapes of the 2 physical therapy sessions were used during separate semi-structured interviews (Appendix 2) that occurred within 1 to 2 weeks from the observed session to gain insight into the patient-therapist interaction with respect to reflection and clinical reasoning from the participant’s perspective. In the third interview, participants were asked about their thoughts and use of clinical decision making and reflection and completed a re´sume´ sort (Appendix 3).

Artifacts

Re´sume´: Each participant’s re´sume´ was used to structure a re´sume´ sort. The purpose of the re´sume´ sort was to understand how prior experience shaped each participant’s abilities. The re´sume´ sort required the participant to categorize his or her personal and professional experiences as they related to the development of clinical decision making. Medical Record: The medical record was used to explore each participant’s clinical decision making through his or her documentation.

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Demographic Data Form

Each participant completed a questionnaire outlining his or her age, sex, years of experience as a physical therapist, employment at other clinical sites, professional (entry-level) degree, and participation in pursuit of post–entry-level credentialing.

Field Notes

During each treatment session, the researcher made field notes specific to observations and personal notes35,39 about the clinical environment and the interaction between the therapist and the patient. The value of these observations lies in the researcher’s ability to note occurrences, activities, or environmental artifacts or contexts.36

Reflective Memos

Throughout the data collection process, the researcher recorded insights gained through observation of and interaction with the participants.

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Use of Reflection in Clinical Decision Making Appendix 2. Semi-Structured Interview Question Guide: Think-Aloud Videotape Analysis Interviews

These 2 interviews were conducted within 1 week of each videotaped session. The questions were presented in a nonscheduled, nonstandardized format. Introduction: I have selected several portions of the videotape for you to review. I would like you to share your thoughts about what you were thinking while treating this patient. Do you have any questions? 1. What are you doing in this portion of the videotape? For what purpose are you doing this? What about this patient indicated that this would be an effective intervention? How did you come to know to try this? Where/from whom did you learn this? 2. I would like to move on to another segment. (This will occur numerous times throughout the interview.) Repeat questions above. 3. How does what is happening in this segment compare with what happened in the previous segment? 4. When do you opt to ______________ as compared with ________________? 5. Is this evaluation/treatment session indicative of a “typical” evaluation/treatment session? 6. How would you describe your clinical reasoning processes? That is, can you tell me step by step how you________________? How have these thought processes evolved? 7. If this is not a typical session, what was different about this treatment session? 8. Is there anything else you want to tell me about the treatment sessions and how you make clinical decisions?

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Use of Reflection in Clinical Decision Making Appendix 3. Semi-Structured Interview Question Guide: Role of Prior Experience on Development of Clinical Decision-Making and Reflection Processes Interview

Introduction: The purpose of this interview will be to gain insight into your thoughts about how your personal and professional experiences have shaped your clinical decision-making processes. 1. Tell me what you think clinical reasoning is. 2. What do you think reflection is? 3. How is clinical reasoning tied to reflection? Re´sume´ Sort Instructions: You have provided me with a copy of your re´sume´. I have placed each item on your re´sume´ on a separate card. I would like you to place each card on 1 of 3 piles: • Those experiences that have been most important in developing your clinical decision-making abilities. • Those experiences that have been somewhat important in developing your clinical decision-making abilities. • Those experiences that have not been important in developing your clinical decision-making abilities.

Re´sume´ Sort Questions: 4. You have identified X experiences as being most important in developing your clinical decision-making abilities. a. How were your clinical decision-making abilities developed during X experience? Y experience? Etc . . . b. What similarities were there between these experiences that you identified as most important? What differences? 5. You have identified X experiences as being somewhat important in developing your clinical decision-making abilities. a. How were your clinical decision-making abilities developed during X experience? Y experience? Etc . . . 6. You have identified X experiences as not being very important in developing your clinical decision-making abilities. a. How were your clinical decision-making abilities developed during X experience? Y experience? Etc . . . Exemplar Questions: I would like to you answer the following question. 7. Tell me about an instance when you used reflection to assess your clinical decision making through patient management. Closing Questions: 8. What would you tell a coworker who was thinking of taking this job with the goal of improving clinical decision-making and reflection skills? 9. Is there anything else you want to tell me about your use of clinical decision-making skills and reflection in patient management?

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Research Report

Walking Skill Can Be Assessed in Older Adults: Validity of the Figure-of-8 Walk Test Rebecca J. Hess, Jennifer S. Brach, Sara R. Piva, Jessie M. VanSwearingen

Background. The Figure-of-8 Walk Test (F8W) involves straight and curved paths and was designed to represent walking skill in everyday life. Objective. The purposes of this study were to validate the measure in older adults with walking difficulties and to explore correlates of the curved-path walking measure not represented by a straight-path walking measure.

Design. Fifty-one community-dwelling older adults with mobility disability participated in 2 baseline visits as part of an intervention study.

Methods. The F8W time, steps, and smoothness and measures of gait (gait speed, modified Gait Abnormality Rating Scale [GARS-M]), physical function (Late Life Function and Disabilities Index [LLFDI], Survey of Activities and Fear of Falling in the Elderly [SAFFE], Gait Efficacy Scale [GES], Physical Performance Test [PPT], and fall history), and movement control and planning (gait variability, Trail Making Test B [Trails B]) were recorded in each test session. Bivariate correlations for the F8W with each variable were conducted to examine concurrent and construct validity. Adjusted linear regression analyses were performed to explore the variance in mobility explained by F8W independent of gait speed.

Results. Figure-of-8 Walk Test time correlated with gait (gait speed, r⫽⫺.570;

R.J. Hess, BS, is a graduate physical therapist student in the Department of Physical Therapy, University of Pittsburgh, 6035 Forbes Tower, Pittsburgh, PA 15260 (USA). Address all correspondence to Ms Hess at: rjh22⫹@pitt.edu. J.S. Brach, PT, PhD, GCS, is Assistant Professor, University of Pittsburgh. S.R. Piva, PT, PhD, OCS, is Assistant Professor, University of Pittsburgh. J.M. VanSwearingen, PT, PhD, FAPTA, is Associate Professor, University of Pittsburgh. [Hess RJ, Brach JS, Piva SR, VanSwearingen JM. Walking skill can be assessed in older adults: validity of the Figure-of-8 Walk Test. Phys Ther. 2010;90:89 –99.] © 2010 American Physical Therapy Association

GARS-M, r⫽.281), physical function (LLFDI function, r⫽⫺.469; SAFFE restriction subscale, r⫽.370; PPT, r⫽⫺.353), confidence in walking (GES, r⫽⫺.468), and movement control (step length coefficient of variation, r⫽.279; step width coefficient of variation, r⫽⫺.277; Trails B, r⫽.351). Figure-of-8 Walk Test steps correlated with step width variability (r⫽⫺.339) and was related to fear of falling (t⫽⫺2.50). All correlations were significant (P⬍.05).

Limitations. This pilot study had a small sample size, and further research is needed.

Conclusions. The F8W is a valid measure of walking skill among older adults with mobility disability and may provide information complementary to gait speed.

Post a Rapid Response or find The Bottom Line: www.ptjournal.org January 2010

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Measuring Skill in Walking of Older Adults

W

alking is a complex motor skill, involving interactions between brain and body systems to walk and rapidly adapt to changes in conditions and the intent for walking.1–3 Subtle changes in walking skill (ie, slowing, greater variability) have been associated with fall risk,4 – 6 mobility and disability in activities of daily living,7,8 nursing home placement, and death.8 Most clinical measures of walking skill consist of straight-path walking,8 –11 yet activities of daily living in the home and community require curved-path walking ability (eg, walking around a table, avoiding obstacles, navigating street corners).12 Straight- and curved-path walking differ in gait characteristics and the distribution of body mass with respect to the base of support.12,13 In curved-path walking, shorter stride lengths occur for the inner leg than for the outer leg compared with straight-path walking, with the outer leg traversing a longer distance to round the curve.12 During curvedpath walking, the body’s center of mass shifts to the inner foot, with an increase in stance time for the inner foot.12 For circular walking in a counterclockwise direction, medial balance (center of mass distributed over the medial aspect of the foot) is the predominant pattern for the outer foot. Walking in a clockwise direction results in balance over the lateral aspect of the inner foot, whereas for straight-path walking, balance is more equitably shared by the medial and lateral aspects of both

Available With This Article at ptjournal.apta.org • Audio Abstracts Podcast This article was published ahead of print on November 26, 2009, at ptjournal.apta.org

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feet.13 Such gait adaptations for curved paths may be difficult for the older adult with mobility problems. Current gait assessment methods provide little or no account of the motor skills necessary for curved path walking. Daily life walking often involves the added complexity of walking while doing other activities (ie, dual-task or multi-task walking). A complex walking task may require a greater proportion of physical and mental capacity, resulting in decrements in gait performance not seen for simple walking tasks.14 Older adults with mobility problems may dedicate greater attention to gait while walking under challenging conditions, with the potential consequence of the competing cognitive demand for brain resources (eg, limited information-processing capacity) under complex, dual-task walking being a marked decline in walking performance for some older adults.11,14,15 In a previous study,16 walking while carrying objects or responding to visual or auditory signals has been a typical method of testing walking under complex, dual-task conditions; however, the dual-task walk tests occurred over straight paths. Navigating everyday life environments requires creating an internal (mental) map of the environment, planning the path and executing the walk (eg, walking through a grocery store, walking to a table to be seated in a restaurant). As such, daily life walking even without objects to carry or signals to respond to is, by nature, a dual-task or even multi-task activity.15 In the newly developed Figure-of-8 Walk Test (F8W), we combined curved-path walking and navigation to better test the complex walking abilities necessary for independence in daily walking activities. Mobility measures previously described, such as the Timed “Up &

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Go” Test (TUG),17 the Emory Functional Ambulation Profile (E-FAP),18 and the Dynamic Gait Index (DGI),19 involve walking about a curve. However, the curved path in the previous mobility measures is either a single turn or one task embedded in a composite measure,17–19 whereas the curved-path walking of the F8W involves curves in clockwise and counterclockwise directions and is the single mobility task of interest represented by the score. The purpose of this research was to determine the concurrent and construct validity of the F8W, which was designed to be used to assess curvedpath as well as straight-path walking skill necessary for daily life walking in older people with walking difficulties. We determined the concurrent validity of the F8W with established measures of gait and construct validity with measures of physical function in activities of daily living and measures of movement control and planning. Secondarily, we explored whether the F8W measure of curvedpath walking reflects components of physical function in daily life not represented by the gait speed measure of straight path walking by describing the relationships in common and different for the 2 measures with the constructs of mobility performance. We expected the F8W to correlate with established clinical measures of gait and with measures of physical function in daily living, especially instrumental activities of daily living, which include tasks that require curved-path walking ability. We also expected the F8W to correlate with measures of movement control and planning (ie, tasks requiring timing and coordination to adapt muscle activation and movements to changes in the task or conditions for performance, the ability to smoothly alternate movement direction, and the ability to recognize the demands of the task1,20), such as gait variability and executive function. January 2010

Measuring Skill in Walking of Older Adults

Figure 1. Figure-of-8 Walk Test design. Visual schematic of the test layout illustrating an example of a completed test. Cones are represented by the large Xs. Arrows illustrate steps taken and the direction of the walking path. Numbers correspond to steps taken (straight steps: 1, 2, 7, 8, 9, 15, and 16; curve steps: 3, 4, 5, 6, 10, 11, 12, 13, and 14).

Method Development of a Measure of Walking Skill: The F8W The F8W (Fig. 1) requires a person to walk a figure-of-8 around 2 cones placed 5 ft (1 ft⫽0.3048 m) apart. A figure-of-8 was chosen because: (1) the task is readily recognized by name alone; (2) the pattern consists of walking on curved paths, clockwise and counterclockwise, with straight-path walking between the curved paths; (3) alternation between straight and curved paths requires switching motor strategies, including biomechanical and movement control adjustments; and (4) motor planning is needed to navigate the straight and curved paths. Designed to be a measure of walking skill, we based scoring for the F8W on 3 components of skilled movement20: (1) speed (time for completion), 2) amplitude (number of steps taken), and 3) accuracy (a tight versus an overly wide curved path). The accuracy component was defined as follows: F8W completed within a 2-ft surround of the cones (yes or no) (Fig. 1). The 2-ft boundary was chosen to impose some level of difficulty and to constrain the task to a space believed to fit the confined space of clinical settings (eg, a hallway). January 2010

Highly skilled movement or walking also has been described as smooth.21 We included a rater-based score for “walking smoothness” (ie, the consistent, continuous forward progression and regular pattern of steps during walking) to explore this descriptor of motor skill in walking. The harmonic ratio of trunk acceleration has been used to quantify smoothness in laboratory measures of gait.21 We defined an observational, rater-based, 3-item smoothness component scale as completion of the F8W without stopping, hesitating, or changing pace. The 3 smoothness items are each scored as 0 (any difficulty) or 1 (no difficulty), for a total smoothness score ranging from 0 (not smooth) to 3 (smooth). Higher smoothness scores represent better performance. The F8W requires minimal equipment (2 cones [we also have used plastic cups as markers], stopwatch, tape measure), training, and time to complete and to score. The 5-ft distance between the cones was determined by asking individuals to walk a figure-of-8 around cones placed 4, 5, and 6 ft apart. The distance of 5 ft proved to be challenging but similarly completed by adults of different sizes and ages.

Administration of the F8W The F8W was verbally explained and demonstrated to the participants prior to performance. The participants were instructed: (1) to stand midway between the cones, facing outward from the plane of the cones; (2) to begin walking at their usual pace when ready, choosing the direction of the figure-of-8 walking path about the cones; and (3) to stop upon return to the start position. Recording of test measures began with the first step and continued until the last step brought the performer to side-by-side stance of the feet at the start position. We did not mark a start (or stop) position or the walking path in order to avoid influencing the movement planning for the task. Longer time and greater number of steps to complete the task and walking outside of the 2-ft surround from the cones correspond to poorer performance. The 2-ft surround test boundary was not marked on the course. The tester determined the 2-ft boundary area for the test setup and the relationships of the boundary to the testing space (eg, distance from the hallway walls, floor markings, or landmarks) prior to testing, and estimated whether the test was completed within the boundary by comparison with the tester’s mental map of the testing space. Reliability of the F8W The F8W’s interrater and betweensessions test-retest reliability were determined in a pilot study of gait variability in older adults with mobility disability (N⫽18; mean age [SD]⫽83.9 [4.1] years; mean gait speed [SD]⫽0.90 [0.20] m/s, range⫽0.60 –1.24 m/s).22 Participants were residents of a senior living community who had consented to participate in a study of walking ability.36 Two trials of the test were performed in both the initial baseline testing visit and the repeat baseline testing visit about 1 week later. The 2 trials in the initial visit were admin-

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Measuring Skill in Walking of Older Adults outside of the 2-ft boundary area. The ICCs (95% CI) for test-retest reliability were .84 (.62–.94), .82 (.59 – .93), and .61 (.19 –.84) for time, number of steps, and smoothness, respectively. Although the components of the F8W smoothness score are criterion-based, we justified the use of the ICC for determining agreement of the total smoothness score because the total score is rank ordered. However, we also provide Cohen kappa statistics for agreement for the smoothness scores: interrater agreement, kappa value⫽.40; testretest agreement, kappa value⫽.25. The low kappa values for interrater and test-retest reliability reflect the ambiguity of the 3 components of the smoothness score (hesitancy, stopping, and changing pace). The assessors rating smoothness reported difficulty distinguishing hesitancy and changing pace. For example, slowing of gait around a curve could be scored as hesitancy, or changing pace, or both. As a result of the pilot study trial of the F8W, the smoothness components were defined in greater detail: hesitancy⫽submovements, or extra movements, made to adjust position or to complete the curve about a marker; changes in pace⫽a timing issue, or the interruption of a consistent pace of stepping for the entire walk pattern. Figure 2. Study flow chart. MMSE⫽Mini Mental State Examination score, COV⫽coefficient of variation, F8W⫽Figure-of-Eight Walk Test.

istered by 2 different assessors and were used to determine interrater reliability. The first trials of the initial and repeat visits were used to calculate test-retest reliability. Intraclass correlation coefficients (ICCs) (95% confidence interval [CI]) for interrater reliability were .90 (.71–.97), .92 (.77–.97), and .85 (.64 –.95) for time, number of steps, 92

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and smoothness, respectively. All participants completed the walk within the 2-ft surround of the cones with no difficulty. Subsequently, we eliminated scoring the accuracy component (eg, within the 2-ft boundary) because the score: (1) did not discriminate performance among participants, and (2) the number of steps to complete the F8W would account for a walking path

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Overview of Procedures An overview of the procedures is shown in Figure 2. Participants were volunteers recruited from the Pittsburgh Claude D Pepper Older Americans Independence Center Registry of older adults interested in studies of mobility and balance between February 2006 and March 2007. A registry sample of older adults over the age of 65 years who reported walking independently, but with some difficulty, and using a straight cane or no assistive device were contacted by telephone about participating. Interested individuals, who obJanuary 2010

Measuring Skill in Walking of Older Adults tained approval of their personal physician to engage in low- to moderate-intensity exercise, were scheduled for clinical screening and baseline testing at the Senior Mobility Aging Research and Training Center of the Pittsburgh Claude D Pepper Older Americans Independence Center, University of Pittsburgh, Pittsburgh, Pennsylvania. Eligible individuals participated in preintervention testing and 1 of 2 interventions, followed by immediate postintervention reassessment. Testing sessions were conducted by the study research physical therapists experienced in assessment and treatment of older adults with mobility problems. All assessors were trained in the administration of all measures, with a manual of operations, including printed directions and reference citations for the method of administering the tests, available for reference. All measurements were collected as a part of the baseline data collection for a randomized controlled trial of walking in community-dwelling older adults with mobility disability.23 Participants Community-dwelling older adults were eligible to participate if they were cognitively intact (Mini Mental State Examination24 score of ⱖ24) and demonstrated walking difficulty. Walking difficulty was defined as having gait that was slow (walking speed of ⱖ0.6 m/s and ⱕ1.0 m/s)25 and variable (coefficient of variation [COV] of ⬎4.5% for step length variability5 or COV of ⬍7% or ⬎30% for step width variability4). We excluded older adults with: (1) persistent lower-extremity pain or muscle weakness (⬍4 out of 5 on manual muscle testing for the ankle dorsiflexor and plantar-flexor, knee extensor and flexor, and hip flexor, extensor, and abductor muscle groups), such as residual deficits associated with a stroke, fixed or fused joints, amputation, and prosthetic lower January 2010

limb; (2) hospitalization for 3 days or more in the past 6 months; (3) acute or chronic cardiopulmonary or metabolic conditions not well controlled with medication; (4) progressive neuromotor disorder (eg, multiple sclerosis, Parkinson disease); or (5) uncontrolled hypertension in the resting state. Gait speed and variability to determine eligibility were derived at self-selected walking speed in 2 passes over an instrumented walkway. Of the participants screened (n⫽111), 52 met the inclusion criteria, and 51 individuals had complete data and were included in the study (Fig. 2). The participants’ mean (SD) age was 76.8 (5.5) years, their mean height was 165.1 (9.8) cm, and their mean weight was 80.5 (18.4) kg. The sample consisted of 17 men (33.3%) and 34 women (66.7%). Forty-five participants (88.2%) were white, and 6 (11.8%) were African American. Measures of Gait Figure-of-8 Walk Test. Participants walked a figure-of-eight at their self-selected usual pace around 2 cones placed 5 ft apart. Time and number of steps to complete the F8W and smoothness were recorded as described above. Gait speed. Participants walked at their usual speed on a 4-m instrumented walkway (GaitMat II*)26 with 2-m noninstrumented sections at either end to allow for acceleration and deceleration. After 2 practice walks, 2 walks were used for data collection. Gait speed was averaged over the 2 walks. Gait speed has demonstrated test-retest reliability (ICC⫽.78),27 validity by comparison with other gait characteristics,9 and predictive validity for mobility disability.8

* EQ Inc, PO Box 16, Chalfont, PA 189140016.

