Physical Therapy- Journal of the APTA- March 2009, Volume 89, Issue 3

March 2009  Volume 89  Number 3

Research Reports

Perspectives

204

Predicting Productivity in Scholarship

267

221

Use of Diffusion of Innovations Theory to Examine Determinants of Guideline Adherence

Movement Variability and the Use of Nonlinear Tools

286

Assessment in Oncology Rehabilitation

233

Decision Making for Balance Assessment

Case Reports 248

Nonmusculoskeletal Hip Pain Screening

257

Inspiratory Muscle Performance and Suspected Statin-Induced Myopathy

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Questions? E-mail [email protected] or call 800/999-2782 (ext 8534). Open Door is an APTA members–only benefit.

Physical Therapy Journal of the American Physical Therapy Association

Editorial Office

Editor in Chief

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

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

PTJ Online Editor / Assistant Managing Editor: Steven Glaros

Deputy Editor in Chief

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

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

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

Board of Directors

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

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

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

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

President: R Scott Ward, PT, PhD

Statistical Consultants

Vice President: Randy Roesch, PT, MBA, DPT

Steven E Hanna, PhD, Hamilton, Ont, Canada; John E Hewett, PhD, Columbia, MO; Hang Lee, PhD, Boston, MA; Samuel Wu, PhD, Gainesville, FL

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

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

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

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

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

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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.

Technologies. Ingenta provides online document delivery for articles published since September 1988. Full-text articles are available for free at www.ptjournal.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 PTJ’s Web site 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.

Indexing and Document Delivery

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 Nancy Boyles, Cadmus Reprints, at 800/4079190, or [email protected]. Nonacademic institutions needing reprint permission information should go to www.ptjournal.org/misc/terms.dtl.

Advertising

PTJ is indexed and/or abstracted by Abridged Index Medicus, Abstracts of Health Care Management Studies, AgeLine, AMED (Allied and Complementary Medicine Database), 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 www.ptjournal.org (1980 through present) and via DataStar, Dialog, FirstSearch, Information Access, Ovid

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.

Statement of Nondiscrimination APTA prohibits preferential or adverse discrimination on the basis of race, creed, color, gender, age, national or ethnic origin, sexual orientation, disability, or health status in all areas including, but not limited to, its qualifications for membership, rights of members, policies, programs, activities, and employment practices. APTA is committed to promoting cultural diversity throughout the profession.

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Editorial “Just the Facts, Ma’am”: If It Were Only That Simple, Joe

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hange is in the air. Climate change, economic change, political change. In this month’s issue of PTJ, we read that even our view of “variability” itself is changing. Specifically, Regina Harbourne and Nicholas Stergiou in “Movement Variability and the Use of Nonlinear Tools: Principles to Guide Physical Therapist Practice”1 argue that nonlinear measures, such as the Lyapunov exponent and approximate entropy, can reveal the “hidden structure” within the variability of data over time. These methods were developed to handle complexity and, thus, often fit well with rehabilitation research. They are, however, a bit complex themselves. To assist readers like me, the authors provide an appendix of jargon terms; multiple examples of nonlinear analysis of biological systems, including clinical studies; and a virtual case study illustrating the use of nonlinear thinking in clinical decision making. Nice. But wait, there’s more. Accompanying this article is a commentary2 by Daniela Corbetta, a developmental psychologist, who provides insights from her own work on infant motor-perceptual development in support of the authors’ perspective. This article-commentary combination is exactly the “translational” information that both you, the readers, and we, the Editorial Board, desire for our Journal. But because we’re friends, let’s be honest. You may get a sinking feeling that something is amiss as you seriously consider the implications for your own work. For example, certain features of variability, rather than simply being a reflection of movement error, may reveal the very processes by which impairments might be increasing or decreasing. Interesting, but which is it—increasing, or decreasing? Changes in variability, as reflected by nonlinear analysis, might signal that movements are becoming more or less optimal. That would be valuable information—if only I knew whether it was “more” or “less.” The same pattern of change could be signaling that the time is right for more task-specific practice or more focus on impairments, more balance training or less, the addition of a modality or not. “That doesn’t make any sense,” you say.

Obviously, what’s missing is interpretation—specifically, the requirement to interpret one set of results in light of all other relevant information. Interpretation is, of course, not specific to nonlinear analysis. We would interpret a change in range of motion differently depending on whether the change was associated with increases or decreases in muscle performance. Clinical interpretation is necessary, as we never have all the relevant information we would like. As Dragnet’s Joe Friday might have said, the “facts,” no matter how comprehensive and clear, never really “speak for themselves,” do they? Even more important, the researchers who conduct studies don’t make clinical decisions based on data interpretation—clinicians do. The PTJ Editorial Board under-

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

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Editorial stands this and strives to make PTJ a consistently useful clinical tool. To this end, PTJ provides multiple sources of information to assist readers in making their own interpretation. These include: • Podcasts • Video clips • Perspective articles • Commentaries • Bottom Line summaries • Rapid Response e-letters • Journal issues focused on a single topic There also are “hidden” features that elevate the level of interpretation and increase the impact of the articles in PTJ. The review process is one such feature and begins with a review team led by an Editorial Board member with content expertise. Paul Helders and I, for example, handle all pediatric content. Editorial Board members personally read each of their assigned manuscripts, including the multiple revisions and all the reviewers’ comments, leading up to publication. The intent here is not to micromanage or extend the review process, but rather to publish clear, concise, comprehensive, clinically focused reports. In addition to our individual duties, Editorial Board members form work groups that engage in continuous dialogue about issues ranging from the statistics available for clinical trials, to ideas for new special series topics, to how to assist authors in publishing case reports, to contacting top scientists for commentaries and perspective articles. You also see us at Annual Conference and Combined Sections Meeting, where we provide educational sessions and hold meetings to chart the future of PTJ. In closing, I encourage reviewers, authors, and readers to communicate with the Editorial Board about your ideas on how to increase the impact of your Journal. Clinical decisions based on our interpretation of data are rarely black and white— and that won’t change—but our patients await our best interpretation, and PTJ is here to help. James C (Cole) Galloway, PT, PhD Editorial Board Member Department of Physical Therapy University of Delaware Newark, DE 19716 References 1 Harbourne RT, Stergiou N. Movement variability and the use of nonlinear tools: principles to guide physical therapist practice. Phys Ther. 2009;89:267–282. 2 Corbetta D. Invited commentary on “Movement variability and the use of nonlinear tools: principles to guide physical therapist practice.” Phys Ther. 2009;89:282–284. [DOI: 10.2522/ptj.2009.89.3.e5] e6 ■ Physical Therapy Volume 89 Number 3

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Research Report Career Factors Help Predict Productivity in Scholarship Among Faculty Members in Physical Therapist Education Programs Regina R Kaufman RR Kaufman, PT, EdD, NCS, is Associate Professor of Physical Therapy, Springfield College, 263 Alden St, Springfield, MA 01109 (USA). Address all correspondence to Dr Kaufman at: rkaufman@ spfldcol.edu. [Kaufman RR. Career factors help predict productivity in scholarship among faculty members in physical therapist education programs. Phys Ther. 2009;89:204 –216.] © 2009 American Physical Therapy Association

Background. Academic institutions and scholars play a critical role in the development of a unique and substantive professional science and disciplinary literature. Individual and environmental characteristics influence the scholarly work of higher education faculty generally, but little is known about factors that influence scholarly productivity of physical therapist faculty members.

Objective. The purpose of this study was to identify the factors that contribute to the variability in scholarly productivity among faculty members in physical therapist education programs.

Design. A cross-sectional study design was used. Methods. A survey of a representative sample of faculty members in accredited professional (entry-level) physical therapist education programs in the United States was conducted. Descriptive analysis was conducted, and 5 blocked hierarchical regression models were constructed to identify factors that help explain variability in grantsmanship, peer-reviewed publications, and peer-reviewed presentations.

Results. A usable response rate of 58% was obtained. The 520 participants displayed variability in scholarly productivity. The regression models explained half of the variance in career publishing productivity and 28% to 44% of the variance in productivity in presentations and grants. Career factors, including discipline of highest degree, appointment status, and faculty rewards, contributed most substantially to the explained variance. Several phenomena unique to physical therapy were considered in light of these findings. The multidisciplinary nature of the faculty, national trends in faculty hiring and appointment, and the status of the DPT-trained faculty cohort all may influence physical therapy faculty scholarship. Limitations. Unidentified errors in sampling or reporting may limit the results of this study.

Conclusions. Career factors generally predict the largest proportion of explained variance in scholarly productivity. Large numbers of questions remain regarding the status of scholarship and scholars in physical therapy.

Post a Rapid Response or find The Bottom Line: www.ptjournal.org 204

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Predicting Productivity in Scholarship

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cholarly activity in the forms of discovery, integration, application, and teaching results in the extension and transformation of knowledge.1 Scholarly activity is considered the purview of higher education institutions.2 Faculty scholars play a critical role in the development of disciplinary literature. Leaders within the American Physical Therapy Association (APTA) advocate strongly that every core faculty member in physical therapist professional (entry-level) education programs demonstrate engagement in scholarship.3 The evaluative criteria for accreditation of professional programs articulate expectations that each core faculty member fulfill his or her role as scholar in a consistent and substantial manner.4 The APTA has promoted efforts toward developing a comprehensive body of evidence for practice through formulation of the Clinical Research Agenda (CRA) for physical therapy.5 Scholarly products include publications, presentations, grants, and other scholarly works.1,6,7 Fulfillment of the scholarly role often is evaluated in terms of scholarly productivity by measuring the quantity of scholarly works published or presented. Despite efforts to elevate the status of other scholarly products, the peerreviewed journal article is generally the most highly regarded form of scholarly work.1,7,8 Efforts to quantify scholarly productivity often use the number of peer-reviewed journal publications as the unit of interest. Faculty rewards, including tenure and promotion, are dependent, in part, on the volume and characteristics of scholarly works produced throughout the faculty member’s academic career.9 Scholarly productivity of higher education faculty members has been examined from a variety of perspectives.9 –14 Characteristics such as gender, disciplinary affiliation, instiMarch 2009

tutional type, appointment, and rank are all connected, either directly or indirectly, to scholarly productivity in general and to publishing productivity in particular. Factors influencing productivity tend to have directional effects. Female gender has a negative influence on publishing productivity, either directly or indirectly, as a result of gender patterns in disciplinary and institutional affiliation, workload, and faculty rewards.9,12–14 Faculty in researchintensive institutions publish more than faculty in teaching-intensive settings due to institutional resources and time allocation that favor scholarly work.15 Although the relationship of publishing productivity to promotion appear equivocal,10,16 –22 most faculty agree that achievement of tenure and promotion is difficult without a sufficient quantity of scholarly publications.7–9 Two conceptual frameworks are useful to consideration of scholarly productivity of physical therapist academicians. First, disciplinary structure and culture influence processes and products of scholarly endeavor.23–25 Structure refers to content matter and inquiry processes that characterize disciplinary fields.24 Fields identified as “hard,” or paradigmatic, hold distinct bodies of knowledge and utilize fixed theoretical frameworks and modes of inquiry to develop the disciplinary substance.23,26 Physical and biological sciences are examples of paradigmatic disciplines. “Soft,” or nonparadigmatic, fields have poorly delineated boundaries, loosely defined bodies of knowledge, and a variety of interpretive frames and methodological approaches to advancing the discipline’s knowledge.24,25 Anthropology and sociology are examples of nonparadigmatic disciplines. The discipline of physical therapy, drawing upon an array of sciences and utilizing a variety of interpretive frames and research methods, is a nonparadigmatic discipline.27

Disciplinary culture is reflected in types of activities, strategies for collaboration, modes of communication, and patterns of socialization practiced by disciplinary scholars.23 Paradigmatic disciplinary scholars (PDS) are socialized to the problems of the discipline and engage in collaborative, competitive, and fastpaced scholarly activity. Nonparadigmatic disciplinary scholars (NPDS) receive little socialization to central concerns of the discipline and often represent a broad range of problems within any given field. They usually work singly or in small groups, with relatively little competition and little support and at a slower pace than PDS.23 Differences in structural and cultural characteristics of disciplines are associated with varying patterns of scholarly productivity.23–25 Differences include numbers and types of venues for publications and presentations. Works by PDS generally appear earlier in their career and with greater frequency than those by NPDS. The PDS are more likely to publish peer-reviewed journal articles, whereas NPDS are more likely to publish books and other types of nonjuried products.23–25 The condition of physical therapy as a nonparadigmatic discipline may influence both the volume and qualities of the profession’s scholarship.27 Physical therapy, as a soft field, would be inclined toward lower and slower rates of publication. Additionally, physical therapy has a multidisciplinary academy. Although the number of physical therapist faculty holding academic doctoral degrees has grown significantly over the last several decades,28 –30 those degrees represent many different academic fields,30 suggesting the research agendas of physical therapist faculty may be widely divergent, with some inclined to greater productivity than others, based in part on disciplinary

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Predicting Productivity in Scholarship affiliation.27 How the nature of the discipline and the multidisciplinary nature of the faculty influence the academy’s scholarly productivity has not been explored. The second body of literature guiding consideration of physical therapist faculty scholarship addresses scholarly productivity of higher education faculty generally. Blackburn and Lawrence31 developed a conceptual framework that encompasses the variety of factors that influence scholarly productivity. Their framework includes 7 antecedents characterized as individual or environmental in nature. Individual antecedents include sociodemographic variables such as gender, career factors such as the academic discipline, and selfknowledge such as insight into institutional culture. Environmental antecedents include environmental conditions such as institutional mission, environmental responses such as faculty rewards of tenure and rank, and personal social contingencies such as family responsibility. Little is known about how individual or environmental antecedents influence the scholarly productivity of faculty members in physical therapist education programs. Historically, individual physical therapist faculty scholarly productivity appears to be quite low.28,29 The mean number of article publications was 1.33 per subject, with 43% of respondents reporting no publications, in a 1987 study of 127 faculty members.29 Recently, Richter and colleagues32 measured physical therapist program publishing productivity and found that half of the programs sampled had fewer than 5 citations in the PubMed and CINAHL databases for the 5-year period studied. Higher numbers of per-program citations were associated with research and doctoral-level institutions. That study was limited in several regards. Productivity was described per academic unit 206

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and not per academician. In addition, the bibliographic search strategy was limited by design and, therefore, omitted citations by contributing authors and authors of works indexed in other bibliographic databases. No study has analyzed factors that contribute to scholarly productivity of individual physical therapist faculty members. The purpose of this study was to develop and test a model to help explain how individual, career, institutional, and work factors help explain variability in peer-reviewed publications, peer reviewed presentations, and peer reviewed grant awards of individual physical therapist academicians.

Method This cross-sectional study used survey methods. Submission of a completed survey questionnaire by a participant signified informed consent. Instrumentation A 49-question survey (eAppendix; available at www.ptjournal.org) was developed to capture information regarding sociodemographic characteristics, environmental factors, career factors, work factors, and numbers of peer-reviewed and non–peerreviewed scholarly products. Survey variables were based on the framework of Blackburn and Lawrence.31 The survey was modeled after questionnaires used by the Higher Education Research Institute33 and the National Center for Education Statistics National Study of Postsecondary Faculty.34 The survey was constructed in online and paper formats using identical text and minor differences in layout. A pilot test evaluated the survey instrument for test-retest consistency, format consistency, and face and content validity. The 17 pilot study participants were 12 physical therapy faculty volunteers not included in the current study sample and 5

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faculty members from a professional program in occupational therapy. Participants completed the online version of the survey questionnaire twice, at 1-week intervals. They completed the paper version of the survey questionnaire once, 1 month following the first online submission. Percentage of agreement was assessed for each item across electronic and paper submissions. Items with less than 75% agreement were edited for clarity and precision. Additional written comments affirmed face and content validity and resulted in minor clarifications in survey language. Participants A stratified random sampling procedure was used to obtain the study sample. A sampling frame of 1,735 full-time faculty members from 188 accredited physical therapist education programs in the United States was developed in January 2006 through review of program Web sites and personal contact with each program. Information for faculty from the remaining programs was not confirmed, and they were excluded from the sampling frame. The 188 programs were stratified by institutional type based on their 2000 Carnegie classification35 (research/ doctoral, master’s, baccalaureate, specialized) and by size (small⫽4 – 7 faculty, medium⫽8 –10 faculty, large⫽11 or more faculty), creating 12 categories. Programs were sampled at random from within each category using the random case selection function in SPSS base version 14.0.36,* Every faculty member in each program selected was surveyed. The final sample consisted of 97 programs and 881 faculty members.

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

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Predicting Productivity in Scholarship Data Collection The survey dissemination process involved Web-based and standard mailing procedures.37 The Survey Monkey service38 was used for online administration. An e-mail invitation was sent to all participants. Participants who followed an embedded link to the survey questionnaire were able to complete the survey and submit responses online. Two additional e-mail invitations were sent to nonrespondents 7 days and 14 days following initial contact. Three weeks following initial contact, a final request for participation and a paper copy of the survey questionnaire with a postage-paid return envelope were sent to remaining nonrespondents via standard mail. Data Analysis A total of 568 participants responded to the survey. Of those respondents, 519 submitted their questionnaire via the survey Web site and 49 submitted their questionnaire on paper. Any respondent who failed to provide data pertaining to scholarly productivity was omitted. The final number of usable responses was 520, for a final response rate of 58%. A wave analysis was used to assess for nonresponse bias.39 A wave analysis identifies differences between early and late responders. If early responders are different from late responders, they also probably are different than nonresponders, and nonresponse bias is of concern.40 There were no consistent patterns in response characteristics, including gender, highest degree, institutional type, and number of career article publications, that would suggest early and late responders were different from each other. The SPSS base version 14.036 was used to calculate measures of central tendency, frequencies, and cross tabulations for selected demographic,

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environmental, career, work, and productivity factors. A regression analysis was conducted using a blocked hierarchical design. Five regression models were constructed for dependent variables of career grant awards, career peerreviewed article publications, 2-year peer-reviewed article publications, career peer-reviewed presentations, and 2-year peer-reviewed presentations. The choice of dependent variables was based on the primacy of the peer-reviewed publication in the evaluation of scholarly productivity,1,6 – 8 the relatively higher frequency of presentations than publications within the study data, and the enabling value of grant support to scholarly work.15 The selection of independent variables was based on Blackburn and Lawrence’s framework.31 The blocks represented both individual and environmental factors and included demographic, institutional, career, and work characteristics. As previously noted, “career grant awards” was the dependent variable for the first model. Career grant awards also was included as the fifth independent block variable for the remaining 4 models. In addition to their usefulness as a measure of scholarly productivity, grants enable productivity in publication and presentation.15 “Discipline of highest degree” was included with the career factors block because of the multidisciplinary composition of the physical therapy academy and the presumed influence of disciplinary affiliation on scholarly work. Role of the Funding Source This study was funded, in part, by the Springfield College Faculty Research Fund. Springfield College played no role in the design, conduct, or reporting of the study.

Results A description of the participants, levels of scholarly productivity, results of the regression analyses, and descriptive information for selected variables pertaining to “career factors” are presented. Participant characteristics are provided in Table 1. Sixty-three percent of the participants were female, and almost all of the participants were white. Almost half of the participants held the PhD as the highest degree. More than half of the participants were tenured or on a tenure track, and a large majority were assistant or associate professors. Approximately 40% of the participants worked in research or doctoral institutions. The participants represented 32 different academic fields within the disciplines of their highest degrees (Tab. 2). Approximately 63% of those reporting were affiliated with soft academic disciplines (Tab. 2). Using the 2005 Fact Sheet for Physical Therapist Education Programs30 for comparison, the sample was representative of the national faculty. Participants varied widely in the extent to which they were productive as scholars (Tab. 3). They engaged in peer-reviewed presentations to a greater extent than peer-reviewed article publication, and they engaged in both activities to a greater extent than other activities. For purposes of further discussion, results will focus on peer-reviewed article publications, peer-reviewed presentations, and grants. The terms “nonpublishers” and “nonpresenters” will refer to those respondents who did not had a product in either of those peerreviewed categories. Nearly 20% of the respondents were nonpublishers, and more than 10% were nonpresenters. Just 12.5% of the participants had published more than 20 peer-reviewed articles. The results of the regression models are presented in Table 4. The models

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Predicting Productivity in Scholarship Table 1. Characteristics of Physical Therapist Faculty Participantsa Percentage of Sample

Comparison Data (%) From 2005 CAPTE Fact Sheet30

Male

37.1

37

Female

62.9

63

Characteristicsb Sex (n⫽518)

Race/ethnicity (n⫽508) Asian American/Asian

2.7

3

African American/black

1.8

2

Native Hawaiian/Pacific Islander

0.2

NAc

Hispanic/Latino

2.0

2

White/Caucasian

93.3

90

0.6

NA

24.7

36

Highest degree (n⫽519) Baccalaureate Master’s Transitional DPT

7.1

4

EdD

8.9

NA

PhD

48.1

45

Other doctorate

7.7

16d

Professional (entry-level) physical therapy degree

2.9

NA

Disciplinary type (n⫽482) Hard or high consensus field

37

NA

Soft or low consensus field

63

NA

Research/doctoral

40.1

40

Master’s

36.0

37

Institutional type (n⫽519)

Baccalaureate

2.9

5

21.0

18

Lecturer/instructor

7.1

NA

Assistant professor

41.2

39

Associate professor

34.0

30

Professor

14.6

12

3.1

NA

11.9

NA

Specialized Academic rank (N⫽520)

Other Appointment status (n⫽519) No tenure system Not on tenure track

31.2

26

On tenure track

25.0

26

Tenured

31.9

29

Core faculty

69.1

78

ACCE/DCE

10.2

11

Chair/director

11.8

10

8.9

NA

Position (n⫽519)

Other

a CAPTE⫽Commission on Accreditation in Physical Therapy Education, DPT⫽Doctor of Physical Therapy, ACCE/DCE⫽academic coordinator of clinical education/director of clinical education. b Variation in number of participants is due to missing data. c None available (no comparison data are available). d This includes EdD and other postprofessional doctoral degrees, excluding the PhD and DPT.

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Predicting Productivity in Scholarship explained from one quarter to one half of the variance for each of the dependent variables. Generally, career factors predicted the largest proportion of explained variance. The first model explained 36% of the variability in career grant awards. Career factors accounted for more than half of the explained variance, and demographic attributes contributed 7.9%. The second model explained half of the variance in career peerreviewed article publications, with career factors contributing 17% and demographic factors contributing 12.4%. The third model predicted 41.2% of the variance in career presentations. Career factors again predicted the largest portion of the variance at 15.2%. The fourth model explained 44.4% of the variance in 2-year publications. Work factors predicted the largest proportion of the variance at 18.6%, and career factors were the second-largest predictor at 16.6%. The fifth model explained just more than one fourth of the variance in 2-year presentations. The career factors block again predicted the largest proportion of the variance (12.7%). Because career factors tended to predict the largest proportion of explained variance, additional descriptive information is provided regarding career factors. In areas of rank and tenure status, faculty with non– tenure track appointments were more likely to be nonpublishers and less likely to be high-frequency publishers than faculty with tenure track appointments (Tab. 5). In relation to type of doctoral degree (Tab. 6), the 2-year publication and presentation rates for the Doctor of Physical Therapy (DPT)-trained faculty were lower than for any other type of doctorally prepared faculty member. The DPT-trained faculty were least likely of all of the doctorally prepared faculty to prefer the research component of their work. Approximately 78% of the DPT-trained facMarch 2009

Table 2. Second Disciplines of the Faculty Sample Discipline

Frequency

Typea

Administration

18

3.5

Soft

Anatomy

24

4.6

Soft

Biochemistry

1

0.2

Hard

Biology

5

1.0

Hard

16

3.1

Hard

5

1.0

Hard

Biomechanics Biomedical engineering Biomedical sciences

4

0.8

Hard

Chiropractic

1

0.2

Soft

Computer technology

2

0.4

Hard

Conflict resolution

1

0.2

Soft

1

0.2

Soft

82

15.8

Soft

Corporate communications Education Engineering

2

0.4

Hard

Epidemiology and biostatistics

9

1.7

Soft

Ergonomics

4

0.8

Hard

Ethics

3

0.6

Soft

41

7.9

Hard

1

0.2

Hard

Exercise science Genetics Gerontology

2

0.4

Soft

Health promotion

1

0.2

Soft

20

3.8

Hard

4

0.8

Soft

Kinesiology Law Medicine

3

0.6

Soft

Movement science

15

2.9

Hard

Neuroscience

13

2.5

Hard

Pharmacology

4

0.8

Soft

Physiology

18

3.5

Hard

Psychology

8

1.5

Hard

141

27.1

Soft

6

1.2

Soft

26

5.0

Soft

1

0.2

Soft

Physical therapy Public health Rehabilitation sciences Social work Total a

%

482

Categorization of hard or soft discipline based on Sax et al.54

ulty either were working without a tenure system or were not on a tenure track. As regards productivity across disciplinary types, participants holding the highest degrees in paradigmatic fields were more likely to be higher-frequency publishers and less likely to be lower-frequency

publishers than NPDS (Tab. 5). The PDS were more likely than the NPDS to engage in scholarship of discovery and basic or applied science research (Tab. 7). The PDS were less likely than the NPDS to direct explicit attention toward the CRA.5

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Predicting Productivity in Scholarship Table 3. Scholarly Products of Physical Therapist Faculty Participants

a

Levels of Productivity by Percentage of Participants at Each Level

Scholarly Products

Na

Median (Range)

0

1–2

3–5

6–10

>11

Career peer-reviewed articles

510

4 (0–75)

18.3

23.1

17.1

13.6

27.9

Career peer-reviewed presentations

517

8 (0–200)

12.8

12.2

17.8

17.0

40.2

2-year peer-reviewed articles

519

1 (0–20)

35.8

36.6

17.2

8.1

2.3

2-year peer-reviewed presentations

520

2 (0–40)

25.0

30.0

25.0

14.9

5.1

Career grant awards

505

2 (0–43)

28.1

26.1

23.6

12.9

9.3

Career textbooks

518

0 (0–19)

69.3

18.9

6.8

3.3

1.7

Career non⫺peer-reviewed articles

510

2 (0–65)

51.5

23.8

13.9

7.1

3.7

Variation in number of participants is due to missing data.

Discussion These results suggest important variations in individual, career, and work factors that influence scholarly productivity of physical therapist academicians. The factors identified, in the context of the evolving academic culture of the physical therapy profession, raise important questions about the status of scholarship within the field. In many ways, the sample in this study is similar to and appears subject to factors affecting higher education faculty generally. Like faculty in many academic fields, these participants displayed variability in peerreviewed article publications. As noted earlier, about 18% of the physical therapist faculty participants were nonpublishers, and 12.5% had published more than 20 peer-reviewed articles. Across higher education in general, estimates of nonpublishers are around 25%.1,9 Approximately 15% of the faculty produce about 50% of the publications for many fields.9 It appears that physical therapist faculty are similar to faculty at large when it comes to peer-reviewed article publications. Career factors, including discipline of highest degree, appointment status, and faculty rewards, contributed most substantially to the explained 210

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variance. Several phenomena warrant consideration in light of these findings. These phenomena include the multidisciplinary nature of the faculty, the hiring and appointment patterns of the faculty, and the status of the DPT-trained faculty cohort. The Multidisciplinary Academy Has Strengths and Challenges The discipline of physical therapy is nonparadigmatic. The profession draws its foundational information from a variety of fields such as physics, anatomy, physiology, psychology, and education.41 The body of knowledge unique to physical therapy is arguably the specialized application of information from disciplines such as exercise science and movement science.42,43 The nonparadigmatic nature of the field may predispose the profession to lower and slower rates of peer-reviewed article publication in particular and of scholarly work in general.23–25,27 To complicate the issues of disciplinary type and scholarly productivity, the physical therapy academy is multidisciplinary. There were 32 distinct academic fields represented in the degrees earned by the participants in this study (Tab. 2). Nonparadigmatic disciplines accounted for 53% of the academic fields and 63% of the participants. Paradigmatic disciplines

Number 3

accounted for 47% of the academic fields and 37% of the participants. Although some fields, such as movement science, kinesiology, exercise science, and biomechanics, have clear links to the clinical and foundational sciences of physical therapy, other fields, such as biochemistry, corporate communications, and law, are less clearly or directly related. With a large array of second disciplines and with a large proportion of the disciplines characterized as nonparadigmatic, faculty no doubt experience a diversity in research cultures that includes differences in questions and priorities, methodological approaches, tendencies toward collaboration, modes of communication, and, ultimately, amounts of publishing and other forms of scholarly productivity.23–26 As noted previously, participants in paradigmatic and nonparadigmatic fields displayed different patterns of scholarly work in several regards. The PDS were more likely to be prolific publishers and less likely to be low-frequency publishers than the NPDS (Tab. 5). The PDS were more likely than the NPDS to engage in scholarship of discovery and to engage in basic or applied science research (Tab. 7). The Commission on Accreditation in Physical Therapy Education (CAPTE) position paper on March 2009

Predicting Productivity in Scholarship Table 4. Predicting Productivity in Scholarship: Summary of Standardized Coefficients ␤-Weights for Dependent Variables Career Grant Awards

Career Peer-Reviewed Articles

Sex

.062

⫺.125a

Race

.051

.078b

Independent Variables

⫺.060

.054

.030

.051

.044

.008

.045

⫺.017

.015

⫺.067

.062

⫺.076

⫺.071

⫺.005

.003

Years as physical therapist

.013

.001

.003

⫺.051

⫺.037

Years as faculty member

.097

.087

.063

⫺.030

⫺.078

R for demographic block

.079

.124

Master’s degree–level institution

.031

⫺.102b

.092

.019

.012

⫺.055

⫺.072

⫺.039

⫺.039

⫺.065

.035

⫺.042

.066

.085

.011

⫺.033

.025

.059

Rural location

.007

⫺.073

⫺.059

⫺.076

⫺.031

R2 for institutional block

.023

.040

.009

.043

.010

Urban location

b

No tenure system

.023

.085

.054

.075

.082

Tenure track

.116b

.060

.030

.090

.144b

Tenured

.180a

.077

.074

.058

.032

Assistant professor

⫺.086

.002

.012

.004

.003

Associate professor

.036

.144

.098

.035

.073

Professor

.142

.283a

.275a

.072

.219b

Master’s degree

.067

.006

⫺.013

⫺.080

⫺.039

EdD

.057

⫺.033

⫺.076

⫺.073

⫺.099

⫺.001

⫺.093

⫺.014

⫺.080

⫺.018

⫺.036

⫺.097

⫺.105

⫺.093

.033

⫺.012

.058

.097

.204

.172

.152

.166

.127

⫺.068

.019

PhD

.215

PT/tDPTc

.066

Hard or soft discipline R2 for career block Prefer teaching

b

b

Prefer research

.074

Time teaching

⫺.013

Time research Time service Time administration R2 for work block

.178

.147b

.005

.083

a

.227a

.133b

.115

⫺.261a

⫺.199b

⫺.165b

.008

⫺.046

.270

⫺.071

⫺.040

⫺.007

.023

⫺.195b

⫺.143

⫺.119

⫺.135

.119

.068

.186

.082

.276a

.378a

.216a

.288a

.048

.091

.030

.053

.503

.412

.444

.284

.197

b

.014 ⫺.039 .054

Career grant awards R2 for block Total R2

c

.043

Marital status

Specialized institution

b

2-Year Peer-Reviewed Presentations

Children

2

a

2-Year Peer-Reviewed Articles

Career Presentations

.360

a

⫺.187b .096

Pⱕ.01. Pⱕ.05. PT/tDPT⫽physical therapy/transitional Doctor of Physical Therapy.

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Predicting Productivity in Scholarship Table 5. Two-Year and Career Peer-Reviewed Publishing Rates (%) by Rank, Tenure-Related Status, and Disciplinary Type 2-Year Peer-Reviewed Article Publication

Appointment Status

Career Peer-reviewed Article Publication

None

1–2

3–5

>6

T/TT,a n⫽104

30.8

34.6

19.3

15.3

NTT/NTS,b n⫽109

51.4

32.2

10.1

6.3

T/TT, n⫽123

22.8

42.3

19.6

15.3

NTT/NTS, n⫽54

37.0

51.8

9.3

1.9

None

1–2

3–5

>6

n⫽103

19.4

20.4

19.4

40.8

n⫽108

35.2

31.4

10.1

23.3

n⫽121

5.0

19.0

21.4

54.6

n⫽53

9.4

39.6

20.8

30.2

Assistant professor

Associate professor

Professor T/TT, n⫽64

25.0

26.5

32.9

15.6

n⫽62

3.2

1.6

14.5

80.7

NTT/NTS, n⫽11

18.2

45.5

36.3

0.0

n⫽10

10.0

20.0

0.0

70.0

Hard, n⫽168

21.5

36.6

25.0

16.9

n⫽168

6.5

12.5

18.1

62.9

Soft, n⫽307

43.1

36.7

13.8

6.4

n⫽307

24.4

28.0

16.9

30.7

Disciplinary type

a b

Tenured or on tenure track. Non–tenure track or no tenure system.

Table 6. Characteristics of Faculty Holding Master’s and Doctoral Degrees (%) Master’s (nⴝ128)

DPTa (nⴝ37)

PhD (nⴝ250)

EdD (nⴝ46)

Other Doctorate (nⴝ40)

Mean years of faculty experience

12.2

5.7

14.0

16.6

10.5

2-year peer-reviewed article publications is equal to “none”

58.3

59.5

19.2

37.0

27.5

2-year peer-reviewed presentations is equal to “none”

37.5

45.9

17.2

17.4

17.5

Prefer teaching

75.8

63.6

46.8

56.5

70.0

Characteristic

Prefer research

a

3.1

5.5

43.6

15.2

15.0

Prefer service

17.2

21.8

6.0

23.9

12.5

Non–tenure track

55.5

60.0

16.4

13.0

25.0

Tenure track

10.9

18.2

32.4

30.4

27.5

Tenured

19.5

3.6

42.4

43.5

30.0

No tenure system

14.1

18.2

8.8

10.9

17.5

Scholarship of discovery

39.8

29.7

72.0

47.8

50.0

Scholarship of integration

28.1

32.4

29.2

34.8

32.5

Scholarship of application

48.4

37.8

40.0

45.7

45.0

Scholarship of teaching

39.1

54.1

22.4

34.8

32.5

DPT⫽Doctor of Physical Therapy.

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Predicting Productivity in Scholarship Table 7. Characteristics of Scholarly Work by Disciplinary Type

Type of Scholarship

a

Explicit Consideration of the Clinical Research Agenda

General Topic of Scholarship Physical Therapy Educationa

Sciencea

Othera

N

Yesa

Noa

Characteristic

Discoverya

Integrationa

Applicationa

Teachinga

Patient Carea

Hard discipline (n⫽163)

73.0

28.8

38.0

22.7

49.7

22.1

63.2

3.1

158

21.5

78.5

Soft discipline (n⫽287)

48.4

28.9

45.6

35.5

62.4

40.4

20.9

10.5

270

33.8

61.3

Number is percentage of participants.

faculty scholarship articulates value for the full range of scholarship, including discovery, integration, application, and teaching.3 Despite the broad view of CAPTE, physical therapist scholars work within the higher education culture that honors and rewards discovery more highly than other forms of scholarship.1,7 Thus, the generally nonparadigmatic physical therapy academy may be at a disadvantage within the academic workplace. In addition, it is not clear whether the priorities for clinical research articulated by professional leadership are subject to desired attention or produced in desired volume. A driving force behind the call for physical therapist faculty scholarship is the need to develop a strong evidence base for clinical practice. This requires, among other things, a sufficient volume of studies addressing efficacy and effectiveness of clinical interventions—the scholarship of discovery.5 Furthermore, only a small proportion of the respondents considered the CRA5 in planning a research agenda. The PDS were even less likely than the NPDS to tailor research activities to the CRA (Tab. 6). Perhaps the lack of attention to the CRA reflects limited exposure to the document. Perhaps it reflects tension between physical therapy and the discipline of highest March 2009

degree. Although the second discipline may or may not result in a propensity toward scholarship of discovery, divided interests of faculty members may reduce the likelihood that physical therapist scholars will examine the clinical priorities of the profession in sufficient volume. The multidisciplinary nature of the physical therapy academy is both a strength and a challenge for the physical therapy profession. The strength of the multidisciplinary faculty may be that it serves the wide array of interests and questions inherent in the nonparadigmatic field itself. Scholarship that addresses the needs of the diverse populations, clinical problems, and practice settings served by the field may require a diverse and multidisciplinary group of scholars. On the other hand, the large proportion of participants who held degrees in soft fields appeared predisposed toward lesser and slower publishing productivity, more-limited grant support for scholarly work, and fewer and lesser rewards for accomplishments as faculty scholars.23,24,44,45 Scholars across the wide variety of fields represented may or may not hold mutual or complementary objectives related to physical therapy.27 The inclination and propensity among faculty members to communicate, collaborate, and pro-

duce scholarly works that contribute to the advancement of the profession’s science should be more closely examined. The Changing Lives of Higher Education Faculty Are Reflected in Physical Therapy Faced with public demand for accountability and cost containment, an evolving technology base, a rapidly expanding knowledge base, unprecedented fiscal constraints, and an increasingly diverse workforce, higher education institutions are seeking to increase their flexibility and responsiveness.2,46,47 For faculty, this means an increasing number of part-time, provisional, and non–tenure track appointments. These appointments may “unbundle” the faculty role by emphasizing just one element of the traditional teaching/research/service triad. The non–tenure track and contract appointments may offer some faculty members desirable opportunities to develop, market, and use intellectual talents in a flexible manner. However, some view such appointments as “second class,” with unclear expectations, limited rewards, lack of equity and power within faculty governance systems,47 and uncertain security.2 With fully 43% of the participants reporting non–tenure track appointments (Tab. 1), it is apparent that

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Predicting Productivity in Scholarship physical therapist faculty are subject to national trends in faculty hiring. These non–tenure track appointments may allow physical therapist education programs flexibility in hiring and may offer some faculty members welcome opportunities for flexibility and specialization in roles. However, the participants with non– tenure track appointments were more likely to be nonpublishers and less likely to be high-frequency publishers than the participants with tenure track appointments (Tab. 5). Given the terms of any individual non– tenure track appointment, a lower rate of publishing productivity might be quite acceptable at the institutional level. The physical therapist program accreditation standards require that every physical therapist faculty member demonstrate a consistent and ongoing record of scholarly productivity. Therefore, the non–tenure track appointments may be problematic for the profession. In addition, a disproportionate number of non–tenure track appointments may diminish the influence of the physical therapist programs within their institutions. Attention to hiring practices and evaluation of the accreditation criteria related to individual versus programmatic scholarship may be useful as the profession moves forward. The DPT-Trained Faculty Cohort The extent to which DPT-trained faculty are prepared to fulfill roles as scholars, particularly in the area of discovery, is a matter of ongoing discussion.48 –52 Many authors49 –52 suggest that DPT-trained faculty members are best prepared to teach and to engage in scholarships of integration, application, and teaching. The DPT-trained participants comprised only a small proportion (7.7%) of the study participants. They had an average of 5 years of experience as a faculty member. Based on their limited representation and experience, it is difficult to draw precise impressions of their work as schol214

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ars. However, they do allow initial consideration of the DPT-trained faculty cohort in relation to scholarly work. It appears that DPT-trained faculty members were working differently than other doctorally trained faculty members (Tab. 7). The 2-year publication and presentation rates for DPTtrained faculty members were lower than for any other type of doctorally prepared faculty member. The DPTtrained faculty members were least likely of all doctorally prepared faculty members to prefer research to teaching or service. Approximately 78% of the DPT-trained faculty members were working without a tenure system or were not on a tenure track. The DPT-trained faculty members appear more similar to the master’s degree-prepared participants than to the other doctorally trained participants (Tab. 7). The implications of the work patterns of this small cohort are not clear, but several thoughts bear consideration. First, some authors50,51 have suggested that clinical doctoral training should prepare the DPTtrained faculty member to engage in scholarly integration, application, and teaching, but not discovery. The results of our study suggest the DPTtrained faculty cohort is most active in nondiscovery scholarship. Second, the emphasis on teaching among DPT-trained individuals is consistent with suggestions that DPT-trained faculty members are best prepared to serve in teaching rather than research roles.50,51 The DPT-trained participants in our study appeared to at least prefer teaching to research. Third, even accounting for the early career stage of a large proportion of the DPT-trained participants, there was a high number of nonpublishers and nonpresenters during the 2-year period reported; higher than for any other type of doctorally trained participant. Persistently low performance

Number 3

in scholarship could jeopardize professional development and program standing. Fourth, a high proportion of DPT-trained participants held non– tenure track appointments, which may serve as a disincentive to productivity as a scholar. Thus, it appears the DPT-trained faculty may be engaged in precisely the kinds of activities for which some authors suggest they are best prepared. The optimal composition of the physical therapy academy may well include a proportion of faculty with professional clinical degrees.53 What is not at all clear is whether an increase in the proportion of faculty prepared at the clinical doctoral level will enhance or compromise the profession’s research mission.49,52 The DPT-trained faculty cohort should be subject to ongoing study. Limitations Limitations to external validity of the survey include sampling error and a low response rate.39 The sampling frame consisted of 1,735 faculty members representing 188 out of 194 accredited programs. The 3.1% of programs and the similar proportion of faculty omitted from the sampling frame most likely resulted in little compromise to the representative nature of the sample. Careful development of a the survey instrument and 2 methods of followup with nonrespondents helped minimize nonresponse. The wave analysis indicated little likelihood of nonresponse bias. Threats to internal validity included reporting inaccuracy.39 There were errors in reporting of institutional type, and corrections were made by checking individual responses. Other possibilities of systematic response error cannot be ruled out. Directions for Future Study This study did not include part-time faculty, nor did it explore the terms March 2009

Predicting Productivity in Scholarship of non–tenure track appointments. Future research should examine the circumstances, roles, and responsibilities of faculty with alternative appointments and the relationships of non–tenure track and part-time appointments to scholarly productivity. An additional line of inquiry is the relationship of professional standards for scholarly productivity to institutional missions and productivity standards, particularly in nonresearch institutions. Additional study should examine in greater detail the contributions of each disciplinary field to priorities of the profession. Such inquiry should distinguish among cohorts of academic and clinical doctorally trained individuals in order to contribute to the analysis of the DPT degree as an appropriate credential for faculty scholars.

Conclusion This study is the first to examine factors associated with the scholarly productivity of individual faculty members in physical therapist education programs. Demographic, environmental, career, and work characteristics were included in a model by which productivity was analyzed. A national sample of physical therapist faculty members was surveyed using an instrument developed for the purposes of this study. Career factors generally predicted the largest proportion of variance in peer-reviewed article publications, peer-reviewed presentations, and grantsmanship. The study provides ample direction for future inquiry regarding the status of scholarship and of scholars in physical therapy. The study was approved by the Institutional Review Board of the School of Education at the University of Massachusetts, Amherst. This research was presented at the Combined Sections Meeting of the American Physical Therapy Association; February 14 – 18, 2007; Boston, Massachusetts. This study was funded, in part, by the Springfield College Faculty Research Fund.

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Springfield College played no role in the design, conduct, or reporting of the study. This article was received March 13, 2008, and was accepted December 12, 2008. DOI: 10.2522/ptj.20080076

References 1 Boyer EL. Scholarship Reconsidered: Priorities of the Professoriate.Princeton, NJ: Carnegie Foundation for the Advancement of Teaching; 1990. 2 Finkelstein M. The morphing of the American academic. Liberal Education. 2003; 89:6 –15. 3 Physical Therapy Faculty and Scholarship. American Physical Therapy Association Web site. Available at: http://www.apta. org/AM/Template.cfm?Section⫽General_ Information & Template ⫽ / CM / Content Display . cfm & ContentID ⫽ 23140. Accessed October 22, 2008. 4 Evaluative Criteria for Accreditation of Education Programs for the Preparation of Physical Therapists. Alexandria, VA: American Physical Therapy Association; 2006. 5 Clinical Research Agenda for Physical Therapy. Phys Ther. 2000;80:499 –513. 6 Glassick CE, Huber MT, Maeroff GI. Scholarship Assessed: Evaluation of the Professoriate. San Francisco, CA: Jossey-Bass Inc Publishers; 1997. 7 O’Meara K. Principles of good practice: encouraging multiple forms of scholarship in policy and practice. In: O’Meara K, Rice RE, eds. Faculty Priorities Reconsidered: Rewarding Multiple Forms of Scholarship. San Francisco, CA: Jossey-Bass Inc Publishers; 2005:290 –302. 8 O’Meara, K. Encouraging multiple forms of scholarship in faculty reward systems: Does it make a difference? Research in Higher Education. 2005;46:479 –510. 9 Creamer EG. Assessing Faculty Publication Productivity: Issues of Equity. Washington, DC: ASHE-ERIC Higher Education Report No. 420 243; 1998. 10 Creswell JW. Faculty Research Performance: Lessons From the Sciences and the Social Sciences. Washington, DC: ASHE-ERIC Higher Education Report; 1985. 11 Braxton JM, Luckey W, Helland P. Institutionalizing a Broader View of Scholarship Through Boyer’s Four Domains. Washington, DC: ASHE-ERIC Higher Education Report; Vol. 29, No. 2; 2002. 12 Nettles MT, Perna LW. Sex and Race Differences in Faculty Salaries, Tenure, Rank, and Productivity. Washington, DC: ASHE-ERIC Higher Education Report No. ED 391 402; 1995. 13 Poole M, Bornholt L, Summers F. An international study of the gendered nature of academic work: some cross-cultural explorations. Higher Education. 1997;34: 373–396. 14 Teodorescu D. Correlates of faculty publication productivity: a cross-national analysis. Higher Education. 2000;39:201–222.

15 Dey EL, Milem JF, Berger JB. Changing patterns of publication productivity: accumulative advantage or institutional isomorphism? Sociology of Education. 1997; 70:308 –323. 16 Flanigan KS, Ballinger PW, Grant HK, et al. Research productivity profile of allied health faculty. J Allied Health. 1988; 17:87–100. 17 Hannafin KM. An analysis of the scholarly productivity of instructional technology faculty. Educational Technology, Research, and Development. 1991;39:39 – 42. 18 Kraemer LG, Lyons KJ. Research productivity of allied health faculty in academic health centers. J Allied Health. 1989; 18:349 –359. 19 Paul S, Liu Y, Ottenbacher KJ. Research productivity among occupational therapy faculty members in the United States. Am J Occup Ther. 2002;56:331–333. 20 Tien FF, Blackburn RT. Faculty rank system, research motivation, and faculty research productivity: measure refinement and theory testing. Journal of Higher Education. 1996;67:2–22. 21 Vardan S, Smulyan H, Mookherjee S, Mehrotra KG. Factors encouraging research productivity in a division of general internal medicine. Acad Med. 1990;65: 772–774. 22 Waller KV, Wyatt D, Karni KR. Research productivity and activities of clinical laboratory science faculty: a follow-up study. J Allied Health. 1998;27:142–149. 23 Becher T. Academic Tribes and Territories: Intellectual Enquiry and the Cultures of Disciplines. Bristol, PA: Society for Research Into Higher Education and Open University Press; 1989. 24 Biglan A. The characteristics of subject matter in different academic areas. J Appl Psychol. 1973;57:195–203. 25 Biglan A. Relationships between subject matter characteristics and the structure and output of university department. J Appl Psychol. 1973;57:204 –213. 26 Kezar A. Higher education research at the millennium: still trees without fruit? Review of Higher Education. 2000;23: 443– 468. 27 Kaufman RR. A reflection on disciplinary nature and the status of physical therapy scholarship. J Phys Ther Educ. 2005;19(1): 3– 8. 28 Worthingham CA. The clinical environment for basic physical therapy education, part II: staff. Phys Ther. 1968;48: 1353–1382. 29 Holcomb DJ, Selker LG, Roush RE. Scholarly productivity: a regional study of physical therapy faculty in schools of allied health. Phys Ther. 1990;70:118 –124. 30 2005 fact sheet: physical therapist education programs. American Physical Therapy Association Web site. Available at: http:// www.apta.org/AM/Template.cfm?Section⫽ PT_Programs1&TEMPLATE⫽/CM/Content Display.cfm & CONTENTID ⫽ 43471. Accessed July 9, 2005.

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Predicting Productivity in Scholarship 31 Blackburn RT, Lawrence JH. Faculty at Work: Motivation, Expectation, Satisfaction. Baltimore, MD: Johns Hopkins University Press; 1995. 32 Richter RR, Schlomer SL, Krieger MM, Siler WL. Journal publication productivity in academic physical therapy programs in the Unites States and Puerto Rico from 1998 to 2002. Phys Ther. 2008;88: 376 –386. 33 Higher Education Research Institute Faculty Survey. University of California, Los Angeles, Higher Education Research Institute Web site. Available at: http://www. gseis.ucla.edu/heri/facoverview.php. Accessed October 22, 2008. 34 National Center for Education Statistics National Survey of Postsecondary Faculty. National Center for Education Statistics Web site. Available at: http://nces.ed.gov/ surveys/nsopf/. Accessed October 22, 2008. 35 The Carnegie Classification of Institutions of Higher Education. Carnegie Foundation for the Advancement of Teaching Web site. Available at: http://www. carnegiefoundation . org / Classification/ index.htm. Accessed October 22, 2008. 36 SPSS [computer program]. Base version 14.0. Chicago, IL: SPSS Inc; 2005. 37 Dillman, DA. Mail and Internet Surveys: The Tailored Design Method. 2nd ed. New York, NY: John Wiley & Sons Inc; 2000.

Invited Commentary

The need to support faculty development and scholarship has been recognized in all disciplines in higher education, most consistently in clinical disciplines. Studies in medicine, nursing, clinical laboratory medicine, occupational therapy, and other disciplines have all documented low publication rates of faculty.3–7 These studies also have investigated the barriers to faculty scholarship, agreeing on the obvious hurdles of time (teaching and clinical responsibility), research knowledge

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48 The Doctor of Physical Therapy (DPT) as a faculty credential. American Physical Therapy Association Web site. Available at: http://www.apta.org/AM/Template.cfm? Section⫽General_Information&Template⫽/ CM/ContentDisplay.cfm&ContentID⫽23141. Accessed October 22, 2008. 49 Jette AM. A future with increased rather than diminished research capabilities. Phys Ther. 2005;85:710 –711. 50 Sahrmann SA. Moving precisely? Or taking the path of least resistance? Phys Ther. 1998;78:1208 –1218. 51 Threkheld AJ, Jensen GM, Royeen CB. The clinical doctorate: a framework for analysis in physical therapist education. Phys Ther. 1999;79:567–581. 52 Simoneau GG. The DPT: will the research keep up? J Orthop Sports Phys Ther. 2002;32:546 –547. 53 Brueilly KE, Williamson EM, Morris GS. Defining core faculty for physical therapist education. J Phys Ther Educ. 2007; 21(2):10 –14. 54 Sax LJ, Hagedorn LS, Arredondo M, Dicrisi FA. Faculty research productivity: exploring the role of gender and family-related factors. Research in Higher Education. 2002;43:423– 446.

Leslie G Portney

I applaud Kaufman for her attention to this important issue in this study1 and her 2005 treatise on scholarship.2 She has recognized a longstanding challenge that has been the topic of extensive conversation but little analysis in physical therapy.

