Physical Therapy- Journal of the APTA- November 2009, Volume 89, Issue 11

November 2009  Volume 89  Number 11

Research Reports 1126

Constraint-Induced Movement Therapy in Children With CP

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Supported Treadmill Stepping and Walking Attainment in Preterm and Full-Term Infants

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Intensive, Progressive Exercise Program for Patients After Single-Level Lumbar Microdiskectomy

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Patient Goal Priority Questionnaire for People With Persistent Musculoskeletal Pain

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Physical Therapists’ Management of Patients in the Acute Care Setting

Fortieth Mary McMillan Lecture 1236

The Best We Can Be Is Yet to Come

Predicting Performance on the Licensure Examination

2009 APTA Presidential Address

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A Conceptual Model of Optimal International Service-Learning

Health Policy in Perspective

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EMG Activity During Step-up Exercises in Older Adults

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We Must See the Possibilities

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A Systems View of Physical Therapy Care

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Cancer Prevention

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Next month—in PTJ or online at ptjournal.org: •

Effects of Spinal Manipulative Therapy on Thermal Pain Sensitivity in People With LBP

•

Social and Community Participation of Children and Youth With Cerebral Palsy

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Physical Performance, Gait Variability, Falls, and Fractures in Women Who Are Early Postmenopause

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Understanding the Functional Threshold

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Assessment of Need for Physical Therapy Following Traumatic Lower-Extremity Injury

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Center-of-Pressure Movement Variability in Infants

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Nonpharmacological and Nonsurgical Interventions for Hand Osteoarthritis

•

Primary Care for Osteoarthritis

•

And much more!

“Just had to RAVE about PTJ Online! I received the email ToC alert, and clicked on the article I wanted. Not only could I cut and paste the references for an upcoming talk, but with a click of the mouse I was transported to the FREE FULL TEXT of these reference articles. Magic! I also listened to 2 podcasts while I was making dinner!“ --Janet Peterson, PT, DPT, MA

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

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The Bottom Line The Bottom Line is a translation of study findings for application to clinical practice. It is not intended to substitute for a critical reading of the research article. Bottom Lines are written by invitation only. On “An Intensive, Progressive Exercise Program Reduces Disability and Improves Functional Performance in Patients After Single-Level Lumbar Microdiskectomy” What problems did the researchers set out to study, and why? Low back pain is a common musculoskeletal problem, and individuals who have low back pain with sciatica often undergo lumbar microdiskectomy. Rehabilitation following microdiskectomy may improve outcomes, but the ideal program of rehabilitation is unknown. The researchers set out to examine the effectiveness of a new intervention protocol to improve functional performance following lumbar microdiskectomy. Who participated in this study? This study included 98 subjects who exhibited low back pain with signs of disk herniation and nerve root compression as demonstrated through radiological imaging and physical examination. The participants had a single-level lumbar microdiskectomy and a 4- to 6-week postoperative period without adverse events. What new information does this study offer? A progressive exercise program combined with education resulted in greater reduction of disability compared with education only or “usual” physical therapy. What new information does this study offer for patients? Patients are often presented with varying options following surgery for low back pain. This trial provides information that a specific intervention protocol is effective in reducing disability and improving functional ability. Patients can use this information along with consultation from health care professionals to choose the best course of care following surgery for low back pain. How did the researchers go about the study? The researchers developed a novel, progressive 12-week exercise program that was periodized and rigorously applied. Subjects began the program 4 to 6 weeks after the surgery with a 1-hour educational session with a physical therapist. The program was administered 3 times per week and included back extensor strengthening, endurance exercise, and mat activities. Outcome measures included the Oswestry Disability Index and several functional tests and were measured before and after intervention. How might these results be applied to physical therapist practice? The results of this trial can help physical therapists apply a standardized intervention protocol to patients following single-level lumbar microdiskectomy. Patients who receive this protocol may experience improved functional ability and reduced disability compared with usual physical therapy interventions. What are the limitations of the study, and what further research is needed? The limitations to this study included lack of group adherence and disproportionate therapist contact time between groups as well as multiple univariate analysis, which may increase the risk for a type 1 error. Future research should examine the costeffectiveness of rehabilitation following lumbar microdiskectomy as well as the ef-

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

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The Bottom Line fectiveness of rehabilitation programs following other surgical procedures for patients with low back pain. Eric K. Robertson E.K. Robertson, PT, DPT, OCS, is Assistant Professor, Department of Physical Therapy, Texas State University, San Marcos, Texas. This is the Bottom Line for: Kulig K, Beneck GJ, Selkowitz DM, et al. An Intensive, Progressive Exercise Program Reduces Disability and Improves Functional Performance in Patients After Single-Level Lumbar Microdiskectomy. Phys Ther. 2009;89:1145–1157.

On “Comparison of Gluteus Medius Muscle Electromyographic Activity During Forward and Lateral Step-up Exercises in Older Adults. ” What problems did the researchers set out to study, and why? Weakness of the hip abductor muscles in older adults is an important contributor to balance difficulties. Step-up exercises are often prescribed to strengthen the hip abductor muscles, but little is known about whether forward or lateral step-ups are more effective in activating the gluteus medius muscle. The researchers set out to determine which exercise may be most effective in strengthening the hip abductors. Who participated in this study? Twenty-eight community-dwelling adults over the age of 65 and who were free from lower-extremity or back problems participated. What new information does this study offer? The researchers determined that, although both forms of step-up exercises are effective in activating the gluteus medius, lateral step-ups provided a greater activation of that muscle compared with forward step-ups. What new information does this study offer for patients? This study provides information about ways to activate the gluteus medius muscle in older adults. This muscle stabilizes the pelvis in the frontal plane when body weight is supported on one leg. The results of this study suggest that performing a lateral step-up can activate this muscle to a greater degree when compared with a forward step-up. Using this information, therapists and patients can work together to design an effective strengthening program. How did the researchers go about the study? The researchers used electromyographic data to measure gluteus medius muscle activation. The subjects performed a set of forward and lateral step-ups. Force plates were used to determine ascent and descent phases. Data was recorded bilaterally for each phase of each exercise. How might these results be applied to physical therapist practice? The results suggest that physical therapists interested in strengthening the hip abductors in older adults would be well-served by prescribing lateral step-up exercises and that forward step-up exercises also can be an effective means of strengthening the gluteus medius muscle.

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The Bottom Line What are the limitations of the study, and what further research is needed? The study included only healthy subjects without weakness or dysfunction, which limits the ability to generalize the results to those with lower-extremity problems. The researchers did not perform repeat testing of the normalization contraction for the electromyographic analysis; therefore, the test-retest reliability for this analysis is unknown. Future research is needed to examine the clinical effectiveness of lateral versus forward step-ups for patients with weakness of the gluteus medius. Eric K. Robertson E.K. Robertson, PT, DPT, OCS, is Assistant Professor, Department of Physical Therapy, Texas State University, San Marcos, Texas. This is the Bottom Line for: Mercer VS, Gross MT, Sharma S, Weeks E. Comparison of Gluteus Medius Muscle Electromyographic Activity During Forward and Lateral Step-up Exercises in Older Adults. Phys Ther. 2009;89:1205–1214.

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Physical Therapy Journal of the American Physical Therapy Association

Editorial Office

Editor in Chief

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

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

PTJ Online Editor / Assistant Managing Editor: Steven Glaros

Deputy Editor in Chief

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

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

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

Board of Directors President: R. Scott Ward, PT, PhD Vice President: Paul A. Rockar Jr, PT, DPT, MS Secretary: Babette S. Sanders, PT, MS Treasurer: Connie D. Hauser, PT, DPT, ATC Speaker of the House: Shawne E. Soper, PT, DPT, MBA Vice Speaker of the House: Laurita M. Hack, PT, DPT, MBA, PhD, FAPTA Directors: Sharon L. Dunn, PT, PhD, OCS; Kevin L. Hulsey, PT, DPT, MA; Dianne V. Jewell, PT, DPT, PhD, CCS, FAACVPR; Aimee B. Klein, PT, DPT, DSc, OCS; Kathleen K. Mairella, PT, DPT, MA; Stephen C.F. McDavitt, PT, DPT, MS, FAAOMPT; Lisa K. Saladin, PT, PhD; Mary C. Sinnott, PT, DPT, MEd; Nicole L. Stout, PT, MPT, CLT-LANA

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

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

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

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

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

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

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Subscriptions

Physical Therapy (PTJ) (ISSN 00319023) is published monthly by the American Physical Therapy Association (APTA), 1111 North Fairfax Street, Alexandria, VA 22314-1488, at an annual subscription rate of $12 for members, included in dues. Nonmember rates are as follows: Individual (inside USA)— $99; individual (outside USA)—$119 surface mail, $179 air mail. Institutional (inside USA)—$129; institutional (outside USA)—$149 surface mail, $209 air mail. Periodical postage is paid at Alexandria, VA, and at additional mailing offices. Postmaster: Send address changes to Physical Therapy, 1111 North Fairfax Street, Alexandria, VA 22314-1488. Single copies: $15 USA, $15 outside USA; with the exception of January 2001: $50 USA, $70 outside USA. All orders payable in US currency. No replacements for nonreceipt after a 3-month period has elapsed. Canada Post International Publications Mail Product Sales Agreement No. 0055832.

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Mission Statement

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

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

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.

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Editorial A Responsibility to Put “Health Policy in Perspective”

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he month of November always feels unique to me because it challenges the “rules” used to establish priorities among competing responsibilities to family, country, and self. Everything seems to be a priority right now: local, state, and national elections for political office require even more attention than usual to current events; planning for Thanksgiving requires more attention to extended family; and, with only 2 months left in the calendar year, activities become more frenetic to address expected annual personal goals. In the same way, there are (sometimes competing) responsibilities that we as individual professionals and we as a profession cannot—and should not—avoid. One of those responsibilities is health policy. In 1995, referring to the previous year’s failed health care reform efforts and to managed care, my predecessor, Jules Rothstein,1 wrote: Physical therapists have played too small a role in the revolution that we have seen…. The time has come for us to consider the levels at which we must interact with a health care enterprise that lives in a state of chaos and flux. Our patients cannot go away until we sort out the mess that is our current reimbursement and access schemes. Therefore, it remains socially irresponsible for us not to find the most effective means for dealing with patient problems within the confines of existing reimbursement and organizational structures. We also would be irresponsible if we did not document and prove in a scientific manner how we and our patients are compromised by any system that we feel is inappropriate…. On a second level, we must remain active and participatory in the dialogue relating to change. This means activism within the organizations that employ our services, and activism at all governmental levels.

Since Jules wrote those words, everything and nothing has changed. On the one hand, many of the same issues that legislators and activists debated then persist in today’s health insurance reform discussions. On the other hand, the profession of physical therapy has made great strides in engaging with the larger health care arena. Physical therapists are running for and others have already been elected to public office; APTA has become a clear, strong voice to the legislators on Capitol Hill; and physical therapist scientists are engaged in health services research. We are collaborating with other professionals to produce research with robust health care data that includes physical therapy services, such as Shumway-Cook et al,2 Peterson et al,3 Landry et al,4 Carter and Rizzo,5 and Freburger and Holmes.6 This type of work was only just beginning in the mid-1990s.

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

As a result of these strides, physical therapists are no longer merely reacting to policies developed by other groups; in some cases, we are being asked to help establish policy. For instance, a physical therapist chaired an Institute of Medicine committee that identified steps to strengthen evidence for public and private actions to reduce the impact of disabilities on individuals and society in the United States.7 In another example, the Canadian Stroke Network has a vision to achieve measurable improvement in prevention, treatment, and rehabilitation for Canadian individuals, families, and society by 2010,8 and physical therapists are participating in this effort as members of boards of directors, as scientists, and as clinicians. There are many other examples that demonstrate that our profession is at the table in 2009 in a way that it wasn’t 15 years ago.

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Editorial Our profession has matured. We now have physical therapist scholars—not just physical therapists with opinions—to assist in translating evidence into health care policy. Physical therapists can influence the “big picture” with more than anecdotal information. It’s time for PTJ to serve as a scholarly venue to share relevant healthy policy issues (and related ethical considerations) and provide commentary about physical therapists’ role in helping to promote, implement, refine—or defy—health policy. This month PTJ launches “Health Policy in Perspective” (page 1117) with articles by Kigin9 and Stout.10 Led by Editorial Board Member Linda Resnik, PT, PhD, OCS, and PTJ’s health policy committee (Janet Freburger, PT, PhD; Alan Jette, PT, PhD, FAPTA; Michael Johnson, PT, PhD, OCS; Justin Moore, PT, DPT; Ruth Purtilo, PT, PhD, FAPTA), this quarterly segment should compel each of us to participate in formulating and “living” health policies that will improve quality of care—and quality of life—for patients, consumers, and society as a whole. Rebecca L. Craik, PT, PhD, FAPTA Editor in Chief Readers can share their comments at [email protected] or on Twitter at: @PTJournal. References 1 Rothstein JM. Change and reform [editorial]. Phys Ther. 1995;75:251–252. 2 Shumway-Cook A, Ciol MA, Hoffman J, et al. Falls in the Medicare population: incidence, associated factors, and impact on health care. Phys Ther. 2009;89:324–332. 3 Peterson LE, Goodman C, Karnes EK, et al. Assessment of the quality of cost analysis literature in physical therapy. Phys Ther. 2009;89:733–755. 4 Landry MD, Ricketts TC, Fraher E, Verrier MC. Physical therapy health human resource ratios: a comparative analysis of the United States and Canada. Phys Ther. 2009;89:149–161 5 Carter SK, Rizzo JA. Use of outpatient physical therapy services by people with musculoskeletal conditions. Phys Ther. 2007;87:497–512. 6 Freburger JK, Holmes GM. Physical therapy use by community-based older people. Phys Ther. 2005;85:19–33. 7 Field MJ, Jette AM, eds; Committee of Disability in America, Board on Health Sciences Policy. The Future of Disability in America. Washington, DC: The National Academies Press; 2007. 8 The Canadian Stroke Strategy. http://www.canadianstrokestrategy.ca/eng/aboutus/aboutus.html. Accessed October 8, 2009. 9 Kigin C. A systems view of physical therapy care: shifting to a new paradigm for the profession [Health Policy in Perspective]. Phys Ther. 2009;89:1117–1119. 10 Stout NL. Cancer prevention in physical therapist practice [Health Policy in Perspective]. Phys Ther. 2009;89:1119–1122. [DOI: 10.2522/ptj.2009.89.11.1114]

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Health Policy in Perspective A Systems View of Physical Therapy Care: Shifting to a New Paradigm for the Profession Colleen Kigin

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hysical therapist management of patients who are acutely ill is receiving increased attention. This year, 2 observational and descriptive studies were published that report on the utilization of physical therapy in the acute care setting.1,2 This attention is timely as health care reform is debated and changes are proposed to current care delivery. As Jette et al2 state, the advent of bundled payments, or reimbursement based on the entire episode of care, will test not only the profession of physical therapy, but every profession providing care in the acute care setting and on through all care settings, including the home. All health care professions will have to adequately describe and quantify current practice, establish more robust outcome measures, and perform research to understand optimal or preferred practice as it relates to patient outcome. Physical therapists have a long history of treating people in acute care settings, and there is evidence that physical therapy intervention can make a positive difference. For example, a landmark study in 1954 defined the abnormality (postoperative pulmonary complications), divided a relatively large patient cohort (172 patients who had undergone upper-abdominal surgery) into 3 intervention groups, and measured significant decreases in the complication rate with one preferred physical therapy approach.3 Those patients who received both preoperative and postoperative pulmonary physical therapy had a 12% incidence of pulmonary complications, compared with those who received only postoperative pulmonary physical therapy (27% incidence of pulmo-

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nary complications) and those who received usual care (42% incidence of pulmonary complications). Postoperative complications for patients who had undergone upperabdominal surgery were a major cause of morbidity and mortality in the 1950s. The reasons for that were many, including longer and less-sophisticated use of anesthesia, more-invasive procedures for abdominal surgery, and the philosophy of keeping a patient in bed for extended periods of time postsurgery. These “reasons” share a common theme—they are functions of the settings in which the patient received care and in which the team delivered care. Today, the amount and type of care required to minimize postoperative complications are quite different, reflecting the changes in care settings during the past half century as well as a greater focus on the needs of the individual patient. Some studies have examined early intervention as compared to delayed care. In 1982, for instance, Cope and Hall4 documented that early intervention for individuals with head injuries, as compared with later intervention, achieved the same level of function but with half the total number of treatments and an estimated savings per patient of $40,000. With the availability of this evidence, our challenge is to determine whether the approach is currently used, and, if so, whether it has the same or different effect today. Anecdotal reports indicate that some believe the physical therapist should simply evaluate for discharge in the acute care setting and not provide intervention. Is there evidence to support

this approach? How can we best address care for the patient in the acute care setting that indeed maximizes function while providing the most efficient delivery of care? Jette et al2 collected data at 3 academic medical centers regarding the practice of physical therapy in the acute care setting. The researchers make an important statement that the first step in reducing variation in practice is to describe practice and the variability of practice from setting to setting. They acknowledge that variations of practice observed in the 3 centers likely included factors related to the practice setting and that previous research has shown that choice of interventions are affected by factors such as caseload or reimbursement. They cited a model described by O’Neill and Kuder5 that suggests a “baseline heuristic” that reflects the practitioner’s education, experience, and professional style. This heuristic is adapted to the practice environment and then further modified to reflect the specific situations of individual patients in decision making. Any of these sets of factors could result in different decisions about how to manage patients with similar conditions; these differences result in variations in practice across practitioners and practice settings…. Applying the conclusions of the aforementioned studies to physical therapy in the acute care setting, it might be speculated that decisions about patient management could be related to physical therapists’ education and experience, the environment and resources of the facility, and the general characteristics of the patients treated at the facility.2(p1159)

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Health Policy in Perspective

Physical Therapist and Patient/Client

I , the PT

Figure 1. The traditional paradigm of care from the physical therapist’s perspective.