Modified Gait Abnormality Rating Scale. The modified Gait Abnormality Rating Scale (GARS-M),10 a 7-item, criterion-based, observational rating of gait abnormalities associated with fall risk,10,28 was used to assess gait characteristics. Reliability is excellent (ICC⫽.95–.99) among experienced assessors. Each item is scored 0 to 3, for a total score of 0 to 21. Higher scores reflect poorer performance.10 Measures of Physical Function in Activities of Daily Living Late-Life Function and Disability Instrument. We used the Late-Life Function and Disability Instrument (LLFDI)29,30 function scale to assess perceived physical function related to walking ability. We used the LLFDI disability scale to assess perceived limitations in ability to perform socially defined life tasks in the home and community.30 The LLFDI function and disability scales both have a possible score range of 0 to 100, with higher scores indicating better function and less disability (reproducibility of the scores, ICC⬎.80).29,30 Survey of Activities and Fear of Falling in the Elderly. The Survey of Activities and Fear of Falling in the Elderly (SAFFE) questionnaire43 consists of 11 activities of everyday life necessary for independent living. Three subscale scores are derived: (1) SAFFE activity—the number of activities performed; (2) SAFFE fear—the average “worried about falling” rating on a 4-point rating scale, from 0 (not worried) to 3 (very worried), for each item performed; and (3) SAFFE restriction—the number of activities performed less compared with the past 5 years. Internal consistency (Cronbach alpha⫽.91) and validity are established for the ability of the SAFFE to differentiate between adults who are afraid and those who are not afraid of falling in daily activities.31

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Measuring Skill in Walking of Older Adults Gait Efficacy Scale. The Gait Efficacy Scale (GES)32 is a self-report, 10-item scale of perceived confidence in walking with a range of challenges, from level walking to walking on uneven surfaces, curbs, or stairs. Item scores range from 1 (no confidence) to 10 (complete confidence), with a possible total score of 10 to 100.32 Physical Performance Test. The 7-item Physical Performance Test (PPT)33 is a performance-based measure of basic and instrumental activities of daily living. Time to complete 6 items and the observation rating for 1 item are converted to a score of 0 to 4 (0⫽unable, 4⫽fastest time or best completion), with a summary score for the 7 items of 0 to 28; higher scores represent better performance. The PPT has established reliability and construct validity for activities of daily living and predictive validity for nursing home placement and death.33,34 Fear of falling and fall history. We used a fall history survey questionnaire with specific questions about fear of falling and history of falls in the past year.35 Scores are dichotomized for, fear of falling (yes or no) and number of falls in the past year (ⱖ1, yes or no). Measures of Movement Control and Planning Gait variability. Gait variability7,36 was assessed from the gait data recorded using the GaitMat II instrumented walkway. Step length, step width, and stance time variability were calculated as the standard deviation of the measure and as the COV, based on the average standard deviation of all right and left steps over the 2 walks divided by the mean step length, step width, or stance time.7 The number of steps used to estimate variability is somewhat less than that used by some other authors,6,37 but allows for measures of 94

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spatial and temporal variability during natural walking (ie, not on a treadmill) and has acceptable reliability.38 We used both the standard deviation and the COV for variability to be able to compare our findings with those of previous reports of gait variability in older adults in which both statistics have been used.5–7 Validity of gait variability has been established for fall risk5–7 and as a measure of movement control by association with measures of executive function39 and brain vascular abnormalities in older adults.40 Trail Making Test B. The Trail Making Test B (Trails B)41 is a neuropsychological test of executive function, specifically the ability to shift attentional resources (set shifting) in the visuomotor domain.41 Reliability and validity of the Trails B have been established, and a known normative sample has been described.42 Poorer scores, representing longer time to complete the test, have been associated with functional decline (odds ratio⫽1.34) and a higher risk of mortality (hazard ratio⫽1.48).43 Data Analysis Descriptive statistics (mean and CI) for each measure were used to describe characteristics and performance of the participants. The appropriate correlation, Pearson product moment correlation (r) or Spearman rank order correlation (␳), was used to define the bivariate relationships of each of the variables with the F8W scores. We interpreted the associations as strong (.7–1.0), moderate (.4 –.69), and weak (⬍.39).44 An independent-sample t test or Mann-Whitney U test was used to compare mean F8W variables between participants categorized by history of falls and fear of falling. Lastly, we described the pattern of correlations of F8W time and gait speed with the constructs of gait, physical function, and movement control and planning. Linear

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regression analyses were used to correlate each dependent variable with gait speed or the F8W time, with each adjusted for the other to determine the independent contributors (gait speed, F8W time) to the constructs. Role of the Funding Source The authors acknowledge the support of National Institutes of Health grant 1 P30 AG024827-01 awarded to the Pittsburgh Older Americans Independence Center (Principal Investigator: Stephanie Studenski, MD, MPH).

Results Descriptive Characteristics The older adults studied walked slowly (mean [SD] gait speed⫽0.89 [0.15] m/s), compared with the usual adult walking speed of 1.2 to 1.3 m/s.45 The older adults had a moderate number of abnormalities of gait related to fall risk, with a mean GARS-M score (SD) of 6.69 (2.58) (Tab. 1). A GARS-M score of ⱕ3 signifies little or no risk for falling, and scores of ⱖ9 are associated with risk for recurrent falls among community-dwelling older adults.10,28 The older adults with walking difficulties exhibited a mean (SD) for F8W time and steps of 10.49 (2.60) s and 17.51 (3.94) steps (Tab. 1) and a median (interquartile range) of 2.0 (1.0) for the smoothness rating. Specific difficulties for the component of smoothness included problems of hesitancy and pace. Almost all participants (92%) completed the F8W without stopping. The older adults with mobility problems demonstrated moderate activity (mean SAFFE activity score⫽8.37, mean SAFFE restriction score⫽3.47) and mild to moderate deficits in physical function based on mean LLFDI function and disability limitations summary scores between 50 and 70 and the mean PPT score beJanuary 2010

Measuring Skill in Walking of Older Adults tween the 50th and 75th percentiles for community-dwelling older adults.33 The participants reported moderate confidence in their walking ability (mean GES scores of ⬎70) (Tab. 1), yet the majority reported fear of falling (n⫽33, 64.7%), and almost half had fallen at least once in the past year (n⫽23, 45.1%). Similar to physical function, the older adults demonstrated moderate problems in movement control and planning. Mean step length variability, step width variability, and stance time variability exceeded values of each associated with risk for falling.4 – 6 The mean stance time (0.04 second) was greater than the value of stance time variability associated with an increased risk for mobility disability (SD ⱖ0.037 second).46 Mean time to complete the Trails B task (135.71 seconds) was well above the mean time previously demonstrated for older adults with a history of falls (70.65 seconds) and older adults without a history of falls (58.4 seconds).47 Concurrent and Construct Validity The F8W was correlated to gait, with time negatively correlated to gait speed and positively correlated to the GARS-M (P⬍.05) (Tab. 2). The F8W time was associated with physical function in daily life (LLFDI function), activity restriction (SAFFE restriction), and activities of daily living performance (PPT); a similar relationship was found for the number of steps to complete the test (Tab. 2). Confidence in walking skill (GES) correlated to all F8W variables (time, steps, and smoothness) (Tab. 2). The number of steps and smoothness scores of the F8W differed by fear of falling status (Tab. 3). Construct validity for the F8W with movement control was established by the relationship of all F8W scores (time, number of steps, and smoothJanuary 2010

Table 1. Figure-of-8 Walk Test, Gait, Physical Function in Daily Life, and Movement Control and Planning in Older Adults With Slow and Variable Gait (n⫽51)a Mean

95% CI

F8W time, s

Measure

10.49

9.78–11.21

F8W steps, n

17.51

16.43–18.59

1.75

1.49–2.00

F8W smoothness (0–3) Gait speed, m/s

0.89

0.85–0.93

GARS-M (0–21)

6.69

5.99–7.39

SAFFE activity (0–11)

8.37

7.95–8.80

SAFFE fear (0–3)

0.56

0.43–0.68

SAFFE restriction (0–11)

3.47

2.74–4.20

PPT (0–28)

20.53

19.79–21.26

LLFDI disability (0–100)

69.28

66.45–72.11

LLFDI function (0–100)

54.70

52.93–56.48

Gait Efficacy Scale (0–100)

72.52

66.78–76.24

0.04

0.032–0.041

Step length SD, m Step length COV, %

7.37

6.33–8.41

Step width SD, m

0.03

0.031–0.038

76.52

47.73–105.31

0.04

0.038–0.045

Step width COV, % Stance time SD, s Stance time COV, %

5.61

Trails B, s

135.71

5.12–6.11 117.77–153.65

a CI⫽confidence interval, F8W⫽Figure-of-Eight Walk Test, GARS-M⫽modified Gait Abnormality Rating Scale, SAFFE⫽Survey of Activities and Fear of Falling in the Elderly, PPT⫽Physical Performance Test, LLFDI⫽Late-Life Function and Disability Instrument, Trails B⫽Trail Making Test B, SD⫽standard deviation, COV⫽coefficient of variation.

ness) with step width variability (COV). The F8W time correlated to step length COV, and the number of steps to complete correlated to step width standard deviation. Both F8W time and number of steps were associated with the Trails B measure of planning and navigation (Tab. 2). The pattern of correlations of both the F8W time and gait speed with gait, physical function, and movement control and planning variables illustrated similarities and differences (Tab. 4, significant correlations only are shown). The F8W time pattern of associations was with measures of perception of walking difficulties in the environment (SAFFE restriction), confidence (GES), and planning (Trails B). The pattern of associations demonstrated

for gait speed was with measures of gait and physical function (GARS-M, PPT, LLFDI disability). For the variables to which the F8W and gait speed were both related, the regression analysis indicated F8W independently explained the variance in walking confidence, and gait speed was the independent contributor to gait abnormalities (GARS-M), physical function (PPT and LLFDI function), and step length variability (step length COV) (Tab. 4).

Discussion The results support the validity of the F8W as a measure of walking ability in older adults with mobility disability for the constructs of gait (gait speed, GARS-M), physical function in activities of daily living (SAFFE restrictive, LLFDI function,

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Measuring Skill in Walking of Older Adults Table 2. Correlations of Figure-of-8 Walk Test With Measures of Gait, Physical Function in Daily Life, and Movement Control and Planning (n⫽51)a F8W Time r (P)

F8W Steps rb (P)

⫺.570 (.000)b

⫺.503 (.000)

.144 (.315)

.281 (.045)c

.235 (.097)

⫺.146 (.308)

⫺.221 (.119)c

⫺.217 (.127)

.183 (.198)

SAFFE fear

.088 (.541)

c

⫺.042 (.768)

⫺.030 (.835)

SAFFE restriction

.370 (.008)c

.280 (.047)

⫺.183 (.199)

PPT

⫺.353 (.011)c

⫺.343 (.014)

.221 (.119)

LLFDI disability

⫺.259 (.067)c

⫺.160 (.261)

⫺.052 (.717)

LLFDI function

⫺.469 (.001)c

⫺.348 (.012)

.225 (.113)

Gait efficacy

⫺.468 (.001)c

⫺.435 (.002)

.304 (.032)

Step length SD

.035 (.806)b

⫺.081 (.571)

.001 (.994)

Step length COV

.279 (.047)b

Measure

F8W Smoothness rb (P)

may be useful to differentiate less skilled individuals from highly skilled individuals with a narrow step width, who could be considered skilled based on a fast F8W time.

Gait measures Gait speed GARS-M Physical function measures SAFFE activity

Movement control and planning measures

.149 (.295)

⫺.103 (.473)

Step width SD

⫺.205 (.150)

b

⫺.339 (.015)

.052 (.718)

Step width COV

⫺.277 (.049)b

⫺.308 (.028)

.336 (.016)

b

⫺.012 (.935)

.013 (.925)

⫺.050 (.729)b

⫺.027 (.852)

⫺.061 (.669)

.351 (.012)b

.389 (.005)

⫺.267 (.059)

Stance time SD Stance time COV Trails B

.072 (.613)

a

F8W⫽Figure-of-8 Walk Test, GARS-M⫽Gait Abnormality Rating Scale, SAFFE⫽Survey of Activities and Fear and Fall in the Elderly, PPT⫽Physical Performance Test, LLFDI⫽Late Life Function and Disability Instrument, SD⫽standard deviation, COV⫽coefficient of variation, Trails B⫽Trail Making Test B. b Pearson product moment correlation. c Spearman rank order correlation.

PPT, GES), and movement control and planning (step length COV, step width COV, Trails B). In clinical practice, we often have found that if older adults or their family complain about poor walking performance, the F8W exposes the walking difficulties not obvious during the straight path walk. Mild slowing and few abnormalities of gait during the straight path walk become short steps, uneven and hesitant steps rounding the corner of the figure-of-eight, pace changes with every change of path direction, markedly slower speed of gait, and unsteadiness. Interestingly, individuals with less step width COV (ie, better gait control) performed worse on the F8W, 96

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requiring more time to complete the test (Tab. 2). Mean step width may drive the association of the F8W time with step width COV. Gaybell and Nayak36 suggested a wide step width may be a compensation for instability, whereas a narrow step width likely contributes to instability. In our experience, a wide step width usually yields a smaller step width COV and is associated with more time and steps to complete the F8W compared with a narrow step width. Individuals with a narrow step width may exhibit a shorter path around the curves of the F8W (less time), but test performance is characterized by stumbling; multiple adjustments to pace, path, and speed; and even near falls. A smoothness rating

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Interrater reliability for F8W time (ICC⫽.90) and steps (ICC⫽.92) was slightly lower than for the composite measures of mobility that included a turn or curve,18,48 but acceptable for clinical measures. Test-retest reliability for F8W time (ICC⫽.84) and steps (ICC⫽.82), although acceptable for clinical measures, also was lower than for one composite measure of mobility with a curved-path walk (E-FAP).18 Although both the F8W and gait speed correlated to performancebased measures of gait (GARS-M, step length and step width variability) and to the LLFDI self-report of function in essential activities of daily living, many of which involve walking, the associations with curved- and straight-path walking differed for disability limitations and executive function. We expected curved-path walking to be a good representative of physical function in community-dwelling older adults. Such was the case for walking confidence and activities in specific conditions or when fulfilling certain roles in the environment, but the F8W was not related to disability limitations. The endurance aspect of walking performance represented by some LLFDI disability items may have led to the lack of association. The movement control required to walk under certain conditions or in certain environments may underlie the association of the GES and the SAFFE measures of walking activities with the F8W. The association of the F8W with the Trails B executive function measure of cognition illustrates the planning and navigation aspects of mobility represented by the measure. In the January 2010

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Uc (P)

⫺.45 (.66)

⫺.61 (.54)

257.00 (.196)

Variable

0.50 (⫺1.75, 2.74)

SAFFE restriction PPT

Independent Contributorb P<.05

⫺.526d (.000)

Gait speed

⫺.570c (.000) .281d (.045) d

.370 (.008)

F8W time

⫺.353d (.011)

.378d (.006) d

Gait speed

.429d (.002)

Gait speed

Gait Efficacy Scale

⫺.468 (.001)

.321 (.023)

.279c (.047)

⫺.414c (.002)

d

Step Width COV

Gait speed

.296 (.035) ⫺.469d (.001)

d

.337c (.015)

Step Width SD

F8W time Gait speed Gait speed

⫺.277 (.049)

F8W time

.351c (.012)

F8W time

c

a

c

F8W⫽Figure-of-8 Walk Test, IQR⫽interquartile range, CI⫽confidence internal. Independent t test. Mann-Whitney U test.

F8W⫽Figure-of-Eight Walk Test, GARS-M⫽modified Gait Abnormality Rating Scale, SAFFE⫽Survey of Activities and Fear of Falling in the Elderly, PPT⫽Physical Performance Test, LLFDI⫽Late-Life Function and Disability Instrument, SD⫽standard deviation, COV⫽coefficient of variation, Trails B⫽Trail Making Test B. b Independent contribution to the variance in the construct variable, determined by linear regression analysis with gait speed and F8W time, with each adjusted for the other variable. c Pearson product moment correlation. d Spearman rank order correlation.

b

2.00 (1.0, 2.0) 211.00 (.075) 1.00 (1.0, 2.0) FW8 smoothness, (0–3)

2.00 (1.75, 3.0)

Uc (P)

Gait Speed r (P)

LLFDI function

Step length COV

a

17.78

Median (IQR)

⫺2.50 (.02) 16.00

Median (IQR)

18.33

Median (IQR)

FW8 steps, (#)

Measure

1.12 (0.09, 4.58)

10.74 ⫺1.79 (.08) 0.75 (⫺0.16, 2.83) 9.63 FW8 time, s

10.96

Yes, Mean tb (P) No, Mean Yes, Mean Measure

Mean Difference (95% CI)

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F8W Time r (P)

LLFDI disability

2.00 (1.0, 3.0)

17.29

GARS-M

Median (IQR)

0.45 (⫺1.03, 1.93) 10.29

Mean Difference (95% CI)

Gait speed

No, Mean

History of Falls (>1 Fall in Past Year)

Pattern of Significant Correlations of Figure-of-8 Walk Test Time and Gait Speed With Dependent Variables (n⫽51)a

Trails B

Fear of Falling

Construct Validity: Mean Difference for Figure-of 8-Walk Test Scores Based on Fear of Falling and Fall History (n⫽51)

Table 3.

tb (P)

Table 4.

F8W, the cognitive challenge (planning and navigation) of walking is embedded in the mobility task, similar to the Walking Trail Making Test of stepping accuracy.49 The F8W and the Walking Trail Making Test differ from other dual-task and multi-task tests in which the cognitive task typically is distinct from the walking task and the cognitive challenge serves to distract from walking or compete for attention to the task. Because the F8W was associated with measures representative of walking in more complex conditions of the environment not associated with gait speed, we suggest the F8W can provide different information about mobility performance of older adults than that provided by gait speed alone. Measures used to identify individuals with walking difficulties that predispose older adults to greater dependence and loss of independent community dwelling need to be representative of the complexity of mo-

bility tasks in home and community navigation.15 As individuals age, changes in cognitive and sensorimotor processing functions of the brain contribute to a decline in navigational skill for walking in some environments.15 A decline in motor skill with aging has been described previously for specific movements or motor functions. For example, older adults are slower initiating and performing movements,50 their movements lack smoothness and are less consistent,6 and they hesitate when switching directions or motor tasks, such as changing from knee extension to knee flexion.51 We believe the F8W may capture similar deficits in motor skill but at the level of mobility performance for socially defined roles in the home and community. The F8W may be able to provide information complementary to the information obtained from straight-path walking measures and enhance current assessment and un-

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Measuring Skill in Walking of Older Adults derstanding of mobility problems in older adults.

Older Americans Independence Center (Principal Investigator: Stephanie Studenski, MD, MPH).

The limitations of the study are primarily related to sample selection, which restricts the ability to generalize the findings to a general population of older adults. We studied older adults recruited to participate in a clinical trial of interventions to improve walking. Thus, sample size was limited, powered for the intervention outcomes; the participants were volunteers interested in improving their walking; and the findings are relevant only for older adults with mobility disability, specifically slow and variable gait.

This article was received April 21, 2008, and was accepted September 6, 2009.

Conclusions The findings provide evidence to support the validity of the F8W as a measure of walking skill among older adults with mobility disability. Future study of the F8W in a sample of older adults with a greater range of walking abilities and study of the responsiveness of the measure will be helpful in understanding the usefulness of the measure for assessing the mobility abilities of communitydwelling older adults. Ms Hess, Dr Brach, and Dr VanSwearingen provided concept/idea/research design. All authors provided writing, data analysis, and consultation (including review of manuscript before submission). Ms Hess and Dr VanSwearingen provided data collection. Dr VanSwearingen provided project management, participants, and facilities/equipment. This research was conducted in partial fulfillment of the thesis requirements for completion of Ms Hess’ Bachelor of Philosophy degree. This research was approved by the Institutional Review Board for Human Subjects Research, University of Pittsburgh. Portions of this work were presented at the University of Pittsburgh Institute on Aging Celebration of Aging Research Day; December 10, 2007; Pittsburgh, Pennsylvania.

DOI: 10.2522/ptj.20080121

References 1 Capaday C. The special nature of human walking and its neural control. Trends Neurosci. 2002;25:370 –376. 2 Schneider C, Capaday C. Progressive adaptation of the soleus H-Reflex with daily training at walking backward. J Neurophysiol. 2003;89:648 – 656. 3 Ferrucci L, Baninelli S, Benvenuti E, et al. Subsystems contributing to the decline in ability to walk: bridging the gap between epidemiology and geriatric practice in the InCHIANTI study. J Am Geriatr Soc. 2000; 48:1618 –1625. 4 Brach JS, Berlin JE, VanSwearingen JM, et al. Too much or too little step width variability is associated with a fall history in older persons who walk at or near normal gait speed. J Neuroeng Rehabil. 2005; 2:21. 5 Maki BE. Gait changes in older adults: predictors of falls or indicators of fear? J Am Geriatr Soc. 1997;45:313–320. 6 Hausdorff JM, Rios DA, Edelberg HK. Gait variability and fall risk in community-living older adults: a 1-year prospective study. Arch Phys Med Rehabil. 2001;82:1050 – 1056. 7 Brach JS, Studenski SA, Perera S, et al. Gait variability and the risk of incident mobility disability. J Gerontol A Biol Sci Med Sci. 2007;62:983–988. 8 Guralnik JM, Simonsick EM, Ferrucci L, et al. A short physical performance battery assessing lower extremity function: association with self-reported disability and prediction of mortality and nursing home admission. J Gerontol. 1994;49:M85–M94. 9 Imms FJ, Edholm OG. Studies of gait and mobility in the elderly. Age Ageing. 1981; 10:147–156. 10 VanSwearingen JM, Paschal KA, Bonino P, Yang JF. The modified Gait Abnormality Rating Scale and recognizing recurrent fall risk of community-dwelling, frail older veterans. Phys Ther. 1996;76:994 –1002. 11 Verghese J, Buschke H, Viola L, et al. Validity of divided attention tasks in predicting falls in older individuals: a preliminary study. J Am Geriatr Soc. 2002;50: 1572–1576. 12 Courtine G, Schieppati M. Human walking along a curved path, I: body trajectory, segment orientation and the effect of vision. Eur J Neurosci. 2003;18:177–190. 13 Kiriyama K, Warabi T, Kato M, et al. Medial-lateral balance during stance phase of straight and circular walking of human subjects. Neurosci Lett. 2005;388:91–95.

The authors acknowledge the support of National Institutes of Health grant 1 P30 AG024827-01 awarded to the Pittsburgh

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14 Brauer S, Woollacott MH, Shumway-Cook A. The interacting effects of cognitive demand and recovery of postural stability in balance-impaired elderly persons. J Gerontol A Biol Sci Med Sci. 2001;56:489 – 496. 15 Lovden M, Schellenbach M, GrossmanHutter B, et al. Environmental topography and postural control demands shape agingassociated decrements in spatial navigation performance. Psychol Aging 2005;20: 683– 694. 16 Bloem BR, Valkenburg VV, Slabbekoorn M, Willemsen MD. The Multiple Tasks Test: development and normal strategies. Gait Posture. 2001;14:191–202. 17 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. 18 Wolf SL, Catlin PA, Gage K, et al. Establishing the reliability and validity of measurements of walking time using the Emory Functional Ambulation Profile. Phys Ther. 1999;79:1122–1133. 19 Shumway-Cook A, Woollacott MH. Motor Control: Theory and Practical Applications. 2nd ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2001. 20 Brooks VB. The Neural Basis of Motor Control. New York, NY: Oxford University Press; 1986. 21 Menz HB, Lord SR, Fitzpatrick RC. Acceleration patterns of the head and pelvis when walking on level and irregular surfaces. Gait Posture. 2003;18:35– 46. 22 VanSwearingen JM, Brach JS, Hess RJ, et al. Clinical correlates of motor control in walking: the Figure-of-8 Walk Test. Presented at: 59th Annual Scientific Meeting of the Gerontological Society of America; November 16 –20, 2006; Dallas, Texas. 23 VanSwearingen JM, Perera S, Brach JS, et al. A randomized trial of two forms of therapeutic activity to improve walking: effect on the energy cost of walking. J Gerontol A Biol Sci Med Sci. 2009; 64;1190 –1198. 24 Folstein MF, Folsetein SE, McHugh PR. Mini-Mental State: a practical method for grading the cognitive state of patients for the clinician. J Psych Res. 1975;12: 189 –198. 25 Studenski SA, Perera S, Wallace D, et al. Physical performance measures in the clinical setting. J Am Geriatr Soc. 2003;51: 314 –322. 26 Walsh JP. Foot fall measurement technology. In: Craik RL, Oatis CA, eds. Gait Analysis: Theory and Application. St Louis, MO: Mosby-Year Book Inc; 1995:125–142. 27 Tager IB, Swanson A, Satariano WA. Reliability of physical performance and selfreported functional measures in an older population. J Gerontol A Biol Sci Med Sci. 1998;53:M295–M300. 28 VanSwearingen J.M., Paschal K, Bonino P, Chen T. Assessing recurrent fall risk of community-dwelling, frail older veterans using specific tests of mobility and the Physical Performance Test of function. J Gerontol A Biol Sci Med Sci. 1998;53: M457–M464.