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38 Survey Monkey Web site. Available at: http://www.surveymonkey.com. Accessed November 16, 2008. 39 Fowler FJ. Survey Research Methods. 3rd ed. Thousand Oaks, CA: Sage Publications Inc; 2002. 40 Creswell JW. Research Design: Qualitative, Quantitative, and Mixed Methods Approaches. 2nd ed. Thousand Oaks, CA: Sage Publications Inc.; 2003 41 A Normative Model of Physical Therapist Professional Education, Version 2004. Alexandria, VA: American Physical Therapy Association; 2004. 42 Cott CA, Finch E, Gasner D, et al. The movement continuum theory of physical therapy. Physiother Can. 1995;47:87–95. 43 O’Hearn M. The elemental identity of physical therapy. J Phys Ther Educ. 2002;16:4 –7. 44 Schon DA. The new scholarship requires a new epistemology. Change. 1995;27: 26 –34. 45 Slaughter S. Federal policy and supply-side institutional resource allocation at public research universities. Review of Higher Education. 1998;21:209 –244. 46 Finkelstein M, Schuster JH. Assessing the silent revolution: how changing demographics are reshaping the academic profession. AAHE Bulletin. 2001;54:3–7. 47 Gappa JM, Austin AE, Trice AG. Rethinking academic work and workplaces. Change. 2005;37:32–39.

and experience (lack of research doctorates), and limited support (mentorship). These factors also have been shown to be related to the research mission of the institution, which influences resources and scholarship expectations. Kaufman has shown that, not surprisingly, physical therapy faculty are subject to these same constraints. Kaufman adds an important consideration to this discussion, however, by postulating about the nature of our science and the “soft” focus of physical therapy research. Based on her 2005 thesis, she has cited an interesting model to help explain limitations of faculty research in physical therapy. The concept of “soft” and “hard” disciplines is helpful to appreciate varied research ap-

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proaches in different fields. The author also points out a lack of a unifying theory in physical therapy, which is reflected in the diversity of concentrations for those who have advanced degrees. Unfortunately, the study does not include data on which fields of study faculty have pursued. If we accept that physical therapy is a soft discipline because of its diversity of content, then I would assume this is also true of other diverse clinical professions, such as nursing and medicine. Research in these fields can be equally eclectic in terms of focus. Therefore, studies in these disciplines should be useful for understanding our own scholarship struggles. Kaufman comments that the nonparadigmatic nature of physical ther-

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Predicting Productivity in Scholarship 31 Blackburn RT, Lawrence JH. Faculty at Work: Motivation, Expectation, Satisfaction. Baltimore, MD: Johns Hopkins University Press; 1995. 32 Richter RR, Schlomer SL, Krieger MM, Siler WL. Journal publication productivity in academic physical therapy programs in the Unites States and Puerto Rico from 1998 to 2002. Phys Ther. 2008;88: 376 –386. 33 Higher Education Research Institute Faculty Survey. University of California, Los Angeles, Higher Education Research Institute Web site. Available at: http://www. gseis.ucla.edu/heri/facoverview.php. Accessed October 22, 2008. 34 National Center for Education Statistics National Survey of Postsecondary Faculty. National Center for Education Statistics Web site. Available at: http://nces.ed.gov/ surveys/nsopf/. Accessed October 22, 2008. 35 The Carnegie Classification of Institutions of Higher Education. Carnegie Foundation for the Advancement of Teaching Web site. Available at: http://www. carnegiefoundation . org / Classification/ index.htm. Accessed October 22, 2008. 36 SPSS [computer program]. Base version 14.0. Chicago, IL: SPSS Inc; 2005. 37 Dillman, DA. Mail and Internet Surveys: The Tailored Design Method. 2nd ed. New York, NY: John Wiley & Sons Inc; 2000.

Invited Commentary

The need to support faculty development and scholarship has been recognized in all disciplines in higher education, most consistently in clinical disciplines. Studies in medicine, nursing, clinical laboratory medicine, occupational therapy, and other disciplines have all documented low publication rates of faculty.3–7 These studies also have investigated the barriers to faculty scholarship, agreeing on the obvious hurdles of time (teaching and clinical responsibility), research knowledge

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48 The Doctor of Physical Therapy (DPT) as a faculty credential. American Physical Therapy Association Web site. Available at: http://www.apta.org/AM/Template.cfm? Section⫽General_Information&Template⫽/ CM/ContentDisplay.cfm&ContentID⫽23141. Accessed October 22, 2008. 49 Jette AM. A future with increased rather than diminished research capabilities. Phys Ther. 2005;85:710 –711. 50 Sahrmann SA. Moving precisely? Or taking the path of least resistance? Phys Ther. 1998;78:1208 –1218. 51 Threkheld AJ, Jensen GM, Royeen CB. The clinical doctorate: a framework for analysis in physical therapist education. Phys Ther. 1999;79:567–581. 52 Simoneau GG. The DPT: will the research keep up? J Orthop Sports Phys Ther. 2002;32:546 –547. 53 Brueilly KE, Williamson EM, Morris GS. Defining core faculty for physical therapist education. J Phys Ther Educ. 2007; 21(2):10 –14. 54 Sax LJ, Hagedorn LS, Arredondo M, Dicrisi FA. Faculty research productivity: exploring the role of gender and family-related factors. Research in Higher Education. 2002;43:423– 446.

Leslie G Portney

I applaud Kaufman for her attention to this important issue in this study1 and her 2005 treatise on scholarship.2 She has recognized a longstanding challenge that has been the topic of extensive conversation but little analysis in physical therapy.

216

38 Survey Monkey Web site. Available at: http://www.surveymonkey.com. Accessed November 16, 2008. 39 Fowler FJ. Survey Research Methods. 3rd ed. Thousand Oaks, CA: Sage Publications Inc; 2002. 40 Creswell JW. Research Design: Qualitative, Quantitative, and Mixed Methods Approaches. 2nd ed. Thousand Oaks, CA: Sage Publications Inc.; 2003 41 A Normative Model of Physical Therapist Professional Education, Version 2004. Alexandria, VA: American Physical Therapy Association; 2004. 42 Cott CA, Finch E, Gasner D, et al. The movement continuum theory of physical therapy. Physiother Can. 1995;47:87–95. 43 O’Hearn M. The elemental identity of physical therapy. J Phys Ther Educ. 2002;16:4 –7. 44 Schon DA. The new scholarship requires a new epistemology. Change. 1995;27: 26 –34. 45 Slaughter S. Federal policy and supply-side institutional resource allocation at public research universities. Review of Higher Education. 1998;21:209 –244. 46 Finkelstein M, Schuster JH. Assessing the silent revolution: how changing demographics are reshaping the academic profession. AAHE Bulletin. 2001;54:3–7. 47 Gappa JM, Austin AE, Trice AG. Rethinking academic work and workplaces. Change. 2005;37:32–39.

and experience (lack of research doctorates), and limited support (mentorship). These factors also have been shown to be related to the research mission of the institution, which influences resources and scholarship expectations. Kaufman has shown that, not surprisingly, physical therapy faculty are subject to these same constraints. Kaufman adds an important consideration to this discussion, however, by postulating about the nature of our science and the “soft” focus of physical therapy research. Based on her 2005 thesis, she has cited an interesting model to help explain limitations of faculty research in physical therapy. The concept of “soft” and “hard” disciplines is helpful to appreciate varied research ap-

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proaches in different fields. The author also points out a lack of a unifying theory in physical therapy, which is reflected in the diversity of concentrations for those who have advanced degrees. Unfortunately, the study does not include data on which fields of study faculty have pursued. If we accept that physical therapy is a soft discipline because of its diversity of content, then I would assume this is also true of other diverse clinical professions, such as nursing and medicine. Research in these fields can be equally eclectic in terms of focus. Therefore, studies in these disciplines should be useful for understanding our own scholarship struggles. Kaufman comments that the nonparadigmatic nature of physical ther-

March 2009

Predicting Productivity in Scholarship apy may predispose the profession to lower publication rates. This begs the question, then, as to why being a soft and diverse discipline should somehow discourage faculty research. In presenting this argument, the author does not provide this understanding. Rather than seeing the soft science as a negative influence, perhaps we can ask why this has not made the goal of scholarship more attainable. We are not confined in our scholarly pursuits to one research approach, and the opportunities, therefore, are numerous. The author suggests, however, that the wealth of topics and methodological approaches is problematic. How can we turn this into a positive influence to satisfy faculty interests? Rather than stimulating ideas, Kaufman suggests this diversity has stifled research by not providing enough guidance or framework for the profession’s research agenda. The author does try to look at the difference in publication rates for faculty whose backgrounds are in hard or soft disciplines, as shown in Table 5. What is not clear, however, is how she determined who fits in each category, based on the questions that were asked in the survey. The question of how the discipline influences scholarly productivity conjures up the notion of “nature versus nurture.” Is it the nature of our professional discipline as a soft science that hampers research development, or have we not nurtured our faculty (and potential faculty) sufficiently so that they feel empowered to do research, no matter what their area of interest? Kaufman’s study is only a first step in understanding the issues that affect our scholarly productivity, as her data do not include information regarding the development of faculty research skills.

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Kaufman looked at several factors as potential barriers to scholarship, and her analysis has shown that very few have any consistent bearing on productivity. The few factors that have emerged are consistent with studies in other fields. I hope further research can clarify the relative contribution of the nature of the discipline versus the resources that constrain productivity. This dilemma also may be a reflection of how we have grown as an academic discipline—trying to become a legitimate member of the academy in a liberal arts culture. This has been a good thing in terms of our entry into higher education, but perhaps a disadvantage to our growing up. In our efforts to belong, have we sacrificed our value of clinical practice for academic credentials? I am not suggesting that we do not belong in the academy, but that we recognize different faculty roles and allow faculty to shine in the roles they fulfill—rather than trying to make everyone fit one mold. We have not established a strong research culture, which is why our clinical research agenda is so diffuse. In its current format, the American Physical Therapy Association (APTA) research agenda provides little guidance to frame the important questions and totally ignores educational research. This is being revisited, and the agenda hopefully will become a stronger construct for research in epidemiology, health policy, education, psychology, and so on. If we accept the general consensus that time and background are the primary barriers to scholarship, then it is our responsibility to figure out how to give faculty the resources to succeed in their scholarship goals. With tightening budgets and faculty shortages, this is a remarkable challenge. We are seeing fewer physical therapists going for advanced de-

grees as they obtain their clinical doctorate. And there is little doubt that experience in an advanced doctoral program does generally provide the skills to become a researcher. We have not cultivated this career path and often find clinicians seeking faculty positions before they have a PhD. Some work toward a PhD while teaching, taking years to finish at a distinct personal cost financially and emotionally. Others have no intention of pursuing an advanced degree, focusing instead on clinical specialist certification. This clinical expertise, while providing wonderful background for teaching clinical skills, will not necessarily help them become scholars. Kaufman does address the importance of the nature of the academic institution, its research mission and scholarly environment. Her finding that those in research-intensive universities have higher publication rates is supported throughout the literature3,7–9 and is not surprising. These universities will generally have an institutional culture of research and criteria for maintaining faculty appointments, as well as having resources in place, including mentors, to foster this culture. Gruppen10 has described how scholarly productivity is influenced by the complementary areas of faculty expertise, a critical mass of scholars, collaborations of faculty with colleagues in other departments, and the departmental status and visibility within the institution. These findings force us to examine the nature of physical therapy as an academic discipline, what we expect of faculty, and what kinds of resources are provided for them to fulfill their scholarly goals. Should all faculty be involved in research or other scholarly endeavors? How much of the clinical expectations of faculty who teach in a clinical discipline can be integrated into scholar-

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Predicting Productivity in Scholarship ship? We recognize the need for research in the profession and that most of that research will be generated by those in academia, but it may not be by all faculty. We need to let those most qualified and interested do good, meaningful research and let others use their time constructively in other ways, rather than forcing expectations of scholarship that do not make any meaningful contribution to the science of physical therapy or the effectiveness of teaching. We also have to consider the rationale for expecting faculty to do research. Kaufman suggests that leaders within APTA have set the standard for core faculty, but she is referencing a position paper that was developed by the Commission on Accreditation in Physical Therapy Education (CAPTE), not APTA. This distinction is important. It is unfortunate that the impetus for this issue often comes back to CAPTE requirements, as if the evaluative criteria somehow govern our values. In fact, the criteria should reflect our values as a profession. We should have a concern for scholarship because we need evidence to make sound decisions—not because we may be cited in an accreditation review. Interestingly, there is no strong evidence to show that one becomes a better faculty member or teacher by virtue of being a strong producer of scholarship (as opposed to someone who uses scholarly works to support their teaching).9 Kaufman did ask about the influence of CAPTE requirements on scholarly activity, but did not report these results in her article. It would be interesting to see how these requirements were related to presentations versus publications, as many faculty find poster and platform presentations at conferences to be an easier road to meeting this criterion. Many of these presentations are special interest papers, rather than true research. Most never get translated to a peer-reviewed publi218

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cation and, therefore, are not making a true contribution to our science. One rationale that does have implications for accreditation is the need to maintain a stable faculty over time, which in many institutions will require tenure. Faculty on tenure tracks will lose their appointments after a set number of years if they are not productive. Other clinical disciplines have developed clinical tracks that do not lead to tenure, allowing faculty to be continually reappointed without expectations of publishing. This practice was begun in medical schools11 and has been adopted by many physical therapy programs. The clinical track was developed to protect teacher/clinicians, whose primary role was to teach. But regardless of whether tenure is at stake, faculty do have to consider the criteria for promotion, which typically include a benchmark of publications.3,11 We all are aware of faculty who have stayed at the assistant professor level for decades, which puts the program in a weakened position within the academy. Even on clinical tracks, some form of scholarship is going to be expected for all faculty to be promoted to higher ranks. Boyers’ model of scholarship has become widely accepted and has expanded to include the scholarship of engagement, which provides opportunities for scholarship within service learning.12 The Boyer model is ideal for a soft discipline to find many avenues of scholarly endeavor. The scholarship of discovery, aligned with traditional explanatory research, is the most well understood. But the other 4 areas—teaching, application, integration, and now engagement—are not well understood. These areas potentially provide a wealth of research or scholarly paths, but we have not done a good job as a discipline of defining what they mean for physical

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therapy and how faculty and clinicians might contribute to them. The scholarship of teaching, for example, is not the same as being a scholarly teacher.13 If we expect to see a broad acceptance of scholarship responsibility among faculty, we must first help each other figure out what these domains mean. Kaufman did ask her respondents to indicate in which area of scholarship their work is primarily directed, but I would question the validity of their responses given the lack of clarity in these definitions. Kaufman also brings up the touchy subject of the Doctor of Physical Therapy (DPT) degree as a faculty credential. Because we are still in the early stages of our transition to the clinical doctorate, the education community is wrestling with how this degree fulfills the requirements for a faculty position. It is, after all, a doctorate. But we must put this degree in its appropriate academic perspective. It is not a research degree, and there is no expectation that it signifies expertise in scholarship. As a first professional degree, it signals only the competence to enter practice. Most professional (entry-level) and transitional DPT programs provide only a research base for evidence-based practice, not a thesis, as this is not the intent of the degree. An advanced degree is needed to foster research competencies. This does not mean, however, that faculty with a DPT are not qualified to teach as clinical experts. We might equate this degree to the MD, which qualifies medical school faculty, most of whom will serve on a clinical track if they do not have other research training or a PhD. It also may be relevant to distinguish whether a faculty member achieved the DPT as his or her entry-level degree, or whether the faculty member went through a transitional program, which would be built upon a strong clinical background, serving a differMarch 2009

Predicting Productivity in Scholarship ent function in that individual’s professional development. The author does recognize the limitations of her study. The response rate must be addressed in terms of potential bias. It is not unusual to see 50% response rates, but it is necessary then to ask who would have been more likely to respond to this survey. Given the questions in the survey questionnaire, would those who are not involved in scholarship be less likely to take the time to fill it out? If that is the case, the estimates of publication rates would probably be even less than these results show. The emergence of physical therapy as a doctoral-level discipline has made the issue of scholarship an essential consideration in our status in the academy. This study has started the discussion by exploring varied influences that must be addressed as our faculties grow. I look forward to Kaufman’s continued exploration of

Author Response I would like to thank Portney for her thoughtful commentary1 on my study.2 She is an important and influential voice for academic physical therapy, and it is an honor to have her respond to this work. It is precisely because faculty scholarship has been the “topic of extensive conversation but little analysis in physical therapy”1(p216) that I undertook this project. Portney highlights some of the many considerations that the findings of my study raise. The issues of scholarly productivity require deliberation by a variety of stakeholders and from a variety of perspectives. Physical therapist professionals need a body of evidence upon which to base practice; physical therapy programs need a stable, flexible, productive, and effective faculty; and inMarch 2009

this topic, helping us to ask the difficult questions. LG Portney, PT, DPT, PhD, FAPTA, is Professor and Director, Graduate Programs in Physical Therapy, MGH Institute of Health Professions, Charlestown Navy Yard, 36 1st Ave, Boston, MA 02129 (USA). Address all correspondence to Dr Portney at: [email protected]. DOI: 10.2522/ptj.20080076.ic

References 1 Kaufman RR. Career factors help predict productivity in scholarship among faculty members in physical therapist education programs. Phys Ther. 2009;89:204 –216. 2 Kaufman RR. A reflection on disciplinary nature and the status of physical therapy scholarship. J Phys Ther Educ. 2005;19(1): 3– 8. 3 Roberts KL, Turnbull BJ. Nurse-academics’ scholarly productivity: perceived frames and facilitators. Contemporary Nurse. 2004;17:282–292. 4 Barhyte DY, Redman BK. Factors related to graduate nursing faculty scholarly productivity. Nurs Res. 1993;42:179 –183. 5 Fauber TL, Legg JS. Research and scholarship among R.T. educators. Radiol Technol. 2003;74:376 –384.

6 Ransdell LB, Dinger MK, Cooke C, Beske S. Factors related to publication productivity in a sample of female health educators. Am J Health Behav. 2001;25:468 – 480. 7 Waller KV, Wyatt D, Karni KR. Scholarly activities among clinical laboratory science faculty. Clin Lab Sci. 1999;12: 19 –27. 8 Richter RR, Schlomer SL, Krieger MM, Siler WL. Journal publication productivity in academic physical therapy programs in the United States and Puerto Rico from 1998 to 2002. Phys Ther. 2008;88:376 –386. 9 Melland HI. Great researcher: good teacher? J Profess Nurs. 1996;12:31–38. 10 Gruppen LD. The Department of Medical Education at the University of Michigan Medical School: a case study in medical education research productivity. Acad Med. 2004;79:997–1002. 11 Jones RF, Gold JS. Faculty appointment and tenure policies in medical schools: a 1997 status report. Acad Med. 1998;73: 212–29. 12 Bringle RG, Hatcher JA. Campuscommunity partnerships: the terms of engagement. J Soc Issues. 2002;58:503–516. 13 Allen MN, Field PA. Scholarly teaching and scholarship of teaching: noting the difference. Int J Nurs Educ Scholarsh. 2005;2: Article 12. Epub 2005 Jun 10.

Regina R Kaufman

dividual faculty members need opportunities to pursue work that is personally and professionally meaningful and rewarding. The characterization of physical therapy as a soft academic discipline3 and the analysis of scholarly productivity using models that incorporate disciplinary affiliation are critical to our abilities to define our research needs and to define our potential strengths and limitations as a scholarly profession. The models of disciplinary structure and culture presented by Biglan,4,5 Becher,6 and Sax et al7 suggest that hard and soft disciplines are fundamentally different in terms of the organization of their content and the behavior of their scholars. As noted in the study,

soft disciplines have poorly delineated boundaries, loosely defined bodies of knowledge, and diversity in conceptual frameworks and approaches to developing the knowledge of the field. Being a soft and diverse discipline does not discourage faculty research per se, but rather may predispose the physical therapy academy by its very nature toward a smaller volume and slower production of scholarly works. Table 2 is derived from information provided in faculty responses to item 9 of the survey questionnaire (see the eAppendix). As Table 2 indicates, the physical therapy academy is a multidisciplinary entity. In addition to being almost universally physical therapists, physical therapist fac-

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Predicting Productivity in Scholarship ent function in that individual’s professional development. The author does recognize the limitations of her study. The response rate must be addressed in terms of potential bias. It is not unusual to see 50% response rates, but it is necessary then to ask who would have been more likely to respond to this survey. Given the questions in the survey questionnaire, would those who are not involved in scholarship be less likely to take the time to fill it out? If that is the case, the estimates of publication rates would probably be even less than these results show. The emergence of physical therapy as a doctoral-level discipline has made the issue of scholarship an essential consideration in our status in the academy. This study has started the discussion by exploring varied influences that must be addressed as our faculties grow. I look forward to Kaufman’s continued exploration of

Author Response I would like to thank Portney for her thoughtful commentary1 on my study.2 She is an important and influential voice for academic physical therapy, and it is an honor to have her respond to this work. It is precisely because faculty scholarship has been the “topic of extensive conversation but little analysis in physical therapy”1(p216) that I undertook this project. Portney highlights some of the many considerations that the findings of my study raise. The issues of scholarly productivity require deliberation by a variety of stakeholders and from a variety of perspectives. Physical therapist professionals need a body of evidence upon which to base practice; physical therapy programs need a stable, flexible, productive, and effective faculty; and inMarch 2009

this topic, helping us to ask the difficult questions. LG Portney, PT, DPT, PhD, FAPTA, is Professor and Director, Graduate Programs in Physical Therapy, MGH Institute of Health Professions, Charlestown Navy Yard, 36 1st Ave, Boston, MA 02129 (USA). Address all correspondence to Dr Portney at: [email protected]. DOI: 10.2522/ptj.20080076.ic

References 1 Kaufman RR. Career factors help predict productivity in scholarship among faculty members in physical therapist education programs. Phys Ther. 2009;89:204 –216. 2 Kaufman RR. A reflection on disciplinary nature and the status of physical therapy scholarship. J Phys Ther Educ. 2005;19(1): 3– 8. 3 Roberts KL, Turnbull BJ. Nurse-academics’ scholarly productivity: perceived frames and facilitators. Contemporary Nurse. 2004;17:282–292. 4 Barhyte DY, Redman BK. Factors related to graduate nursing faculty scholarly productivity. Nurs Res. 1993;42:179 –183. 5 Fauber TL, Legg JS. Research and scholarship among R.T. educators. Radiol Technol. 2003;74:376 –384.

6 Ransdell LB, Dinger MK, Cooke C, Beske S. Factors related to publication productivity in a sample of female health educators. Am J Health Behav. 2001;25:468 – 480. 7 Waller KV, Wyatt D, Karni KR. Scholarly activities among clinical laboratory science faculty. Clin Lab Sci. 1999;12: 19 –27. 8 Richter RR, Schlomer SL, Krieger MM, Siler WL. Journal publication productivity in academic physical therapy programs in the United States and Puerto Rico from 1998 to 2002. Phys Ther. 2008;88:376 –386. 9 Melland HI. Great researcher: good teacher? J Profess Nurs. 1996;12:31–38. 10 Gruppen LD. The Department of Medical Education at the University of Michigan Medical School: a case study in medical education research productivity. Acad Med. 2004;79:997–1002. 11 Jones RF, Gold JS. Faculty appointment and tenure policies in medical schools: a 1997 status report. Acad Med. 1998;73: 212–29. 12 Bringle RG, Hatcher JA. Campuscommunity partnerships: the terms of engagement. J Soc Issues. 2002;58:503–516. 13 Allen MN, Field PA. Scholarly teaching and scholarship of teaching: noting the difference. Int J Nurs Educ Scholarsh. 2005;2: Article 12. Epub 2005 Jun 10.

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dividual faculty members need opportunities to pursue work that is personally and professionally meaningful and rewarding. The characterization of physical therapy as a soft academic discipline3 and the analysis of scholarly productivity using models that incorporate disciplinary affiliation are critical to our abilities to define our research needs and to define our potential strengths and limitations as a scholarly profession. The models of disciplinary structure and culture presented by Biglan,4,5 Becher,6 and Sax et al7 suggest that hard and soft disciplines are fundamentally different in terms of the organization of their content and the behavior of their scholars. As noted in the study,

soft disciplines have poorly delineated boundaries, loosely defined bodies of knowledge, and diversity in conceptual frameworks and approaches to developing the knowledge of the field. Being a soft and diverse discipline does not discourage faculty research per se, but rather may predispose the physical therapy academy by its very nature toward a smaller volume and slower production of scholarly works. Table 2 is derived from information provided in faculty responses to item 9 of the survey questionnaire (see the eAppendix). As Table 2 indicates, the physical therapy academy is a multidisciplinary entity. In addition to being almost universally physical therapists, physical therapist fac-

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Predicting Productivity in Scholarship ulty in this study reported advanced academic training representing more than 30 disciplinary fields that I categorized as either hard or soft based on the work by Sax et al.7 As I suggested in my discussion, this diversity carries both strengths and challenges with respect to scholarly productivity. This diverse group of scholars may be just what is needed for the profession to explore its wide array of problems and interests. The diversity also poses challenges. These include challenges in communication, coordination, and collaboration as scholars pursue their different interests using different paradigms and profiting from different types of relationships, resources, and outputs. Recognizing both the strengths and the challenges based on the nature of the disciplines may be an important step in crafting the nurturing of both current and prospective faculty members that Portney suggests would be useful, particularly in light of a revised professional research agenda. Portney’s comments regarding our maturation as an academic discipline, her contention that more physical therapists are obtaining clinical doctoral degrees or specialist certification rather than academic doctoral degrees, and her comments pertaining to the motives that drive our scholarship are perhaps best framed within our notions of what comprises an academic life. Rice8 has noted that for many scholars, the dominant conception of the academic role is one in which research and the pursuits of knowledge are at the core of the academic life. In contrast, the primary concerns of professional programs have historically been the preparation of practitioners and the production of knowledge directed toward solving the problems of professional practice.9,10 For many faculty in professional disciplines, the demands of competing

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interests in practitioner education, practice, and scholarship may result in fragmented efforts within and across faculties and difficulty in satisfying either professional or institutional expectations.10 I fully agree with Portney that the evaluative criteria for professional education programs should reflect our values rather than drive our behavior. I also think that physical therapists, and in particular the members of the physical therapy academy, have work to do to clarify and clearly articulate values and goals for the academic profession in physical therapy. Once we have established a clear set of values for professional education in an academic milieu, we could more effectively advocate for our professional needs relative to institutional needs and promote the creation of more-informed policies for faculty credentials, faculty appointments, and faculty work expectations. Improved policies and their associated practices could help minimize fragmentation while enabling scholarly productivity in all its forms. Role differentiation, with qualifications and work expectations commensurate with each role, may be a very reasonable part of the faculty equation. A mix of faculty with research doctorates, clinical doctorates, and clinical specialization may ultimately be what the profession needs, but without further study, it is difficult to determine useful proportions or best practices in hiring and faculty development. I agree that with a response rate of 58%, the potential for nonresponse bias is a limitation of this study. The wave analysis11,12 I described provided some indication that nonresponse bias was not of considerable concern. I share Portney’s contention that those less involved in scholarly activity might have been less likely to complete the survey. If

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so, I concur that the actual productivity rates might be less than those reported. What, then, would that mean for our profession? I look forward to the conversation and future scholarly work that I hope this study and this dialogue help to engender. I thank Portney again for her thought-provoking commentary. DOI: 10.2522/ptj.20080076.ar

References 1 Portney LG. Invited commentary on “Career factors help predict productivity in scholarship among faculty members in physical therapist education programs.” Phys Ther. 2009;89:216 –219. 2 Kaufman RR. Career factors help predict productivity in scholarship among faculty members in physical therapist education programs. Phys Ther. 2009;89:204 –216. 3 Kaufman RR. A reflection on disciplinary nature and the status of physical therapy scholarship. J Phys Ther Educ. 2005;19: 3– 8. 4 Biglan A. The characteristics of subject matter in different academic areas. J Appl Psychol. 1973;57:195–203. 5 Biglan A. Relationships between subject matter characteristics and the structure and output of university department. J Appl Psychol. 1973;57:204 –213. 6 Becher T. Academic Tribes and Territories: Intellectual Enquiry and the Cultures of Disciplines. Bristol, PA: Society for Research into Higher Education and Open University Press; 1989. 7 Sax LJ, Hagedorn LS, Arredondo M, Dicrisi FA. Faculty research productivity: exploring the role of gender and family-related factors. Research in Higher Education. 2002;43:423– 446. 8 Rice RE. Making a Place for the New American Scholar. Washington, DC: American Association for Higher Education; 1996. 9 Clark BR. Small worlds, different worlds: the uniqueness and troubles of the American academic professions. Daedelus. 1997;126:180 –191. 10 Schon DA. The new scholarship requires a new epistemology. Change. 1995;527: 26 –34. 11 Fowler FJ. Survey Research Methods. 3rd ed. Thousand Oaks, CA: Sage Publications Inc; 2002. 12 Creswell JW. Research Design: Qualitative, Quantitative, and Mixed Methods Approaches. 2nd ed. Thousand Oaks, CA: Sage Publications Inc; 2003.

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Research Report A Qualitative Application of the Diffusion of Innovations Theory to Examine Determinants of Guideline Adherence Among Physical Therapists Janneke Harting, Geert MJ Rutten, Steven TJ Rutten, Stef P Kremers

Background. Evidence-based practice has become a major issue in physical therapy. Many evidence-based guidelines, however, are not used extensively after dissemination, and interventions aimed at increasing guideline adherence often have limited effects.

Objective. As a prerequisite for changing this situation, the aims of this study were to gain an in-depth understanding of the determinants of guideline adherence among physical therapists in the Netherlands and to evaluate the opportunities of a theoretical framework in this respect.

Design and Methods. This observational study consisted of 3 focus group interviews (n⫽12, 10, and 8) between November 2002 and January 2003. Physical therapists were asked to discuss their opinions about and experiences with the Dutch guidelines for low back pain. Data were analyzed qualitatively using a directed approach to content analysis. Both the interview route and the analysis of the interviews were informed by Rogers’ Diffusion of Innovations Theory.

Results. Our study yielded in-depth insights into the various determinants of guideline adherence. Overall, the participants had rather unfavorable opinions about issues related to the dissemination of the guidelines (first phase of the diffusion process) and provided relatively little information on the subsequent adoption process (second phase of the diffusion process). The theoretical framework appeared to be a useful tool to properly structure the focus group interviews, to systematically analyze the data collected, and to determine that supplementary interviews would be necessary to cover the entire diffusion process.

Conclusions. Our findings indicated that the diffusion process of guidelines among physical therapists was not yet completed. The use of theory can provide added value to guideline implementation studies.

J Harting, PhD, BA in Physiotherapy, is Postdoctoral Researcher, IQ Healthcare, University Medical Centre St Radboud, PO Box 9101, 6500 HB Nijmegen, the Netherlands, and Department of Social Medicine, Amsterdam Medical Centre, Amsterdam, the Netherlands. Address all correspondence to Dr Harting at: j.harting@ iq.umcn.nl. GMJ Rutten, MPT, MPH, is a PhD student, IQ Healthcare, University Medical Centre St Radboud, and a practicing manual physical therapist, Uden, the Netherlands. STJ Rutten, MPT, MPH, is a practicing manual physical therapist, Aachen, Germany. SP Kremers, PhD, is Assistant Professor, Department of Health Promotion, Maastricht University, the Netherlands. [Harting J, Rutten GMJ, Rutten STJ, Kremers SP. A qualitative application of the Diffusion of Innovations Theory to examine determinants of guideline adherence among physical therapists. Phys Ther. 2009;89:221–232.] © 2009 American Physical Therapy Association

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

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E

vidence-based practice has become a major issue in physical therapy.1,2 Evidence-based practice has been defined as “the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients.”3(p2) Over the past 2 decades, physical therapists increasingly have been encouraged to take an evidence-based approach.1,4 Although most physical therapists have a favorable attitude to the use of evidence in practice, they also encounter several barriers to evidence-based practice.1,5 As a means of enhancing evidence-based physical therapy, clinical practice guidelines have become a familiar part of physical therapist practice.6 Such guidelines thus create an ideal opportunity to systematically bring scientific evidence into practice.7

Therefore, clinical practice guidelines are a promising and effective tool for improving the quality of care.8,9 Many guidelines, however, are not extensively used after dissemination.10 –12 With regard to the further adoption and implementation of guidelines, it has been suggested that it is important to acknowledge the complexity of clinical behavior and especially the role of motivational determinants, such as opinions, values, and vested interests.13 Many interventions aimed at changing behavior have been pursued in the absence of clear information about the reasons why practitioners did not exhibit the preferred behavior.14 Consequently, such interventions may have lacked a rationale for the choice of their content and, there-

1. Contact physician in case of specific low back pain 2. Additional diagnostics a. Use questionnaires to assess daily functioning b. Assess psychosocial factors that influence recovery process 3. Treatment objectives a. Enhance knowledge and insight b. Improve activities and social participation c. Improve relevant physiological functions d. Improve coping strategies 4. Treatment strategies a. Provide information and advice b. Train physiological functions and activities 5. Number of sessions a. ⱕ3 in case of normal recovery process 6. Provide the following information: a. Stay active b. Pain does not always mean tissue damage c. Low back pain has a favorable prognosis d. Practice sports on a regular basis e. Perform exercises on a regular basis f. Restrict work to actual capacity

fore, produced only small to moderate effects.11,15–17 More research into the details of actual implementation is needed to better understand the critical determinants of change in practice, and such research preferably should be systematic and theory based.11,15 This article reports on one of the first steps in such a planned approach,18 that of theorybased focus group interviews amongst Dutch physical therapists with regard to the national guidelines for the treatment of people with low back pain. The Dutch physical therapy guidelines for low back pain were developed by the Central Guideline Project (CGP) under the auspices of the Royal Dutch Society of Physiotherapy (referred to below as “the Society”) in collaboration with the Dutch Institute of Allied Health Care.19 The guidelines describe the diagnostic and therapeutic actions that physical therapists should perform when faced with patients with nonspecific low back pain (Fig. 1). This diagnosis is defined as “low back pain without a specified physical cause, eg nerve root compression (radicular syndrome), trauma, infection or tumour.”19(p83) The essential physical therapy decisions recommended by the guidelines are based on the best available scientific evidence. A vital difference from previous practice is the lower importance assigned to the management of patients’ impairments. Instead, the guidelines emphasize an activating approach, in which physical activity is advised instead of bed rest, active strategies such as exercise therapy and training are applied, and a handsoff policy is recommended for patients with acute low back pain. The guidelines also introduce a behavioral approach aimed at restoring activities and social participation for patients with chronic low back pain.

Figure 1. Recommendations of Dutch physical therapy guidelines for low back pain.19

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Use of Diffusion of Innovations Theory to Examine Determinants of Guideline Adherence The guidelines are composed of several parts: a summary, an extensive description of preferred procedures and available evidence, and recommended measurement instruments (Fig. 2). As the implementation of the guidelines was recognized to be the “Achilles heel” of the project, the CGP decided to apply a culturalpolitical strategy for their development.20 Such a strategy acknowledges that physical therapists, as relatively autonomous professionals, should be regarded as active partners in the developments and innovations in their field. In addition, the CGP chose to design a stepwise diffusion plan for the dissemination and adoption of the guidelines.20 Such a plan recognizes that the consecutive steps of the diffusion process may present different barriers, which, in turn, may require different diffusion strategies (Fig. 3). Despite these deliberately selected development and diffusion efforts, adherence to the Dutch physical therapy guidelines for low back pain recently was found to be still only moderate.12,21,22 This article reports on a qualitative study to gain an in-depth understanding of the determinants of adherence to the guidelines for low back pain among physical therapists in the Netherlands. Because Dutch physical therapists were assumed to perceive the then-recently developed guidelines, with their change in treatment strategies, as an innovation, we adopted the stepwise Innovation Decision Process of Rogers’ Diffusion of Innovations Theory as the basis for the present study.23,24 Rogers’ widely used theory covers the entire diffusion process and offers the opportunity to integrate various theoretical constructs in the different steps of the diffusion process.25 Its application, therefore, was considered especially helpful in examining the progression of the diffusion process of low back pain guidelines and in identifying the potential March 2009

1. A 2-page summary of the main issues of the guidelines for daily use: “the card” 2. A booklet that provides: a. A description of the recommendations for the diagnostic and therapeutic process when treating patients with nonspecific low back pain b. An extensive description of the best available evidence and an explanation of the process of developing the guidelines 3. Three recommended measurement instruments: a. Visual analog scale for pain b. Quebec Back Pain Disability Scale c. Dutch version of the Patient-Specific Functional Scale

Figure 2. Contents of the Dutch physical therapy guidelines for nonspecific low back pain.19

promoting and impeding determinants throughout the diffusion process. Rogers’ Innovation Decision Process23 distinguishes 5 successive stages (Fig. 4).26 The first 2 are mental stages and are referred to as the “dissemination process.” The first dissemination stage, the “knowledge stage,” requires that the potential users become acquainted with the innovation and develop an adequate understanding of it. In the subsequent “persuasion stage,” the potential adopters have to develop a positive attitude toward the innovation.23,27 The decisive factors for this

Diffusion Steps Orientation

mostly affective process are the perceived characteristics of the innovation, such as its relative advantage, compatibility, complexity, “trialability” (the ability to test an innovation), observability (the degree to which the results of an innovation are visible to others), and flexibility.23,28 In addition, the perceived consequences, that is, the perceived social or material risks, may play a part in this persuasion stage.23,27,29 The last 3 stages of the diffusion process are behavioral stages and are called the “adoption process.” First, potential adopters have to decide whether to adopt or reject the inno-

Likely Barriers ● ●

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Not familiar with No interest

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No knowledge or understanding Not aware of own performance

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Negative attitude Not ready to change

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Not starting the implementation Not continuing the implementation

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Publications in physical therapy journals Permanent topic at professional conferences Thematic meetings (work groups) Guideline examination form (individual) Thematic meetings (work groups) Discussing guideline (work groups) Discussing guideline (collaboration with general practitioners) Guideline examination form (individual) Discussion guideline (work groups) Competency manuals (individual)

Figure 3. Diffusion plan of the Dutch physical therapy guidelines for nonspecific low back pain.20

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Figure 4. Theoretical framework based on Rogers’ Innovation Decision Process.23,26

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Use of Diffusion of Innovations Theory to Examine Determinants of Guideline Adherence vation. Activities in this “decision stage” include gathering further information, trying out the innovation to a limited degree, and trial by others. During the subsequent “implementation stage,” the diffusion process can be facilitated by positive experiences gained previously and by positive social influences.23,30 In contrast, perceived barriers may impede the actual implementation. In the “confirmation stage,” the innovation becomes part of the work routine, requiring that its users receive reinforcement and positive feedback.23,31 The progression of an innovation through the 5 successive stages is further influenced by situational factors, the nature of the innovation decision, the communication channels applied, and the facilitators involved (Fig. 4, blue parts).26 In the present study, Rogers’ theory informed both the focus group meetings and the analysis of the interviews. This report concentrates on the 5 consecutive stages of the diffusion process, as described above and depicted in Figure 4. For a more extensive outline of Rogers’ Innovation Decision Process, readers are referred to the primary source.23 The results of this study may contribute to subsequent implementation studies, the debate on evidence-based medicine,32,33 and recent developments in the use of theory in implementation research.34 –36

Method Focus Group Interviews The focus group interview route was constructed in accordance with the theoretical framework (Fig. 4). The semistructured route consisted of a topic list, meant to ensure that the main issues with regard to the 5 steps of the innovation decision process would be discussed, and included follow-up probes to elicit more detailed information.37 To avoid prejudiced interpretation on the part of the researchers and to March 2009

stimulate a free discussion among the focus group participants, the questions were formulated in an open and inviting way.37,38 For example, to explore the topic of “persuasion stage,” the question could read “We are highly interested in your opinions on the guidelines,” while the follow-up prompt of “perceived complexity” could be addressed by a query such as “We have not heard anything on the userfriendliness of the guidelines yet.” Another example is the question “What could you tell each other about the way you apply the guidelines in your practice?” to investigate the topic of “implementation stage” and the query “While you are applying the guidelines, we are interested in whether you also come across any obstacles” to address the follow-up prompt of “perceived barriers.” An eAppendix showing a complete focus group interview route is available at www.ptjournal.org. To obtain a representative sample of physical therapists, the interviews were conducted during meetings of peer consultation groups (PCGs), as these meetings at the time were obligatory for members of the Society and because practice guidelines were one of the subjects that the Society had recommended them to discuss. The sampling procedure started at the Society’s Department of Staff Training. The head of the department provided telephone numbers of the 3 regional PCG coordinators who covered the southern part of the Netherlands (which was chosen for logistic reasons). Two of these coordinators asked for additional authorization by the Society, which was regarded as conflicting with the independent nature of the study. The third regional coordinator provided us with telephone numbers of the 7 local PCG chairs within his region. Four of these local PCG chairs were willing to participate but were unable to organize a PCG meet-

ing in time. Three PCGs were willing to participate as well as able to devote one of their meetings to discussing practice guidelines within the time frame of the study. The focus group interviews took place between November 2002 and January 2003, and the first, second, and third interviews involved 12, 10, and 8 physical therapists, respectively. The total sample consisted of both men (n⫽21) and women (n⫽9) and covered a wide range in terms of age (25– 62 years) and number of years of work experience (5–30 years). The interviews were conducted by 2 members of the research team (GMJR and STJR), who were both practicing physical therapists. Being experienced physical therapists as well as experienced lecturers in physical therapy, both interviewers were assumed to possess the skills and abilities to lead focus groups effectively.37 They alternately acted as chair and observer.38 The observer recorded the interview on audiotape, prepared minutes of the meeting, and took notes about moregeneral aspects of the discussion, such as the atmosphere, group dynamics, and emotions expressed.38 The interviews were conducted at the location where the PCGs usually met and lasted 75 to 90 minutes. As no new information was obtained during the third interview, the focus group procedure was regarded as completed (theoretical saturation).38 Data Analysis The audiotaped focus group interviews were transcribed verbatim and imported as text documents in the NVivo 2.0 qualitative analysis program.* We performed a qualitative content analysis with a directed approach.37,39 Such an approach is appropriate if existing theory and prior research about a phenomenon (eg, * QSR International Pty Ltd, 28 Hoghton St, Southport, United Kingdom PR9 OPA.

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Use of Diffusion of Innovations Theory to Examine Determinants of Guideline Adherence the diffusion of physical therapy guidelines) are incomplete or would benefit from further description.39 Our structured analysis was based on a prestructured coding scheme.39,40 Such a coding scheme serves to classify large amounts of text into a predefined number of categories that represent similar meanings.39 Our coding scheme had been composed so as to reflect the most salient aspects of Rogers’ 5 diffusion of innovation stages. The initial codes thus mirrored the topics (eg, “persuasion stage” and “implementation stage”) and prompts (eg, “perceived complexity” and “barriers”) of the focus group interview route, while the entire coding scheme looked similar to the framework shown in Figure 4. Additional flexible codes were used to label other prominent topics that emerged during the analysis.39,40 The directed approach to content analysis, therefore, could serve to conceptually validate or extend the theoretical framework used.39 The initial coding was done by the first author (JH), as she was experienced in directed qualitative content analysis and had a behavioral science background and physical therapy background but had not been present during the focus groups interviews. The interviewers (GMJR and STJR), both of whom have a Master of Public Health degree, thoroughly checked the first coding for its exhaustiveness and appropriateness by verifying whether all instances of a particular theoretical construct had been identified and correctly categorized. Disagreements were discussed by comparing the text passages with the operational definitions of the various constructs until consensus was reached. In the end, all flexible codes were integrated in the original code tree that represented Rogers’ Innovation Decision Process.

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Results General Observations All 3 focus group interviews were characterized by a pleasant and open atmosphere. The debate was often quite lively, and sometimes feelings even ran high. Although the interviews elicited a wide variety of opinions, the common tendency among the respondents was to dismiss practice guidelines in general and the guideline for low back pain in particular. Knowledge Stage Acquainted with innovation. All but one of the focus group members had received the guidelines by mail, but most of them had not felt much inclined to pay much attention to it. Yes, that is how they were sent to me, without any explanation or whatever. So I briefly glanced through the guidelines and then put them aside. Who cares? And I left it at that. We received a whole set of guidelines at once. I think there were 4 of them, and you do not read all 4 of them immediately, and once you put them aside, they stay aside.

Likewise, most physical therapists had not taken a warm interest in the guidelines. For instance, one therapist commented, “No, I read the essence, the card, for instance.” Another therapist, commenting on the content of the guidelines, stated, “I did not read it. I thought the term ‘nonspecific’ was already dubious, so I did not read any further.” Another reason was the large size of the guidelines (eg, “Such a huge heap, such a bundle of paper, such a bundle of characters.”). This way of presenting information did not fit in well with the respondents’ more practical learning attitude. According to one therapist, “That is because we have been educated to do things. So if you give this group a pile of papers, who will read them? I think nobody will.”

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Understanding of innovation. The perceived aims of the guidelines were related to standardization and quality of care. It turned out that the aim of the guideline was to create a bit more uniformity in practical procedures. In other words, it should not be possible that one physical therapist uses one approach and the other a different one. That [lack of consistency] is not good for the profession.

Few data were provided on the different sections of the guidelines and their actual content. Most physical therapists regarded the guidelines as a package of general information that could be interpreted in various ways (eg, “What actually is nonspecific low back pain?”). For some therapists, the distinction between specific and nonspecific low back pain was an eye-opener. Others felt it mostly related to their own skilfulness. As one respondent stated, “To me, ‘nonspecific’ stands for ‘I don’t know,’ meaning that I should have the patient checked by a colleague or that he should be examined by a good orthopedist or neurologist.” A commonly shared idea was, however, that nonspecific low back pain “includes such a variety of disorders that they cannot be captured within one single guideline. You will often try to make a specific case for you and your patient, and different physical therapists may not come up with exactly the same diagnosis.” The respondents disagreed about the intended use of the guidelines, especially about the extent to which they should be seen as obligatory. Although they are called “guidelines,” they want all of us to adhere to them. You’re supposed to do what the guidelines prescribe, for all patients. Of course, it is not necessary to follow the guidelines exactly; it is more like: this is roughly the approach, regardless of the background you have.

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Use of Diffusion of Innovations Theory to Examine Determinants of Guideline Adherence As long as you have good reasons to do so, you are free to work in your own way, because that is more effective than what is prescribed, or because you have another objective in mind, then there should be no problem.

Persuasion Stage In addition to the characteristics of the guidelines, whose influence had been predicted by the literature, a commonly expressed doubt concerned the credibility of the guidelines. This was partly due to the perceived lack of evidence of the effectiveness of the various physical therapy interventions. More effectiveness research should first be done with regard to physical therapy interventions. That could then be used for the guidelines. There is a lot that helps for sure. Take, for instance, massage—it is not proven that it is not effective, is it?

Other therapists doubted the credibility of the available evidence. The way it is described in the guidelines, that is not the way it works. You’re actually expected to do no more than coaching, and then it [the pain] should spontaneously disappear. But in practice, it simply does not spontaneously fade away.

Some of the participants, however, felt more confident. If the Society assures you that the guidelines are evidence-based, then you, as a practicing physical therapist, can assume that that is correct. Otherwise, you could just close down the whole club [the Society].

Some of the focus group members saw advantages for the profession. The guidelines, for instance, are “good for the uniformity of care” and give “a global overview of treatment options.” Others reported morepersonal benefits (eg, “I think it is a great advantage that you start thinkMarch 2009

ing again about what you are actually doing . . . that you can see what the state of the art is and how you should act.”). The majority, however, saw mainly disadvantages for their practical work (eg, “If you work according to the guidelines, you are constrained in your performance, and that is neither good for the physical therapist nor good for the patient.”). One commonly agreed-upon exception was made: “If there were a guarantee that applying the guidelines for low back pain would speed up the patients’ recovery processes, yes, then I would act in accordance with them.” Most physical therapists saw problems regarding the compatibility of the guidelines. These problems were related to the patients; the therapists’ autonomy, experience and education; and other, competing guidelines.

The guidelines say, if you don’t know the cause, then it is nonspecific. But I regard it more as a lack of knowledge on my part. When you do some additional courses, such as manual therapy, you notice that you become more able to identify specific problems. Yes, is your nonspecific the same nonspecific as in the guideline?

One participant concluded, “Only specific low back problems can be included in guidelines, resulting in a whole lot of small guidelines. So, they [the present guidelines] should definitely be split up.” Although some physical therapists stated that “anything can be tried,” most of them felt that the trialability of the guidelines was limited. This had to do with the way the guidelines had been presented. If they had made them somewhat easier, or if they had been explained in a lecture, then it would have been much easier, much more practical.

I have a lot of trouble with them [the guidelines], because each patient is different. Their treatment should be tailored to their specific characteristics. And indeed, all patients wish to be treated in a different way. What would be left of your independence, your own competence, your own practical experience? I completed my education only 5 years ago, and I learned things that the guidelines say I shouldn’t do. Am I to conclude then that my training was useless? It simply does not fit in with the way I normally work. The main problem is that the regional or hospital guidelines, which physical therapists are expected to adhere to, are not in line with the national guidelines, or the other way around.

The guidelines for low back pain were regarded as quite complex, mainly because of the syndrome they addressed.

That is what you are used to in courses. There you pick up some practical things, which you think you can apply. But these guidelines are just presented very, very badly.

The interviews offered little information with regard to the observability of positive effects, even though such observability was expected to stimulate guideline adherence. One therapist stated, “If others had better results when working in accordance with the guideline, then I would start working in the same way.” The same would hold in case current practice did not show favorable effects. A therapist stated, “If you are getting poor results, then it becomes interesting to see what your neighbor is doing, especially if he has better results.” The majority of the physical therapists regarded the flexibility of the guidelines as minimal: much too re-

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Use of Diffusion of Innovations Theory to Examine Determinants of Guideline Adherence strictive, much too standardized, and a coercive protocol from which deviations were not allowed. This also related to the diversity of patients. One respondent stated, “Three patients with low back pain, who are similar according to the guidelines, can get 3 completely different treatments from me. And then the guidelines would force you to use the same approach, because guidelines can’t make that distinction.” Other participants perceived more freedom. One therapist responded, “But of course, I’m free to take or leave these things, to look at whether they suit my own ideas of how to approach my patients.” Yet, a broadly shared opinion was that the guidelines “should be more like a framework with more freedom of choice.” Several, mostly negative, consequences were discussed. There were, for instance, some concerns about the future of the profession. You throw away part of your job. No evidence base available for physical therapy? Then no guidelines! Otherwise, you destroy the whole profession.

Other respondents foresaw a shortage of physical therapists. As one participant commented, “I already know some physical therapists who have quit their job because they do not like all this.” In addition, several practice requirements were anticipated. My practice would have to be completely reconstructed. A psychologist needed, extensive training equipment needed. And who is going to pay for that?

Some participants were already complaining about financial compensations that did not materialize. One respondent commented, “So, we are supposed to be engaged in quality of care, but we’re still waiting for the 228

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money.” In addition, most physical therapists thought that there would be financial consequences, in which their fees would come to depend on whether they adhered to the guidelines. One therapist remarked, “I think the insurance companies are going to use them [the guidelines]. That is rather threatening.” Other therapists, however, questioned the legitimacy of this consequence. One therapist stated, “We are all certified physical therapists, who also take part in advanced courses. And all that is suddenly regarded as worthless, because we have to work in accordance with the guidelines?” Decision Stage No clear statements were made about the decision to adopt or reject the guidelines, but the physical therapists mentioned several actions they should or would engage in during this stage. For instance, gathering further information with regard to the content of the guidelines was presumed to activate the adoption decision. According to one therapist, “That would at least allow you to consider more carefully whether it appeals to you.” The physical therapists clearly differed, however, in their efforts to gain new knowledge or to acquire new skills, although they basically felt the required competencies should be present. Because the guidelines were written for us. If, on average, we did not possess the knowledge and skills, then “those” who produced the guidelines should say that you were only allowed to apply them after you had taken some additional courses.