These examples from acute care are emblematic of all of physical therapy. Whether we are academicians who prepare practitioners, clinicians who practice within a particular health care system or a particular setting, or investigators who conduct research— we rarely, if ever, understand (let alone validate) the impact of these systems or settings on our own prac-

tice or on patient response. Perhaps it is time to challenge the status quo and look more closely at these influences on the patients and clients we treat. Our understanding of these influences is critical if the physical therapy profession is to engage in the national health care debate and determine the role of physical therapists in the care delivery system.

Society Community Health Care Team Health Care Consumer Physical Therapist

Earlier this year I had the privilege of chairing the Physical Therapy and Society Summit (PASS), which was sponsored by the American Physical Therapy Association (APTA). PASS occurred in response to an APTA House of Delegates motion that the association should convene a group of thought leaders to envision how physical therapists can address current, evolving, and future health care needs. The summit was attended by more than 100 individuals, including 30 thought leaders in policy, technology, and innovation outside the physical therapy profession. The group addressed issues from health care access, to health care systems and funding, to practice models. One striking paradigm shift was thematic throughout the event, encompassing all of the factors that have an impact on patient care—and we will need to absorb it into our professional souls as we help to reframe how care is delivered. The usual paradigm of care from the perspective of the physical therapist involves the patient and the physical therapist (Fig. 1). Jette et al2 allude to this tangentially, as their survey revealed that only 70% of visits included communication with other health care team members. There was no mention of how the physical therapy intervention fit or was accomplished collaboratively with other professionals or how the physical therapy intervention assisted or added to the positive outcome of the individual returning to his or her own life—an important consideration that extends beyond the simple patient– physical therapist paradigm. The paradigm of the future as envisioned by PASS (Fig. 2) places the patient/client—the health care consumer—in the center, surrounded

Figure 2. Paradigm of care envisioned by the Physical Therapy and Society Summit (PASS).

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Health Policy in Perspective by a team of health care providers that includes the physical therapist. The members of the health care team collaborate with one another to share data and communicate outcomes as they provide care to each individual, with recognition of and attention to the community (availability of support, level of function needed to be independent) and the society (responsibility of providing services, ability to cover services) within which the patient lives. Each level in the paradigm—the individual health care consumer, the health care team, the community, and society—affects the outcomes of care, including the physical therapist’s essential focus on functional outcomes. What would our education and practice look like if we used this paradigm in a more intentional manner? The notion that the physical therapist operates as one entity among many

in a multilevel system challenges us C. Kigin, PT, DPT, FAPTA, is Chief of Staff, to think differently, practice differ- CIMIT, 165 Cambridge St, Suite 702, Boston, MA 02144 (USA). Address all correspondence ently, teach differently, and conduct to Dr Kigin at: [email protected]. research from a larger perspective. For example, research would require com- DOI: 10.2522/ptj.2009.89.11.1117 plex designs, involve multiple centers and multiple disciplines, and follow References a cohort of patients with a given dis- 1 Hodgin KE, Nordon-Craft A, McFann KK, et al. Physical therapy utilization in intensive ability throughout their entire episode care units: results from a national survey. Crit Care Med. 2009;37:561–566. of care—from acute care, to rehabilitation, to home. Adoption of the PASS 2 Jette DU, Brown R, Collette N, et al. Physical therapists’ management of patients in model would stimulate researchers the acute care setting: an observational study. Phys Ther. 2009;89:1158–1181. to explore factors related to the setting of care, services provided by the 3 Thoren L. Post-operative pulmonary complications: observations on their prevenhealth care team, characteristics of tion by means of physiotherapy. Acta Chir Scand. 1954;107:193–205. the reimbursement and health care system, as well as resources provided 4 Cope DN, Hall K. Head injury rehabilitation: benefit of early intervention. Arch by the community and society to fully Phys Med Rehabil. 1982;63:433–437. explain physical therapy outcomes, 5 O’Neill L, Kuder J. Explaining variation in physician practice patterns and their propractice, and practice variation. This pensities to recommend services. Med Care type of systems approach will advance Res Rev. 2005;62:339–357. the role of physical therapy to better address the needs of society.

Cancer Prevention in Physical Therapist Practice Nicole L. Stout

I

n the United States, 34% of cancers in 12 sites (mouth, larynx, and pharynx; esophagus; lung; stomach; pancreas; gall bladder; liver; colorectum; breast postmenopause; endometrium; prostate; kidney) are attributed to obesity, reduced physical activity, and poor nutrition.1(p17) In other words, these cancers are preventable. Traditional preventive efforts, founded in the public health arena, have contributed to an overall decrease in cancer mortality rates and improvement in cancer screening rates during the last quarter century.2 Cancer incidence rates are decreasing; however, the absolute number of cancer cases is increasing.3 The current health care delivery system virtually neglects the provision of and payment for preventive care. Approximately 90% of health care resources continue

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to focus on treating and managing chronic diseases, including cancer.4 In their study of disease prevention published by Trust for America’s Health, Levi et al5 concluded that a paradigm shift away from merely treating the disease and toward prevention is effective and cost effective. This paradigm shift has been espoused by prominent figures in the health care reform debate as both an optimal and a necessary component of reform. In this context, cancer prevention is intimately connected to physical therapist practice. The World Cancer Research Fund/ American Institute for Cancer Research (WCRF/AICR) released Food, Nutrition, Physical Activity and the Prevention of Cancer: A Global Perspective,6 an evaluation

of scientific evidence in 2007, and the companion report, Policy and Action for Cancer Prevention1 in 2009. Developed by an international panel of researchers and specialists in public health policy, these guidelines go well beyond the 10 recommendations for cancer prevention (Figure).6,7 Underlying them is a call for all of society, including the health care community, to globalize efforts to prevent cancer. Currently, the responsibility for preventive efforts falls to the primary care provider and to the health educator. The reality, however, is that cancer prevention transcends every health care discipline and should permeate every aspect of society. The global effort spearheaded by the WCRF/AICR report requires

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Health Policy in Perspective by a team of health care providers that includes the physical therapist. The members of the health care team collaborate with one another to share data and communicate outcomes as they provide care to each individual, with recognition of and attention to the community (availability of support, level of function needed to be independent) and the society (responsibility of providing services, ability to cover services) within which the patient lives. Each level in the paradigm—the individual health care consumer, the health care team, the community, and society—affects the outcomes of care, including the physical therapist’s essential focus on functional outcomes. What would our education and practice look like if we used this paradigm in a more intentional manner? The notion that the physical therapist operates as one entity among many

in a multilevel system challenges us C. Kigin, PT, DPT, FAPTA, is Chief of Staff, to think differently, practice differ- CIMIT, 165 Cambridge St, Suite 702, Boston, MA 02144 (USA). Address all correspondence ently, teach differently, and conduct to Dr Kigin at: [email protected]. research from a larger perspective. For example, research would require com- DOI: 10.2522/ptj.2009.89.11.1117 plex designs, involve multiple centers and multiple disciplines, and follow References a cohort of patients with a given dis- 1 Hodgin KE, Nordon-Craft A, McFann KK, et al. Physical therapy utilization in intensive ability throughout their entire episode care units: results from a national survey. Crit Care Med. 2009;37:561–566. of care—from acute care, to rehabilitation, to home. Adoption of the PASS 2 Jette DU, Brown R, Collette N, et al. Physical therapists’ management of patients in model would stimulate researchers the acute care setting: an observational study. Phys Ther. 2009;89:1158–1181. to explore factors related to the setting of care, services provided by the 3 Thoren L. Post-operative pulmonary complications: observations on their prevenhealth care team, characteristics of tion by means of physiotherapy. Acta Chir Scand. 1954;107:193–205. the reimbursement and health care system, as well as resources provided 4 Cope DN, Hall K. Head injury rehabilitation: benefit of early intervention. Arch by the community and society to fully Phys Med Rehabil. 1982;63:433–437. explain physical therapy outcomes, 5 O’Neill L, Kuder J. Explaining variation in physician practice patterns and their propractice, and practice variation. This pensities to recommend services. Med Care type of systems approach will advance Res Rev. 2005;62:339–357. the role of physical therapy to better address the needs of society.

Cancer Prevention in Physical Therapist Practice Nicole L. Stout

I

n the United States, 34% of cancers in 12 sites (mouth, larynx, and pharynx; esophagus; lung; stomach; pancreas; gall bladder; liver; colorectum; breast postmenopause; endometrium; prostate; kidney) are attributed to obesity, reduced physical activity, and poor nutrition.1(p17) In other words, these cancers are preventable. Traditional preventive efforts, founded in the public health arena, have contributed to an overall decrease in cancer mortality rates and improvement in cancer screening rates during the last quarter century.2 Cancer incidence rates are decreasing; however, the absolute number of cancer cases is increasing.3 The current health care delivery system virtually neglects the provision of and payment for preventive care. Approximately 90% of health care resources continue

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to focus on treating and managing chronic diseases, including cancer.4 In their study of disease prevention published by Trust for America’s Health, Levi et al5 concluded that a paradigm shift away from merely treating the disease and toward prevention is effective and cost effective. This paradigm shift has been espoused by prominent figures in the health care reform debate as both an optimal and a necessary component of reform. In this context, cancer prevention is intimately connected to physical therapist practice. The World Cancer Research Fund/ American Institute for Cancer Research (WCRF/AICR) released Food, Nutrition, Physical Activity and the Prevention of Cancer: A Global Perspective,6 an evaluation

of scientific evidence in 2007, and the companion report, Policy and Action for Cancer Prevention1 in 2009. Developed by an international panel of researchers and specialists in public health policy, these guidelines go well beyond the 10 recommendations for cancer prevention (Figure).6,7 Underlying them is a call for all of society, including the health care community, to globalize efforts to prevent cancer. Currently, the responsibility for preventive efforts falls to the primary care provider and to the health educator. The reality, however, is that cancer prevention transcends every health care discipline and should permeate every aspect of society. The global effort spearheaded by the WCRF/AICR report requires

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Health Policy in Perspective

General Recommendations of the 2007 WCRF/AICR Diet and Cancer Report BODY FATNESS Be as lean as possible within the normal range of body weight PHYSICAL ACTIVITY Be physically active as part of everyday life FOODS AND DRINKS THAT PROMOTE WEIGHT GAIN Limit consumption of energy-dense foods Avoid sugary drinks PLANT FOODS Eat mostly foods of plant origin ANIMAL FOODS Limit intake of red meat and avoid processed meat ALCOHOLIC DRINKS Limit alcoholic drinks PRESERVATION, PROCESSING, PREPARATION Limit consumption of salt Avoid mouldy cereals (grains) or pulses (legumes) DIETARY SUPPLEMENTS Aim to meet nutritional needs through diet alone BREASTFEEDING Mothers to breastfeed; children to be breastfed CANCER SURVIVORS Follow the recommendations for cancer prevention

Figure.

Ten recommendations for cancer prevention.6,7 Adapted with permission of World Cancer Research Fund/American Institute for Cancer Research (WCRF/AICR).

a substantial shift in the current medical paradigm toward a population-based prevention approach. Evidence-based, effective models for cancer-related primary and secondary preventive care do exist.5 The biggest obstacles to implementing these types of programs in medical disciplines are provider attitudes and the lack of a reimbursement structure to support preventive efforts.8 For these reasons, a paradigm shift will require policy reform as well as buy-in from the health care community to demand advancement of population-based preventive efforts. Health care reform may be an ideal way to usher in new models and approaches for chronic disease prevention, and the ideal health care reform policy will promote a shift in resources toward prevention and preventive medicine. Recommendations for policy reform include9,10:

• Improving access to clinical preventive services. • Providing basic coverage for preventive services in federal, state, and public health plans. • Providing reimbursement incentives for the provision of wellness and preventive care. • Streamlining and promoting the work of preventive service entities within the federal government, including the US Preventive Services Taskforce, the Agency for Healthcare Research and Quality, and the Institute of Medicine. • Expanding programs such as the National Health Services Corps to include physical therapists for incentivizing work in community health centers and rural health clinics. • Unrestricted direct access to physical therapist services.

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In addition, the WCRF/AICR guidelines highlight suggested policy action for cancer prevention and provide targeted recommendations for intervention for government, industry, media, and health care professionals, among others (Table).1 The key message: promoting public health is not just the responsibility of governments and health departments—it’s shared by all sectors of society, and action across society needs to be consistent. The physical therapy profession plays a role in health promotion, wellness, and prevention. In medicine, prevention is viewed as “any activity which reduces the burden of mortality or morbidity from disease.”11 Physical therapy practitioners contribute to prevention with every patient interaction. They can play a key role in primary prevention and in the mitigation (secondary prevention) of chronic diseases such as cancer by promoting prevention guidelines to patients and clients. They have well-established relationships with patients and are likely spend more one-to-one time with patients than anyone else on the health care team—making physical therapists an optimal conduit for the dissemination of evidence-based preventive education. Survey evidence shows that patients who have not sought out recommended cancer screening cite many reasons, including time, access to care, and payment issues.12 One striking finding from this research is that patients also report that “my provider never told me...to seek screening.” The power of the health care provider is never more evident than in this statement. Patients expect (and deserve) that their health care providers will empower them with knowledge so that they can adequately manage their own health. The WCRF/AICR recommendations for cancer prevention are a November 2009

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Health Policy in Perspective Table.

Suggested Policy Action for Cancer Preventiona Entity

Aim

Multinational Bodies

Originate and promote coordinated strategies that protect public health through food, nutrition, and physical activity

Civil Society Organizations

Create, advocate, and develop sustainable policies and actions that ensure healthy food, nutrition, and physical activity for all

Government

Use legislation, pricing, and other policies at all levels of government to promote healthy patterns of diet and physical activity

Industry

Emphasize the priority given to public health including cancer prevention in strategic planning and action

Media

Sustain increased coverage of public health and well-being and prevention of obesity and chronic diseases including cancer

Schools

Make food systems, food, nutrition, and regular physical activity essential parts of school life and learning

Workplaces and Institutions

Institute and implement policies that promote physical activity, and healthy meals and bodyweight

Health and Other Professionals

Conduct professional practice to realize the potential for promoting health including cancer prevention

All Professionals

Recommendations Include food, nutrition, physical activity, and cancer prevention in core professional training and continuing development Work with other disciplines to help understand how to improve public health, including cancer prevention, through food, nutrition, and physical activity

Health Professionalsb

Recommendations Prioritize public health including cancer prevention, and food, nutrition, and physical activity, in core training, practice, and professional development Take a lead in educating and working with colleagues, other professionals, and other actors to improve public health including cancer prevention Involve people as family and community members, and take account of their personal characteristics in all types of professional practice

People

Act as members of households and communities and as citizens, not just as customers and consumers, in achieving healthy ways of life

Adapted from World Cancer Research Fund/American Institute for Cancer Research. Policy and Action for Cancer Prevention. Food, Nutrition, and Physical Activity: A Global Perspective. Washington, DC: AICR; 2009:141–145. a

Health professionals include relevant academics and researchers, and physicians, nutritionists, dietitians, nurses, and other health workers in medicine, public health, environmental health, and associated fields. Other professionals include architects and engineers, relevant civil servants, trades unionists, social scientists, economists, environmentalists, agronomists, food scientists and technologists, journalists, and teachers.

b

dations for cancer prevention are a simple tool that clinicians can incorporate into their interactions with all patients, in any setting, to communicate concise information as part of primary prevention. Discussions with patients about cancer should not be taboo, and recommendations for cancer prevention certainly are not superfluous to a visit to the physical therapist. Men November 2009

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have a 1 in 2 chance of developing cancer in their lifetime, women 1 in 3. That means that between 33% and 50% of the patients that therapists see will develop cancer.2 Faced with these odds, it makes sense for physical therapist practice to regard the health of the population as a whole and not simply focus on treating a single impairment, activity limitation, or participation restriction. Physical therapists must look at the larger

picture of health for the aggregate population with whom they interact and recognize that their responsibility in health promotion involves bringing preventive education into their daily practice. Efforts in cancer-related secondary prevention also are congruent with physical therapist practice. Secondary prevention strategies involve screening, community assessments, and early identification and treatment of disease and disease-related morbidity. In the context of the accelerating incidence rates of chronic disease in the United States, there is perhaps no greater role for the physical therapist to play. Every person who has cancer treatment is at life-long risk for a variety of physical impairments as well as for recurrent disease. Without the use of proper prospective screening, education, and intervention, physical therapists will fail to meet the pending needs of this population. New models for preventive screening, prospective surveillance, and early detection and intervention should be embraced by the physical therapy profession. Emerging data demonstrate the effectiveness of such physical therapy–based programs.13–16 Cost-analysis and comparative effectiveness research initiatives are needed to investigate these promising models of care. As professionals in the larger arena of health care, physical therapists have the responsibility to recognize, apply, scientifically evaluate, and be a policy advocate for preventive approaches to health and wellness. These efforts build on an already existing tradition of strong patienttherapist relationships, enhance collaborations with peers in medicine, and support the physical therapist’s role as a provider of choice.