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Measuring Skill in Walking of Older Adults 29 Haley SM, Jette AM, Coster WJ, et al. Late Life Function and Disability Instrument, II: development and evaluation of the function component. J Gerontol A Biol Sci Med Sci. 2002;57:M217–M222. 30 Jette AM, Haley SM, Coster WJ, et al. Late Life Function and Disability Instrument, I: development and evaluation of the disability component. J Gerontol A Biol Sci Med Sci. 2002;57:M209 –M216. 31 Lachman ME, Howland J, Tennstedt S, et al. Fear of falling and activity restriction: the Survey of Activities and Fear of Falling in the Elderly (SAFFE). J Gerontol B Psychol Sci Soc Sci. 1998;53:43–50. 32 Rosengren KS, McAuley E, Mihalko SL. Gait adjustments in older adults: activity and efficacy influences. Psychol Aging. 1998;13:375–380. 33 Reuben DB, Siu AL. An objective measure of physical function of elderly outpatients: the Physical Performance Test. J Am Geriatr Soc. 1990;38:1105–1112. 34 Reuben DB, Siu AL, Kimpau S. The predictive validity of self-report and performance-based measures of function and health. J Gerontol A Biol Sci Med Sci. 1992;47:M106 –M110. 35 Studenski SA, Duncan PW, Chandler J, et al. Predicting falls: the role of mobility and nonphysical factors. J Am Geriatr Soc. 1994;42:297–302. 36 Gabell A, Nayak USL. The effect of age and variability in gait. J Gerontol. 1984;39: 662– 666.

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37 Owings TM, Grabiner MD. Measuring step kinematic variability on an instrumented treadmill: how many steps are enough? J Biomech. 2003;36:1215–1218. 38 Brach JS, Perera S, Studenski SA. Reliability and validity of measures of gait variability in community-dwelling older adults. Arch Phys Med Rehabil. 2008;89:2293–2296. 39 Lovden M, Schaefer S, Poirier V, Lindenberger U. Walking variability and workingmemory load in aging: a dual-process account relating cognitive control to motor control performance. J Gerontol B Psychol Sci Soc Sci. 2008;63:P121–P128. 40 Rosano C, Brach JS, Studenski SA, et al. Gait variability is associated with subclinical brain vascular abnormalities in highfunctioning older adults. Neuroepidemiology. 2007;29:193–200. 41 Reitan RM, Wolfson D. The HaslteadReitan Neuropsychological Test Battery: Therapy and Clinical Interpretation. Tucson, AZ: Neuropsychological Press; 1985. 42 Fals-Stewart W. An interrater reliability study of the Trail Making Test (Parts A and B). Percept Mot Skills. 1992;74:39 – 42. 43 Johnson JK, Lui LY, Yaffe K. Executive function, more than global cognition, predicts functional decline and mortality in elderly women. J Gerontol A Biol Sci Med Sci. 2007;62:1134 –1141. 44 Cohen J. Statistical Power Analysis for the Behavioral Sciences. 2nd ed. Hillsdale, NJ: Lawrence Erlbaum Associates; 1988.

45 Craik RL. Changes in locomotion in the aging adult. In: Woollacott MH, ShumwayCook A, eds. Development of Posture and Gait Across the Lifespan. Columbia, SC: University of South Carolina Press; 1989: 176 –201. 46 Brach JS, Studenski SA, Perera S, et al. Values of stance time variability related to mobility disability. Presented at: Combined Sections Meeting of the American Physical Therapy Association; February 14 –18, 2007; Boston, Masschusetts. 47 Lord S, Fitzpatrick R. Choice stepping reaction time: a composite measure of falls risk in older people. J Gerontol. 2001;56: M627–M632. 48 McConvey J, Bennett SE. Reliability of the Dynamic Gait Index in individuals with multiple sclerosis. Arch Phys Med Rehabil. 2005;86:130 –133. 49 Alexander NB, Ashton-Miller JA, Giordani B, et al. Age differences in timed accurate stepping with increasing cognitive and visual demand: a walking trail making test. J Gerontol A Biol Sci Med Sci. 2005;60: 1558 –1562. 50 Morgan M, Phillips J, Bradshaw J, et al. Age-related motor slowness: simply strategic? J Gerontol. 1994;49:M133–M139. 51 Connelly DM, Carnahan H, Vandervoort AA. Motor skill learning and eccentric isokinetic movements in older adults. Exp Aging Res. 2000;26:209 –228.

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Case Report Pursuit and Implementation of Hospital-Based Outpatient Direct Access to Physical Therapy Services: An Administrative Case Report William G. Boissonnault, Mary Beth Badke, Jane Megan Powers W.G. Boissonnault, PT, DHSc, is Associate Professor, Department of Orthopedics and Rehabilitation, University of Wisconsin–Madison, 1300 University Ave, 5190 MSC, Madison, WI 53706 (USA). Address all correspondence to Dr Boissonnault at: boissonnaultw@ pt.wisc.edu. M.B. Badke, PT, PhD, is Director, Outpatient Rehabilitation Services, Department of Orthopedics and Rehabilitation, University of Wisconsin Hospital and Clinics, Madison, Wisconsin. J.M. Powers, MA, is Director, Department of Orthopedics and Rehabilitation, University of Wisconsin Hospital and Clinics. [Boissonnault WG, Badke MB, Powers JM. Pursuit and implementation of hospital-based outpatient direct access to physical therapy services: an administrative case report. Phys Ther. 2010;90: 100 –109.] © 2010 American Physical Therapy Association

Background and Purpose. Despite legislative approval of direct access to physical therapy, other regulatory barriers and internal institutional policies often must be overcome before this practice model can be fully adopted. Few institutional initiatives have been published describing strategies designed to change policies restricting direct patient access. This case report describes steps and strategies associated with successful implementation of a direct access physical therapy model at a large academic medical center.

Case Description. The process of obtaining institutional medical board and hospital authority board approval and implementing a pilot program is described. Program details, including therapist qualifications and scope of practice, the required internal training program, and program outcome assessment, are provided. The therapist scope of practice includes the ability to refer patients directly to a radiologist for plain film radiography. Early pilot program findings, including challenges faced and subsequent actions, are described.

Outcomes. Reviewed patient care decisions by therapists participating in the pilot program were deemed appropriate 100% of the time by physician chart reviewers. Approximately 10% of the patients seen were referred to a radiologist for plain film imaging, and 4% and 16% of the patients were referred to physicians for pain medications or medical consultation, respectively. The pilot program’s success led to institutional adoption of the direct access model in all physical therapy outpatient clinics.

Discussion. Autonomy is described, in part, as self-determined professional judgment and action. This case report describes such an effort at a large academic medical center. The interdependent, collaborative relationship among physical therapists, physicians, and hospital administrators has resulted in the implementation of a patient-centered practice model based on the premise of patient choice.

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irect access, defined as “the legal right to seek and receive the examination, evaluation and intervention of the physical therapist without the requirement of a physician referral,” is core to the American Physical Therapy Association’s (APTA) 2020 Vision Statement: By 2020, physical therapy will be provided by physical therapists who are doctors of physical therapy, recognized by consumers and other health care professionals as practitioners of choice to whom consumers have direct access for the diagnosis of, interventions for, and prevention of impairments, functional limitations, and disabilities related to movement, function, and health.1

The state law first enacted allowing physical therapists such practice privileges was passed in Nebraska in 1957, and subsequent legislative activity has resulted in 48 states and the District of Columbia permitting patients to be examined by physical therapists without referral. Of these states, 44 allow provision of treatment in addition to evaluation. Advocating for more timely access to physical therapy services has been the primary impetus for such legislative action.2 In view of rapidly escalating health care costs, direct access to physical therapy may be a valuable health care strategy and resource, especially considering that most current direct access programs emphasize care for musculoskeletal conditions that are common and costly to man-

Available With This Article at ptjournal.apta.org • Audio Abstracts Podcast This article was published ahead of print on November 5, 2009, at ptjournal.apta.org.

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age. In 2004, the estimated cost for treatment of patients with musculoskeletal conditions was $510 billion (of which expenditures related to physical therapy care constituted approximately 3%–5%), the equivalent of 4.6% of the gross domestic product.3 Reduced employment rates and lost work contributed an additional $339 billion of indirect costs for musculoskeletal conditions. Researchers recently reported that from 1997 to 2005 the inflation-adjusted annual medical costs for spinal problems increased from $4,695 to $6,096 per person.4 In comparison, the mean annual physical therapy expenditures for spinal problems increased minimally, from $115 to $129, over this same time span. Radiographs, magnetic resonance imaging (MRI) scans, and medications constituted the largest proportions of total cost associated with outpatient visits. The greatest relative increase observed was for medications, increasing approximately 423% from 1997 to 2005.4 Other authors noted increases related to medical imaging and diagnostic tests,5 spinal injections,6 and increasing use of spinal fusion surgery and instrumentation.7,8 Articles dating back to the early 1970s have described outcomes, including cost of care, related to provision of physical therapy direct access care.9 –11 Mitchell and de Lissovoy10 compared resource utilization and cost for physician-referral versus direct access episodes for patients with acute musculoskeletal disorders. The physician referral episodes were marked by greater rates of physical therapy claims (67%) and office visits (60%), and total claims of $2,236 per episode versus $1,004 for the direct access episodes.10 Similarly, after initiation of a direct access model for patients with low back pain, the Virginia Mason Medical Center noted decreased costs per episode of care, in part from reduced ordering of MRI

scans (from 15.4% of patients to 10% within 1 year).11 With the new program, only 6% of patients lost time from work, and mean wait times for appointments dropped to 1 day.11 Similarly, Overman et al12 reported that fewer patients seen initially by physical therapists were prescribed muscle relaxants and narcotic analgesics compared with those seen first by internists (24% versus 44%, respectively). The patients seen by physical therapists reported fewer back pain episode recurrences.12 Additionally, other studies have demonstrated that physical therapists provide cost-effective, high-quality care to people with common musculoskeletal conditions.13–15 Physical therapy direct access models possess enormous potential for reducing health care costs as an alternative to high-tech medical testing and invasive interventions and for reducing the emphasis on medication therapies. Despite the growing body of literature describing virtues of the direct access model, challenges and obstacles remain for establishing this practice paradigm— even in some states with laws permitting such practice. For example, in Wisconsin, a direct access law initially was passed in 1997 and then most recently revised in 2002. Yet, provision of hospitalbased outpatient physical therapy services still required a physician referral. Wisconsin hospitals must meet strict Wisconsin Administrative Code guidelines, which supersede the physical therapy practice act language. Not only is the updated practice act language not reflected in the current Wisconsin Administrative Code, but the code reflects Centers for Medicare and Medicaid Services guidelines related to the provision of physical therapy services.16 We are uncertain whether all states have similar language affecting physical therapist practice, but correspondence with APTA Governmental Af-

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Hospital-Based Outpatient Direct Access to Physical Therapy Services fairs staff provided the opinion that many states do. The Wisconsin Physical Therapy Association (WPTA) sought the opinion of the Wisconsin Department of Health and Family Services regarding the Wisconsin Administrative Code language. The Department of Health and Family Services responded that hospitals could implement a policy, authorized by their medical staff, designating physical therapists as “allied health personnel” who could order outpatient physical therapy for patients who were not receiving Medicare or Medicaid. This opinion was consistent with HFS 124.21(4) Rehabilitation Services Order: “Physical therapy, occupational therapy, speech therapy and audiology services shall be given in accordance with orders of a physician, a podiatrist or any allied health staff member who is authorized by the medical staff to order the service.”16 Regardless of practice act and regulatory language, establishing direct access models in large hospital systems carries some unique administrative and procedural challenges. This case report describes the process leading to medical staff and hospital administration authorization of physical therapists assuming a direct access practitioner role at a large hospital—the University of Wisconsin Hospital and Clinics Authority (UWHCA), Madison, Wisconsin. In addition, the implementation of the pilot program is described. The importance of strong collaborative efforts among physical therapists, hospital administrators, and physicians is highlighted throughout the case report.

Case Description The Institutional Initiative The Wisconsin Department of Health and Family Services’ opinion provided the mechanism to pursue adoption of the consumer direct ac102

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Figure 1. Order of approval and implementation activities.

cess to physical therapist practice model. The facility’s large administrative organizational structure required program approval at multiple levels, and the large number and geographical diversity of department clinical sites required a coordinated effort of multiple program staff members. The UWHCA’s strategic planning model includes the University of Wisconsin (UW) School of Medicine and Public Health Executive Leadership, the UW Medical Foundation Board of Directors, the University of Wisconsin Hospital (UWHC) and Clinics Authority Board, and the UWHCA Executive Leadership Team. The Department of Orthopedics and Rehabilitation has a service line director and management team with oversight of orthopedics and rehabilitation inpatient and outpatient services. Ten outpatient therapy clinics, including general outpatient and specialty clinics such as

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spine physical therapy, sports rehabilitation and performance, geriatric falls, neurorehabilitation, pediatrics, and upper extremity and hand, operate in the hospital and in 4 off-site locations. The department employs more than 50 outpatient physical therapists. Initial Step: Staff Consensus The pursuit of “allied health” staff status at UWHCA started during a physical therapy staff meeting. Discussion occurred regarding delays and challenges associated with accessing physical therapy services. For example, a patient wanting a one-visit update to a home exercise program was required to see a physician for a referral. Therapists agreed that patient examples such as this should be brought to department administrators for discussion of current policy. Coincidently, administration had recently identified imJanuary 2010

Hospital-Based Outpatient Direct Access to Physical Therapy Services proved patient access as a major initiative in the upcoming year’s department service line business plan after receiving decreased patient satisfaction reports because of access issues. The administrators agreed that it was an opportune time to pursue direct access approval. Figure 1 provides the sequence of activities leading to approval. Direct Access Initiative Proposal We developed the action plan knowing that approval was needed from the chair of the Department of Orthopedics and Rehabilitation, the hospital’s fiscal, legal, and risk management departments, the hospital’s Medical Board, and finally the Hospital Authority Board. Multiple sources, including APTA, WPTA’s Autonomous Practice Task Force, and published literature, provided supporting information. Relevant literature included studies describing results associated with direct access service models9 –12,17 and publications describing long-standing models, including the military and Kaiser Permanente in northern California.18 The APTA’s Data, Evidence, and Research Supporting Direct Access to Physical Therapist Services2 contains multiple papers describing a historical overview of direct access history, patient safety, costeffectiveness, and quality-of-life outcomes associated with direct access models. The WPTA task force provided resources developed by Amery Regional Medical Center, the first Wisconsin facility to grant physical therapists “allied health” status. Considering most physicians and the administrators outside our department were unaware the direct access model existed and was legal in Wisconsin, the resources provided valuable background information. A 2-page Executive Summary was created, providing: (1) an overview of the Wisconsin Physical Therapy Practice Act, including the extra January 2010

direct access step required for hospital-based physical therapy; (2) names of other large institutions that had implemented a similar practice model; (3) UWHCA’s business plan initiative to deploy resources at all levels to eliminate inappropriate patient care delays and promote patient choice; (4) evidence of direct access cost-effectiveness; and (5) proposed outcome measures for program assessment. The proposed outcome measures would allow for later analyses, comparing data of patients seen by physical therapists with versus without physician referral. The information collected would include: (1) number of new patients seen; (2) average number of visits per episode of care; (3) average duration (in weeks) of episodes of care; (4) patient functional outcomes per episode of care, using department standard outcome measures; (5) patient adverse events; and (6) resource utilization such as continuation of physical therapy services beyond the initial visit, referral of patients to physicians and other health care providers for consultation, and direct referral of patients to the radiology department for plain film radiography and equipment orders (eg, orthotics, durable medical equipment). The Executive Summary was presented to selected department clinic supervisors and physicians for review and feedback and then to the chair of the Department of Orthopedics and Rehabilitation, an orthopedic spine surgeon. Agreeing with the need for improved patient access to services, he provided valuable advice on how to proceed through the hospital’s administrative channels and produced a letter of support for all future meetings. The Executive Summary then was sent to the UWHCA legal and risk management departments for review. No objections were raised,

with the following provisos: (1) policies and procedures are in place to ensure that physical therapists are functioning within their scope of practice and refer or seek medical assistance when needed, and (2) physical therapists are not functioning independently (ie, they are functioning under the general supervision of physicians). The institution’s definition of general supervision includes the availability of physicians for consultation and a periodic chart audit of selected cases. Other health care providers (eg, physician assistants, nurse practitioners) employed by the UWHCA work under these provisos. An Oversight Committee made up of department administrators, physical therapists, and physicians was established to ensure: (1) broad representation of primary stakeholders for program development and (2) ongoing program assessment, with quick resolution of issues as they arose. The Oversight Committee may be dissolved eventually as the program becomes established, with the standard departmental quality, safety, and competency assessments assuming oversight. An initial committee action was to develop a practice model including therapist qualifications, with an application process and a scope of practice. Therapist qualification included any one or more of the following 5 requirements, followed by successful completion of the UWHC direct access training: (1) APTA American Board of Physical Therapy Specialties current certification in a relevant practice area (Orthopaedic Certified Specialist for therapists practicing in an orthopedic setting), (2) completion of an APTA-credentialed residency or fellowship program in a relevant practice area, (3) an advanced academic degree with a clinical emphasis, (4) advanced clinical practice training (based on quality, emphasis, and extent of practice experience or

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Hospital-Based Outpatient Direct Access to Physical Therapy Services a certain number of continuing education units), and (5) UWHCA Advanced/Expert Clinical Practice Level per the institution’s professional advancement and recognition program. Once practicing in this model, therapists must maintain the advanced competency status, as determined by the department’s annual staff performance review process, and be current on all institutional safety, educational, and internal training offerings. The scope-of-practice statements included: (1) practice according to APTA’s Standards of Practice for Physical Therapy,19 Code of Ethics,20 and Guide for Professional Conduct21; (2) practice according to established UWHCA department standards, regulations, and clinical pathways; (3) provision of care per the Wisconsin Physical Therapy Practice Act and Rules and Regulations, including practice requirements 448.56 (4) (Duty to refer: A physical therapist shall refer a patient to an appropriate health care practitioner if the therapist has reasonable cause to believe that symptoms or conditions are present that require services beyond the scope of physical therapy) and 448.56 (1a) (Responsibility: A physical therapist is responsible for managing all aspects of the physical therapy care of each patient under his or her care); and (4) provision of timely and appropriate referral of patients to the radiology department for plain film imaging studies. The only scope-ofpractice item representing a new patient care responsibility was “timely and appropriate referral of patients to the radiology department for plain film imaging studies.” Therapists interested in direct access practice were to provide the Oversight Committee with a cover letter of intent, a description of their qualifications, and a re´sume´. Once approved, the therapists began the in104

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ternal training program. Once completed, the above proposal was taken to outpatient physical therapy clinic staff meetings for feedback and discussion. Direct Access Model Approval Prior to presenting the model to the Medical Board (18-member board made up primarily of hospital physicians) for a vote, we met individually with half of the Medical Board members to present the Executive Summary and practice model, the department chair’s letter of support, steps taken to ensure patient safety, and the required training program and to discuss any issues of concern. The potential for over-utilization of therapy services without physician oversight was the only issue raised (one physician). This issue was addressed by noting the availability of 6 years’ worth of benchmark data (per therapist) describing average number of patient visits over average number of weeks and patient functional status at the initial visit and at discharge. Therefore, administration would note a marked deviation from the norms. Critical to gaining Medical Board members’ backing were having the department chair’s letter of support and emphasizing that, except for referring patients directly to the radiology department for plain films, therapist practice responsibilities would be no different than when seeing patients via a physician referral. In addition, providing a historical overview including the number of states having adopted direct access since 1957, Wisconsin’s 20-year direct access history, and the military’s long track record with the lack of evidence describing adverse events and complaints filed against therapists allayed concerns that we were implementing a new and untested practice model. A PowerPoint presentation was prepared for the Medical Board meeting, including: (1) an overview of the Ex-

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ecutive Summary, (2) a description of the proposed model, and (3) the list of physicians and hospital administrators who participated in developing the model. The Medical Board unanimously approved the proposal and then moved the presented model and necessary “allied health” language to the Hospital Authority Board as a proposed hospital bylaw change. The Hospital Authority Board unanimously approved the proposal, a culmination of 7 months of activity. Required Direct Access Training Program The UWHCA program, developed by physical therapists and physicians, is based, in part, on training modules developed for the military and Kaiser Permanente direct access models.18 The program emphasizes clinical “red flag” recognition, suggesting a physician consultation is warranted, and plain film indication guidelines recognizing when to refer patients to the radiology department. The referring criteria for plain films were developed jointly with department orthopedists and radiologists based on current evidence22–27 and existing departmental guidelines. The training program includes required readings, lecture and discussion sessions, and a patient case series take-home assignment, followed by group discussion. The take-home assignment consisted of 10 patient case vignettes, which were variations of published cases,28,29 and therapists were asked to respond to the questions presented in Figure 2. Therapists, with an Oversight Committee physician, met to present the cases and discuss plans of care. Upon successful completion of the program, therapists were allowed to practice in the direct access model. Per the hospital’s policy, the House and Medical Staff Affairs Office assigned each therapist a provider number necessary for referring patients directly to the radiology department. January 2010

Hospital-Based Outpatient Direct Access to Physical Therapy Services All therapists noted value in participating in the educational training program. For some therapists, the result was an increased comfort level in seeing patients without physician referral, especially referring patients for plain film imaging. This level of comfort encouraged early program participation. Pilot Program Once the Hospital Authority Board had approved the program and the selected therapists had completed the training program, the model was initiated in 2 specialty clinics (spine and sports rehabilitation clinics, with 2 therapists from each clinic providing the services). Operationally, specific direct access patient care slots were identified on therapists’ schedules on days when physicians were physically on-site. If these slots were not filled with direct access patients, within 24 to 48 hours from that day, other patients were scheduled. To promote awareness of the direct access program, presentations were made to staff members who field patient calls, including reception desk staff and other personnel (eg, nurses, physician assistants) working in the spine and sports rehabilitation clinics. For example, the spine clinic nurse manager routinely screens patients calls and determines whether patients need to see a surgeon immediately. If an urgent surgeon visit is not indicated, options for nonsurgical management, now including provision by physical therapists, would be presented. Scenarios were described where direct access recommendations would not be appropriate (ie, patients covered by Medicare or Medicaid). In addition, letters describing the new practice model were sent to patients previously seen by the 4 direct access therapists. One issue that quickly arose was pain medication, a potential need January 2010

For each of the cases, based on the provided patient information, respond to the following: ● Should plain films be ordered (yes/no and why/why not)? If yes, include what views are indicated. ● Of the following choices, state your decision, accompanied by a rationale: 䡩 Treat and not refer 䡩 Treat and refer to physician (nonurgent referral) 䡩 Not treat and refer to physician (nonurgent referral) 䡩 Not treat and refer to physician (urgent referral—emergency department, urgent care clinic, etc) ● Besides examination data provided in the patient vignette, what additional review of systems questions would you ask to help clarify the need for a referral? ● Besides examination data provided in the patient vignette, what additional tests would you include in the physical examination to help clarify the need for a referral?