Not many physical therapists reported partially trying out the guidelines. A participant stated, “Now and then I apply parts of it.” Neither did the participants provide much confirmation of trial by others. As one participant noted, “In my opinion, less than 50% of the colleagues have ever read these guidelines, let alone

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worked with them. Where do you find people who have experience with them?” They even seriously doubted the reports of their colleagues claiming to apply the guidelines. One participant responded, “My experience is that therapists say they adhere to the guidelines, although they still all work in different ways.” Implementation Stage None of the participants had applied the guidelines regularly or completely. They had implemented them not at all or only partly, or they had used them in a somewhat different way than originally intended. I have never, ever treated one patient in accordance with the guidelines. I use small parts, or I find I’m already doing the things that are recommended, and then I think “Gosh, I am not doing so badly.” Well, I wouldn’t say I really use them . . . not as such. It demands a very rigorous strategy. That is not what I do. I read the guidelines, and I agree with them, but I do not use them strictly as they are intended. Well, if I have a very difficult patient, with whom I’m not making any progress, then perhaps yes.

Little practical experience with the guidelines was reported. Some of the experience they had was positive (eg, “I started to pay somewhat more attention to the social participation aspect”), whereas some of the experience they had was negative (eg, “Then you hear stories [from patients], such as, ‘I’d rather go to a sports masseur; at least then I will be massaged’—so all at once you’ve turned into a bad physical therapist.”). Several sources of social influence were mentioned, such as conflicts of interest with patients. March 2009

Use of Diffusion of Innovations Theory to Examine Determinants of Guideline Adherence To patients, the story of nonspecificity is often hard to sell.

Measurement instruments are not available.

The patients mostly want to go back to the level of impairments.

We’re not familiar instruments.

Although the guidelines seem to be the cause of this problem, they also can be used to solve it. In the case of disagreement between physical therapist and patient about the treatment policy, you can always turn to the guidelines, and you can argue while showing them these national guidelines.

A second type of social influence came from colleagues. Within a group practice, I think it is important that there are agreements about the implementation of certain procedures. At least you should ensure that your treatments are in accordance with the same principle used within the practice. What other practices do, that’s their business, of course.

It became only partly clear to what extent the physical therapists knew how to use the guideline. One therapist stated, “I do not know exactly what the requirements are.” Although some physical therapists expected to possess the required knowledge and skills, others thought that “the psychological skills are lacking. We have not been trained to do that, and then suddenly it appears in a guideline as a treatment strategy. However, to some extent, and subconsciously, you definitely do these things in a correct way.” Notwithstanding the low level of guideline implementation, the participants perceived a variety of barriers. The problem is the time. If you do something new, then at first you lack sufficient skills. You are not fast enough. The way our office is built is not suitable.

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with

those

One respondent, quite cynically, commented, “I have them [the guidelines] all within reach, and then a patient comes in, and then I tell my secretary, ‘Please, keep the guidelines at hand.’” Confirmation Stage Little information was provided about the confirmation stage. Overall, the respondents showed little commitment to the guidelines (eg, “We do not feel committed to them.”). However, they felt that positive reinforcement by certain facilitators could help to increase their commitment in the future, for instance, by the insurance companies, but especially by their own professional organization. One participant remarked, “Political support. It would be nice if the Society gave us the idea that there is support on the road toward working in accordance with the guidelines.”

Discussion Our theory-based focus group study on the diffusion of the Dutch physical therapy guidelines for low back pain yielded in-depth insights into the various determinants of guideline adherence. Despite the variety of opinions expressed, most of the participating physical therapists had rather unfavorable opinions about issues related to the dissemination process and provided relatively little information on the subsequent adoption process. Although all but one of the participants had possessed a recent copy of the guidelines for more than a year, none of them had applied the guidelines regularly or fully. These findings indicate that, notwithstanding the carefully considered development strategy and stepwise implementation plan,20 the diffusion of the guidelines among

our participants had not actually reached the stages of implementation and maintenance. Two recent Dutch surveys also showed that the diffusion process had not been completed yet.12,21 In one of the surveys, this was attributed to discrepancies between current practice and the recommendations in the guidelines.12 Physical therapists perceived several barriers to guideline implementation, including a lack of knowledge or skills and the need for substantial structural changes relating to practice organization, staff, and equipment.12 The rather unfavorable attitude identified in our study, reflected by opinions about the characteristics of the guidelines in the persuasion stage, contrasts not only with the findings of a Dutch survey,12 but also with the positive attitude toward evidencebased practice that was found in surveys in Spain,41 the United States,5 and Australia.1 Such differences among countries in the attitudes of physical therapists might be attributable to differences in the contents of the various national guidelines, which may reflect either a more biomedically oriented culture (eg, United States) or a more biopsychosocially oriented culture (eg, the Netherlands), making them more or less acceptable for individual therapists. The observed discrepancies could, however, also stem from the fact that participants generally tend to be more open and critical in qualitative studies42 or from the development of a negative group norm during focus group interviews.38 Such a tendency to express negative feelings as a result of certain group dynamics may have resulted in a negative bias.38 Another explanation could be that we selected a nonrepresentative sample of PCG groups, with unfavorable opinions. As attending PCG group meetings was obligatory, however, our sample of physical therapists can be assumed

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Use of Diffusion of Innovations Theory to Examine Determinants of Guideline Adherence to be representative. In fact, our sample also included critical members, who can be assumed to be more reluctant to take part in voluntary surveys. The relatively low level of guideline adherence and the commonly shared unfavorable opinions that were reported in this study seem to be related to perceived differences between the evidence-based guidelines and “the art of caregiving” as an inherent part of physical therapist practice.43 Although guidelines were associated with uniformity of care, the individuality of each patient was considered to reflect the importance of intuition and creativity in daily practice. This perceived inconsistency coincides with current debates in the literature about evidencebased medicine versus commonsense medicine and the integration of scientific evidence and clinical expertise.32,33 Although the Dutch physical therapy guidelines for nonspecific low back pain are not intended as a “cookbook” but as a guide,19 our participants nevertheless perceived them as rigid recommendations. Such rigidity has been challenged as being at odds with individual patient needs and practitioner preferences, not allowing for any individual variation, and as being used as a standard against which clinicians may be judged without outside variables being taken into account.44 Indeed, the use of guidelines as a simplistic algorithm has been acknowledged to have a potentially harmful effect on professionalism, which may do injustice to the complexity of medicine and the parallel and iterative thought processes assumed to be inherent in clinical judgment.8 Our findings imply that the implementation and adoption processes of guidelines may benefit from strategies that are able to convince physical therapists of the intended judicious use of guidelines. Such strategies, for instance, may be 230

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derived from theories on information processing, which suggest discussion as a method to change knowledge, and from theories on attitude change, which indicate that message repetition is important in this respect, as is the provision of information tailored to the individual physical therapist’s perceptions and behavior-specific beliefs.45 The theoretical framework that served as the foundation of our study enabled us to properly structure the focus group interviews, to produce a systematic and detailed analysis of the data collected, and to assign the various determinants to the consecutive stages of the diffusion process. The theory-based approach allowed us first of all to recognize that, due to the relatively nonadherent sample, the information we obtained did not cover the entire diffusion process.23 The participants provided relatively little information on the determinants of the decision, implementation, and confirmation stages. This means that the theoretical saturation we observed after 3 focus group interviews applied only to the first 2 stages of the diffusion process and that a better understanding of the other 3 stages would require additional interviews with physical therapists with higher levels of adherence. A second, somewhat related finding is the lack of information about communication channels and facilitators. Both aspects may be related to the organizational level rather than the individual level,23,46 whereas the interviews concentrated on individual motivational determinants. Supplementary interviews, therefore, should take the organizational determinants into account as well.41,47– 49 Third, the analysis revealed a new perceived characteristic of the guidelines in the persuasion stage, in addition to those predicted as being

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important by the original theory, namely the perceived credibility of the guidelines. Although empirical findings indicate that users want guidelines to be scientifically justifiable50 and that the scientific evidence should be straightforward and not conflicting,51 we came across only one framework of guideline adherence determinants that acknowledged that the potential adopters actually have to perceive them as credible, by identifying lack of agreement with the interpretation of evidence as a potential barrier.17 Several limitations should be mentioned. First, due to the limited space available in scientific journals, we had to restrict our report to only one part of Rogers’ Diffusion of Innovations Theory. Reporting on the application of the entire theory, including the situational factors and the characteristics of the innovation decision, would have done more justice to the complex picture of guideline adherence. Second, the various theoretical concepts related to the successive stages of the diffusion process are not mutually exclusive. This overlap complicated the analysis of the focus group interviews considerably. Third, the trustworthiness of the results may be threatened by the use of theory and by a certain subjectivity on the part of the researchers.39 This, for instance, may have made it more likely to find evidence that is supportive rather than nonsupportive for the theory and to have blinded the researchers to contextual aspects of the diffusion process. In addition to the measures we already applied to prevent such biases, the trustworthiness of the study could have been increased further by the use of an audit process.39 As a final limitation, the actual level of guideline adherence by the physical therapists who participated in the focus group interviews was subjectively assessed. Despite the low levels of adoption and implementation March 2009

Use of Diffusion of Innovations Theory to Examine Determinants of Guideline Adherence that could be inferred from the physical therapists’ statements, most of them nevertheless had explicit and clear-cut opinions about the guidelines. These opinions, however, reflected several misconceptions with regard to the content, the aim, and the use of the guidelines, such as the exact meaning of nonspecific low back pain and the idea that the guidelines were meant as rigid treatment instructions. Thus, it could be questioned to what extent the determinants identified in our study are indeed related to actual guideline adherence. Our theory-based qualitative study has offered the in-depth understanding of determinants of guideline adherence that is seen as the necessary start of a planned approach to develop effective interventions to increase evidence-based practice in physical therapy.11,15,18 The detailed information we collected served as valuable input for a follow-up survey to gain further insight into the association between the qualitatively identified determinants and the actual level of guideline adherence among a representative sample of Dutch physical therapists.26 That survey, in turn, offered some of the necessary foundations for the choice of potentially effective methods and strategies to enhance guideline implementation. Future studies on guideline implementation in physical therapy, as well as other health care disciplines, therefore, may benefit from adopting our approach while taking into account the limitations we discussed above. For a complete inventory of possible determinants of guideline adherence, it is especially recommended to apply a purposeful sampling strategy37 to guarantee that the focus group interviews include physical therapists from each of the various stages of the diffusion process. Such a sampling strategy, in turn, could profit from the use of objective measures of March 2009

guideline adherence, such clinical vignettes.22,52

Conclusion We believe that the application of a theoretical framework offers an important advantage over other qualitative examinations of determinants of guideline adherence. Although the benefits of applying theory in implementation studies have been questioned,53 we believe that our results illustrate the added value of such an approach. The limitations we encountered with regard to our approach, however, also support the view that applying theory in this field remains a challenging exercise.34 All authors provided concept/idea/research design. Dr Harting, Geert Rutten, and Dr Kremers provided writing. Dr Harting, Geert Rutten, and Steven Rutten provided data collection and analysis. Geert Rutten, Steven Rutten, and Dr Kremers provided consultation (including review of manuscript before submission). The authors thank all of the therapists who participated in the focus group interviews. This research was presented at the 15th International Congress of the World Confederation for Physical Therapy; June 2– 6, 2007; Vancouver, British Columbia, Canada, and the Dutch Conference on Physical Therapy; November 9 –10, 2007; Amsterdam, the Netherlands. This article was received June 18, 2008, and was accepted December 8, 2008. DOI: 10.2522/ptj.20080185

References 1 Iles R, Davidson M. Evidence based practice: a survey of physiotherapists’ current practice. Physiother Res Int. 2006;11: 93–103. 2 Evidence-Based Practice—An International Perspective: Report of an Expert Meeting of WCPT Member Organizations. London, United Kingdom: World Confederation for Physical Therapy; 2001. 3 Sackett DL, Strauss SE, Richardson WS, et al. Evidence-Based Medicine: How to Teach and Practice EBM. 2nd ed. Edinburgh, United Kingdom: Churchill Livingstone; 2000. 4 Koes BW. Now is the time for evidencebased physiotherapy [editorial]. Physiother Res Int. 1997;2:iv–v.

5 Jette DU, Bacon K, Batty C, et al. Evidencebased practice: beliefs, attitudes, knowledge, and behaviors of physical therapists. Phys Ther. 2003;83:786 – 805. 6 Van der Wees PJ, Hendriks EJ, Custers JW, et al. Comparison of international guideline programs to evaluate and update the Dutch program for clinical guideline development in physical therapy. BMC Health Serv Res. 2007;7:191. 7 Field MJ, Lohr KN. Guidelines for Clinical Practice: From Development to Use. Washington DC: National Academy Press; 1992. 8 Woolf SH, Grol RP, Hutchinson A, et al. Clinical guidelines: potential benefits, limitations, and harms of clinical guidelines. BMJ. 1999;318:527–530. 9 Campbell SM, Braspenning J, Hutchinson A, Marshall MN. Research methods used in developing and applying quality indicators in primary care. BMJ. 2003;326:816 – 819. 10 Bero LA, Grilli R, Grimshaw JM, et al. Closing the gap between research and practice: an overview of systematic reviews of interventions to promote the implementation of research findings. BMJ. 1998;317: 465– 468. 11 Grimshaw JM, Thomas RE, MacLennan G, et al. Effectiveness and efficiency of guideline dissemination and implementation strategies. Health Technol Assess. 2004;8: 1–72. 12 Bekkering GE, Van Tulder MW, Hendriks EJ, et al. Implementation of clinical guidelines on physical therapy for patients with low back pain: randomized trial comparing patient outcomes after a standard and active implementation strategy. Phys Ther. 2005;85:544 –555. 13 Grilli R. Developing recommendations to promote the uptake of research information in clinical practice. Therapie. 1996; 51:265–268. 14 Poses RM. One size does not fit all: questions to answer before intervening to change physician behavior. Jt Comm J Qual Improv. 1999;25:486 – 495. 15 Grol RP. Successes and failures in the implementation of evidence-based guidelines for clinical practice. Med Care. 2001;39: II46 –II54. 16 Oxman AD, Thomson MA, Davis DA, Haynes RB. No magic bullets: a systematic review of 102 trials of interventions to improve professional practice. CMAJ. 1995; 153:1423–1431. 17 Cabana MD, Rand CS, Powe NR, et al. Why don’t physicians follow clinical practice guidelines? A framework for improvement. JAMA. 1999;282:1458 –1465. 18 Green LW, Kreuter MW. Health Promotion Planning: An Educational and Ecological Approach. Mountain View, CA: Mayfield Publishing Co; 1999. 19 Bekkering GE, Hendriks HJM, Koes BW, et al. Dutch physiotherapy guidelines for low back pain. Physiotherapy. 2003;89: 82–96.

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Use of Diffusion of Innovations Theory to Examine Determinants of Guideline Adherence 20 Hendriks HJM, Bekkering GE, Van Ettekoven H, et al. Development and implementation of National Practice Guidelines: a prospect for continuous quality improvement in physiotherapy. Physiotherapy. 2000;86:535–547. 21 Swinkels I, Van den Ende C, Van den Bosch W, et al. Physiotherapy management of low back pain: does practice match the Dutch guidelines? Aust J Physiother. 2005;51:35– 41. 22 Rutten GMJ, Harting J, Rutten STJ, et al. Measuring physiotherapists’ guideline adherence by means of clinical vignettes: a validation study. J Eval Clin Pract. 2006; 12:491–500. 23 Rogers EM. Diffusion of Innovations. New York, NY: The Free Press, 1995. 24 Berwick DM. Disseminating innovations in health care. JAMA. 2003;289:1969 –1975. 25 Fleuren M, Wiefferink K, Paulussen T. Determinants of innovation within health care organizations: literature review and Delphi study. Int J Qual Health Care. 2004;16:107–123. 26 Rutten GMJ, Kremers S, Rutten STJ, Harting J. A theory-based cross-sectional survey demonstrated the important role of awareness in guideline implementation. J Clin Epidemiol. 2009;62:167–176. 27 Kok G, Schaalma H, De Vries H, et al. Social psychology and health education. In: Stroebe W, Hewstone M, eds. European Review of Social Psychology. Chichester, United Kingdom: Wiley & Sons Ltd; 1996: 241–282. 28 Oldenburg B, Hardcastle DM, Kok G. Diffusion of innovations. In: Glanz K, Lewis FM, Rimer BK, eds. Health Behavior and Health Education: Theory, Research, and Practice. San Franscisco, CA: Jossey-Bass Inc, Publishers; 1997:270 –286. 29 Fischhoff B, Bostrom A, Quadrel MJ. Risk perception and communication. Annu Rev Public Health. 1993;14:183–203. 30 Bandura A. Social Foundations of Thought and Action. A Social Cognitive Theory. Englewood Cliffs, NJ: Prentice Hall Inc; 1986. 31 DiClemente CC, Marinilli AS, Singh M, Bellino LE. The role of feedback in the process of health behavior change. Am J Health Behav. 2001;25:217–227.

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32 Miles A, Grey JE, Polychronis A, et al. Current thinking in the evidence-based health care debate. J Eval Clin Pract. 2003;9: 95–109. 33 Miles A, Grey JE, Polychronis A, et al. Developments in the evidence-based health care debate: 2004. J Eval Clin Pract. 2004; 10:129 –142. 34 Eccles M, Grimshaw J, Walker A, et al. Changing the behavior of healthcare professionals: the use of theory in promoting the uptake of research findings. J Clin Epidemiol. 2005;58:107–112. 35 Michie S, Johnston M, Abraham C, et al. Making psychological theory useful for implementing evidence based practice: a consensus approach. Qual Saf Health Care. 2005;14:26 –33. 36 Grol RP, Bosch MC, Hulscher ME, et al. Planning and studying improvement in patient care: the use of theoretical perspectives. Milbank Q. 2007;85:93–138. 37 Polit DF, Beck CT. Nursing Research, Principles, and Methods. 7th ed. Philadelphia, PA: JB Lippincott Co; 2004. 38 Morgan DL, Krueger RA. The Focus Group Kit. Thousand Oaks, CA: Sage; 1997. 39 Hsieh H-F, Shannon SE. Three approaches to qualitative content analysis. Qual Health Res. 2005;15:1277–1288. 40 Gibbs GR. Qualitative Data Analysis: Explorations With NVivo. Maidenhead, Berkshire, United Kingdom: Open University Press; 2002. 41 Medina i Mirapeix F, Meseguer Henarejos AB, Saturno Hernandez PJ, et al. Factores que influyen en el uso de los protocolos clinicos, segun la opinion de los fisioterapeutas de los centros de salud de la region de Murcia. MEDIFAM. 2001;11:325–330. 42 Zastowny TR, Stratmann WC, Adams EH, Fox ML. Patient satisfaction and experience with health services and quality of care. Qual Manage Health Care. 1995;3: 50 – 61. 43 Haynes RB. What kind of evidence is it that evidence-based medicine advocates want health care providers and consumer to pay attention to? BMC Health Serv Res. 2002; 2:3.

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44 Green S, Piehl J. Clinical practice guidelines: a guide to better practice, not a recipe for uniformity. Aust J Physiother. 2003;49:3– 4. 45 Bartholomew LK, Parcel GS, Kok G, Gottlieb NH. Planning Health Promotion Programs. An Intervention Mapping Approach. 2nd ed. San Francisco, CA: JosseyBass Inc, Publishers; 2006. 46 Basch CE, Eveland JD, Portnoy B. Diffusion systems for education and learning about health. Fam Community Health. 1986;9: 1–26. 47 Dijkstra R, Wensing M, Thomas R, et al. The relationship between organisational characteristics and the effects of clinical guidelines on medical performance in hospitals: a meta-analysis. BMC Health Serv Res. 2006;6:53. 48 Solberg LI. Guideline implementation: what the literature doesn’t tell us. Jt Comm J Qual Improv. 2000;26:525–537. 49 Medina F, Lillo MC, Montilla J, et al. Opinion de los fisioterapeutas sobre los facores que influyen en el uso de los protocolos: estudio cualitativo. Rev Calidad Asistencial. 2002;17:632– 638. 50 Bekkering GE, Engers AJ, Wensing M, et al. Development of an implementation strategy for physiotherapy guidelines on low back pain. Aust J Physiother. 2003;49: 208 –214. 51 Grol RP, Dalhuijsen J, Thomas S, et al. Attributes of clinical guidelines that influence the use of guidelines in general practice: observational study. BMJ. 1998;317: 858 – 861. 52 Peabody JW, Luck J, Glassman P, et al. Measuring the quality of physician practice by using clinical vignettes: a prospective validation study. Ann Intern Med. 2004;141:771–780. 53 Bhattacharyya O, Reeves S, Garfinkel S, Zwarenstein M. Designing theoretically informed implementation interventions: fine in theory, but evidence of effectiveness in practice is needed. Implement Sci. 2006;1:5.

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Research Report Factors That Influence the Clinical Decision Making of Physical Therapists in Choosing a Balance Assessment Approach Patricia Q McGinnis, Laurita M Hack, Kim Nixon-Cave, Susan L Michlovitz

Background. Many methods for examining patients with balance deficits are supported by the literature. How or why therapists choose specific balance assessment methods during examination of patients remains unclear.

Objectives. The aims of this study were: (1) to explore decision making during examination of patients with balance deficits, (2) to understand the selection and use of assessment methods from the clinician’s perspective, and (3) to explore why specific methods were selected. Design. A qualitative design using a grounded theory approach permitted exploration of clinical decision making. Methods. Eleven therapists were purposefully selected (6 from outpatient offices, 5 from inpatient rehabilitation settings) to participate in repeated interviews. Credibility of the findings was established through low-inference data, member check, and triangulation among participants and multiple data sources.

Results. A highly individualized approach to patient examination based on therapists’ practical knowledge emerged from the data, with limited influence of the literature. Movement observation was the primary assessment and diagnostic tool. When selecting assessment approaches for specific patients, the perceived value of information gathered mattered more than testing time. A 3-stage model of assessment decision making portrayed both the process and reasons influencing therapists’ choices. Conclusions. In the context of the complex and busy nature of clinical practice, therapists gathered data that they considered meaningful during patient examination. The findings provide insight into factors influencing assessment decisions and suggest mechanisms to foster translation of research into clinical practice.

PQ McGinnis, PT, PhD, is Associate Professor of Physical Therapy, Richard Stockton College of New Jersey, PO Box 195, Pomona, NJ 08240 (USA). Address all correspondence to Dr McGinnis at: [email protected]. LM Hack, PT, DPT, PhD, MBA, FAPTA, is Professor, Department of Physical Therapy, Temple University, Philadelphia, Pennsylvania. K Nixon-Cave, PT, PhD, PCS, is Associate Professor, University of the Sciences in Philadelphia, and Physical Therapy Manager, Children’s Hospital of Philadelphia. SL Michlovitz, PT, PhD, CHT, is Adjunct Associate Professor, Department of Rehabilitation Medicine, Columbia University, New York, New York. [McGinnis PQ, Hack LM, NixonCave K, Michlovitz SL. Factors that influence the clinical decision making of physical therapists in choosing a balance assessment approach. Phys Ther. 2009;89: 233–247.] © 2009 American Physical Therapy Association

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herapists make multiple patient care decisions against the backdrop of the complexities and uncertainties of clinical practice. Exploration of clinical decision making is essential to fully understand physical therapist practice.1 The multifactorial nature of clinical reasoning encompasses the therapist’s ability to make use of multiple sources of knowledge to selectively gather and evaluate data during patient examination. Therapists’ judgments about examination findings serve as the basis for developing a plan of care; therefore, we wanted to understand factors influencing assessment decision making. We chose examination of patients with balance deficits as a model for studying clinical decision making in the context of a multidimensional and complex patient problem. The purpose of this study was to explore factors that influence the decision-making process of physical therapists when examining patients with balance deficits. Good practice is based on sound decision making incorporating the best available evidence. Evidence-based practice (EBP) has been identified as one of the key components of the Vision 2020 statement put forth by the American Physical Therapy Association (APTA).2 Using reliable and valid tests during examination of patients is one element of EBP.3 Several authors have recommended physical therapists use examination methods supported by research evidence4 – 6 and based on accepted standards for tests and measurements.7 Assessment is defined as quantifying a variable or placing a value on something.6 The professional literature provides a variety of balance assessment methods that physical therapists could choose to use. Many quantitative tests and measures meet these criteria, with numerous publications addressing the psychometric properties of various tests.5,8 –12 Numerous studies have addressed the 234

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usefulness of specific balance assessment methods to help clinicians determine patients’ risk for falls11–14 or for particular populations such as patients with Parkinson disease,15,16 patients with multiple sclerosis,17,18 or community-dwelling older adults.12–14 Given this wealth of available literature, the question of interest is: What do therapists do in clinical practice? Previous survey studies have identified balance tests used most frequently in clinical practice by therapists practicing in a particular state19 or by APTA section members.20,21 However, survey results did not fully explain how or why therapists selected specific balance assessment approaches during patient examination. Survey responses provided limited understanding of various factors influencing therapists’ choices. The primary aims of this study were: (1) to explore clinical decision making within the context of examination of patients with balance deficits, (2) to understand the selection and use of balance assessment methods from the clinician’s perspective, and (3) to ascertain what therapists in the study knew about available options and explore why they selected the specific methods they chose. An initial conceptual framework that served to bound and guide the study was developed from a review of the literature and pilot work (Fig. 1). There were 5 important elements contributing to choice of assessment methods: (1) therapist knowledge,22–25 (2) patient factors,25 (3) potential constraints,5,9,10,23,25–29 (4) therapists’ intended use of data gathered,5,9,10 and (5) available options for assessment of potential balance deficits.5,6,8 –21 This framework represented our initial understanding of potential factors related to the research aims and served as the basis for interview questions.

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Method A qualitative design using a grounded theory approach was chosen to permit in-depth exploration of clinical decision making during initial examination. Participants A purposeful sample of knowledgeable informants30 whom we believed would have knowledge of the topic of interest was selected. Participants were drawn from a large multisite suburban health system located in the northeastern United States, which included an 80-bed inpatient rehabilitation unit where patients with balance deficits from a variety of disorders were treated. Selection of this health system permitted exploration of factors proposed in the initial conceptual framework. For example, inclusion of therapists working in inpatient rehabilitation or outpatient settings within the system facilitated exploration of differences in clinical practice. Therapists with less than 1 year of clinical experience and former students of the researchers were excluded to reduce potential bias. Ten therapists in inpatient rehabilitation settings and 9 therapists in a hospital-based outpatient department were eligible for inclusion. The director of off-site centers identified 3 therapists from various satellite offices for possible inclusion based on the patient population seen at those sites. One therapist was excluded as a former student of one of the researchers. Participant recruitment continued until data saturation, or redundancy, was achieved. Data saturation is reached when the addition of subsequent participants no longer yields new findings.31,32 Eleven physical therapists who worked either in the inpatient rehabilitation settings (n⫽5) or in one of the outpatient offices (n⫽6) throughout the system (drawn from 4 sites) participated in the study. The March 2009

Decision Making for Balance Assessment

Figure 1. Initial conceptual framework of factors that influence clinician use of balance assessment methods.

average age of the participants was 34.2 years (range⫽27– 43), with an average of 9.4 years (SD⫽4.2) of practice experience. Demographic information of the participants is provided in Table 1. Professional education represented 6 different academic institutions located in 3 northeastern states.

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Procedure During the initial session, informed consent was obtained and mechanisms to ensure confidentiality were explained. Repeated semistructured interviews with each participant were audiotaped and transcribed. The initial interview included questions about examination of patients with balance deficits in general (Ap-

pendix). The second interview focused on participants’ description of their clinical decisions during a specific patient case (Appendix). Prior to analysis, the primary researcher (PQM) reviewed each audiotape to ensure accuracy of transcripts. Two sorting activities were designed to ascertain what the therapists be-

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Decision Making for Balance Assessment Table 1. Participant Demographic Characteristics

a

Academic Program (Code)

No. of Years Physical Therapist Practice

Participant (Pseudonym)

Practice Setting

Professional (Entry-Level) Educationa

Jamie

Outpatient (hospital based)

MPT

1

1

10

Inpatient rehabilitation Acute care

Randy

Outpatient

MPT

2

1.5

11

Acute care Home care Skilled nursing facilities

Nicky

Inpatient rehabilitation

MPT

1

3

4

Acute care Skilled nursing facilities

Dana

Inpatient rehabilitation

BSPT

3

3.5

5.5

Outpatient

Jackie

Outpatient (hospital based)

MPT

1

3.75

4.5

Inpatient rehabilitation Acute care

Chris

Inpatient rehabilitation

MPT

4

6

7

Outpatient Acute care

8.5

Inpatient rehabilitation

No. of Years in Setting

Lee

Outpatient (hospital based)

BSPT

5

Andy

Inpatient rehabilitation

BSPT

5

8.5

Jordi

Outpatient

BSPT

5

10

10

Terry

Outpatient (hospital based)

BSPT

5

14

14.75

Casey

Inpatient rehabilitation

MPT

6

18

18

10

Other Practice Experience

10

Inpatient rehabilitation Acute care

MPT⫽Master of Physical Therapy degree, BSPT⫽Bachelor of Science in Physical Therapy degree.

ing studied knew about available balance assessment approaches, which approaches they selected, and how they used them during examination. Participants identified all approaches they were aware of for examining patients with potential balance deficits and sorted them according to frequency of use, with a discussion of their choices and rationale. Participants then sorted the assessment approaches according to the following purposes: screening, identify impairments, identify functional limitations, establish diagnosis, establish prognosis, or measure outcomes. These categories were provided by the primary researcher, consistent with the patient management model described in the Guide to Physical Therapist Practice (Guide).6 Prior to the second interview, participants completed a demographic data form that included questions related to education, practice experience, certifications, memberships in professional organizations, continuing 236

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education, and identification of any resources used (eg, textbooks, journals) for balance assessment. The primary investigator’s background included courses and a laboratory rotation in qualitative research methods and conducting a pilot study to field test methods and refine necessary interviewing skills. Two of the coauthors (LMH, KNC) have extensive backgrounds in qualitative research methods, including peer-reviewed publications and presentations. Data Analysis Constant comparative analysis was used whereby data collection and analysis were ongoing. Data sources included interview transcripts, results of sorting activities, field notes, reflective memos, and comparison with expert opinion. Field notes were written during and immediately after each interview. They included descriptions of clinical sites

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and participants’ nonverbal expressions during interviews. Reflective memos included impressions and analytical insights written after each interview and throughout data analysis. Use of qualitative data analysis software (QSR NUD*IST 6 [N6]*) facilitated data management and analysis. Generation of code reports and identification of text units for specific codes within the data assisted identification of prominent factors influencing balance assessment decision making. Data analysis consisted of comprehending, synthesizing, theorizing, and recontextualizing.31 Each transcript was reviewed line by line to gain an understanding of the raw data. This process of comprehensive content analysis is called “open coding.” Codes were refined throughout data collection and analysis until mu* QSR International (Americas) Inc, 90 Sherman St, Cambridge, MA 02140.

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Decision Making for Balance Assessment tually exclusive and exhaustive categories were defined. Open codes were grouped into categories of related concepts known as “axial codes.” The second step of data analysis, synthesis, moved from concrete description of the data toward identification of common themes within and among interviews, sort results, field notes, and reflective memos.31 Interviewee summaries were developed, describing the factors influencing assessment decision making for each participant. An inductive process was used to derive conceptual elements and to develop a theory of balance assessment decision making that was grounded in the data. The conceptual framework was revised to depict findings. Contrast cases were used to elucidate and confirm emerging theory. Finally, emerging theory was compared with existing literature to recontextualize findings. Verification Methods There were several strategies to ensure scientific rigor and trustworthiness of the data.31 Multiple examples of low-inference data were used during analysis to support findings. Use of direct quotes from participants, with limited interpretation by the researcher, was an example of lowinference data. Another strategy, member check, consisted of sending each participant an interviewee summary that included data and the researcher’s preliminary interpretations. Each summary identified factors influencing decision making for that participant, including sources of information used and descriptions of the decision-making process and reasons. In addition to direct quotes, sort results, excerpts from reflective memos, and demographic information were incorporated into each summary. After reviewing the interviewee summary, 3 participants requested minor additions to clarify or provide context for their original comments, which March 2009

were included. The researcher’s analysis and preliminary themes were confirmed by the participants, thus ensuring the “truth” of the findings.31,32 The consistency of the data was established by triangulation of the findings from various data sources. For example, answers to questions from the first interview and the second interview and results of the sorting activities were compared. If a participant identified time as an important factor influencing his or her selection of assessment approaches, examples of this were present in the discussion of patients in general and the specific patient case, and approaches listed in the sort as “frequently used” exhibited this characteristic. Similarly, the presence or absence of continuing education related to balance deficits on demographic forms of participants was a source of triangulation for this factor. Confirmability, or neutrality, was established through identification and reflexive bracketing of biases about the research question during data collection and analysis. The investigator’s bias was that evidence from the professional literature should shape clinical practice choices. To avoid the influence of this bias, interview questions were worded neutrally to solicit participants’ views. For example, we used the broad term “balance assessment methods” rather than “balance tests or measures” so that our questions did not limit participant responses to an implied acceptance of only standardized tests. Use of member checks and low-inference data during analysis ensured that findings were grounded in the data. In order to reduce potential researcher bias about how balance assessment approaches should be used, a panel of experts was used to establish content validity of the researcher’s sum-

mary of the literature through a Delphi process.33 Interrater reliability of the coding scheme was established through use of an outside reader (80% agreement; kappa coefficient⫽.79 [⬎80% excellent agreement, ⱖ60% represents substantial agreement]).34 Discussion of discrepancies and establishment of decision rules made the coding process explicit, enhancing trustworthiness. Finally, a record of activities and decisions made throughout data collection and analysis was maintained by the primary investigator. This audit trail was reviewed by the dissertation committee, whose members served as peer reviewers to verify the research findings and emerging themes.

Results Seven themes emerged from the data and will be presented in the following categories: sources of information, decision-making process, decision-making reasons, and professional role. Sources of Information The first theme was the limited influence of the literature in guiding participants’ selection of a balance assessment method, with only 2 participants noting this as a consideration. Practical knowledge as the primary source of information guiding balance assessment decisions emerged as the second theme. Although participants identified a combination of factors contributing to their practical knowledge, all acknowledged the primary role of experience in influencing their decisions. Chris described how he relied on prior experience during assessment:

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Your clinical experience, enough patients, if you put them in certain situations, this is generally what happens. Usually when I have people walk on their heels, actually their trunk will go. I’ve seen it so many times. . . . My

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Nine participants also noted that interactions with colleagues contributed to their practical knowledge. Three participants stated that academic education contributed significantly to their balance assessment decisions. Nicky described how the following helped shape her assessment decisions: From school you get the foundation, these are the things to look at when you’re in an assessment. Then, after being in the clinic, you put it to use and get your own little system.

Two participants acknowledged that their academic education provided a foundation, but emphasized how clinical experience built on that. Andy, for instance, stated, “I was just trying to think, it’s hard to pinpoint stuff that I do now, say there are 5 things that I do in a day. What did I learn in school, and what did I gather from here?” The remaining participants did not identify academic education as a primary influence when examining patients with balance deficits. All of the participants had attended continuing education on a variety of topics, but this did not emerge as a significant factor in thematic analysis.

and ataxia, so we had a pretty good idea what was going on before he came in.” (Jordi) Patient factors contributing to examination decisions most commonly identified by participants were medical diagnosis (n⫽11), age (n⫽9), and history (n⫽8). The fourth theme was that physical therapists rely on movement observation to guide assessment decisions. Lee stated, “As I start walking with them, generally, I’ll just make an overall observation and decide where to start, if they need balance (assessment), and where to start with that.” Jackie described using movement observation to select specific tests: “I chose that one (the Berg Balance Scale) because, by watching her walk I knew she was going to get 4’s on some and zeros on the others.” Jordi described how the patient’s initial presentation and early movements influenced his decisions about what to include in his examination: I guess as soon as they walk in, you notice. You tell them to come back to the table, and you see them struggling to get out of the chair. You see them struggling with their walker, and they’re not transferring well. Then you’re like “Wait a minute, we need to look at his balance or gait.” As soon as they get up you pretty much know exactly what kind of things you should be honing into.

Decision-Making Process The most pronounced themes that emerged from the data were related to the decision-making process, or descriptions of how therapists made assessment decisions. Examples of both of these themes were found in all 22 interview transcripts.

Movement observation was used by participants for many purposes: preliminary observation, screening, determining areas to include in the examination, as a diagnostic tool, and as an outcome measure.

The third theme that emerged was that therapists use patient factors to initiate decision making and to contribute to expected patient presentation based on their experience, as seen in the following: “His diagnosis was CVA [cerebrovascular accident]

Decision-Making Reasons The fifth theme that emerged from the data was therapists’ perspective that the primary advantage of using standardized balance tests was to have quantitative data for documentation purposes. Participants noted

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the usefulness of balance assessment approaches with numeric scoring to assist with specific purposes such as goal setting or demonstrating patient progress in response to therapy: But honestly, a lot of this stuff is necessary for paperwork purposes and not so much for my treatment. I could treat this guy perfectly fine without doing any Berg balance assessment, but then later on I have nothing objectively to compare it back to. (Jordi)

Only 2 participants (Randy and Casey) indicated that the psychometric properties of reliability or validity were a primary consideration in their selection of balance assessment approaches. The sixth theme that emerged was that the therapists’ views of the perceived value of information gathered from a particular balance assessment approach mattered more than the testing time when selecting methods during examination of patients. They considered both aspects and selected an approach that they valued or considered relevant. Participants who considered information gained from the Berg Balance Scale as useful, described it as a quick and easyto-administer test. Jackie described her reasons for using the Berg Balance Scale to assess a specific patient: “I chose that one for ease. It’s very specific, there’s 1, 2, 3, 4, and you can grade them, and you can get a real quick general assessment.” Jackie preferred the Berg Balance Scale over the Timed “Up & Go” Test (TUG), which was shorter but, in her view, did not provide useful information: “I can show improvement with the TUG, but it doesn’t necessarily, for me as a clinician, show me what I need to work on.” Chris had a different point of view regarding the Berg Balance Scale: So if that takes me a long time to do, to get the tape measure to do the measurements and those steps to it,

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Decision Making for Balance Assessment and I don’t believe it, in that sense I’ll go with my clinical judgment, which doesn’t make it right or better, but that’s the decision I make.

Table 2. Balance Assessment Approaches Identified by Participants During Sorting Activities (Responses to Interview Question 1 in the Appendix) Neuromuscular examination Diagnosis Range of motion/strength Coordination History/interview Sensation Vision/cognition/medications Proprioception/kinesthesia Endurance History of falls Information from team Gait: level/uneven surfaces Standardized tests Single-leg stance (time) Single-limb stancea Romberg test/Sharpened Romberg test (time) Romberg testa Tandem stance (time) Tandem stancea Berg Balance Scale Functional Reach Test Clinical Test of Sensory Integration in Balance Timed “Up & Go” Test Balance Masterb Tinetti Mobility Assessment Amputee Balance Index Dynamic Gait Index Vestibular tests (Fukuda marching) Assistance level for functional tasks Sit to stand: assistance Loss of balance: assistance needed/ able to regain

Chris mentioned time, but the underlying reason for his choice was that he valued information gained from his observations more than the Berg Balance Scale scores. Perceived relevance of information also depended on the circumstances. All therapists working in the inpatient rehabilitation setting described examples of using the Berg Balance Scale score to assist with discharge planning in situations of uncertainty, even though 4 of the 5 therapists did not use it frequently. All participants selected methods that provided information that they considered meaningful. Professional Role The final theme was difficulty with the concept of physical therapists as diagnosticians, which emerged during the second sorting activity. Nicky noted that the medical diagnosis was provided in the patient’s chart: “Usually here, I have my diagnosis already, so I don’t really have to diagnose anything.” The concept of physical therapists as diagnosticians was discussed by only 3 of the participants (Randy, Jamie, and Terry). Based on examination data, Randy established a diagnosis that was consistent with the Guide. “It’s going to help me put them in one practice pattern versus another. And that’s what I consider diagnosis.” Jamie made the distinction between a patient’s medical diagnosis and the diagnosis made by the physical therapist in the following example: I have a patient who has a brain tumor, absent proprioception, kinesthesia, poor coordination, poor endurance, good strength, some rangeof-motion limitations, decreased ankle strategies. He had his medical diagnosis, but his physical therapy di-

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Movement observation and description Sitting balance: description of postural reflexes Ability to withstand perturbations Sitting reaching (dynamic) Sitting posture/balance Protective responses/strategies: ankle, hip, stepping Weight shift/base of support Gait observation: loss of balance/base of support Standing balance: base of support/ sway/eyes open/eyes closed Standing balance: Normal, Good, Fair, Poor Sitting balance: Normal, Good, Fair, Poor Static standing: description Sitting balance: description Description of performance during treatment activities Quick stop while walking Backward walking Tandem walking Developmental positions (quadriped, tall kneeling) Side stepping/backward walking (loss of balance) Braiding (loss of balance) Unstable surfaces/foam Obstacle course Trampoline (strategies)

a

Description of ability with eyes open/eyes closed, protective responses, sway. Balance Master assessment includes the following items: eyes open/eyes closed, foam, tandem stance/walking, turns, walking forward/backward, stepping over blocks. b

agnosis was the deconditioned component for balance, decreased coordination. I use all of these as my diagnosis.

pointing the real problem.” Thus, participants engaged in a diagnostic process even though they did not view it as such.

Most participants focused on the “medical diagnosis” or the pathology-based diagnosis and did not view establishing a diagnosis as part of their role as physical therapists. Further analysis revealed that therapists being studied clearly used balance assessment approaches to identify patient problems and to develop a plan of care. Chris described using observations to identify patient problems to address: “So there comes a decision, is this a weakness issue? Is it a vision issue? You have to, the main thing is pin-

Balance Assessment Approaches Used by Participants A highly individualized approach to examining patients with balance deficits emerged from the data collected with open-ended interview questions (Tab. 2). Participants identified components of a neuromuscular examination, such as strength (forcegenerating capacity) or range-ofmotion tests, that are consistent with the Guide. Many participants used standardized balance tests consistent with recommendations from litera-

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Decision Making for Balance Assessment ture. In addition, they used these approaches for other purposes, including using numeric scores as outcome measures (regardless of the psychometric properties). Participants also used a wide range of approaches based on movement observation and description.

Discussion A 3-stage model of balance assessment decision making was derived from the data and represents the revised conceptual framework (Fig. 2). Assessment decision making started with initial impressions formed in stage 1 as a basis for gathering data (Fig. 2, arrow). A cyclical process ensued, consisting of data gathering in stage 2 and diagnosis and treatment planning in stage 3, as depicted by circular arrows. Each stage will be presented in greater detail. Stage 1: Initial Impressions Patient information gained from the chart or interview was combined with participants’ knowledge from prior experience to develop an expected patient presentation (Fig. 3). Therapists compared expectations with initial observations in the early moments of the encounter.

Figure 2. Three-stage model of balance assessment decision making. Shaded area represents overlap between stage 2 and stage 3; dashed arrow represents activities not explored in current study.

I guess the script, before they come in, I have an idea. OK, I have a patient with total knee replacement. I can tell he’s 3 weeks out. I have a picture of the person. And he comes in, and he’s either that or he’s not, or I notice something that I didn’t expect. So in that little walk back in to the office, my picture starts changing. (Jordi)

Preliminary decisions about which assessment tools to include in patient examination were made at this point. Stage 2: Data Gathering Items in Figure 4 are listed in descending order based on the prominence of the findings in the data. During the data-gathering stage, therapists engaged in back and forth con240

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Figure 3. Stage 1: initial impressions drawn from experience-based practical knowledge, patient factors, and therapist’s initial observations of movement lead to preliminary assessment decisions.

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Figure 4. Stage 2: data gathering with selected assessment approaches. Elements of decision-making process and reasons listed in order of prominence reported in the data.

sideration of how and why choices when selecting assessment approaches, as depicted by back and forth arrows between the decisionmaking process and reasons. Therapists combined procedural knowledge of how to conduct a neuromuscular examination with their observations of a patient’s movements and engaged in a matching process for selection of assessment approaches for a specific patient. The patient’s level of function also contributed to therapists’ choices as they matched assessment approaches to the patient.

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I probably have a repertoire of things, but depending on what’s appropriate for this person’s cognition and their physical ability. Someone who is 20 and someone who is 80, you look at a little bit differently. (Casey) If they’re higher-level patients, I have them walk on unlevel surfaces. I might even put them on, not just the foam but have them walk on the grass, have them walk on the rocks outside. I use that a lot for some of the higher-level brain injury patients that I see. (Dana)

Dana’s comments also provide an example of the overlap between assess-

ment and treatment whereby participants used intervention activities as part of their examination. Participants described why they chose assessment approaches for specific patients. At times, assessment tools were selected to address documentation concerns. Tools with numeric scores were used by therapists to describe balance ability, identify expected outcomes, and report patient progress. At other times, standardized balance assessment tools such as the Berg Balance Scale were selected to assist with dis-

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Decision Making for Balance Assessment charge planning. Rehabilitation therapists who did not use this method frequently noted that the numeric score was useful in situations where decisions about patient safety were less clear-cut. Finally, 9 of the participants described the influence of practice setting on their selection of assessment approaches. Jackie, an outpatient therapist, noted, “I find that you’re not putting inpatients on the Balance Master† because they have so many other things that are more important. Let’s get them standing.” Stage 3: Diagnosis and Treatment Planning Although the focus of this study was clinical reasoning during examination, therapists described how they began treatment planning during the initial encounter with patients. Data gathering (stage 2) and diagnosis and treatment planning (stage 3) were overlapping, iterative processes. The final component of the model was implementing the plan of care and reassessment (Fig. 2). Although this was not specifically explored in this study, analysis of interview transcripts revealed the link between these aspects of clinical reasoning. When participants described specific patient cases, they easily moved from their thought process at initial examination to subsequent interventions and reexamination. Conceptual Framework Revisions Although the initial conceptional framework depicted a linear process with a specific endpoint, findings revealed that therapists engaged in a series of assessment decisions during examination of patients with potential balance deficits. Initial impressions and findings from data gathering, in turn, triggered additional choices of assessment activities. Clinical reasoning was a complex, ongo† NeuroCom International Inc, 9570 SE Lawnfield Rd, Clackamas, OR 97015.

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ing process influenced by many factors that therapists considered as they conducted their initial examination. The iterative or cyclical nature of clinical reasoning during examination of patients with balance deficits was similar to models proposed by Jones22 and Edwards et al.35 Likewise, the clinical reasoning process described by the participants was similar to that described by previous authors.24,36 Movement observation was a central focus of the initial examination among the participants interviewed. This feature was found in all 22 interview transcripts, and it also accounted for the greatest percentage of data coded. The central role of movement evaluation is consistent with previous reports.24,37,38 Embrey et al38 proposed that movement scripts were used by pediatric physical therapists in clinical decision making. The prevalence of movement observation and description during examination may be due, in part, to participants’ organization of practical knowledge. Patients’ movements were an important source of knowledge for participants, as they compared their observations with their knowledge of normal and atypical movement. If tacit or practical knowledge gained through experience is stored in the form of movement scripts, this explains the inherent relevance of movement observation and description as an assessment approach. The primary importance placed by therapists being studied on movement observation during examination of patients was articulated by Casey: “I think what really separates a good clinician from the average clinician is their observation skills.” Six of the participants described using pattern recognition, or the ability to quickly recognize common patterns of movement problems, during examination of patients.