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Health Policy in Perspective N.L. Stout, MPT, CLT-LANA, is a practicing clinician and clinical researcher at the National Naval Medical Center, Breast Care Center, Bethesda, Maryland. The views expressed here are solely those of the author and do not necessarily reflect the official policy or position of the Department of the Navy, Department of Defense, nor the US Government. DOI: 10.2522/ptj.2009.89.11.1119

References 1 World Cancer Research Fund/American Institute for Cancer Research. Policy and Action for Cancer Prevention. Food, Nutrition and Physical Activity: A Global Perspective. Washington, DC: AICR; 2009. 2 Jemal A, Siegel R, Ward E, et al. Cancer statistics, 2009. CA Cancer J Clin. 2009;59:225–249. 3 Jemal A, Thun MJ, Ries LA, et al. Annual report to the nation on the status of cancer, 1975-2005, featuring trends in lung cancer, tobacco use, and tobacco control. J Natl Cancer Inst. 2008;100:1672–1694. 4 Thorpe KE, Howard DH. The rise in spending among Medicare beneficiaries: the role of chronic disease prevalence and changes in treatment intensity. Health Aff (Millwood). 2006;25(5):w378–w388. http:// content.healthaffairs.org/cgi/content/ full/25/5/w378. Accessed October 2, 2009.

5 Levi J, Segal LM, Juliano C. Prevention for a Healthier America: Investments in Disease Prevention Yield Significant Savings, Stronger Communities. http://healthy americans.org/reports/prevention08/ Prevention08.pdf. Accessed October 2, 2009.

12 Ogedegbe G, Cassells AN, Robinson CM, et al. Perceptions of barriers and facilitators of cancer early detection among low-income minority women in community health centers. J Natl Med Assoc. 2005;97:162–170.

6 World Cancer Research Fund/American Institute for Cancer Research. Food, Nutrition, and Physical Activity: A Global Perspective. Washington, DC: AICR; 2007.

13 Stout Gergich NL, Pfalzer LA, McGarvey C, et al. Preoperative assessment enables the early diagnosis and successful treatment of lymphedema. Cancer. 2008;112:2809– 2819.

7 World Cancer Research Fund/American Institute for Cancer Research. Food, Nutrition and Physical Activity: A Global Perspective—Online. http://www.dietand cancerreport.org/?p=recommendations. Accessed October 9, 2009.

14 Stout Gergich NL, Levy E, Springer B, et al. Preoperative assessment enables early detection and treatment of shoulder impairments related to breast cancer treatment (abstract). Cancer Res. 2009;69(suppl 2):4091.

8 Baron RJ, Cassel CK. 21st-century primary care: new physician roles need new payment models. JAMA. 2008;299:1595–1597.

15 Cinar N, Seckin U, Keskin D, et al. The effectiveness of early rehabilitation in patients with modified radical mastectomy. Cancer Nurs. 2008;31(2):160–165.

9

Baucus M. Call to Action Health Care Reform 2009. Available at: http://www. finance.senate.gov. Accessed December 20, 2008.

10 The Patients’ Choice Act. Available at: http://www.house.gov/ryan/PCA/PCA. htm. Accessed May 30, 2009.

16 Findley PA, Sambamoorthi U. Preventive health services and lifestyle practices in cancer survivors: a population health investigation. J Cancer Surviv. 2009;3:43–58.

11 Wallace R, ed. Public Health and Preventive Medicine. 15th ed. New York, NY: McGraw Hill; 2007.

Available @ PTJ Online: Audio of the 2009 Rothstein Debate “When Does Regulation Become Over-Regulation, and When Does UnderRegulation Invite Abuse?” The 2009 Rothstein Debate, held at PT 2009 in Baltimore, Maryland, covered topics ranging from the perceived positives and negatives of Medicare regulations, to the use of extenders, to the future of regulatory efforts. Among other questions, Moderator and PTJ Steering Committee Chair Anthony Delitto, PT, PhD, FAPTA, asked debaters Larry Benz, PT, DPT, ECS, and Steve Levine, PT, DPT, MSHA, whether they could foresee a time when the focus of regulation would be more on outcomes than on process. Listen to the debate at www.ptjournal.org/misc/podcasts/dtl. The 2010 Rothstein Debate will focus on health care reform.

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Research Report Bound for Success: A Systematic Review of Constraint-Induced Movement Therapy in Children With Cerebral Palsy Supports Improved Arm and Hand Use Hsiang-han Huang, Linda Fetters, Jennifer Hale, Ashley McBride H. Huang, MS, OT, is an ScD student in the Department of Physical Therapy and Athletic Training, Boston University, Boston, Massachusetts, and currently is working in the Department of Biokinesiology and Physical Therapy, University of Southern California, 1540 E Alcazar St, CHP 155, Los Angeles, CA 90033 (USA). Address all correspondence to Ms Huang at: [email protected]. L. Fetters, PT, PhD, FAPTA, is Professor, Department of Biokinesiology and Physical Therapy, and Department of Pediatrics, Keck School of Medicine, University of Southern California. J. Hale, PT, DPT, is Physical Therapist, The Institute for Rehabilitation and Research (TIRR), Houston, Texas. A. McBride, PT, DPT, is Physical Therapist, Providence Portland Medical Center, Portland, Oregon. [Huang H, Fetters L, Hale J, McBride A. Bound for success: a systematic review of constraintinduced movement therapy in children with cerebral palsy supports improved arm and hand use. Phys Ther. 2009;89:1126 –1141.] © 2009 American Physical Therapy Association

Background. Constraint-induced movement therapy (CIMT) is a potentially effective intervention for children with hemiplegic cerebral palsy (CP). Purpose. The objectives of this systematic review are: (1) to investigate whether CIMT is supported with valid research of its effectiveness and (2) to identify key characteristics of the child and intervention protocol associated with the effects of CIMT.

Data Sources and Study Selection. A search of MEDLINE (1966 through March 2009), Entrez PubMed (1966 through March 2009), EMBASE (1980 through March 2009), CINAHL (1982 through March 2009), PsychINFO (1887 through March 2009), and Web of Science (1900 through March 2009) produced 23 relevant studies. Data Extraction and Synthesis. The 2 objectives of the review were addressed by: (1) scoring the validity and level of evidence for each study and calculating evidence-based statistics, if possible, and (2) recording and summarizing the inclusion and exclusion criteria, type and duration of constraint, intervention and study durations, and outcomes based on the International Classification of Functioning, Disability and Health (ICF). Limitations. Only studies published in journals and in English were included in the systematic review. Conclusions. Studies varied widely in type and rigor of design; subject, constraint, and intervention characteristics; and ICF level for outcome measures. One outcome measure at the body functions and structure level and 4 outcome measures at the activity level had large and significant treatment effects (dⱖ.80), and these findings were from the most rigorous studies. Evidence from more-rigorous studies demonstrated an increased frequency of use of the upper extremity following CIMT for children with hemiplegic CP. The critical threshold for intensity that constitutes an adequate dose cannot be determined from the available research. Further research should include a priori power calculations, more-rigorous designs and comparisons of different components of CIMT in relation to specific children, and measures of potential impacts on the developing brain.

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CIMT in Children With Cerebral Palsy

R

ecent studies of constraintinduced movement therapy (CIMT) support the improvement in use of the affected arm for adults with stroke1– 4 and suggest similar effects in children with hemiplegic cerebral palsy (CP).5– 8 Constraint-induced movement therapy is based on studies of young monkeys in which somatosensory deafferentation was performed on a single forelimb.9,10 Following deafferentation, the monkeys failed to use the affected forelimb, a phenomenon termed by Taub as “learned non-use.”9,10 When the unaffected forelimb was constrained and could not be used for functional activities, the monkeys overcame the learned non-use. The new functional movements of the deafferented forelimb were sustained, but only if the period of constraint was greater than 7 days.10 Forced-use therapy for adult humans was derived from this approach and revealed practical implications for rehabilitation.11,12 Shaping techniques and repetitive practice later were added to constraint.9,13 With shaping, a behavior was progressively modified toward a goal through successive approximation and reinforcement. This intervention is now termed “constraintinduced movement therapy.”3,14 Studies performed on monkeys in utero and shortly after birth supported the idea that forced use or

Available With This Article at www.ptjournal.org • Invited Commentary by Jeanne Charles and Steven L. Wolf and the Author Response • Audio Abstracts Podcast This article was published ahead of print on September 3, 2009, at www.ptjournal.org.

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CIMT also might be effective early in development.10,15 Following deafferentation both in monkey fetuses and on the day of birth, researchers restrained the less-affected forelimb and forced the use of the affected forelimb with shaping techniques.15 These newborn monkeys for the first time were developing the use of the affected forelimb in contrast to relearning previous skilled movements, as occurred in the adult monkeys. The young monkeys progressed from a loose, 4-finger grasp to thumb-forefinger prehension and could self-feed with the affected limb. These results supported the hypothesis that children with hemiplegic CP who have not yet developed skilled arm use, or “developmental disuse” as described by Gordon and colleagues,16 also might achieve improved upper-extremity (UE) function following forced use or CIMT. Of note is that the central nervous system in these young children is still in the early stages of development. The impact on the developing brain of constraining the unaffected limb and the effects of intense practice on this immature brain require careful study. If “true recovery” as defined by Krakauer17 is achieved, then undamaged brain regions may be recruited to support the developing skills. However, this recruitment in the developing brain must be understood in light of future neurobiological development. Moreover, compensatory strategies might be adopted that would allow for improved functional use of the UE, with potentially little impact on the underlying developmental neurobiology. Although the majority of pediatric studies emphasize the effects of CIMT on improving UE function, there remains a significant gap in our understanding of the implications of CIMT for recovery or compensation in the developing child. Charles and Gordon5 reviewed 15 studies on the efficacy of CIMT or Volume 89

forced-use therapy in children with either traumatic brain injury (TBI) or CP and suggested that both CIMT and forced-use therapy were effective for improving UE function. However, they did not systematically appraise the validity of the studies or compute evidence-based statistics. Evidence-based statistics refer to the treatment effects calculated from the studies, such as effect size (ES) or control and experimental event rate. A narrative review by Taub et al8 discussed the origin and mechanism of pediatric and adult CIMT, but did not systematically review each study or compute relevant statistics. A Cochrane review6 included only 3 randomized controlled trials (RCTs) and excluded studies that were considered less rigorous. In this review, we add to the validity of previous reviews and extend the scope of review by: (1) appraising only research on children with hemiplegic CP (previous reviews included subjects with TBI and children with late-onset stroke); (2) including all published studies regardless of design; (3) applying levels of evidence and validity scores for all studies; (4) calculating the evidence-based statistics, as possible; and (5) applying the International Classification of Functioning, Disability and Health18 (ICF) levels to all outcome measures. The ICF includes the levels of body functions and structure, activity, and participation19 and provides a common language to express outcomes across studies that used different measures. Although in the Cochrane review6 the ICF was used to determine inclusion criteria for studies, it was not used to determine the levels of the outcomes. The specific objectives of this review are: (1) to investigate whether CIMT is supported with valid research of its effectiveness and (2) to identify key characteristics of the child and intervention protocol associated with effects of CIMT. Number 11

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CIMT in Children With Cerebral Palsy Table 1. Levels of Evidence of Studiesa Grade of Recommendation

Level of Evidence

A

1a

Systematic review with homogeneity of RCT

2

1b

Individual RCT with narrow confidence interval

2

1c

All or none

None

2a

Systematic review of cohort studies (with homogeneity)

None

2b

Individual cohort study (including lowquality RCT; eg, ⬍80% follow-up)

5

3a

Systematic review (with homogeneity) of case-control studies

None

3b

Individual case-control study

4

Case series (and poorquality cohort and case-control studies)

6

Expert opinion without explicit critical appraisal on physiology, bench research, or ”first principles”

8

B

C

D

Description

5

No. of Studies

Validity Score (Out of 16 or 11)

Study Hoare et al, 20077,b Hoare et al, 20076,b

11/16 10/16

Taub et al, 200422 DeLuca et al, 200624

8/16 7/16 9/16 9/16 8/16

Willis et al, 200221 Eliasson et al, 200526 Sung et al, 200525 Gordon et al, 200627 Charles et al, 200623

5/11 7/11

Crocker et al, 199731 Eliasson et al, 200328 Naylor et al, 200532 Charles et al, 200730 Dickerson et al, 200733 Wallen et al, 200829 Charles et al, 200135 Glover et al, 200236 Pierce et al, 200237 DeLuca et al, 200338 Sutcliffe et al, 200739 Fergus et al, 200840 Martin et al, 200841 Cope et al, 200834

a Levels of evidence are based on Sackett and colleagues’ description of levels of evidence and grades of recommendations.20 RCT⫽randomized controlled trial. b The Cochrane Review7 is a summarized version of the Cochrane Systematic Review.6

Method Objective 1: Investigate Whether CIMT Is Supported With Valid Research of Its Effectiveness Data sources and study selection. We searched MEDLINE (1966 through March 2009), Entrez PubMed (1966 through March 2009), EMBASE (1980 through March 2009), CINAHL (1982 through March 2009), PsychINFO (1887 through March 2009), and Web of Science (1900 through March 2009) using the key words “hemiplegic,” “cerebral palsy,” “constraint-induced movement therapy,” and “forced-use therapy.” References found in other 1128

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publications also were included, as appropriate. Articles not written in English were excluded. Included studies met the following criteria: (1) participants were children with hemiplegic CP (younger than 18 years of age), (2) CIMT or forced-use therapy was used for intervention, and (3) outcome measures related to the effects of CIMT or forced-use therapy. Twenty-one intervention studies and 2 systematic reviews met the inclusion criteria (Tab. 1).6,7 The level of evidence ranged from 1a to 5 (Tab. 1).20 Of the 21 intervention

Number 11

studies, 5 were RCTs,21–25 2 were nonequivalent pretest-posttest control group designs,26,27 3 were onegroup pretest-posttest designs,28 –30 3 were single-subject research designs (SSRDs),31–33 and 8 were case reports34 – 41 (Tabs. 2, 3, 4, 5, and 6). The results from the study by Juenger et al42 were not included in the tables of this review due to the age of the subjects (range⫽10 –30 years). Assessing validity of studies. The validity of RCTs and nonequivalent pretest-posttest control group deNovember 2009

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a

Gray cell⫽nonapplicable item for the study. In the “Effect Size” column, direction of change is provided when effect size has not been calculated. ICF⫽International Classification of Functioning, Disability and Health, PT⫽physical therapy, OT⫽occupational therapy, PDMS⫽Peabody Developmental Motor Scales, EBS⫽Emerging Behavior Scale, PMAL⫽Pediatric Motor Activity Log, TAUT⫽Toddler Arm Use Test, BBT⫽Box and Block Test, EDPA⫽Erhardt Developmental Prehension Assessment, Wee-FIM⫽Functional Independence Measure for Children, TPD⫽2-point discrimination, MAS⫽Modified Ashworth Scale, J-T Test⫽Jebsen-Taylor Test of Hand Function, BOTMP⫽Bruininks-Oseretsky Test of Motor Proficiency, CFUS⫽Caregiver Functional Use Survey, QUEST⫽Quality of Upper Extremity Skills Test.

Activity ⫹ ⫹ ⫹ 1b

DeLuca et al, 200624 (N⫽18)

10

7–96 mo

Cast

24

PT, OT (6 hr/d for 21 d)

126

12 wk

Activity QUEST PMAL EBS

Body structure No or small Medium Small or large Activity Medium Medium Large Body structure Grasp strength TPD MAS Activity J-T Test BOTMP CFUS 6 mo 60 PT, OT (6 hr/d for 10 d) 6 Sling 4–8 y 8 Charles et al, 200623 (N⫽22) 2b

Activity No effect Small Small or medium 2b

Sung et al, 200525 (N⫽31)

9

ⱕ96 mo

Cast

2

OT (ADL) (1 hr/wk for 6 wk)

6

6 wk

Activity BBT EDPA WeeFIM

Activity Large Large ⫹ Activity EBS PMAL TAUT 126 PT, OT (6 hr/d for 21 d) Cast 11 Taub et al, 200422 (N⫽18) 1b

ⱕ96 mo

24

PT, OT (no detailed information about time) 24 Cast 1–96 mo 8 Willis et al, 200221 (N⫽25)

Study

8 mo

Activity ⫹ Activity PDMS 8 mo

Effect Size or Effect/Direction of Change (ⴙ/ⴚ) ICF Levels: Outcome Measures Length of Study Total Amount of Intervention (hr) Frequency and Duration of Intervention Sessions Hours/Day of Constraint Type of Constraint Age of Subjects Validity Scores (Out of 16)

2b

Nine of these 21 studies were scored for internal validity (Tabs. 2, 3, and 4) using the scoring protocol for group designs and included 173 subjects.21–28,30 Seven of the 9 studies were scored out of 16 points,21–27 and 2 studies were scored out of 11

Table 2.