Figure 2. Patient case vignette assignment

when seeing patients with acute conditions. The Wisconsin Physical Therapy Practice Act states that therapists cannot prescribe medications. The Oversight Committee decided that if a patient had been seen previously by a physician for a condition, the physician would be contacted regarding the prescription. For patients not seen, their primary care physician would be contacted. After 6 months, the program was evaluated for: (1) patient utilization of direct access opportunities, (2) hospital reimbursement, (3) obstacles encountered by therapists (eg, when referring patients for plain films, arranging for provision of pain medication, accessing physician assistance when patient health concerns were identified), and (4) physical therapist plan-of-care decision making. Evaluation of Pilot Program Despite letters to patients who had been seen previously and extensive intradepartmental and interdepartmental communications, approximately 33% to 50% of the designated

direct access patient scheduled slots were used. Most patients who had been seen previously were informed of the direct access option by local clinicians; very few patients called the scheduling desk directly. The need to develop a comprehensive, system-wide marketing plan quickly became evident. The internal marketing plan included: (1) meeting with primary care clinic (PCP) managers and presenting the new program, (2) describing the program in the institution’s newsletter and its Web site (eg, creating a “Did you know . . . ” feature), (3) creating printed materials (brochures and posters) for reception areas and PCP entranceways, and (4) distributing flyers as part of the employee Wellness and Ergonomic Injury Reduction Program and to fitness club members. External marketing efforts included contacting local media for news features and high school coaches and athletic directors to promote the program, as well as attending health fairs. A review of hospital reimbursement revealed that reimbursements for patients billed with

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Hospital-Based Outpatient Direct Access to Physical Therapy Services Table. Summary of Pilot Program Findings (N⫽81 patients) Outcome

Yes

No

Patients referred for plain films

8 (9.9%)

73 (90.1%)

Patients referred for pain medication

3 (3.7%)

78 (96.3%)

Patients referred to physicians for health management issues other than plain films and pain medications

13 (16%)

68 (84%)

Total patient referrals initiated by physical therapists

24 (30%)

57 (70%)

direct access rates were consistent with those for patients seen via a physician referral.

2. Would the patient have benefited significantly from medication therapy?

Eighty-one patients were seen during the pilot program. The Table summarizes the degree to which the participating therapists initiated other health care services. A physician consultation was initiated for approximately 30% of the patients. Of the 13 patients referred for health management issues other than plain films and pain medications, 1 patient was referred for possible deep venous thrombosis and another patient was referred for exacerbation of ankylosing spondylitis. A majority of patient referrals were for nonurgent orthopedic-related consultations (eg, further testing for suspicion of a glenoid labral tear or knee meniscus tear). Therapists noted that initiating the referrals took time, but not more time than when therapists initiated consultations for patients referred by a physician. As the program becomes more widespread, allowing for more data to be collected, an in-depth analysis can be done regarding the institutional impact the direct access program has had.

3. Did the patient exhibit “red flags” that were not adequately addressed? 4. Was a radiology consultation requested by the therapist? If so, was it justified? 5. Under what circumstances should the patient have been referred to a medical doctor or doctor of osteopathy? 6. Did the number of therapy sessions and treatment duration seem appropriate for the condition? 7. If adverse events were noted, did the therapist take appropriate action? The reviewing physicians determined the therapists made appropriate decisions of referring or initiating treatment in 100% of the reviewed cases. Subsequently, the Oversight Committee decided to open the direct access model to all outpatient clinics and thus remove the necessity of having physicians on-site when therapists were seeing patients. The group deemed it adequate for physicians being available for telephone contact.

A physician from the spine and sports rehabilitation clinics reviewed randomly selected charts for the 4 therapists and reported findings to the Oversight Committee. The chart review included responding to the following questions:

Discussion

1. Was the patient appropriate for direct access? Why or why not?

Years of intense lobbying by APTA and its components to promote state practice act changes have led to di-

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rect patient access to physical therapy services being available in a majority of states. With emphasis on removing existing access restrictions in many of these states and gaining access in the few remaining states, little organized effort has occurred related to developing institutional and organizational strategies promoting the implementation of this practice model. As noted previously, the UWHCA direct access effort was in response to the Wisconsin Administrative Code language for hospitals, language that may not be in effect in all states. Even in these states, however, direct access may be prohibited or restricted by internal policies set forth by institutions and thirdparty payers, illustrating that passage of direct access laws may be just the initial step in fully implementing this model of health care delivery. Despite the long-standing success of the military direct access program9,18 and the previously described potential benefits to health care delivery, there has not been widespread institutional adoption in the public sector. Although the literature provides descriptions of direct access program implementation in a large health maintenance organization system and veterans hospital, as well as in military hospitals,18 to our knowledge this is the first case describing establishment of such a model in a large academic medical center. Requiring approval from a large board of physicians and numerous administrators (unfamiliar with current physical therapy laws and education and practice standards), although unique compared with private practice settings, is not unlike the decision-making processes found within insurance companies, smaller hospitals, and large corporations. Strategies promoting widespread approval of the direct access model are paramount to the potential positive impact on health care quality and costs being realized. Once approval January 2010

Hospital-Based Outpatient Direct Access to Physical Therapy Services is gained, other challenges exist in many practice settings that must be met for this practice model to have its full impact.

provides an opportunity for APTA and its components to work with institutions of all types to develop effective marketing plans.

Establishing a direct access program does not guarantee patients will fully utilize this entry point to the health care system, as evidenced by our initial low numbers of scheduled appointments. At institutions such as UWHCA, the sheer size can be an obstacle. More than 80 primary care and specialty physician clinics scattered geographically are all potential patient entry points into our system. In these clinics, medical assistants, nurses, nurse practitioners, and physician assistants field calls and triage where patients are to be seen. Educating these practitioners, along with the clinic managers, provided logistical challenges. Scheduling the clinic meetings and subsequent travel was time-consuming, and after the initial contact, follow-up periodic reminders that direct access to physical therapy existed were needed. Complicating the process for practitioners triaging the patient telephone calls was that some patients’ health plans (ie, Medicare and Medicaid) required a physician referral, so asking questions regarding patients’ health plans was necessary.

The successful implementation of direct access models may result in a shift of patient volume from one institutional cost center to another, leading to a potential conflict for those triaging patient calls. Attempting to keep medical providers’ schedules full could lead to patients appropriate for physical therapy being triaged instead to physicians, nurse practitioners, or physician assistants. The Virginia Mason Medical Center report described the need to shift hospital resources in response to changing practice patterns once direct access was initiated. The hospital’s state-of-the-art chronic pain center ended up treating fewer, but more complex, patient cases, resulting in 15 of the clinic’s medical staff leaving.11 Reallocation of financial and staff resources may need to occur in large institutions before the positive impact of the direct access model can be fully appreciated.

Besides the internal challenges associated with utilization, lack of public awareness of and familiarity with the direct access option to physical therapy also is a factor. For decades, when patients called our clinics, they were told a physician referral was needed, the referral-based model being the only model previously experienced. A comprehensive marketing plan can facilitate the necessary wide-range “educational initiative,” with the hope that word-of-mouth informing of family members and friends will ensue. The process for direct access programs becoming routine and common knowledge in the public’s eye can take time. This challenge January 2010

The UWHC direct access program requirements raised some issues among the physical therapy staff. Although not required by Wisconsin statutes, a decision was made to implement an application process for practicing in this model and requiring successful completion of the direct access training program. Some of the more recent therapist graduates expressed frustration being unable to practice in this model due to not meeting the established requirements—a requirement not present if they practiced in non– hospitalbased practice environments. We explained to therapists (and administrators) that our process was consistent with long-standing models developed in other large institutions (the military and Kaiser Permanente), models demonstrating very positive outcomes to date.18 The process

eased concerns expressed by some hospital administrators and physicians, who noted the variety of degrees held by therapists (BS, MPT, MSPT, and DPT) and questioned what this meant in terms of practice capabilities. The discussion included the impact of DPT professional degree programs evolving, possibly including residency-like clinical educational models,30 and how comfort levels of new graduates practicing in direct access environments might be enhanced. The Oversight Committee agreed the application requirements would be revisited in the future. With all challenges come opportunities and the potential for positive far-reaching changes. The meetings with individual hospital administrators and Medical Board members as preparation for the formal board approval meetings presented us with excellent opportunities to educate administrators and physicians regarding the evolving nature of physical therapist practice. Follow-up meetings with specific physician groups to describe the program afforded the occasion to emphasize the model’s goal is not to promote therapists’ practicing independent of, or in isolation from, physicians. Instead, the goal is interdependent practice and patient-centered care, as described by Johnson and Abrams— care marked by therapists working collaboratively with patients, other practitioners, and payers.31 Therapists initiating a consultation for 30% of the patients during the pilot program provided good examples of the nature of collaborative practice afforded by the direct access model. The public marketing program allows us to not only promote the direct access model but also describe the variety of services physical therapists can provide. Taking full advantage of these opportunities requires cooperation among institutions of similar organizational designs, as well as cooperation be-

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Hospital-Based Outpatient Direct Access to Physical Therapy Services tween APTA and its components. This cooperation will help ensure appropriate resources being developed and disseminated, encourage efficiency, limit reinventing of the wheel, and promote a consistent message being provided to the public.

Summary Consumer choice and timely patient access to the appropriate practitioner were the impetus for obtaining UWHCA administrative approval of and implementation of the direct access model. The initiative’s success was facilitated by: (1) APTA and WPTA resources and (2) relevant published research, combined with the institution’s administrative commitment to improve patient access coinciding with physical therapists’ readiness to redesign their practice model. This administrative case illustrates the importance of communication, collaboration, advanced planning, and consensus building to organizational change of this nature. Program evaluation over time will reveal the institutional impact this model has had. Previous studies provide us with comparison markers, including: (1) patient, therapist, and physician satisfaction; (2) patient functional status at initial visits and outcomes at discharge; (3) number of visits over number of weeks per episode of care; (4) cost per episode of care; (5) utilization of radiology services; and (6) numbers of and reasons for referrals of patients to physicians and other practitioners. Publication of such direct access data from different health care delivery systems (eg, urban versus rural hospitals, private practice clinics, the military) may identify different issues and outcomes that influence institutional policy decisions, staffing models, therapist educational training, and government approval of direct access legislative initiatives.

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All authors provided concept/idea/project design. Dr Boissonnault and Dr Badke provided writing and data collection and analysis. Ms Powers provided consultation (including review of manuscript before submission). The authors thank all of those whose dedication and commitment led to the development and implementation of the physical therapy direct access program at the University of Wisconsin Hospital and Clinics: David Bernhardt, MD, Dan Enz, PT, Karl Fry, PT, Ellen Heiser, RN, Kris Jensen, PT, Jenny Kempf, PT, James Leonard, DO, Julie Sherry, PT, Marc Sherry, PT, Kip Schick, PT, Kristen Traino, PT, and Thomas Zdeblick, MD. Portions of the article were presented at PT 2009: Annual Conference and Exposition of the American Physical Therapy Association; June 10 –13, 2009; Baltimore, Maryland. This article was received August 11, 2008, and was accepted August 30, 2009. DOI: 10.2522/ptj.20080244

References 1 APTA Vision Sentence for Physical Therapy 2020 and APTA Vision Statement for Physical Therapy 2020 [HOD P06 – 00 – 24 –35]. Available at: http://www.apta. org/AM/Template.cfm?Section⫽Home& Template⫽/CM/HTMLDisplay.cfm&Con tentID⫽25855. Accessed August 1, 2008. 2 Data, Evidence, and Research Supporting Direct Access to Physical Therapist Services. Alexandria, VA: American Physical Therapy Association; 2007. 3 US Bone and Joint Decade. The Burden of Musculoskeletal Diseases in the United States. Rosemont, IL: American Academy of Orthopaedic Surgeons; 2008. 4 Martin BI, Deyo RA, Mirza SK, et al. Expenditures and health status among adults with back and neck problems. JAMA. 2008;299:656 – 664. 5 Weiner DK, Kim YS, Bonino P, Wang T. Low back pain in older adults: are we utilizing healthcare resources wisely? Pain Med. 2006;7:143–150. 6 Friedly J, Chan L, Deyo R. Increases in lumbosacral injections in the Medicare population: 1994 to 2001. Spine. 2007;32: 1754 –1760. 7 Deyo RA, Gray DT, Kreuter W, et al. United States trends in lumbar fusion surgery for degenerative conditions. Spine. 2005;30:1441–1445; discussion 1446 –1447. 8 Deyo RA, Mirza SK. Trends and variations in the use of spine surgery. Clin Orthop Relat Res. 2006;443:139 –146. 9 James JJ, Stuart RB. Expanded role for the physical therapist: screening musculoskeletal disorders. Phys Ther. 1975;55: 121–131.

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10 Mitchell JM, de Lissovoy G. A comparison of resource use and cost in direct access versus physician referral episodes of physical therapy. Phys Ther. 1997;77:10 –18. 11 Fuhrmans V. Withdrawal treatment: a novel plan helps hospital wean itself off pricey tests. The Wall Street Journal. January 12, 2007. 12 Overman SS, Larson JW, Dickstein DA, Rockey PH. Physical therapy care for low back pain: monitored program of firstcontact nonphysician care. Phys Ther. 1988;68:199 –207. 13 Deyle GD, Henderson NE, Matekel RL, et al. Effectiveness of manual physical therapy and exercise in osteoarthritis of the knee: a randomized, controlled trial. Ann Intern Med. 2000;132:173–181. 14 Li LC, Iversen MD. Outcomes of patients with rheumatoid arthritis receiving rehabilitation. Curr Opin Rheumatol. 2005;17:172–176. 15 Boshuizen HC, Stemmerik L, Westhoff MH, Hopman-Rock M. The effects of physical therapists’ guidance on improvement in a strength-training program for the frail elderly. J Aging Phys Act. 2005;13:5–22. 16 Nasman J. Vision 2020: autonomous practice for hospital PTs. PT Connections. 2006;36(2):11. 17 Moore JH, McMillian DJ, Rosenthal MD, Weishaar MD. Risk determination for patients with direct access to physical therapy in military health care facilities. J Orthop Sports Phys Ther. 2005;35:674 – 678. 18 Ryan GG, Greathouse D, Matsui I, Murphy BP. Introduction to primary care medicine. In: Boissonnault WG, ed. Primary Care for the Physical Therapist: Examination and Triage. St Louis, MO: Elsevier Saunders; 2005:8 –16. 19 APTA Standards of Practice for Physical Therapy. Available at: http://www.apta. org. 20 APTA Code of Ethics, Available at: http:// www.apta.org. 21 APTA Guide for Professional Conduct. Available at: http://www.apta.org. 22 Stiell I, Wells G, Vandemheen KL. The Canadian C-spine rule for radiography in alert and stable trauma patients. JAMA. 2001; 286:1841–1848. 23 Seaberg D, Yealy M, Lukens T, et al. Multicenter comparison of two clinical decision rules for the use of radiography in acute, high-risk knee injuries. Am Emerg Med. 1998;32:8 –13. 24 Bachman LM, Haberzeth S, Steurer J, et al. The accuracy of the Ottawa knee rule to rule out knee fractures: a systematic review. Ann Intern Med. 2004;140:121–124. 25 Stiell I, Greenberg G, McKnight R, et al. Decision rules for the use of radiography in acute ankle injuries: refinement and prospective validation. JAMA. 1993;269: 1127–1132. 26 Bachmann LM, Kolb E, Koller MT, et al. Accuracy of Ottawa ankle rules to exclude fractures of the ankle and mid-foot: systematic review. BMJ. 2003;326:417– 419.

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Hospital-Based Outpatient Direct Access to Physical Therapy Services 27 Chou R, Qaseem A, Snow V, et al. Diagnosis and treatment of low back pain: a joint clinical guideline from the American College of Physicians and the American Pain Society. Ann Int Med. 2007;147: 478 – 491. 28 Jette DU, Ardleigh K, Chandler K, McShea L. Decision-making ability of physical therapists: physical therapy intervention or medical referral. Phys Ther. 2006;86: 1619 –1629.

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29 Meadows J. Orthopedic Differential Diagnosis in Physical Therapy. A Case Study Approach. New York, NY: McGraw-Hill; 1999. 30 Delitto A. Thirty-Ninth Mary McMillan Lecture: We are what we do. Phys Ther. 2008; 88:1219 –1227.

31 Johnson MP, Abrams SL. Historical perspectives of autonomy within the medical profession: considerations for 21st century physical therapy practice. J Orthop Sports Phys Ther. 2005;35:628 – 636.

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Perspective

Hallux Valgus and the First Metatarsal Arch Segment: A Theoretical Biomechanical Perspective Ward M. Glasoe, David J. Nuckley, Paula M. Ludewig W.M. Glasoe, PT, MA, ATC, is Instructor, Program in Physical Therapy, University of Minnesota, Medical School, Mayo Mail Code 388, 420 Delaware St SE, Minneapolis, MN 55455 (USA). Address all correspondence to Mr Glasoe at: [email protected]. D.J. Nuckley, PhD, is Assistant Professor, Program in Physical Therapy, University of Minnesota, Medical School. P.M. Ludewig, PT, PhD, is Associate Professor, Program in Physical Therapy, University of Minnesota, Medical School.

Hallux valgus is a progressive foot deformity characterized by a lateral deviation of the hallux with corresponding medial deviation of the first metatarsal. Late-stage changes may render the hallux painful and without functional utility, leading to impaired gait. Various environmental, genetic, and anatomical predispositions have been suggested, but the exact cause of hallux valgus is unknown. Evidence indicates that conservative intervention for hallux valgus provides relief from symptoms but does not reverse deformity. Part 1 of this perspective article reviews the literature describing the anatomy, pathomechanics, and etiology of hallux valgus. Part 2 expands on the biomechanical initiators of hallux valgus attributed to the first metatarsal. Theory is advanced that collapse of the arch with vertical orientation (tilt) of the first metatarsal axis initiates deformity. To counteract the progression of hallux valgus, we use theory to discuss a possible mechanism by which foot orthoses can bolster the arch and reorient the first metatarsal axis horizontally.

[Glasoe WM, Nuckley DJ, Ludewig PM. Hallux valgus and the first metatarsal arch segment: a theoretical biomechanical perspective. Phys Ther. 2010;90:110 –120.] © 2010 American Physical Therapy Association

Post a Rapid Response or find The Bottom Line: www.ptjournal.org 110

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Hallux Valgus and the First Metatarsal Arch Segment

H

allux valgus (Fig. 1) is an irreversible foot deformity.1–3 The condition, which in lay terminology is called “bunion,” is characterized by a lateral deviation (abduction) of the hallux with a corresponding medial deviation (adduction) of the first metatarsal. Deformity disrupts the normal straight alignment of the first metatarsophalangeal (MTP) joint. When hallux valgus is severe, the first MTP joint may dislocate, leading to impaired gait.3 “Bunion” is a Latin word meaning enlargement, which refers to the chronic swollen appearance of the medial projected eminence that develops as the hallux deviates laterally into deformity.1,4 Pain, when experienced, is usually localized to the swelling (bunion) or in the first MTP joint itself.3 Shoes may aggravate the condition. To reduce discomfort, individuals having hallux valgus are advised to avoid wearing high-heeled, pointed-toed shoes. Shoes made from soft leather that are flat in style work best and if necessary, the toe box can be stretched to accommodate for bunion enlargement.5,6

that deformity will progress until fixed by surgery.1 Indications for surgery include pain or dysfunction that prevents activity or lifestyle choices, the inability to find shoes that fit, and cosmetic concerns.4 More than 100 surgical techniques are used to correct for variation in hallux valgus deformity,9 with an estimated 210,000 surgeries performed each year in the United States.10,11 Part 1 of this perspective reviews the anatomy, pathomechanics, and the etiology of hallux valgus. This review suggests a characteristic or behavior of the first metatarsal may initiate hallux valgus or contribute to its recurrence following surgery. The kinetic and kinematic behaviors of the first metatarsal arch segment are fur-

ther evaluated in part 2, wherein a theoretical perspective on the genesis of hallux valgus is presented. The purpose of the article is to develop a biomechanically derived perspective on hallux valgus and suggest indications for conservative orthotic treatment strategies.