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Limited Influence of Constraints An unexpected finding was the limited influence of various constraints, such as time or resources, on assessment decisions among participants. Time often is presented as a barrier to implementing research evidence into clinical practice.26,27,39 – 44 In the current study, item analysis revealed that testing time was mentioned as a consideration in choosing balance assessment approaches in only 8 of the 22 interviews. Two of the participants did not identify time as a consideration in assessment decisions in either interview, and issues of time did not figure prominently for 5 of the participants. When time was mentioned by participants, it was a secondary issue to the perceived value of information resulting from various balance assessment approaches. Therapists who valued the information took the time to gather it. This is an important consideration influencing translation of knowledge into clinical practice. Limited access to resources also has been identified as a barrier to incorporating evidence into practice.27,40 – 43 Participants in the current study had access to specialized equipment, various standardized tests, and a knowledgeable colleague to answer clinical questions. It became clear that participants did not view their choices as limited by constraints; rather, they selected approaches that they considered best suited for specific patients, as noted in the following: I don’t feel like I’m limited at all. I feel like there’s so much I could choose from and evaluate the patient and get a good picture of what the patient looks like. And then get a good picture of where I would like to take the patient. (Lee)

Canadian studies examining utilization of outcome measures in clinical practice27–29 cited time and lack of knowledge as primary barriers to March 2009

Decision Making for Balance Assessment their widespread implementation. However, study participants’ choices of balance assessment tools cannot be ascribed to a knowledge gap. A regional continuing education program by a nationally known speaker on examination and treatment of balance disorders had been offered by the health system. Participants in this study were aware of a variety of balance assessment approaches and were clearly choosing some options over others. The critical component to translating research information into clinical use was individual therapists’ perceptions of the value of the information provided by different assessment approaches. The final participant interviewed at the hospital-based outpatient site indicated that the health system had identified preferred balance tests: “It was sort of a global health system thing. They wanted us to stick with certain standard tests, the Berg Balance Scale preferably, then the Tinetti.” (Terry) The health system recommendation may have been based on the literature supporting these standardized tests. As such, research evidence may have indirectly influenced clinical practice. Specifically, this organizational guideline may have had some impact on therapist behavior because the Berg Balance Scale was the most frequently used standardized balance test among participants. However, there still was considerable variability among staff in the selection of balance assessment approaches, and none of the other participants mentioned this guideline as a factor influencing their choices. All of the participants selected assessment approaches that they deemed useful or meaningful. They did not use assessment approaches that they considered to be of little value. As one example, Dana did not consider information from standardMarch 2009

ized balance tests relevant to the inpatient rehabilitation initial examination, based on her perspective of reimbursement issues: “I generally don’t use the Berg or Tinetti (Mobility Assessment) scales, just because I find when you do the evaluation, all the insurance company seems to care about is function, function, function.” Higgs and Titchen noted the importance of personal knowledge in clinical reasoning: The individual’s behavior is highly influenced by his/her frame of reference. Within this frame of reference, scientific knowledge and professional knowledge are translated into decisions for practice, which are influenced by the individual’s convictions and judgments about the worth of this knowledge and its relevance to the current situation.45(p528)

A person’s values influence his or her development of practical knowledge. This perspective helps explain why therapists working in identical settings had opposing points of view about a particular balance assessment approach. Each therapist made judgments about his or her arsenal of balance assessment approaches and deemed some approaches more useful than others. This was part of developing tacit knowledge of how to examine patients and using experience to determine what worked. “Learning what works best for me” is one component of tacit knowledge.46 In essence, each participant had determined his or her own view of what constitutes “best practice.” Greenhalgh et al47 explored the role of tacit knowledge and standardized outcome measures in decision making by multidisciplinary teams. In situations of agreement between outcome measure scores and tacit knowledge, scores were used to reinforce, rather than determine, clinical opinions. When scores and tacit knowledge differed, clinicians relied on their clinical experience and in-

tuition. Greenhalgh et al concluded that standardized outcome measures supported, rather than determined, clinical judgments. Likewise, participants in the current study noted that the primary advantage of standardized balance tests was for documenting what they already knew about patients. Implications for Clinical Practice Evidence-based practice integrates clinical experience, patient values, and the best available evidence from systematic research.3 It also has been described as a philosophy whereby clinicians consistently consider evidence in every aspect of practice.48 Participants in the current study relied on clinical experience as their primary source of information during patient examination. It is possible that research evidence supporting various balance tests indirectly influenced clinical practice choices. For example, participants may have learned about specific tests through educational experiences that were based on the presenter’s knowledge of the literature. However, the limited influence of research evidence in clinical practice described by the participants is consistent with the literature in physical therapy, nursing, and medicine. In a survey of APTA members, physical therapists reported positive attitudes toward EBP, but infrequent use of the literature to guide clinical decisions.26 Salbach et al44 found similar disparities between attitudes and actual use of research findings in clinical decision making when they surveyed Canadian physical therapists about the use of research findings in stroke rehabilitation. High self-efficacy and positive attitudes regarding usefulness of research findings promoted the physical therapists’ use of research findings in making clinical decisions for patients with stroke. Salbach et al44 suggested enhancing therapists’ self-efficacy through continuing education to develop skills

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Decision Making for Balance Assessment needed to search and evaluate research literature. These strategies, although important, do not fully address the complex factors influencing clinician choices of examination tools or interventions. In her invited commentary on the article by Salbach et al,44 Duncan49 called upon researchers to evaluate the feasibility of research-based interventions for clinical practice and select clinically relevant outcomes. Current findings offer insights into clinicians’ views of relevance. We agree that both researchers and clinicians have responsibilities to consider and address to foster translation of research evidence into practice. The open-ended nature of questions used in this study elicited perspectives of clinicians not captured by surveys. We expected participants to identify many of the barriers previously presented in the literature related to EBP. Although issues of time or access to resources were mentioned by some of the participants, these issues were secondary to the importance of therapists’ perspectives on the relevance or value of information gained from various tools when selecting balance assessment approaches during examination. Two of the participants studied (Casey and Randy) were contrast cases. Although movement observation helped guide their assessment decisions, they also made a point of selecting tests and measures supported by research evidence, as seen in the following: Tinetti, I never use. I think more of the research supports the Berg Balance Scale. And it’s more functional, so that to me makes more sense. And for observation skills, there are many more components you can look at. It’s quick and easy, and the reliability piece is greater, at least from what I’ve read. (Casey)

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Casey and Randy differed from other participants in their espoused commitment to using research evidence to support their clinical practice. These values were formed early in their careers, and their practice choices were based, in part, on their personal convictions. They also differed from other participants as APTA members. Although this factor was noted on the demographic forms, neither mentioned it in either interview. Unlike previous studies26,44 where the most recent graduates were more likely to use the literature to guide clinical decisions, Casey and Randy were among the study participants with the greatest number of years of practice experience. Recommendations The participants primarily made decisions based on their clinical judgment drawn from practical experience. They used observations of gait, posture, and functional activities to identify balance problems. They selected standardized balance tests for specific reasons such as documentation purposes or to assist with decision making in situations where clinical judgment alone was insufficient. In most cases, participants based examination and diagnostic decisions on their observations and then selected additional assessment approaches to meet their needs. Given these clinical realities, efforts to foster increased utilization of research evidence into clinical practice must move beyond dissemination of the psychometric properties of various tests and measures. Insights gained from this study demonstrate that aspects of clinical relevance or utility also must be addressed. Several authors26,39,41,44 have noted clinicians’ views that research findings have limited application to specific patients seen in their practice, which poses a significant barrier to translating research evi-

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dence into practice. Among the participants in our study, perceived clinical usefulness was the determining factor in selection of balance assessment approaches for specific patient cases. Researchers should consider the practical knowledge of clinicians and address their concerns of perceived value when recommending various tests and measures for use during examination of patients. Ideally, EBP is a blending of clinical experience and the best available evidence. Finally, current emphasis in physical therapist education to integrate concepts of EBP into clinical decision making may help influence development of this core value in students. Opportunities for explicit discussion of how personal and professional values influence clinical reasoning in specific patient cases would be a useful component of the curriculum. We believe that educators who provide context, as well as content knowledge, may better prepare students for the realities of clinical practice and foster development of highquality decision making. Limitations With qualitative research small numbers of participants are studied in greater depth. Reader generalizability is the important construct, meaning that sufficient description is provided to permit readers to determine whether the findings apply to their situation. In the present study, certain groups were not represented (ie, therapists with less than 4 years of clinical experience, therapists with Doctor of Physical Therapylevel professional education). Each of these areas would be recommended for future study. Participants were recruited from multiple sites within a large health system to explore a variety of clinical experiences. Low staff turnover and the culture of the environment may March 2009

Decision Making for Balance Assessment have been factors influencing assessment decisions. Organizational expectations may influence patterns of practice27,44 as well as the development of tacit knowledge.46 Thus, future studies should include specific questions to explore organizational influences on clinical reasoning. Suggestions for Future Study The intent of this study was to describe balance assessment decisions made by generalist clinicians. A follow-up study exploring the factors influencing assessment decisions of clinical specialists is strongly recommended. Finally, the 3-stage model of assessment decision making should be tested in other areas of practice in order to confirm or further refine theory elements. Although we focused on examination of patients with balance deficits, the themes that emerged likely have more universal application. In particular, exploration of factors influencing assessment decisions in patients with other multidimensional problems such as low back disorders or complex cardiopulmonary disorders is recommended. Previous authors26 –29,39 – 44 have described the challenges of implementing evidence into clinical practice. Our model is useful in thinking about how to address challenges and implement known evidence into practice.

Conclusions In the complex and busy nature of clinical practice, physical therapists gather data they consider to be meaningful during examination of patients. Physical therapists rely on what they see to make decisions, and they trust clinical judgments based on movement observation. Most therapists use standardized measures when they consider it appropriate to do so. If the goal of the profession is to foster EBP, the practical knowledge and perceived values of clinicians must be integrated with findMarch 2009

ings from the research literature. Therapists’ views of relevance of various assessment approaches offer insights for consideration in identifying mechanisms to foster translation of research into clinical practice. All authors provided concept/idea/research design. Dr McGinnis and Dr Hack provided writing. Dr McGinnis provided data collection, project management, participants, facilities/equipment, and institutional liaisons. Dr McGinnis and Dr Nixon-Cave provided data analysis. Dr Nixon-Cave provided consultation (including review of manuscript before submission). The authors express their sincere appreciation to the 11 physical therapists who generously offered their time and clinical wisdom. Graduate assistants supported by Richard Stockton College of New Jersey’s School of Graduate and Continuing Studies provided assistance with data transcription. The Richard Stockton College of New Jersey Physical Therapy Foundation provided support to offer small tokens of appreciation to participants in the study. This research was completed by Dr McGinnis in partial fulfillment of the requirements for the Doctor of Philosophy in Physical Therapy degree at Temple University. Dr Hack served as Chair and Dr Nixon-Cave and Dr Michlovitz served as members of the Dissertation Advisory Committee. This project was approved by the Office for Human Subjects Protections Institutional Review Board of Temple University. An abstract of this work was presented at the 15th International Congress of the World Confederation for Physical Therapy; June 2– 6, 2007; Vancouver, British Columbia, Canada, and at the Combined Sections Meeting of the American Physical Therapy Association; February 14 –18, 2007; Boston, Massachusetts. This article was received May 1, 2008, and was accepted December 29, 2008. DOI: 10.2522/ptj.20080131

References 1 Jensen GM, Givens D. Clinical reasoning: linking theory to practice and practice to theory. Neurol Rep. 1999;23:137–144. 2 American Physical Therapy Association. APTA vision statement for physical therapy 2020. Available at : http://www.apta. org. Accessed April 2, 2006.

3 Sackett DL, Strauss SE, Richardson WS, et al. Evidence-based Medicine: How to Practice and Teach EBM. 2nd ed. Edinburgh, Scotland: Churchill Livingstone; 2000. 4 Rothstein JM, Echternach JL, Riddle DL. The Hypothesis-Oriented Algorithm for Clinicians II (HOAC II): a guide for patient management. Phys Ther. 2003;83: 455– 470. 5 VanSwearingen JM, Brach JS. Making geriatric assessment work: selecting useful measures. Phys Ther. 2001;81:1233–1252. 6 Guide to Physical Therapist Practice. 2nd ed. Phys Ther. 2001;81:9 –746. 7 Task Force on Standards for Measurement in Physical Therapy: standards for tests and measurements in physical therapy practice. Phys Ther. 1991;71:589 – 622. 8 Russo SG. Clinical balance measures: literature resources. Neurol Rep. 1997;21: 29 –36. 9 Whitney SL, Poole JL, Cass SP. A review of balance instruments for older adults. Am J Occup Ther. 1998;52:666 – 671. 10 Finch E, Brooks D, Stratford PW, Mayo NE. Physical Rehabilitation Outcome Measures: A Guide to Enhanced Clinical Decision Making. 2nd ed. Hamilton, Ontario, Canada: BC Decker Inc; 2002. 11 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. 12 Duncan PW, Studenski SA, Chandler J, Prescott B. Functional reach: predictive validity in a sample of elderly male veterans. J Gerontol. 1992;47:M93–M98. 13 Brauer SG, Burns YR, Galley P. A prospective study of laboratory and clinical measures of postural stability to predict community-dwelling fallers. J Gerontol A Biol Sci Med Sci. 2000;55:469 – 476. 14 Shumway-Cook A, Brauer SG, Woollacott MH. Predicting the probability for falls in community-dwelling older adults using the Timed Up & Go Test. Phys Ther. 2000;80:896 –903. 15 Morris S, Morris ME, Iansek R. Reliability of measurements obtained with the Timed “Up & Go” Test in people with Parkinson disease. Phys Ther. 2001;81:810 – 818. 16 Dibble LE, Lange M. Predicting falls in individuals with Parkinson disease: a reconsideration of clinical balance measures. J Neurol Phys Ther. 2006;30:60 – 67. 17 Frozic D, Morris ME, Vowels L. Clinical tests of standing balance: performance of persons with multiple sclerosis. Arch Phys Med Rehabil. 2000;81:215–221. 18 McConvey J, Bennett S. Reliability of the dynamic gait index in individuals with multiple sclerosis. Arch Phys Med Rehabil. 2005;86:130 –133. 19 Saliga S, Bongiovanni C. Standing balance tests used by employed physical therapists in Michigan: a pilot study. J Geriatr Phys Ther. 2005;28:123–124. 20 Finn LM, Stout JR, Topolosky LA, et al. Analysis of clinically used balance measures. Neurol Rep. 2000;24:180 –181.

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Decision Making for Balance Assessment 21 McGinnis PQ, Bonstead K, Gorden J. Balance assessment methods utilized by members of the section on geriatrics. J Geriatr Phys Ther. 2002;25:27–28. 22 Jones MA. Clinical reasoning in manual therapy. Phys Ther. 1992;72:875– 884. 23 Rivett D, Higgs J. Hypothesis generation in the clinical reasoning behavior of manual therapists. J Phys Ther Educ. 1997;11: 40 – 45. 24 Rogers J, Masagatani G. Clinical reasoning of occupational therapists during the initial assessment of physically disabled patients. Occup Ther J Res. 1982;2:195–219. 25 Jette DU, Grover L, Keck CP. A qualitative study of clinical decision making in recommending discharge from the acute care setting. Phys Ther. 2003;83:224 –236. 26 Jette DU, Bacon K, Batty C, et al. Evidencebased practice: beliefs, attitudes, knowledge, and behaviors of physical therapists. Phys Ther. 2003;83:786 – 805. 27 Huijbregts MP, Myers AM, Kay TM, Gavin TS. Systematic outcome measurement in clinical practice: challenges experienced by physiotherapists. Physiother Can. 2002:25–31. 28 Kay TM, Myers AM, Huijbregts MP. How far have we come since 1992? A comparative survey of physiotherapists’ use of outcome measures. Physiother Can. 2001:268 –281. 29 Mayo N, Cole B, Dowfer J, et al. Use of outcome measurement in physiotherapy: survey of current practice. Can J Rehabil. 1993;7:81– 82. 30 Patton MQ. Qualitative Evaluation Methods. Thousand Oaks, CA: Sage Publications Inc; 1980.

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31 Morse JM, Field PA. Qualitative Research Methods for Health Professionals. Thousand Oaks, CA: Sage Publications Inc; 1995:125–149. 32 Merriam SB. Qualitative Research in Practice. San Francisco, CA: Jossey-Bass Inc Publishers; 2002. 33 McGinnis PQ. Factors That Influence the Decision-Making Process of Clinicians in Choosing a Balance Assessment Method [dissertation]. Philadelphia, PA: Temple University; 2006. 34 Portney LG, Watkins MP. Foundation of Clinical Research: Application to Practice. 2nd ed. Upper Saddle River, NJ: Prentice Hall Health; 2000. 35 Edwards I, Jones M, Carr J, et al. Clinical reasoning strategies in physical therapy. Phys Ther. 2004;84:312–330. 36 Fleming M. Clinical reasoning in medicine compared with clinical reasoning in occupational therapy. Am J Occup Ther. 1991;45:988 –996. 37 Jensen GM, Gwyer J, Hack LM, Shepard KF. Expertise in Physical Therapy Practice. 2nd ed. St Louis, MO: Saunders Elsevier; 2007. 38 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. 39 Cranney M, Warren E, Barton S, et al. Why do GPs not implement evidence-based guidelines? A descriptive study. Fam Prac. 2001;18:359 –363. 40 McColl A, Smith H, White P, Field J. General practitioners’ perceptions of the route to evidence based medicine: a questionnaire survey. Br Med J. 1998;316:631–365.

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41 Haynes B, Haines A. Getting research findings into practice: barriers and bridges to evidence based clinical practice. Br Med J. 1998;317:273–276. 42 Retsas A. Barriers to using research evidence in nursing practice. J Adv Nurs. 2000;31:599 – 606. 43 Kajermo KN, Nordstrom G, Krusebrant A, Bjorvell H. Barriers to and facilitators of research utilization, as perceived by a group of registered nurses in Sweden. J Adv Nurs. 1998;27:798 – 807. 44 Salbach NM, Jaglal SB, Korner-Bitensky N, et al. Practitioner and organizational barriers to evidence-based practice of physical therapists for people with stroke. Phys Ther. 2007;87:1284 –1303. 45 Higgs J, Titchen A. The nature, generation and verification of knowledge. Physiotherapy. 1995;81:521–530. 46 Leonard N, Insch GS. Tacit knowledge in academia: a proposed model and measurement scale. J Psychol. 2005;139:495–512. 47 Greenhalgh J, Flynn R, Long AF, Tyson S. Tacit and encoded knowledge in the use of standardized outcome measures in multidisciplinary team decision making: a case study of in-patient neurorehabilitation. Soc Sci Med. 2008;67:183–194. 48 Dopson S, Locock L, Gabbay J, et al. Evidence-based medicine and the implementation gap. Health. 2003;7:311–330. 49 Duncan PW. Invited commentary on: “Practitioner and organizational barriers to evidence-based practice of physical therapists for people with stroke.” Phys Ther. 2007;87:1304.

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Decision Making for Balance Assessment Appendix. Questions for First and Second Interview Sessions Questions for First Interview Session 1. Please name all of the methods you might use to assess potential/actual balance problems in your patients. Are there any that you are aware of that you never use? 2. Now place those methods in 1 of 4 piles: those that you use frequently, those that you use sometimes, those that you seldom use, and those that you never use. Can you tell me a little bit about why you put the methods in those categories? 3. Now that we have discussed which assessment methods you use for your patients, I would like you to tell me how you use them. Please place them into the following categories according to how you use them. (If it fits into more than one category, then you can tell me that as we discuss them.) ● Screening ● Identify impairments ● Identify functional limitations ● Establish a diagnosis ● Establish a prognosis ● Measure outcomes 4. What is it about patients, in general, that makes you decide to look at these things? What aspects about the patient do you consider when selecting an assessment method? Questions for the Second Interview Session 5. As you think back over all the patients you have examined who had potential/actual balance problems, I would like you to tell me about a case that was particularly memorable in terms of the initial examination. (Please be careful not to reveal any personal identifying information.) a. Can you describe that case? b. Can you describe how you decided what to include in your examination of this patient? c. Why did you select that particular balance assessment method? What was your most important reason for choosing that approach? d. Was there anything that limited your choices of assessment approaches? e. How did you use the information you gathered from your assessment? 6. How did you know to look at these things? Is there anything from your demographic data form that influenced your choices? 7. As you think back over your clinical experience, has your approach to examining potential balance problems in your patients changed? Why or why not? 8. Is there anything else you would like to tell me about examining patients with potential balance problems?

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Case Report

Patient Screening by a Physical Therapist for Nonmusculoskeletal Hip Pain William R VanWye WR VanWye, PT, DPT, ACSMRCEP, CSCS, is Staff Physical Therapist, Physical Medicine and Rehabilitation Services, Richard L Roudebush Veterans Affairs Medical Center, 1481 W 10th St, PMRS117, Indianapolis, IN 46202 (USA). Address all correspondence to Dr VanWye at: [email protected]. [VanWye WR. Patient screening by a physical therapist for nonmusculoskeletal hip pain. Phys Ther. 2009;89:248 –256.] © 2009 American Physical Therapy Association

Background and Purpose. Mechanical hip pain and disease-based hip pain can have similar signs and symptoms, thereby presenting a differential diagnostic challenge for clinicians. Hip pain is a common complaint addressed by physical therapists; therefore, it would be advantageous for them to be knowledgeable about differential diagnosis for hip pain, so that they can screen for possible serious conditions outside the realm of physical therapist practice and make the appropriate referral. Case Description. A 77-year-old man was referred for physical therapy by his primary care physician (PCP) with diagnoses of lumbar spine and left hip osteoarthritis and possible trochanteric bursitis. After the examination, the physical therapist determined that the patient should return to his PCP for further testing. Findings leading to this conclusion were pain severity out of proportion to the reported injury, the presence of night pain, a positive “sign of the buttock,” and empty end feels of all hip joint motions, which represented a noncapsular pattern of joint restriction. Outcomes. The patient was diagnosed later with primary lung adenocarcinoma with widespread metastases. A computerized tomography scan of the left hip revealed a metastatic lesion at the left proximal femur. Discussion. Physical therapists’ ability to adequately screen for conditions requiring examination by a physician can lead to a more timely diagnosis of serious medical conditions. Investigators have found published descriptions of end feels, capsular versus noncapsular patterns of restriction, and the sign of the buttock to be beneficial screening tools for use in people with hip, pelvis, or lumbar spine pain.

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Nonmusculoskeletal Hip Pain Screening

H

ip pain is a common complaint, especially in older adults.1 More than 5 million people visited a physician in 2005 because of a musculoskeletal hip pain complaint.2 It is a familiar complaint addressed by physical therapists as well.3 Osteoarthritis (OA) is the most common form of arthritis in the United States. However, estimating the prevalence of any form of OA is made difficult by the variable diagnostic criteria used (ie, clinical signs and symptoms, radiographic evidence, or a combination of findings).4 Estimates of hip OA prevalence range from 9% to as high as 27% for people 45 years of age or older.4 Although there are numerous causes of hip pain, OA is recognized as the most common in people more than 50 years of age.5

occult hip fracture.8,14,15 Although rare, conditions such as psoas muscle abscess or septic arthritis of the hip joint have high mortality rates associated with delayed diagnosis and, therefore, are considered medical emergencies.8,15 The purpose of this case report is to describe a physical therapist’s evaluation of a patient referred by his primary care physician (PCP) with diagnoses of lumbar spine and left hip OA and possible trochanteric bursitis. Examination and history findings of concern led the therapist to refer the patient back to the referring PCP. At the time of the initial physical therapy visit, the physical therapist, who had a bachelor of science degree in physical therapy, had been practicing for 10 years and had worked in multiple outpatient settings.

Arthritis, including other rheumatic conditions, is the leading cause of disability in the United States.6 Furthermore, a 2003 analysis by the Centers for Disease Control and Prevention showed that the direct and indirect medical costs related to these conditions accounted for approximately $128 billion.7 There are several causes of hip pain, both neuromusculoskeletal and systemic.* Many of these conditions can have similar signs and symptoms; therefore, it would be prudent for physical therapists to be familiar with hip pain differential diagnosis, including screening for serious underlying pathology and making the appropriate referral. For example, some conditions in which the main complaint is “hip” or “buttock” pain are psoas muscle abscess, tumor or neoplasm (ie, metastases), septic arthritis, arterial insufficiency (eg, ruptured abdominal aneurysm), and * References 8 –12(pp190, 205–212, 215, 239, 416 – 421, 434 – 469) and 13(pp947).

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Case Description History A 77-year-old man who was 1.56 m (5 ft 11 in) tall and weighed 88.45 kg (195 lb) was referred for outpatient physical therapy by his PCP. The physical therapy order read, “Complaints of lower back pain and left hip pain for approximately one month, having difficulty with bearing weight on the left leg. Please eval and make recommendations for treatment.” The order included diagnoses of lumbar spine and left hip OA and possible trochanteric bursitis. At the initial physical therapy visit, the patient’s main complaint was left hip pain (Fig. 1). His symptoms began about 1 month before the physical therapy visit, when he and his wife were moving furniture. He described pain that was worse initially in the low back but extended to the left lateral and posterior aspects of

Figure 1. Patient self-report pain diagram. L⫽left, R⫽right, solid black area⫽original presentation of pain, dots⫽initial examination complaint of deep ache at rest, ⫻⫽initial examination complaint of sharp pain with weight bearing.

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Nonmusculoskeletal Hip Pain Screening Table.

child. There was no personal history of cancer.

Hip Passive Range of Motion (ROM) and Normative Data17 ROM, °, for: Left Hip

Right Hip

X (SD) Normative Hip ROM, °

50a

110

118 (10)

Extension

5

a

10

17 (7)

Abduction

20a

35

39 (13)

Adduction

a

10

Not reported

Lateral (external) rotation

20a

30

27 (9)

Medial (internal) rotation

15

a

25

31 (8)

Straight leg raise

30a

50

Not reported

Hip Motion Flexion

a

5

Empty (painful) end feel.

the hip as well. After a few days, his back pain resolved, but the left lateral and posterior hip pain intensified. He noted pain with all movement of the left lower extremity, describing it as severe and rating it as 9/10 at worst, 3/10 at best, and 4/10 at the examination. He described the pain as sharp with standing and walking. Even though this sharp pain was typically relieved with rest, a constant dull ache remained. He could not lie on his left side, and the pain was severe enough to limit his ability to become comfortable and often woke him. He felt that his pain was more severe at night than at any other time, but he attributed this feature to lying on his left side, having difficulty becoming comfortable, and having nothing to divert his attention from the pain. The patient denied changes in sensation, bowel or bladder function, weight, or appetite as well as radiating pain. For pain management, the patient was taking 500 mg of hydrocodone every 6 hours and was using a heating pad as well; he reported that each of these helped minimally. Before this incident, the patient was independent with ambulation, driving, and all activities of daily living (ADLs) and was an avid fisherman. However, since the injury, it had become increasingly difficult for the patient to accomplish ADLs without 250

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some form of assistance, and he began using a cane or standard walker (ie, a walker with no front wheels) to ambulate short distances. The patient’s wife added that the preceding year had been very stressful for both of them because of ongoing problems with one of their children and that this recent injury had compounded their family issues. Radiographs of the patient’s lumbar spine, pelvis, and bilateral hips were obtained 2 weeks before the examination by the physical therapist. The radiology report read, “Osteopenia of the spine, lumbar vertebra are intact without fractures or dislocations, degenerative changes” and, regarding the hip and pelvis, “No acute fracture or dislocation is seen. There are moderate degenerative changes bilaterally (ie, hip joint) with osteophyte formation.” The patient’s medical history included chronic low back pain, degenerative arthritis, episodes of dyspnea, benign paroxysmal positional vertigo, venous insufficiency, longterm use of anticoagulants, and a history of deep venous thrombosis. Although he had quit smoking cigarettes 7 years before this incident, the patient had smoked for nearly 50 years. Family history of cancer included his father, 2 brothers, and a

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Physical Examination The patient was brought to the clinic in a wheelchair by his wife. He was able to rise to a standing position independently and ambulate 30 m (100 ft) using the clinic’s front-wheel walker. His gait was antalgic, as he used a step-to pattern with toe-touch weight bearing and maintained left knee flexion throughout the gait cycle. The patient did not appear to exhibit Trendelenburg gait. The patient complained of left hip pain with all functional tasks and movement of the left lower extremity. A formal assessment of trunk range of motion (ROM) was not performed. Instead, the physical therapist assessed the patient’s trunk ROM using visual observation (eg, observation of the patient performing functional tasks such as donning and doffing his jacket, sitting transfers to and from standing and supine positions) and deemed it to be within functional limits. The therapist believed that such observation was sufficient because of the patient’s overall presentation (ie, severity of pain with basic functional tasks). The patient experienced left hip pain during these tasks. The possibility that the patient’s symptoms were referred from the back appeared unlikely because the back pain had resolved and the pain was isolated to the left hip. The physical therapist used visual observation to obtain supine hip passive range of motion (PROM) measurements, as agreement between goniometric measurements and visual observations for hip PROM has been found to be good.16 The Table shows the patient’s hip PROM details and normative data for comparison.17 The PROM for each left hip motion, including a straight leg raise, was limited and reproduced the March 2009

Nonmusculoskeletal Hip Pain Screening patient’s pain (ie, empty end feels). Because of pain before resistance and limited antigravity ROM, no manual resistance was used; therefore, all left hip motion manual muscle strength (force-generating capacity) grades were 3–/5.18 The right lower-extremity manual muscle strength grade was 4/5 to 5/5.18 Finally, with the patient lying on his right side, palpation of the left greater trochanteric soft-tissue structures and palpation directly over the bone also reproduced the patient’s pain. Further special or provocative orthopedic tests of the hip were not used, as these tests are typically used to aid in differential diagnosis and, because of the patient’s pain with all active and passive ranges of motion, the physical therapist believed that any results would have added little clinical information.19 The results of bilateral lower-extremity dermatome testing were unremarkable. Myotome testing and reflex testing were not used because of the severity of pain and subsequent left lowerextremity guarding. Evaluation and Prognosis The patient was referred for physical therapy by his PCP with diagnoses of hip OA and possible trochanteric bursitis. Hip OA typically presents as morning stiffness relieved within an hour of waking.20,21 However, clinical features of severe hip OA include pain at rest, pain at night, restricted and painful ROM, difficulty with gait and ADLs, and variable pain locations and descriptions, ranging from dull ache to sharp or stabbing.21 Furthermore, the patient was extremely tender with palpation of the left greater trochanter, which has been associated with trochanteric bursitis or femoral stress fracture.22 Roberts and Williams5 reported that the most common cause of trochanteric pain, other than hip OA, is trochanteric bursitis.

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Trochanteric bursitis also is commonly found in conjunction with hip OA.23 Characteristics of trochanteric bursitis include onset that may or may not be associated with trauma, initial pain in the low back area with progression of pain to the lateral aspect of the hip, pain that is worse at night, pain described as sharp or achy, and pain severity ranging from mild to disabling.23 On examination, people typically experience pain with hip abduction and lateral (external) rotation active ROM.22,23 Several factors may have led to the PCP’s initial diagnoses. For example, the patient’s signs and symptoms were moderately consistent with severe forms of hip OA and trochanteric bursitis. In addition, the patient had a history of low back pain and hip OA. The onset of symptoms also was associated with a specific incident of lifting furniture. Finally, the findings on radiographs of the lumbar spine, pelvis, and hips were deemed to be negative for fractures or dislocations. Despite this reasoning, the treating physical therapist was concerned with many of the physical examination and history findings. For example, the patient’s pain pattern (ie, severity) appeared to be incongruent with what would be expected with hip OA and trochanteric bursitis. In addition, the patient reported that the pain was worse at night and was unrelieved with a change in position. Furthermore, all left hip motions were limited and painful (ie, empty end feels) and, therefore, represented a noncapsular pattern of restriction. According to Cyriax, findings of limited and painful passive hip flexion with the knee flexed and extended, as well as a noncapsular pattern of restriction of the hip joint, constitute a positive “sign of the buttock,” which he described as an indication of possible serious underlying pathology of the hip or

Finally, even pelvis.24(pp375–377) though the patient did not have a history of cancer, several of his firstdegree relatives did. Therefore, considering each of these findings, the therapist determined that the patient’s presentation justified referral back to his PCP for further diagnostic testing.

Outcomes Day 1 Events After the initial physical therapy examination, the referring PCP was contacted to discuss the physical therapist’s findings. The physical therapist described the concerns listed above and recommended further diagnostic imaging (such as magnetic resonance imaging [MRI] or computed tomography [CT]). The patient’s PCP verbalized skepticism regarding the need for such imaging, citing the negative plain radiographs, and advised the physical therapist to continue with therapy until the next available PCP appointment. The physical therapist instructed the patient in safe gait with a front-wheel walker and weight bearing as tolerated. The patient also was instructed to avoid pain-provoking activities. For home pain management, the patient and his spouse were instructed in the application of ice and analgesic gel to the painful region. The patient’s treatment was placed on hold until his next PCP appointment, which was to be scheduled within the week. Day 10 Events Ten days after the initial physical therapy examination, the patient returned to physical therapy with his wife and other family members, who were concerned about his continued complaints of pain. The patient reported that he had seen his PCP 3 days before this visit. The patient’s PCP ordered a second radiograph of the left hip. Again, it was concluded that the patient had no frac-

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Nonmusculoskeletal Hip Pain Screening previously, reveal no fracture or dislocation, positive for arthritis. Discharge home, ED diagnosis of DJD [degenerative joint disease] of hip and spine.” Hospital Admission (Day 21) The patient next was seen by his PCP for regular blood tests to assess the international normalized ratio because the patient was taking warfarin for a history of recurrent deep venous thrombosis. The international normalized ratio was found to be uncharacteristically high, even though there had been a reduction in the medication dose 1 month earlier. The patient’s wife described him as being more irritable and confused and stated that she could no longer take care of him. Therefore, the PCP decided to admit the patient to a hospital to “expedite diagnostic testing.” Figure 2. Anterior-posterior radiograph of the left hip revealing irregularity of the bony cortex along the lateral aspect of the proximal femur.

ture or dislocation, with the impression of “unchanged bilateral hip and lumbar spine degenerative disease.” No other testing was ordered. The patient’s PCP concluded that the findings of the second examination were unremarkable and recommended that the patient continue physical therapy. The patient also was diagnosed by his PCP as having depression and was referred for counseling. At the beginning of the physical therapy session, the patient was tearful, stating that his left hip pain was unbearable, rating it 10/10. The patient described pain at rest, pain worsening at night, and an inability to tolerate any movement of the left lower extremity. His family members noted that he also was exhibiting atypical behavior, such as irritability, confusion, and decreased appetite. 252

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His functional status had further declined. Because of these current signs and symptoms, a pain rating of 10/10, and the initial suspicion that the patient’s pain was not musculoskeletal in nature, the physical therapist referred the patient to the nearest emergency department (ED) to obtain immediate care. The patient’s family members agreed with this recommendation. Emergency Department (Day 10) The patient was seen later the same day at an ED. The ED assessment noted a history similar to that given to the physical therapist by the patient. The patient reported to the ED staff a recent onset of nausea and vomiting. The ED physician assessment read, “His only complaint is left hip and thigh pain. X-rays done

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Events on Days 22 Through 28 The patient was diagnosed with primary lung adenocarcinoma. A plain radiograph revealed “irregularity of the bony cortex along the lateral aspect of the proximal femur. Recommend bone scan for further evaluation” (Fig. 2). The bone scan revealed “increased perfusion, bloodpool phase, and delayed-phase uptake centered over the proximal left femur just distal to the lesser trochanter . . . recommend whole-body bone scanning as well as CT scanning of chest, abdomen, and pelvis” (Fig. 3). A CT scan of the chest, abdomen, and pelvis confirmed widespread metastases (in the lungs, liver, brain, lumbar spine, and thoracic spine), including a metastatic lesion at the proximal left femur (Fig. 4).

Discussion Metastasis is the spread of cancer cells from the original site (ie, primary site) to a secondary site.12(pp336 –338) The leading sites of metastasis for all cancers are bone, lymph nodes, March 2009

Nonmusculoskeletal Hip Pain Screening lungs, liver, and brain.12(pp336 –338) Bone metastasis is common in lung cancer.13,25 The thoracic spine has been reported to be the most common site of metastasis in patients with lung cancer,13(pp607– 613),26 followed by the lumbar spine and cervical spine.26 Additionally, the femur has been reported to be the most common extravertebral site for metastasis in patients with lung cancer, with an incidence of 12%.26 Although more rare, there have been reports of lung cancer metastasis to more distal sites, such as the foot and ankle.27,28 Lung cancer is the leading cause of cancer-related death in the United States for both men and women.29 The leading risk factor for lung cancer is cigarette smoking; genetics plays a role as well.29 The most common form of lung cancer in the United States is a type of non–small cell lung cancer known as adenocarcinoma.13(pp607– 613) Adenocarcinoma is a type of cancer that arises from glandular cells that line internal organs (such as the respiratory mucosa of the lungs).13(pp607– 613) Although its growth rate is considered to be slow to moderate, adenocarcinoma metastasizes early throughout the lungs, brain, and other organs.13(pp607– 613) Hanagiri et al30 examined 177 patients diagnosed with stage I and II primary lung cancer and found postsurgical recurrence of metastases, both intrathoracic and extrathoracic, in 21% of these patients. Early metastasis can be attributed to the rich lymphatic and blood supplies of the lungs; these vast networks permit systemic spread.13(pp607– 613) Metastasis also may occur through direct extension, which is the invasion of nearby structures by direct passage through the pleura.13(pp607– 613) Initial warning signs of lung cancer are commonly found in people who March 2009

Figure 3. Bone scan revealing increased perfusion, blood-pool phase, and delayed-phase uptake centered over the proximal left femur just distal to the lesser trochanter.

Figure 4. Axial (transverse) computerized tomography scan revealing a metastatic lesion at the proximal left femur.

smoke cigarettes, as well as in people with many common pulmonary conditions (such as shortness of breath, coughing, and increased or bloody sputum production) and, therefore, can delay early diagnosis.12(pp161–163),13(pp607– 613),29 Some advanced signs include weight loss, diminished appetite, nausea, vomiting, fatigue, weakness, wheezing, chest pain, hoarseness, productive cough with blood, headaches, and confusion.12(pp161–163),13(pp607– 613),29 Because metastasis to the spine is quite common in people with lung

cancer, it is important for physical therapists to be aware of the signs and symptoms of spinal metastasis and possible cord compression. These signs and symptoms include back pain, changes in deep tendon reflexes, diminished or absent lowerextremity sensation, muscle weakness, and loss of bowel or bladder control.12(pp161–163,336 –338) Routine chest radiographs typically yield early detection of lung cancer; however, because chest radiographs lack sensitivity, smaller, more re-

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Nonmusculoskeletal Hip Pain Screening sectable tumors typically are not detected.13(pp607– 613) Because of this lack of sensitivity of radiographs and the advantage of assessing the entire thorax with CT, scanning by CT is recommended.31 Although MRI can be more accurate, CT may be preferential because of efficacy, improved patient tolerance, and safety (eg, claustrophobia and metal implants are issues encountered with MRI).31 Even with advancing technology, early detection has not led to improved mortality rates.29 The prognosis for all stages of lung cancer combined is poor, with a 5-year survival rate of 15%.29 In addition to risk factors such as the patient’s history of smoking and family history of cancer, the physical therapist considered some of the clinical findings detailed below. For example, the therapist believed that the patient’s pain severity was out of proportion with diagnoses of purely hip OA and trochanteric bursitis. Specifically, the patient’s symptoms began 1 month before the initial examination, had not improved, and, according to the patient, had even worsened. Goodman and Snyder cautioned, “When the symptoms seem out of proportion to the injury, or when the symptoms persist beyond the expected time for that condition, a red flag should be raised in the therapist’s mind.”12(p57) In addition, the patient felt that his pain was worse at night, when he lay down to sleep. Although he attributed this feature to difficulty becoming comfortable, long-standing night pain that is unaltered with a change in position is associated with the possibility of a neoplasm or tumor.12(pp16,17,436) Another alarming discovery was the presence of limited and painful left hip PROM (ie, empty end feels) in all directions. Cyriax defined empty end feels as motion restricted by the patient because of pain and asso254

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ciated this feature with the possibility of a more serious condition, such as an infection or a neoplasm or tumor.24(pp53–57) Cyriax also described the sign of the buttock as an indication of possible serious underlying pathology of the hip or pelvis.24(pp375–377) The 3 primary components include a limited and painful straight leg raise, limited and painful passive hip flexion with the knee flexed, and a noncapsular pattern of hip joint restriction.24(pp375–377) Cyriax included possible findings of limited trunk flexion, empty end feels of hip joint motions, pain with resisted hip movements, and a swollen buttock.24(pp375–377) Cyriax claimed that a capsular pattern of hip joint restriction (eg, arthritic hip joint) would manifest as limitations in flexion, abduction, and medial (internal) rotation and minimal to no limitation in extension or lateral rotation.24(pp53–57) The patient in this case report exhibited limited and painful hip motions in all directions and, therefore, a noncapsular pattern of restriction. Consequently, the physical therapist deemed that the patient’s presentation constituted a positive sign of the buttock. The validity of the capsular pattern for the hip described by Cyriax has been called into question and, unfortunately, no studies have examined the clinical accuracy of the sign of the buttock.32,33 However, earlier case reports found the sign of the buttock as well as the presence of empty end feels and the use of capsular versus noncapsular patterns of joint restriction to be beneficial screening tools that can be used to aid in proper intervention for people with pain in the hip, pelvis, or lumbar spine.34 –39 Interestingly, the patient reported a traumatic event associated with the onset of pain. Traumatic onset is found more commonly in musculo-

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skeletal complaints, whereas systemic pathology is associated more commonly with insidious and gradual onset.12(pp26,64) However, various authors10,11,36 have cautioned against assigning too much importance to such reports, especially when the trauma would be considered minor or trivial in nature, because it may act as a diversion from the true cause (eg, neoplasm) and delay proper treatment. It is not uncommon for patients with primary or secondary malignant processes of the musculoskeletal system to relate a traumatic event with the onset of symptoms.11,40,41 Finally, the patient was referred with negative findings (ie, no fractures or dislocations) on radiographs of the lumbar spine, pelvis, and hips. However, occult fractures of the proximal femur are not entirely uncommon on initial standard radiographs, especially in elderly patients.42– 46 For this reason, advanced imaging (eg, CT, MRI) has been recommended for patients with negative findings on initial radiographs and continued hip pain, especially those over the age of 70 years.47,48 Other clinical tools may have aided in the differential diagnosis in this case. One relevant tool is the auscultatory patellar-pubic percussion test, which can be used when an occult hip fracture is suspected.49 The patient is positioned in the supine position with the lower extremities extended and symmetrical. The examiner then places the diaphragm of a stethoscope over the pubic symphysis and commences tapping each patella to compare the quality and intensity of the sound. In such a side-by-side comparison, the presence of diminished or muffled sound signifies a positive test and should prompt advanced imaging.49 This test was not used in this case because the physical therapist was unaware of its existence until a review of the literature regarding this case. March 2009

Nonmusculoskeletal Hip Pain Screening Furthermore, many other common tests and measures were not used because it was determined that further tests, especially provocative or special tests, would have added little clinical information and would have resulted in unnecessary pain for the patient. Although the physical therapist’s examination findings were sufficient to determine that physical therapy intervention was not appropriate for the patient, there were areas for improvement in the therapist’s actions. First, other examination tools and techniques, such as the auscultatory patellar-pubic percussion test mentioned above, might have assisted in this case. Second, during the initial call to the PCP, the therapist could have provided moredetailed findings, such as the sign of the buttock and the implications of this finding. Third, the therapist could have been more attentive when suggesting further testing. The therapist did not cite evidence to support such a request; this omission may have led the PCP to reject the suggestion and subsequently order a second radiograph. Finally, the therapist could have contacted the PCP when the patient was referred to an ED. This action might have led to cooperation among the therapist, the PCP, and the ED staff. By referring the patient to an ED and not informing the PCP, the therapist used what may be considered a passive-aggressive approach. Even with good intentions, such an approach may hinder the process of accurate diagnosis.

culoskeletal disorders in the military for more 30 years; evidence shows that patients receiving care from physical therapists in a direct-access military setting are at minimal risk for grossly negligent care.53,54 Physical therapists working in outpatient settings are ideally suited to screen for conditions outside the scope of physical therapist practice and to make the appropriate referral. It would be of benefit to physical therapists to have regular contact with their referral sources with the goal of building relationships in which open dialogue is acceptable and expected. It also would be beneficial for physical therapists to use evidence to support claims or when sending requests to referring providers. It is important for physical therapists to recognize warning signs, such as pain that appears to be out of proportion to the reported diagnosis or injury as well as pain that is worse at night. Cyriax’s descriptions of end feels, capsular versus noncapsular patterns of joint restriction, and the sign of the buttock are useful screening tools, as in this case, for use in people with nonmusculoskeletal hip, pelvis, or lumbar spine pain.

The author thanks Kevin Jones, PT, DPT, for review of the manuscript. This work was solely researched and completed by the author and is not necessarily the opinion of the Richard L Roudebush Veterans Affairs Medical Center or any other federal agency. This article was submitted December 14, 2007, and was accepted November 24, 2008. DOI: 10.2522/ptj.20070366

Conclusion Physical therapists have been shown to be competent, effective, and costefficient in managing musculoskeletal conditions, which includes screening for conditions outside the scope of physical therapist practice.50 –52 Physical therapists have been involved in screening for musMarch 2009

References 1 Christmas C, Crespo CJ, Franckowiak SC, et al. How common is hip pain among older adults? Results from the Third National Health and Nutrition Examination Survey. J Fam Pract. 2002;51:345–348.

2 American Academy of Orthopaedic Surgeons. Physician visits for musculoskeletal symptoms. Source: Physician Visits— National Ambulatory Medical Care Survey 1998 –2005. Available at: http://www.aaos. org/Research/stats/Common%20Orthopae dic%20Symptoms%20Seen%20by%20a%20 Physician.pdf. Accessed December 9, 2008. 3 Jette AM, Smith K, Haley SM, Davis KD. Physical therapy episodes of care for patients with low back pain. Phys Ther. 1994;74:101–115. 4 Lawrence RC, Felson DT, Helmick CG, et al. Estimates of the prevalence of arthritis and other rheumatic conditions in the United States. Part II. Arthritis Rheum. 2008;58:26 –35. 5 Roberts WN, Williams RB. Hip pain. Prim Care. 1998;15:783–793. 6 Centers for Disease Control and Prevention (CDC). Prevalence of disabilities and associated health conditions among adults—United States, 1999. MMWR Morb Mortal Wkly Rep. 2001;50:120 –125. 7 Centers for Disease Control and Prevention (CDC). National and state medical expenditures and lost earnings attributable to arthritis and other rheumatic conditions—United States, 2003. MMWR Morb Mortal Wkly Rep. 2007;56:4 –7. 8 Zacher J, Gursche A. “Hip” pain. Best Pract Res Clin Rheumatol. 2003;17:71– 85. 9 Margo K, Drezner J, Motzkin D. Evaluation and management of hip pain: an algorithmic approach. J Fam Pract. 2003;52: 607– 617. 10 DeAngelis NA, Busconi BD. Assessment and differential diagnosis of the painful hip. Clin Orthop Relat Res. 2003;406:11–18. 11 Lane JM. When to consider malignant tumor in differential diagnosis after athletic trauma. J Musculoskelet Med. 1990;7:16. 12 Goodman CC, Snyder TE. Differential Diagnosis in Physical Therapy. 3rd ed. Philadelphia, PA: WB Saunders Co; 2000:16, 17, 26, 57, 64, 161–163, 190, 205–212, 215, 239, 336 –338, 416 – 421, 434 – 469. 13 Goodman CC, Boissonnault WG, Fuller KS. Pathology: Implications for the Physical Therapist. 2nd ed. Philadelphia, PA: WB Saunders Co; 2003:607– 613, 947. 14 Mahmood F, Ahsan F, Hockey M. Ruptured abdominal aortic aneurysm presenting as buttock pain. Emerg Med J. 2005;22:453– 454. 15 Chern CH, Hu SC, Kao WF, et al. Psoas abscess: making an early diagnosis in the ED. Am J Emerg Med. 1997;15:83– 88. 16 Holm I, Bolstad B, Lutken T, et al. Reliability of goniometric measurements and visual estimates of hip ROM in patients with osteoarthrosis. Physiother Res Int. 2000; 5:241–248. 17 Roach KE, Miles TP. Normal hip and knee active range of motion: the relationship to age. Phys Ther. 1991;71:656 – 665. 18 Kendall FP, McCreary EK, Provance PG. Muscles: Testing and Function. 4th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 1993:184 –190.

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Nonmusculoskeletal Hip Pain Screening 19 Hertling D, Kessler RM. Management of Common Musculoskeletal Disorders. 3rd ed. Philadelphia, PA: Lippincott Williams & Wilkins; 1996:91–92. 20 Altman R, Alarcon G, Appelrouth D, et al. The American College of Rheumatology criteria for the classification and reporting of osteoarthritis of the hip. Arthritis Rheum. 1991;34:505–514. 21 Manek NJ, Lane NE. Osteoarthritis: current concepts in diagnosis and management. Am Fam Physician. 2000;61:1795–1804. 22 Traycoff RB. Pseudotrochanteric bursitis: the differential diagnosis of lateral hip. J Rheumatol. 1991;18:1810 –1812. 23 Shbeeb MI, Matteson EL. Trochanteric bursitis (greater trochanter pain syndrome). Mayo Clin Proc. 1996;71:565–569. 24 Cyriax J. Textbook of Orthopaedic Medicine. 8th ed. London, United Kingdom: Bailliere Tindall; 1982:53–57, 375–377. 25 Capanna R, Campanacci DA. The treatment of metastases in the appendicular skeleton. J Bone Joint Surg Br. 2001;83: 471– 481. 26 Aydinli U, Ozturk C, Bayram S, et al. Evaluation of lung cancer metastases to the spine. Acta Orthop Belg. 2006;72: 592–597. 27 Ramkumar U, Munshi NI, El-Jabbour JN. Occult carcinoma of the lung presenting as pain in the hallux: a case report. J Foot Ankle Surg. 2005;44:483– 486. 28 McGarry RC. Images in clinical medicine: lung cancer presenting as an ankle metastasis. N Engl J Med. 2000;343:268. 29 American Cancer Society. Cancer Facts & Figures 2008. Atlanta, GA: American Cancer Society. 2008:13–15. Available at: http://www.cancer.org /downloads /STT/ 2008CAFFfinalsecured.pdf. Accessed December 9, 2008. 30 Hanagiri T, Kodate M, Nagashima A, et al. Bone metastasis after a resection of stage I and II primary lung cancer. Lung Cancer. 2000;27:199 –204. 31 Hollings N, Shaw P. Diagnostic imaging of lung cancer. Eur Respir J. 2002;19: 722–742.

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32 Bijl D, Dekker J, van Baar ME, et al. Validity of Cyriax’s concept capsular pattern for the diagnosis of osteoarthritis of hip and/or knee. Scand J Rheumatol. 1998; 27:347–351. 33 Klassbo M, Harms-Ringdahi K, Larsson G. Examination of passive ROM and capsular patterns in the hip. Physiother Res Int. 2003;8:1–12. 34 Jones DL, Erhard RE. Diagnosis of trochanteric bursitis versus femoral neck stress fracture. Phys Ther. 1997;77:58 – 67. 35 Greenwood MJ, Erhard RE, Jones DL. Differential diagnosis of the hip vs lumbar spine: five case reports. J Orthop Sports Phys Ther. 1998;27:308 –315. 36 Erhard RE, Egloff BP. Patient with metastatic adenocarcinoma imitating lumbar herniated nucleus pulposis. J Manipulative Physiol Ther. 2004;27:569 –573. 37 Ross MD, Bayer E. Cancer as a cause of low back pain in a patient seen in a direct access physical therapy setting. J Orthop Sports Phys Ther. 2005;35:651– 658. 38 Browder DA, Erhard RE. Decision making for a painful hip: a case requiring referral. J Orthop Sports Phys Ther. 2005;35: 738 –744. 39 Gurney B, Boissonnault WG, Andrews R. Differential diagnosis of a femoral neck/ head stress fracture. J Orthop Sports Phys Ther. 2006;36:80 – 88. 40 Mazanec DJ, Segal AM, Sinks PB. Identification of malignancy in patients with back pain: red flags. Arthritis Rheum. 1993; 36(suppl):S251–S258. 41 Widhe B, Widhe T. Initial symptoms and clinical features in osteosarcoma and Ewing sarcoma. J Bone Joint Surg Am. 2000;82:667– 674. 42 Deutsch AL, Mink JH, Waxman AD. Occult fractures of the proximal femur: MR imaging. Radiology. 1989;170:113–116. 43 Alba E, Youngberg R. Occult fractures of the femoral neck. Am J Emerg Med. 1992; 10:64 – 68. 44 Bogost GA, Lizerbram EK, Crues JV III. MR imaging in evaluation of suspected hip fracture: frequency of unsuspected bone and soft-tissue injury. Radiology. 1995; 197:263–267.

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45 Newberg AH, Newman JS. Imaging the painful hip. Clin Orthop Relat Res. 2003;406:19 –28. 46 Dominguez S, Liu P, Roberts C, et al. Prevalence of traumatic hip and pelvic fractures in patients with suspected hip fracture and negative initial standard radiographs: a study of emergency department patients. Acad Emerg Med. 2005;12: 366 –369. 47 Oka M, Monu JU. Prevalence and patterns of occult hip fractures and mimics revealed by MRI. AJR. 2004;182:283–288. 48 Chana R, Noorani A, Ashwood N, et al. The role of MRI in the diagnosis of proximal femoral fractures in the elderly. Injury. 2006;37:185–189. 49 File P, Wood JP, Kreplick LW. Diagnosis of hip fracture by the auscultatory percussion technique. Am J Emerg Med. 1998; 16:173–176. 50 Childs JD, Whitman JM, Sizer PS, et al. A description of physical therapists’ knowledge in managing musculoskeletal conditions. BMC Musculoskelet Disord. 2005; 6:32. 51 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. 52 Weale AE, Bannister GC. Who should see orthopaedic outpatients: physiotherapists or surgeons? Ann R Coll Surg Engl. 1995; 77:71–73. 53 James JJ, Stuart RB. Expanded role for the physical therapist: screening musculoskeletal disorders. Phys Ther. 1975;55: 121–131. 54 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.

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Case Report Suspected Statin-Induced Respiratory Muscle Myopathy During Long-Term Inspiratory Muscle Training in a Patient With Diaphragmatic Paralysis Ken Chatham, Colin M Gelder, Thomas A Lines, Lawrence P Cahalin

Background and Purpose. Abnormal lipids are associated with the development of coronary heart disease; for this reason, lipid-lowering agents have become a standard of care. The purposes of this case report are: (1) to highlight the association of impaired inspiratory muscle performance (IMP) with statin therapy and (2) to describe potentially useful methods of examining and treating people with known or suspected statin-induced skeletal myopathies (SISMs).