Because the scoring protocol was designed for RCTs and nonequivalent pretest-posttest control group designs, we modified the validity scoring for the studies with one-group pretest-posttest designs by deleting categories (D) and (G) (Appendix 2). These studies were scored 0/1 on an 11-point scale that measured aspects of: (A) study population, (B) design, (C) blinding procedure, (D) measurement instruments, (E) control of cointerventions, (F) control for dose of therapy, and (G) appropriate statistical analysis. The kappa coefficient was used to measure scoring agreement between raters. Kappa values for agreement between 2 raters have been categorized as poor (.00), slight (.01–.20), fair (.21–.40), moderate (.41–.60), substantial (.61– .80), and almost perfect (.81–1.00).49

Level of Evidence

signs (ie, the subjects are not assigned to groups randomly)43 using a between-group comparison was evaluated by 2 reviewers not blinded to authors or journals. We used the scoring protocol developed by Kwakkel et al44 and Cambach et al45 containing 16 items, each scored 0/1, which measured study validity for the following methodological categories: (A) randomization, (B) matching, (C) blinding procedure, (D) dropouts and intention-to-treat analysis, (E) characteristics of measurement instruments, (F) control of cointerventions, (G) comparability of group characteristics, and (H) control for dose of therapy (Appendix 1). The protocol was recommended by the Potsdam standards46 and other investigators47,48 to identify the potential confounders for the ES of individual studies.

Summary of Constraint-Induced Movement Therapy and Forced-Use Therapy in Children With Hemiplegic Cerebral Palsy—Randomized Controlled Trial Designa

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Gordon et al, 200627 (N⫽20)

2b 4–13 y

18–48 mo

Age of Subjects

Sling

Splint

Type of Constraint

6

2

Hours/Day of Constraint

PT, OT (6 hr/d for 10 d)

Functional activities (2 hr/d for 2 mo)

Frequency and Duration of Intervention Sessions

60

120

Total Amount of Intervention (hr)

6m

6 mo

Length of Study

Body structure: Grasp strength TPD MAS Activity J-T Test BOTMP CFUS

Activity AHA

ICF Levels: Outcome Measures Effect Size

Body structure No or smallb No or smallb No or smallb Activity Largeb Largeb Largeb

Activity Large

Number 11 7

Charles et al, 200730 (N⫽8)

Wallen et al, 200829 (N⫽10)

4

4 6–96 mo

5–11 y

13–18 y

Age of Subjects

Mitt

Sling

Splint

Type of Constraint

2

6

7

Hours/Day of Constraint

Play activities (2 hr/d for 8 wk)

PT, OT (6 hr/d for 10 d)

Daily recreational activity (7 hr/d for 10 d)

Frequency and Duration of Intervention Sessions

112

60

70

Total Amount of Intervention (hr)

6 mo

18 mo

5 mo

Length of Study

Body structure Tardieu Scale Activity AHA MAUULF PMAL Participation COPM GAS

Activity J-T Test BOTMP CFUS

Body structure Grip strength Activity BOTMP AMPS J-T Test

ICF Levels: Outcome Measures

Body structure ⫹ Activity ⫹ ⫹ ⫹ Participation ⫹ ⫹

Activity ⫹ ⫹ ⫹

Body Structure ⫺ Activity ⫹ ⫹ ⫹

Effect/Direction of Change (ⴙ/ⴚ)

a Gray cell⫽nonapplicable item for the study. ICF⫽International Classification of Functioning, Disability and Health, PT⫽physical therapy, OT⫽occupational therapy, BOTMP⫽Bruininks-Oseretsky Test of Motor Proficiency, AMPS⫽Assessment of Motor and Process Skills, J-T Test⫽Jebsen-Taylor Test of Hand Function, CFUS⫽Caregiver Functional Use Survey, AHA⫽Assisting Hand Assessment, MAUULF⫽Melbourne Assessment of Unilateral Upper Limb Function, PMAL⫽Pediatric Motor Activity Log, COPM⫽Canadian Occupational Performance Measure, GAS⫽goal attainment scaling.

5

Eliasson et al, 200328 (N⫽9)

Study

Validity Score (Out of 11)

4

Level of Evidence

Summary of Constraint-Induced Movement Therapy and Forced-Use Therapy in Children With Hemiplegic Cerebral Palsy—One-Group Pretest-Posttest Designsa

Table 4.

a ICF⫽International Classification of Functioning, Disability and Health, PT⫽physical therapy, OT⫽occupational therapy, AHA⫽Assisting Hand Assessment, TPD⫽2-point discrimination, MAS⫽Modified Ashworth Scale, J-T Test⫽Jebsen-Taylor Test of Hand Function, BOTMP⫽Bruininks-Oseretsky Test of Motor Proficiency, CFUS⫽Caregiver Functional Use Survey. b The effect size was from the authors’ report, which did not provide mean, standard deviation, or 95% confidence interval values. The calculation of 95% confidence interval and examination of significance were not applicable for this study.

7

Eliasson et al, 200526 (N⫽41)

Study

Validity Score (Out of 16)

2b

Level of Evidence

Summary of Constraint-Induced Movement Therapy and Forced-Use Therapy in Children With Hemiplegic Cerebral Palsy—Nonequivalent Pretest-Posttest Control Group Designa

Table 3. CIMT in Children With Cerebral Palsy

November 2009

November 2009

A-B-A Dickerson et al, 200733 (N⫽1) 4

A-B-A Naylor et al, 200532 (N⫽9)

A-B-A

4

Study

Crocker et al, 199731 (N⫽1) 4

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a Gray cell⫽nonapplicable item for the study. ICF⫽International Classification of Functioning, Disability and Health, OT⫽occupational therapy, ST⫽speech therapy, PT⫽physical therapy, PDMS-F⫽Peabody Developmental Motor Scales–Fine Motor, QUEST⫽Quality of Upper Extremity Skills Test.

Activity ⫹ Activity Behavioral Observation (eg, reach, grasp) 37 d 126 OT (6 hr/d for 21 d) 10 Splint 2y

Activity ⫹ Activity QUEST 12 wk 28 Functional and play activities (1 hr/d for 4 wk) 1 Adult held 18–60 mo

Activity ⫹ Activity PDMS-F 6 mo 4.5 OT, ST, PT (1.5 hr/wk for 3 wk) 10 Splint 2y

Effect/Direction of Change (ⴙ/ⴚ) ICF Levels: Outcome Measures Length of Study Total Amount of Intervention (hr) Type of Constraint Age of Subjects Study Design

Moreover, when sufficient data (ie, number or percentage improved in each group) were provided in the study, treatment effects were calculated and presented, including the control event rate, experimental event rate, number needed to treat, absolute benefit increase, and relative benefit increase.20

Table 5.

where XT is the mean result for the treatment group, XC is the mean result in the control group, and sdpooled is the pooled standard deviation.

Level of Evidence

共X T ⫺ X C 兲/sd pooled

Frequency and Duration of Intervention Sessions

Evidence-based statistics. If means and standard deviations were included in the published studies, ES was calculated using the Cohen d statistic.50 This ES formula is readily accepted in the meta-analysis literature and calculated to determine the overall effect of treatment. It is expressed by the following equation:

Hours/Day of Constraint

Of note is that 3 of the RCTs were assigned level 2b due to the loss of participants (ie, less than 80% in the follow-up phase),21 lack of statistical control at baseline,23 or no reports regarding the dropouts in the trial or the lack of blinding of outcome assessors25 (Tabs. 1 and 2).

Validity Scores (Out of 16 or 11)

points.28,30 This was a sufficient number of studies to achieve substantial interrater reliability. The remaining 11 studies31– 41 were not scored for internal validity because the items from the scoring protocol did not apply to the study designs (SSRD and case report) (Tabs. 5 and 6). Case reports were systematically reported as the results of clinical practice without the application of inferential statistics. To our knowledge, there is no available validity scoring for this design.

Summary of Constraint-Induced Movement Therapy and Forced-Use Therapy in Children With Hemiplegic Cerebral Palsy—Single-Subject Research Designsa

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Pierce et al, 200237 (N⫽1)

DeLuca et al, 200338 (N⫽1)

Sutcliffe et al, 200739 (N⫽1)

Martin et al, 200841 (N⫽1)

Cope et al, 200834 (N⫽1)

Fergus et al, 200840 (N⫽1)

5

5

5

5

5

5

Cast

Cast

Mitt

35 mo

12 mo

13 mo

Splint, cast

15 mo

Cast

Mitt

12 y

8y

Splint, cast

Sling

Type of Constraint

19 and 39 mo

9–13 y

Age of Subjects

6 hr/d for 3 wk, then 5 wk of decreasing by 1 hr/wk

24

7.5

24

24

24

24

6

Hours/Day of Constraint

PT, OT (6 hr/d for 3 wk, then 5 wk of decreasing by 1 hr/wk)

PT, OT (8 hr/wk for 2 wk)

OT (4 hr/d for 12 d)

OT (1 hr/wk for 3 wk)

PT, OT (6 hr/d for 36 d)

PT, OT (4 hr/wk for 3 wk)

PT, OT (2 hr/d for 2 wk)

Functional and play activities (6 hr/d for 14 d)

Frequency and Duration of Intervention Sessions

99

16

48

3

216

12

28

64

Total Amount of Intervention (hr)

18 mo

6 mo

3 mo

6 mo

7 mo and 1 wk

8 mo

6 wk

6 mo

Length of Study

Activity Modified PMAL, interview

Activity PDMS PMAL TAUT Knox Parent Questionnaire

Body structure Grip and pinch strength Activity MAUULF PEDI–Self-Care Participation COPM

Body structure fMRI Activity PMAL QUEST AHA Participation COPM

Activity PDMS-F DDST PMAL TAUT

Body structure: Grip strength Activity WMFT AMPS

Clinical observation Parent report

Body structure Grasp strength TPD Activity J-T Test

ICF Levels: Outcome Measures

Activity ⫹

Activity ⫹ ⫹ ⫹ ⫹

Activity ⫹ ⫹ Participation ⫹

Body structure ⫹

Body structure ⫹ Activity ⫹ ⫹ ⫹ Participation ⫹

Activity ⫹ ⫹ ⫹ ⫹

Body structure ⫹ Activity ⫹ ⫹

Clinical observation ⫹

Body structure ⫹ ⫹ Activity ⫹

Effect/Direction of Change (ⴙ/ⴚ)

a Gray cell⫽nonapplicable item for the study. ICF⫽International Classification of Functioning, Disability and Health, PT⫽physical therapy, OT⫽occupational therapy, TPD⫽2-point discrimination, J-T Test⫽Jebsen-Taylor Test of Hand Function, WMFT⫽Wolf Motor Function Test, AMPS⫽Assessment of Motor and Process Skills, PDMS-F⫽Peabody Developmental Motor Scales–Fine Motor, DDST⫽Denver Developmental Screening Tool, PMAL⫽Pediatric Motor Activity Log, TAUT⫽Toddler Arm Use Test, QUEST⫽Quality of Upper Extremity Skills Test, AHA⫽Assisting Hand Assessment, COPM⫽Canadian Occupational Performance Measure, MAUULF⫽Melbourne Assessment of Unilateral Upper Limb Function, PEDI⫽Pediatric Evaluation of Disability Inventory.

Glover et al, 200236 (N⫽2)

Charles et al, 200135 (N⫽3)

5

5

Level of Evidence

Validity Scores (Out of 16 or 11)

Summary of Constraint-Induced Movement Therapy and Forced-Use Therapy in Children With Hemiplegic Cerebral Palsy—Case Report Designa

Table 6.

CIMT in Children With Cerebral Palsy

November 2009

CIMT in Children With Cerebral Palsy Objective 2: Identify Key Characteristics of the Child and Intervention Protocol Associated With Effects of CIMT In addition to assessing the validity of the studies, we recorded: (1) inclusion and exclusion criteria, (2) type of constraint, (3) duration of constraint, (4) intervention duration, (5) study duration, and (6) outcomes measures at the ICF levels. We included the definitions of these features for each study and the rationale for choosing the definitions. We believe that examining the rationale for the choices for each component of CIMT will give the reader insight into which choices might warrant inclusion in future studies and how the specific children in their clinical caseloads compare with research participants.

Results Reliability of Scoring Each RCT and nonequivalent pretestposttest control group study was scored by 2 reviewers on the 16 validity items, totaling 112 items scored across 7 studies.21–27 Reviewers agreed on 82 of the 112 items scored, for a kappa coefficient of .66. Reviewers’ disagreements were resolved easily with discussion. There were 22 items scored for the 2 studies that used a one-group, pretest-posttest design.28,30 Reviewers agreed on 20 of the 22 items scored, for a kappa coefficient of .76. Objective 1: Investigate Whether CIMT Is Supported With Valid Research of Its Effectiveness Validity scores and study characteristics are shown in Tables 2 through 6. Validity scoring. The 7 RCTs and nonequivalent pretest-posttest control group designs had validity scores between 7 and 11 of the maximum 16 points21–27 (Tabs. 2 and 3). The 2 one-group designs had validity

November 2009

scores between 5 and 7 of the maximum 11 points28,30 (Tab. 4). Effect size. Only 4 studies provided means and standard deviations to enable computation of Cohen d and the 95% confidence interval (CI), for a total of 12 outcome measures22,25,26,51 (Tab. 7). Cohen49 defined ES as no effect (d⬍0.2), small (0.2ⱕd⬍0.5), medium (0.5ⱕd⬍0.8), and large (dⱖ0.8). We also included in Table 7 the ES (eta values) published in the studies by Charles et al23 and Gordon et al.27 There were 5 ES values at the body functions and structure level, but only 1 was significant (ie, the CI did not include zero), and there were 14 ES values at the activity level, with 4 being significant (Tab. 7). All significant ES values were medium to large (ie, d⫽0.6 –1.61). Of particular note is the significant treatment effect reported by Eliasson et al26 favoring the CIMT on the Assisting Hand Assessment (AHA) immediately posttreatment (large ES) and sustained at 6 months (medium ES). The AHA is currently the only reliable and valid measure used in pediatric CIMT studies that measures functional use of the affected UE in bimanual tasks.6 The norm-referenced tests evaluating fine motor development (eg, Peabody Developmental Motor Scale) were used in several studies.28,31,38 However, these tests do not measure the functional use of the affected hand in bimanual tasks. Some tests (eg, Pediatric Motor Activity Log [PMAL], Emerging Behavior Scale [EBS]) were developed specifically to examine the effects of CIMT, but the psychometric properties of these tests have not been established. A significant treatment effect favoring CIMT with a large ES was reported by Charles et al23 on the frequency of use portion of the CareVolume 89

giver Functional Use Survey. Taub et al22 also found significant and large ES values for amount of use on the PMAL immediately posttreatment and 3 weeks posttreatment and for the EBS. Only the study by Eliasson et al26 provided sufficient data for calculating control event rate (0.78), experimental event rate (1), number needed to treat (5), absolute benefit increase (0.22), and relative benefit increase (0.28). The control event rate and experimental event rate are determined in order to compute number needed to treat, which is the number of children who would need to be treated to achieve one additional favorable outcome.20 To increase the score on the AHA for children with hemiplegic CP, 5 children with hemiplegic CP must be treated with CIMT (2 hours of constraint per day and 2 hours of intervention per day for 2 months). The absolute benefit increase is the difference in rates of positive outcomes between experimental and control subjects in the same trial,20 and it was 22% in the study by Eliasson et al.26 The absolute benefit increase is divided by the control event rate to give the relative benefit increase, which is the proportional increase in rates of positive outcomes between experimental and control subjects in the same trial (28%).20 Direction of change results. For the 16 studies for which ES could not be calculated, outcome measures were primarily at the activity level and supported positive change immediately and up to 12 months postintervention in fine motor and functional activities (Tabs. 2, 3, 4, 5, and 6). Change at the body structures and function level was mostly positive. Three studies measured changes at the participation level, with positive changes reported.29,39,41

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MAS-Wrist

d

BOTMP

1.36 (0.28 to 2.31)c

1.48 (0.48 to 2.35)c

0.20 (⫺0.65 to 1.03)

CFUS-How Well

0.49d

CFUS-How Well

0.76 (⫺0.23 to 1.68)

1.61 (0.48 to 2.59)c

PMAL-Amount of Use

PMAL-Quality of Use

1.28 (0.21 to 2.22)c

EBS

Activity

Assisting Hand Assessment

1.16 (0.46 to 1.78)c

⫺0.19 (⫺0.90 to 0.53)

Activity

⫺0.23 (⫺0.94 to 0.49)

WeeFIM-Self-Care

WeeFIM-Cognitive

0.60 (0.15 to 1.31)

WeeFIM-Motor

WeeFIM-Communication

0.37 (⫺0.36 to 1.08) 0.38 (⫺0.35 to 1.09)

EDPA

0.15 (⫺0.57 to 0.86)

Box and Block Test

Activity

0.37d

0.41d

BOTMP

CFUS-How Frequently

0.43d

J-T Testb

0.70 (⫺0.28 to 1.62)

0.90 (⫺0.01 to 1.74)

1.26 (0.31 to 2.13)c

Activity

0.96 (0.05 to 1.80)c

0.49 (⫺0.37 to 1.32)

0.13 (⫺0.71 to 0.97)

⫺0.11 (⫺0.94 to 0.73)