Part 1: Anatomy, Pathomechanics, and Etiology Functional Anatomy and Associated Kinematics The hallux has a distal phalanx and proximal phalanx (Fig. 1). The proximal phalanx articulates with the first metatarsal. The MTP joint is a biaxial condylar articulation that relies on a synovial capsule, collateral liga-

Therapy for hallux valgus aims to correct the forces acting on the first MTP joint. Suggestions for care include foot exercise to rebalance muscle strength (force-generating capacity),7 and the use of toe spacers and splinting to stretch tissue tightness.5,6 Foot orthoses also may be incorporated into treatment.8 Regardless of the treatment applied, current available evidence indicates

Available With This Article at ptjournal.apta.org • Audio Abstracts Podcast This article was published ahead of print on November 19, 2009, at ptjournal.apta.org.

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Figure 1. Hallux valgus disrupts normal alignment of the metatarsophalangeal joint. Arrows indicate the direction of joint member deformity displacements. The hallux abducts while the first metatarsocuneiform segments adduct. The severity of the halluxmetatarsal deformity is measured by (A) hallux valgus angle and (B) intermetatarsal 1–2 angle.

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Hallux Valgus and the First Metatarsal Arch Segment ments, and a fibrous plantar plate to maintain joint stability.12 A medial sesamoid bone and a lateral sesamoid bone, encased in the tendons of the intrinsic muscles, lie beneath the head of the first metatarsal.13 The first metatarsal articulates proximally with the medial cuneiform and the base of the second metatarsal.12,14 The metatarsocuneiform (MC) joint is a stable union having a dense plantar ligament that works to fortify the medial longitudinal arch.14 The base of the first metatarsal makes neighboring contact with the second metatarsal (Fig. 1). The Lisfranc ligament connects the first and second metatarsals.12 Severe hallux valgus deformity may disrupt each of these bony contacts and joint structures. The first metatarsal in connection with the medial cuneiform is called the first ray. The first metatarsal and cuneiform bones move together as a single, unified arch segment but separately from the second metatarsal.12–14 As is commonly done in the literature,12–14 the term “first metatarsal” is used generically in this perspective to describe the combined kinematics of the first metatarsalcuneiform arch segment. Bone segments rotate around joint axis systems. A joint axis can be thought of as a line that varies in 3-dimensional position and orientation about which a segment rotates in a perpendicular plane.15 In its simplest form, a joint axis may be likened to a pin about which a hinge rotates. In the foot, sagittal-plane dorsiflexion and plantar flexion occur about a mediolaterally directed joint axis, transverse-plane adduction and abduction occur about a vertical axis, and frontal-plane inversion and eversion occur about a longitudinal axis. Because joints do not truly align perpendicular to the cardinal planes,16,17 rotations of the hallux and first metatarsal segments occur in some proportion across each of 112

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the cardinal planes. Besides describing motion, the terms “abduction of the hallux” and “adduction of the first metatarsal” describe the direction of hallux valgus foot deformity (Fig. 1). Pathomechanics of Hallux Valgus The progression of hallux valgus, although not well understood, is predictable.3,18 The tensile strength of the medial collateral ligament of the first MTP joint weakens and the hallux abducts laterally into valgus.18 Coincident with abduction of the hallux, the metatarsal shifts medially into adduction, potentially subluxating the sesamometatarsal articulation.19,20 Hallux valgus angle (Fig. 1A) refers to the offset in first MTP joint positioning.21 The related separation between the first and second metatarsals, which increases as deformity becomes worse, is called the intermetatarsal 1–2 angle (Fig. 1B).12 Deformity is judged to be severe when the hallux valgus angle is greater than 40 degrees and the intermetatarsal 1–2 angle is greater than 16 degrees.21,22 Severe deformity leaves the medial aspect of the metatarsal articular surface uncovered and exposed to trauma. This gives rise to hypertrophy, resulting in the cosmetic feature most commonly associated with hallux valgus.3 Hallux valgus alters bony contact pressures across the first MTP joint members.3,18 As a result of incongruity in contact pressures, lesions develop in the articular cartilage. Eventually, the cartilage erodes and changes the shape of the first metatarsal head (Fig. 1). Scranton and Rutkowski23 qualitatively evaluated the extent of cartilage and subchondral bone damage in 35 cadavers having hallux valgus. Erosion of the plantar surface of the metatarsal head was present in every specimen having completely dislocated sesamoids. In a different study, Roukis et al24 mapped articular wear patterns in

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166 feet undergoing hallux valgus surgery. All patients older than 50 years showed erosive damage involving nearly half of the combined MTP joint surface area. Such late-stage changes in joint structure may render the hallux painful and without functional utility.3,4,18 Deformity remains and worsens due to the unbalance of moments acting on the hallux during gait. Plantar pressure measurements are highest near the end of stance when loads carried by the hallux approach 40% of body weight.25 Walking with a laterally rotated foot angle and walking in excess foot pronation are gait compensations known to redirect the distribution of weight to the medial side of the hallux.3,19,26 Moment generated mostly by the flexor hallucis longus (FHL) counters the ground force moment reacting to dorsiflex the hallux.27–29 These action-reaction moments have been modeled to explain the progression of deformity.28,29 As the hallux abducts, the ground reaction force (GRF) acting on the hallux has a medial component that increasingly works to displace the first metatarsal into adduction. The magnitude of this medial force component equals the GRF acting on the hallux multiplied by the tangent of the angle approximating the hallux valgus angle.29 For example, should the angle of hallux deformity be 45 degrees (Fig. 1), the medial component of force pushing the first metatarsal into adduction would be equal to the load carried by the hallux. Added to this is the misdirected moment action of FHL muscle. In response to developing deformity, the resultant pull of the FHL shifts from a plantar direction to a lateral direction, changing the joint moment action from the sagittal plane to the transverse plane.27,28 Etiology The cause of hallux valgus is unknown.1 Many theories have been January 2010

Hallux Valgus and the First Metatarsal Arch Segment put forth, and perhaps most common is that ill-fitting footwear may contribute.30 –32 The prevalence of hallux valgus is highest in the female populations living in Western societies that wear fashionable shoes.33 Shoes worn by women typically have a high-heel and narrow toe box.34 Heeled shoes increase pressure borne by the forefoot and, when worn over prolonged time periods, may lead to adaptive shortening of the ankle plantar-flexor muscles.3,34 Decreased ankle dorsiflexion, by itself, is considered a factor in hallux valgus.3 Epidemiologic data demonstrate the highest incidence of hallux valgus in elderly people,35 with women representing 90% of all cases.22 Specifically, Gould et al36 estimated the deformity to affect 1 in every 45 individuals over the age of 50 years. Deformity also may develop in childhood. The term “juvenile hallux valgus” is used when the condition presents prior to skeletal maturity.37,38 Greater than 60% of patients having hallux valgus show a family history of the deformity.39,40 Congenital neurological pathology, such as ankle equinus associated with cerebral palsy, and chronic inflammatory conditions have been found to be related to hallux valgus.3,4,41 Damage of the first MTP joint occurs in nearly 25% of patients having rheumatoid arthritis (RA).42 Arthritis weakens the articular tissues, leaving the weightbearing joints at risk of dislocation; collapse of the arch is common.43– 45 Coughlin and colleagues18,21,39 reported that 10% of surgeries performed in their practice to correct hallux valgus were for inflammatory arthritic conditions, predominantly RA.22 Premised on the belief that structure influences function, research has investigated length of the first metatarsal as a separate factor in hallux January 2010

valgus. Both relative long2,46,47 and short48 –50 first metatarsals have been reported as associated with deformity progression. These opposing results suggest that length of the first metatarsal may be incidental to the development of deformity, or that length effects are significant only when combined with other precursor traits. Shape of the first metatarsal head also has been explored as a potential predisposition of hallux valgus.3,47,51,52 A flattened head is considered to be resistive to deforming forces, whereas a round head is thought more prone to allow the hallux to drift into deformity.3 A retrospective review of 110 foot radiographs of patients having hallux valgus identified the head of the first metatarsal to be shaped “round” in 100% of those having a long first metatarsal in comparison with their second metatarsal.47 When discussing this no-exception finding, the authors postulated that a long first metatarsal impedes MTP joint dorsiflexion and redirects the hallux into valgus. The finding,47 however, may be questioned because the contribution of joint erosion was not considered in the visual analysis used in classifying shape of the metatarsal head. Other studies3,51,52 that also reviewed radiographs in patients with hallux valgus showed no trends in data to support the notion that roundness of the metatarsal head leads to deformity.

women were shaped to permit the first metatarsal to translate medially into adduction. Ferrari et al53 discussed this difference in joint structure between sexes to explain why hallux valgus develops most often in women. These results, although interesting, cannot be easily incorporated into treatment. The predisposition most often identified with hallux valgus is collapse of the medial arch, especially as it relates to instability of the first metatarsal.37,55– 60 Because the first metatarsal and the neighboring bones of the medial longitudinal arch can be supported with foot orthoses, this area of biomechanical study holds promise for treatment. Part 2 of this perspective article explores the codependent kinetic and kinematic behaviors of the arch and first metatarsal. We advance a theory that collapse of the arch with vertical orientation of the first metatarsal axis initiates hallux valgus. Consistent with the research reviewed, we discuss a novel mechanism by which orthoses used to bolster the arch might counteract deformity progression.

Part 2: A Theoretical Perspective on Hallux Valgus More than 40 years ago, Ebisui suggested the first metatarsal axis could precipitate hallux valgus and issued the following challenge to understanding and treatment:

Even though the shape and geometry of the first metatarsal head exhibit little correlation with the development of hallux valgus, variation in first MC joint osteology is thought to precipitate first MTP joint malalignment.14,41,53,54 Ferrari et al53 reconstructed the bones of the medial arch from image data in the feet of 107 skeletons. Measurements made on the bone images showed the connecting facets of the MC joint in Volume 90

Whether the first ray axis is intimately related to hallux valgus is a matter of conjecture. Further investigation will be necessary before any definitive conclusion can be made. It is hoped that this study will stimulate others to investigate the fundamental mechanics of hallux valgus. It is our contention that more emphasis should be placed upon the cause and prevention of deformity rather than on the many variations of surgical procedures for its correction.61(p168)

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Figure 2. The first metatarsal axis represented in 3 different foot postures: (A) pronation, (B) neutral, and (C) supination. Orientation of the axis changes as a function of arch height.

Part 2 of this perspective article gives a response to this challenge wherein the first metatarsal axis and its predisposition to hallux valgus are described. The literature and theory are predicated upon 3 major tenets: (1) the first metatarsal rotates about its own axis; (2) collapse of the arch orients (tilts) of the first metatarsal axis toward vertical, which allows the first metatarsal to adduct with less anatomical resistance; and (3) instability of the first metatarsal arch segment is a related factor of hallux valgus. These tenets of first metatarsal biomechanics support our theory for hallux valgus that collapse of the arch with vertical orientation of the first metatarsal axis initiates deformity. Part 2 concludes with a discussion using this theoretical perspective to advocate for orthoses-based treatment strategies. First Metatarsal Axis Studies on cadavers provide the only primary source research describing the first metatarsal axis.16,61– 66 Hicks16 was the first researcher to describe the position and orientation of the first metatarsal axis. He located the axis by observing the trajectory of an external jig fastened to bone while imposing an external load to move the first metatarsal. With the foot (N⫽15) in a non– weight-bearing position, the metatar114

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sal arch segment rotated about an axis estimated to orient almost horizontal and pass between the navicular and the base of the third metatarsal (Fig. 2). The observed motion of the first metatarsal in relation to the navicular coupled dorsiflexion with inversion (DF-IN) and plantar flexion with eversion (PF-EV).16 Kelso and coworkers65 also conducted a non– weight-bearing experiment (N⫽24) using similar methods, except that first metatarsal motions were measured by a gravity-sensitive device. Data confirmed the metatarsal moved independent of the foot in the pattern of motion Hicks16 had described. Kelso et al65 expressed reservations that non–weightbearing measurements may not capture the kinematics of foot function. Some studies67,68 support this concern, noting that weight-bearing and non–weight-bearing measurements differ. This disparity explains why the patterns of motion (DF-IN, PFEV) reported by Hicks16 and by Kelso et al65 have been measured opposite (DF-EV, PF-IN) in cadaveric weightbearing experiments62,63,66,69 and in gait.68,70,71 Collectively, this research demonstrates 2 key findings: (1) the first metatarsal has the capacity to move as an independent foot segment, and (2) the parameters defining the first metatarsal axis can be quantified.

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Position and orientation are physical traits of a joint axis. An axis defines a location in 3-dimensional space about which neighboring segments displace. Figure 2B shows a visual representation of the first metatarsal axis. The axis is drawn passing between navicular and the base of the third metatarsal.15 The position of these 2 bones in relation to the first metatarsal provides an estimate of how the axis orients in space. One would anticipate that axis orientation would be unique among individuals but similar across foot types. Joint axis orientation can influence the direction of segment rotations. This characteristic of directed joint motion may play a role in the genesis of hallux valgus. If the first metatarsal axis runs mediolaterally across the foot and orients horizontally in the transverse plane,16 resulting segment rotations would occur in the sagittal plane. Change the orientation of the first metatarsal axis, however, and the direction of segment rotation must change accordingly. Collapse of the Arch Orients the First Metatarsal Axis Toward Vertical Building on the previous biomechanical perspective, we evaluate the collapse for the arch under weight-bearing load and its potential January 2010

Hallux Valgus and the First Metatarsal Arch Segment

Figure 3. Estimates of helical axis vectors about which the first metatarsal rotated (N⫽9). The reference coordinate frame is embedded in the midfoot, as shown in the superimposed image of the foot. Copyright © 2008 by the American Orthopedic Foot and Ankle Society Inc. Originally published in and reproduced here with permission from: Glasoe W, Pena F, Phadke V, Ludewig PM. Arch height and first metatarsal joint axis orientation as related variables in foot structure and function. Foot Ankle Int. 2008;29:647– 655.

to orient the first metatarsal axis vertically, creating first metatarsal adduction known to precipitate hallux valgus deformity. A recent study did link orientation of the first metatarsal axis to arch height. Glasoe and colleagues63 quantified orientation of the first metatarsal axis in cadaver specimens during a sequence of static gait events. Staged gait events included foot flat, heel-off, and terminal stance. Orientation of the first metatarsal axis was extracted as helical parameters.72 The helical axis (Fig. 3) represented the location about which the first metatarsal and midfoot segments rotated in relation to each other. Orientation of the axis varied among specimens and was found to be inversely related to arch January 2010

height (r⫽⫺.73).63 The metatarsal axis oriented more toward vertical (Fig. 3, see vectors colored red, blue, green) as the arch dropped in height. When considered as conjoined variables, vertical axis orientation and arch height accounted for 69% of the variance in intermetatarsal 1–2 angle and change in metatarsal adduction positioning. The experiment63 had several limitations in helping clinicians and researchers understand whether the axis of the first metatarsal may contribute to hallux valgus. The specimens tested did not have obvious deformity, foot type was not defined, the sample was small, the load imposed was below physiologic levels (100 N), only selected foot postures were studied, and arch height was measured while the foot was static. Nevertheless, results did

show the first metatarsal axis to orient more vertical in the low-arched foot, and its action directed the metatarsal into adduction.63 Flattening of the foot under body weight may alter the orientation of the first metatarsal axis. Should the medial arch flatten completely under imposed load, the navicular could drop to the ground. The navicular then would rest in a relative position below the more stable and centrally located tarsometatarsal midfoot joints (Fig. 2A). Such a precipitous drop in navicular position would lower the most medial point of the first metatarsal axis while raising the lateral point of the axis. This collapse of the medial arch could orient the axis toward vertical and, by effect, transfer partial angular rotation

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Hallux Valgus and the First Metatarsal Arch Segment about the axis from the sagittal plane to the transverse anatomical plane.63 Dorsiflexion of the first metatarsal, as should occur in early stance as the arch lowers under advancing weight, then would become dorsiflexion/adduction (directed rotation about an axis oriented vertical). In addition, adduction of the first metatarsal occurring under full weightbearing load could progressively enlarge the intermetatarsal 1–2 angle (Fig. 1). Thus, the condition of hallux valgus may develop secondary to changes in the orientation of the first metatarsal axis.63 Orientation of the first MTP joint axis (different from the first metatarsal axis) is known to be altered in latestage hallux valgus.19,23 The axis about which the hallux rotates is located in the first metatarsal head. In the nondeformed, well-aligned foot structure, the joint axis of hallux rotation runs horizontally, passing mediolaterally through the metatarsal head.17 When deformity is severe, the distal arch segments pronate (evert), tilting the first MTP joint axis toward vertical,26 which changes the direction of available hallux joint motion from the sagittal plane to the transverse plane.19,23 Instability of the First Metatarsal Arch Segment Instability of the first metatarsal arch segment is a related factor of hallux valgus.73–75 Stability of the first metatarsal is assessed as a static clinical measurement using a variety of methods to include manual, mechanical, and radiographic stress testing.55,57,73 Common across testing methods is that a displacement force is imposed on the first metatarsal head while the relative position of the lesser metatarsals is held stable.55 The condition, called first metatarsal hypermobility,13 is defined clinically as demonstrable laxity of the distal arch segment with

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related widening of the intermetatarsal 1–2 angle.73–75 Hypermobility of the first metatarsal is a frequent predisposition listed for hallux valgus.55,57,73–75 Faber and coworkers73 identified the first metatarsal to be hypermobile in 60 of 94 (64%) patients undergoing corrective hallux valgus surgeries. Lee and Young74 reported the metatarsal to be hypermobile in 38% of patients having hallux valgus. Roukis and Landsman75 agreed that a relationship does exist but estimated the incidence of hallux valgus and associated metatarsal hypermobility to be no higher than 10%. The presence of hypermobility was judged in each of these studies73–75 by manual test methods. Manual assessment of first metatarsal hypermobility has uncertain reliability, and measured results may be influenced by examiner bias.76,77 This weakness in the testing procedure may account for the wide discrepancy in reported incidence across studies.73–75 Nevertheless, sufficient evidence exists to show that first metatarsal mobility is increased in individuals having hallux valgus and that a large intermetatarsal 1–2 angle is an indicator of first metatarsal hypermobility.55,57,73–75 Results from other studies78 – 80 have revealed that the first metatarsal may become hypermobile as deformity progresses. Coughlin and colleagues78,79 demonstrated nearly a 50% reduction in dorsal excursion of the first metatarsal in cadavers (from 11.0 to 5.2 mm) and in patients (from 7.2 to 4.5 mm) after the deformity into hallux valgus was corrected with surgery. Deformity was corrected using a proximal osteotomy realignment of the first metatarsal, a technique that did not incorporate arthrodesis of the first MC joint. Kim et al80 reported a similar mean drop (from 6.8 to 3.2 mm) in metatarsal mobility in a consecutive series of 67 patients who underwent cor-

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rective hallux valgus surgery. Realignment was made without arthrodesis of the first MC joint. Coughlin and colleagues78,79 reasoned that realignment, by itself, reduced mobility of the first metatarsal to levels considered normal because the plantar fascia could better stabilize the metatarsal when the arch and hallux were aligned. However, because Coughlin and colleagues’ method of making mechanical measurement of first metatarsal mobility did not tighten the plantar fascia,78,79 other medial arch joint structures must act to limit motion of the first metatarsal in the correctly aligned foot. Two critical points can be taken from these studies.78 – 80 First, passive mobility of the first metatarsal is dependent upon its alignment in the foot. Second, adduction of the first metatarsal as occurs with hallux valgus can make the first metatarsal unstable. Lapidus58 labeled adduction of the first metatarsal leading to first metatarsal hypermobility to be a nonevolved primate trait when he introduced surgical arthrodesis of the first MC joint to correct severe hallux valgus deformity. Currently, there is no consensus on whether fusion of the first MC joint is routinely necessary when correcting for hallux valgus.58 – 60,78,79 The surgery is technically demanding,22 and the rate of patient satisfaction ranges between 75% and 90%, with nonunion and other long-term complications approaching 10%.59,60,81 There is agreement across studies,58 – 60,78,79 however, that adduction of the first metatarsal disrupts the capacity of the medial arch to carry weight and that gait impairments will become worse if deformity is left uncorrected.20,64 Generalized joint laxity is a significant predictor of first metatarsal hypermobility.82– 84 Patients having hallux valgus demonstrate a high inJanuary 2010

Hallux Valgus and the First Metatarsal Arch Segment cidence of multijoint laxity.37,85 Harris and Beeson37 identified generalized joint laxity in 42% of females (age 10 –21 years) having symptomatic hallux valgus. The hallux drifts into deformity because the collateral ligaments lack sufficient stiffness to stabilize the first MTP joint.86 What precipitates malpositioning of the first MTP joint members may stem from laxity of the Lisfranc (tarsometatarsal) or the other plantar arch ligaments that permit the first metatarsal to deviate away from the stable second metatarsal, collapsing the truss mechanics of the medical arch.12,13 The exact mechanism that precipitates deformity in the hyperlax foot is unknown.