Case Description. The patient had breathlessness on exertion and a restrictive lung disorder from a right hemidiaphragmatic paralysis, for which he was prescribed high-intensity inspiratory muscle training (IMT). He had a secondary diagnosis of hyperlipidemia, which was treated with 40 mg of simvastatin after 51⁄2 months of IMT.

Outcomes. The improvements in IMP, symptoms, and functional status obtained from almost 6 months of high-intensity IMT were lost after the commencement of simvastatin. However, 3 weeks after termination of simvastatin combined with high-intensity IMT, the patient’s IMP, symptoms, and functional status exceeded pre-statin levels. Discussion. This case report suggests that high-intensity IMT can be used effectively in a patient with impaired diaphragmatic function and during recovery from a respiratory SISM. The marked reduction in IMP and inability to perform IMT resolved with the cessation of statin therapy. The case report also highlights the potential effects of SISMs in all skeletal muscle groups. The clinical implications of this case report include the potential role of physical therapy in monitoring and possibly facilitating the spontaneous recovery of an SISM, as well as the need to investigate the IMP of a person with dyspnea and fatigue who is taking a statin.

K Chatham, Grad Dip Phys, is Clinical Specialist Physiotherapist, Physiotherapy Department, Llandough Hospital, Cardiff, United Kingdom. CM Gelder, MB, PhD, FRCP, is Chest Physician, Section of Respiratory Medicine, Llandough Hospital. TA Lines, BsCHonsPhys, is Senior Physiotherapist, Physiotherapy Department, Llandough Hospital. LP Cahalin, PT, PhD, is Clinical Professor, Department of Physical Therapy, Northeastern University, 6 Robinson Hall, Boston, MA 02115 (USA). Address correspondence to Dr Cahalin at: [email protected]. [Chatham K, Gelder CM, Lines TA, Cahalin LP. Suspected statininduced respiratory muscle myopathy during long-term inspiratory muscle training in a patient with diaphragmatic paralysis. Phys Ther. 2009;89:257–266.] © 2009 American Physical Therapy Association

View a video clip related to this article at www.ptjournal.org.

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

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bnormal lipids have long been associated with coronary heart disease.1 The lipid abnormalities found to be associated with coronary heart disease include: (1) elevated total cholesterol, lowdensity lipoprotein-cholesterol, and triglycerides and (2) depressed levels of high-density lipoprotein-cholesterol.1,2 Because of the favorable effects of statins (3-hydroxy-3methylglutaryl coenzyme A [HMGCoA] reductase inhibitors) on these lipid abnormalities, they have become a standard of care for people with abnormal lipids.3 The use of statin drugs such as atorvastatin (Lipitor*), simvastatin (Zocor†), and lovastatin (Mevacor†) to lower cholesterol is extremely common.3 More than 76 million prescriptions for statin drugs were filled in 2000.4 Additionally, the number of US prescriptions for statins increased 50% between 2002 and 2006, and the number of Canadian prescriptions for statins increased 69% during the same 4-year period.5 As these data indicate, the use of statin drugs to improve abnormal lipid levels has increased considerably. Furthermore, it is possible that the use of statin drugs will increase even more due to questionable cardioprotective results from the drugs ezetimibe (Zetia‡) and ezetimibe ⫹ simvastatin (Vytorin†,‡).6 In view of these findings, the use of statins to lower cholesterol is very likely to continue to rise. The mechanism of action of statin drugs is blocking the rate-limiting step in de novo cholesterol biosynthesis.7,8 Blocking HMG-CoA reductase inhibits the formation of mevalonate (Fig. 1). Mevalonate is a * Parke-Davis, Div of Warner-Lambert Co LLC (a Pfizer company), 235 E 42nd St, New York, NY 10017-5755. † Merck & Co Inc, PO Box 4 WP39-206, West Point, PA 19496-0004. ‡ Schering-Plough Corp, Galloping Hill Rd, Kenilworth, NJ 07033-0530.

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precursor to cholesterol, farnesylated proteins, and ubiquinone. The statin-induced effect upon cholesterol production has a similar effect upon ubiquinone (coenzyme Q10) by inhibition of the same biosynthetic pathway, which has the potential to decrease mitochondrial adenosine diphosphate production and antioxidant activity.8 Thus, decreases in ubiquinone can lead to decreased energy availability, insufficient DNA repair, and muscle fatigue. The consequence of blocking the HMG-CoA channel, therefore, may explain the potential muscle abnormalities associated with statin administration.7,8 Although statin drugs are commonly used to improve abnormal lipid levels, they have been observed to have numerous adverse effects on skeletal muscle and tendons. Skeletal muscle pain, weakness, rhabdomyolysis, and myopathies have been observed with the administration of statins.3 Tendon damage, including tendinitis and tendon rupture, has been reported.9 Factors associated with the occurrence of these adverse effects include a high dosage of statins (⬎60 mg per day), concomitant use of glucocorticoids and other myotoxic medications, older age (⬎80 years), female sex, frailty, small body frame, multisystem disease, and perioperative periods.3 The mechanism of action of statin-induced skeletal myopathies (SISMs) has been hypothesized to be due to a variety of factors (Appendix).3,10 The major factor appears to be the inhibited synthesis of compounds arising from cholesterol synthesis, such as ubiquinone or other essential intracellular compounds (eg, guanosine triphosphate binding proteins). The interaction of statins with the cytochrome P-450 hepatic enzyme system also has been implicated as a potential mechanism for SISMs.3,10 –12 In addition, altered gene expression and apoptosis have

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been hypothesized as factors responsible for SISMs.10 –12 Several case reports have described the development of an SISM, and the majority have reported marked dyspnea and fatigue.13–16 In these case reports, it is difficult to determine whether the dyspnea and fatigue were due to a general peripheral SISM, respiratory SISM, or combined peripheral and respiratory SISM. Only one case report16 mentioned the potential effects of statins on respiratory muscles, but it did not examine measures of respiratory performance in the recipient of a heart transplant who required mechanical ventilation. We are unaware of any literature that has investigated the specific effects of exercise training with and without statin drugs. Our case report appears to be the first describing the effects of a statin drug on respiratory muscle performance and the subsequent changes after the drug was discontinued and the patient underwent extensive training of the respiratory muscles. A recent update by Tomlinson and Mangione17 on the potential adverse effects of statins on muscle posed several important questions related to statin use and the role of physical therapy, including: (1) Can physical therapists provide interventions that facilitate the spontaneous recovery that occurs after discontinuation of the statin? (2) Is exercise contraindicated in people who have SISMs? and (3) Does high-intensity exercise exacerbate complaints of muscle weakness or pain in patients taking statins? The authors concluded that patients with unexplained muscle pain or weakness who are taking statins should be referred to a physician and that intense exercise should be discontinued until the cause of the muscle problem is determined.17 In this case report, we will begin to address the questions that were March 2009

Inspiratory Muscle Performance and Suspected Statin-Induced Myopathy posed by Tomlinson and Mangione in 2005.17 We will examine and describe the effects of high-intensity inspiratory muscle training (IMT) in a patient with hemidiaphragmatic paralysis. We also will report on the association of commencement and cessation of statin therapy on inspiratory muscle performance (IMP) during IMT. This may have bearing on the suggestion posed by Tomlinson and Mangione that physical therapy may facilitate recovery from SISMs.17 Finally, due to the methods of testing that we used with out patient, we will identify the metabolic abnormalities that appear to be associated with statins and the tests and measures that a physical therapist may consider using when an SISM is suspected in such a patient.

Patient History and Review of Systems The patient was a 57-year-old man who was referred for physical therapy for examination and IMT after a variety of medical tests performed over the previous year led to a diagnosis of hemidiaphragmatic paralysis and brachial plexus neuritis. It was unclear whether the diaphragmatic impairment was related to an extension of the neuritis or previous trauma to the neck during his sporting history as a first-class rugby player. A computed tomography scan of the cervical spine revealed a cervical spondylosis, with severe degenerative changes and narrowing of the foramen of C5, C6, and C7. Electromyographic testing revealed denervation of both the deltoid and infraspinatus muscles, bilaterally. The symptoms reported included dyspnea on exertion (DOE), particularly if swimming or bending forward, and bilateral shoulder weakness. His occupation was a computer programmer. He took no medications. His height was 185.4 cm (6 ft 1 in), and his weight was 86.2 kg (190 lb).

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Figure 1. Mechanism of action of statins on lipids, proteins, and ubiquinones. Blocking 3-hydroxy-3-methylglutaryl coenzyme A (HMG-CoA) reductase inhibits the formation of mevalonate and every subsequent product below the entry point of statins, including cholesterol, isoprenylated proteins, and coenzyme Q10.

Prior to commencing IMT, the patient demonstrated a mild to moderate restrictive impairment of lung function with a forced expiratory volume in the first second of expiration (FEV1) and a forced vital capacity (FVC) of 58% and 59%, respectively, of predicted values and an FEV1/FVC of 82%. Chest radiography revealed an elevated right hemidiaphragm and paradoxical abdominal movement during inspiration. Arterial blood gas (ABG) analysis revealed a pH of 7.44, a partial pressure of oxygen (PO2) of 74 mm Hg, a partial pressure of carbon dioxide (PCO2) of 37 mm Hg, and a bicarbonate level (HCO3) of 25 mEq/L. Functionally, the patient was unable to fully participate in his hobby of gardening due to DOE with bending and gardening tasks.

Clinical Impression The clinical decision-making process used to select the below-mentioned tests and measures for the patient was based on progressive DOE; pulmonary function test (PFT) results revealing a mild to moderate restrictive lung disorder based on the FEV1, FVC, and FEV1/FVC; chest radiograph consistent with right hemidiaphragmatic paralysis; a paradoxical breathing pattern; ABG analysis identifying mild hypoxia18; and limited gardening due to DOE during gardening tasks and bending. The DOE, right hemidiaphragmatic paralysis, and mild hypoxia warranted the examination of the strength (forcegenerating capacity) and endurance of the inspiratory muscles. Thus, the clinical impression of the patients problems was one of impaired ventilation and respiration/gas exchange

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Figure 2. Training with the Test of Incremental Respiratory Endurance (TIRE). (A) A subject matches the on-screen training template within the TIRE protocol. (B) A sample computer screen showing the ongoing inspiratory effort (line B) exceeding the 80% training template (line A, the longer diagonal line). Numerical data are presented in the middle of the computer screen (identified within brackets) listing: (1) initial test data, including the peak inspiratory pressure (PImax) (T1: MIP⫽191 cm H2O, and PAve1⫽185; PAve1 is PImax measured over 1 second) and sustained peak inspiratory pressure (SPImax) (area⫽1,467.50 pressure-time units [PTUs], representing the area under the curve) from which the 80% training template (line A) was automatically developed via TIRE software, and (2) first inspiratory effort during the first TIRE level (A1: MIP⫽165 cm H2O, PAve1⫽158, area⫽1,225.38 PTUs, % of the target area⫽104) with the inspiratory effort ending at 7 seconds, but passing the template requirements because both the PImax (MIP⫽165/ 191⫽86%) and SPImax (1,225.38/1,467.50⫽83.5%, which represents an SPImax that achieves 104% of the submaximal target area; 104%⫽83.5%/80%) have achieved 80% of the training template. The calculations of power and work at several different time points also are shown for lines A and B. For line A, PImax⫽158 cm H2O (yielding a power of 6.22 W) at 1 second, PImax⫽88 cm H2O (yielding a power of 2.587 W) at 8 seconds, and PImax⫽10 cm H2O (yielding a power of 0.99 W) at 16 seconds, with total amount of work for line A⫽40.3 J. For line B, PImax⫽170 H2O (yielding a power of 6.947 W) at 1 second and PImax⫽100 cm H2O (yielding a power of 3.13 W) at 7 seconds, with total amount of work for line B⫽33.5 J. The amount of work described above is ongoing because the line is obtained during mid-effort. A1⫽the first level of high-intensity inspiratory muscle training via the TIRE, T1⫽test 1, MIP⫽maximal inspiratory pressure.

associated with ventilatory pump dysfunction.19

Examination The IMP of the patient was measured using the Test of Incremental Respiratory Endurance (TIRE) incorporated within the RT2 device.§ A video showing a person performing high-intensity inspiratory muscle training via the TIRE within the RT2 device is available at www.ptjournal. org. Inspiratory muscle strength was measured as peak inspiratory pressure (PImax) at residual volume (RV). Inspiratory work capacity was measured as sustained peak inspiratory pressure (SPImax) measured from RV to total lung capacity (TLC), and inspiratory muscle work/endurance was measured as accumulated §

DeVilbiss Healthcare, High Street, Wollaston, West Midlands, DY8 4PS United Kingdom.

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80% SPImax or ⌺SPImax. We have previously described the conversion of pressure generation through the 2-mm leak of the manometer to SI units of power and work.20,21 The TIRE is characterized by the serial presentation of submaximal isokinetic profiles based on maximum voluntary contraction (MVC) of the respiratory muscles. These efforts are presented at an on-screen target of 80% of MVC or SPImax within a progressive work-to-rest ratio, with rest periods decreasing from 60 seconds at level A to 45, 30, 15, 10, and 5 seconds at levels B through F, respectively (Fig. 2). Each level has 6 resisted breaths through the manometer’s 2-mm leak but is fixed at 80% of SPImax at each examination. Thus, the examination session continues until task failure, as indicated by an inability to match the on-

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screen target, or until a maximum of 36 resisted breaths have been performed (Fig. 2). Measurement of IMP via the TIRE has been shown to be valid and reliable as an examination and training method in a variety of patient populations.20 –26 Baseline IMP included a PImax of 80 cm H2O (2.16 W), a SPImax of 404 pressure-time units (PTUs; 10.7 J), and work/endurance of 7,800 PTUs (162 J) at level D2 (Fig. 3). These measures of IMP were reduced, with PImax being 76% of the predicted value27 and other values being lower than expected.20 –26,28 –30 Clinical Impression These examination findings supported the initial clinical impression of impaired ventilation and respiration/gas exchange associated with ventilatory pump dysfunction,19 as March 2009

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Figure 3. Several measures of inspiratory muscle performance. Each data point for each week is the best result of the 3 Test of Incremental Respiratory Endurance (TIRE) sessions performed that week. Visual examination of the data for (A) peak inspiratory pressure (PImax), (B) sustained peak inspiratory pressure (SPImax), and (C) inspiratory work performed at test completion (totalized sustained peak inspiratory pressure [totalized SPImax]) reveals that the level and trend of data were most dramatic at the commencement and cessation of the statin. The slopes of the trend lines during the inspiratory muscle training (IMT) and statin⫹IMT phases in Figure 3C are steeper than the same phases in Figures 3A and 3B. FEV1⫽forced expiratory volume in the first second of expiration, FVC⫽functional vital capacity, PaO2⫽arterial partial pressure of oxygen, PTU⫽pressure-time unit.

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Inspiratory Muscle Performance and Suspected Statin-Induced Myopathy the PFT results revealed a restrictive lung disorder combined with decreased IMP that resulted in pronounced dyspnea and fatigue. The lower-than-expected PImax, SPImax, and inspiratory work/endurance identified the ventilatory pump dysfunction and provided a baseline measure from which to develop the plan of care, which included highintensity IMT via the TIRE and patient education about IMT. All baseline measurements of IMP were reduced, but the measure of inspiratory work/endurance identified the patients inability to complete the TIRE protocol due to very poor inspiratory muscle endurance (Fig. 3). The RT2 TIRE system was used to perform high-intensity IMT because it provided the serial presentation of submaximal isokinetic profiles at 80% of MVC within a progressive work-to-rest ratio, with rest periods decreasing from 60 seconds to 5 seconds. Currently, the RT2 TIRE system used with this patient has limited availability. However, standard examination of inspiratory muscle strength (eg, PImax) and endurance (eg, duration of repeated inspirations at a particular percentage of PImax until task failure) would provide potentially useful information regarding IMP and the possibility of a respiratory muscle SISM.

Intervention The patient attended the clinic 3 times weekly and performed the TIRE protocol described earlier. After 51⁄2 months of successful IMT, the patient began treatment for abnormal lipids, commencing with 40 mg of simvastatin. Approximately 10 years earlier, the patient was diagnosed with type V hyperlipidemia, which had been controlled with dietary and lifestyle adjustments. Due to increasing dyspnea and fatigue, inability to perform IMT, and decreased IMP, simvastatin was terminated after 3 weeks of use, with subsequent improvement in symptoms, 262

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ability to perform IMT 1 week after the cessation of the statin, and an increase in IMP (Fig. 3).

Outcome After 51⁄2 months of TIRE training, the PImax had risen from 80 cm H2O to 100 cm H2O (3.13 W), the SPImax had increased from 404 PTUs to 605 PTUs (17.3 J, with a contraction time of 16 seconds), and work/endurance had increased from 7,800 PTUs to 20,120 PTUs (492 J) at level F6. These increases were associated with the patient’s reported improvements in activities of daily living (ADLs), with reduced breathlessness and self-reported improved quality of life resulting primarily from greater gardening abilities. During the sixth month of IMT, all measurements of IMF began to fall (Fig. 3). This trend continued for a period of 3 weeks such that the TIRE data were reduced to levels below starting values: PImax⫽67 cm H2O (1.72 W), SPImax⫽378 PTUs (8.9 J), and ⌺SPImax⫽1,340 PTUs (28.4 J; the patient failed at the A2 level). The fall in work/endurance indicated that the patient was unable to effectively perform IMT, completing only 2 resisted breaths. Visual analysis of the TIRE results shown in Figure 3 demonstrates the favorable changes in IMP before commencement and after cessation of statin therapy, which were accompanied by substantial improvements in pulmonary function and PO2 (Fig. 3A). The observed improvements in pulmonary function consisted of the FEV1 and FVC increasing from 58% and 59%, respectively, to 73% and 74%, respectively, of predicted values. The PO2 level increased from 74 mm Hg to 93 mm Hg. These changes led to an improved ability to garden, with less dyspnea.

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Discussion The clinical intervention of fixedload, high-intensity IMT was associated with increases in IMP. These increases were manifested by the patient’s reports of improved quality of life and ADLs similar to several studies of IMT.23–31 The substantial improvement in IMP during the first several weeks of IMT may represent a learned response and neural adaptation, with slower yet steady improvements thereafter, possibly representing a morphological response to IMT.22–31 The prescription of simvastatin to treat hyperlipidemia was associated with a dramatic fall in IMP and an inability to undertake the serial resisted breaths required for effective and progressive IMT. The decrease in IMP was progressive and more profound through the 3 weeks of statin treatment. After withdrawal of simvastatin and initiation of highintensity IMT, IMP exceeded previous levels of strength, power output, single-breath work capacity, and work/endurance within a 3-week period of IMT. The patient reported feeling better, and his ADLs returned to levels he had attained following the initial 51⁄2 months of IMT. We are unaware of any previous reports or studies identifying the decrement in IMP associated with commencement of a statin. However, a recent case report of a recipient of a heart transplant who had been administered simvastatin and a variety of immunosuppressive agents, including prednisone, described the need for mechanical ventilation due to a fatal toxic myopathy.16 Some studies32,33 have identified the effect of glucocorticoids on IMP, finding that patients without underlying pulmonary disease who received highdose corticosteroids (range⫽40 –90 mg per day) developed inspiratory muscle weakness. Furthermore, IMT performed at 60% of PImax over an 8-week period prevented the decrement in IMP.33 These findings and March 2009

Inspiratory Muscle Performance and Suspected Statin-Induced Myopathy those of our case report highlight several important issues, including: (1) the potential effect of statins, glucocorticoids, and other myotoxic medications on IMP; (2) the frequent chronic or intermittent use of glucocorticoids in the management of many pulmonary diseases and the possibility that many patients with pulmonary disorders may be prescribed glucocorticoids and statins concomitantly; and (3) the possible preventative role of IMT on a respiratory SISM or myopathy due to myotoxic agents.16,32,33 Worsening dyspnea or nonresponse to physical therapy after administration of a statin, glucocorticoid, or a combined regimen should warrant the examination of IMP. Furthermore, IMT may be used as a preventative measure if measurements of IMP are known or suspected to be reduced and statin or glucocorticoid therapy is being considered. Our patient complained of a general malaise at the same time his IMP deteriorated. The breathlessness associated with reduced IMP may have contributed to this, but there also may have been a generalized SISM affecting all muscle groups. Furthermore, this patient was not at increased risk for SISMs, because he was young, took no other myotoxic medications, had no multisystem disease, and had no other recognized risk factors for SISMs.3 These issues have profound implications for individuals undergoing rehabilitation. Due to the underlying pathology of patients in both pulmonary and cardiac rehabilitation, there is a high likelihood that statins will be prescribed. Future investigation of the occurrence of SISMs in such patients appears to be warranted. The examination and management of IMP was the focus of our patient care due to the diagnosis of impaired ventilation and respiration/gas exchange associated with ventilatory March 2009

pump dysfunction.19 We were able to identify and address task failure during the TIRE sessions as an indicator of fatigue in the measures of power and single- and multiplebreath work capacity. The limitation of our case report is that peripheral skeletal muscle function was not addressed, because this was not the focus of our intervention. A comprehensive assessment of the peripheral skeletal muscles would have provided additional information that may have facilitated the physical therapy intervention provided to this patient. This speculation is particularly relevant to this case report because IMP has been observed to fall with a loss of lean body mass, progression of chronic lung disease, or during infective exacerbations.20,22,24 Between weeks 26 and 27, the patient vacationed in Australia, and the decrease in IMP initially was thought to be associated with some degree of detraining effect, jet lag, and possibly a viral infection. The patient did not demonstrate signs suggestive of a viral infection (eg, elevated body temperature or auscultation findings associated with an upper respiratory tract infection) or a change in lean body mass (determined via appearance and no change in body weight).20,22,24 Additionally, the decrease in IMP was progressive and more pronounced as statin treatment continued; jet lag, detraining, and infection are unlikely to demonstrate such a response. Furthermore, the patient was provided with the handheld mouthpiece resistor from the TIRE device to perform IMT on his vacation, which he did but without the fixation of through-range resistance or the measure of IMT adherence provided by the complete RT2 TIRE system. Although PImax was reduced in the patient prior to IMT and after statin prescription, the SPImax and ⌺SPImax

(reflecting power output and work capacity of single and multiple resisted breaths, respectively) were particularly affected. Although several clinical trial databases have observed the incidence of severe SISMs to be 0.08%, the incidence of lesssevere myopathy has not been reported.3 Furthermore, it does not appear that the power output or work capacity of SISMs has been investigated previously, which, based on our results, may be better markers for myopathy than muscle strength. If future studies demonstrate results similar to ours, power output and work capacity of people with known or suspected SISMs may be helpful to identify and manage the SISMs. It has been hypothesized that the presence of a severe or less-severe SISM is likely due to the disruption of muscle energy production by reduction of ubiquinone and coenzyme Q10 production.3,7–12 The PImax can be described as a maximal inspiratory muscle power effort at RV, the SPImax can be described as the accumulated power output (reflecting single-breath work capacity from RV to TLC), and the ⌺SPImax can be described as the work/endurance achieved at 80% of MVC or SPImax throughout the entire TIRE training session. These latter measures are likely to more sensitively reflect impaired muscle energetics than the one on-off power effort of PImax (particularly work/endurance). This has been alluded to in corticosteroidinduced respiratory myopathies.33 In addition, SPImax, used as a measure of single-breath capacity, has been described as a more-sensitive indicator than PImax of readiness to wean from mechanical ventilation.26 The data provided by the measures of power, work capacity, and work/ endurance of the inspiratory muscles have provided unique insights into this case report and the possible examination and management of

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Inspiratory Muscle Performance and Suspected Statin-Induced Myopathy SISMs. These measures enable us to speculate upon the possible pathophysiological mechanisms that may have taken place during and after statin administration. Fatigue, muscle weakness, and pain have been described previously as side effects of statin use.3,9,17 However, despite not being addressed previously, the loss of work capacity and, most importantly, work/ endurance (SPImax and ⌺SPImax, respectively) could be explained by a reduction of ubiquinone levels and subsequent ATP synthesis due to inhibition of the HMG-CoA channel. This explanation would suggest that measures of work and work/endurance are of particular value when statin therapy is instigated and an SISM is suspected. The addition of measures of isokinetic performance of the limb girdle muscles to SPImax and ⌺SPImax measures of the respiratory muscles would be of particular interest in better understanding these speculations. Furthermore, our observation of a 15% improvement in lung function during highintensity IMT makes the measurement of pulmonary function a potentially valuable tool when statin therapy is known or suspected to produce an SISM. Due to the clinical impact of dramatically reduced IMP, no pulmonary function tests were performed at the cessation of simvastatin. However, PFTs combined with measures of IMP may help to detect and quantify the potential effects of an SISM on respiratory performance and the effects of physical therapy intervention.

tervention when an SISM is discovered. The questions posed by Tomlinson and Mangione17 that we would like to address include: (1) Can physical therapists provide interventions that facilitate the spontaneous recovery that occurs after discontinuation of the statin? (2) Is exercise contraindicated in people who have an SISM? and (3) Does high-intensity exercise exacerbate complaints of muscle weakness or pain in patients taking statins?

Implications for Physical Therapy

The information provided by this case report makes it difficult to determine whether the decrement in IMP during statin administration was worsened by high-intensity IMT. Conversely, it also is difficult to determine whether IMP would have decreased more if high-intensity IMT were not performed, as observed when IMT was not performed during glucocorticoid administration.33 It also is difficult to know whether high-intensity IMT facilitated the improvement in IMP after cessation of the statin. It has been suggested that an SISM resolves spontaneously upon cessation of a statin.3 However, no previous case reports or studies have investigated the manner by which skeletal muscle recovers after an SISM. The findings of this case report indicate that combined statin administration and high-intensity IMT worsened IMP, which improved once the statin was terminated, suggesting that the statin was the primary offender of poor IMP. Highintensity IMT performed for 3 weeks after statin withdrawal produced results that were greater than those obtained before statin commencement, which took almost 6 months to achieve.

The implications of this case report for physical therapy include the need to be aware of the occurrence of respiratory and peripheral SISMs as well as potential examinations when an SISM is suspected and the possible role of physical therapy in-

We believe that the early improvements in IMP due to learning and neural adaptation that we observed in this case and that were observed by numerous investigators22–31 contributed less to the improvements in

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IMP after the statin was terminated and more to an improved morphological and physiological response. In view of this, it appears that the spontaneous recovery of the respiratory SISM after cessation of the statin in our patient was facilitated by physical therapy intervention. Surprisingly, the short-term administration of a statin in this patient appeared, paradoxically, to stimulate improvements in IMP after 3 weeks of high-intensity IMT, resulting in greater IMP and a steeper trend line than before commencement of the statin. However, further investigation is needed to determine the manner and magnitude of recovery associated with an SISM alone and combined with different levels of exercise. Perhaps low-intensity IMT rather than high-intensity IMT would produce changes during and after statin administration that are different from those that we observed. Moreover, perhaps the muscles of patients after long-term statin therapy recover differently than those of patients who receive short-term statin administration. Based on our case report and the slope of the poststatin trend line, short-term statin administration may have facilitated exercise training adaptations after the cessation of the statin by favorably altering DNA transcription and synthesis, regulating cytotoxic activity, and improving vasomotor tone (relaxation and constriction of the vasculature) via activation of endothelium-derived relaxing factor.34 In addition, a unique set of operational conditions under which the respiratory muscles function, such as the metaboreflex,35 may have allowed an earlier return to high-intensity exercise than that which might occur in the peripheral musculature. These speculations should be examined in prospective controlled studies. Given the widespread prescription of statins, their potential effects March 2009

Inspiratory Muscle Performance and Suspected Statin-Induced Myopathy on all muscle groups are of some concern. The findings of this case report suggest an association between the commencement of simvastatin and the impairment of both IMP and the ability to effectively perform IMT. We believe that in individuals with compromised cardiorespiratory systems, such as those undergoing cardiac or pulmonary rehabilitation, further investigation of IMP and skeletal muscle function is needed. It is likely that many individuals undergoing cardiac or pulmonary rehabilitation may have been prescribed statins and that nonresponse to rehabilitation or breathlessness secondary to impaired IMP could be due to statin administration. Furthermore, patients with preexisting muscle disorders (such as the right hemidiaphragm paralysis in our patient) or those who are receiving glucocorticoids or other myotoxic medications appear to be more susceptible to an SISM.3,13–17,32,33 In summary, this case report is the first published description of an intervention aimed at facilitating the recovery of an SISM. Our case report and the report by Francis et al16 show that the respiratory muscles can be affected by statin use, with our case report being the first to identify the progressive decrements in IMP. Furthermore, it appears to be the first report examining the endurance and work capacity associated with an SISM. The clinical implications of this case report are substantial and include the potential role of physical therapy intervention in monitoring and possibly facilitating the spontaneous recovery of an SISM as well as the need to investigate the performance of the respiratory muscles in people with unexplained dyspnea and fatigue who are prescribed statin drugs.

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All authors provided concept/idea/project design, writing, and consultation (including review of manuscript before submission). Mr Chatham, Dr Gelder, and Mr Lines provided data collection. Mr Chatham and Dr Cahalin provided data analysis. Mr Chatham, Dr Gelder, and Dr Cahalin provided project management. Mr Chatham and Mr Lines provided the patient. Mr Chatham and Dr Gelder provided facilities/ equipment. Mr Chatham provided institutional liaisons. This article was received May 23, 2008, and was accepted November 19, 2008. DOI: 10.2522/ptj.20080155

References 1 Castelli WP. Lipids, risk factors, and ischemic heart disease. Athersclerosis. 1996; 124:S1S9. 2 Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults. Executive summary of the third report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III). JAMA. 2001;285; 2486 –2497. 3 Pasternak RC, Smith SC Jr, Balrey-Merz CN, et al. ACC/AHA/NHLBI clinical advisory on the use and safety of statins. Circulation. 2003;106:1024 –1028. 4 Smith CC, Bernstein LI, Davis RB, et al. Screening for statin-related toxicity: the yield of transaminase and creatine kinase measurements in a primary care setting. Arch Intern Med. 2003;163:688 – 692. 5 Jackevicius CA, Ross JS, Ko DT, Krumholz HM. Use of ezetimibe in the United States and Canada. N Engl J Med. 2008;358:110. 6 Johnson LA. Congress-Vytorin makers held bad news. Associated Press. Available at: http: // www.wtopnews.com / ?nid⫽111& sid⫽1333328. Accessed April 1, 2008. 7 Dirks AJ, Jones KM. Statin-induced apoptosis and skeletal myopathy. Am J Physiol Cell Physiol. 2006;291:1208 –1212. 8 Marcoff L, Thompson PD. The role of coenzyme Q10 in statin-associated myopathy: a systemic review. J Am Coll Cardiol. 2007;49:2231–2237. 9 Marie I, Delafeneˆtre H, Massy N, et al; Network of the French Pharmacovigilance Centers. Tendinous disorders attributed to statins: a study of ninety-six spontaneous reports in the period 1990 –2005 and review of the literature. Arthritis Rheum. 2008;59:367–372. 10 Laaksonen R, Katajamaa M, Pa¨iva¨ H, et al. A systems biology strategy reveals biological pathway and plasma biomarker candidates for potentially toxic statin-induced changes in muscle. PLoS ONE. 2006; 1(1):e97.

11 Hanai J, Cao P, Tanksale P, et al. The muscle-specific ubiquitin ligase atrogin-1/ MAFbx mediates statin-induced muscle toxicity. J Clin Invest. 2007;117: 3940 –3951. 12 Oh J, Ban MR, Miskie BA, et al. Genetic determinants of statin intolerance. Lipids Health Dis. 2007;6:15. 13 Phillips O, Haas R, Bannykh S, et al. Statinassociated myopathy with normal creatine kinase levels. Ann Intern Med. 2002; 138:581–585. 14 Baker SK, Goodwin S, Sur M, Tarnopolsky MA. Cytoskeletal myotoxicity from simvastatin and colchicine. Muscle Nerve. 2004; 30:799 – 802. 15 Tufan A, Dede DS, Cavus S, et al. Rhabdomyolysis in a patient treated with colchicine and atorvastatin. Ann Pharmacother. 2006;40:1466 –1469. 16 Francis L, Bonilla E, Soforo E, et al. Fatal toxic myopathy attributed to propofol, methylprednisolone, and cyclosporine after prior exposure to colchicine and simvastatin. Clin Rheumatol. 2008;27: 129 –131. 17 Tomlinson SS, Mangione KK. Potential adverse effects of statins on muscle. Phys Ther. 2005;85:459 – 465. 18 West JB. Pulmonary Pathophysiology: The Essentials. 7th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2008. 19 Part two: preferred practice patterns. In: Guide to Physical Therapist Practice. 2nd ed. Phys Ther. 2001;81:139 – 681. 20 Ionescu AA, Nixon LS, Evans WD, et al. Bone density, body composition, and inflammatory status in cystic fibrosis. Am J Respir Crit Care Med. 2000;162(3 pt 1):789 –794. 21 Mickleborough TD, Nichols T, Chatham K, et al. The effect of high- and low-intensity inspiratory muscle training on the physiological response to exercise in recreational runners [abstract]. Am J Respir Crit Care Med. 2003;167:A541. 22 Chatham K, Ionescu AA, Nixon LS, Shale DJ. A short-term comparison of two methods of sputum expectoration in cystic fibrosis. Eur Respir J. 2004;23:435– 439. 23 Chatham K, Baldwin J, Griffiths H, et al. Inspiratory muscle training improves shuttle run performance in healthy subjects. Physiotherapy. 1999;85:676 – 683. 24 Enright SJ, Chatham K, Ionescu AA, et al. Inspiratory muscle training improves lung function and exercise capacity in adults with cystic fibrosis. Chest. 2004;126: 405– 411. 25 Enright SJ, Unnithan VB, Heward C, et al. Effect of high-intensity inspiratory muscle training on lung volumes, diaphragm thickness, and exercise capacity in subjects who are healthy. Phys Ther. 2006;86:345–354. 26 Bruton A. A pilot study to investigate any relationship between sustained maximal inspiratory pressure and extubation outcome. Heart Lung. 2002;31:141–149.

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Inspiratory Muscle Performance and Suspected Statin-Induced Myopathy 27 Black LF, Hyatt RE. Maximal respiratory pressures: normal values and relationship to age and sex. Am Rev Respir Dis. 1969;99:696 –702. 28 Gething AD, Williams M, Davies B. Inspiratory resistive loading improves cycling capacity: a placebo controlled trial. Br J Sports Med. 2004;38:730 –736 29 Reid WD, Crowe J, OBrien K, Brooks D. Inspiratory muscle training in adults with chronic obstructive pulmonary disease: a systematic review. Respir Med. 2005;99: 1440 –1458.

30 Lotters F, van Tol B, Kwakkel G, Gosselink R. Effects of controlled inspiratory muscle training in patients with COPD: a metaanalysis. Eur Respir J. 2002;20:570 –576. 31 Cahalin LP, Semigran MJ, Dec GW. Inspiratory muscle training in patients with chronic heart failure awaiting cardiac transplantation: results of a pilot clinical trial. Phys Ther. 1997;77:830 – 838. 32 Weiner P, Azgad Y, Weiner M. The effect of corticosteriods on inspiratory muscle performance in humans. Chest. 1993; 104:1788 –1791.

33 Weiner P, Azgad Y, Weiner M. Inspiratory muscle training during treatment with corticosteroids in humans. Chest. 1995;107: 1041–1044. 34 Vaughan CJ, Murphy MB, Buckley BM. Statins do more than just lower cholesterol. Lancet. 1996;348:1079 –1082. 35 Witt JD, Guenette JA, Rupert JL, et al. Inspiratory muscle training attenuates the human respiratory muscle metaboreflex. J Physiol. 2007;584:1019 –1028.

Appendix. Mechanisms Hypothesized to be Responsible for Statin-Induced Skeletal Myopathy

1. Inhibited synthesis of compounds arising from cholesterol synthesis: a. Ubiquinone b. Other essential intracellular compounds such as guanosine triphosphate binding proteins 2. Interaction of statins with the cytochrome P-450 hepatic enzyme system 3. Altered muscle gene expression, resulting in metabolic and signaling pathway abnormalities (eg, eicosanoid synthesis, phospholipase C, atrogin-1a) 4. Statin-induced apoptosis via isoprenoid depletion, leading to a cascade of events, including a lack of geranylgeranylation, farnesylation of proteins, increase in cytosolic calcium, calpain activation, Bax translocation, cytochrome c release, and activation of caspase-9 and caspase-3 5. Genetic predisposition due to COQ2 genomic variationb a b

Atrogin-1 is a key gene involved in skeletal muscle atrophy. COQ2 gene disturbances are common in severe, inherited skeletal muscle myopathies.

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Perspective

Movement Variability and the Use of Nonlinear Tools: Principles to Guide Physical Therapist Practice Regina T Harbourne, Nicholas Stergiou Fields studying movement generation, including robotics, psychology, cognitive science, and neuroscience, utilize concepts and tools related to the pervasiveness of variability in biological systems. The concepts of variability and complexity and the nonlinear tools used to measure these concepts open new vistas for physical therapist practice and research in movement dysfunction of all types. Because mounting evidence supports the necessity of variability for health and functional movement, this perspective article argues for changes in the way therapists view variability, both in theory and in action. By providing clinical examples, as well as applying existing knowledge about complex systems, the aim of this article is to create a springboard for new directions in physical therapist research and practice.

RT Harbourne, PT, MS, PCS, is Assistant Professor, Physical Therapy Department, Munroe-Meyer Institute, University of Nebraska Medical Center, 985450 Nebraska Medical Center, Omaha, NE 68198-5450 (USA). Address all correspondence to Ms Harbourne at: [email protected]. N Stergiou, PhD, is Director of the Nebraska Biomechanics Core Facility, College of Education and College of Public Health, University of Nebraska at Omaha and University of Nebraska Medical Center. [Harbourne RT, Stergiou N. Movement variability and the use of nonlinear tools: principles to guide physical therapist practice. Phys Ther. 2009;89:267–282.] © 2009 American Physical Therapy Association

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

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ariability in human performance and the nonlinear manner in which skills and characteristics of movement change over time reflect the complexity of the movement system. As Bernstein1 described, multiple degrees of freedom of the body, including joints, muscles, and the nervous system, combine with external forces during movement to produce countless patterns, forms, and strategies. The redundancy of the system allows for the use of multiple strategies to accomplish any given task. Logically, there are multiple performance variants for each movement, depending on the constraints of each individual’s system. How do therapists utilize these redundancies in practice? Although many movement science and neuroscience students are now well versed in the importance of variability, this information has not been integrated into many physical therapy interventions and is far from being embedded in general practice.2 Think about the last time you encouraged a patient to acquire a new or more-efficient movement. How did you go about it? Did you demonstrate the movement and ask the patient to copy your movement pattern? Did you ask the patient to experiment with various movement strategies to find success? Perhaps you asked the patient to think about the movement, the goal, a similar task, or a mental image of performance. Was some feature of the movement a focus for measurement to determine progress or change? Regardless of the practice setting, we ask patients to move, and we generally ask them to move differently than they moved before they came to us. Although our goals often do not explicitly target variability in movement, our implied expectation is that the functional movement that emerges will be adaptive and flexible enough to meet the everyday goals of our patients. To achieve this flex268

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ibility, our patients need adequate variability of the motor system. It follows that adequate variability should be a focal point of examination and intervention in order to achieve optimal function for the individual. Clinicians trained in medical fields use linear models for prediction and problem solving.3 However, it is becoming increasingly clear that linear models are limited in many cases and are certainly not the optimal model for function. Professionals in several areas of health care, including epidemiology, infectious disease processes, and biomedicine, are turning to nonlinear models for solutions to difficult problems.4 For example, drug dosages are nonlinear; one cannot increase the dose for more effect because there is generally a threshold value at which the desired effect occurs and beyond which negative effects occur.5 In our field, therapists know that a given amount of practice cannot ensure the learning of a skill in a linear manner. Our patients usually learn sporadically, progressing in a nonlinear manner over time. In addition, rates and paths of progress vary among individuals with the same diagnoses who are similar in characteristics. Motor learning progresses nonlinearly, exhibiting nonlinear learning curves depending on the task, conditions, and characteristics of the learner.6 Linear can be defined as pertaining to a straight line, or consisting of only one dimension. Nonlinear, usually used with the term “dynamics,” as in “nonlinear dynamics,” can be defined as “not in a straight line,” or as a system whose output is not proportional to its input.* Nonlinear systems are more complex than linear systems, necessitating the use of sets of equations producing unpredictable outcomes that exhibit chaotic * Terms needed to understand nonlinear concepts are underlined and are listed in Appendix 1.

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features. In general, biological systems, including humans, are complex, nonlinear systems with inherent variability in all healthy organisms.7 In this perspective article, we will provide an overview of the constructs of variability, complexity in human movement, and nonlinear analysis. This overview focuses on clinical relevance; therefore, the definitions and explanations herein are more conceptual than mathematical. We first describe variability of movement and its relationship to complexity and the changing view of the importance of variability for successful function. Next, we review nonlinear measures and the concept of complexity in movement. Finally, we propose principles and examples of the use of variability, complexity, and nonlinearity in examination, intervention, and research components of physical therapist practice.

The Importance of Variability and the Concepts of Nonlinearity Variability: For Better or Worse? Before discussing the changing perspective on variability as it pertains to clinical application, consistent interpretation requires definitions of terminology. First, the definition of variability occurs in behavioral, biological, and statistical forms. Behavioral variability describes differences in observed behavior when an entity is placed in the exact same situation.8 Webster’s Dictionary defines variability in a biological sense as “the power possessed by living organisms, both animal and vegetable, of adapting themselves to modifications or changes in their environment, thus possibly giving rise to ultimate variation of structure or function.”9 Statistical variability refers to measures of centrality around a mean or an average and includes measures such the standard deviation, the range of possible values,

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Movement Variability and the Use of Nonlinear Tools and the variance. All of these definitions contribute to our understanding of human variability. Human movement variability encompasses the normal variations that occur in motor performance across multiple repetitions of a task over time.10 Variability is inherent within all biological systems and reflects variation in both space and time, which can be illustrated easily in human movement. As a person walks through sand or snow, his or her footprints never repeat exactly, reflecting variability from step to step in a continuous cycle of movement. During quiet standing, we sway around a central equilibrium point without ever remaining exactly still as we maintain orientation to the world. Are these examples of variability in movement considered errors in motor performance, or are they normal output of a healthy motor system? Traditionally, random error or noise within the system was deemed responsible for the variability measured during repetitions of a skill.11 Motor learning textbooks usually describe movement variability as error and skilled movement as movement with decreased variability.12 Generalized motor program theory (GMPT) considers variation in a given movement pattern to be the result of errors in the ability to predict the necessary parameters for using the underlying motor program.13 However, there is mounting evidence of the importance of variability in normal movement, which reveals variation not as error but as a necessary condition for function. Variability reflects multiple options for movement, providing for flexible, adaptive strategies that are not reliant on rigid programs for each task or for each changing condition encountered. Optimal variability as a central feature of normal movement is consistent with a nonlinear approach. March 2009

Counter to a therapeutic assumption that equilibrium is an indicator of health, nonlinear theories emphasize disequilibrium as healthy. This means that the system never quite settles into a stable state, and constant fluctuations characterize the healthy variability that allows adaptation to environmental change.4 A complex dynamic system is in slight disequilibrium with the environment and maintains this disequilibrium over time.14 Goldberger15 described complete equilibrium as equivalent to the death of the organism because it implies a static, nondynamic state. Therefore, health is indicated by a dynamic equilibrium that is not a static state. Rather than being a negative feature, variability reflects important information for the maintenance of the health of the system. Reduced variability is known to cause repetitive stress injury in a mechanical sense. Although outwardly this appears to be a mechanical problem, the underlying story describes an information problem. The lack of variability in movement leads to abnormal mapping of the sensory cortex, which subsequently disturbs motor function. These neural maps (both sensory and motor) are more complex when movement variability is present and less complex when variability is reduced.16 –18 Movements with an optimal amount of variability avoid this abnormal mapping and essentially contribute to the neuroplasticity needed for maintaining or achieving functional skill. Thus, variability of the movements used for the task contributes information to the nervous system, which then serves to prevent injury. Too much variability also can be a problem, such as in an individual with an ataxic movement disorder. Movements that usually fall within a specific range of variability to accomplish a task such as gait unexpect-

edly fall both in and outside the acceptable range in such an individual. When one movement falls outside the expected range, the next movement is perturbed. Gait is an example of a continuous, cyclic task, within which the steps cannot be random but also are not completely repeatable or robotic. Thus, we propose that optimal movement variability lies between too much variability and complete repeatability.10 Scientists define this optimal range of variability using mathematical chaos. Furthermore, techniques from mathematical chaos describe important features of variability.19,20 How Nonlinear Tools Advance Understanding of Variability We have established that variability is not a negative feature of functional movement or of biological systems in general. However, exactly when is variability good? Moreover, how do we determine whether the variability we see is good variability or bad variability? The answers to these questions lie in understanding dynamic models of movement. The conversation about variability began with systems theory, a departure from linear models. In 1990 at the II STEP conference, dynamic systems theory (DST) was promoted as a model for the progression of movement skills and as a way to model change in movement skills for physical therapists.21,22 Dynamic systems theory introduced the notions of stability and nonlinearity to explain variability. Based on environmental, biomechanical, and morphological constraints, any biological system will self-organize to find the most stable solution. An increased amount of variability indicates less cooperative behavior among the components of the system, which eventually can drive the system to new attractor states or behaviorally stable solutions. This is a nonlinear system because the input does not lead to a

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Movement Variability and the Use of Nonlinear Tools linear change in output. Input changes the variability of the system, which may drive the emergence of a new behavior. Importantly, the measure of the variability provides a means to classify the stability of the system. Thus, in DST, small amounts of variability will indicate a highly stable behavior. The GMPT and DST perspectives are similar in that both recognize that decreased variability results from the efficient execution of a given movement pattern. Dynamic systems theory differs, however, because it proposes that at a specific critical point, variability increases and dominates the system as new movement emerges. The system becomes highly unstable and switches to a new, stable behavioral state. An example of this process occurs when an individual learns to ride a bicycle. If a child has been using training wheels, pedaling and controlling the direction of the bicycle are stable behaviors. However, when the training wheels are removed, the system is perturbed. Pedaling and directional control are very erratic and unstable as the individual learns the interaction of balance with the speed of the bicycle and controlling movement through space. At the point where the individual understands how the parameters of speed, balance, and directional control interact, the behavioral state (independent bicycle riding) becomes stable. The system must cross a critical point, where the speed of the bicycle makes balance easier for the behavior to become less variable in its new state. In DST, increased variability in the system reveals growing instability, which may lead to a shift to a new attractor, or a new behavior. Conversely, a lack of variability traps a behavior in a specific state or attractor. Thus, DST advances our understanding of transitions between be270

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havioral states, with variability considered not as error but rather as a source of behavioral change. Through DST, the importance of variability attracted the attention of developmentalists, who recognize DST as a theoretical starting point to study the emergence or selforganization of developmental actions, perceptions, and cognitive skills.23 However, the variability within an existing state (as opposed to a developing state), behavior, or established movement function has not been appreciated as important to skillful movement in adults or in describing pathological conditions. The use of linear measures, such as the standard deviation, limits our understanding of variability as a window to view the nature of adaptation in functional skills. Consequently, the ideas from DST of “stable state” and “attractor” are not intrinsically accepted as part of our therapeutic world. This is partially because we have lacked the tools to see the “hidden” information in the variability of movement progressing over time. Variability and its underlying characteristics are not completely described or quantified in either GMPT or DST, even though variability has an important role in both theories. Over time, it was recognized that neither GMPT nor DST accounts for the observation that some behaviors, which appear to be stable, paradoxically occur in quite variable ways. This is especially evident when we observe elite sports players or musicians performing skillfully. Even though they perform the same skill as others, they seem to have developed an infinite number of ways to perform it. Thus, it seems that a very stable behavioral state is supported by a very “rich” behavioral repertoire. If we consider fundamental motor skills (ie, gait, posture) and not the skills of an elite athlete, we are all skillful in our ability to walk through crowds or on diverse and

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challenging terrains. Therefore, it seems that variability does not decrease when we develop and refine a stable behavioral state but actually increases. The structure of variability (as opposed to amount) can be described using nonlinear tools. These nonlinear tools best capture variation in how a motor behavior emerges in time, for which the temporal organization in the distribution of values is of interest. Temporal organization, or “structure,” is quantified by the degree to which values emerge in an orderly (ie, predictable) manner, often across a range of time scales. Nonlinear tools quantify the nature or the structure of variability and provide the missing ability to quantify the concept of “stability” from DST. Figure 1 illustrates these concepts of variability. The figure pictures 4 different time series, with the linear measure of range and the nonlinear measure of approximate entropy (ApEn) listed beside each signal. The first and third rows show signals that look messy, seeming to be random, with one signal larger in amplitude than the other. Beside these rows, the range values reflect the varying amount of the signal between the 2 traces, with the larger number by the larger signal; however, the ApEn values are equivalent for these 2 signals. This reflects the fact that only the amplitude varies and not the structure of the time series. The second and fourth rows depict time series that are very regular, a sine wave. Again, comparison of the range shows they are different in amplitude but the same in structure, as reflected in the ApEn value. However, comparison of the first signal with the second signal (and the third signal with the fourth signal) shows that the amplitude, quantified by the range, is the same (and the standard deviation, a linear measure of variability, also would be the same) but that the structure of the series, deMarch 2009

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Figure 1. Comparison of linear and nonlinear measures of several signals. Four signals are displayed, with the respective values for range and approximate entropy (ApEn).

scribed by the nonlinear ApEn value, is different. Therefore, the amount of variability measured by the standard deviation (linear) and the structure of variability measured by ApEn (nonlinear) are not at all the same. In fact, as we will discuss later, they often are inversely related. Moreover, these different facets of variability can reveal information that may lead to different clinical decisions, which is illustrated in a clinical example later.