⫺0.50 (⫺1.32 to 0.37)

⫺0.46 (⫺1.29 to 0.40)

⫺1.18 (⫺2.03 to ⫺0.23)c

0.61 (⫺0.26 to 1.44)

0.28 (⫺0.57 to 1.11)

6-Month Posttest

0.55 (⫺0.32 to 1.38)

0.72 (0.10 to 1.37)c

5-Month Posttest

1.15 (0.21 to 2.00)c

0.04 (⫺0.80 to 0.88)

⫺0.18 (⫺1.01 to 0.66)

⫺0.45 (⫺1.28 to 0.41)

⫺0.11 (⫺0.94 to 0.73), 0.32d

0.15 (⫺0.69 to 0.98)

0 (⫺0.84 to 0.84)

0.70 (⫺0.19 to 1.53) ⫺0.60 (⫺1.43 to 0.28)

0.74 (⫺0.15 to 1.57)

⫺0.42 (⫺1.24 to 0.44)

1-Month Posttest

Effect Size (95% CI) 3-Week Posttest

⫺1.69 (⫺2.59 to ⫺0.66)c

⫺0.05 (⫺0.88 to 0.79)

1-Week Posttest

CFUS-How Frequently

0.55

0.47d

b

Posttreatment

J-T Testb

Activity

b

MAS-Elbowb

MAS-Shoulderb

2-point discrimination

Grasp strength

Body structure

Outcome Measure

ICF⫽International Classification of Functioning, Disability and Health, MAS⫽Modified Ashworth Scale, J-T Test⫽Jebsen-Taylor Test of Hand Function, BOTMP⫽Bruininks-Oseretsky Test of Motor Proficiency, CFUS⫽Caregiver Functional Use Survey, EDPA⫽Erhardt Developmental Prehension Assessment, Wee-FIM⫽Functional Independence Measure for Children, EBS⫽Emerging Behavior Scale, PMAL⫽Pediatric Motor Activity Log. b Lower scores on the test correspond to better performance. c The CI does not include zero, which corresponds to a significant treatment effect. d The numbers are from the authors’ reports. The authors used “eta square” for calculating effect size instead of Cohen d. Eta square values of 0.01 to 0.03, 0.06 to 0.09, and ⬎0.14 represent small, medium, and large effect sizes, respectively. Cohen50 defined effect size as no effect (d⬍.02), small (0.2ⱕd⬍0.5), medium (0.5ⱕd⬍0.8), and large (dⱖ0.8).

a

Taub et al, 200422 (N⫽18)

Eliasson et al, 200526 (N⫽41)

Sung et al, (N⫽31)

200627

200525

Gordon et al, (N⫽38)

Charles et al, (N⫽22)

200623

Study

Effect Sizes and 95% Confidence Intervals (CI) of 5 Studies From the Outcome Measures Based on 3 ICF Levelsa

Table 7. CIMT in Children With Cerebral Palsy

November 2009

CIMT in Children With Cerebral Palsy Objective 2: Identify Key Characteristics of the Child and Intervention Protocol Associated With Effects of CIMT Common features of studies. The following features are summarized by study in Tables 2 through 6: (1) inclusion and exclusion criteria, (2) type of constraint, (3) duration of constraint, (4) intervention duration, (5) study duration, and (6) outcome measures at the ICF levels. Inclusion and exclusion criteria. Hemiplegic CP was the only consistent criterion across all studies. There was heterogeneity across the studies regarding the inclusion criteria (ie, the required minimal wrist range of motion and UE movement abilities). Four studies required subjects to have at least 20 degrees of active extension at the wrist and 10 degrees of active extension at the metacarpophalangeal joints.23,27,30,41 These were the same criteria for inclusion used in the studies of adults with stroke, specifically in the EXCITE trial.3,14,52–54 One study recruited children who were able to actively extend the affected wrist at least 10 degrees with finger extension and lift the arm from resting on a table and place it on a 13-cm-high box,35 and 2 studies required that subjects be able to use the affected extremity only as a gross functional assist in tasks (eg, reaching) or have some active wrist or finger extension of the affected UE.29,31 Movement ability was not an inclusion criterion in the other 14 studies. Three studies excluded children with severe paralysis of the UE.23,25,27 Only 4 studies addressed the issue of sensory impairments and excluded children with major sensory disorders or vision problems.23,27,30,31 Positive outcomes were reported in all 4 studies following implementation of CIMT. No specific criteria for sensory abilities were included in the other studies. November 2009

Age and CP severity varied across studies. The association between subject characteristics and the effects of CIMT has not been systematically evaluated through research. Type of constraint. There was wide variability in the type of constraint, ranging from a full-arm cast to gentle parental restraint (Tabs. 2, 3, 4, 5, and 6). Nine studies included a cast as the constraint,21,22,24,25,34,36,38,39,41 referencing the literature on adults with stroke in justifying their selection. Five of the studies used bivalved casts,22,24,25,38,41 and Cope et al34 used a nonremovable cast and determined it was the best method of restraint for the particular child in their study. Willis et al21 did not bivalve the cast and reported that several subjects dropped out of the study due to the irritability from casting. Two studies did not provide information regarding the cast.36,39 Wallen et al29 and Pierce et al37 selected a fabric mitt, with no specified reason provided. Fergus et al40 reported that using a soft, removable mitt provided a simple, easily manipulated constraint. Researchers in 5 studies chose a splint,26,28,31,33,36 citing previous literature. Glover et al36 used 2 types of restraint: cast and splint. Eliasson et al26 reported that the splint restricted use of the unaffected hand but allowed for necessary balance reactions. Four studies used a sling strapped to the child’s trunk to prevent bimanual tasks.23,27,30,35 Gordon and colleagues’ choice27 was derived from positive results of their pilot studies. The parent gently restrained the child’s unaffected extremity in the study by Naylor and Bower.32 Duration of constraint. Constraint duration ranged from 1 to 24 hours per day (Tabs. 2, 3, 4, 5, and 6). The unaffected UE was constrained for at least 10 hours per day in 11 studies.21,22,24,25,31,33,34,36 –39 In 9 of these studies, the subjects wore the reVolume 89

straint for 24 hours.21,22,24,25,34,36 –39 Two studies used a splint continuously except for bathing, sleeping, and short rests.31,33 The remaining 10 studies used a constraint only during treatment.26 –30,32,35,40,41,51 Treatment duration in these studies varied from 1 to 7.5 hours per day. The authors justified the duration of constraint based on previous studies of adult and pediatric CIMT literature and in order to create a “child-friendly” intervention. Martin et al41 casted children’s affected UE for 4 hours during therapy and for an additional 3 to 5 hours per day without providing a rationale. Eliasson et al26 had children wear a glove for 7 hours,28 and Eliasson and collegues26 and Wallen et al29 had children wear a glove for 2 hours per day. Intervention duration. Intervention duration ranged from 1 hour per week to 7 hours per day (Tabs. 2, 3, 4, 5, and 6). Ten studies included 6 to 7 hours of therapy per day.22–24,27,28,30,33,35,38,40 This high-intensity intervention was based on the interventions used in studies of adult subjects.2,55–58 DeLuca et al37 chose this intensity, stating that the prior pediatric literature on CIMT had yet to match the intensity of the studies of adults with stroke. Furthermore, the authors noted that the intensity used for adults with stroke was exceeded in order to maximize cortical reorganization, although no supporting data in a pediatric population were provided. Treatment in the studies by Eliasson et al26 and Wallen et al29 consisted of 2 hours of therapy per day within the child’s usual environment (ie, at home or in the preschool setting). The authors noted that a rich natural environment was important to facilitate the learning process. Glover et al36 applied 2-hour sessions of occupational therapy or physical therapy as weekday treatment without proNumber 11

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CIMT in Children With Cerebral Palsy viding a rationale for intervention duration. Naylor and Bower32 also provided therapy within the home setting for 1 hour per day, stating that treatment in the child’s natural environment increased adherence among parents and teachers, thus decreasing the need for an intense training schedule in clinical settings. Pierce et al37 included two 1-hour sessions of physical therapy and two 1-hour sessions of occupational therapy per week (ie, a total of 4 hours of treatment per week), noting that the high intensity of treatment in studies by Taub and colleagues59,60 was not feasible in a managed care environment. Similarly, Cope et al33 applied a total of 8 hours of treatment per week. Four studies provided little intervention (eg, 1 hour of physical therapy or occupational therapy per week) and assessed the effectiveness of constraint alone.20,24,30,38 The optimal durations of constraint and intervention have not been systematically evaluated. Study duration. Study durations in 19 of the studies ranged from 6 weeks to 18 months (Tabs. 2, 3, 4, 5, and 6),21–24,26 –35,37– 41 with 2 studies without a follow-up period, only evaluation immediately after intervention.25,36 Eight of the 19 studies used a 6-month intervention,23,26,27,29,31,34,35,39 and the intervention was of 8 months’ duration in 4 studies.21,22,30,37 Positive effects were demonstrated in most studies up to 6 to 8 months after intervention. Outcome measures. Eight studies used outcome measures with multiple ICF levels (Tabs. 2, 3, 4, 5, and 6).23,27–29,35,37,39,41 Eight studies had outcome measures at the body functions and structure level,23,27–29,35,37,39,41 including functional magnetic resonance imaging (fMRI), muscle tone (velocity-dependent resistance to stretch), sensation, grip strength (forcegenerating capacity), 2-point discrimination, and pinch gauge, and 20 1136

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studies measured change at the activity level.21–35,37– 41 There was little consistency in these 20 studies as to which activities were assessed. Only 3 studies26,29,39 used the AHA. In addition, 3 studies measured outcomes at the participation level by using the Canadian Occupational Performance Measures (COPM).29,39,41 A systematic evaluation of shared and valid outcome measures is critical to understanding the impact of CIMT.

Discussion The Cochrane review,6 which represents the highest level of research evidence (ie, 1a), determined that there was insufficient evidence to either support or refute the use of CIMT for children with hemiplegic CP and that more-rigorous research was needed and specifically research with valid outcome measures. However, if we consider studies at all levels of evidence, as we did in this systematic review, there is positive support for the use of CIMT to improve the frequency of use of the UE for children with hemiplegic CP. The strongest evidence for this improvement comes from the 3 RCTs22–24 and 1 nonequivalent pretestposttest study,27 but an increased frequency of use of the UE following CIMT also was supported in studies with less-rigorous designs.30,38 Taub et al22 and Charles et al23 demonstrated large ES values for the frequency of use, with the findings from the study by Charles et al23 extended to 6 months posttherapy. Of particular note is that both Charles et al23 and Gordon et al27 had only half of the total time for intervention (60 hours) and a fourth of the time wearing the restraint (6 hours per day) in comparison with the study by Taub et al22 (total intervention time⫽120 hours; restraint time⫽24 hours per day). It is not apparent from the available literature whether even less intervention time and less time in restraint also could have a positive and large impact on the fre-

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quency of use of the UE. This remains an empirical question. Although improving the frequency of use of the affected extremity is an excellent starting point, improving the quality of use, particularly for functional activities, also is an important goal. Charles et al23 reported a large and significant ES for the quality of use of the UE on the Caregiver Functional Use Survey (CFUS), a caregiver questionnaire of UE skills, although subjects in this study showed these effects only at 1 month posttreatment and not at 1 week or 6 months posttreatment. Subjects in the study by Gordon et al27 showed a large ES on the CFUS 1 week posttreatment. Taub et al22 showed a significant and large ES following CIMT on the EBS, which is a scale that quantifies the number of different movement patterns that are observed. This same trend, but without available ES, was demonstrated by DeLuca et al24 on the EBS. The most compelling data on the positive impact of CIMT comes from the study by Eliasson et al26 with a large and sustained ES for the AHA.6,61,62 The AHA measures the frequency of use of the affected UE but also captures aspects of quality of use.62 This study,26 however, had a rather low validity score (7 of 16) because it was not an RCT and the control of cointervention was not adequate. Of importance is that the constraint was worn for only 2 hours per day and intervention was 2 hours per day during the constraint period, but the treatment was implemented over a 60-day period. This again raises the question of what is the appropriate dose for intervention and constraint. The critical threshold for intensity in terms of both number of hours per day and number of weeks that constitute an adequate dose cannot be determined from the available research.

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CIMT in Children With Cerebral Palsy We cannot identify key characteristics of the child and intervention protocol associated with effects of CIMT. The reviewed studies have few common features regarding the method. However, based on the current findings, all future CIMT studies could calculate power a priori in order to have a sufficient sample size. Although no a priori power calculations were reported or provided in the reviewed studies,22,23,25,26 the actual statistical power can be computed from the numbers of subjects and the reported means and standard deviations in the studies. The results show that outcomes at the body functions and structure and activity levels have power between 50% and 70% and 80% and 95%, respectively. Thus, for example, to provide 80% statistical power and a medium to large ES (d⫽0.8) at the activity level, a CIMT RCT design study would require at least 20 subjects in the treatment group and 20 subjects in the control group. Impact on the Developing Brain As mentioned in the introduction to this review, Krakauer17 described true recovery in contrast to compensation in motor learning. True recovery involves recruiting the undamaged brain regions to control the muscles previously used for a movement. Compensation, in contrast, involves the use of different muscle groups to achieve the same movement goal.17 The use of inappropriate compensatory strategies may limit development or recovery in children or adults after neurological impairments.63,64 The effects of CIMT on the brain that result in either true recovery or compensation require more-detailed analysis, particularly for the developing brain. The impact of CIMT on undamaged brain regions during development remains largely unknown, and the potential impact may differ with the stage of development during which CIMT is applied.5 November 2009

To our knowledge, only 2 studies have investigated the potential cortical changes from CIMT in children.39,42 Sutcliffe et al39 reported the effects of cortical reorganization in an 8-year-old child with hemiplegic CP following a 3-week CIMT intervention (24 hours of constraint per day, 1 hour of therapy per week). The results of fMRI indicated increased bilateral cortical activation in the sensorimotor cortex of the affected UE after therapy and a shift in laterality from the ipsilateral hemisphere to the contralateral hemisphere. Modified CIMT led to increased activity of the contralateral somatosensory cortex. Sutcliffe and colleagues39 also found increased cortical activation in the ipsilateral motor cortex and contralateral somatosensory cortex after therapy. These cortical changes were associated with improvements in clinical measures and persisted at 6 months. Juenger et al42 also reported increased fMRI activations in the primary sensorimotor cortex of the lesioned hemisphere in 3 children with congenital hemiparesis (age range⫽12–16 years) after a 12-day CIMT intervention (10 hours of constraint per day, 2 hours of therapy per day), suggesting that these results supported the mechanism of cortical reorganization for improvements of UE function after modified CIMT. Eyre et al65 suggested that due to the loss of competition from the lesioned hemisphere in children with hemiplegic CP, the unlesioned hemisphere might have acquired bilateral organization. They found that transcranial magnetic stimulation of the unlesioned hemisphere evoked bilateral motor responses in 10 children with hemiplegic CP (median age⫽11.5 years), demonstrating persistence of ipsilateral and contralateral corticospinal projections from the unlesioned hemisphere. There was only a sparse contralateral corVolume 89

ticospinal projection from the lesioned hemisphere after transcranial magnetic stimulation. The organization of the corticospinal system in children with hemiplegic CP is characterized by the loss of motor responses of the lesioned side and emergence of bilateral responses from the unlesioned side. However, the authors did not specify whether the unlesioned hemisphere was the dominant hemisphere. Preliminary work by Kuhnke and colleagues66 with adolescents with congenital hemiparesis suggests that individuals with preserved crossed cortical projections versus ipsilateral projections may have different outcomes from CIMT. Although both groups of subjects had significant improvements of UE function, subjects with preserved crossed cortical projections performed the relatively short tasks of the Wolf Motor Function Test more rapidly compared with those with ipsilateral projections. Constraintinduced movement therapy might influence interhemispheric inhibition by reducing cortical activity in the unlesioned hemisphere (by constraining the unaffected UE), while increasing cortical activity in the lesioned hemisphere (by implementing the intensive intervention).66 Nevertheless, it is still unclear whether similar results will be found in children with congenital hemiparesis. Thus, Hoare67 recommends stratification on cortical-spinal organization for future studies of congenital hemiplegia. Future Research There have been insufficient studies systematically comparing the critical variables of duration and type of constraint and the duration and type of intervention using valid and reliable outcome measures. The future direction for CIMT studies is to develop further good-quality research with a priori power calculations to examine the different features of CIMT, including the effectiveness of the reNumber 11

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CIMT in Children With Cerebral Palsy straint and the frequency and duration of the intervention sessions. Measures at the participation level of the ICF also should be included in future studies, as well as an elucidation of the relationships among ICF levels. Finally, there has been insufficient investigation of the potential central nervous system changes that may ensue from constraining the extremity of a developing child to support the use of prolonged constraint of an unaffected extremity. Research using CIMT should incorporate outcome measures of the effects on the developing brain to guide best physical therapist practice. Ms Huang and Dr Fetters provided concept/ idea/research design and project management. All authors provided writing, data collection and analysis, and consultation (including review of manuscript before submission). This article was received April 14, 2008, and was accepted July 15, 2009. DOI: 10.2522/ptj.20080111

References 1 Bonaiuti D, Rebasti L, Sioli P. The constraint induced movement therapy: a systematic review of randomised controlled trials on the adult stroke patients. Eura Medicophys. 2007;43:139 –146. 2 Taub E, Uswatte G, Pidikiti R. Constraintinduced movement therapy: a new family of techniques with broad application to physical rehabilitation—a clinical review. J Rehabil Res Dev. 1999;36:237–251. 3 Wolf SL. Revisiting constraint-induced movement therapy: are we too smitten with the mitten? Is all nonuse “learned”? and other questions. Phys Ther. 2007;87:1212– 1223. 4 Winstein CJ, Prettyman MG. Constraintinduced therapy for functional recovery after brain injury:unraveling the key ingredients and mechanisms. In: Baudry M, Bi X, Schreiber S, eds. Synaptic Plasticity. New York, NY: Marcel Dekker Inc; 2005: 281–328. 5 Charles J, Gordon AM. A critical review of constraint-induced movement therapy and forced use in children with hemiplegia. Neural Plast. 2005;12:245–261. 6 Hoare BJ, Imms C, Carey L, Wasiak J. Constraint-induced movement therapy in the treatment of the upper limb in children with hemiplegic cerebral palsy: a Cochrane systematic review. Clin Rehabil. 2007;21:675– 685.