Theory-Derived Evidence for Orthotic Treatment A pendulum attached to the hallux (Fig. 4) demonstrates how standing in extreme pronation orients the first MTP joint obliquely.87 Biomechanical modeling19,88 suggests the GRF vector shifts to the medial side of the hallux during late stance in the gait cycle, imposing a net valgus moment to the MTP joint, thus predisposing the development of deformity. Extreme pronation of the foot joints as quantified by radiographic methods is commonly seen in patients having hallux valgus.23,26,41,56 The incidence has been reported to be as high as 50%.89 This relationship has not been confirmed with measurements taken from footprints.39,52,78 Footprints, however, do not predict arch height90 or identify the behavior or motion of the arch under weightbearing load.90,91 The pendulum demonstration (Fig. 4) was first published by Inman.26 He concluded that a hyper-lax arch with corresponding extreme pronation of the medial arch joints was a certain predisposition of hallux valgus. Treatment of early-stage hallux valgus, Inman urged, should involve “a heel cup, shoe insert, or arch supJanuary 2010

Figure 4. A pendulum glued to the nail of the hallux demonstrates how foot posture affects the alignment of the first metatarsophalangeal joint: (A) supination, and (B) pronation. Reprinted with permission from: Coughlin MJ. Adult hallux valgus. In: Coughlin MJ, Mann RA, Saltzman CL, eds. Surgery of the Foot and Ankle. Vol 1. 8th ed. Philadelphia, PA: Mosby; 2007:200.

port to rectify the pronation, rather than by an attempt to make surgical correction.”26(p64) A randomized controlled trial conducted by Kilmartin et al38 showed that orthoses made deformity worse in children aged 9 and 10 years having juvenile hallux valgus. The study assessed the use of rigid, partialcontact, custom-made orthoses designed to limit hindfoot pronation versus no treatment. Those children who received treatment were judged to be adherent if orthoses were worn to follow-up appointments. Followup radiographic evaluations were performed 3 years after enrollment. Hallux valgus angle had “deteriorated” in both groups, and the angle of deformity had become largest in children treated with orthoses. Concern has been voiced regarding the suitability of the orthoses prescribed.1 Besides this very relevant concern, as well as the issue of nonverifiable adherence, the orthoses custom fit by Kilmartin et al38 were never re-made in response to the child’s growth or change in foot-

wear. The perspective weighs these cumulative limitations when drawing conclusions on whether orthoses have value in the treatment of hallux valgus. More current randomized controlled trial evidence has recognized the benefits of treating hallux valgus with foot orthoses. Torkki and coworkers published 1-year11 and 2year8 follow-up trials comparing orthoses, surgery, and no treatment. A consecutive series of 211 adult patients (mean age⫽49 years) seeking care for mild or moderate hallux valgus deformity participated. The orthoses were custom-made using a negative cast technique, with individual prescription written according to the presenting deformity. Patients treated with orthoses described themselves as improved on a global assessment scale at 1-year follow-up.11 At year 2,8 patients treated with orthoses were as satisfied as those having surgery, and more satisfied than controls. Torkki and colleagues11 did not speculate on why early intervention with or-

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Hallux Valgus and the First Metatarsal Arch Segment thoses might forestall the need for corrective surgery.8 Consistent with theory advanced in this perspective, however, it could be that orthoses fit to the arch may orient the first metatarsal axis horizontal. This horizontal orientation of the first metatarsal axis ultimately changed the associated joint interactions. We contend, therefore, that orthoses constructed to bolster the arch and orient the first metatarsal horizontal may work to contain the kinetics and kinematics of the first metatarsal to the sagittal plane.19,23,63

Summary Multiple factors have been implicated in the etiology of hallux valgus. This perspective suggests that collapse of the arch under weightbearing load orients the first metatarsal axis toward vertical and predisposes adduction of the first metatarsal, which initiates deformity. This grounded theory was built upon the following points: • The first metatarsal rotates about its own axis. • Orientation of this axis is variable and dependent upon the shape of the medial arch. • The arch is best able to carry weight and keep its shape when the first metatarsal is properly aligned. • Collapse of the arch tends to orient the first metatarsal axis towards vertical. • Adduction of the first metatarsal occurs about a vertical axis. • Adduction of the first metatarsal predisposes hallux valgus.

Orthoses designed to keep the medial arch from collapsing under load may orient the first metatarsal axis toward the horizontal, which, in theory, may help contain physiological rotation of the first metatarsal to the sagittal plane and optimize the internal properties of the medial arch to carry weight. For this reasoning to 118

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be applied in practice, research is needed to identify specific foot types and patient populations that would benefit from wearing orthoses constructed to support the arch with intent to orient the first metatarsal axis horizontal. Clinical trials then could be pursued to investigate whether orthoses used early in the treatment of hallux valgus may reduce or even reverse the progression of deformity. Mr Glasoe provided concept/idea/project design. All authors provided writing. This work was supported by the Arthritis Foundation North Central Chapter and, in part, by a scholarship from the Foundation for Physical Therapy. This article was received September 26, 2008, and was accepted September 2, 2009. DOI: 10.2522/ptj.20080298

References 1 Ferrari J, Higgins J, Prior T. Interventions for treating hallux valgus (abductovalgus) and bunions. Cochrane Database Syst Rev. 2004;1:CD000964. 2 Hardy RH, Clapham JC. Observations on hallux valgus: based on a controlled series. J Bone Joint Surg Br. 1951;33:376 –391. 3 Mann RA, Coughlin MJ. Hallux valgus: etiology, anatomy, treatment and surgical considerations. Clin Orthop Relat Res. 1981;157:31– 41. 4 Easley ME, Trnka HJ. Current concepts review: hallux valgus, part 1: pathomechanics, clinical assessment, and nonoperative management. Foot Ankle Int. 2007;28: 654 – 659. 5 Caselli MA, George DH. Foot deformities: biomechanical and pathomechanical changes associated with aging, part 1. Clin Podiatr Med Surg. 2003;20:487– 509. 6 Hart ES, deAsla RJ, Grottkau BE. Current concepts in the treatment of hallux valgus. Orthop Nurs. 2008;27:274 –280. 7 Groiso JA. Juvenile hallux valgus: a conservative approach to treatment. J Bone Joint Surg Am. 1992;74:1367–1374. 8 Torkki M, Malmivaara A, Seitsalo S, et al. Hallux valgus: immediate operation versus 1 year of waiting with and without orthoses: a randomized controlled trial of 209 patients. Acta Orthop Scand. 2003;74: 209 –215. 9 Easley ME, Trnka HJ. Current concepts review: hallux valgus, part II: operative treatment. Foot Ankle Int. 2007;28:748 –758.

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10 Thompson FM, Coughlin MJ. The high price of high-fashion footwear. J Bone Joint Surg Am. 1994;10:1586 –1593. 11 Torkki M, Malmivaara A, Scitsalo S, et al. Surgery vs orthosis vs watchful waiting for hallux valgus a randomized controlled trial. JAMA. 2001;285:2474 –2480. 12 Romash MM, Fugate D, Yanklowit B. Passive motion of the first metatarsal cuneiform joint: preoperative assessment. Foot Ankle. 1990;10:293–298. 13 Glasoe WM, Yack HJ, Saltzman CL. Anatomy and biomechanics of the first ray. Phys Ther. 1999;79:854 – 859. 14 Wanivenhaus A, Pretterklieber M. First tarsometatarsal joint: anatomical biomechanical study. Foot Ankle. 1989;9:153–157. 15 Woltring H. Representation and calculation of 3-D joint movement. Hum Mov Sci. 1991;10:603– 616. 16 Hicks JH. The mechanics of the foot, I: the joints. J Anat. 1953;87:345–357. 17 Shereff M. Pathophysiology, anatomy, and biomechanics of hallux valgus. Orthopedics. 1990;13:939 –945. 18 Coughlin MJ. Hallux valgus. J Bone Joint Surg Am. 1996;78:932–966. 19 Talbot KD, Saltzman CL. Hallucal rotation: a method of measurement and relationship to bunion deformity. Foot Ankle Int. 1997;18:550 –556. 20 Tanaka Y, Takakura Y, Sugimoto K, et al. Precise anatomic configuration changes in the first ray of the hallux valgus foot. Foot Ankle Int. 2000;21:651– 656. 21 Coughlin MJ, Saltzman CL, Nunley JA Jr. Angular measurements in the evaluation of hallux valgus deformities: a report of the ad hoc committee of the American Orthopaedic Foot & Ankle Society on angular measurements. Foot Ankle Int. 2002;23: 68 –74. 22 Coughlin MJ. Hallux valgus in men: effect of the distal metatarsal articular angle on hallux valgus correction. Foot Ankle Int. 1997;18:463– 470. 23 Scranton PE Jr, Rutkowski R. Anatomic variations in the first ray, part I: anatomic aspects related to bunion surgery. Clin Orthop Relat Res. 1980;151:244 –255. 24 Roukis TS, Weil LS Jr, Weil LS Sr, Landsman AS. Predicting articular erosion in hallux valgus: clinical, radiographic, and intraoperative analysis. J Foot Ankle Surg. 2005;44:13–21. 25 Kernozek TW, Elfessi A, Sterriker S. Clinical and biomechanical risk factors of patients diagnosed with hallux valgus. J Am Podiatr Med Assoc. 2003;93:97–103. 26 Inman VT. Hallux valgus: a review of etiologic factors. Orthop Clin North Am. 1974;5:59 – 66. 27 Saltzman CL, Aper RL, Brown TD. Anatomic determinants of first metatarsophalangeal flexion moments in hallux valgus. Clin Orthop Relat Res. 1997;339:261–269. 28 Sanders AP, Snijders CJ, van Linge B. Medial deviation of the first metatarsal head as a result of flexion forces in hallux valgus. Foot Ankle. 1992;13:515–522.

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Hallux Valgus and the First Metatarsal Arch Segment 29 Snijder CJ, Snijder JG, Philippens MM. Biomechanics of hallux valgus and spread foot. Foot Ankle. 1986;7:26 –39. 30 Barnicott N, Hardy R. The position of hallux in Western Africans. J Anat. 1952;89: 355–361. 31 MacLennan R. Prevalence of hallux valgus in neolithic New Guinea population. Lancet. 1966;1:1398 –1400. 32 Sim-Fook L, Hodgson AR. A comparison of foot forms among the non-shoe and shoewearing Chinese population. J Bone Joint Surg Am. 1958;40:1058 –1062. 33 Kato T, Watanabe S. The etiology of hallux valgus in Japan. Clin Orthop Relat Res. 1981;157:78 – 81. 34 Menz HB, Morris ME. Determinants of disabling foot pain in retirement village residents. J Am Podiatr Med Assoc. 2005;95: 573–579. 35 Dunn JE, Link CL, Felson DT, et al. Prevalence of foot and ankle conditions in a multiethnic community sample of older adults. Am J Epidemiol. 2004;159:491– 498. 36 Gould N, Schneider W, Ashikaga T. Epidemiological survey of foot problems in the continental United States: 1978 –1979. Foot Ankle. 1980;1:8 –10. 37 Harris M-C, Beeson P. Generalized hypermobility: Is it a predisposing factor towards the development of juvenile hallux abducto-valgus? Part 2. The Foot. 1998;8: 203–209. 38 Kilmartin TE, Barrington RL, Wallace WA. A controlled prospective trial of a foot orthosis for juvenile hallux valgus. J Bone Joint Surg Br. 1994;76:210 –214. 39 Coughlin MJ. Juvenile hallux valgus: etiology and treatment. Foot Ankle Int. 1995; 16:682– 697. 40 Hardy RH, Clapham JC. Hallux valgus: predisposing anatomical causes. Lancet. 1952:1180 –1183. 41 Scranton PE Jr, McDermott JE. Prognostic factors in bunion surgery. Foot Ankle Int. 1995;16:698 –704. 42 Belt EA, Kaarela K, Lehto MU. Destruction and arthroplasties of the metatarsophalangeal joints in seropositive rheumatoids arthritis: a 20-year follow-up study. Scand J Rheumatol. 1998;27:194 –196. 43 Turner D, Woodburn J, Helliwell P, et al. Pes planovalgus in rheumatoid arthritis: a descriptive and analytical study of foot function determined by gait analysis. Musculoskeletal Care. 2003;1:21–33. 44 Turner DE, Helliwell PS, Lohmann KL, Woodburn J. Biomechanics of the foot in rheumatoid arthritis: identifying abnormal function and the factors associated with localized disease “impact.” Clin Biomech. 2008;23:93–100. 45 Woodburn J, Nelson KM, Siegel KL, et al. Multisegment foot motion during gait: proof of concept in rheumatoid arthritis. J Rheumatol. 2004;31:1918 –1927. 46 Bryant A, Tinley P, Singer K. A comparison of radiographic measurements in normal, hallux valgus, and hallux limitus feet. J Foot Ankle Surg. 2000;39:39 – 43.

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47 Mancuso JE, Abramow SP, Landsman MJ, et al. The zero-plus first metatarsal and its relationship to bunion deformity. J Foot Ankle Surg. 2003;42:319 –326. 48 Ross-Smith N. Hallux valgus and rigidus treated by arthrodesis of the metatarsophalangeal joint. Br Med J. 1952;2:1385– 1387. 49 Truslow W. Metatarsus primus varus or hallux valgus? J Bone Joint Surg. 1925;7: 98 –108. 50 Viladot A. Metatarsalgia due to biomechanical alterations of the forefoot. Orthop Clin North Am. 1973;4:165–178. 51 Ferrari J, Malone-Lee J. The shape of the metatarsal head as a cause of hallux abductovalgus. Foot Ankle Int. 2002;23:236 – 242. 52 Kilmartin TE, Wallace WA. First metatarsal head shape in juvenile hallux abducto valgus. J Foot Surg. 1991;30:506 –508. 53 Ferrari J, Hopkinson DA, Linney AD. Size and shape differences between male and female foot bones: is the female foot predisposed to hallux abducto valgus deformity? J Am Podiatr Med Assoc. 2004;94: 434 – 452. 54 Johnson KA, Kile TA. Hallux valgus due to cuneiform-metatarsal instability. J South Orthop Assoc. 1994;3:273–282. 55 Glasoe WM, Allen MK, Saltzman CL. First ray dorsal mobility in relation to hallux valgus deformity and first intermetatarsal angle. Foot Ankle Int. 2001;22:98 –101. 56 Kalen V, Breecher A. Relationship between adolescent bunions and flatfeet. Foot Ankle. 1988;8:331–336. 57 Klaue K, Hansen ST, Masquelet AC. Clinical, quantitative assessment of first tarsometatarsal mobility in the sagittal plane and its relation to hallux valgus deformity. Foot Ankle Int. 1994;15:9 –13. 58 Lapidus P. The operative correction of the metatarsus varus primus in hallux valgus. Surg Gynecol Obstet. 1934;58:183–191. 59 Myerson M. Metatarsocuneiform arthrodesis for treatment of hallux valgus and metatarsus primus varus. Orthopedics. 1990;13: 1025–1031. 60 Sangeorzan BJ, Hansen ST Jr. Modified Lapidus procedures for hallux valgus. Foot Ankle. 1989;9:262–266. 61 Ebisui J. The first ray axis and first metatarsophalangeal joint: an anatomical and pathomechanical study. J Am Podiatr Assoc. 1968;58:160 –168. 62 D’Amico JC, Schuster RO. Motion of the first ray: clarification through investigation. J Am Podiatr Assoc. 1979;69:17–23. 63 Glasoe W, Pena F, Phadke V, Ludewig PM. Arch height and first metatarsal joint axis orientation as related variables in foot structure and function. Foot Ankle Int. 2008;29:647– 655. 64 Johnson CH, Christensen JC. Biomechanics of the first ray, part 1: the effects of peroneus longus function: a threedimensional kinematic study on a cadaver model. J Foot Ankle Surg. 1999;38:313– 321.

65 Kelso SF, Richie DH Jr, Cohen IR, et al. Direction and range of the first ray. J Am Podiatr Med Assoc. 1982;72:600 – 605. 66 Oldenbrook LL, Smith CE. Metatarsal head motion secondary to rearfoot pronation and supination: an anatomical investigation. J Am Podiatr Assoc. 1979;69:24 –28. 67 Khaw FM, Mak P, Johnson GR, Briggs PJ. Distal ligamentous restraints of the first metatarsal: an in vitro biomechanical study. Clin Biomech. 2005;20:653– 658. 68 Wolf P, Stacoff A, Liu A, Nester C, et al. Functional units of the human foot. Gait Posture. 2008;28:434 – 441. 69 Nester CJ, Liu AM, Ward E, et al. In vitro study of foot kinematics using a dynamic walking cadaver model. J Biomech. 2007; 40:1927–1937. 70 Allen MK, Cuddeford TJ, Glasoe WM, et al. Relationship between static mobility of the first ray and first ray, midfoot, and hindfoot motion during gait. Foot Ankle Int. 2004;25:391–396. 71 Cornwall MW, McPoil TG. Motion of the calcaneus, navicular, and first metatarsal during the stance phase of walking. J Am Podiatr Med Assoc. 2002;92:67–76. 72 Engsberg JR, Andrews JG. Kinematic analysis of the talocalcaneal/talocrural joint during running support. Med Sci Sports Exerc. 1987;19:275–284. 73 Faber FW, Kleinrensink GJ, Mulder PG, Verhaar JA. Mobility of the first tarsometatarsal joint in hallux valgus patients: a radiographic analysis. Foot Ankle Int. 2001; 22:965–969. 74 Lee KT, Young K. Measurement of first-ray mobility in normal vs. hallux valgus patients. Foot Ankle Int. 2001;22:960 –964. 75 Roukis TS, Landsman AS. Hypermobility of the first ray: a critical review of the literature. J Foot Ankle Surg. 2003;42:377–390. 76 Cornwall MW, Fishco WD, McPoil TG, et al. Reliability and validity of the clinically assessing first-ray mobility of the foot. J Am Podiatr Med Assoc. 2004;94:470 – 476. 77 Glasoe WM, Allen MK, Saltzman CL, et al. Comparison of two methods used to assess first-ray mobility. Foot Ankle Int. 2002;23:248 –252. 78 Coughlin MJ, Jones CP. Hallux valgus and first ray mobility: a prospective study. J Bone Joint Surg Am. 2007;89:1887– 1898. 79 Coughlin MJ, Jones CP, Viladot R, et al. Hallux valgus and first ray mobility: a cadaveric study. Foot Ankle Int. 2004;25: 537–544. 80 Kim JY, Park JS, Hwang SK, et al. Mobility changes of the first ray after hallux valgus surgery: clinical results after proximal metatarsal chevron osteotomy and distal soft tissue procedure. Foot Ankle Int. 2008;29:468 – 472. 81 Coetzee JC, Wickum D. The Lapidus procedure: a prospective cohort outcome study. Foot Ankle Int. 2004;25:526 –531. 82 Beighton P, Horan F. Orthopaedic aspects of the Ehlers-Danlos syndrome. J Bone Joint Surg Br. 1969;51:444 – 453.

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Hallux Valgus and the First Metatarsal Arch Segment 83 Glasoe WM, Allen MK, Kepros T, et al. Dorsal first ray mobility in women athletes with a history of stress fracture of the second or third metatarsal. J Orthop Sports Phys Ther. 2002;32:560 –565. 84 Glasoe WM, Allen MK, Ludewig PM, Saltzman CL. Dorsal mobility and first ray stiffness in patients with diabetes mellitus. Foot Ankle Int. 2004;25:550 –555. 85 Carl A, Ross S, Evanski P, Waugh T. Hypermobility in hallux valgus. Foot Ankle. 1988;8:264 –270.

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86 Uchiyama E, Kitaoka HB, Luo ZP, et al. Pathomechanics of hallux valgus: biomechanical and immunohistochemical study. Foot Ankle Int. 2005;26:732–738. 87 Coughlin MJ. Adult hallux valgus. In: Coughlin MJ, Mann RA, Saltzman CL, eds. Surgery of the Foot and Ankle. Vol 1. 8th ed. Philadelphia, PA: Mosby; 2007: 183–362. 88 Eustace S, Byrne JO, Beausang O, et al. Hallux valgus, first metatarsal pronation and collapse of the medial longitudinal arch: a radiological correlation. Skeletal Radiol. 1994;23:191–194.

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89 Scranton PE Jr. Adolescent bunions: diagnosis and management. Pediatr Ann. 1982;11:518 –520. 90 Hawes MR, Nachbauer W, Sovak D, Nigg BM. Footprint parameters as a measure of arch height. Foot Ankle. 1992;13:22–26. 91 Mathieson I, Upton D, Prior TD. Examining the validity of selected measures of foot type: a preliminary study. J Am Podiatr Med Assoc. 2004;94:275–281.

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CARE V Conference Series What’s in Team Rehabilitation Care After Arthroplasty for Osteoarthritis? Results From a Multicenter, Longitudinal Study Assessing Structure, Process, and Outcome Margreth Grotle, Andrew M. Garratt, Mari Klokkerud, Ida Løchting, Till Uhlig, Kåre B. Hagen

Background. Clinical course and outcome connected to rehabilitation after hip or knee arthroplasty have been studied extensively, but few studies have assessed the content of team rehabilitation care for these patients. Objective. The purpose of this study was to provide a thorough description of the structure, process, and outcome of team rehabilitation care for patients with hip or knee arthroplasty for osteoarthritis.

Design. This was a multicenter, longitudinal observational study. Methods. Patients (N⫽183) from 6 rehabilitation centers in Norway who were undergoing inpatient rehabilitation following hip or knee arthroplasty were included in the study. Structure and process components were recorded by participants and health care professionals in a patient diary. Participants also completed questionnaires regarding their experiences during their rehabilitation stay and recorded data for outcome measures at admission, at discharge, and 6 months after discharge. The main outcome measures were pain intensity and physical function, as assessed with the physical function scale of the Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36). Results. Data were complete for 172 participants (94%) at discharge and for 148 patients (81%) at the 6-month follow-up. Health care professionals, physical therapists, nurses, and physicians were most often involved in team care. Occupational therapists, social workers, and psychologists were seldom part of the rehabilitation team. Exercises provided by physical therapists were the most common treatment modality. Patient education, massage, and manual therapy also frequently were provided. The participants were very satisfied with their care and its organization, information, and communication and with the availability of health care professionals. They were moderately satisfied with the social environment of the rehabilitation setting. The participants had large improvements in the outcome measures during the rehabilitation stay and at the 6-month follow-up.

Limitations. For typical physical therapy modalities such as exercises, electrotherapy, and acupuncture, there are limited descriptions and assessments of treatment doses.

Conclusions. Current team rehabilitation care involves a traditional team with physical therapists, nurses, and physicians. Several types of treatment modalities are used, with greatest emphasis on physical training. This detailed description of current team rehabilitation practice might help clinicians and researchers in planning clinical trials within a rehabilitation setting, as well as in improving rehabilitation practice.