Nonlinear Measurement and Description How Does Variability Relate to Complexity in Functional Movement? In terms of physical therapy, variability describes the behavioral repertoire possible for a given function. We will use the example of controlling balance in a new task. If you have never walked on a tightMarch 2009

rope, imagine your first attempt. You would likely have wide-ranging excursions of your center of pressure (COP) at the support surface and wide movements of your body segments as you try to balance. This reveals large variability according to many measures, including kinematics, COP movement, and center-ofmass movement. The performer tries many different strategies that may include stiffening or loosening various body segments in an attempt to balance on the tightrope. The speed of the performer’s reactions also may be varied. However, these early attempts to accomplish the task of balancing on the tightrope would not be complex, even though they were highly variable. Complexity would arise from fine-tuned adjustments, with selected and well-practiced yet flexible strategies for balance. These strategies utilize specific information to make the optimal response, which

is characteristic of a skilled and practiced tightrope walker. The overall task is difficult to break into parts and analyze because the different components are interdependent, and there must be online adjustments calibrated to the rest of the system. The overall system is complex because the analysis of the system or function is inaccurate if examined part by part. Although describing a range of movement options quantifies variability, complexity is more difficult to measure. This is because measuring each part of the movement separately will not give us an overall measure of the complexity required for success in the function. Complexity is something that is “hidden” within the time series of a movement sequence or strategy as it emerges over time. Movements that occur at one moment affect and are affected by

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Movement Variability and the Use of Nonlinear Tools movements that occur either before or after the movement in the moment. Tools for measuring complexity come from nonlinear dynamics, and mathematical models incorporate time to describe this complexity. Linear Measures: Traditional Measures of Dispersion Linear tools to measure variability provide information about the quantity of a signal, they but do not tell us about the time-evolving nature of the signal. Linear tools include the statistics of range, standard deviation, and coefficient of variation and are limited in their explanation of human movement variability for several reasons. One reason is that data from several averaged trials generate a “mean” picture of an individual’s movement pattern. The mean removes the temporal variations of the movement and masks the true structure of variability present in the movement pattern. In addition, the valid use of linear tools to study variability assumes that variations between repetitions of a task are random and independent (of past and future repetitions), which has been shown to be false.24 –26 Finally, linear tools provide different answers when compared with nonlinear tools regarding the way that they evaluate variability. For example, traditional linear measures of postural sway quantify only the magnitude of sway and not the temporally evolving dynamics (or disequilibrium) of postural control. Despite their use in many studies, it is becoming evident that linear measures, such as the range and standard deviation of the COP, do not quantify stability of the postural control system because it is possible to have a large area of the COP path while having a stable posture or an unstable posture.27,28 Therefore, linear measures of variability do not accurately define constructs important in movement, such as stability, because they only pro-

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vide insight into the amount of variability (Fig. 1). Nonlinear tools give us additional information about the structure of variability, which describes the evolution of the movement over time. This is possibly the reason why previous theoretical accounts of variability in human movement (ie, GMPT, DST) supported the notion that small amounts of variability characterize a very stable behavioral state and that improved stability links directly to decreasing variability. If we measure improved performance linearly, this conclusion is very reasonable. However, nonlinear measures provide additional information and allow understanding of complexity. In Figure 2, it is evident that the time series signals on the left are different from each other; the first is very regular, the second seems to have some type of pattern that is difficult to describe verbally, and the third seems to have no pattern. However, when these signals are plotted versus their velocities (phase plane), it becomes clear that the first signal is completely regular, with no variation from the first cycle to the last cycle. The second signal forms a complex, yet organized, pattern, with similar paths for each cycle, but not repeating the same path and with each path dependent on a previous path and influencing the next path. The third is a random signal, where the paths are not similar and not dependent on each other. We propose that functional and healthy movement resembles chaos, the complex center picture. Nonlinear tools can determine whether a chaotic structure, or complexity, is present in movement. Why Is Variability Inherent in Biological Systems? Variability is inherent in biological systems because it ensures survival. Gerald Edelman, a Nobel laureate, described this pervasive rule as

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“population thinking,” and he used it to describe the complexities of the immune system and then expanded the principles to neuroscience and the way the mind works.29 The basic idea is that variability allows an organism or group of organisms to be more successful. This pertains to antibodies and viral agents, animal species, the nervous system, and the evolutionary progress of plants and animals. Variability allows choices among options, selection of strategies, and flexibility to adapt to variations in the environment. If an animal rigidly performs limited behaviors or functions only within a restricted environment, it is challenged for survival by a moreadaptive animal. This Darwinian principle describing the advantage of variability lies within many levels of organisms and is explicitly described for the growth of genetic complexity in an information-rich environment.30 Variability exists at many levels and within interacting components of a system, often operating at different time scales. Thus, variability may not be obvious at one level but can be revealed at another level. The variability inherent in biological systems from genes to behavior cannot be considered error if it is pervasive from one species to another and is linked to survival. Why Isn’t Movement Variability Just Error? If movement variability is equivalent to error, we can reasonably assume that more-skillful individuals would have less error (or variability) at the outset of learning and then quickly drop to zero error. In fact, the opposite is true. Individuals who use a high degree of variability in cognitive strategies at the beginning of task development have greater learning and eventual success in performing the task.31 Movement researchers have started to understand the importance of variability in motor skill learning and examine performance March 2009

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Figure 2. Time series and corresponding phase-plane plot. (A) periodic function; (B) time series from a chaotic system, the Lorenz attractor; (C) random time series.

differently. For example, a study of coordination variability in jumpers revealed a U-shaped curve in the progression of variability.32 Initial high variability occurs as different strategies are attempted. Subsequently, the learner moves toward a reduction in variability as he or she performs more successfully. Then, surprisingly, as the learner becomes an expert, the variability increases again. This skillful variability indicates increasing flexibility of skill to allow adaptation to perturbations.

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Thus, the variability at the beginning of task learning may seem like error because the task is not performed efficiently or accurately. However, this initial variability also can be seen as necessary to map the possibilities of movement for the task. It then is refined into a different type of variability when the performer is skillful. Although variability typically is known to decrease as a skill is acquired, think about how our notions of the mechanisms of skill acquisition change if we consider the role

of variability. If therapists consider variability to be error, it is seen as an impairment. However, if therapists consider variability necessary for skill acquisition, they will examine the structure of variability to help build skill. Nonlinear measures can unmask the hidden structure inherent in variability so that intervention can successfully address different features of variability as necessary during skill development. Although clinicians can easily understand the behavioral variability we have been

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Movement Variability and the Use of Nonlinear Tools discussing, such as the number of strategies for accomplishing a functional task, it is more difficult to understand what underlies that variability. Motor skills researchers increasingly find nonlinear tools useful in revealing information through time series analysis. The ApEn measure revealed significant differences between athletes who had a concussion and controls who were healthy by analysis of the COP time series, even after other standard linear measures indicated that the athletes had fully recovered from the concussion.33,34 Moraiti et al35 used the Lyapunov exponent (LyE) measure to show that a group of patients with anterior cruciate ligament deficiencies exhibited significantly more rigid and predictable walking patterns than controls who were healthy, suggesting a decrease in system complexity and narrowed functional responsiveness. Kurz and Stergiou36 used an entropy measure to show that neurophysiological changes associated with aging may result in less certainty of the neuromuscular system in selecting a stable gait. Therefore, utilizing a nonlinear perspective to examine variability can assist in differentiating between health and nonhealth. Nonlinear Measures: New Ways to Describe the Nature of Variability We have established that the amount and structure of variability are 2 different things (Fig. 1). As a result, changes in measures of the amount of variability may be in a completely different direction than changes in measures that evaluate the structure of variability. Similarly, in studies of postural control, gait, and force production, researchers found that as measures of the amount of variability increased, measures of the structure or organization of variability decreased.37–39 Let us reflect on an example of postural sway in standing. 274

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As a person’s range of sway increases, the standard deviation increases, indicating a greater amount of variability. However, if we use a nonlinear tool to examine the features of the variability in postural sway, we may note that sway has become more regular (with morerepeatable movement patterns). This makes sense, because the individual must have some specific strategy of control to make the appropriate adjustments for balance maintenance when the range of movement is large; otherwise, he or she would fall. The relationship between linear and nonlinear tools as described above can further our understanding of the emergence of functional, adaptive movement. Nonlinear measures always describe a time series, or a series of measurements taken at specific intervals over uninterrupted time. For example, the range of motion of a joint during each step as a person walks, taken with an electrogoniometer or motion analysis equipment sampled at 30 times per second over a 2-minute period of time, can be presented as a time series. Looking at a measure in the context of time because it enables us to understand the ability of the system to adapt as conditions change. The period of time may vary from seconds to days, but the important concept is that a behavior emerging from the complex system can be described over time with specific mathematical nonlinear tools that are used to quantify order, predictability, regularity, and complexity. A time series also is valuable because information that is important to understand the health or function of the individual may be revealed at different time scales. Characterizing the nature of the complexity present in a time series is of great interest in many scientific domains, including biology. Healthy systems, whether referring to heart

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rate or the COP time series, correspond to a rich behavioral state with high complexity.10 This state is defined as highly variable fluctuations in physiological processes resembling mathematical chaos. This allows the system to have a relatively predictable course, which can adapt if a change in the environment occurs. Low levels of complexity correspond to states that resemble random, noisy, and erratic behavior or rigid, periodic, and regular behavior. Therefore, with low complexity, adaptability suffers. Nonlinear measures allow us to extract information hidden in a time series and to evaluate complexity. Some examples of possible tools follow. Approximate entropy is a measure that can quantify the regularity or predictability of a time series (Fig. 1).40 – 44 Increasing ApEn values reveal greater irregularity. Conversely, lower values reveal a more regular or periodic behavior. Approximate entropy has been useful in the identification of differences between young and old people in the COP time series in standing,45 in revealing deficits in athletes with a concussion compared with athletes who were healthy,33,34 and in detecting developmental changes in sitting postural control.25 Approximate entropy measures the probability that the configuration of one segment of data in a time series will allow the prediction of the configuration of another segment of the time series a certain distance apart.41 Data segments with a greater likelihood of having the same configuration or pattern upon comparison will result in lower approximate entropy values, and data segments with a low likelihood of similarity between segments will result in higher values. Values closer to zero are consistent with maximum regularity, and values nearing 2 represent maximum irregularity.

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Movement Variability and the Use of Nonlinear Tools Clinically, ApEn is useful for understanding the predictability of a movement. For example, Cavanaugh et al46 utilized ApEn to determine the predictability of everyday walking activities, using time series data from a pedometer. They found that inactive elderly individuals walked less and had more-predictable walking activity than active elderly individuals. This finding allows a more complete picture of the differences in walking between inactive and active individuals and allows the clinician to understand why some elderly people may have a more-difficult time responding to fluctuations in routine or adapting to different walking demands. This insight suggests intervention that can elicit greater complexity in the activity, rather than just simply increasing the amount of activity. The largest LyE is a nonlinear measure that can measure the divergence of the movement trajectories (Fig. 2). The LyE describing purely sinusoidal and completely repeatable data with no divergence in the trajectories is zero because the trajectories overlap rather than diverging (Fig. 2A). This shows minimal change in the structure of the variability over time in the data. The LyE for random, noisy data indicates greater divergence in the data trajectories (Fig. 2C). The LyE values for the random data are larger, with values above 0.4.19 The LyE values from data that are described by mathematical chaos (ie, Lorenz attractor; Fig. 2B) are between these 2 extremes. Thus, the values between random and periodic define complexity, or highly variable fluctuations in physiological processes resembling mathematical chaos. The LyE has been used with gait time series data to characterize the underlying complexity during movement.19,47– 49

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Using the LyE, Yamada50 reported body sway that resembles mathematical chaos from COP data during standing in adults who were healthy, thus revealing inherent complexity. Use of the LyE in an ongoing intervention study with infants with cerebral palsy was important as a finegrained measure to detect advancing postural control in sitting, when linear measures of the COP and clinical tools did not detect change.51 A standardized test, the sitting section of the Gross Motor Function Measure,52 did not consistently detect change. However, a variety of features of the child’s movement (more attempts to stay vertical, the ability to turn the head without falling, more attempts to reach while sitting with support) were noted as changes in behavior by the parents and therapist. These small changes in movement, or attempts at new strategies, were quantified by the nonlinear measures of ApEn and LyE, but were not indicated in the linear measures. This is an example of a nonlinear tool providing “hidden” information that would not be easily measured or documented otherwise. Surrogation is a technique used to determine whether the source of a given time series is deterministic (has order) in nature.19,53 The technique compares the actual data and a random data set that has a similar structure with the original data set in question. That is, the deterministic structure from the original data set is removed by generating a random equivalent with the same mean, variance, and power spectra as the original data. Subsequently, the LyE (or another nonlinear measure) value of the surrogate data is compared with the LyE value of the original data. Significant differences between the LyE value of the surrogate data and the LyE value of the original data indicate that the original data are not randomly derived and, therefore, may be deterministic and possibly

complex in nature. Harbourne and Stergiou25 and Boker et al26 have used this technique to show that variability in the COP time series from infants during the development of independent sitting is not just noise but has a deterministic origin. This means that infants learning to sit are not just randomly “wiggling.” For the clinician, it is important to recognize that within these outwardly unorganized and noisy-looking movements are orderly patterns and the beginnings of strategies for postural control. The implication for therapists is that a movement that is just beginning to emerge will be unorganized, but necessarily so. The variability inherent in this disorganization may be necessary for ultimate successful selection of movement and postural strategies. This may reflect the system “mapping” the territory around the skill region, allowing the individual to “get back” to the successful region when perturbed. Nonlinear analysis includes several additional tools such as detrended fluctuation analysis,54 correlation dimension, mutual information, Hurst exponent, symbolic entropy, recurrence quantification analysis, and others. These methods have a common goal: to evaluate the structure or organization of variability and uncover the underlying complexity. However, they differ in the mathematic manipulation of the available time series. Here we do not provide a complete list of all nonlinear tools but describe only a few tools to provide the basic concepts of nonlinear analysis. A more comprehensive review on the topic is available for the interested reader.19

Application of Nonlinear Concepts in Practice Complexity in Health Goldberger55 described the use of complexity at the bedside for physicians by providing examples of periodic behavior of pathologic systems.

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Movement Variability and the Use of Nonlinear Tools Disease brings about a loss of complexity, with resulting increased rigidity, such as Cheyne-Stokes breathing in patients with heart failure, tremors in patients with neurologic disease, and a sinusoidal appearance of heart rate variability in patients with congestive heart failure.56,57 The medical field is beginning to recognize the need for a nonlinear view toward complexity, particularly for problems that affect multiple systems. Ahn et al58 described a traditional reductionist approach as the antithesis of a complexity-oriented approach, with the reductionist approach being appropriate for use with acute, single-system problems, such as an acute infection. However, a disease such as diabetes requires management of a problem affecting many systems that interact in various ways. Extending the nonlinear view, it could be argued that very few problems are truly single-system problems and solvable by linear reasoning because each system interacts with other systems for optimal function. As in medicine, many clinical problems seen in physical therapy need a nonlinear approach. Clinical uses for nonlinear analysis appear in a variety of disciplines, including cardiology, neurology, and psychiatry. Heart rate analysis using ApEn has been used to evaluate risk factors for sudden infant death syndrome.41,42 Nonlinear analysis has been useful in verification of implantable cardiac defibrillator interventions by using entropy analysis of heart rate variability.59 In addition, postural control analysis using stabilometry has been improved by the addition of nonlinear analysis, which can serve to more accurately identify features of postural control indicating subtle problems in infants,51 developmental differences between young and elderly people,43 or changes that accompany a disease state such as parkinsonism.60,61 Gait variability also has been studied and 276

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modeled using nonlinear tools.62 Applications in the clinic for physical therapy intervention are now a realistic possibility. Clinical Application of Nonlinear Principles and Use of Complexity in Physical Therapy Appendix 2 lists some proposed principles for physical therapy intervention emerging from the theory and applications in other fields. An example of clinical application in intervention follows. Two clinicians must perform an initial evaluation on an elderly man who has had a stroke. One therapist will use a traditional, linear approach, and the other therapist will use an approach based on principles of nonlinearity. As a general rule, the therapist using a linear approach assumes that decreasing the variability of movement is equivalent to improving functional skill. Therefore, the therapist has in mind the “correct” movement pattern for various functional skills, which she will guide her patient toward during intervention. Using principles of motor learning, the therapist first gives 100% feedback, and then fades subsequently to 50% feedback for various skills.63 Because the therapist wants measurable outcomes, she uses a standard walking course that has 7.6-m (25-ft) increments up to 61 m (200 ft). To determine decreasing variability and increasing accuracy, the therapist counts errors in the set of procedures to sit-stand-walk over a standardized course. This principle of fading feedback applies as she guides the patient in transferring out of the wheelchair. She first locks the brakes of the patient’s wheelchair and tells the patient to scoot to the edge of the chair. The patient receives assistance to lean forward and place his feet under his center of mass, both with physical guidance and with ver-

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bal guidance. As the patient starts to reach for the walker, the therapist tells the patient to push up from the arms of the chair. The clinician then has the patient practice the sit-tostand activity 5 times, giving feedback as described each time. The next day, the patient makes the same errors, and the therapist provides less cueing, hoping to fade cueing over the next 2 weeks. In addition to counting errors during the sit-standwalk practice, the therapist notices that the patient’s steps are of unequal length and the affected side shuffles forward rather than exhibiting a heel-toe pattern of stepping. The therapist uses the same approach of using verbal and physical guidance to point out the errors in the patient’s gait pattern, fading the feedback over time and counting errors within the measured distance of the walking track. In contrast, the therapist using a nonlinear approach assumes that the general rule for this patient is to enhance complexity of movement in order to improve gait and functional mobility skills. This will include the concept of disequilibrium, or keeping the patient in a state of dynamic equilibrium (as described earlier) during therapy sessions. Additionally, the therapist uses the strategy of providing only information for the patient on how to do a task if the patient does not have a way to get the information; the rationale is that variability is encouraged if the patient seeks information independently, and the patient is kept in a dynamic state. The therapist first asks the patient whether he would like to go sit in a chair 3.05 m (10 ft) away next to his wife. He agrees, and the therapist invites the patient to begin the task, assuring the patient that the task is safe while the therapist is present. The patient pushes back in the unlocked wheelchair, and the wheelMarch 2009

Movement Variability and the Use of Nonlinear Tools chair rolls back, putting the patient further away from the targeted goal. The therapist notes that this is a point where the patient is not gathering enough information for the task and addresses this problem by having the patient do some guided exploration within the task to increase flexibility in terms of availability of options. The therapist tells the patient that he can roll the wheelchair in many different directions just using his feet and challenges him to find 10 different directions of wheelchair movement by pushing with his feet. During this exercise, the patient maps the way that foot force affects the wheelchair movement. The therapist asks whether there is a way to keep the wheelchair from rolling, and the patient remembers the brakes. The patient then makes multiple errors in his attempts to stand, including incorrect foot placement, reaching for the walker instead of the wheelchair arms, and leaning back and to one side instead of leaning forward to get up. However, the therapist does not provide guidance at this point because the patient is not making the same error but rather is exhibiting a variety of strategies, which at this stage of skill development is desirable. At several points, the therapist asks whether the strategy just used was successful, and when answered in the negative, reminds the patient to try some different strategies, just as they did by pushing the wheelchair in different directions with the feet. Occasionally, the therapist gives light touch cues to suggest an effective strategy. At the end of the trial-and-error session, the patient stands and walks over to his wife to sit in the chair. After resting and conversing, the therapist asks the patient to walk back to the wheelchair, without giving any verbal instructions. The patient makes a few errors, selfcorrects, and visibly thinks through March 2009

the process of coming to a standing position but is markedly faster than on the first try. The next day the patient makes only one error, moves from a sitting position to a standing position with guarding, and elects to sit on a couch for some social contact with another patient. The therapist notes that during walking the patient had short steps and shuffled with the affected leg. The therapist sees this as a possible problem. The therapist then uses barefoot tasks, having the patient identify different textures or objects under the feet, place pressure on different parts of his feet during walking and standing, and walk with a variety of patterns through different paths and obstacle courses. The therapist is more concerned about increasing the adaptive capacity of walking by increasing variability at a functional speed than in producing a consistent heel-toe pattern. What differs in these approaches? The basic difference is that the therapist using the linear measure seeks to reduce variability of responses within the intervention and the measurement of the task goals and come to a state of complete equilibrium, whereas the therapist using the nonlinear measure seeks to enhance complexity by encouraging slight disequilibrium, particularly at the initial stage of task learning. The therapist using the nonlinear measure builds complexity into the task, with the use of multiple systems: cognitive, social, motor, and sensory. The practice space is strategically varied, and multiple movement approaches are encouraged, as well as having an expanded environmental context in which the practice takes place. In addition, the functional task proceeds in such a way that the series of movements within the task are related to each other and dependent on each other. In the linear measure approach, each subtask is a task unto itself and separated from the other

parts of the task due to the interjection of the therapist’s instructions. Therefore, the series of movements and postural adjustments in the task of standing from the wheelchair are unrelated to each other and unrelated to the overriding environmental context and underlying values of the patient. Most importantly, the therapist using the linear measure prevents response flexibility from being part of the learning process by insisting that the patient avoid errors, precisely because the therapist considers them undesirable. Thus, this therapist focuses on the absolute “correct” pattern of movement, allowing little complexity in the intervention and preventing the emergence of a flexible strategy that works for this individual patient. If these therapists had the benefit of examining the patient’s initial gait by linear and nonlinear analysis, they may have noted high variability of the step length (by looking at the standard deviation) but low values on a nonlinear measure (LyE), somewhat like the signal shown in the last row of Figure 1. If the therapists wanted to decrease variability, they would work toward a time series with a signal like that shown in the second row of Figure 1 (linear approach). However, if the goal was to increase the structure of the variability for greater complexity, they would work in a nonlinear fashion toward a time series with a signal like that shown in the third row of Figure 1. You can see that looking at variability from these differing perspectives could lead toward different types of intervention, as we have just described. Another example of the use of the principles of nonlinearity to acquire or maintain motor skill is a treatment approach for the movement problems of patients with Parkinson disease (PD). The BIG training program focuses on a single attentional pa-

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Movement Variability and the Use of Nonlinear Tools rameter to drive changes in the motor system.64 This parameter is “Think BIG,” emphasizing attention to large-amplitude movements. The principles of treatment include highintensity, multiple repetitions, saliency, and complexity, leading to neuroplastic changes and functional improvement. Although patients with PD have many movement problems, including problems with speed, smoothness, accuracy, and quality of movement patterns such as step length during gait, this approach ignores these other movement deficiencies. The focus on increasing amplitude changes the initial conditions driving the movement and shifts the system into a new state space where the movement is more skillful and complex. In this way, the BIG approach addresses complexity because amplitude serves as the avenue to provide enhanced adaptability and increased responsiveness. Several principles of nonlinearity are inherent in this approach. First, the overall variability of movement behavior for these patients is increased as a fallout of the increase in amplitude. The individuals with PD can now make large movements as well as small movements, and all the increments in between, whereas they had previously been restricted to only small movements. Second, another principle of nonlinearity is apparent because a change in just one movement parameter, amplitude, causes a change in other movement parameters that are difficult to predict precisely. Third, the input needed for a motor system change can come from a different system (eg, cognitive, attentional, perceptual). The focus on attending to making a “bigger” movement, in this case, recalibrates the perceptual system to recognize when a movement is actually big versus the small movements common to individuals with PD. The therapist would not teach a 278

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particular movement form or strategy, but rather let the patient discover that increased complexity of various movements has an inherent value in producing success during daily tasks. Use of Nonlinear Tools in Motor Skill Research Setting up methodology for nonlinear analysis in a research project may seem to be a daunting task. Here are suggestions to keep in mind when designing such a project: 1. Carefully design your experimental setup, incorporating a matched control group of healthy participants to provide reference points for observed changes in the nonlinear parameters. 2. Seek partnerships with mathematicians, neuroscientists, and biomechanists who are knowledgeable about nonlinear tools. Technical expertise is needed from start to finish on the project, including sampling frequency, the length of the time series needed, and examination of the data with appropriate nonlinear tools for your questions. Knowledge of movement measurement is a benefit in interpretation of the results. Remember that you will not “speak the same language” as your collaborator, and be very patient so that ideas can be exchanged comfortably. 3. Measure a task, skill, or variable that may show emergence of a new level of function. 4. Variable and task selection must incorporate a time series; you should take as long a time series as possible within the constraints of your target population and considering the tools you are using. Many nonlinear tools need thousands of data points for accurate use.

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5. Examine pilot data to get an idea of the nature of the fluctuations in the variable or in the behavior. Plotting position and velocity against each other and even 3-dimensionally by incorporating acceleration can help examine the organization in the data. 6. Replication of a previously reported project, but with the addition of nonlinear tools, can help with planning the methods and interpreting your results. This is a new area, and, consequently, it is difficult to know the “standard” approach to common issues. 7. If you are considering an intervention study, keep in mind that a focus on increasing or decreasing variability will need to be determined carefully, using a variety of tools to measure both linear and nonlinear factors. The 2 approaches are complementary, and they do not negate each other. 8. Measure more than one variable; different variables may reflect component skills or constructs differently. Limitations of Nonlinear Measures Because nonlinear measurement tools require the use of mathematical equations and software to evaluate time series data, nonlinear analysis is primarily done in the research setting. However, the burgeoning interest in nonlinear tools in many scientific fields bodes well for clinicians. In the future, there will likely be devices that have embedded software to calculate important measures of variability using nonlinear tools. Another limitation is the lack of understanding of variability and complexity in the field of physical therapy. Physical therapists are taught to use a reductionist approach, as in most medical fields. This lack of introduction to nonlinear principles March 2009

Movement Variability and the Use of Nonlinear Tools early in the education of physical therapists biases the field against the productive use of variability and complexity. Additional limitations of the technique itself create challenges for clinical use. Translation of nonlinear measures to clinical problems requires concurrent use of linear tools to make associations and determine clinical meaning. The lengthy time series required for analysis prohibits the use of nonlinear tools for movement that is extremely limited. Lastly, these measures require multiple repetitions or cycles of a movement.

Conclusions Optimal variability in human movement is a characteristic of healthy functioning. Nonlinear tools reveal complexity inherent in normal variability, indicating features of motor control that are important for physical therapists to measure and implement in intervention. The application of principles based on nonlinear dynamics and use of nonlinear tools for analysis can provide innovations to guide physical therapist practice and research. Both authors provided concept/idea/project design and writing. This work was funded by a National Institute of Child Health and Human Development grant (NIH 1K25 HD 047194-01A1) to Dr Stergiou (primary investigator); a US Department of Education, National Institute for Disabilities and Rehabilitation Research grant (USDE FIP 84.1336-1) to Dr Stergiou (primary investigator); and the Nebraska Research Initiative. This article was received May 1, 2008, and was accepted December 12, 2008. DOI: 10.2522/ptj.20080130

References 1 Bernstein N. The Coordination and Regulation of Movements. London, United Kingdom: Pergamon Press; 1967.

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2 Larin H. Quantifying instructional interventions in pediatric physical therapy with the Motor Teaching Strategies Coding Instrument (MTSCI-1): a pilot study. Internet J Allied Health Sci Prac. 2007;5: 1–9. Available at: http://ijahsp.nova.edu/ articles/vol5num1/Larin.pdf. Accessed March 16, 2008. 3 Katerndahl DA. Is your practice really that predictable? Nonlinearity principles in family medicine. J Fam Prac. 2005;54: 970 –977. 4 Rickles D, Hawe P, Shiell A. A simple guide to chaos and complexity. J Epidemiol Community Health. 2007;61:933–937. 5 Klonowski W. From conformons to human brains: an informal overview of nonlinear dynamics and its application in biomedicine. Nonlinear Biomed Phys. 2007;1:5–18. Available at: http://www. nonlinearbiomedphys.com/content/1/1/5. Accessed March 16, 2008. 6 Newell KM, Liu YT, Mayer-Kress G. Time scales in motor learning and development. Psychol Rev. 2001;108:57– 82. 7 Walleczek J. Self-organized Biological Dynamics and Nonlinear Control: Toward Understanding Complexity, Chaos, and Emergent Function in Living Systems. Cambridge, United Kingdom: Cambridge University Press; 2000. 8 Wray RE, Laird JE. Variability in human behavior modeling for military simulations. Presented at: Behavior Representation in Modeling and Simulation Conference (BRIMS); 2003. Available at: http://www.speakeasy.org/⬃wrayre/pubs/ VariabilityinHumanBehaviorModeling_Wray Laird_BRIMS2003.pdf. Accessed March 16, 2008. 9 Definition of variability. Available at: http: //www.webster-dictionary.net/definition/ variability. Accessed March 16, 2008. 10 Stergiou N, Harbourne R, Cavanaugh J. Optimal movement variability: a new perspective for neurologic physical therapy. J Neurol Phys Ther. 2006;30:120 –129. 11 Glass L, Mackey MC. From Clocks to Chaos. Princeton, NJ: Princeton University Press; 1988. 12 Schmidt RA, Lee TD. Motor Control and Learning: A Behavioral Emphasis. 4th ed. Champaign, Ill: Human Kinetics Publishers; 2005. 13 Schmidt RA. Motor schema theory after 27 years: reflections and implications for a new theory. Res Q Exerc Sport. 2003;74: 366 –375. 14 Price I. Complexity, complicatedness and complexity; a new science behind organizational intervention? E:Co. 2004;6:40 – 48. 15 Goldberger AL. Heart rate variability: techniques, applications and future directions. Available at: http://www.physionet.org/ events/hrv-2006/goldberger-1.pdf. Accessed March 16, 2008. 16 Byl NN, Nagarajan SS, Merzenich MM, et al. Correlation of clinical neuromusculoskeletal and central somatosensory performance: variability in controls and patients with severe and mild focal hand dystonia. Neural Plast. 2002;9:177–203.

17 Nudo RJ, Milliken GW, Jenkins WM, Merzenich MM. Use-dependent alterations of movement representations in primary motor cortex of adult squirrel monkeys. J Neurosci. 1996;16:785– 807. 18 Merzenich MM, Jenkins WM. Reorganization of cortical representations of the hand following alterations of skin inputs induced by nerve injury, skin island transfers, and experience. J Hand Ther. 1993;6:89 –104. 19 Stergiou N, Buzzi UH, Kurz MJ, Heidel J. Nonlinear tools in human movement. In: Stergiou N, ed. Innovative Analyses for Human Movement. Champaign, IL: Human Kinetics Publishers; 2004:63–90. 20 Shelhamer M. Nonlinear Dynamics in Physiology: A State Space Approach. Hackensack, NJ: World Scientific Publishing Co; 2007. 21 Heriza C. Designing practice for motor learning: clinical implications. In: Lister MJ, ed. Contemporary Management of Motor Control Problems: Proceedings of the II STEP Conference. Alexandria, VA: Foundation for Physical Therapy; 1991. 22 Giuliani CA. Designing practice for motor learning: clinical implications. In: Lister MJ, ed. Contemporary Management of Motor Control Problems: Proceedings of the II STEP Conference. Alexandria, VA: Foundation for Physical Therapy; 1991. 23 Thelen E, Smith LB. A Dynamic Systems Approach to the Development of Cognition and Action. Cambridge, MA: MIT Press; 1999. 24 Hausdorff JM, Purdon PL, Peng CK, et al. Fractal dynamics of human gait: stability of long-range correlations in stride interval fluctuations. J Appl Physiol. 1996;80: 1448 –1457. 25 Harbourne RT, Stergiou N. Nonlinear analysis of the development of sitting postural control. Dev Psychobiol. 2003;42:368 –377. 26 Boker SM, Schreiber T, Pompe B, Bertenthal BI. Nonlinear analysis of perceptual-motor coupling in the development of postural control. In: Kantz H, Kurths J, Mayer-Kress G, eds. Nonlinear Techniques in Physiological Time Series Analysis. Heidelberg, Germany: Springer; 1998:251–270. 27 Palmieri RM, Ingersoll CD, Stone MB, Krause BA. Center-of-pressure parameters used in the assessment of postural control. J Sport Rehabil. 2002;11:51– 66. 28 Hughes MA, Duncan PW, Rose DK, et al. The relationship of postural sway to sensorimotor function, functional performance, and disability in the elderly. Arch Phys Med Rehabil. 1996;77:567–572. 29 Edelman GM. Bright Air, Brilliant Fire: On the Matter of the Mind. New York, NY: Basic Books; 1992. 30 Adami C, Ofria C, Collier TC. Evolution of biological complexity. Proc Natl Acad Sci U S A. 2000;97:4463– 4468. 31 Siegler RS. Emerging Minds: The Process of Change in Children’s Thinking. New York, NY: Oxford University Press Inc; 1996.

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Movement Variability and the Use of Nonlinear Tools 32 Wilson C, Simpson SE, van Emmerik RE, Hamill J. Coordination variability and skill development in expert triple jumpers. Sports Biomech. 2008;7:2–9. 33 Cavanaugh, JT, Guskiewicz KM, Giuliani C, et al. Recovery of postural control after cerebral concussion: new insights using approximate entropy. J Athl Train. 2006; 41:305–313. 34 Cavanaugh JT, Guskiewicz KM, Stergiou N. A nonlinear dynamic approach for evaluating postural control: new directions for the management of sport-related cerebral concussion. Sports Med. 2005;35:935–950. 35 Moraiti C, Stergiou N, Ristanis S, Georgoulis AD. ACL deficiency affects stride-tostride variability as measured using nonlinear methodology. Knee Surg Sports Traumatol Arthrosc. 2007;15:1406 –1413. 36 Kurz M, Stergiou N. The aging human neuromuscular system expresses less certainty for selecting joint kinematics during gait. Neurosci Lett. 2003;348:155–158. 37 Slifkin AB, Newell KM. Noise, information transmission, and force variability. J Exp Psychol Hum Percept Perf. 1999;25: 837– 851. 38 Riley MA. Turvey MT. Variability of determinism in motor behavior. J Mot Behav. 2002;34:99 –125. 39 Balasubramaniam R, Riley MA, Turvey MT. Specificity of postural sway to the demands of a precision task. Gait Posture. 2000;11:12–24. 40 Oppenheim U, Kohen-Raz R, Alex D, et al. Postural characteristics of diabetic neuropathy. Diabetes Care. 1999;22:328 –332. 41 Pincus SM, Gladstone IM, Ehrenkranz RA. A regularity statistic for medical data analysis. J Clin Monit. 1991;7:335–345. 42 Pincus SM. Approximate entropy as a measure of system complexity. Proc Natl Acad Sci U S A. 1991;88:2297–2301. 43 Newell KM, Van Emmerik REA, Lee D, Sprague RL. On postural stability and variability. Gait Posture. 1993;1:225–230.

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44 Georgoulis AD, Moraiti C, Ristanis S, Stergiou N. A novel approach to measure variability in the anterior cruciate ligament deficient knee during walking: the use of the Approximate Entropy in Orthopaedics. J Clin Monit Comput. 2006;20:11–18. 45 Newell KM. Degrees of freedom and the development of center of pressure profiles. In: Newell KM, Molenaar PMC, eds. Applications of Nonlinear Dynamics to Developmental Process Modeling. Hillsdale, NJ: Erlbaum;1997:63– 84. 46 Cavanaugh JT, Coleman KL, Gaines JM, et al. Using step activity monitoring to characterize ambulatory activity in community-dwelling older adults. J Am Geriatr Soc. 2007;55:120 –124. 47 Buzzi UH, Ulrich BD. Dynamic stability of gait cycles as a function of speed and system constraints. Motor Control. 2004;8: 241–254. 48 Kurz M, Stergiou N. Do horizontal propulsive forces influence the nonlinear structure of locomotion? J Neuroeng Rehabil. 2007;1:4 –30. 49 Yoshino K, Motoshige T, Araki T, Matsuoka K. Effect of prolonged free-walking fatigue on gait and physiological rhythm. J Biomech. 2004;37:1271–1280. 50 Yamada N. Chaotic swaying of the upright posture. Hum Mov Sci. 1995;14:711–726. 51 Harbourne RT, Deffeyes JE, DeJong SL, et al. Nonlinear variables can assist in identifying postural control deficits in infants. J Sport Exerc Psychol (Suppl). 2007;29:S9. 52 Russell D, Rosenbaum P, Gowland C, et al. Gross Motor Function Measure. 2nd ed. Hamilton, Ontario, Canada: McMaster University; 1993 53 Miller DJ, Stergiou N, Kurz MJ. An improved surrogate method for detecting the presence of chaos in gait. J Biomech. 2006;39:2873–2876. 54 Hausdorff JM, Peng CK, Ladin Z, et al. Is walking a random walk? evidence for longrange correlations in stride interval of human gait. J Appl Physiol. 1995;78: 349 –358.

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55 Goldberger AL. Non-linear dynamics for clinicians: chaos theory, fractals, and complexity at the bedside. Lancet. 1996;347: 1312–1314. 56 Goldberger AL, Amaral LA, Hausdorff JM, et al. Fractal dynamics in physiology: alterations with disease and aging. Proc National Acad Sci USA. 2002;99: 2466 –2472. 57 Goldberger AL, Rigney DR, West BJ. Chaos and fractals in human physiology. Sci Am. 1990;262:42– 49. 58 Ahn AC, Tewari M, Poon C, Phillips RS. The limits of reductionism in medicine: could systems biology offer an alternative? Plos Med. 2006;3:e208. 59 Przybylskia A, Baranowskia R, Zebrowskib JJ, Szweda H. Verification of implantable cardioverter defibrillator (ICD) interventions by nonlinear analysis of heart rate variability: preliminary results. Europace. 2004;6:617– 624. 60 Bartsch R, Plotnik M, Kantelhardt JW, et al. Fluctuation and synchronization of gait intervals and gait force profiles distinguish stages of Parkinson’s disease. Physica A. 2007;383:455– 465. 61 Schmit JM, Riley MA, Dalvi A, et al. Deterministic center of pressure patterns characterize postural instability in Parkinsons disease. Exp Brain Res. 2006;168: 357–367. 62 Hausdorff JM. Gait variability: methods, modeling, and meaning. J Neuroeng Rehabil. 2005;2:1–9. 63 Winstein CJ. Knowledge of results and motor learning: implications for physical therapy. Phys Ther. 1991;71:140 –149. 64 Farley BG, Koshland GF. Training BIG to move faster: the application of the speedamplitude relation as a rehabilitation strategy for people with Parkinson’s disease. Exp Brain Res. 2005;167:462– 467.

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Movement Variability and the Use of Nonlinear Tools Appendix 1. Working Definitions for Terms Needed to Understand Nonlinear Concepts

Attractor, attractor state: Behaviorally, an attractor is a preferred state (ie, walk, run). Mathematically, an attractor is a set to which a dynamic system evolves after time. Points that get close enough to the attractor remain close even if slightly perturbed. Geometrically, an attractor can be a point, a curve, or even a fractal structure known as a strange attractor. Describing the attractors of chaotic dynamical systems is the focus of the mathematical theory of chaos. Chaos: One subject in the field of nonlinear dynamics, which is part of the broader field of dynamic systems.

have a deterministic pattern, meaning that their future dynamics are fully defined by their initial conditions. This behavior is known as mathematical or deterministic chaos, or simply chaos. Noise: That part of a system description that is not deterministic. For simplicity, it is usually assumed to have a simple form, such as white noise. Nonlinear measures: Measures that quantify the relationship, or dependency, of the numbers throughout the time series. Nonlinear measures describe the patterns or structure within the time series, not simply the quantity.

Complexity: Highly variable fluctuations in physiological processes resembling mathematical chaos.

Periodic: Happening or appearing at regular intervals like a sine wave.

Constraints: Variability is introduced into the system from the constraints that dictate the system’s behavior. The constraints are morphological, biomechanical, environmental, and task specific.

Phase plane: A representation of the behavior of the dynamic system in state space. Typically, it takes the form of a 2-dimensional plot of the position X of the time series (on the horizontal-axis) versus the first derivative X⬘ (on the vertical axis).

Deterministic: For a given starting condition, the future state of the system is determined; randomness is not present.

Random: Lack of pattern or order; lack of a relationship between points in a time series or parts of a system.

Dynamic system: A system that evolves over time. Dynamic systems theory (DST): An area of applied mathematics used to describe complex dynamic systems. Linear measures: Measures that describe the central tendency or dispersion of the values within a set of numbers, such as the mean, the range, and the standard deviation.

Regularity: The repeatability of a pattern. Self-organization: The formation of moving patterns is a function of the cooperation of all of the subsystems and their interaction with the environment; it is not centrally coded or commanded.

Sinusoidal: A regular waveform that exactly repeats itself over time. Stability, stable state: A rich behavioral state characterized by high complexity. The stability of an orbit in a dynamic system determines whether nearby orbits remain near or are repelled by that orbit. State space: The set of all possible states of a dynamic system. When modeling a dynamic system, the number of variables needed to describe the system is called the dimension of the state space. Systems theory: A field of science studying the nature of complex systems. Time series: Time series data are a specific example of an ordered list of numbers, where time is the parameter that gives order to the list. Suggested Readings Gleick J. Chaos: Making a New Science. New York, NY: Penguin Books; 1987. Smith LB, Thelen E. Development as a dynamic system. Trends Cogn Sci. 2003:7; 343–348. Stergiou N, Buzzi UH, Kurz MJ, Heidel J. Nonlinear tools in human movement. In: Stergiou N, ed. Innovative Analyses for Human Movement. Champaign, IL: Human Kinetics Publishers; 2004:63–90. Stergiou N, Harbourne R, Cavanaugh J. Optimal movement variability: a new perspective for neurologic physical therapy. J Neurol Phys Ther. 2006;30:120 –129. Strogatz S. Sync: How Order Emerges From Chaos in the Universe, Nature, and Daily Life. New York, NY: Hyperion; 2004.

Mathematical chaos: The behavior of several related systems many times seems to be erratic, with no order (ie, random). However, nonlinear measures demonstrate that such variations are not random but

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Movement Variability and the Use of Nonlinear Tools Appendix 2. Proposed Principles of Nonlinearity in the Acquisition and Maintenance of Motor Skill

1. An optimal amount of variability is necessary for movement to be functional and efficient; normal, efficient movement includes both deterministic and random characteristics, which can fluctuate within an optimal range. 2. Healthy motor control has characteristics of nonlinearity, including the spontaneous generation of new patterns of movement, movement possibilities that are sensitive to initial conditions, and a limited ability to precisely predict future movement based on current status. 3. If variability increases in a system without enough variability, new movement options can emerge spontaneously.

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5. Input into the system can drive the system into other possibilities for movement that are not predictable. The input can come from more than one system (ie, not only motor but also sensory, cognitive, emotional, or social). 6. Measures of complexity can help predict the emergence of a new

behavior or direct appropriate intervention to allow variability changes to affect function. 7. Traditional measures of variability are not equivalent to measures of complexity. For example, as the measure of standard deviation increases, the measure of approximate entropy can decrease. Measures of complexity describe the structure of variability in new ways that can help quantify subtle movement changes or characteristics. 8. Complexity is necessary for systems to adapt to changing conditions; loss of complexity means decreased ability for adaptation.

Daniela Corbetta

One of the ways in which progress in movement performance and coordination traditionally has been assessed is to measure the amount of movement variability across repetitions of the same movement. In their perspective article, Harbourne and Stergiou1 argue that progress in movement coordination should rather be indexed by analyzing the hidden structure of movement variability embedded in time series using time-dependent, nonlinear tools rather than by assessing the overall amount of variability. By focusing their article on the time structure of variability, the authors make a point of fundamental importance for our understanding of biological motion and its implications for development, learning, and rehabilitation. They show through clear examples that patterns with similar ranges of variation can contain very different 282

4. Because motor function is sensitive to initial conditions, each person brings a slightly different set of conditions to a motor problem, and the optimal solution to that problem may be unique to that person. Therefore, therapists cannot “prescribe” the best motor pattern or strategy that is common to all patients.

structures. These structures, which are not detected by traditional measures of response variation (such as standard deviations or coefficients of variation), are critical for understanding change and progress in movement control. They provide direct information on the regulation processes used to control movement. Harbourne and Stergiou also remark that variability does not always decrease linearly as a function of learning time and control. In some instances, and as further illustrated below, it can evolve in a nonlinear fashion over learning time. Harbourne and Stergiou tell us that variability should not always be considered a reflection of movement error or imperfect control. As they point out, variability is an omnipresent characteristic of biological motion, regardless of the stage of profi-

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ciency. Whether one is beginning to learn a new skill, is an expert performer, is experiencing a decline in performance, or is being rehabilitated, variability is an inherent property of the process of movement regulation. In all of those cases, however, variability may have a different structure. Again, this is why the structure of variability should be looked at closely; patterns of variability can directly inform the practitioner about the control process involved in the movement. In their examples, Harbourne and Stergiou remind us that even within the most skilled and most highly repeatable behaviors, there is no stereotypy. Rather, ongoing small variations in movement are continuously generated to tailor the movement to its goal and to respond to the everchanging action context. Clearly, as they remark, lack of movement variMarch 2009

Movement Variability and the Use of Nonlinear Tools Appendix 2. Proposed Principles of Nonlinearity in the Acquisition and Maintenance of Motor Skill

1. An optimal amount of variability is necessary for movement to be functional and efficient; normal, efficient movement includes both deterministic and random characteristics, which can fluctuate within an optimal range. 2. Healthy motor control has characteristics of nonlinearity, including the spontaneous generation of new patterns of movement, movement possibilities that are sensitive to initial conditions, and a limited ability to precisely predict future movement based on current status. 3. If variability increases in a system without enough variability, new movement options can emerge spontaneously.

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5. Input into the system can drive the system into other possibilities for movement that are not predictable. The input can come from more than one system (ie, not only motor but also sensory, cognitive, emotional, or social). 6. Measures of complexity can help predict the emergence of a new

behavior or direct appropriate intervention to allow variability changes to affect function. 7. Traditional measures of variability are not equivalent to measures of complexity. For example, as the measure of standard deviation increases, the measure of approximate entropy can decrease. Measures of complexity describe the structure of variability in new ways that can help quantify subtle movement changes or characteristics. 8. Complexity is necessary for systems to adapt to changing conditions; loss of complexity means decreased ability for adaptation.

Daniela Corbetta

One of the ways in which progress in movement performance and coordination traditionally has been assessed is to measure the amount of movement variability across repetitions of the same movement. In their perspective article, Harbourne and Stergiou1 argue that progress in movement coordination should rather be indexed by analyzing the hidden structure of movement variability embedded in time series using time-dependent, nonlinear tools rather than by assessing the overall amount of variability. By focusing their article on the time structure of variability, the authors make a point of fundamental importance for our understanding of biological motion and its implications for development, learning, and rehabilitation. They show through clear examples that patterns with similar ranges of variation can contain very different 282

4. Because motor function is sensitive to initial conditions, each person brings a slightly different set of conditions to a motor problem, and the optimal solution to that problem may be unique to that person. Therefore, therapists cannot “prescribe” the best motor pattern or strategy that is common to all patients.

structures. These structures, which are not detected by traditional measures of response variation (such as standard deviations or coefficients of variation), are critical for understanding change and progress in movement control. They provide direct information on the regulation processes used to control movement. Harbourne and Stergiou also remark that variability does not always decrease linearly as a function of learning time and control. In some instances, and as further illustrated below, it can evolve in a nonlinear fashion over learning time. Harbourne and Stergiou tell us that variability should not always be considered a reflection of movement error or imperfect control. As they point out, variability is an omnipresent characteristic of biological motion, regardless of the stage of profi-

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ciency. Whether one is beginning to learn a new skill, is an expert performer, is experiencing a decline in performance, or is being rehabilitated, variability is an inherent property of the process of movement regulation. In all of those cases, however, variability may have a different structure. Again, this is why the structure of variability should be looked at closely; patterns of variability can directly inform the practitioner about the control process involved in the movement. In their examples, Harbourne and Stergiou remind us that even within the most skilled and most highly repeatable behaviors, there is no stereotypy. Rather, ongoing small variations in movement are continuously generated to tailor the movement to its goal and to respond to the everchanging action context. Clearly, as they remark, lack of movement variMarch 2009

Movement Variability and the Use of Nonlinear Tools ability would be nonadaptive and more likely to reflect rigid or stereotypical behavior. Thus, Harbourne and Stergiou meaningfully portray movement variability as the inherent product of a continuous dynamic process necessary to behave adaptively and whose forms and patterns can change as a function of development and learning. Here, I would like to elaborate on one key aspect of the article—the fundamental adaptive value of movement variability for development, learning, and rehabilitation. Beyond the fact that time-dependent structures of movement variability can be useful for indexing progress in movement control, Harbourne and Stergiou suggest that movement variability also can entail fundamental functions for learning and development. Such functions can differ depending on the level of proficiency. Here, I point to 3 such functions that I illustrate with examples from research on infant motor development. (1) At the earliest stage of learning, variability is crucial to foster the emergence of new movement forms. In early development, infants often display rigid behaviors, such as being “stuck” in a sitting or standing position, before they can straighten up their trunk or perform their first independent steps. Creating variability from these initially rigid postures is the process by which infants can begin to move out of these locked postures and progress to the next level.2– 4 Infants also can display stereotypical behaviors, such as repeatedly reaching for objects with both hands regardless of object size. Our research revealed that such seemingly locked patterns prevented infants from mapping their actions to the perceived characteristics of objects in the environment. However, when they started varying their movement patterns between hands, they also began developing meaningMarch 2009

ful and more-adaptive links between perception and action.5,6 (2) The increased variability that typically follows the emergence of a new skill is critical for movement exploration and the selection of more-effective movement patterns. Traditionally, such high movement variability has been perceived as the reflection of poor movement control, but more recently, as we begin to understand the complex dynamic processes involved in motor control, we see such variability as a necessary period for the individual to explore and discover the wide range of potential movement patterns producible and to experience their unique outcome. Exploration is a necessary step for the discovery and selection of optimal movement patterns.7 For example, in a longitudinal study on the development of infant reaching, Diedrich et al8 discovered that infants went through periods in which they generated slower movements, while at other periods, they became very active and generated faster movements. Such highly variable movement patterns clearly depicted a very unstable developmental picture, but the productions of slow and fast movements provided unique experiences to the child to understand and map out the impact of these movements on the resulting hand paths to the target. When infants produced fast movements, they generated high motion-dependent forces that dragged the arm away from the intended trajectory. Thus, to attain the target, infants had to learn to slow down their movement to reduce the occurrence of high distortions in movement trajectory. When they produced slow movements, they appeared to show more direct hand paths to the target, but it was not until much later, and after infants had experienced a wide range of reaching movements at different speeds, that they truly learned to calibrate the proper amount of

energy to impart to their movement and bring their hand more directly and smoothly to the target. Thus, in this developmental process, movement variability (that is, experiencing movement at different speeds and associating it with its sensorymotor outcome and goal attainment) was part of the process of movement exploration that ultimately led to the discovery and selection of more effective reaching patterns. But selection is not the final stage of learning. Movements that may seem optimal actually can lack movement adaptability and may not always fully accommodate the dynamic properties of our changing environment. For example, by 8 months of age, infants have learned to regulate the speed of their movement and as a result have developed relatively stable reaching patterns. In some contexts, however, they may again display some form of movement rigidity. This has been observed in tasks where 8- to 10-month-old infants were cued to a target in a new location after having been cued several times to a prior and different target location. When cued to the new location, infants at those ages often continued to reach for the first location as if they could not change the direction of their movement.9,10 Such error in movement direction has been interpreted as a lack in movement flexibility.11 Thus, even though movement selection had occurred and movements had become more predictable, more repeatable, and less variable, it remained somewhat inflexible in certain contexts. (3) Variability provides movement flexibility; this is the true definition of movement stability. In motor learning, low movement variability is commonly equated with skilled behaviors that are highly repeatable and performed with great accuracy and without unwanted movements. But, from a dynamic systems per-

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Movement Variability and the Use of Nonlinear Tools spective, movement stability is defined as the ability to recover quickly from unexpected perturbations or as the ability to shift smoothly from one behavioral attractor to another (eg, from standing to walking, from reaching to grasping, from stepping to jumping). In all cases, biological systems must maintain a level of flexibility, or range of variability, in order to accommodate the everchanging goals and environmental conditions. Clearly, what makes a behavior stable is not its ability to repeat itself closely over time, but rather its ability to modulate its space-time structure adaptively to meet the ever-changing task demands. In this perspective article, Harbourne and Stergiou send a very important message to researchers and practitioners in movement science. I hope that their message will have an impact on the way movement scientists and therapists will interpret movement variability, that it will

Author Response

Several ideas from her comments stimulate further questions for therapists: (1) Are there times when we purposely look for disorganization in our patients as an indicator of progress? This idea is inherent not only to motor control. Brazelton,3 the legendary pediatrician, talked about periods of disorganization in f

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D Corbetta, PhD, is Associate Professor and Director of the Infant Perception Action Laboratory, Department of Psychology, The University of Tennessee, Knoxville, TN 37996 (USA). Address all correspondence to Dr Corbetta at: [email protected]. DOI: 10.2522/ptj.20080130.ic

References 1 Harbourne RT, Stergiou N. Movement variability and the use of nonlinear tools: principles to guide physical therapist practice. Phys Ther. 2009;89:267–282. 2 Clark JE, Truly TL, Phillips SJ. On the development of walking as a limit-cycle system. In: Smith LB, Thelen E, eds. A Dynamic Approach to Development: Applications. Cambridge, MA: The MIT Press; 1993:71–93. 3 Harbourne RT, Sergiou N. Nonlinear analysis of the development of sitting postural control. Dev Psychobiol. 2003;42:368 –377.