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7 Hoare BJ, Wasiak J, Imms C, Carey L. Constraint-induced movement therapy in the treatment of the upper limb in children with hemiplegic cerebral palsy. Cochrane Database Syst Rev. 2007;2:CD004149. 8 Taub E, Griffin A, Nick J, et al. Pediatric CI therapy for stroke-induced hemiparesis in young children. Dev Neurorehabil. 2007; 10:3–18. 9 Taub E. Movement in nonhuman primates deprived of somatosensory feedback. Exerc Sports Sci Rev. 1976;4:335–374. 10 Taub E. Somatosensory deafferentation research with monkeys: implications for rehabilitation medicine. In: Ince LP, ed. Behavioral Psychology in Rehabilitation Medicine: Clinical Applications. Baltimore, MD: Williams & Wilkins; 1980:371– 401. 11 Wolf SL, Lecraw DE, Barton LA, Jann BB. Forced use of hemiplegic upper extremities to reverse the effect of learned nonuse among chronic stroke and head-injured patients. Exp Neurol. 1989;104:125–132. 12 Ostendorf CG, Wolf SL. Effect of forced use of the upper extremity of a hemiplegic patient on changes in function. Phys Ther. 1981;61:1022–1028. 13 Knapp HD, Taub E, Berman AJ. Movements in monkeys with deafferented limbs. Exp Neurol. 1963;7:305–315. 14 Wolf SL, Winstein CJ, Miller JP, et al. Effects of constraint-induced movement therapy on upper extremity function 3 to 9 months after stroke: the EXCITE randomized clinical trial. JAMA. 2006;296: 2095–2104. 15 Taub E, Perrella PN, Miller EA, Barro G. Diminution of early environmental control through perinatal and prenatal somatosensory deafferentation. Biol Psychiatry. 1975; 10:609 – 626. 16 Gordon AM, Charles J, Wolf SL. Methods of constraint-induced movement therapy for children with hemiplegic cerebral palsy: development of a child-friendly intervention for improving upper-extremity function. Arch Phys Med Rehabil. 2005;86: 837– 844. 17 Krakauer JW. Motor learning: its relevance to stroke recovery and neurorehabilitation. Curr Opin Neurol. 2006;19:84 –90. 18 International Classification of Functioning, Disability and Health: ICF. Geneva, Switzerland: World Health Organization; 2001. 19 Jette AM. The changing language of disablement. Phys Ther. 2005;85:118 –119. 20 Sackett DL, Straus SE, Richardson WS, et al. Evidence Based Medicine: How to Practice and Teach EBM. 2nd ed. New York, NY: Churchill Livingstone Inc; 2000. 21 Willis JK, Morello A, Davie A, et al. Forced use treatment of childhood hemiparesis. Pediatrics. 2002;110:94 –96. 22 Taub E, Ramey SL, DeLuca SC, Echols K. Efficacy of constraint-induced movement therapy for children with cerebral palsy with asymmetric motor impairment. Pediatrics. 2004;113:305–312.

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23 Charles JR, Wolf SL, Schneider JA, Gordon AM. Efficacy of a child-friendly form of constraint-induced movement therapy in hemiplegic cerebral palsy: a randomized control trial. Dev Med Child Neurol. 2006; 48:635– 642. 24 DeLuca SC, Echols K, Law CR, Ramey SL. Intensive pediatric constraint-induced therapy for children with cerebral palsy: randomized, controlled, crossover trial. J Child Neurol. 2006;21:931–938. 25 Sung IY, Ryu JS, Pyun SB, et al. Efficacy of forced-use therapy in hemiplegic cerebral palsy. Arch Phys Med Rehabil. 2005;86: 2195–2198. 26 Eliasson A-C, Krumlinde-Sundholm L, Shaw K, Wang C. Effects of constraintinduced movement therapy in young children with hemiplegic cerebral palsy: an adapted model. Dev Med Child Neurol. 2005;47:266 –275. 27 Gordon AM, Charles J, Wolf SL. Efficacy of constraint-induced movement therapy on involved upper-extremity use in children with hemiplegic cerebral palsy is not agedependent. Pediatrics. 2006;117:363–373. 28 Eliasson A-C, Bonnier B, KrumlindeSundholm L. Clinical experience of constraint-induced movement therapy in adolescents with hemiplegic cerebral palsy: a day camp model. Dev Med Child Neurol. 2003;45:357–360. 29 Wallen M, Ziviani J, Herbert R, et al. Modified constraint-induced therapy for children with hemiplegic cerebral palsy: a feasibility study. Dev Neurorehabil. 2008;11: 124 –133. 30 Charles JR, Gordon AM. A repeated course of constraint-induced movement therapy results in further improvement. Dev Med Child Neurol. 2007;49:770 –773. 31 Crocker MD, MacKay-Lyons M, McDonnell E. Forced use of the upper extremity in cerebral palsy: a single-case design. Am J Occup Ther. 1997;51:824 – 833. 32 Naylor CE, Bower E. Modified constraintinduced movement therapy for young children with hemiplegic cerebral palsy: a pilot study. Dev Med Child Neurol. 2005; 47:365–369. 33 Dickerson AE, Brown LE. Pediatric constraint-induced movement therapy in a young child with minimal active arm movement. Am J Occup Ther. 2007;61: 563–573. 34 Cope SM, Forst HC, Bibis D, Liu XC. Modified constraint-induced movement therapy for a 12-month-old child with hemiplegia: a case report. Am J Occup Ther. 2008;62:430 – 437. 35 Charles J, Lavinder G, Gordon AM. Effects of constraint-induced therapy on hand function in children with hemiplegic cerebral palsy. Pediatr Phys Ther. 2001;13: 68 –76. 36 Glover JE, Mateer CA, Yoell C, Speed S. The effectiveness of constraint-induced movement therapy in two young children with hemiplegia. Pediatr Rehabil. 2002;5: 125–131.

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CIMT in Children With Cerebral Palsy 37 Pierce SR, Daly K, Gallagher KG, et al. Constraint-induced therapy for a child with hemiplegic cerebral palsy: a case report. Arch Phys Med Rehabil. 2002;83: 1462–1463. 38 DeLuca SC, Echols K, Ramey SL, Taub E. Pediatric constraint-induced movement therapy for a young child with cerebral palsy: two episodes of care. Phys Ther. 2003;83:1003–1013. 39 Sutcliffe TL, Gaetz WC, Logan WJ, et al. Cortical reorganization after modified constraint-induced movement therapy in pediatric hemiplegic cerebral palsy. J Child Neurol. 2007;22:1281–1287. 40 Fergus A, Buckler J, Farrell J, et al. Constraint-induced movement therapy for a child with hemiparesis: a case report. Pediatr Phys Ther. 2008;20:271–283. 41 Martin A, Burtner PA, Poole J, Phillips J. Case report: ICF-level changes in a preschooler after constraint-induced movement therapy. Am J Occup Ther. 2008;62: 282–288. 42 Juenger H, Linder-Lucht M, Walther M, et al. Cortical neuromodulation by constraint-induced movement therapy in congenital hemiparesis: an FMRI study. Neuropediatrics. 2007;38:130 –136. 43 Portney LG, Watkins MP. Experimental design. In: Mehalik C, ed. Foundations of Clinical Research: Applications to Practice. 2nd ed. Englewood Cliffs, NJ: Prentice Hall; 2000:196 –197. 44 Kwakkel G, Wagenaar RC, Koelman TW, et al. Effects of intensity of rehabilitation after stroke: a research synthesis. Stroke. 1997;28:1550 –1556. 45 Cambach W, Wagenaar RC, Koelman TW, et al. The long-term effects of pulmonary rehabilitation in patients with asthma and chronic obstructive pulmonary disease: a research synthesis. Arch Phys Med Rehabil. 1999;80:103–111. 46 Cook DJ, Sackett DL, Spitzer WO. Methodologic guidelines for systematic reviews of randomized control trials in health care from the Potsdam consultation on metaanalysis. J Clin Epidemiol. 1995;48:167– 171.

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47 Detsky AS, Naylor CD, O’Rourke K, et al. Incorporating variations in the quality of individual randomized trials into metaanalysis. J Clin Epidemiol. 1992;45:255– 265. 48 Jenicek M. Meta-analysis in medicine: where we are and where we want to go. J Clin Epidemiol. 1989;42:35– 44. 49 Landis JR, Koch GG. The measurement of observer agreement for categorical data. Biometrics. 1977;33:159 –174. 50 Cohen J. Statistical Power Analysis for the Behavioral Sciences. 2nd ed. Hillsdale, NJ: Lawrence Earlbaum Associates; 1988. 51 Charles J, Gordon AM. Development of hand-arm bimanual intensive training (HABIT) for improving bimanual coordination in children with hemiplegic cerebral palsy. Dev Med Child Neurol. 2006;48: 931–936. 52 Taub E, Uswatte G. Constraint-induced movement therapy: bridging from the primate laboratory to the stroke rehabilitation laboratory. Scand J Rehabil Med Suppl. 2003;41:34 – 40. 53 Winstein CJ, Miller EA, Blanton S, et al. Methods for a multisite randomized trial to investigate the effect of constraintinduced movement therapy in improving upper extremity function among adults recovering from a cerebrovascular stroke. Neurorehabil Neural Repair. 2003;17: 137–152. 54 Blanton S, Morris DM, Prettyman MG, et al. Lessons learned in participant recruitment and retention: the EXCITE trial. Phys Ther. 2006;86:1520 –1533. 55 Taub E, Miller NE, Novack TA, et al. Technique to improve chronic motor deficit after stroke. Arch Phys Med Rehabil. 1993;74:347–354. 56 Miltner WH, Bauder H, Sommer M, et al. Effects of constraint-induced movement therapy on patients with chronic motor deficits after stroke: a replication. Stroke. 1999;30:586 –592. 57 Kunkel A, Kopp B, Muller G, et al. Constraintinduced movement therapy for motor recovery in chronic stroke patients. Arch Phys Med Rehabil. 1999;80:624 – 628.

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58 Sterr A, Elbert T, Berthold I, et al. Longer versus shorter daily constraint-induced movement therapy of chronic hemiparesis: an exploratory study. Arch Phys Med Rehabil. 2002;83:1374 –1377. 59 Taub E, Morris DM. Constraint-induced movement therapy to enhance recovery after stroke. Curr Atheroscler Rep. 2001; 3:279 –286. 60 Taub E, Crago JE, Uswatte G. Constraint induced movement therapy: a new approach to treatment in physical rehabilitation. Rehabil Psychol. 1998;43:152–170. 61 Krumlinde-Sundholm L, Holmefur M, Kottorp A, Eliasson A-C. The Assisting Hand Assessment: current evidence of validity, reliability, and responsiveness to change. Dev Med Child Neurol. 2007;49:259 –264. 62 Krumlinde-Sundholm L. Development of the Assisting Hand Assessment: a Raschbuilt measure intended for children with unilateral upper limb impairments. Scand J Occup Ther. 2003;10:16 –26. 63 Cirstea MC, Levin MF. Compensatory strategies for reaching in stroke. Brain. 2000; 123(pt 5):940 –953. 64 Chan TW, Law SH. Eliminating toe-fixing pattern can improve standing and gait pattern of children with cerebral palsy in a qualitative way. Int J Rehabil Res. 2008; 31:199 –206. 65 Eyre JA, Taylor JP, Villagra F, et al. Evidence of activity-dependent withdrawal of corticospinal projections during human development. Neurology. 2001;57:1543– 1554. 66 Kuhnke N, Juenger H, Walther M, et al. Do patients with congenital hemiparesis and ipsilateral corticospinal projections respond differently to constraint-induced movement therapy? Dev Med Child Neurol. 2008;50:898 –903. 67 Hoare BJ. Unravelling the cerebral palsy upper limb. Dev Med Child Neurol. 2008; 50:887.

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CIMT in Children With Cerebral Palsy Appendix 1. Scoring Protocol44,45,a Methodological aspect:

Criteria for operationalization:

Operationalization (yesⴝ1/noⴝ0)

1. concealed allocation is applied (ie, sealed envelopes)

1. 䡺 ⫽ 1

䡺⫽0

2. random sequence generation is applied (ie, random numbers table, coin tossing, computer random numbers or shuffling)

2. 䡺 ⫽ 1

䡺⫽0

B. Matching procedure is adequate if:

3. patients are matched according to relevant patient characteristics (ie, age, type of stroke, initial activities of daily living score, and time since stroke onset)

3. 䡺 ⫽ 1

䡺⫽0

C. Blinding procedure is adequate if:

4. observer(s) are kept unaware of the groups to which patients have been assigned

4. 䡺 ⫽ 1

䡺⫽0

5. those performing statistical analysis are kept unaware of the groups to which patients have been assigned

5. 䡺 ⫽ 1

䡺⫽0

6. patients are kept unaware with respect to the condition to which they have been assigned

6. 䡺 ⫽ 1

䡺⫽0

7. the number of dropouts is described for each group separately

7. 䡺 ⫽ 1

䡺⫽0

8. the number of intercurrent dropouts is described for each group separately

8. 䡺 ⫽ 1

䡺⫽0

9. intention-to-treat analysis has been applied

9. 䡺 ⫽ 1

䡺⫽0

10. statistically significant test-retest correlation coefficients and/or intraobserver/interobserver reliability of relevant measurement instruments have been reported by the authors or have been established in studies that are cited by the authors

10. 䡺 ⫽ 1

䡺⫽0

11. the relevant measurement instruments are compared statistically with other instruments measuring the same modality by the authors or in studies reported by the authors

11. 䡺 ⫽ 1

䡺⫽0

12. other cointerventions leading to systematic differences in results are avoided

12. 䡺 ⫽ 1

䡺⫽0

13. adjunctive (medical) interventions are reported for each individual separately

13. 䡺 ⫽ 1

䡺⫽0

G. Comparability of patients characteristics is adequate if:

14. relevant patient characteristics (ie, initial activities of daily living score, type of stroke, age, and time since stroke onset) are not statistically significantly different between experimental and control groups

14. 䡺 ⫽ 1

䡺⫽0

H. Control for dose of therapy is adequate if:

15. predetermined rehabilitation time (in minutes or hours) and/or number of exercises and/or dosage of applied exercises have been reported in experimental and control groups

15. 䡺 ⫽ 1

䡺⫽0

16. actual rehabilitation time spent (in minutes or hours) and/or number of exercises and/or dosage of applied exercises have been reported in experimental and control groups

16. 䡺 ⫽ 1

䡺⫽0

A. Randomization procedure is adequate if:

D. Dropouts and intention-to-treat analysis are adequate if:

E. Measurement instruments are adequate if:

F. Control of cointervention(s) is adequate if:

a E. Control for measurement error: A test was considered to be reliable if test-retest correlation coefficient and/or interobserver reliability and/or intraobserver reliability was significant according to the authors or according to the studies that were cited by the authors. The (construct) validity of a measurement instrument was considered to be demonstrated if a significant relationship between this instrument and a “gold standard” had been established according to the authors or according to the studies that were cited by the authors. F. Control for cointervention: Control for adjunctive (medical) cointervention was judged to be adequate (score 1) if: (1) trials in which other interventions were avoided or (2) trials in which data on cointervention were presented were not significantly different between groups (P⬍.05). H. Control for dose therapy: Dose of therapy was judged to be monitored adequately if predetermined (15) and actual rehabilitation time spent (16) were reported in experimental and control groups. Reprinted with permission from: Kwakkel G, Wagenaar RC, Koelman TW, et al. Effects of intensity of rehabilitation after stroke: a research synthesis. Stroke. 1997;28:1550 – 1556.