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M. Grotle, PT, PhD, is Senior Researcher, National Resource Center for Rehabilitation in Rheumatology, Diakonhjemmet Hospital, PO Box 23, 0319 Oslo, Norway. Address all correspondence to Dr Grotle at: margreth.grotle@ medisin.uio.no. A.M. Garratt, PhD, is Senior Researcher, National Resource Center for Rehabilitation in Rheumatology, Diakonhjemmet Hospital, and Norwegian Knowledge Center for the Health Services, Oslo, Norway. M. Klokkerud, OT, Master in Health Science, is a PhD student at National Resource Center for Rehabilitation in Rheumatology, Diakonhjemmet Hospital. I. Løchting, MSci, is a PhD student at National Resource Center for Rehabilitation in Rheumatology, Diakonhjemmet Hospital. T. Uhlig, MD, PhD, is Senior Researcher, National Resource Center for Rehabilitation in Rheumatology, Diakonhjemmet Hospital. K.B. Hagen, PT, PhD, is Professor and Leader of the National Resource Center for Rehabilitation in Rheumatology, Diakonhjemmet Hospital. [Grotle M, Garratt AM, Klokkerud M, et al. What’s in team rehabilitation care after arthroplasty for osteoarthritis? Results from a multicenter, longitudinal study assessing structure, process, and outcome. Phys Ther. 2010;90: 121–131.] © 2010 American Physical Therapy Association

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Team Rehabilitation Care After Arthroplasty for Osteoarthritis

O

steoarthritis (OA) is a prevalent joint disease in the Western world and is expected to increase with increases in age and obesity in the general population.1 Although most patients who undergo total hip or knee joint arthroplasty have a good clinical result after routine surgical interventions, inpatient rehabilitation often is necessary for patients who cannot function at home after surgery. Elderly people, people who live alone, and people with comorbid conditions, in particular, are at high risk for requiring further inpatient rehabilitation.2 It has been estimated that about 15% to 20% of patients have substantial dysfunction for various reasons after total joint replacements for the hip or knee.3 With increased pressure to reduce the length of hospital stay after joint arthroplasty surgery and with an increased elderly population, it is expected that inpatient rehabilitation will become an increasingly important component of future health services use. In Norway and other European countries, specialized rehabilitation institutions have a long tradition of providing inpatient rehabilitation for patients with OA who have undergone total joint replacements for the hip or knee. Still, the vast majority of these patients in Norway are offered inpatient team rehabilitation care. Rehabilitation practice has changed in recent years, including the move from passive to more active treatment modalities.4 There also has been a switch from a predominantly medical approach to one in which psychological, social, and environmental aspects are included. Among health care providers today, Available With This Article at ptjournal.apta.org • Audio Abstracts Podcast

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it is now well established that inpatient rehabilitation is a multidisciplinary process, where rehabilitation is provided by multidisciplinary teams comprising health care professionals from various disciplines working toward a common goal.4 The complexity of a rehabilitation process, with its many different interacting components, is reflected in the International Classification of Functioning, Disability and Health (ICF).5 This model has gained a broad international consensus regarding the conceptual basis of rehabilitation and provides a good framework for understanding and analyzing patients’ problems, for deciding goals and interventions, and for evaluating outcomes of the rehabilitation process. It also is useful when planning research by ensuring a broad biopsychosocial perspective in data collection. However, the model has some inherent limitations. It has been criticized for not considering quality of life explicitly and for not allowing for patients’ personal experiences.6 Another weakness is that it does not provide an explicit definition of rehabilitation. Furthermore, it cannot be used to describe the content of the rehabilitation interventions. To our knowledge, there is no existing model or classification for describing the content of multidisciplinary rehabilitation. Wade and de Jong6 suggested a definition of rehabilitation based on the concepts of structure, process, and outcome, which frequently are used when assessing the content of health care services. The definition includes different aspects of structure (the operational characteristics of a rehabilitation service), process (how rehabilitation services work), and outcome (the aims of rehabilitation services). In this project, we used both the definition of Wade and de Jong and the ICF model as a framework when assessing structure, process, and outcome of

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current rehabilitation practice in Norway. Clinical studies relating to specific interventions for rehabilitation after joint replacement7,8 lack a thorough description of the rehabilitation process. The main objective of this study was to provide a thorough description of the structure, process, and outcome of rehabilitation practice for patients receiving inpatient rehabilitation after hip or knee arthroplasty for OA in Norway.

Method Design and Setting This was a multicenter, longitudinal observational study, and all relevant patients at the participating centers were recruited consecutively over a 3-month period. Data collection took place from September to December 2006, plus 6 months of followup, in 6 rehabilitation centers in Norway. Participants All eligible patients aged 18 to 75 years with arthroplasty for hip or knee OA scheduled for a rehabilitation stay of at least 1 week between September and December 2006 were invited to participate in the study. In Norway, approximately 70% of these arthroplasties are due to primary OA.9 The participants were recruited by research assistants at the institutions, who provided information about the study to them, including informed agreement and written consent. The study was approved by the Norwegian Regional Committee for Medical Research Ethics and the Data Inspectorate and the Norwegian Board of Health. Measurements Diagnostic information was obtained by examination by a physician at admission. Also at admission, participants completed questionnaires that January 2010

Team Rehabilitation Care After Arthroplasty for Osteoarthritis

Figure. Model of structure, process, and outcome of team rehabilitation care, including details of the variables used in the analysis. ICF⫽International Classification of Functioning, Disability and Health, ADL⫽activities of daily living, RePEQ⫽Rehabilitation Patient Experiences Questionnaire, HSCL-25⫽Hopkins Symptom Checklist-25, MHAQ⫽Modified Health Assessment Questionnaire, SF36⫽Medical Outcomes Study 36-Item Short-Form Health Survey.

included questions relating to health status and outcome, use of pain medication, and sociodemographic variables (Figure). Structure variables comprised information regarding patient involvement, family involvement, and knowledge and skills of health care professionals. This information was collected by single items from the Rehabilitation Patient Experiences Questionnaire (Re-PEQ).10 Process variables comprised information regarding assessment of patients’ problems and goals, type and frequency of group interventions (patient education, exercises, and self-monitored training) and individual interventions (information and counseling, exercises, electroJanuary 2010

therapy, thermotherapy, “hands-on” modalities, psychological counseling, nurse’s help with activities of daily living [ADL]), and evaluation. This information was recorded in a patient diary, which the participants filled in daily together with the health care providers. The diary was developed as a standardized method for collecting data on team rehabilitation care in clinical settings in patients with rheumatic disease. The development of the diary was based on Donabedian’s framework for describing different quality aspects of health services in terms of structure, process, and outcome.11 For the assessment of participants’ problems and goals, we used the ICF framework to distinguish among different types of functioning. Furthermore, the diary was developed in close col-

laboration with health care providers at rheumatology hospital departments and rehabilitation centers (rheumatologists, nurses, physical therapists, occupational therapists, and psychologists) and a broad research group representing the different health care professions involved in rheumatology research. There is ongoing work to validate the diary across different groups of patients with rheumatic diseases and across different clinical settings. The participants’ experiences with team rehabilitation care were assessed with the Re-PEQ.10 The RePEQ has 18 items scored on a 5-point scale, which sum to 4 scale scores (rehabilitation care and organization, information and communication, availability of staff, and social envi-

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Team Rehabilitation Care After Arthroplasty for Osteoarthritis ronment) from 0 to 100, where 100 is the best possible experiences. The Re-PEQ has evidence for reliability and validity, and the questionnaire is suitable for patients receiving rheumatologic rehabilitation. In a sample of participants with rheumatic disease who were receiving inpatient rehabilitation, reliability was supported by Cronbach alpha values of .87, .86, .78, and .77 for the 4 scales, respectively, and construct validity was supported by correlations between the 4 scales and responses to individual questions, which were largely in the direction as hypothesized.10 Participants completed the Re-PEQ at discharge and handed it in a closed envelope to a research coordinator at each of the study sites.

ables and chi-square tests for categorical and ordinal variables, respectively. Changes in outcome measures during the rehabilitation period and from admission to 6-month follow-up were tested by paired-samples t tests. The differences between the 2 rehabilitation groups in the outcome measures for each of the time points were assessed with independent-samples t tests. Independent-samples t tests also were used to compare Re-PEQ scores for the 2 groups. The statistical analysis was performed using SPSS version 14.0.* Due to the large number of variables and analyses, a level of significance of P⫽.01 was used.

Results Pain intensity, fatigue, and joint stiffness were assessed on a numerical rating scale from 0 to 10.12 Functional status was assessed with the Modified Health Assessment Questionnaire (MHAQ),13 and physical function was assessed using the physical function scale of the Medical Outcomes Study 36-Item ShortForm Health Survey (SF-36).14 The Arthritis Self-Efficacy Scale15 was used to assess self-efficacy, or the extent to which an individual believes he or she is capable of carrying out a behavior, and reflects a concept of perceived control. Participants filled in the outcome measures at admission, at discharge, and 6 months after discharge. The 6-month follow-up was administered by a mailed questionnaire that was returned in a prepaid envelope. Data Analysis Data are presented as means and standard deviations for continuous variables and as frequencies and percentages for categorical variables. Differences between the group with total knee arthroplasties and the group with total hip arthroplasties were compared using independentsamples t tests for continuous vari124

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Study Sample The study sample comprised 183 patients from 6 rehabilitation centers in Norway who were undergoing inpatient rehabilitation following hip arthroplasty (n⫽133) or knee arthroplasty (n⫽50). All included patients had undergone a primary unilateral total joint arthroplasty. Three participants were sent back to the hospital due to complications after surgery, 1 participant withdrew before the rehabilitation started, 6 participants withdrew during the rehabilitation stay, and 1 participant had incomplete diary data, leaving 172 participants (94%) for the rehabilitation period. At the 6-month follow-up, 25 participants did not return the mailed questionnaire, leaving 148 participants (81%). There were no statistically significant differences between the respondents and those who did not respond at 6 months with respect to age, sex, primary diagnosis, and work situation, but the nonrespondents were significantly more likely to have a lower level of education and to smoke (P⬍.05).

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

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Table 1 shows the baseline characteristics of the respondents. The majority had rehabilitation after hip arthroplasty (73%). The mean age (SD) was 64.2 (8.1) years, 63% were female, and the majority had an old age- or disability-related pension. Comparisons of baseline health status, comorbidity, use of pain medication, and sociodemographic variables revealed one statistically significant difference between the hip arthroplasty group and the knee arthroplasty group: the latter group had poorer initial functional status, as measured by the MHAQ. Structure and Process of Team Rehabilitation Care Table 2 shows the structural aspects of team rehabilitation care. Most participants were referred directly from the hospital department in which their surgery was carried out from 1 to 3 weeks after surgery. Mean length of rehabilitation stay was approximately 20 days. The rehabilitation team typically comprised a physician, physical therapists, and nurses, with physical therapists providing most of the individual consultations. Occupational therapists were seldom included in the rehabilitation team, and psychologists and social workers were not involved with these participants. There were few interdisciplinary meetings and little participant and family involvement. There were no statistical differences between the 2 rehabilitation groups in relation to these variables; however, the number of interdisciplinary meetings showed a tendency to be higher in the knee arthroplasty group (P⫽.014). Aspects of the rehabilitation process are shown in Table 3. Most of the examination findings at arrival were related to impairments within the body function and structure component of the ICF, with pain/fatigue/ symptoms and impairments in joint range of mobility and muscle funcJanuary 2010

Team Rehabilitation Care After Arthroplasty for Osteoarthritis tions most frequently reported. Also at discharge, evaluation of the participants’ health status was mainly directed toward body function and structure. Within the activity limitations and participation restrictions components, problems with ADL at home were reported most frequently. The primary goals were directed toward improving function within the body function and structure component and the activity limitations and participation restrictions components.

Table 1. Participant Characteristics and Health Assessment Scores at Baseline

Approximately 75% of the participants needed help with ADL and received passive treatment modalities such as massage and manual therapy. Thermotherapy was used with approximately half of the participants, whereas other individual treatment modalities such as electrotherapy, acupuncture, and psychological therapy were rarely provided. January 2010

Hip Arthroplasty Group (nⴝ126)

Knee Arthroplasty Group (nⴝ46)

Pa

64.2 (8.1)

64.3 (7.7)

64.0 (7.3)

.839

109 (63)

76 (60)

33 (72)

.581

63 (37)

50 (40)

13 (28)

ⱕ9

46 (28)

38 (31)

8 (18)

ⱕ12

30 (18)

21 (18)

9 (21)

⬎12

89 (54)

62 (51)

27 (61)

12 (7)

11 (9)

1 (2)

2 (1)

2 (2)

0

Disability pension

39 (23)

24 (19)

15 (33)

Age pension

78 (46)

58 (47)

20 (43)

Sick leave

38 (23)

28 (23)

10 (22)

Never smoked

70 (41)

46 (37)

24 (52)

Previous smoker

70 (41)

53 (43)

17 (37)

Current smoker

29 (18)

27 (20)

5 (11)

⬍25

47 (30)

34 (30)

13 (28)

25–29

66 (41)

47 (41)

19 (41)

Variable Age (y), mean (SD) Sex, n (%) Women Men Education (y), n (%)

Patient education was provided to most of the participants, both as information and counseling within individual treatment and as group treatment. All participants had several group training sessions provided by physical therapists and did a lot of self-monitored training. Most of the group treatment sessions were of low duration of less than 30 minutes. Advice and information typically were directed toward pain, physical activity, and coping issues, whereas information regarding ADL, social network, leisure-time activities, and so on was seldom provided. Individual exercises, provided by physical therapists, were the most common intervention modality. Mobility, muscle strength (forcegenerating capacity), and coordination exercise were clearly the most frequently used exercise modalities (Appendix). All participants had several group training sessions provided by physical therapists and did a lot of self-monitored training.

Postsurgery Rehabilitation (nⴝ172)

.246

Work situation, n (%) Employed Homeworker

.239

Smoking, n (%) .523

Body mass index (kg/m2), n (%)

ⱖ30

a

.842 47 (29)

33 (29)

14 (30)

Daily use of pain medication, n (%)

124 (80)

95 (83)

29 (71)

.106

Comorbid conditions, n (%)

138 (80)

104 (82)

34 (74)

.209

Comparison between hip and knee arthroplasty groups.

The participants’ evaluation of the team rehabilitation care according to the 4 subscales of the Re-PEQ (Tab. 4) showed that they were very satisfied with the care and its organization, with information and communication, and with availability of health care professionals and that they were moderately satisfied with the social environment of the rehabilitation setting. There were no statistically significant differences between the hip and knee arthroplasty groups with regard to evaluation of team rehabilitation care (Tab. 4).

Outcome During the rehabilitation stay, the participants had statistically significant improvements in pain, physical function, fatigue, and stiffness (P⬍.001) (Tab. 5). There was no statistically significant improvement in self-efficacy for pain or symptoms (P⬎.08), except for a minor improvement in self-efficacy of symptoms in the hip arthroplasty group (P⫽.008). The same pattern of within-group changes was found in the change in outcome scores from admission to 6-month follow-up.

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Team Rehabilitation Care After Arthroplasty for Osteoarthritis Table 2. Structural Aspects of Team Rehabilitation Carea Hip Arthroplasty Group (nⴝ126)

Variable

Knee Arthroplasty Group (nⴝ46)

Referral process (%) Hospital

91

89

General practice (primary care)

5

2

Missing

4

9

Time from surgery until rehabilitation stay, mean no. of days (SD)

23.7 (9.0)

22.8 (9.4)

Length of rehabilitation stay, mean total days (SD)

19.8 (4.1)

20.6 (4.5)

Costs, mean US dollars (SD)

b

$4,240 ($874)

Health care professionals involved (%)c

%

$4,411 ($963) Mean (SD)

%

Mean (SD)

Medical doctor

51

1.7 (1.0)

46

1.7 (0.7)

Physical therapist

97

10.0 (4.2)

100

10.9 (4.5)

Occupational therapist

21

1.2 (0.5)

11

2.2 (2.2)

Nurse

84

5.5 (5.0)

76

5.0 (4.9)

Psychologist

0

0

Social worker

0

0

Other

8

1.1 (0.3)

11

2.2 (2.2)

Health care professionals involved in team care (%) ⬍2

11

22

2 or 3

75

67

ⱖ4

14

11

3

13

Patients involved in decisions about treatment and rehabilitationd (%)

45 55 not relevant

46 54 not relevant

Family involved in treatmentd (%)

28 72 not relevant

26 74 not relevant

Yes, completely

71

58

Yes, partly

28

35

1

7

Interdisciplinary meetings (%)

Goal achievement on patients’ primary goal (%)

No a

Results are presented as percentage of patients for categorical variables and as mean (SD) for continuous variables. 1 US dollar⫽7 Norwegian krones; the costs refer to the whole rehabilitation stay. Health care professionals involved in individual treatment. Mean (SD) refer to number of treatment sessions during the rehabilitation stay for each type of health provider. d For the questions regarding patients involved in decisions about treatment and rehabilitation and family involved in treatment, there was an option called “not relevant to me.” b c

Table 5 shows that there was statistically significant improvement in self-efficacy of symptoms and functional status as assessed with the MHAQ in the hip arthroplasty group compared with the knee arthroplasty group. The same tendency was seen for pain and fatigue, but it was not significant.

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Discussion This study describes current practice of team rehabilitation care in terms of structure, process, and outcome for patients who received inpatient rehabilitation after hip or knee arthroplasty. Clinical course and outcome connected to rehabilitation after hip or knee arthroplasty have been extensively studied,16 –21 but, to

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our knowledge, this is the first study in which the content of team rehabilitation care has been recorded prospectively by individual patients and their health care providers throughout the rehabilitation period. Quality of care includes many elements, in particular in multidisciplinary rehabilitation settings. Be-

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98

Self-monitored training (nonsupervised)

ADL help by nurseh

Group training

84

Psychological consultation

68

10

“Hands-on”g

Group education

1 71

Acupuncture

0 31

Thermotherapyf

91

Individual exercisesd

Electrotherapye

88

Information/counselingc

Hip Arthroplasty Group (nⴝ126)

98

98

61

70

15

83

2

57

11

93

87

Knee Arthroplasty Group (nⴝ46)

78

50

14.1 (5.3)

10.3 (4.3)

4.7 (4.3)

7.4 (5.5)

5.3 (5.9)

10.1 (9.4)

3 patients

5.9 (4.6)

27.3 (14.7)

6.2 (5.1)

Hip Arthroplasty Group (nⴝ126)

14.0 (6.7)

10.4 (5.1)

4.8 (4.0)

5.9 (5.0)

5.9 (5.9)

11.7 (8.9)

4 patients

8.1 (5.3)

3.0 (2.9)

31.0 (14.4)

7.1 (5.3)

Knee Arthroplasty Group (nⴝ46)

Frequency (mean, SD)

⬍30 min

23

77 30–60 min

⬍30 min

66 34

⬍30 min 30–60 min

23

78

36

64

Hip Arthroplasty Group (nⴝ126)

Duration (%)

7

7

Hip Arthroplasty Group (nⴝ126)

30–60 min

⬍30 min

30–60 min

39

46

22

17

44

Knee Arthroplasty Group (nⴝ46)

22

78

18

82

17

83

63

37

Knee Arthroplasty Group (nⴝ46)

4

4

Knee Arthroplasty Group (nⴝ46)

Other (eg, Medical Topicsb)

Results are presented as percentage of patients for categorical variables and as mean (SD) for continuous variables. ICF⫽International Classification of Functioning, Disability and Health, ADL⫽activities of daily living. b Medical topics such as blood pressure, diabetes, and heart and lung issues. c Sum of 20 modalities: pain, physical activity, coping, weight control and nutrition, joint protection, assistive tools, ADL at home, social network, leisure-time activities, economy, official services, home visit, work and education, individual plan, other consultations, contact family and relatives, contact official services, contact health care providers, external collaboration meeting, and other external meetings. d Sum of 7 modalities: mobility, muscle strength, coordination, aerobic capacity, relaxation, ADL, and other individual exercises. e Sum of 6 modalities: ultrasound, transcutaenous electrical nerve stimulation, low-level laser therapy, shortwave therapy, pulsed electromagnetic energy, and shock-wave therapy. f Heat or cold packs. g Sum of 5 modalities: massage, passive joint mobility and manipulation, stretching, acupressure and trigger point treatment, and other soft tissue techniques. h Help with daily life activities.

a

Group treatment

Individual treatment modalities

Procedures

77

Evaluation Type (%)

40

49

20

Leisure

48

20

Not classified in ICF (eg, medical topics)

56

26

Work/education

37

Aerobic fitness

37

96

96

17

91

Hip Arthroplasty Group (nⴝ126)

Activity Limitations and Participation Restrictions

Activities, home

85 32

88

Joint range of motion

Coordination

21

Mental functions

Muscles

88

Pain/fatigue/symptoms

Knee Arthroplasty Group (nⴝ46)

Impairments in Body Function and Structure Hip Arthroplasty Group (nⴝ126)

Primary goals

Examination findings at arrival

Domains Within the ICF (%)

Assessment

Process Aspects of Team Rehabilitation Carea

Table 3.