4 Snapp-Childs W, Corbetta, D. Evidence of early strategies in learning to walk. Infancy. In press. 5 Corbetta D, Thelen E, Johnson K. Motor constraints on the development of perception-action matching in infant reaching. Infant Behav Dev. 2000;23: 351–374. 6 Corbetta D, Snapp-Childs W. Seeing and touching: the role of sensory-motor experience on the development of infant reaching. Infant Behav Dev. In press. 7 Thelen E, Corbetta D. Exploration and selection in the early acquisition of skills. Int Rev Neurobiol. 1994; 37:75–102. 8 Thelen E, Corbetta D, Spencer JP. The development of reaching during the first year: the role of movement speed. J Exp Psychol Hum Percept Perf. 1996;22: 1059 –1076. 9 Diedrich FJ, Thelen E, Smith LB, Corbetta D. Motor memory is a factor in infant perseverative errors. Dev Sci. 2000;3:479 – 494. 10 Smith LB, Thelen E, Titzer R, McLin D. Knowing in the context of acting: the task dynamics of the A-not-B error. Psychol Rev. 1999;106:235–260. 11 Clearfield MW, Thelen E. Stability and flexibility in the acquisition of skilled movements. In Nelson CA, Luciana M, eds. Handbook of Developmental Cognitive Neuroscience. Cambridge, MA: The MIT Press; 2001:253–266.

Regina T Harbourne, Nicholas Stergiou

The insightful commentary by Corbetta1 provides an elaboration on the ideas presented in our perspective article2 and allows us to bring motor development further into the big picture of motor control and motor learning. Corbetta illustrates clearly, with examples from research in infant development, how the issue of variability carries importance from the very start of movement control.

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affect the way therapists will envision and plan rehabilitation, and ultimately, that researchers and practitioners alike will adopt the nonlinear tools proposed by the authors to measure variability and assess progress in movement control.

development as being a harbinger of change, as a sign of new skills coming just on the horizon, and as an opportunity to guide a child to a new skill. This notion supports families in the quest to help a child develop, providing reinforcement for continued engagement and positive emotional support during skill building. How can therapists know when disorganization is a preview to skill development in a positive way or in a negative way, such as in a loss of skill? Perhaps examining the time structure of variability more closely as skill develops can help us clinically to answer this most important question.

that need to be addressed equally, such as cognitive or perceptual skills? Therapists might consider whether other practice issues, such as practice solving problems of a spatial nature, can coincide with problem solving in movement. Do we learn to move, or do we move to learn? The interaction of cognition, perception, and movement is critical to the advancement of overall skill, but therapists are not always tuned in to the perceptual aspects of teaching a motor activity. Corbetta’s research examples point out the need for greater attention to the structure of variability inherent in the interaction of movement and cognition, particularly in early intervention.

(2) Can lack of variability in movement signal issues in other areas

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Movement Variability and the Use of Nonlinear Tools spective, movement stability is defined as the ability to recover quickly from unexpected perturbations or as the ability to shift smoothly from one behavioral attractor to another (eg, from standing to walking, from reaching to grasping, from stepping to jumping). In all cases, biological systems must maintain a level of flexibility, or range of variability, in order to accommodate the everchanging goals and environmental conditions. Clearly, what makes a behavior stable is not its ability to repeat itself closely over time, but rather its ability to modulate its space-time structure adaptively to meet the ever-changing task demands. In this perspective article, Harbourne and Stergiou send a very important message to researchers and practitioners in movement science. I hope that their message will have an impact on the way movement scientists and therapists will interpret movement variability, that it will

Author Response

Several ideas from her comments stimulate further questions for therapists: (1) Are there times when we purposely look for disorganization in our patients as an indicator of progress? This idea is inherent not only to motor control. Brazelton,3 the legendary pediatrician, talked about periods of disorganization in f

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D Corbetta, PhD, is Associate Professor and Director of the Infant Perception Action Laboratory, Department of Psychology, The University of Tennessee, Knoxville, TN 37996 (USA). Address all correspondence to Dr Corbetta at: [email protected]. DOI: 10.2522/ptj.20080130.ic

References 1 Harbourne RT, Stergiou N. Movement variability and the use of nonlinear tools: principles to guide physical therapist practice. Phys Ther. 2009;89:267–282. 2 Clark JE, Truly TL, Phillips SJ. On the development of walking as a limit-cycle system. In: Smith LB, Thelen E, eds. A Dynamic Approach to Development: Applications. Cambridge, MA: The MIT Press; 1993:71–93. 3 Harbourne RT, Sergiou N. Nonlinear analysis of the development of sitting postural control. Dev Psychobiol. 2003;42:368 –377.

4 Snapp-Childs W, Corbetta, D. Evidence of early strategies in learning to walk. Infancy. In press. 5 Corbetta D, Thelen E, Johnson K. Motor constraints on the development of perception-action matching in infant reaching. Infant Behav Dev. 2000;23: 351–374. 6 Corbetta D, Snapp-Childs W. Seeing and touching: the role of sensory-motor experience on the development of infant reaching. Infant Behav Dev. In press. 7 Thelen E, Corbetta D. Exploration and selection in the early acquisition of skills. Int Rev Neurobiol. 1994; 37:75–102. 8 Thelen E, Corbetta D, Spencer JP. The development of reaching during the first year: the role of movement speed. J Exp Psychol Hum Percept Perf. 1996;22: 1059 –1076. 9 Diedrich FJ, Thelen E, Smith LB, Corbetta D. Motor memory is a factor in infant perseverative errors. Dev Sci. 2000;3:479 – 494. 10 Smith LB, Thelen E, Titzer R, McLin D. Knowing in the context of acting: the task dynamics of the A-not-B error. Psychol Rev. 1999;106:235–260. 11 Clearfield MW, Thelen E. Stability and flexibility in the acquisition of skilled movements. In Nelson CA, Luciana M, eds. Handbook of Developmental Cognitive Neuroscience. Cambridge, MA: The MIT Press; 2001:253–266.

Regina T Harbourne, Nicholas Stergiou

The insightful commentary by Corbetta1 provides an elaboration on the ideas presented in our perspective article2 and allows us to bring motor development further into the big picture of motor control and motor learning. Corbetta illustrates clearly, with examples from research in infant development, how the issue of variability carries importance from the very start of movement control.

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affect the way therapists will envision and plan rehabilitation, and ultimately, that researchers and practitioners alike will adopt the nonlinear tools proposed by the authors to measure variability and assess progress in movement control.

development as being a harbinger of change, as a sign of new skills coming just on the horizon, and as an opportunity to guide a child to a new skill. This notion supports families in the quest to help a child develop, providing reinforcement for continued engagement and positive emotional support during skill building. How can therapists know when disorganization is a preview to skill development in a positive way or in a negative way, such as in a loss of skill? Perhaps examining the time structure of variability more closely as skill develops can help us clinically to answer this most important question.

that need to be addressed equally, such as cognitive or perceptual skills? Therapists might consider whether other practice issues, such as practice solving problems of a spatial nature, can coincide with problem solving in movement. Do we learn to move, or do we move to learn? The interaction of cognition, perception, and movement is critical to the advancement of overall skill, but therapists are not always tuned in to the perceptual aspects of teaching a motor activity. Corbetta’s research examples point out the need for greater attention to the structure of variability inherent in the interaction of movement and cognition, particularly in early intervention.

(2) Can lack of variability in movement signal issues in other areas

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Movement Variability and the Use of Nonlinear Tools (3) How can therapists encourage optimal variability in behavior outside the clinic while still helping patients to practice safely? The bestcase scenario for clinicians is for our patients to go home or out into the community and “self-medicate,” engaging in variable activities that will extend the program or practice that started in the clinic. Can a focus on variability improve on the extension of therapy outside the clinic? (4) How can we integrate the concepts of optimal variability with our need for accurate and repeatable testing in the clinic? Standardized testing focuses on reducing the variability of response so that our

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results can be considered reliable. This presents a problem if variability is a focus of intervention and forces the issue of whether testing to determine the variability of skills is optimal. This issue requires further discussion and reveals potential obstacles to the use of variability for building skills when measurement is not focused on the value of variability. All of these questions require creativity, research, diversification of training, and collaboration among disciplines to advance our profession and improve patient care. Corbetta’s commentary reinforces the value of utilizing research support and guid-

ance from other fields to guide our ideas for intervention and physical therapist practice. We thank Corbetta for her excellent commentary and for giving us more food for thought. DOI: 10.2522/ptj.20080130.ar

References 1 Corbetta D. Commentary on “Movement variability and the use of nonlinear tools: principles to guide physical therapist practice.” Phys Ther. 2009;89:282–284. 2 Harbourne RT, Stergiou N. Movement variability and the use of nonlinear tools: principles to guide physical therapist practice. Phys Ther. 2009;89:267–282. 3 Brazelton TB. How to help parents of young children: the Touchpoints model. Clin Child Psychol Psychiatry. 1998;3;481– 483.

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Perspective

LS Gilchrist, PT, PhD, is Associate Professor, Doctor of Physical Therapy Program, College of St Catherine, 601 25th Ave S, Minneapolis, MN 55454 (USA), and Clinical Research Scientist, Children’s Hospitals and Clinics of Minnesota, Minneapolis, Minnesota. Address all correspondence to Dr Gilchrist at: [email protected]. ML Galantino, PT, PhD, is Professor of Physical Therapy, Richard Stockton College of New Jersey, Pomona, NJ, and Adjunct Research Scholar, University of Pennsylvania, Philadelphia, Pennsylvania. M Wampler, PT, DPTSc, is Physical Therapist, Harrison Medical Center, Bremerton, Washington. VG Marchese, PT, PhD, is Assistant Professor, Department of Physical Therapy, Lebanon Valley College, Annville, Pennsylvania, and Assistant Professor of Pediatrics, Penn State Hershey College of Medicine, The Pennsylvania State University, Hershey, Pennsylvania.

A Framework for Assessment in Oncology Rehabilitation Laura S Gilchrist, Mary Lou Galantino, Meredith Wampler, Victoria G Marchese, G Stephen Morris, Kirsten K Ness Although the incidence of cancer in the United States is high, improvements in early diagnosis and treatment have significantly increased survival rates in recent years. Many survivors of cancer experience lasting, adverse effects caused by either their disease or its treatment. Physical therapy interventions, both established and new, often can reverse or ameliorate the impairments (body function and structure) found in these patients, improving their ability to carry out daily tasks and actions (activity) and to participate in life situations (participation). Measuring the efficacy of physical therapy interventions in each of these dimensions is challenging but essential for developing and delivering optimal care for these patients. This article describes the acute and long-term effects of cancer and its treatment and the use of the World Health Organization’s International Classification of Functioning, Disability and Health (ICF) as a basis for selection of assessment or outcome tools and diagnostic or screening tools in this population.

GS Morris, PT, PhD, is Director of Clinical Research in Rehabilitation Sciences, The University of Texas MD Anderson Cancer Center, Houston, Texas. KK Ness, PT, PhD, is Assistant Member, Department of Epidemiology and Cancer Control, St Jude Children’s Research Hospital, Memphis, Tennessee. [Gilchrist LS, Galantino ML, Wampler M, et al. A framework for assessment in oncology rehabilitation. Phys Ther. 2009;89:286 –306.] © 2009 American Physical Therapy Association

Post a Rapid Response or find The Bottom Line: www.ptjournal.org 286

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ancer has a high incidence in the United States, where 46% of all males and 41% of all females can expect to develop either an invasive or in situ cancer.1 An estimated 1.4 million new cases of cancer are diagnosed each year, with nearly 13,500 of these cases occurring in individuals younger than 20 years of age.2 In years past, survival following a diagnosis of cancer was problematic; however, dramatic progress in the ability to diagnose cancers earlier and to provide moreeffective and targeted treatments has led to substantial increases in survival. The National Cancer Institutes Surveillance, Epidemiology, and End Results Program estimates that 65.3% of adults diagnosed with cancer between the years 2001 and 2005 will survive for at least 5 years.1 In addition, about 80% of people younger than 19 years of age who are diagnosed with cancer today are expected to survive for 5 years or longer.1,3 All told, an estimated 10 million people are living in the United States today who have or have had a diagnosis of cancer.1 As the population ages and treatments improve, these numbers are expected to continue to rise. Currently available medical interventions for cancer are designed to eliminate or control disease by suppressing cell growth (chemotherapy, irradiation) or directly removing the tumor (surgery).4 –15 These treatments may lack specificity and can damage normal tissue.16 –19 Thus, cancer is no longer an acute disease, with mortality as the primary outcome. Rather, treatment successes have made cancer a chronic disease, with many survivors developing significant sequelae to either the disease itself or to the treatment.20 –23 Oncology rehabilitation has long been a part of the management of cancer, but with increased survivorship, these efforts have evolved from simple supportive and palliative care to now include complex rehabilitaMarch 2009

tion interventions designed to restore the integrity of organ structure and function, to remediate functional loss, and to adapt to the environment so as to allow full participation in daily activities and life roles. In the current medical environment, demonstrating treatment efficacy by means of quantifiable outcome measures is increasingly important. As such, the expansion of interventions provided to patients with cancer and survivors of cancer must be accompanied by the appropriate application of new and existing measures. Because the information generated by these tools may be seen by many health care professionals and can extend across broad spans of time, the utility of such information is greatest when it is presented within a framework of standardized language and concepts. Such a framework can be found in the International Classification of Functioning, Disability and Health (ICF).24 This classification system is designed to describe health and health-related status from biological, personal, and societal perspectives. Disorders across the domains of body structure and function, activities, and participation are referred to as impairments, limitations, and restrictions, respectively. “Functioning” is an umbrella term that encompasses these 3 domains. Health conditions or disease states, personal factors, and the environment interact with these constructs to determine whether disordered functioning will result in disability.24 The primary purpose of this article is to use the ICF framework and its language to describe outcome measures and diagnostic screening tools that the rehabilitation therapist will find useful in assessing patients with an oncology diagnosis. Some of these outcome measures may be new to therapists; others may already be part of their routine assessment. However, factors unique to a diagnosis of cancer or to its treatment may

influence how and when such routine measures are used. Thus, the second purpose of this article is to provide greater understanding of the clinical issues common to the oncology population. Collectively, we hope to improve clinical care, facilitate communication across different rehabilitation disciplines, and encourage further study in the area of oncology rehabilitation.

The ICF Function Classification Framework The ICF was developed by the World Health Organization24 to provide a framework to describe health and health-related states and to suggest standardized language to describe these states. The ICF framework (Figure) is increasingly being used in the rehabilitation field and has recently been endorsed by the American Physical Therapy Association (APTA) House of Delegates for incorporation into all relevant Association publications, documents, and communications.25 Based on the work of Nagi,26,27 the ICF model shifts the focus of disablement from cause to impact, from disability to health and function, and from a static process to a dynamic process.24,28 As stated previously, the ICF defines 3 domains of human function (Figure): body function and structure, activity, and participation. Body function and structure refers to the anatomical and physiological function of the body systems, and these body functions and body structures are categorized into the subdomains listed in the Figure. Deficits in this domain are called “impairments” (eg, muscle weakness, restricted joint motion, poor cardiorespiratory fitness) and often are identified, measured, and treated by physical therapists. The activity domain describes the ability of an individual to perform specific tasks such as sweeping the floor, raking the yard, or putting away groceries. Dec-

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Figure. International Classification of Functioning, Disability and Health (ICF) model24 modified for populations of people with cancer. Modified and reprinted with permission of the World Health Organization from: International Classification of Functioning, Disability and Health: ICF. Geneva, Switzerland: World Health Organization; 2001.

rements in the activity domain are called “limitations” and describe the difficulty an individual has performing a particular task.24 Physical therapy goals often are aimed at reversing or normalizing such activity limitations. The participation domain describes the ability of a person to be involved in life situations. Participation restrictions describe the reduced ability of a person to maintain normal role functions and interact with society.24,29,30 Physical therapy interventions are designed, directly or indirectly, to enhance participation levels for every client at home, 288

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school, or work; on the athletic field; or in any community setting. The activity and participation subdomains are given as a single list (Figure), and their use will be discussed in the “Measurement of Activity and Participation” section of this article. In the ICF model, health conditions, personal factors, and the environment interact dynamically across the 3 domains of body function to help determine whether disordered function results in disability. For example, if a cancer treatment (eg, chemotherapy) causes a patient to

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develop unresolved peripheral neuropathy and ankle weakness,31 this patient may have a limited ability to walk (limitation) and may require long-term use of an ankle brace. Limited ability to walk could result in an employment restriction for a firefighter, but not for a computer programmer. Participation restrictions occur when activity limitations cannot be sufficiently overcome to maintain role functions in the person’s normal environment.29,30 Formal work is emerging that uses the ICF classification scheme to deMarch 2009

Assessment in Oncology Rehabilitation scribe overall function of populations who have specific chronic health conditions, including, but not limited to, multiple sclerosis,32 stroke,33,34 osteoarthritis,35 diabetes,36 low back pain,37 obesity,38 osteoporosis,39 and rheumatoid arthritis.40,41 This growing body of literature uses the ICF framework to identify measurements relevant to a specific illness. The ICF Core Sets provide clinicians and researchers with comprehensive but concise measurement categories that describe a patient’s global function from a biopsychosocial view. Some investigators42– 46 have used the ICF Core Sets as the comparison standard for the assessment of function and disability when evaluating the content of a previous or newly developed measurement tool. A limited number of ICF Core Sets have been developed for patients with head and neck cancer47 and breast cancer.48 Although the ICF Core Sets have not been widely used in the US physical therapy or oncology communities, the ICF framework is a useful model for describing global function in patients with a new or previous cancer diagnosis.49 Consideration of the interaction among cancer as a health condition, impairments in body function and structure, activity limitations, and participation restrictions in the context of the person and the environment are essential to the design of an effective oncology rehabilitation intervention.50

Selecting Appropriate Measures In this article, we describe measures as potential descriptors of particular ICF function domains. We encourage therapists to use this schema to assist them in deciding which measures to include in their baseline, continuing, and final outcome assessments of their patients and clients. To do this, the therapist should reMarch 2009

view the primary goals of the intervention and determine how these goals fit into the ICF domains. That is, which of the ICF domains is the intervention intended to affect? If the intervention is designed to make a change at the tissue level, then the appropriate measure would assess a specific change at the body function and structure level. For example, a patient with restricted shoulder mobility (decreased range of motion [ROM]) after a mastectomy may be treated with a regimen of stretching and scar tissue mobilization where the intended outcome is lengthened tissue, making ROM an appropriate measure. By increasing ROM, this intervention also may improve the patient’s ability to reach overhead, making certain daily tasks possible (an activity-level measure), which, in turn, may increase the patient’s ability or willingness to engage in life activities such as work or education (a participation-level measure). In this example, outcome measures at each level would be appropriate, and such information would speak to the efficacy of the intervention across functional domains. Selecting an outcome measure also requires consideration of the psychometric properties of the instrument or tool the therapist is planning to use. Validity, reliability, and responsiveness are 3 properties the therapist should consider.51 The measure should make sense (face validity), be accepted by experts in the field (content validity), and correlate with an expected outcome (predictive validity) and with other measures that evaluate the same construct (concurrent validity). The instrument should yield the same results (reliability) when repeated by separate examiners (interrater reliability), by the same examiner on the same patient (intrarater reliability), or on separate occasions within a time period when no changes would be expected (test-retest reliability).

The therapist also will want to select an instrument that is capable of detecting change resulting from an intervention (responsiveness).51 Instruments that place individuals into a limited number of categories,51 such as the Functional Independence Measure,52 tend not to be responsive because very large changes are required to move from one category to another. Additionally, instruments should not have a ceiling effect. If many respondents initially score at the highest level, there is no room for improvement, and change will not be detected.51 It is important to understand that the psychometric properties of validity for diagnostic and screening measures are different than for outcome measures.53 Clinicians need to know how accurate the diagnostic tool is in identifying the presence or absence of the target condition. Often a new tool is compared with a gold standard, and its validity is described using sensitivity and specificity. Sensitivity, often referred to as a “true positive rate,” is defined as a test’s ability to correctly identify the target condition when the target condition is present. A high sensitivity is desirable, as it will rarely miss someone who has the condition. Specificity describes a test’s ability to identify those without the target condition who really do not have the target condition, a “true negative rate.” If an instrument has a high specificity, then this instrument will rarely test positive when a person does not have the disease (ie, a low chance of false positive predictions). In this article, we provide examples of measures that are relevant to particular impairments, limitations, and restrictions experienced by patients with cancer or survivors of cancer. The list is not exhaustive and is not restricted by documented reliability, validity, or responsiveness of the particular instrument; however, it

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Assessment in Oncology Rehabilitation does include instruments commonly used by physical therapists, some specifically developed for oncology populations. When choosing a measurement tool, the therapist should investigate its psychometric properties in relation to the population of interest. The references given in Tables 1, 2, and 3 provide a starting point for those searches.

Measurement of Body Function and Structure The specific tests and measures used by the physical therapist to measure body function and structure in patients with a cancer diagnosis often are not unique to the assessment of this population. However, these measures provide relevant information about cancer-related impairments, prognostic considerations, and safety factors. This section highlights some common cancer-related changes in body function and structure and suggests some appropriate measurement tools for assessing these impairments. Mental Functions Mental functions (Tab. 1, Mental Functions), although not the primary interest of most physical therapists, play an important role in determining how best to interact with and provide interventions for our patients. Both radiation and chemotherapy can alter the structure and function of the central nervous system and may result in impaired mental function in patients during or following treatment for their cancer.54 – 65 Specific mental function sequelae, including impaired memory and difficulty with sustained attention (concentration), may be evident years after treatment.58,66 Proposed mechanisms for these impairments include chemical toxicity, oxidative damage, inflammation, and destructive autoimmune responses.67– 69 The Mini-Mental State Examination70 is a simple tool for screening mental functions and has been used by physical therapists. Al290

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though an array of more-complex and detailed neuropsychological tests are available to measure the various domains of cognitive function, information is lacking regarding the sensitivity and specificity of the tests to detect changes in cognitive function from chemotherapy. The identification of sensitive neuropsychological tests is crucial to further understanding of chemotherapy-induced cognitive impairments.71 Emotional functions also may affect the ability of a patient to participate in the physical therapy intervention. A tool that has been used to evaluate emotional functions in patients with cancer is the Profile of Mood States.72,73 This self-report instrument is easy to use and may provide insight into our patient’s ability to respond to and participate in a physical therapy program. Sensory Functions and Pain Table 1 (Sensory Functions and Pain) describes several potential measures for vestibular, somatosensory, and pain impairments. These impairments are common in patients who are undergoing cancer treatment or have a history of cancer. Hearing and vestibular functions can be affected by tumor growth or by chemotherapy. Although auditory impairments are infrequently targets of physical therapy assessment, vestibular impairments and their relationship to balance dysfunction should be considered. Vestibular schwannoma, a relatively rare benign tumor, can impair vestibular function, usually unilaterally. Cisplatin, a chemotherapy drug used to treat many types of tumors (eg, lung, breast, ovarian) has been associated with both vestibular toxicity and ototoxicity.74,75 Tests of vestibular function can help physical therapists document change during or after treatment (Tab. 1). It also is important for therapists to use a measure

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of balance for patients with these impairments (see the “Neuromusculoskeletal and Movement-Related Functions and Structures” section for more information on balance measures). Treatment-induced peripheral nerve impairments are common. Several chemotherapy drugs (ie, taxanes, platinum agents, vinca alkaloids, and thalidomide) can damage peripheral axons and nerve cell bodies.76 Chemotherapy-induced peripheral neuropathy (CIPN) is characterized by sensory impairments, including paresthesias, dysesthesias, decreased touch thresholds, decreased vibration thresholds, and reduced deep tendon reflexes.77–79 As CIPN worsens, muscle weakness and limb movement disorders, such as foot drop, may develop and require the use of an orthosis. Multidimensional tests, such as the modified Total Neuropathy Scale, may be beneficial in fully describing the severity of CIPN (Tab. 1).77,80,81 Anesthesia or dysesthesias may occur when compression or surgical dissection of a nerve occurs.82 Radiation plexopathies also may occur but are much less common, as radiation oncologists have developed techniques to shield delicate neural structures.83 Many patients with cancer, particularly those with advanced or metastatic disease, have increased levels of pain.84 Cancer-related pain may arise from the tumor itself or as a side effect of treatment. Some forms of cancer are inherently more painful, specifically any cancer originating in or metastasizing to the bone. Pain can have a large impact on mobility, and some researchers have even established cut-points for moderate and severe pain based on its interference with daily activity.85 Evaluation of pain in this population is essential and should be multifaceted (Tab. 1, Pain). Although many March 2009

Assessment in Oncology Rehabilitation Table 1. Measurement Tools for Body Function and Structure, With International Classification of Functioning, Disability and Health (ICF) Code (Alphabetic Chapter and Numeric Second-Level Domains) in Parentheses

Construct

Measurement Tool

a

Measurement Characteristics

Representative Studies in Populations of Patients With Cancer

Mental functions Specific mental functions (b140–b152)

High-sensitivity cognitive screen

An interview-based instrument designed to assess 6 major domains of neuropsychological performance: memory, language, attention/ concentration, visual/motor, spatial, and self-regulation and planning148

Prostate cancer149

Mini-Mental State Examination

An 11-item questionnaire that is used to screen for dementia70

Brain tumor150

Functional Assessment of Cancer Therapy–Cognitive Function (FACT-COG)

A 38-item questionnaire that addresses cognitive issues related to treatment. This instrument assesses an array of generic and targeted measures and has multiple benefits, including validity, ease of administration and interpretation, and global application.151

All populations of patients with cancer; prostate cancer149

Perceived Cognition Questionnaire

A self-report scale that rates an individual’s perception of change in cognition since the inception of chemotherapy152

Breast cancer152

Profile of Mood States

Measures 6 mood or affective states: tension-anxiety, depression-dejection, anger-hostility, vigor-activity, fatigue-inertia, and confusion-bewilderment72,73

Prostate cancer,153 advanced cancer,154 breast cancer,155,156 non–small cell cancer,157 head and neck cancer158

Dizziness Handicap Inventory Questionnaire

A 25-item questionnaire that allows for self-assessment of the impact of disequilibrium on functional activity159

Vestibular schwannoma160,161

Computerized gaze stabilization/ visual acuity tests (eg, NeuroCom inVision System)

A mechanical test that assesses patient difficulty in coordinating eye movements with head movements. Deficits may indicate problems with vestibulo-ocular reflex.162,163

Vestibular schwannoma161

Modified Total Neuropathy Score

Multidimensional test of peripheral nerve function79

Breast cancer79

Semmes-Weinstein monofilaments

Mechanical test that quantifies touch thresholds164

Breast cancer79

Biothesiometer

Mechanical test that quantifies vibration thresholds164,165

Breast cancer79

Visual analog scale

Unidimensional measure of pain intensity166

Lung cancer167

Numeric rating scale

Unidimensional measure of pain intensity86

Pediatric cancers168,169; mixed adult population170

Faces Pain Scale–Revised171

Intensity measure appropriate for children and patients with cognitive decline171

Pediatric cancers168,169

Sensory functions and pain Hearing and vestibular functions (b230–b249)

Additional sensory functions (b250–b279)

Pain (b280–b289)

(Continued)

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Assessment in Oncology Rehabilitation Table 1. Continued

Measurement Characteristics

Representative Studies in Populations of Patients With Cancer

Brief Pain Inventory

Multidimensional measure of pain; includes intensity and impact on function88

Adult pain clinic participants,172 prostate cancer,173 bone metastases174

Pain Treatment Satisfaction Scale

A 5-item questionnaire that measures patient satisfaction with pain management89

None

Goniometry

Mechanical measure, with published normal values175,176

Breast cancer,90,91,177 head and neck cancer,92–94 leukemia,178 osteosarcoma179

Sit-and-reach

Performance test of generalized flexibility180

Lymphoma,21 breast cancer181

Manual muscle testing

Standardized performance test that measures the patient’s ability to resist against therapist-applied force

Osteosarcoma101

Handheld dynamometry

Mechanical measure of force output, with published normal values98

Leukemia178,182

Grip strength

Mechanical measure of force output, with published normal values97

Osteosarcoma,101 breast cancer,183,184 lymphoma185

Structures related to movement–other (b750–b789)

National Cancer Institute’s Common Terminology Criteria for Adverse Events, version 3 (Fibrosis Scale)

This scale provides standardized language to describe fibrosis of tissue due to postsurgical scarring or radiation therapy121

Uterine cancer186

Motor reflex functions (b750)

Deep tendon reflexes

A mechanical test that can be performed in isolation, but often is included in multidimensional peripheral nerve tests such as the Modified Total Neuropathy Score

Breast cancer104

Involuntary movement reaction functions (b765)

Computerized posturography (eg, NeuroCom Sensory Organization Test)

Computer-based, quantitative assessment of postural stability under various sensory conditions187

Breast cancer,104 vestibular schwannoma,188,189 prostate cancer,190 cerebellar tumor191

Gait pattern functions (b770)

Gait speed

Performance measure of gait requiring little equipment

Pediatric sarcoma101

Kinematic gait analysis

Quantitative analysis of joint and limb positions and movement during gait; can require expensive equipment

Pediatric brain tumor,103 bone tumor99

Heart rate

Standard vital sign, with normal values192

Hospice193

Blood pressure

Standard vital sign, with cut-points for hypertension and prehypertension192

Survivors of childhood cancer,194 leukemia,195 testicular cancer,196 brain tumor197

Construct Pain (b280-b289) continued

Measurement Toola

Neuromusculoskeletal and movementrelated functions and structures Functions of the joints and bones (b710–b729)

Muscle functions (b730–b749)

Functions of the cardiovascular, hematologic, immunologic, and respiratory systems Cardiovascular system functions (b410–b429)

(Continued)

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Assessment in Oncology Rehabilitation Table 1. Continued

Construct Respiratory system functions (b440–b449)

Additional functions and sensations of the cardiovascular and respiratory systems– aerobic capacity (b455)

Additional functions and sensations of the cardiovascular and respiratory systems– fatigue (b455)

Immunological system functions (lymphatic system) (b435)

a

Measurement Toola

Measurement Characteristics

Representative Studies in Populations of Patients With Cancer

Respiratory rate

Standard vital sign, with normal values192

Hospice,193 general cancer population198

Oxygen saturation

Indirect measure of oxyhemoglobin level

Lung cancer199

Pulmonary function tests

Direct measures of lung volume and flow rates

General cancer population,198 post-lung irradiation,200 lung cancer,199 Hodgkin disease201

Medical Research Council Dyspnea Scale

Self-report rating of shortness of breath111

None

Graded exercise testing

Estimate of maximal oxygen consumption based on exercise performance192

Breast cancer202–204

Duke Activity Scales Inventory

Estimate of maximal oxygen consumption based on selfreported activity205

None

2- or 6-minute walk test

Performance-based assessment of exercise tolerance and functional capacity110

Osteosarcoma,101 leukemia,182 prostate cancer,190 lung cancer199

9-minute run-walk

Performance-based assessment of exercise tolerance206

Osteosarcoma207

Borg Rating Scale of Perceived Exertion

Self-report of physical effort during exercise or activity112

None

Multidimensional Fatigue Inventory

A 20-item questionnaire with 5 subscales that assesses self-reported fatigue208

Head and neck cancer209

Functional Assessment of Chronic Illness Therapy–Fatigue

A 13-item questionnaire that assesses fatigue and the impact of fatigue210

Patients with cancer and severe pain115

Piper Fatigue Scale

A 26-item multidimensional fatigue assessment instrument211

Leukemia,212 breast cancer213

Brief Fatigue Inventory

A 9-item rapid screening tool for fatigue severity and impact on function214

Lung cancer,136 leukemia,215 lymphoma,21,215 rectal cancer216

Limb volume: water displacement

Direct, mechanical quantitative measurement of limb volume117–119

Breast cancer117–119

Limb volume: infrared optoelectric technology

Direct, quantitative measure of limb volume using computer analysis of a scanned image to document the diameter of the extremity along its length217

Breast cancer120

Limb volume estimates: limb circumferences using a truncated cone formula

Indirect, quantitative measure of limb volume117,118

Breast cancer117,118

National Cancer Institute’s Common Terminology Criteria for Adverse Events, version 3 (lymphatic, integument, and phlebolymphatic cording scales)

Numeric scales that use standardized language to describe impairments in the lymphatic, integument, and phlebolymphatic systems121

Survivors of cancer20

Not intended to be an all-inclusive list of measures, but as examples of measures that have been reported in the oncology literature.

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Assessment in Oncology Rehabilitation scales, such as visual analog scales and numeric rating scales,86,87 specifically focus on pain intensity, other scales are multidimensional and include questions on interference with daily activity88 or acceptability of pain treatments.89 Neuromusculoskeletal and Movement-Related Functions and Structures Table 1 (Neuromusculoskeletal and Movement-Related Functions and Structures) describes useful measures for evaluating potential changes in neuromusculoskeletal and movementrelated functions and structures. Patients with cancer or a history of cancer may experience a number of impairments in this subdomain, including loss of ROM, decreased strength (force-generating capacity), gait pattern abnormalities, and balance deficits. Deficits in ROM may be present in patients who have undergone surgery, chemotherapy, or radiation therapy. Such deficits may result from the formation of scar tissue following surgery, disuse of a joint following chemotherapy or surgery, or fibrosis caused by irradiation. Decreased ROM may occur coincident with treatment or after the completion of treatment. Seemingly lessinvasive surgeries (lumpectomy versus mastectomy) can affect ROM as much as more-invasive procedures.90 Decreased ROM also should be considered if radiation treatment has involved a joint.91 This loss of ROM may occur after radiation is completed and can extend beyond the immediately irradiated joint. For example, patients who have completed surgery or radiation for a head and neck tumor may have impaired shoulder abduction and flexion in addition to the more obvious loss of cervical ROM. These problems are more severe after surgeries involving radical neck dissections and the re-

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moval of nerve.92–94

the

spinal

accessory

Muscle strength deficits can arise from tumor-produced inflammatory intermediates that are catabolic, resulting in muscle wasting (cachexia).95 Surgical interventions also may damage muscle groups and peripheral nerves, leading to loss of strength. Radiation and chemotherapy (especially the vinca alkaloids, taxanes, and platinum agents) can reduce strength by damaging muscle or peripheral nerve tissue.91 Corticosteroids preferentially damage proximal limb muscles, limiting activities such as sit-to-stand and overhead reaching.96 Additionally, pain, fear, and fatigue lead to inactivity, which, in turn, causes further loss of muscle strength and aerobic capacity. Although techniques for manual muscle testing are widely used by therapists to measure strength, measures of dynamometry and grip force provide quantitative documentation of strength deficits.97,98 Cancer or cancer treatments can alter gait characteristics by adversely affecting the function and structure of the lower extremity or the nervous system. The few studies that have assessed these changes have shown deficits in patients with bone tumor lesions of the lower extremity and tumors of the nervous system.99 –103 Traditional gait evaluation tools, such as kinematic analysis or gait speed measurements, are appropriate for patients with cancer. Balance can be disrupted in many patients with cancer or a history of cancer and may arise from impairments in multiple body systems. Problems with sensory input, central processing of balance-related information, ROM limitations, orthostatic hypotension, and muscle force production can all contribute to this multifactorial issue. Specific to the neuromuscular system, patients with

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taxane-induced peripheral neuropathy have limitations in postural stability.104 It is important for physical therapists to measure postural control in a variety of challenging positions to detect and treat balance limitations in patients, especially after chemotherapy. Because the oncology population often is at risk for falls,105 screening for balance disorders is very important. We have included measures that are intended to identify balance impairments and their underlying structural problems in Table 1 (Measurement Tools for Body Function and Structure: Involuntary Movement Reaction Functions) and tests that use mobility skills to rate the level of balance dysfunction in Table 3 (Measurement of Activity and Participation: Mobility– Changing and Maintaining Body Positions). In either case, in the ICF model, a balance disorder is classified as a body function and structure impairment. Functions of the Cardiovascular, Hematologic, Immunologic, and Respiratory Systems Cardiotoxicity is a well-known late effect of several chemotherapeutic agents, particularly the anthracyclines (Adriamycin*) and trastuzumab (Herceptin†). These compounds may damage cardiac myocytes and ultimately can result in congestive heart failure.106,107 Similarly, radiation striking the heart can cause cardiac and coronary artery scarring, leading to restrictive cardiac disease and coronary artery disease.108 In older patients, these cardiovascular changes may be superimposed on already existing cardiovascular disease, further amplifying the impairments associated with this disease. It is important for therapists to ask the patient’s physician for the results of cardiac testing, performed

* Pharmacia Inc, Kalamazoo, MI 49001. † Genentech Inc, 1 DNA Way, South San Francisco, CA 94080-4990.

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Assessment in Oncology Rehabilitation Table 2. Physician-Performed Diagnostic Measures of Body Structure and Function Indicating “Red Flags” or “Yellow Flags” for Physical Therapists, With International Classification of Functioning, Disability and Health (ICF) Code (Alphabetic Chapter and Numeric Second-Level Domains) in Parentheses

Construct

Measurement Tool

Measurement Characteristics and Importance to Physical Therapy

Representative Studies in Populations of People With Cancer

Structures of the nervous system Magnetic resonance imaginga

Preferred method to detect compression of neurologic tissue, (ie, spinal cord, nerve roots, or nerve plexus) by tumor or unstable vertebral fractures123

Patients with vertebral metastases or spinal cord compression123,218

Dual-energy x-ray absorptiometrya

Diagnostic test for osteopenia and osteoporosis

Leukemia,182,219 prostate cancer190

Radiography or computed tomography scana

If 25%–50% of the cortex of bone is degraded, then partial weightbearing precautions should be instituted. If greater than 50% bone degradation, then touch-down or non–weight-bearing precautions are recommended.220

Multiple myeloma220

Hematologic system functions (b430)

Complete blood count (ie, hemoglobin, hematocrit, white blood count, platelet count)a

Diagnostic test to detect anemia, neutropenia, and thrombocytopenia. These values also are useful in exercise prescription, particularly in choosing safe mode and intensity of exercise.

Patients with stem cell transplant221

Cardiovascular system functions (b410–b429)

Echocardiograma

Assesses ventricular function, including ejection fraction, wall movement, and cardiac output

Hodgkin disease,222 breast cancer223

Nervous tissue (s110–s199)

Structures related to movement Skeletal system (s710–s770)

Functions of the cardiovascular, hematologic, immunologic, and respiratory systems

a

These tests are performed by a physician, but yield important information for the physical therapist.

both before and after treatment with cardiotoxic agents (Tab. 2). Primary tumors of the lung are frequent, with 215,020 new cases estimated for 2008 in the United States.1 These space-occupying tumors cause respiratory impairments by limiting the expansion of the thoracic cavity, compressing the airways, and reducing the surface area of the lungs available for gas exchange. As these tumors grow and impinge on other mediastinal structures, they can decrease cardiac function secondary March 2009

to cardiac and vascular compression and cause upper-extremity musculoskeletal injury secondary to brachial plexus compression and infiltration. The respiratory system also can be adversely affected by chemotherapy and radiation treatment for cancers not involving the lung. Chemotherapeutic agents such as bleomycin, methotrexate, and docetaxel can damage pneumocytes and the pulmonary parenchema.109 Such damage can lead to obliteration of alveoli and dilation of air spaces. Likewise,

chest wall irradiation can damage the lining of the alveoli, leading to toxicities such as pneumonitis and fibrosis,109 as well as causing fibrosis of integumentary and musculoskeletal structures that contribute to ventilation. Measurements of vital signs (heart rate, blood pressure, respiratory rate, and oxygen saturation) provide insight into the cardiorespiratory status of patients with cancer. The presence of hemodynamic instability at rest (altered blood pressure, tachy-

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Assessment in Oncology Rehabilitation cardia, light-headedness, cyanosis) suggests that action should be taken to protect the patient. Impairments in cardiorespiratory status may manifest themselves only with increased exertion. For this reason, assessment involving testing under conditions of increased exertional demand (Tab. 1) is preferred and may involve formal exercise testing, self-report of activity levels, or results from a 6-minute walk test or similar aerobic capacity test.110 Failure to meet normal range values for these assessment tools suggests impaired cardiovascular and respiratory function. Patient report of breathing difficulties (Dyspnea Scale111) and of exertional demand (Borg Rating of Perceived Exertion112) during a 6-minute walk test provide further insight into these impairments. Fatigue is a well-documented, multisystem impairment commonly reported in a wide variety of cancers, both acutely and long after cancer treatments have ended.113 Exercise is an effective intervention for cancerrelated fatigue, and it is recommended that a multidimentional measure be used to capture the physical, emotional, and mental aspects of fatigue.114 One such measure is the fatigue subscale of the Functional Assessment of Chronic Illness Therapy (FACIT-F), which initially was developed for the oncology population and has been used in patients with a variety of cancer types115 and in survivors of cancer.116 In the ICF, the function of the lymphatic vessels and nodes are classified under immunologic function. Defects may involve tumor obstruction of lymphatic vessels, but they more likely occur secondary to surgical resection of lymph nodes or radiation-induced fibrotic changes that affect lymphatic vessels. In any case, regional lymphatic drainage is reduced, leading to lymphatic fluid accumulation and regional swelling. 296

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Such swelling compromises the integument by increasing the likelihood of inflammation, infection, skin breakdown, limits in joint ROM, and decreased ability to move the affected limb. Lymphedema may be most associated with surgical resection of the breast and surrounding lymph nodes; however, surgical resection of a variety of tumors, including head and neck, genitourinary, and reproductive tumors, can result in lymphedema. Localized swelling is the most common impairment of lymphedema; therefore, measures of this impairment focus on quantifying limb volume (Tab. 1, Immunological Systems Functions). The water displacement method is a highly reliable method for determining the volume of an extremity with lymphedema.117–119 However, this method requires specific equipment and precise methods to obtain reliable measurements. Methods using lightemitting diodes to calculate limb volume have shown early evidence in detecting subclinical lymphedema, allowing for early intervention and prevention of symptomatic lymphedema.120 Volume estimates made by a truncated cone formula using several limb circumference measures correlate highly with those determined by water displacement.117,118 Limb circumference measurements may be more practical for some clinicians, given its simplicity and minimal equipment requirements. An important component to early detection is the timing of volume measurements. It has been shown that preoperative measurements assist with early detection and successful treatment of lymphedema.120 Volume measures are only one method used to describe the severity of lymphatic impairments. The National Cancer Institute’s Common Terminology Criteria for Adverse Events, version 3,121 has expanded the number of scales to grade the severity of lymphatic and integu-

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mentary toxicity (ICF subdomain “skin and related structures”). There are separate scales for volume of lymphedema in extremities, trunk and genital region, head and neck, and viscera. In addition, there are scales to grade the severity of skin color changes, lymph leakage, lymphocele, fibrosis, and phlebolymphatic cording.121 A weakness of these scales is that the categories are broad and, therefore, not sensitive to small differences that may be clinically important. However, they do provide standardization of language to describe changes to lymphatic tissues and integumentary that may be clinically useful, particularly for long-term goals and clear communication among colleagues.

Diagnostic Measures of Body Function and Structure Indicating “Red Flags” or “Yellow Flags” for Physical Therapists Body function and structure impairments identified through diagnostic tests performed by a physician may have significant implications for the examination by a physical therapist and the physical therapy plan of care (Tab. 2). Conversely, the therapist may identify concerning “red flags” or “yellow flags” during the examination that would warrant recommending that the patient return to his or her physician for further diagnostic testing. Both situations affect patient safety and, therefore, are described below and in Table 2. Some tumors cause neural impairment by compressing or infiltrating a peripheral nerve, nerve plexus, or a nerve tract or nucleus within the central nervous system. The impairment may be sensory, motor, or autonomic, depending on the location, size, and structure of the tumor. Physical therapists must consider common neurological sites at increased risk for tumor compression.

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Assessment in Oncology Rehabilitation For example, breast and lung tumors can compress the brachial plexus, and the lumbosacral plexus is sometimes affected by colorectal tumors, gynecologic tumors, sarcomas, and lymphomas.122 Regardless of the site, the cardinal sign of neural compression is unrelenting pain, particularly at night and later focal sensory disturbances or weakness in the distribution of the plexus or spinal cord segment involved.122,123 These signs and symptoms are particularly important to consider in patients with a history of cancer who may enter the clinic with a seemingly unrelated musculoskeletal problem. If neural compression from a tumor is suspected, the therapist needs to refer the patient back to the primary physician so that further medical tests, such as magnetic resonance imaging, and appropriate treatment may be performed. Skeletal impairments often accompany a cancer diagnosis and reflect a disease-associated loss of bony material (lytic tumor) or invasion of bone (sclerotic tumor) by a primary or secondary tumor. Communication with the medical team can help therapists navigate through the many risks associated with tumor invasion of skeletal structures. It is advantageous for therapists to be familiar with common patterns of cancer-related skeletal system involvement (eg, prostate, breast, lung, and colon cancer often metastasize to the spine; sarcomas commonly present in the femur). As the tumor invades the normal structure of bone, there is reduced bone strength and increased risk of pathological fracture.124 Although there are no definitive guidelines to predict pathologic fracture risk, it is helpful to monitor the amount of cortex that has been disrupted by tumor growth in long bones used for functional tasks (eg, the femur for gait, the humerus if an assistive device is being used). This can be calculated by a radioloMarch 2009

gist, using advanced imaging techniques. Table 2 summarizes specific weight-bearing guidelines. Tumor invasion of the vertebrae also can affect the physical therapy plan of care. If the tumor invades the vertebral arch, the segment may become unstable and possibly compress the spinal cord or adjacent nerve roots, creating a medical emergency. Unrelenting back pain often is the primary or presenting symptom of these lesions, and if a therapist suspects neurologic involvement, a segmental motor, sensory, and autonomic examination should be performed.123 If neural impingement is suspected, the medical team should be notified immediately.125 Osteonecrosis and reduced bone mineral density are common among patients with cancer. Both cancer and cancer treatments increase the risk for developing osteonecrosis in a variety of locations, including proximal or distal femur, proximal humerus, jaw, and metatarsals.126,127 New-onset pain and decreased weight-bearing ability should alert therapists to the possibility of osteonecrosis; however, this condition is not always symptomatic.128 Pharmaceutical therapies (eg, corticosteroids, hormonal therapies, androgen therapy) and radiation are associated with reduced bone mineral density.68 –70 Therefore, dual-energy x-ray absorptiometry or computed tomography test results can alert therapists to this problem and allow for appropriate intervention planning. Tests such as a complete blood count can help physical therapists determine safe exercise guidelines, particularly for patients who are undergoing or have just completed chemotherapy, radiation therapy, or bone marrow transplant.129,130 Each medical center or rehabilitation department has its own criteria for exercise prescription. These values often are the same as those used for

the general acute care population, as—to our best knowledge—there are no evidence-based recommendations specific for patients with cancer.129,130 In addition to checking for anemia, patients not tolerating aerobic exercise should be screened for current or past use of cardiotoxic or pneumotoxic chemotherapy medications and referred as appropriate for further testing (see cardiovascular and respiratory discussion above). Patients should avoid exposure to infectious pathogens while neutropenic (eg, avoid public gyms, health caregivers should avoid patient contact if they are ill). If the patient is thrombocytopenic, high-impact activities or contact sports should be avoided to prevent excessive bleeding.

Measurement of Activity and Participation The activity and participation domains encompass the ability to execute tasks, such as walking or bathing (activity), and the ability to participate in life situations, such as regularly attending work or school and conducting interpersonal relationships (participation). The subdomains for activity and participation (such as mobility and domestic life) are given in a single list in the Figure, with each component being able to denote activity, participation, or both.24 This flexibility allows for individual tailoring and operational differentiation of activity and participation.28,131,132 The ICF beginners guide suggests that clinicians, researchers, and policymakers may use this single list for their needs and purposes to “A) designate some domains as Activities and others as Participation and not allow overlap; B) make this designation but allow overlap in particular cases; C) designate detailed (third- or fourthlevel) categories within a domain as Activities and broad (second-level) categories in the domain as Participation; or D) designate all domains

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Assessment in Oncology Rehabilitation as potentially both Activity and Participation.”24(p127) Impairments in body function and structure discussed in the previous sections can result in changes at both the activity and participation levels. Therefore, assessing change in these constructs is important. Physical therapists typically select primary outcome measures at the activity and participation levels when their intervention plan as a whole is directed toward improving a person’s physical capacity or performance. Individually tailored rehabilitation goals, commonly seen in physical therapy, take into account personal and environmental factors unique to the patient; however, the use of standardized measures allows for the comparison of individual activity and participation performance to what might be expected from control or population-specific values. The ability to make such comparisons may assist the therapist in gauging patient progress during the course of rehabilitation. Important activity and participation domains typically addressed by physical therapy interventions include: (1) mobility, for example changing and maintaining a body position, carrying objects, or walking and moving around; (2) self-care, such as dressing, bathing, and toileting; (3) domestic life (eg, carrying a child, doing dishes); and (4) major life areas such as the ability of a child to access a classroom or the ability of an adult to perform specific tasks related to paid employment (Tab. 3). Currently available measures of activity and participation are rarely limited to a specific subdomain, and most instruments include portions of multiple constructs (eg, mobility and self-care).131 Measuring activity limitations and participation restrictions can be done by timed or clinician-observed 298

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evaluation or by patient self-report. For example, the Functional Mobility Assessment requires patients to physically perform specific tasks and to answer questions, quantifying their level of function.133 In contrast, the Toronto Extremity Salvage Score, lower-extremity version, is a selfadministered questionnaire that asks patients to indicate the level of difficulty they experience in dressing, grooming, mobility, work, sports, and leisure.134,135 Both methods of measurement have different positive attributes. In using quantitative measurement of limitations or restrictions, a therapist removes some of the potential influences of symptom distress or cognitive changes.136 However, the therapist must take into account that performance-based measures are effort dependent and require that the activity be done in a standard way. Severe cognitive problems may make a performance-based measure difficult or impossible to do. Qualitative measures also are important, as patient-reported outcomes reflect the patient’s own perspective on his or her limitations and restrictions. Additionally, some symptoms, such as pain, can be measured only by self-report. By adding the patient’s perspective, we can better document the perceived burden of cancer and meaningful impact of interventions.137 Mobility The mobility subdomain includes the following constructs: changing and maintaining body positions; carrying, moving, and handling objects; walking and moving; and moving around using transportation. We will discuss the changing and maintaining body positions and walking and moving constructs, as they are assessed most commonly by physical therapists.

ring between surfaces. Because the balance deficits discussed in the body function and structure section lead to impaired ability to change and maintain body positions, this is a critical area to explore in this population. Several appropriate activity-based measures of maintaining and changing body positions, including those that relate to balance impairments, are described in Table 3. The concepts of transferring between surfaces and walking and moving often are combined in rehabilitation outcome measures, although they are separate categories in the ICF model. A few examples of combined transfer and mobility status measures include the Timed “Up & Go” Test and the L Test of Functional Mobility (Tab. 3). Self-care The ability to care for one’s self is a construct often measured in rehabilitation settings. A few commonly reported measures are listed in Table 3 (Self-care). The Karnofsky Performance Scale138 has been a “gold standard” measure of overall performance status in cancer treatment trials. In its mid-range values, scores indicate the ability of a person to perform self-care. Because of its limited scope, some authors139,140 have reported that it is potentially limited in its responsiveness, a factor that may make it less useful for measuring rehabilitation outcomes. Other measures, such as the Barthel Index,141 have multiple components, including large representations of self-care activities in their content, and are likely to be more responsive to changes seen with rehabilitation. Although these scales are used often in inpatient rehabilitation research, they have relevance for oncology populations that may or may not be seen in such a setting.