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CIMT in Children With Cerebral Palsy Appendix 2. Modified Scoring Protocola Methodological aspect:

1. a representative sample is selected from a relevant population

1. 䡺 ⫽ 1

䡺⫽0

2. description of inclusion and exclusion criteria, baseline characteristics, and/or pretest are applied

2. 䡺 ⫽ 1

䡺⫽0

3. the follow-up is long enough for important events to occur

3. 䡺 ⫽ 1

䡺⫽0

C. Blinding procedure is adequate if:

4. observers are kept unaware of the objective of the study

4. 䡺 ⫽ 1

䡺⫽0

D. Measurement instruments are adequate if:

5. statistically significant test-retest correlation coefficients and/or intraobserver/interobserver reliability of relevant measurement instruments have been reported by the authors or have been established in studies that are cited by the authors

5. 䡺 ⫽ 1

䡺⫽0

6. the relevant measurement instruments are compared statistically with other instruments measuring the same modality by the authors or in studies reported by the authors

6. 䡺 ⫽ 1

䡺⫽0

E. Control of co-intervention(s) is adequate if:

7. other cointerventions leading to systematic differences in results are avoided

7. 䡺 ⫽ 1

䡺⫽0

F. Control for dose of therapy is adequate if:

8. adjunctive (medical) interventions are reported for each individual separately

8. 䡺 ⫽ 1

䡺⫽0

9. predetermined rehabilitation time (in minutes or hours) and/or number of exercises and/or dosage of applied exercises have been reported

9. 䡺 ⫽ 1

䡺⫽0

10. actual rehabilitation time spent (in minutes or hours) and/or number of exercises and/or dosage of applied exercises have been reported for each individual

10. 䡺 ⫽ 1

䡺⫽0

11. parametric or nonparametric, single-subject statistics are applied

11. 䡺 ⫽ 1

䡺⫽0

A. Study population is adequate if:

B. Design procedure is adequate if:

G. Statistical analysis is appropriate if:

a

Operationalization (yesⴝ1/noⴝ0)

Criteria for operationalization:

Modification from Kwakkel et al.44

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CIMT in Children With Cerebral Palsy

Invited Commentary

Jeanne Charles, Steven L. Wolf

The objectives of this systematic review of the current literature were: (1) to determine whether there was evidence to support the efficacy of constraint-induced movement therapy (CIMT) in children with hemiplegic cerebral palsy (CP) and (2) to identify key child characteristics and intervention protocols that can be associated with the effects of CIMT.1 Huang et al are to be commended for modifying this meta-analysis through a validated scoring system, as well as for calculating treatment effects (when possible) in those studies that did not report them. Although the results of this analysis supported the efficacy of pediatric CIMT to improve more-involved upperextremity function in children with hemiplegia, a by-product of the analysis was the focus placed on the variety of protocols used in these studies. These variations in study designs also were elucidated by the authors’ second objective of their systematic review. Addressing these variations raises the question of why they exist among studies. The authors identified the following common intervention protocol characteristics: inclusion and exclusion criteria, type of constraint, duration of constraint, intervention duration, and outcome measures. They also attempted to identify child or protocol characteristics between studies that were related to the effects of CIMT. In addition, an attempt was made to identify a study characteristic that had been systematically evaluated across studies. The authors concluded that key child characteristics, intervention protocol characteristics, and common methodological features across studies could not be determined. Their inability to identify these common study characteristics across the liter-

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ature cited in this article reflects the lack of rigorous design for pediatric CIMT studies and can be attributed to the variation among studies. The authors’ suggestion that future studies to evaluate the effectiveness of CIMT in the pediatric population should directly compare protocol intervention characteristics should be seriously considered. Systematic research regarding the efficacy of pediatric CIMT should include a review of the methods and results of previous studies. In addition, effect sizes should be reported in each study in order to serve as a comparison of measures across studies. If investigators included these suggestions in subsequent studies, they would begin to “leverage” the results of these studies in order to determine treatment effects of this intervention.2 For example, similarity in effect sizes for frequency of more-involved upperextremity use as reported by caregivers in 2 different studies3,4 cited in this review provided an opportunity to systematically evaluate appropriate dosing for intervention duration and to compare (as the authors did) the differences in intervention duration and constraint duration between the studies. The authors used the International Classification of Functioning, Disability and Health (ICF)5 to provide a common basis for comparison of measures among studies (Tabs. 2, 3, 4, 5, 6, and 7). Although they are to be commended for assessing outcomes measures across studies, this basis of comparison may not be helpful when outcome measures quantify aspects of development. The authors assigned the 2 developmental measures listed in this review—Peabody Developmental Motor Scales–Fine Motor (PDMS-F) and Denver Developmen-

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tal Screening Test (DDST)—to the activity level of the ICF (Tab. 6). Developmental measures compare the activities of infants and small children in relation to their chronological age and are measures of the developmental process. Sensorimotor development of the upper extremity does not mature until age 10 years, but the majority of gross and fine motor skills in the upper extremity are present by 8 years of age.6 The intervention activities for younger children would be designed to promote the development of gross and fine motor skills of the upper limbs. Subsequently, outcome measures for this type of intervention would assess changes in upper-limb sensorimotor development from before to after intervention. However, intervention activities for older children would involve practice of moreadvanced coordinative skills and functional tasks. Therefore, outcomes would include measures of movement efficiency and function. These developmental differences would affect the available measurement options, thus imposing difficulty in determining the value and impact of outcomes among studies. Perhaps, in an effort to promote more rigorous design, studies need to be grouped by participant age for analysis. Another consideration regarding CIMT as an intervention for young children with hemiplegic CP concerns the impact of this intervention on the developing (and damaged) central nervous system. The authors cite 2 studies that examined potential cortical changes resulting from CIMT.7,8 Each study showed changes in cortical activation following a CIMT intervention, thereby suggesting that CIMT may be a mechanism for cortical reorganization. The results of

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CIMT in Children With Cerebral Palsy these studies were similar to those of a study demonstrating changes in cortical activation in adults following CIMT.9 Although the participants in the studies by Sutcliffe et al7 and Juenger et al8 were older children or children whose upper-extremity sensorimotor development had reached or was close to reaching maturity, the impact of CIMT on the developing central nervous system of younger children engaged in CIMT studies needs further consideration. As Huang et al mentioned, results from investigations of the developing damaged central nervous system have suggested that the loss of contralesional limb control is a result of early diminished use of the affected limb.10 As a result of diminished involved upperextremity use, cortical control of the involved upper limb can develop via innervation from corticospinal neurons that descend from the ipsilateral hemisphere rather than the contralateral hemisphere. The resulting “compensatory” anatomical organization may influence a child’s response to CIMT. Finally, animal studies examining the early role of the corticospinal tract in restructuring neural circuits during development11 suggest that restriction of unilateral movement early in development can result in impaired visually guided movements later. This information may prompt caution in restricting movement of the less-involved extremity early in development and may warrant further investigation.

In conclusion, this review provides readers with “food for thought” regarding the design of future studies that explore the efficacy of pediatric CIMT. The use of this intervention to improve more-involved upperextremity function in children with hemiplegic CP differs from its use in adults due to the etiology of the central nervous system damage and its influence on sensorimotor development. Moreover, variation in the ages and, by logical extension, the level of inherent nervous system maturation may imply that training tools and outcome measures must be developmental and age-specific. The heterogeneity of study design and a failure to report effect sizes consistently across the studies reported in this review makes metaanalysis impractical. Systematic reviews of the literature of other small clinical studies have reported similar findings.12 Perhaps the suggestions offered by the authors regarding the design of future pediatric CIMT studies should be carefully considered. J. Charles, PT, PhD, MSW, is Assistant Professor, Division of Physical Therapy, Emory University School of Medicine, 1441 Clifton Rd NE, Atlanta, GA 30322. Address all correspondence to Dr Charles at: [email protected]. S.L. Wolf, PT, PhD, FAPTA, FAHA, is Professor, Departments of Rehabilitation Medicine and Medicine, and Associate Professor, Department of Cell Biology, Emory University School of Medicine; Professor, Health and Elder Care, Nell Hodgson Woodruff School of Nursing at Emory University; and Senior Research Scientist, Atlanta VA Rehab R&D Center. DOI: 10.2522/ptj.20080111.ic

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References 1 Huang H, Fetters L, Hale J, McBride A. Bound for success: a systematic review of constraint-induced movement therapy in children with cerebral palsy supports improved arm and hand use. Phys Ther. 2009;89:1126 –1141. 2 Gould AL, Koglin J, Bain RP, et al. Effects of sources of variability on sample sizes required for RCTs, applied to trials of lipidaltering therapies on carotid artery intimamedia thickness. Clin Trials. 2009; 6:305–319. 3 Taub E, Ramey SL, DeLuca SC, Echols K. Efficacy of constraint-induced movement therapy for children with cerebral palsy with asymmetric motor impairment Pediatrics. 2004;113:305–312. 4 Charles JR, Wolf SL, Schneider, JA Gordon AM. Efficacy of a child-friendly form of constraint-induced therapy in hemiplegic cerebral palsy: a randomized control trial Dev Med Child Neurol. 2006;48:635– 642. 5 International Classification of Functioning, Disability and Health: ICF. Geneva, Switzerland: World Health Organization; 2001. 6 Charles J. Typical and impaired development of the upper limb. In: Eliasson AC, Burtner P, eds. Development of the Upper Extremities. London, United Kingdom: Mac Keith Press; 2008. 7 Sutcliffe TL, Gaetz WC, Logan WJ, et al. Cortical reorganization after modified constraint-induced therapy in pediatric hemiplegic cerebral palsy. J Child Neurol. 2007;22:1281–1287. 8 Juenger H, Linder-Lucht M, Walther M, et al. Cortical neuromodulation by constraint-induced therapy in congenital hemiparesis: an fMRI study. Neuropediatrics. 2007;38:130 –136. 9 Liepert J, Bauder H, Wolfgang HR, et al. Treatment-induced cortical reorganization after stroke in humans. Stroke. 2000; 31:1210 –1216. 10 Eyre J. Development and plasticity of the corticospinal system in man. Neural Plast. 2003;10:93–106. 11 Friel KM, Martin JH. Bilateral activityindependent interactions in the developing corticospinal system. J Neurosci. 2007; 27:11083–11090. 12 Barton CJ, Levinger P, Menz HB, Webster KE. Kinematic gait characteristics associated with patellofemoral pain: a systematic review. Gait Posture. 2009 August 1 [Epub ahead of print].

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Author Response

Hsiang-han Huang, Linda Fetters, Jennifer Hale, Ashley McBride

We thank Charles and Wolf1 for their valuable comments on our article.2 We vigorously agree with their suggestions regarding the need for more-rigorous studies of constraintinduced movement therapy (CIMT) directly comparing different protocols for intervention characteristics and reporting effect sizes. They also suggest analyzing studies by age groupings because the effects of cerebral palsy and CIMT would be potentially different for younger versus older children. Although we understand that developmental differences influence the options for measurement tools and training programs, age may not adequately reflect movement capabilities or response to treatment. Gordon et al3 investigated the effects of CIMT on 2 different age groups (younger children: 4 – 8 years of age; older children: 9 –13 years of age). Both groups had improved movement, but the improvements were not agedependent. Gordon et al3 suggested that the severity of impairments may be a more important predictor of improvements from CIMT. Thus, grouping by age for the analysis of the effects of CIMT may not have been meaningful in this current review.

tious consideration. Martin and colleagues4,5 demonstrated that motor experience shapes the development of the corticospinal system during a critical period in the developing kitten. Restricting movements during this period lead to reduced topography and branching of corticospinal axon terminals and a prehension deficit. The authors suggested that the lack of movements of the unaffected extremity during this early developmental period might “permanently impair control of that limb.”4(p2129) Restraining the unaffected extremity during human development must be closely monitored for possible adverse effects on the developing brain. Charles and Wolf’s comments regarding caution in restricting the movements of the less affected extremity early in development reflect these concerns. In addition, recent evidence in adults with stroke indicates that the exercise program in CIMT may be the more important ingredient in a CIMT protocol and more relevant to cortical changes, in comparison to the constraint.6,7 We recognize that our review is inconclusive in identifying the key child characteristics and intervention protocols in the research to date; however, we believe that our

suggestions and those of Charles and Wolf should be carefully considered by clinicians and researchers for the use and study of CIMT. DOI: 10.2522/ptj.20080111.ar

References 1 Charles J. Wolf SL. Invited commentary on “Bound for success: a systematic review of constraint-induced movement therapy in children with cerebral palsy supports improved arm and hand use.” Phys Ther. 2009;89:1142–1143. 2 Huang H, Fetters L, Hale J, McBride A. Bound for success: a systematic review of constraint-induced movement therapy in children with cerebral palsy supports improved arm and hand use. Phys Ther. 2009;89:1126 –1141. 3 Gordon AM, Charles J, Wolf SL. Efficacy of constraint-induced movement therapy on involved upper-extremity use in children with hemiplegic cerebral palsy is not agedependent. Pediatrics. 2006;117:363–373. 4 Martin JH, Choy M, Pullman S, Meng Z. Corticospinal system development depends on motor experience. J Neurosci. 2004;24: 2122–2132. 5 Martin JH, Friel KM, Salimi I, Chakrabarty S. Activity- and use-dependent plasticity of the developing corticospinal system. Neurosci Biobehav Rev. 2007;31:1125–1135. 6 Sunderland A, Tuke A. Neuroplasticity, learning and recovery after stroke:a critical evaluation of constraint-induced therapy. Neuropsychol Rehabil. 2005;15:81–96. 7 Winstein CJ, Prettyman MG. Constraintinduced therapy for functional recovery after brain injury:unraveling the key ingredients and mechanisms. In: Baudry M, Bi X, Schreiber S, eds. Synaptic Plasticity. New York, NY: Marcel Dekker Inc; 2005:281– 328.

The impact of CIMT on the developing nervous system requires cau-

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Research Report An Intensive, Progressive Exercise Program Reduces Disability and Improves Functional Performance in Patients After Single-Level Lumbar Microdiskectomy Kornelia Kulig, George J. Beneck, David M. Selkowitz, John M. Popovich Jr, Ting Ting Ge, Sean P. Flanagan, Elizabeth M. Poppert, Kimiko A. Yamada, Christopher M. Powers, Stan Azen, Carolee J. Winstein, James Gordon, Srinath Samudrala, Thomas C. Chen, Arya Nick Shamie, Larry T. Khoo, Mark J. Spoonamore, Jeffrey C. Wang; Physical Therapy Clinical Research Network (PTClinResNet)

Background. Restoration of physical function following lumbar microdiskectomy may be influenced by the postoperative care provided. Objective. The purpose of this study was to examine the effectiveness of a new interventional protocol to improve functional performance in patients who have undergone a single-level lumbar microdiskectomy.

Setting. The study was conducted in physical therapy outpatient clinics. Design and Participants. Ninety-eight participants (53 male, 45 female) who had undergone a single-level lumbar microdiskectomy were randomly allocated to receive education only or exercise and education. Intervention and Measurements. The exercise intervention consisted of a 12-week periodized program of back extensor strength (force-generating capacity) and endurance training and mat and upright therapeutic exercises. The Oswestry Disability Index (ODI) and physical measures of functional performance were tested 4 to 6 weeks postsurgery and 12 weeks later, following completion of the intervention program. Because some participants sought physical therapy outside of the study, postintervention scores were analyzed for both an as-randomized (2-group) design and an as-treated (3-group) design.

Results. In the 2-group analyses, exercise and education resulted in a greater reduction in ODI scores and a greater improvement in distance walked. In the 3-group analyses, post hoc comparisons showed a significantly greater reduction in ODI scores following exercise and education compared with the education-only and usual physical therapy groups.

Limitations. The limitations of this study include a lack of adherence to group assignment, disproportionate therapist contact time among treatment groups, and multiple use of univariate analyses.

Conclusions. An intensive, progressive exercise program combined with education reduces disability and improves function in patients who have undergone a single-level lumbar microdiskectomy.

K. Kulig, PT, PhD, is Associate Professor of Clinical Physical Therapy, Division of Biokinesiology and Physical Therapy, University of Southern California, 1540 E Alcazar St, CHP-155, Los Angeles, CA 90089-9006 (USA). Address all correspondence to Dr Kulig at: [email protected]. G.J. Beneck, PT, MS, OCS, is a PhD candidate in the Division of Biokinesiology and Physical Therapy, University of Southern California, and Lecturer, Department of Physical Therapy, California State University–Long Beach, Long Beach, California. D.M. Selkowitz, PT, PhD, OCS, DAAPM, is Professor, Department of Physical Therapy Education, Western University of Health Sciences, Pomona, California. J.M. Popovich Jr, PT, DPT, ATC, CSCS, is a PhD candidate in the Division of Biokinesiology and Physical Therapy, University of Southern California. T.T. Ge, PhD, is Biostatistician, Johnson and Johnson, San Diego, California. S.P. Flanagan, PhD, ATC, CSCS, is Associate Professor, Department of Kinesiology, California State University, Northridge, Northridge, California. E.M. Poppert, PT, DPT, OCS, is Adjunct Assistant Professor of Clinical Physical Therapy, Division of Biokinesiology and Physical Therapy, University of Southern California. Author information continues on next page.