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Team Rehabilitation Care After Arthroplasty for Osteoarthritis Table 4. Participants’ Evaluation of Team Rehabilitation Care According to the Rehabilitation Patient Experiences Questionnaire (0 –100)a Hip Arthroplasty Group (nⴝ126)

Knee Arthroplasty Group (nⴝ46)

P

Care and organization

83.5 (12.5)

85.5 (12.2)

.343

Information and communication

72.2 (14.7)

76.5 (15.9)

.104

Availability of health care professionals

76.5 (19.4)

79.7 (21.4)

.368

Social environment

62.7 (22.5)

60.1 (23.1)

.499

Variable

a

Results are presented as mean (SD).

cause there is no consensus or clear recommendations regarding a theoretical framework for the description of current rehabilitation practice, we used the framework suggested by Wade and de Jong6 to describe the key elements. This framework provided a useful structure for the included variables, and it reflects the perspectives of all the “inside players” in team rehabilitation care. However, several elements of the framework (eg, whether involving and educating the patient and family belong more to the process domain than to the structure domain) are open for discussion. Furthermore, these elements should be explored regardless of whether there are any missing key elements or factors that contribute to quality of care. We have not identified any studies presenting empirical data on structure and process aspects of arthritis team care; thus, it is difficult to compare our results regarding structure and process with other studies. The current findings, however, raise some important issues regarding the delivery of team rehabilitation care. First, the findings suggest that current team rehabilitation care consists of a rather traditional approach with regard to both structural and process aspects. For example, the fact that most of these services are delivered by nurses and physical therapists 128

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challenges the use of the term “multidisciplinary team rehabilitation care.” It also raises questions of whether other team members such as medical doctors, occupational therapists, social workers, and psychologists should be involved in the team and whether a broader multidisciplinary team provides better care than that provided by single therapists. However, the present findings showing that the patients were highly satisfied with the care and organization and the availability of health care professionals indicate that, for most patients, the quality of current rehabilitation care generally is good. On the other hand, the RePEQ scores for the social environment subscale suggest that there is room for improvement in team rehabilitation care. Second, the current findings provide much information about the components of health care that is delivered. The findings can be used to reflect upon current practice and to improve clinical practice, and they should be used to encourage clinically relevant research questions. For example, exercise and physical training were the most commonly used treatment modalities in current rehabilitation care and seem to be among the cornerstones of team rehabilitation care. The clinical effectiveness of providing exercises and physical

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training to patients after knee arthroplasty is supported by many highquality studies7 and thus can be considered as desirable practice. In the current study, exercises were provided as an individual treatment modality 2 to 3 times as often than group training or self-monitored training. This finding challenges clinicians and researchers to reflect upon the advantages and disadvantages of using individual treatment versus group treatment. The current findings also question what type of exercises and level of physical training are optimal for patients after hip or knee arthroplasty. Unfortunately, there is little research evidence relating to these issues,7 and future research should consider the optimal dose, intensity, and delivery of exercises. The research evidence on exercises after hip arthroplasty is scarce. A recently published overview identified 8 trials, but the trial quality was poor, and the authors concluded that currently there is insufficient evidence to establish the effectiveness of exercise provided by physical therapists following primary hip replacement for people with OA.22 Similarly, the findings regarding use of passive treatment modalities and of information and patient education can be used to identify important clinical research questions. Passive treatment modalities were used frequently in this study, a finding that raises the questions of whether and when active treatment modalities should be used instead of passive alternatives. Furthermore, information and patient education—provided as both individual and group treatment modalities—were less common, even though education is strongly recommended in the management of OA.23,24 The information in the present study was directed toward pain, physical activity, and coping issues. Despite January 2010

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Results are presented as mean (SD). Asterisks denote within-group changes with P⬍.01, ns⫽not significant. Numeric rating scale: 0⫽no pain at all, 10⫽unbearable pain. Fatigue: 0⫽no fatigue at all, 10⫽extremely fatigued. d Stiffness: 0⫽no stiffness at all, 10⫽extreme stiffness. e Self-efficacy for pain and symptoms (0 –100): 0⫽worst possible score, 100⫽best possible score. f Modified Health Assessment Questionnaire (MHAQ) score (0 –3): 0⫽best possible score, 3⫽worst possible score g Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36) physical function score (0 –100): 0⫽worst possible score, 100⫽best possible score. c

a

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b

.001 ⫺0.5 (0.4)*

31.5 (19.5)* 34.4 (26.6)*

⫺0.7 (0.4)* .574

.903 14.0 (18.9)*

⫺0.3 (0.4)* ⫺0.4 (0.5)*

14.4 (18.9)* .800

.006 0.8 (0.5)

27.4 (17.5) 28.2 (18.9)

1.0 (0.4) MHAQf

Self-efficacy symptoms

Activity limitations

e

Stiffness in joints

Self-efficacy paine

d

SF-36 physical functiong

.060 ⫺4.1 (16.6) 3.2 (19.1)* .009 ⫺2.5 (9.3) 3.5 (12.7)* .806 75.0 (18.4) 74.2 (17.1)

.438 ⫺3.0 (20.6)ns

ns ns

.733 ⫺2.1 (3.8)*

0.2 (20.2)ns

⫺2.3 (3.3)* .097

.597 2.1 (16.4)ns

⫺2.0 (3.3)* ⫺2.9 (2.9)*

0.5 (16.3)ns .459

.604 6.2 (3.3) 5.9 (2.7)

69.9 (23.2)

.082

4.2 (2.7)

72.4 (17.2)

⫺0.4 (3.6)ns

⫺1.8 (3.3)* ⫺2.9 (3.1)*

⫺1.9 (2.9)* .224 ⫺1.2 (3.1)* ⫺1.8 (2.9)*

.013 ⫺2.3 (2.7)* ⫺3.5 (2.7)*

.433

.432 6.1 (2.3)

Fatiguec

Outcome (ICF)

Body function and structure

Painb

5.7 (2.7)

Knee Arthroplasty Group (nⴝ46) Hip Arthroplasty Group (nⴝ126)

3.8 (2.8)

Knee Arthroplasty Group (nⴝ46) Hip Arthroplasty Group (nⴝ126) P Value Between Groups Knee Arthroplasty Group (nⴝ46) P Value Between Groups

Hip Arthroplasty Group (nⴝ126)

Change From Baseline to 6-Month Follow-up Change During Rehabilitation Stay Baseline

Outcome of Team Rehabilitation Care: Baseline Scores and Change Scores, With Comparisons Between Hip and Knee Arthroplasty Groupsa

Table 5.

The participants in this study had large reductions in pain and improvements in physical function during their rehabilitation stay and at the 6-month follow-up. These findings concur with those of many other studies on outcome and effectiveness of different rehabilitation programs after hip or knee arthroplasty.16 –21 In the present study, there were larger improvements in self-efficacy of symptoms and functional status in the hip arthroplasty group compared with the knee ar-

P Value Between Groups

the importance of weight control or reduction for patients with knee OA, this intervention seemed to be little emphasized, even though approximately 30% of the patients were obese. These findings suggest that there is potential for improving postsurgical rehabilitation for these patients. Moreover, the findings also suggest that little attention was paid to the patients’ activity or restrictions in participation at home or at work, despite the fact that patients frequently had problems with ADL at home. The lack of information regarding ADL and leisure-time activities might be seen in connection with the limited availability of occupational therapists in the rehabilitation teams. Encouraging results have been reported from other fields of team rehabilitation care regarding more focused rehabilitation specifically targeting limitations in activity or restrictions in participation.7,25 In conclusion, there is much uncertainty relating to the evidence for many of the treatment modalities that frequently are provided in current rehabilitation practice. Further clinical research should be aimed toward the structure and process aspects of team rehabilitation care in order to increase knowledge regarding current rehabilitation practice and research. It is also necessary to consider which subgroups of patients with arthroplasty are most in need of rehabilitation.

.012

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Team Rehabilitation Care After Arthroplasty for Osteoarthritis throplasty group. This finding may indicate that patients with knee arthroplasty need a longer recovery time after surgery or that they have a greater need for postsurgery rehabilitation than patients with hip surgery. Other studies also have shown that patients who undergo knee arthroplasty may still experience considerable functional impairment and disability postoperatively.7 A recent systematic review based on 5 randomized controlled trials showed that interventions including functional exercises led by physical therapists after total knee arthroplasty due to OA had a short-term benefit of up to 3 to 4 months postoperatively in functional ADL, joint range of motion, and quality of life.7 However, the effect sizes were small to moderate, with no long-term benefit. The main strengths of this study are the concurrent data for all study institutions and the detailed investigation of the content of current team rehabilitation care. The development of the rehabilitation diary was carried out by an expert group of health care providers in close collaboration with clinicians from different professions working at rehabilitation institutions in Norway. We, therefore, assume the content and face validity of this diary are good. The main limitation of this study is the limited descriptions of the treatment doses. For many of the typical physical therapy modalities, including exercises, electrotherapy, and acupuncture, the dosage could be recorded more thoroughly. More detailed descriptions of treatment doses, however, would involve a more resource-intensive procedure, which was not feasible in this multicenter study. The type and dosage of exercise interventions also need further investigation. Other important issues relate to the validity of the diary, such as whether the clinicians applied similar techniques for the 130

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different process variables and whether there is a good association between patient and clinician reports in the rehabilitation diary and the actual practice that has been carried out. These issues will be investigated in further validation of the rehabilitation diary.

Conclusion This study is an important first step in assessing the content of current team rehabilitation practice. The findings showed that the structure of the team rehabilitation care was rather traditional, with mainly physical therapists and nurses involved in team care, whereas occupational therapists, social workers, and psychologists were seldom involved. Several types of treatment modalities were used, with greatest emphasis on exercises and physical training. The patients had large improvements in the outcome measures and reported high satisfaction with the care and its organization, with information and communication, and with the availability of health care professionals, and they reported moderate satisfaction with the social environment of the rehabilitation setting. The detailed description of current team rehabilitation practice will help clinicians and researchers in planning clinical trials within a rehabilitation setting, as well as in improving rehabilitation practice. Dr Grotle, Ms Klokkerud, Dr Uhlig, and Dr Hagen provided concept/idea/research design. Dr Grotle, Ms Klokkerud, Ms Løchting, Dr Uhlig, and Dr Hagen provided writing. Dr Grotle, Ms Klokkerud, and Ms Løchting provided data collection. Dr Grotle, Dr Uhlig, and Dr Hagen provided data analysis. Dr Grotle and Dr Hagen provided project management. Dr Hagen provided fund procurement. Ms Klokkerud, Ms Løchting, and Dr Uhlig provided participants. Ms Klokkerud, Ms Løchting, Dr Uhlig, and Dr Hagen provided consultation (including review of manuscript before submission).

Grande Rehabiliteringssenter, Jeløy Kurbad, Ringen Rehabiliteringssenter, Skogli Helse-og Rehabiliteringssenter, Tonsåsen Rehabilitering, Valnesfjord Helsesportsenter, and Vikersund Kurbad. This work was presented orally at the CARE V International Conference; April 23–25, 2008; Oslo, Norway. A poster presentation of this research was given at the European League Against Rheumatism (EULAR) Congress; June 10 –13, 2009; Copenhagen, Denmark. This study was supported by research grants from the Norwegian Foundation for Health and Rehabilitation and the European League Against Rheumatism (EULAR). This article was received September 23, 2008, and was accepted October 25, 2009. DOI: 10.2522/ptj.20080295

References 1 Ehrlich GE. The rise of osteoarthritis. Bull World Health Organ. 2003;81:630. 2 Munin MC, Kwoh CK, Glynn N, et al. Predicting discharge outcome after elective hip and knee arthroplasty. Am.J Phys.Med. Rehabil. 1995;74:294 –301. 3 Ranawat CS, Ranawat AS, Mehta A. Total knee arthroplasty rehabilitation protocol: what makes the difference? J Arthroplasty. 2003;18(3 suppl 1):27–30. 4 Petersson IF. Evolution of team care and evaluation of effectiveness. Curr Opin Rheumatol. 2005;17:160 –163. 5 International Classification of Functioning, Disability and Health: ICF. Geneva, Switzerland: World Health Organization; 2001. 6 Wade DT, de Jong BA. Recent advances in rehabilitation. BMJ. 2000;320:1385–1388. 7 Minns Lowe CJ, Barker KL, Dewey M, et al. Effectiveness of physiotherapy exercise after knee arthroplasty for osteoarthritis: systematic review and meta-analysis of randomised controlled trials. BMJ. 2007;335: 812– 821. 8 Munin MC, Seligman K, Dew MA, et al. Effect of rehabilitation site on functional recovery after hip fracture. Arch Phys Med Rehabil. 2005;86:367–372. 9 Havelin LI, Engesæter LB, Espehaug B, et al. The Norwegian Arthroplasty Register: 11 years and 73,000 arthroplasties. Acta Orthop Scand. 2000;71:337–353. 10 Grotle M, Garratt AM, Løchting I, et al. Development of the Rehabilitation Patient Experiences Questionnaire: data quality, reliability, and validity in patients with rheumatic diseases. J Rehabil Med. 2009; 41:576 –581. 11 Donabedian A. The quality of care: how can it be assessed? JAMA. 1988;260: 1743–1748.

The authors thank the rehabilitation centers that participated in the data collection for the SPOR study: Bakke Senter, Borger Bad,

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Team Rehabilitation Care After Arthroplasty for Osteoarthritis 12 Jensen MP, Karoly P. Self-report scales and procedures for assessing pain in adults. In: Turk DC, Melzack R, eds. Handbook of Pain Assessment. New York, NY: The Guilford Press; 1992:135–151. 13 Pincus T, Summey JA, Soraci SA Jr, et al. Assessment of patient satisfaction in activities of daily living using a modified Stanford Health Assessment Questionnaire. Arthritis Rheum. 1983;26:1346 –1353. 14 Ware JE, Sherbourne CD. The MOS 36Item Short-Form Health Survey (SF-36). Med Care. 1992;30:473– 483. 15 Lorig K, Chastain RL, Ung E, et al. Development and evaluation of a scale to measure perceived self-efficacy in people with arthritis. Arthritis Rheum. 1989;32: 37– 44. 16 Gilbey HJ, Ackland TR, Wang AW, et al. Exercise improves early functional recovery after total hip arthroplasty. Clin Orthop Relat Res. 2003;(408):193–200. 17 Harmer AR, Naylor JM, Crosbie J, et al. Land-based versus water-based rehabilitation following total knee replacement: a randomized, single-blind trial. Arthritis Rheum. 2009;61:184 –191.

18 Ridge RA, Goodson AS. The relationship between multidisciplinary discharge outcomes and functional status after total hip replacement. Orthop Nurs. 2000;19: 71– 82. 19 Suetta C, Magnusson SP, Rosted A, et al. Resistance training in the early postoperative phase reduces hospitalization and leads to muscle hypertrophy in elderly hip surgery patients: a controlled, randomized study. J Am Geriatr Soc. 2004; 52:2016 –2022. 20 Trudelle-Jackson E, Emerson R, Smith S. Outcomes of total hip arthroplasty: a study of patients one year postsurgery. J Orthop Sports Phys Ther. 2002;32:260 –267. 21 Wang AW, Gilbey HJ, Ackland TR. Perioperative exercise programs improve early return of ambulatory function after total hip arthroplasty: a randomized, controlled trial. Am J Phys Med Rehabil. 2002;81: 801– 806. 22 Minns Lowe CJ, Barker KL, Dewey ME, et al. Effectiveness of physiotherapy exercise following hip arthroplasty for osteoarthritis: a systematic review of clinical trials. BMC Musculoskelet Disord. 2009;10: 98.

23 Zhang W, Moskowitz RW, Nuki G, et al. OARSI recommendations for the management of hip and knee osteoarthritis, part I: critical appraisal of existing treatment guidelines and systematic review of current research evidence. Osteoarthritis Cartilage. 2007;15:981–1000. 24 Zhang W, Moskowitz RW, Nuki G, et al. OARSI recommendations for the management of hip and knee osteoarthritis, part II: OARSI evidence-based, expert consensus guidelines. Osteoarthritis Cartilage. 2008;16:137–162. 25 van Peppen RP, Kwakkel G, WoodDauphine´e S, et al. The impact of physical therapy on functional outcomes after stroke: what’s the evidence? Clin Rehabil. 2004;18:833– 862.

Appendix.

Individual Exercises by Physical Therapists 10 9 8 7 6 5 4 3 2 1 0

Knee arthroplasty

O

th e

ri

nd

iv

id ua l

ex er

ci se

AD

s

L

tio n Re la xa

Co or di na tio n Ae ro bi c ca pa ci ty

M us cl e

st re ng th

Hip arthroplasty

M ob ili ty

Mean Number During Rehabilitation Stay

Types of Exercises (Mean Number) Provided by Physical Therapists During the Rehabilitation Staya

Types of Exercises

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Scholarships, Fellowships, and Grants News from the Foundation for Physical Therapy Foundation Board of Trustees Awards $100,000 in Scholarships and Grants Congratulations to the 2009 Florence P. Kendall Doctoral Scholarship winners: Meryl Alappattu, PT, DPT (University of Florida), Deborah Michael, PT, DPT, CPEd (Georgia State), Joanne Smith, PT (University of Southern California), and Christopher Thompson, PT, DPT (University of Illinois at Chicago). The Kendall Scholarship program awards $5,000 to first-year physical therapists or physical therapist assistants who are beginning their doctoral studies. The Foundation wishes these students the best of luck during the course of their studies. Congratulations also are in order for 2 recipients of the Foundation for Physical Therapy’s 2010 Research Grant program. Linda Lowes, PT, PhD (Nationwide Children’s Hospital and the Ohio State University), has been awarded a $40,000 Research Grant by the Board of Trustees for her submission “A Comparison of Ankle Distraction With

Keep Up With Research News From the Foundation PTJ readers are encouraged to subscribe to the Foundation’s monthly e-Newsletter and FPT Research Alerts. Not only will subscribers receive alerts when the Foundation’s online grant application system is open, they also will be “in the know” about key Foundation events and activities and will be able view the latest researcher profiles. Subscribe at www. FoundationforPhysicalTherapy. org, and click on “Join Our Email List.”

Movement and Traditional Care for Acute Sprained Ankles.” Another $40,000 Research Grant was awarded to Scott Stackhouse, PT, PhD (Arcadia University), for his protocol, “Combination of High-Intensity Strength and Locomotor Training to Improve Walking Activity in Ambulatory Adolescents With Cerebral Palsy.” These grants are funded through the Marquette Challenge, co-sponsored by Georgia State, an annual grassroots student fundraising effort coordinated by physical therapy students from across the country.

Board of Trustees to Honor Clagett Family in Naming of $300,000 Research Grant The late Lansdale Clagett of Upper Marlboro, Maryland, was diagnosed with polio at a young age. After 20 years of physical therapy, he was able to walk again. To show their gratitude and support for physical therapy research efforts, Clagett and his wife, Gladys, contributed an exceptionally generous gift to the Foundation through their estate. With this contribution, the Board of Trustees has named the $300,000, High-Impact Research Grant “The Clagett Family Research Grant: Physical Therapy Exercise Interventions to Reduce Activity Limitations and Improve Community Participation in Older Adults With Multiple Chronic Conditions.” The Foundation will begin accepting proposals in early 2010 for this 2-year award. This funding mechanism targets projects that are considered to be high-impact and high-risk/high-reward applications. The Foundation encourages multidisciplinary teams to apply for this funding opportunity.

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Recent Publications by Foundation-Funded Researchers “Beyond Minimally Important Change: Defining a Successful Outcome of Physical Therapy for Patients with Low Back Pain,” by Fritz JM, Hebert J, Koppenhaver S, and Parent E, was published online in Spine on November 11, 2009. Julie Fritz, PT, PhD, ATC, received a 2002 Research Grant. “Intertask Comparison of Frontal Plane Knee Position and Moment in Female Athletes During Three Distinct Movement Tasks,” by Harty CM, Dupont CE, Chmielewski TL, and Mizner RL, was published online in Scandinavian Journal of Medicine & Science in Sports on November 5, 2009. Terese Chmielewski, PT, PhD, SCS, received a 2001 Promotion of Doctoral Studies (PODS) I scholarship and Ryan Mizner, PT, PhD, received a 2001 Kendall Scholarship and a 2002 PODS I. “Impact of Body Mass Index on Functional Performance After Total Knee Arthroplasty,” by StevensLapsley JE, Petterson SC, Mizner RL, and Snyder-Mackler L, was published online in the Journal of Arthroplasty on October 29, 2009. Jennifer Stevens-Lapsley, PT, PhD, received a 2000 PODS I, a 2001 PODS II, and a 2007 Research Grant. Ryan Mizner, PT, PhD, is a recipient of a 2001 Kendall Scholarship and a 2002 PODS I. Lynn Snyder-Mackler, PT, ScD, ATC, SCS, received a Foundation scholarship in 1988 and received funding for a research grant in 1991. “Assessing the Effects of Subthalamic Nucleus Stimulation on Gait and Mobility in People with Parkinson Disease,” by Kelly VE, IsraJanuary 2010

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Scholarships, Fellowships, and Grants el SM, Samii A, Slimp JC, Goodkin R, and Shumway-Cook A, was published online in Disability & Rehabilitation on October 30, 2009. Valerie Kelly, PT, PhD, received a PODS II in 2001 and 2002. Ann Shumway-Cook, PT, PhD, received a research grant in 1995 and 1996.

If you are attending the Combined Sections Meeting, be sure to put the following Foundation events on your CSM calendar:

“Development of a Clinical Measure of Dual-Task Performance in Walking: Reliability and Preliminary Validity of the Walking and Remembering Test,” by McCulloch KL, Mercer V, Giuliani C, and Marshall S, was published in the Journal of Geriatric Physical Therapy (2009;32[1]:2–9). Karen McCulloch, PT, PhD, NCS, received a 1999 McMillan Scholarship and a 2001 PODS I. Carol Giuliani, PT, PhD, was the winner of a 1987 Doctoral Training Research Grant.

Friday, February 20: Home Health Section Coffee—Catch the Buzz, 7:00 am–9:00 am, sponsored by Gentiva Health Services, Hilton San Diego Bayfront Hotel, Indigo Terrace Foyer.

Rudolph Named Incoming Chair of SRC The Foundation welcomes Katherine Rudolph, PT, PhD, as the new Chair of the Scientific Review Committee (SRC). Dr Rudolph has been a member of the SRC since January 2008. She currently holds a faculty position with the Department of Physical Therapy at University of Delaware. Dr Rudolph will lead the committee in providing critical review of applications for funding to the Foundation.

Dates to Save at CSM 2010

Thursday, February 18: Sports Physical Therapy Section (SPTS) Beach Party Redux, 8:00 pm– midnight, Hilton San Diego Bayfront Hotel, Indigo C&D.

Tickets are required for both events. To purchase your tickets and learn more, visit the Foundation’s Web site.

Applications Still Being Accepted for PODS I and II Scholarships and NIFTI-HSR The Foundation is still accepting applications for the Promotion of Doctoral Studies (PODS) scholarships and the New Investigator Fellowship Training Initiative– Health Services Research (NIFTI–

The Foundation for Physical Therapy will host a forum on obtaining Foundation funding at CSM 2010 in San Diego! “Foundation Funding for Post-Professional Study: Options and Guidelines” will be held on Thursday, February 18, from 10:30 am–12:15 pm. The program will include 4 roundtable discussion groups on each Foundation funding program. Each discussion group will be led by 1 or 2 members of the SRC. This is a great opportunity to discuss the application process and find out what reviewers look for in potentially successful applications. This program is once again graciously sponsored by the Section on Research.

HSR) award. Please visit the Foundation at www.Foundation forPhysicalTherapy.org for more information and guidelines. Applications will be accepted until noon on January 26, 2010. [DOI: 10.2522/ptj.2010.90.1.132]

The Foundation will be seeking nominations again in 2010 for skilled reviewers to join the SRC. Criteria for membership are posted on the Foundation’s Web site under Grants, Fellowships & Scholarships.

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