Changing and maintaining body positions incorporates both the concepts of maintaining balance and transfer-

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Assessment in Oncology Rehabilitation Table 3. Measurement of Activity and Participation, With International Classification of Functioning, Disability and Health (ICF) Code (Alphabetic Chapter and Numeric Second-Level Domains) in Parentheses

Construct Mobility—changing and maintaining body positions (d410–d429)

Mobility—walking and moving (d450–d469)

Mobility—developmental (d410–d469)

Measurement Tool

a

Measurement Characteristics

Representative Studies in Populations of Patients With Cancer

5-time sit-to-stand

Performance-based assessment of transitional movement ability224

None

Functional reach

Performance-based measure of balance during voluntary movement in standing225

Palliative care226

Berg Balance Scale

Performance-based, standardized measure of static and dynamic balance227,228

None

Dynamic Gait Index

Standardized performance-based assessment of gait characteristics229,230

Vestibular schwannoma102

Standard Romberg Test and Tandem Romberg Test

Standardized performance-based assessment of static balance in various positions229

Breast cancer104

Tinetti Balance and Gait Scale

Simple and easily administered performance test that quantifies gait and balance characteristics. Scored on patient performance of gait- and balance-specific tasks.231

Lymphoma185

Timed “Up & Go” Test

A timed measure of balance and mobility232

Leukemia,178,182,233 lymphoma,185 sarcoma,207,234 breast cancer79

L Test of Functional Mobility

A performance-based assessment of basic mobility skills, including walking, transferring, and turning234

Lower-extremity solid tumor234

Functional Mobility Assessment

An instrument that combines assessment of a patient’s physical performance with self-report assessment of pain, function, supports, satisfaction, participation, and endurance133

Lower-extremity sarcoma133

Toronto Extremity Salvage Scale

A questionnaire that measures the level of difficulty experienced by patients with upper- and lower-extremity sarcoma in performing everyday activities135

Sarcoma134,235,236

Fullerton Advanced Balance Scale

Standardized performance-based clinical test of gait and balance characteristics237

Breast cancer104

Bruininks-Oseretsky Test of Motor Proficiency

A performance-based measure of gross and fine motor skills in children 41⁄2–14 years of age (second edition: 41⁄2–21 years of age)238

Leukemia239

Gross Motor Function Measure

Performance/observation-based measure of movement in children240

Leukemia239

Peabody Developmental Motor Scale

Performance-based measure of motor development in children aged 0–38 months with gross and fine motor scales241

Leukemia,242 children with cancer243

(Continued)

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Assessment in Oncology Rehabilitation Table 3. Continued

Measurement Toola

Construct Self-care (d510–d599)

Domestic life, interpersonal relations, and major life areas (d710–d799)

a

Measurement Characteristics

Representative Studies in Populations of Patients With Cancer

Barthel Index

Performance or self-report measure of independence in basic activities of daily living141

Prostate cancer,244 hospice,245,246 brain tumor247

Physical Performance Test

A 9-item timed test that simulates daily activities248

None

Functional Independence Measure

Provides estimate of burden of care based on level of dependence in performing basic activities of daily living52

Solid tumor,249 brain tumor250

Karnofsky Performance Scale

A standard measure of the ability of adult patients with cancer to perform ordinary tasks. The Karnofsky Performance Scale scores range from 0 to 100. A higher score means the patient is better able to carry out daily activities.251

Most drug clinical trials for all types of cancers

General Sickness Impact Profile

A 136-item questionnaire that measures the effect of sickness on everyday activities and behaviors in adults252

General253

Reintegration to Normal Living Index

An 11-item questionnaire covering mobility, self-care, family roles, family roles and personal relationships, presentation of self, coping skills, work, housework, and recreational and social activities for adults145

Sarcoma146,235

Not intended to be an all inclusive list of measures, but as examples of measures that have been used in the oncology literature.

Domestic Life, Interpersonal Relations, and Major Life Areas Few measures typically used by physical therapists attempt to quantify the capacity of a person to live as a family member and as a member of society (Tab. 3). Restrictions in the ability of an individual to interact with the environment or participate fully in life situations increase the disease burden on the individual, the family, and society. Indeed, people with participation restrictions are more likely to report poor health142 and bouts of depression.143 It is generally recognized that patients and survivors of cancer have restrictions in these domains,144 yet there is a paucity of outcome measures targeted here. A measurement tool that is focused specifically on the return to lifes roles after a major health change is 300

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the Reintegration to Normal Living Index.145 This tool measures adults’ perception of their ability to resume their life roles after a serious illness or trauma. It has been used sparingly in populations of people with cancer.146,147 Because performance of activities and participation in life roles often are the main goals of rehabilitation, measurement of pertinent activity and participation subdomains provides useful information regarding the need for and effectiveness of oncology rehabilitation.

Conclusion This article uses the ICF model to describe outcome measures that allow for broad quantification of global function and methods to document progression in patients with cancer and survivors of cancer. Understanding and documenting how these structural or anatomic deficits

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restrict activities (grooming, dressing, child care) and participation (attending community activities, reduced job expectations) provide a broader view of the patient’s abilities. Therapists need to be adept at understanding the intended focus of their therapeutic interventions and using the most appropriate tools to assess the effectiveness of those interventions. All authors provided concept/idea/project design and writing. Dr Gilchrist and Dr Galantino provided project management. Dr Ness provided consultation (including review of manuscript before submission). As the Research Committee of the Oncology Section of the American Physical Therapy Association, the authors thank the Oncology Section for their assistance and support in the development of the manuscript.

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Assessment in Oncology Rehabilitation This article was received October 10, 2007, and was accepted November 26, 2008. DOI: 10.2522/ptj.20070309

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17 Sklar CA, LaQuaglia MP. The long-term complications of chemotherapy in childhood genitourinary tumors. Urol Clin North Am. 2000;27:563–568. 18 Marina N. Long-term survivors of childhood cancer: the medical consequences of cure. Pediatr Clin North Am. 1997; 44:1021–1042. 19 Dieckmann K, Widder J, Potter R. Longterm side effects of radiotherapy in survivors of childhood cancer. Front Radiat Ther Oncol. 2002;37:57– 68. 20 Oeffinger KC, Mertens AC, Sklar CA, et al. Chronic health conditions in adult survivors of childhood cancer. N Engl J Med. 2006;355:1572–1582. 21 Lee JQ, Simmonds MJ, Wang XS, Novy DM. Differences in physical performance between men and women with and without lymphoma. Arch Phys Med Rehabil. 2003;84:1747–1752. 22 Oeffinger KC, Mertens AC, Hudson MM, et al. Health care of young adult survivors of childhood cancer: a report from the Childhood Cancer Survivor Study. Ann Fam Med. 2004;2:61–70. 23 Oeffinger KC, Eshelman DA, Tomlinson GE, et al. Providing primary care for longterm survivors of childhood acute lymphoblastic leukemia. J Fam Pract. 2000;49:1133–1146. 24 International Classification of Functioning, Disability and Health: ICF. Geneva, Switzerland: World Health Organization; 2001. 25 American Physical Therapy Association. APTA Endorses ICF Model. PT Bulletin. Vol 9, issue 26, 2008. Available at: http:// www.apta.org/AM/Template.cfm?Section ⫽Archives2&Template⫽ / Customsource/ TaggedPage / PTIssue.cfm&Issue⫽06 / 17 / 2008#article49312. 26 Nagi S. A study in the evaluation of disability and rehabilitation potential: concepts, methods, and procedures. Am J Public Health Nations Health. 1964;54: 1568 –1579. 27 Nagi S. Some Conceptual Issues in Disability and Rehabilitation. Washington, DC: American Sociological Association; 1965. 28 Jette AM. Toward a common language for function, disability, and health. Phys Ther. 2006;86:726 –734. 29 Nagi SZ. An epidemiology of disability among adults in the United States. Milbank Mem Fund Q Health Soc. 1976; 54:439 – 467. 30 Nagi SZ. Congruency in medical and selfassessment of disability. IMS Ind Med Surg. 1969;38:27–36. 31 Quasthoff S, Hartung HP. Chemotherapyinduced peripheral neuropathy. J Neurol. 2002;249:9 –17. 32 Kesselring J, Coenen M, Cieza A, et al. Developing the ICF Core Sets for multiple sclerosis to specify functioning. Mult Scler. 2008;14:252–254. 33 Geyh S, Cieza A, Schouten J, et al. ICF Core Sets for stroke. J Rehabil Med. 2004:135–141.

34 Starrost K, Geyh S, Trautwein A, et al. Interrater reliability of the extended ICF Core Set for stroke applied by physical therapists. Phys Ther. 2008;88:841– 851. 35 Dreinhofer K, Stucki G, Ewert T, et al. ICF Core Sets for osteoarthritis. J Rehabil Med. 2004:75– 80. 36 Ruof J, Cieza A, Wolff B, et al. ICF Core Sets for diabetes mellitus. J Rehabil Med. 2004:100 –106. 37 Cieza A, Stucki G, Weigl M, et al. ICF Core Sets for low back pain. J Rehabil Med. 2004:69 –74. 38 Stucki A, Daansen P, Fuessl M, et al. ICF Core Sets for obesity. J Rehabil Med. 2004:107–113. 39 Cieza A, Schwarzkopf S, Sigl T, et al. ICF Core Sets for osteoporosis. J Rehabil Med. 2004:81– 86. 40 Kirchberger I, Glaessel A, Stucki G, Cieza A. Validation of the comprehensive International Classification of Functioning, Disability and Health Core Set for rheumatoid arthritis: the perspective of physical therapists. Phys Ther. 2007;87:368 –384. 41 Uhlig T, Lillemo S, Moe RH, et al. Reliability of the ICF Core Set for rheumatoid arthritis. Ann Rheum Dis. 2007;66: 1078 –1084. 42 Stamm T, Geyh S, Cieza A, et al. Measuring functioning in patients with hand osteoarthritis: content comparison of questionnaires based on the International Classification of Functioning, Disability and Health (ICF). Rheumatology (Oxford). 2006;45:1534 –1541. 43 Stucki A, Borchers M, Stucki G, et al. Content comparison of health status measures for obesity based on the International Classification of Functioning, Disability and Health. Int J Obes (Lond). 2006;30:1791–1799. 44 Sigl T, Cieza A, Brockow T, et al. Content comparison of low back pain-specific measures based on the International Classification of Functioning, Disability and Health (ICF). Clin J Pain. 2006;22:147–153. 45 Borchers M, Cieza A, Sigl T, et al. Content comparison of osteoporosis-targeted health status measures in relation to the International Classification of Functioning, Disability and Health (ICF). Clin Rheumatol. 2005;24:139 –144. 46 Cieza A, Geyh S, Chatterji S, et al. ICF linking rules: an update based on lessons learned. J Rehabil Med. 2005;37: 212–218. 47 Tschiesner U, Cieza A, Rogers SN, et al. Developing core sets for patients with head and neck cancer based on the International Classification of Functioning, Disability and Health (ICF). Eur Arch Otorhinolaryngol. 2007;264: 1215–1222. 48 Brach M, Cieza A, Stucki G, et al. ICF Core Sets for breast cancer. J Rehabil Med. 2004:121–127.

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Assessment in Oncology Rehabilitation 96 Owczarek J, Jasinska M, OrszulakMichalak D. Drug-induced myopathies: an overview of possible mechanisms. Pharmacol Rep. 2005;57:23–34. 97 Mathiowetz V, Kashman N, Volland G, et al. Grip and pinch strength: normative data for adults. Arch Phys Med Rehabil. 1985;66:69 –72. 98 Bohannon RW. Reference values for extremity muscle strength obtained by hand-held dynamometry from adults aged 20 to 79 years. Arch Phys Med Rehabil. 1997;78:26 –32. 99 Ochs BG, Simank HG, Kopp-Schneider A, et al. Gait analysis in limb preserving tumour surgery: kinematic gait patterns after resection of malignant bone tumours near the knee joint. Z Orthop Unfall. 2007;145:763–771. 100 Benedetti MG, Catani F, Donati D, et al. Muscle performance about the knee joint in patients who had distal femoral replacement after resection of a bone tumor: an objective study with use of gait analysis. J Bone Joint Surg Am. 2000; 82:1619 –1625. 101 Gerber L, Hoffman K, Chaudry U, et al. Functional outcomes and life satisfaction in long-term survivors of pediatric sarcoma. Arch Phys Med Rehabil. 2006; 87:1611–1617. 102 Choy N, Johnson N, Treleaven J, et al. Balance, mobility and gaze stability deficits remain following surgical removal of vestibular schwannoma (acoustic neuroma): an observational study Aust J Physiother. 2006;52:211–216. 103 Syczewska M, Dembowska-Baginska B, Perek-Polnik M, Perek D. Functional status of children after treatment for a malignant tumor of the CNS: a preliminary report. Gait Posture. 2006;23:206 –210. 104 Wampler MA, Topp KS, Miaskowski C, et al. Quantitative and clinical description of postural instability in women with breast cancer treated with taxane chemotherapy. Arch Phys Med Rehabil. 2007;88:1002–1008. 105 Holley S. A look at the problem of falls among people with cancer. Clin J Oncol Nurs. 2002;6:193–197. 106 Camp-Sorrell D. Cardiorespiratory effects in cancer survivors. Am J Nurs. 2006; 106:55–59. 107 Floyd J, Nguyen D, Lobins R, et al. Cardiotoxicity of cancer therapy. J Clin Oncol. 2005;23:7685–7696. 108 Harris E, Correa C, Hwang W, et al. Late cardiac mortality and morbidity in earlystage breast cancer patients after breast conservation treatment. J Clin Oncol. 2006;24:4100 – 4106. 109 Limper A. Chemotherapy induced lung disease. Clin Chest Med. 2004;25:53– 64. 110 Butland R, Pang J, Gross E, et al. Two-, six-, and twelve-minute walking tests in respiratory disease. BMJ. 1982;284: 1607–1608. 111 Medical Research Council. Instructions for Use of the Questionaire on Respiratory Symptoms. Dawlish, England: WJ Holman; 1966.

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112 Borg G. Psychophysical bases of perceived exertion. Med Sci Sports Exerc. 1982;4:377–381. 113 Dimeo F, Schmittel A, Fietz T, et al. Physical performance, depression, immune status and fatigue in patients with hematological malignancies after treatment. Ann Oncol. 2004;15:1237–1242. 114 Cramp F, Daniel J. Exercise for the management of cancer-related fatigue in adults. Cochrane Database Syst Rev. 2008: CD006145. 115 Bruera E, Strasser F, Shen L, et al. The effect of donepezil on sedation and other symptoms in patients receiving opioids for cancer pain: a pilot study. J Pain Symptom Manage. 2003;26:1049 –1054. 116 Mulrooney DA, Ness KK, Neglia JP, et al. Fatigue and sleep disturbance in adult survivors of childhood cancer: a report from the Childhood Cancer Survivor Study (CCSS). Sleep. 2008;31:271–281. 117 Taylor R, Jayasinghe UW, Koelmeyer L, et al. Reliability and validity of arm volume measurements for assessment of lymphedema. Phys Ther. 2006;86:205–214. 118 Karges JR, Mark BE, Stikeleather SJ, Worrell TW. Concurrent validity of upperextremity volume estimates: comparison of calculated volume derived from girth measurements and water displacement volume. Phys Ther. 2003;83:134 –145. 119 Megens AM, Harris SR, Kim-Sing C, McKenzie DC. Measurement of upper extremity volume in women after axillary dissection for breast cancer. Arch Phys Med Rehabil. 2001;82:1639 –1644. 120 Stout-Gerich NL, Pfalzer LA, McGarvey C, et al. Preoperative assessment enables the early diagnosis and successful treatment of lymphedema. Cancer Invest. 2008;112:2809 –2019. 121 Common Terminology Criteria for Adverse Events, version 3.0 (CTCAE v3.0). Available at: http://ctep.cancer.gov/ forms/CTCAEv3.pdf. Accessed March 14, 2007. 122 Jaeckle KA. Neurological manifestations of neoplastic and radiation-induced plexopathies. Semin Neurol. 2004;24: 385–393. 123 Lowey SE. Spinal cord compression: an oncologic emergency associated with metastatic cancer: evaluation and management for the home health clinician. Home Healthc Nurse. 2006;24:439 – 446. 124 Hipp J, Springfield D, Hayes W. Predicting pathologic fracture risk in the management of metastatic bone defects. Clin Orthop Relat Res. 1995:120 –135. 125 Rades D, Veninga T, Stalpers L, et al. Improved posttreatment functional outcomes is associated with better survival in patients irradiated for metastatic spinal cord compression. Int J Radiat Oncol Biol Phys. 2007;67:1506 –1509. 126 Majhail N, Ness K, Burns L, et al. Late effects in survivors of Hodgkin and nonHodgkin lymphoma: a report from the Bone Marrow Transplant Survivor Study. Biol Blood Marrow Transplant. 2007; 13:1153–1159.

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170 Villars P, Dodd M, West C, et al. Differences in the prevalence and severity of side effects based on type of analgesic prescription in patients with chronic cancer pain. J Pain Symptom Manage. 2007;33:67–77. 171 Hicks C, von Bayer C, Spafford P, et al. The faces pain scale-revised:toward a common metric in pediatric pain measurement. Pain. 2001;93:173–183. 172 Caraceni A, Portenoy R; a working group of the IASP Task Force on Cancer Pain. An international survey of cancer pain characteristics and syndromes. Pain. 1999;82:263–274. 173 Borden L, Clark P, Lovato J, et al. Vinorelbine, doxorubicin, and prednisone in androgen-independent prostate cancer. Cancer. 2006;107:1093–1100. 174 Miaskowski C, Dodd M, West C, et al. The use of a responder analysis to identify differences in patient outcomes following a self-care intervention to improve cancer pain management. Pain. 2007;129:55– 63. 175 Joint Motion: Method of Measuring and Recording. Chicago, IL: American Academy of Orthopaedic Surgeons; 1965. 176 Reese N, Bandy W. Joint Range of Motion and Muscle Length Testing. Philadelphia, PA: WB Saunders Co; 2002. 177 Leidenius M, Leppanen E, Krogerus L, von Smitten K. Motion restriction and axillary web syndrome after sentinel node biopsy and axillary clearance in breast cancer. Am J Surg. 2003;185: 127–130. 178 Marchese VG, Chiarello L. Relationships between specific measures of body function, activity, and participation in children with acute lymphoblastic leukemia. Rehabil Oncol. 2004;22:5–9. 179 Paulino A. Late effects of radiotherapy for pediatric extremity sarcomas. Int J Rad Oncol Biol Phys. 2004;60:265–274. 180 Golding L, Myers C, Sinning W. Y’s Way to Physical Fitness. Champaign, IL: Human Kinetics Inc; 1989. 181 Kolden G, Straiam T, Ward A, et al. A pilot study of group exercise training for women with primary breast cancer: feasibility and health benefits. Psychooncology. 2006;11:447– 456. 182 Ness KK, Baker KS, Dengel D, et al. Body composition, muscle strength deficits and mobility limitations in adult survivors of childhood acute lymphoblastic leukemia. Pediatr Blood Cancer. 2007;49: 975–981. 183 Hayes S, Battistutta D, Newman B. Objective and subjective upper body function six months following diagnosis of breast cancer. Breast Cancer Res Treat. 2005; 94:1–10. 184 Rietman J, Geertzen J, Hoekstra H, et al. Long-term treatment-related upper limb morbidity and quality of life after sentinal lymph node biopsy for stage I or II breast cancer. Eur J Surg Oncol. 2006;32: 148 –152.

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Assessment in Oncology Rehabilitation 185 Siegel AB, Lachs M, Coleman M, Leonard JP. Lymphoma in elderly patients: novel functional assessment techniques provide better discrimination among patients than traditional performance status measures. Clin Lymphoma Myeloma. 2006;7:65– 69. 186 Abu-Rustum N, Alektiar K, Iasonos A, et al. The incidence of symptomatic lower-extremity lymphedema following treatment of uterine corpus malignancies: a 12-year experience at Memorial Sloan-Kettering Cancer Center. Gynecol Oncol. 2006;103:714 –718. 187 Monsell EM, Furman JM, Herdman SJ, et al. Computerized dynamic platform posturography. Otolaryngol Head Neck Surg. 1997;117:394 –398. 188 Gouveris H, Akkafa S, Lippold R, Mann W. Influence of nerve of origin and tumor size of vestibular schwannoma on dynamic posturography findings. Acta Otolaryngol. 2006;126:1281–1285. 189 Bergson E, Sataloff R. Preoperative computerized dynamic posturography as a prognostic indicator of balance function in patients with acoustic neuroma. Ear Nose Throat J. 2005;84:154 –156. 190 Galvao D, Nosaka K, Taaffe D, et al. Resistance training and reduction of treatment side effects in prostate cancer patients. Med Sci Sports Exerc. 2006;38: 2045–2052. 191 Konczak J, Schoch B, Dimitrova A, et al. Functional recovery of children and adolescents after cerebellar tumour resection. Brain. 2005;128:1428 –1441. 192 American College of Sports Medicine. ACSM’s Guidelines for Exercise Testing and Prescription. Philadelphia, PA: Lippincott Williams & Wilkins; 2000. 193 de Miguel Sanchez C, Elustondo S, Estirado A, et al. Palliative performance status, heart rate and respiratory rate as predictive factors of survival time in terminally ill cancer patients. J Pain Symptom Manage. 2006;31:485– 492. 194 Haddy T, Mosher R, Reaman G. Hypertension and pre-hypertension in longterm survivors of childhood and adolescent cancer. Pediatr Blood Cancer. 2007;49:79 – 83. 195 Kourti M, Tragiannidis A, Makedou A, et al. Metabolic syndrome in children and adolescents with acute lymphoblastic leukemia after the completion of chemotherapy. J Pediatr Hematol Oncol. 2005;27:499 –501. 196 Sagstuen H, Aass N, Fossa S, et al. Blood pressure and body mass index in longterm survivors of testicular cancer. J Clin Oncol. 2005;23:4980 – 4990. 197 Pietila S, Ala-Houhala M, Lenko H, et al. Renal impairment and hypertension in brain tumor patients treated in childhood are mainly associated with cisplatin treatment. Pediatr Blood Cancer. 2005;44: 363–369. 198 Dudgeon D, Lertzman M, Askew G. Physiologic changes and clinical correlations of dyspnea in cancer outpatients. J Pain Symptom Manage. 2001;21:373–379.

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199 Nomori H, Watanabe K, Ohtsuka T, et al. Six-minute walk and pulmonary function test outcomes during the early period after lung cancer surgery with special reference to patients with chronic obstructive pulmonary disease. Jpn J Thorac Cardiovasc Surg. 2004;52:113–119. 200 Weiner D, Maity A, Carlson C, Ginsberg J. Pulmonary function abnormalities in children treated with whole lung irradiation. Pediatr Blood Cancer. 2006;46:222–227. 201 Bossi G, Cerveri I, Volpini E, et al. Longterm pulmonary sequelae after treatment of childhood Hodgkin’s disease. Ann Oncol. 1997;8:19 –24. 202 Herrero F, San Juan A, Fleck S, et al. Effects of detraining on the functional capacity of previously trained breast cancer survivors. Int J Sports Med. 2007;28: 257–264. 203 Herrero F, San Juan A, Fleck S, et al. Combined aerobic and resistance training in breast cancer survivors: a randomized, controlled pilot trial. Int J Sports Med. 2006;27:573–580. 204 Cheema B, Gaul C. Full-body exercise training improves fitness and quality of life in survivors of breast cancer. J Strength Cond Res. 2006;20:14 –21. 205 Hlatky M, Boineau R, Higginbotham M, et al. A brief self-administered questionnaire to determine functional capacity (the Duke Activity Status Index). Am J Cardiol. 1989;64:651– 654. 206 Health Related Physical Fitness: Test Manual. Reston, VA: American Alliance for Health, Physical Education, Recreation and Dance; 1980. 207 Marchese V, Ogle S, Womer R, et al. An examination of outcome measures to asess functional mobility in childhood survivors of osteosarcoma. Pediatr Blood Cancer. 2004;42:41– 45. 208 Smets E, Garssen B, Bonke B, et al. The Multidimensional Fatigue Inventory (MFI) psychometric qualities of an instrument to assess fatigue. J Psychosom Res. 1995;39:315–325. 209 Jereczek-Fossa B, Santoro L, Alterio D, et al. Fatigue during head-and-neck radiotherapy: prospective study on 117 consecutive patients. Int J Radiat Oncol Biol Phys. 2007;68:403– 415. 210 Yellen S, Cella D, Webster K, et al. Measuring fatigue and other anemia-related symptoms with the Functional Assessment of Cancer Therapy (FACT) measurement system. J Pain Symptom Manage. 1997;13:63–74. 211 Piper B, Dibble S, Dodd M, et al. The revised Piper Fatigue Scale: psychometric evaluation in women with breast cancer. Oncol Nurs Forum. 1998;25:677– 684. 212 Meeske K, Siegel S, Globe D, et al. Prevalence and correlates of fatigue in longterm survivors of childhood leukemia. J Clin Oncol. 2005;23:5501–5510. 213 Berger A, Farr L, Kuhn B, et al. Values of sleep/wake, activity/rest, circadian rhythms, and fatigue prior to adjuvant breast cancer chemotherapy. J Pain Symptom Manage. 2007;33:398 – 409.

214 Mendoza T, Wang X, Cleeland C, et al. The rapid assessment of fatigue severity in cancer patients: use of the Brief Fatigue Inventory. Cancer. 1999;85:1186 –1196. 215 Wang X, Giralt S, Mendoza T, et al. Clinical factors associated with cancerrelated fatigue in patients being treated for leukemia and non-Hodgkin’s lymphoma. J Clin Oncol. 2002;20:1319 –1328. 216 Wang X, Janjan N, Guo H, et al. Fatigue during preoperative chemoradiation for resectable rectal cancer. Cancer. 2001; 92:1725–1732. 217 Stanton AW, Northfield JW, Holroyd B, et al. Validation of an optoelectric limb volumeter (Perometer). Lymphology. 1997;30:77–97. 218 Ratliff J, Cooper P. Metastatic spine tumors. South Med J. 2004;97:246 –253. 219 Maniadaki I, Stiakaki E, Germankis I, Kalmanti M. Evaluation of bone mineral density at different phases of therapy for childhood ALL. Pediatr Hematol Oncol. 2006;23:11–18. 220 Karavatas SG, Reicherter A, White N, Strong A. Physical therapy management of patients with multiple myeloma: musculoskeletal considerations. Rehab Oncol. 2006;24:11–16. 221 Dimeo F, Tilmann M, Bertz H, et al. Aerobic exercise in the rehabilitation of cancer patients after high dose chemotherapy and autologous peripheral stem cell transplantation. Cancer. 1997;79:1717–1722. 222 Elbl L, Vasova I, Kral Z, et al. Evaluation of acute and early cardiotoxicity in survivors of Hodgkin’s disease treated with ABVD or BEACOPP regimens. J Chemother. 2006;18:199 –208. 223 Dang C, Fornier M, Sugarman S, et al. The safety of dose-dense doxorubicin and cyclophosphamide followed by paclitaxel with trastuzumab in HER-2/neu overexpressed/amplified breast cancer. J Clin Oncol. 2008;26:1216 –1222. 224 Whitney SL, Wrisley DM, Marchetti GF, et al. Clinical measurement of sit-to-stand performance in people with balance disorders: validity of data for the Five-TimesSit-to-Stand Test. Phys Ther. 2005;85:1034 –1045. 225 Duncan P, Weiner D, Chandler J, Studenski S. Functional reach: a new clinical measure of balance. J Gerontol. 1990;45: M192–M197. 226 Oldervoll LM, Loge JH, Paltiel H, et al. The effect of a physical exercise program in palliative care: a phase II study. J Pain Symptom Manage. 2006;31:421– 430. 227 Berg K, Wood-Dauphine´e SL, Williams J, Gayton D. Measuring balance in the elderly: preliminary development of an instrument. Physiother Can. 1989;41: 304 –311. 228 Berg K, Maki B, Williams J, et al. Clinical and laboratory measures of postural balance in an elderly population. Arch Phys Med Rehabil. 1992;73:1073–1080. 229 Shumway-Cook A, Woollacott MH. Motor Control: Theory and Practical Applications. 2nd ed. Baltimore, MD: Lippincott Williams & Wilkins; 2001.

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Assessment in Oncology Rehabilitation 230 Whitney SL, Wrisley DM, Furman J. Concurrent validity of the Berg Balance Scale and the Dynamic Gait Index in people with vestibular dysfunction. Physiother Res Int. 2003;8:178 –186. 231 Tinetti M. Tinetti performance-oriented mobility assessment in elderly patients. J Am Geriatr Soc. 1986;34:119 –126. 232 Podsiadlo D, Richardson S. The timed “up and go”: a test of basic functional mobility for frail elderly persons. J Am Geriatr Soc. 1991;39:142–148. 233 Marchese VG, Chiarello L, Lange B. Effects of physical therapy intervention for children with acute lymphoblastic leukemia. Pediatr Blood Cancer. 2004;42: 127–133. 234 Deathe AB, Miller WC. The L Test of Functional Mobility measurement properties of a modified version of the Timed “Up & Go” Test designed for people with lower-extremity amputations. Phys Ther. 2005;85:626 – 635. 235 Davis A, Devlin M, Griffin A, et al. Functional outcome in amputation versus limb sparing of patients with lower extremity sarcoma: a matched case-control study Arch Phys Med Rehabil. 1999; 80:615– 618. 236 Nagarajan R, Clohisy D, Neglia J, et al. Function and quality-of-life of survivors of pelvic and lower extremity osteosarcoma and Ewing’s sarcoma: the Childhood Cancer Survivor Study. Br J Cancer. 2004;91:1858 –1865. 237 Rose DJ. Fall Proof! A Comprehensive Balance and Mobility Training Program. Champaign, IL: Human Kinetics Inc; 2003.

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238 Dietz JC, Kartin D, Kopp K. Review of the Bruininks-Oseretsky Test of Motor Proficiency. Phys Occup Ther Pediatr. 2007;27:87–102. 239 Wright M, Halton J, Martin R, Barr R. Long-term gross motor performance following treatment for acute lymphoblastic leukemia. Med Pediatr Oncol. 1998; 31:86 –90. 240 Russell D, Rosenbaum P, Cadman D, et al. The Gross Motor Function Measure: a means to evaluate the effect of therapy. Dev Med Child Neurol. 1989;31: 341–352. 241 Palisano RJ, Kolobe TH, Haley SM, et al. Validity of the Peabody Developmental Gross Motor Scale as an evaluative measure of infants receiving physical therapy. Phys Ther. 1995;75:939 –951. 242 MacLean WJ, Noll R, Stehbens J, et al; the Children’s Cancer Group. Neuropsychological effects of cranial irradiation in young children with acute lymphoblastic leukemia 9 months after diagnosis. Arch Neurol. 1995;52:156 –160. 243 Crisp J, Ungerer J, Goodnow J. The impact of experience on children’s understanding of illness. J Pediatr Psychol. 1996;21:57–72. 244 Aass N, Fossa S. Pre- and post-treatment daily life function in patients with hormone-resistant prostate carcinoma treated with radiotherapy for spinal cord compression. Radiother Oncol. 2005; 74:259 –265. 245 Bennett M, Ryall N. Using the modified Barthel index to estimate survival in cancer patients in hospice: observational study. BMJ. 2000;321:1381–1382.

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246 Yoshioka H. Rehabilitation for the terminal cancer patient. Am J Phys Med Rehabil. 1994;73:199 –206. 247 Osoba D, Aaronson N, Muller M, et al. Effect of neurological dysfunction on health-related quality of life in patients with high-grade glioma. J Neurooncol. 1997;34:263–278. 248 Reuben D, Siu A. An objective measure of physical function of elderly outpatients. J Am Geriatr Soc. 1990;38:1105–1112. 249 Smith D, Ehde D, Hanley M. Efficacy of gabapentin in treating chronic phantom limb and residual limb pain. J Rehabil Res. 2005;42:645– 654. 250 Huang M, Wartella J, Kreutzer J. Functional outcomes and quality of life in patients with brain tumor: a preliminary report. Arch Phys Med Rehabil. 2001; 82:1540 –1546. 251 Yates JW, Chalmer B, McKegney FP. Evaluation of patients with advanced cancer using the Karnofsky performance status. Cancer. 1980;45:2220 –2224. 252 Bergner M, Bobbitt R, Carter W, et al. The Sickness Impact Profile: development and final revision of a health status measure. Med Care. 1981;19:787– 805. 253 De Bruin A, de Witte L, Stevens F, et al. Sickness Impact Profile: the state of the art of a generic functional status measure. Soc Sci Med. 1992;35:1003–1014.

March 2009

Letters to the Editor On “Physical therapist management...” Rundell SD, et al. Phys Ther. 2009;89:82–90. We read with interest Rundell and colleagues’ case report on the International Classification of Functioning, Disability and Health (ICF) and its application to low back pain (LBP).1 The article clearly presented the role of the ICF as a unifying framework that clinicians and researchers (eg, in clinical trials) can use. It also solidified the role of physical therapists’ clinical decision-making skills in effectively managing patients on the basis of the ICF. However, we have some comments regarding the way the authors represented the conceptual model of functioning and disability behind the ICF and practical tools developed based on this classification, such as the ICF Core Sets. Figure 1 does not represent the official depiction of the model as it is in the ICF book2 and can be misleading. The health condition in their figure seems to represent a background experience that directly interacts with all other components of the model. In addition, although the possible direct relationship between contextual factors and activity was mentioned in the text, it was not represented in the figure. The authors did not provide any further explanation of the need for and usefulness of the changes made to the original model. On one hand, readers who are not familiar with the ICF might have the impression that the authors’ presented model is the official model. On the other hand, readers who are familiar with the ICF would have difficulty understanding the rationale behind the changes that were made.

It probably would have been helpful to introduce explicitly the difference between the ICF as a model and the ICF as a classification. The model has 6 interrelated components of health: health condition, body functions and structures, activities, participation, environmental factors, and personal factors. The ICF classification concretizes all of the components except for health conditions and personal factors in the form of ICF categories. The ICF contains a total of 1,454 categories that are hierarchically organized. Health conditions are classified in the International Classification of Diseases (ICD10).3 Thus, the ICD-10 and the ICF are complementary classifications, and the World Health Organization envisions a common application of these classifications in clinical medicine and research.

Reuben Escorpizo and Alarcos Cieza

The authors mentioned the ICF Core Set for LBP.4 However, they did not state its value for clinical practice and research. An ICF Core Set is a list of ICF categories relevant to people with a health condition or health-related event, such as LBP. Thus, the ICF Core Set for LBP contains all areas of functioning that are evaluated and treated by all health care professionals, including physical therapists, as part of a multidisciplinary team. The ICF Core Sets represent the basis to guide multidisciplinary assessment and treatment.5,6

1 Rundell SD, Davenport TE, Wagner T. Physical therapist management of acute and chronic low back pain using the World Health Organization’s International Classification of Functioning, Disability and Health. Phys Ther. 2009;89:82–90.

Finally, in the case description of the use of the ICF model in physical therapist management for the patient with chronic LBP, environmental factors were identified, but not in the “Intervention” section and not until later in the “Outcome” section, thus leaving a gap between the ICF and physical therapist management.

6 Rauch A, Cieza A, Stucki G. How to apply the International Classification of Functioning, Disability and Health (ICF) for rehabilitation management in clinical practice. Eur J Phys Rehabil Med. 2008;44: 329–342.

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R Escorpizo, PT, DPT, is Physical Therapist and ICF Core Set Project Leader, Swiss Paraplegic Research (SPR), Nottwil, Switzerland, and ICF Research Branch of the WHO Collaborating Center for the Family of International Classifications at the German Institute of Medical Documentation and Information (DIMDI) SPR site. A Cieza, PhD, MPH, is Research Scientist and Group Leader, Swiss Paraplegic Research (SPR), Nottwil, Switzerland; Research Scientist and Group Leader, ICF Research Branch of the WHO Collaborating Center for the Family of International Classifications at the German Institute of Medical Documentation and Information (DIMDI) SPR site; and Research Scientist and Group Leader, ICF Research Branch of the WHO Collaborating Center for the Family of International Classifications at the German Institute of Medical Documentation and Information (DIMDI), IHRS, LudwigMaximilian University, Munich, Germany This letter was posted as a Rapid Response on January 12, 2009, at www.ptjournal.org.

References

2 International Classification of Functioning, Disability and Health: ICF. Geneva, Switzerland: World Health Organization; 2001. 3 International Classification of Diseases (ICD-10). Available at: http://www.who. int/classifications/icd/en/. 4 Cieza A, Stucki G, Weigl M, et al. ICF core sets for low back pain. J Rehabil Med Suppl. 2004;36:69–74. 5 Allet L, Cieza A, Burge E, et al. Intervention categories for physiotherapists treating patients with musculoskeletal conditions on the basis of the International Classification of Functioning, Disability and Health. Int J Rehabil Res. 2007;30:273–280.

[DOI: 10.2522/ptj.2009.89.3.308]

March 2009

Letters to the Editor

Author Response We would like to thank Dr Escorpizo and Dr Cieza for their interest in and response1 to our case report on applying the World Health Organization’s (WHO) International Classification of Functioning, Disability and Health (ICF) to the physical therapist management of low back pain (LBP).2 Although an important difference between the Nagi model3 and the ICF model4 includes bidirectional relationships among nonhierarchical domains of function, the WHO’s figure representing the ICF model is still visually linear. We determined that a figure that was less linear would better represent our perceived application of the ICF model in this case report. As mentioned in Escorpizo and Cieza’s response, we did view the health condition as a component that simultaneously interacts with all the other components of the model. In addition, we saw health condition as the greater issue to which we were applying the ICF model for each patient. All the domains in this figure are demonstrated to interact with each other by way of overlap and bidirectional arrows. Ample references to the literature, including the ICF itself, were provided in our article to guide readers who are unfamiliar with the ICF model. PTJ’s readers can decide the clinical relevance of any differences in depiction of the ICF model between our article and others in the literature. We agree that there is a direct relationship between contextual factors and activity. An arrow representing the bidirectional relationship between contextual factors and activity limitations was present in our original Figure 1. Unfortunately, a printing error resulted in omission of this important component. March 2009

[A corrected version of this figure is published in this issue on page 310.] The additional brief description of the ICF model’s use as a conceptual model, classification approach, and the ICF Core Sets5 by Escorpizo and Cieza is appreciated. In our case report, the ICF model was applied to describe the disablement experience for each patient and to assist in the clinical reasoning for each patient’s case. The ICF Core Set concept was briefly applied in Table 1 and, with a couple of additions, in Table 2 for categorization of the body function and structure impairments, activity limitations, participation restrictions, and contextual factors. We believe that Core Sets and the International Classification of Disease-10 (ICD-10) classification6 are important content from the perspective of determination and the study of general trends in clinical management of LBP at the population level. We decided that this depth of information was less essential to satisfy our objective of introducing PTJ’s readership to the process of applying the ICF in the management of individual patients with LBP. Therefore, we think a detailed discussion of the use of the ICF model Core Sets and the ICD-10 remains beyond the intended scope of this case report. We agree that these topics are highly relevant. The derivation and description of guidelines describing practice related to common musculoskeletal health conditions is the subject of ongoing work within the Orthopaedic Section of the American Physical Therapy Association.7–9 Using this work and existing Core Sets for patients with LBP, we believe future mixed methods studies would be better positioned to optimally describe best practices related to physical therapists’ use of the ICD-10 classification and Core Sets

derived from the ICF model, rather than our case report. In the management of the patient with chronic LBP, several environmental factors related to her work were identified by the physical therapist. These environmental factors were not addressed for intervention because they were deemed unable to be changed or extremely difficult to change. A description of an intervention directed to the domain of environmental factors in the “Intervention” section was not included because no intervention was directed to that domain. It is unclear how the lack of intervention directed at this domain or the manner in which it was documented in our case report resulted in any discrepancy between physical therapist management and the ICF model. Instead, we think this highlights the inherently inexact science of applying any conceptual model of clinical management to a specific patient’s case. We are optimistic that our documentation of this experience can contribute to future conceptual and empirical work in this important area for rehabilitation research. Sean D Rundell, Todd E Davenport, and Tracey Wagner SD Rundell, PT, DPT, OCS, is Physical Therapist, Portland Sports Medicine and Spine Physical Therapy, Portland, Oregon. This letter was posted as a Rapid Response on January 27, 2009, at www.ptjournal.org.

References 1 Escorpizo R, Cieza A. Letter to the editor on “Physical therapist management...” Phys Ther. 2009;89:308. 2 Rundell SD, Davenport TE, Wagner T. Physical therapist management of acute and chronic low back pain using the World Health Organization’s International Classification of Functioning, Disability and Health. Phys Ther. 2009;89:82–90. 3 Nagi S. Disability and Rehabilitation. Columbus, OH: Ohio State University Press; 1969.

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Letters to the Editor 4 International Classification of Functioning, Disability and Health: ICF. Geneva, Switzerland: World Health Organization; 2001. 5 Cieza A, Stucki G, Weigl M, et al. ICF core sets for low back pain. J Rehabil Med. 2004(44 suppl);69–74.

6 International Classification of Diseases (ICD-10). Available at: http://www.who. int/classifications/icd/en/. 7 Irrgang JJ, Godges J. Use of the International Classification of Functioning and Disability to develop evidence-based practice guidelines for treatment of common musculoskeletal conditions. Orthopaedic Physical Therapy Practice. 2006;18(4): 24–25.

8 McPoil TG, Martin RL, Cornwall MW, et al. Heel pain-plantar fasciitis: clinical practice guidelines linked to the International Classification of Function, Disability, and Health from the Orthopaedic Section of the American Physical Therapy Association. J Orthop Sports Phys Ther. 2008;38: A1–A18. 9 Childs JD, Cleland JA, Elliott JM, et al. Neck pain: clinical practice guidelines linked to the International Classification of Functioning, Disability and Health from the Orthopaedic Section of the American Physical Therapy Association. J Orthop Sports Phys Ther. 2008;38:A1–A34. [DOI: 10.2522/ptj.2009.89.3.309]

Correction Rundell SD, Davenport TE, Wagner T. “Physical therapist management of acute and chronic low back pain...” Phys Ther. 2009;89:82–90. The bidirectional arrow between “Activity” and “Contextual Factors” was omitted in Figure 1: World Health Organization’s International Classification of Functioning, Disability and Health model. The corrected figure appears below. The Journal regrets the error.

HEALTH CONDITION

¾

¾

¾

ACTIVITY

¾ Contextual Factors: Environment & Personal

¾

¾

¾

¾

PARTICIPATION

¾

¾

BODY FUNCTION AND STRUCTURE

¾

¾

Figure 1. World Health Organization’s International Classification of Functioning, Disability and Health model. [DOI: 10.2522/ptj.20080113.cx]

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March 2009

Letters to the Editor 4 International Classification of Functioning, Disability and Health: ICF. Geneva, Switzerland: World Health Organization; 2001. 5 Cieza A, Stucki G, Weigl M, et al. ICF core sets for low back pain. J Rehabil Med. 2004(44 suppl);69–74.

6 International Classification of Diseases (ICD-10). Available at: http://www.who. int/classifications/icd/en/. 7 Irrgang JJ, Godges J. Use of the International Classification of Functioning and Disability to develop evidence-based practice guidelines for treatment of common musculoskeletal conditions. Orthopaedic Physical Therapy Practice. 2006;18(4): 24–25.

8 McPoil TG, Martin RL, Cornwall MW, et al. Heel pain-plantar fasciitis: clinical practice guidelines linked to the International Classification of Function, Disability, and Health from the Orthopaedic Section of the American Physical Therapy Association. J Orthop Sports Phys Ther. 2008;38: A1–A18. 9 Childs JD, Cleland JA, Elliott JM, et al. Neck pain: clinical practice guidelines linked to the International Classification of Functioning, Disability and Health from the Orthopaedic Section of the American Physical Therapy Association. J Orthop Sports Phys Ther. 2008;38:A1–A34. [DOI: 10.2522/ptj.2009.89.3.309]

Correction Rundell SD, Davenport TE, Wagner T. “Physical therapist management of acute and chronic low back pain...” Phys Ther. 2009;89:82–90. The bidirectional arrow between “Activity” and “Contextual Factors” was omitted in Figure 1: World Health Organization’s International Classification of Functioning, Disability and Health model. The corrected figure appears below. The Journal regrets the error.

HEALTH CONDITION

¾

¾

¾

ACTIVITY

¾ Contextual Factors: Environment & Personal

¾

¾

¾

¾

PARTICIPATION

¾

¾

BODY FUNCTION AND STRUCTURE

¾

¾

Figure 1. World Health Organization’s International Classification of Functioning, Disability and Health model. [DOI: 10.2522/ptj.20080113.cx]

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March 2009

Scholarships, Fellowships, and Grants News from the Foundation for Physical Therapy Recipients in the News The Foundation for Physical Therapy is pleased to announce that Steven George, PT, PhD, a 2001 Promotion of Doctoral Studies (PODS) II funding recipient and a 2000 PODS I funding recipient, was recently awarded the John C Liebeskind Early Career Scholar Award by the American Pain Society. This award recognizes George for his exceptional accomplishment and promise in pain scholarship. The full press release is available at www.ampainsoc.org/ awards/liebeskind.htm.

Georgia State—Marquette Challenge Fundraiser Deadline Approaches Students participating in the Georgia State—Marquette Challenge hope to raise $175,000 this year. Donations must be postmarked by the Challenge deadline, April 21, 2009, to count toward this year’s fundraiser. The student-led fundraiser supports Foundation research grants and PODS I or II scholarships to a physical therapist or physical therapist assistant pursuing a career in research. Visit the Foundation’s Web site at www.Foundation ForPhysicalTherapy.org to learn more about the Georgia State— Marquette Challenge. For more information, contact Barbara Malm at 800/875-1378, ext 8502.

Annual Foundation Split Raffle The 21st Annual Split Raffle fundraiser supports the Foundation’s mission of advancing physical therapy through doctoral scholarships, fellowships, and clinical research.

March 2009

By purchasing a Split Raffle ticket, you are investing in the strength and future of your profession. You also have the chance to win one of nine $2,000 prizes or the $10,000 grand prize. To learn how you can participate, contact Barbara Malm at 800/875-1378, ext 8502. Visit the Foundation’s Web site at www. FoundationForPhysicalTherapy. org for complete Split Raffle rules.

Are You ExcePTional? We think you are. The Foundation is offering a new, budget-friendly giving program that will help you achieve your philanthropic goals during these challenging economic times. Becoming ExcePTional is the perfect way to support the research that benefits you and your patients while helping you stay budget conscious. The program is simple. Visit the Foundation’s Web site at www.FoundationFor PhysicalTherapy.org to determine whether you want to give monthly or quarterly. View the examples provided to see how a small monthly or quarterly gift can turn into $1,000 or even $5,000 over 4 years. Choose the amount that works best for your budget and we’ll take care of the rest! You will always retain full control over your gift, and you may suspend or modify your gift at any time. For more information, contact Jennifer Sharp at 800/875-1378, ext 8569.

Foundation Launches e-Newsletter In celebration of its 30th anniversary, the Foundation for Physical Therapy has launched a monthly e-newsletter to keep you informed about Foundation activities. The newsletter will celebrate 30 years

of innovation in physical therapy research and will include profiles of researchers whose careers were launched with funding from the Foundation. The newsletter also will feature Foundation trivia, information on the latest research projects funded, and updates on Foundation events and activities. You can sign up for the e-newsletter at www.Foundationfor PhysicalTherapy.org or contact Jennifer Sharp at 800/875-1378, ext 8569 for more information. [DOI: 10.2522/ptj.2009.89.3.311]

OUT DK C CHE R GRAN YOU BRAND NEW It’s all about you! See for yourself on APTA’s members-only brand Web page, www.apta.org/brandbeat, your resource for everything related to the new brand. Learn it. Live it. And use it to let existing and potential patients know that you are the practitioner of choice for maximizing movement and function.

www.apta.org/brandbeat

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Association Business In Memoriam The deaths of these members were reported to APTA between January 1, 2008, and December 31, 2008. Joseph Ardizzone Judy W Bailey Pamela Barnett Jacqueline Bellizzi Jill S Berger Beverly P Bishop Joe R Bogue Beatrice B Boody A J Boone John Borreca Thomas Campeau Kellie Jo Carter Granville Chapman Rena E Chiuminato Nadene Coyne Clovis Dailey Nirguna Kathleen Das Helen W Davison Mary Dawson Marisa L De Leon Teresa C Dipietro Carole S Donovan Grace S Ellison June S England Rae Farmer Josephine Finch Shirley C Fisher Daniel J Freitas Mary Gerth Margaret Gill Katherine C Gimmel Mary F Golson Dorothy Harris Anna C Hartman Shirbod Hejazi

March 2009

Elizabeth Hickman Evelyn R Hinson Earl Holbrook Margaret Houts Randall Craig Isley Roberta B Johnson Donald Jones Eleanor G Jorgenson Helen Jorgenson Adam Keisel Eta D Killeen Eleanor M Killip Jack Koster Robert Kurz Jeanene Marie Laegreid Suzanne Lessler Erica Lipman Louise K Lovinger Elizabeth Mack Sonja Mansfield Frank Matrozza Josephine McCarthy Gertrude E McDowell Analea Taylor McGarey Adelaide L McGarrett Shawn Richard McNamar Mary E Melzer J Erin Montanne Carolyn F Morse Theresa Motiff Frederick Murko Paul R Murphy Jim Douglas Nance M Louise Nelson Delmore Newman

Marjorie Overland Mary S Ozburn Inez Peacock Nick W Peters Mary Pingel Dorothy E Pinkney Nathaniel Randolph Barbara P Reed Bettye F Rice Corrine Rizzo Joseph Rossi Patricia D Rothhaas Rita A Salmon Gerda Schechter Roman J Siemback Niki D Sinclair Christopher Smalley Virginia A Smith Janet Sorensen Lois (Burns) Stevens Andrew W Stobie Linda Strupp Sarah Taylor Virginia Thomas Irvin F Travis Ann-Marie Valania Clarissa Anne Smith Vick Marion Kathleen Vitale Gladys Waldrop Charles Michael Weeks Joann Marilyn Wells Rebecca Lynn White Kerry Gene Williams Geri Witte Susan L Worden

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