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

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Intensive, Progressive Exercise Program for Patients After Single-Level Lumbar Microdiskectomy K.A. Yamada, PT, DPT, OCS, ATC, CSCS, is Instructor of Clinical Physical Therapy, Division of Biokinesiology and Physical Therapy, University of Southern California. C.M. Powers, PT, PhD, is Associate Professor, Division of Biokinesiology and Physical Therapy, University of Southern California. S. Azen, PhD, is Professor and Co-Director of Biostatistics, Department of Preventive Medicine, Keck School of Medicine, University of Southern California. C.J. Winstein, PT, PhD, FAPTA, is Professor, Division of Biokinesiology and Physical Therapy, University of Southern California. J. Gordon, PT, EdD, FAPTA, is Associate Dean and Chair, Division of Biokinesiology and Physical Therapy, University of Southern California. S. Samudrala, MD, FACS, is Neurosurgeon, Cedars-Sinai Spine Center, Los Angeles, California. T.C. Chen, MD, PhD, is Associate Professor of Neurological Surgery, Department of Neurological Surgery, Keck School of Medicine, University of Southern California. A.N. Shamie, MD, is Assistant Professor of Orthopaedic Surgery, Department of Orthopaedic Surgery, Santa Monica–UCLA Medical Center and Orthopaedic Hospital, Santa Monica, California. L.T. Khoo, MD, is Assistant Professor, Department of Orthopaedic Surgery, Santa Monica–UCLA Medical Center and Orthopaedic Hospital. M.J. Spoonamore, MD, is Assistant Professor of Orthopaedic Surgery, Department of Orthopaedic Surgery, Keck School of Medicine, University of Southern California. J.C. Wang, MD, is Professor of Orthopaedic Surgery, Department of Orthopaedic Surgery, Santa Monica–UCLA Medical Center and Orthopaedic Hospital. Physical Therapy Clinical Research Network (PTClinResNet) (see list of investigators on page 1155). [Kulig K, Beneck GJ, Selkowitz DM, et al; Physical Therapy Clinical Research Network (PTClinResNet). An intensive, progressive exercise program reduces disability and improves functional performance in patients after single-level lumbar microdiskectomy. Phys Ther. 2009;89:1145–1157.] © 2009 American Physical Therapy Association

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ow back pain continues to be the most prevalent musculoskeletal problem, affecting 70% to 85% of individuals at some time in their lives.1 One source of low back pain is lumbar disk herniation with resultant sciatica. Cases of sciatica due to lumbar disk herniation that do not resolve with conservative interventions often undergo surgical resection of the herniated material. Early success rates of lumbar diskectomy based on pain, function, and patient satisfaction outcomes range from 65% to 91%.2–9 These figures show that in 9% to 35% of cases, the postsurgical results are unsatisfactory and patients continue to have symptoms and functional deficits. The success rates reported in these studies may be influenced by the postoperative care provided. In the case of patients with persisting symptoms and disability, additional interventions such as trunk muscle training exercises often are recommended. The postoperative impairment of trunk muscle performance may explain why the symptoms and functional deficits associated with disk herniation do not fully resolve following the surgical procedure. Due to months of pain and reduced activity prior to surgery, back muscle function may become impaired. In patients with disk herniation, nerve compression and inactivity often result in atrophy, weakness, and greater fatigability of the back extensors.10 –14 Trunk muscles that are weak and more fatigable allow increased stresses on the intervertebral disks, facets, and ligaments.15 Postoperative muscle atrophy also may result from muscle or nerve damage from the surgical procedure.13,16

weeks, with one program lasting 6 months.17 With the exception of one study that omitted abdominal muscle exercises,18 most studies included exercises to promote performance of the trunk musculature.19 –24 Most studies described their intervention on the trunk muscles as strengthening or stabilization exercise, whereas 2 studies described their trunk exercises as endurance exercises.19,23 All exercise programs generally were depicted as being graded and progressive. Some programs included aerobic training,18,19,24,25 lowerextremity strengthening,17,18,20,21,23 and trunk or hip flexibility exercises.19,21,24 An important goal of physical therapy interventions is to resolve functional deficits associated with low back pain. Previous studies assessed the effectiveness of exercise interventions in resolving functional deficits postdiskectomy primarily by means of self-reported questionnaires.17–20,22,24 A reduction in disability was reported in 4 studies.19 –22 Physical measures of performance may afford certain advantages over self-reports, but were rarely reported in these studies. A combination of self-report and physical performance measures seems ideal to represent function and disability. Only one study measured functional performance, and in only one specific task (ie, lifting).21 In addition,

Available With This Article at www.ptjournal.org • The Bottom Line clinical summary • The Bottom Line Podcast • Audio Abstracts Podcast

Previous studies that examined the effectiveness of exercise on patients postdiskectomy conducted training programs ranging from 4 to 12

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This article was published ahead of print on September 24, 2009, at www.ptjournal.org.

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Intensive, Progressive Exercise Program for Patients After Single-Level Lumbar Microdiskectomy with the exception of that study,21 outcomes have not been assessed earlier than 6 months following surgery. Therefore, the purpose of this study was to examine the early effects of a recently developed intensive postoperative exercise program26 on self-report and physical performance measures of function and disability in patients who had undergone a single-level lumbar microdiskectomy.

Method Overall Study Design This prospective study was divided into 3 phases: a protocol development phase, an implementation or intervention phase, and a follow-up phase. During the protocol development phase, a team of researchers and clinicians developed, tested, and standardized the postsurgical intervention and testing protocols. The protocol development phase, including a detailed presentation of the methods used in the entire project, has already been presented elsewhere.26 Participants A total of 176 individuals (100 male, 76 female) between the ages of 18 and 60 years were informed about this study through participating surgeons’ offices. These individuals were scheduled to undergo a singlelevel lumbar microdiskectomy for the first time. Microdiskectomy provides a magnified view of the disk and nerve root, which makes it possible for the surgeon to remove herniated material while minimizing damage to the surrounding tissues. Surgeons screened these patients for presurgical inclusion and exclusion criteria. As previously reported,26 the primary presurgical inclusion criteria were diagnosis of disk protrusion confirmed by magnetic resonance imaging testing, predominant symptoms in the lower extremity, radicuNovember 2009

lar pain distribution, restricted straight leg raise, and positive signs of adverse nerve root tension (ie, impaired mobility, pain, or dysesthesia). An additional inclusion criterion was that the surgery and the 4- to 6-week period after surgery were without an adverse event. There were no enrollment restrictions based on sex, race, or ethnic origin. Presurgical exclusion criteria included: previous back surgeries, presence of concurrent lower-extremity pathology (other than that associated with low back and lowerextremity pain associated with single-level disk injury), neurological disorders (eg, traumatic brain injury, cerebrovascular accident, seizures), uncontrolled cardiovascular disease, evidence of spinal cord compression, infection, severe respiratory disease, pregnancy, rheumatic joint disease, peripheral vascular disease with sensory loss at the foot, or any condition the participant identified that was considered to limit participation in physical activity. Research personnel further screened them for availability and interest in participating in the study. The Institutional Review Board of the University of Southern California (USC) granted approval for this randomized controlled trial and its informed consent process. A total of 98 people who satisfied the inclusion and exclusion criteria were enrolled in the study. The participants signed the informed consent form after receiving a detailed explanation of the study. Interventions The participants were randomly allocated using blocked randomization to 1 of 2 groups: a group that received one session of back care education (education-only group) or a group that received a back care education session followed by the 12week USC Spine Exercise Program Volume 89

(exercise and education group). There were 2 components to this exercise program: (1) back extensor strength (force-generating capacity) and endurance training and (2) mat and upright therapeutic exercises. The education session and the exercise program were implemented by intervention physical therapists at participating physical therapy clinics in the greater Los Angeles area. All intervention therapists received standardized training in implementation of the education session, the exercise protocol, and the method and progression of testing. These intervention therapists passed a videotaped mock testing and intervention session with a score of 90% or more on a checklist of competencies, graded by researchers who developed the interventions, before they administered the interventions to participants.26 Education. Education comprised a 1-hour, one-on-one session with the intervention therapist that occurred after the preintervention testing session, 4 to 6 weeks after surgery. This educational session was tailored specifically for individuals who had undergone a lumbar microdiskectomy, to help them understand their back problem and how to care for their back. It was guided by an educational booklet that was created especially for this study.27 Exercise–USC Spine Exercise Program. The exercise program was initiated 2 to 3 days following the education session and occurred 3 times a week for the remainder of the 12 weeks. The USC Spine Exercise Program is unique compared with other therapeutic interventions for patients with back pain in that it is goal oriented, performance based, and periodized, and it was rigorously applied in a standardized manner.26 It comprised back extensor strength and endurance training and mat and

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Intensive, Progressive Exercise Program for Patients After Single-Level Lumbar Microdiskectomy gains.31 The number of sets and frequency represented the largest effect size for increases in strength of a population of healthy individuals.28 Similarly, rest periods and work-to-rest ratios were extracted from a review of the literature for a population of healthy individuals.32 The systematic and individualized progression or regression of exercise intensity with this protocol complements that of the back extensor strength and endurance training protocol with the variable-angle Roman chair and mimics the clinical decision-making process used by physical therapists. Figure 1. Variable-angle Roman chair. Levels of difficulty of the Roman chair, from easiest (level 1) to most difficult (level 6).

therapeutic exercise training, which were performed concurrently. The back extensor strength and endurance training portion of the program was designed to load the back extensor muscles in a graded manner by varying the angle at which the trunk was held against gravity, using a variable-angle Roman chair* (Fig. 1). Exercise session intensity for each week of the program was determined for each individual at the second training session of each week by testing the amount of time he or she was able to maintain the trunk position against gravity (using the variable-angle Roman chair).26 During the first half of the program, participants trained at 2 levels below their maximum tested level. During the second half of the program, they trained at one level below their maximum tested level, which represented 60% to 80% of the maximum performance of the exercise. These intensities were shown to have the largest increases in strength in a population of health individuals.28 * Backstrong International LLC, 710 N Brea Blvd, Ste G, Brea, CA 92821.

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The goal of the program was for participants to be able to maintain a horizontal body position for 180 seconds. This position is equivalent to the Sorensen test position, and the target time reflects Sorensen test performance by adults who were healthy.29 After an initial 2-week learning phase, participants alternated between phases designed to improve their back extensor strength and their back extensor endurance, starting with a strengthening phase and ending with an endurance phase (Flanagan SP, Kulig K; unpublished research).26,30 A team of 20 physical therapists selected exercises for the mat and upright portion of the program and then ranked them according to the physical demand of each exercise. The purpose of the mat and upright therapeutic exercise portion of the program was to progressively and dynamically develop strength, endurance, and control of movement by the trunk and lower-extremity musculature.26 The number of repetitions was based on a widely accepted continuum for endurance

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Three categories of exercises targeting the abdominal, back, and lower-extremity musculature were selected. A progression of these exercises of increasing difficulty was established.26 The exercises were divided into 3 categories based on performance in supine, quadruped, and standing positions. Each category of exercise included multiple training levels designed to accommodate participants of varying levels of fitness and symptoms and to allow for progression of the workload over the 12-week training period.26 Participants performed exercises from all 3 categories during the entire intervention period. Levels of difficulty of exercises could vary among the exercise categories for an individual participant.26 For example, a person could be training the back extensors at a very high level and performing long-duration holds at level 6 of 6 on the variable-angle Roman chair, while only being able to exercise at level 2 of 7 in the abdominal progression. A testing procedure was developed to determine the appropriate initial training level for each category of exercise and to modify training levels during the training period to allow for progression, regression, or maintenance of exercise intensity November 2009

Intensive, Progressive Exercise Program for Patients After Single-Level Lumbar Microdiskectomy within each category. Test performance was based on each participant’s symptoms, use of correct technique, and rate of perceived exertion. The tests were repeated at 3-week intervals during the 12-week intervention.26 No exercises were performed as part of a home exercise program. Outcome Measures Testing on all outcome measures began 4 to 6 weeks after surgery. All outcome measurements were obtained by evaluators who were blinded to the participants’ group allocation. Each evaluator completed standardization training in the testing procedures and passed a videotaped mock testing session with a score of 90% on a checklist of competencies, graded by other research associates, before administering the outcome measures to participants. The Oswestry Disability Index (ODI) was used to assess the extent to which each participant engaged in activities of daily living. The most recent version of the ODI was used, in which the question regarding sexual activity was replaced with one regarding employment and homemaking.33 Each participant was required to complete the entire questionnaire for it to be considered valid and accepted. The standardized evaluators ensured that all sections were completed during each assessment. Outcome measures assessing observed performance in activities included the Repeated Sit-to-Stand Test, the 50-Foot Walk Test, and 5-Minute Walk Test. The Repeated Sit-to-Stand Test measured the time (in seconds) needed to complete 5 consecutive repetitions of a sit-tostand sequence as fast as tolerated. The same type of metal folding chair without armrests was used by each participant. The 50-Foot Walk Test measured the time (in seconds) needed to walk a distance of 50 ft November 2009

In addition, performance of the back extensor muscles was assessed using a modified Sorensen test (Flanagan SP, Kulig K; unpublished research). This test was derived from the test developed by Biering-Sorensen,29 who used it to assess the isometric strength and endurance of the lumbar back extensors in individuals without low back pain. The variableangle Roman chair, used in the exercise intervention, also was used to perform the modified Sorenson test.

Research Design A 2-group, pretest-posttest (repeatedmeasure) design was planned. Although participants originally were randomly allocated to the 2 groups (education only and exercise and education), not all of the participants adhered to their group allocation. Instead, after their allocation, some of the participants self-selected a course of physical therapy at a clinic of their choosing. This created a third group that we called the “usual physical therapy group.” We were unable to control what comprised physical therapy interventions at these nonparticipating clinics (see Appendix for components of these programs), but they were not using the 12-week USC Spine Exercise Program. Therefore, for the purpose of data analyses, we used both a 2group design (based on the original randomization process) and a 3group design (based on actual treatment received).

The variable-angle Roman chair, when used in conjunction with a weighted vest, allows the resistance to be progressed from much lighter to much heavier than the original Sorensen test. This apparatus allows the angle of a mobile frame to vary from 75 degrees to 0 degrees relative to the horizontal in 6 increments of increasing difficulty: 75, 60, 45, 30, 15, and 0 degrees (Fig. 1). Each angle was replaced with a level identifier (1, 2, 3, 4, 5, and 6, respectively), with level 6 being the position of the original Sorensen test.26 The dependent measure for the modified Sorenson test was “impulse,” defined as the product of the moment (produced by the mass of the trunk, arms, and head and its lever arm) and the time the body was held at a particular level. All of the tests used as outcome measures in this study have been previously described.26

Sample Size Power calculations were based on data from prior published studies. These data indicated that the interparticipant variability, with respect to impairment, activity, and participation outcome measures, was moderate to high, suggesting that sample sizes in the range of 40 to 69 participants per group would detect moderate effect sizes. The outcome measures in the current study assessed the immediate effects of the interventions in addition to surgery; thus, the calculations were made on the assumption that the changes due to exercise and education would be greater than those expected for education alone. Accounting for attrition, we determined that a sample size of 50 participants per group would have 80% power to detect a moderate effect size of 0.50 at an alpha level of .05 (one-sided).26

(15.24 m) as fast as tolerated. The 5-Minute Walk Test measured the distance (in feet) walked in 5 minutes at a self-selected pace. A stopwatch and a tape measure were used for timing and measuring the walking courses, respectively. These measures of functional performance have been shown to be reliable34,35 and to discriminate individuals with low back pain from individuals who were healthy.35

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Figure 2. CONSORT diagram of the MUSSEL randomized clinical trial: number of participants screened, randomized, and retained and analyses. LBP⫽low back pain.

Data Analysis Hard copies of coded data for all outcome measures and relevant independent measures were transferred by the blinded evaluators to data management and analysis personnel. These data were transferred from hard-copy recordings to a menudriven Web-based SQL data entry system (PTClinResNet) and then exported to SAS version 8.2† for statistical analyses. Due to a high and disproportionate dropout rate for the follow-up assessments, the analyses were conducted on preintervention and postintervention data only. Consequently, the † SAS Institute Inc, PO Box 8000, Cary, NC 27513.

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common method of imputation of missing data became unsuitable, so analyses instead were performed only on those participants (n⫽77) with follow-up (ie, evaluable) data. For each outcome measure (ODI score, 5-Minute Walk Test, 50-Foot Walk Test, Sit-to-Stand Test), an analysis of covariance (ANCOVA) was performed using the postintervention scores as the dependent variable with the preintervention scores as the covariate. Given the exploratory nature of the study, we elected not to control for type I error. This analysis was conducted on each of the variables for both the 2-group and 3-group designs. For the 3-group design, if the ANCOVA for any of the outcome measures was significant,

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post hoc testing was performed using the Tukey method to determine statistically significant pair-wise comparisons between the groups.36 The alpha level for all analyses was set at .05. Role of the Funding Source This study was funded by a grant from the Foundation for Physical Therapy.

Results Recruitment and Retention A total of 176 patients were screened for randomization (Fig. 2). Seventyeight of these were excluded for the following reasons: 52 declined to enroll and 26 failed to meet the inclusion criteria. Ninety-eight partici-

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Intensive, Progressive Exercise Program for Patients After Single-Level Lumbar Microdiskectomy pants were randomly allocated using blocked randomization to receive exercise and education (n⫽51) or education only (n⫽47). Of the 98 participants, 21 (6 in the exercise and education group and 15 in the education-only group) were inevaluable because they withdrew from the study before completing the 12week intervention period. In addition, 4 participants in the exercise and education group did not adhere to the group allocation; subsequently, 3 participants received education only and 1 participant sought outside care (usual physical therapy). Furthermore, in the educationonly group, 21 participants did not adhere to group allocation; subsequently 2 participants received exercise and education, and 19 participants received usual physical therapy. The participants who remained in the study provided the basis for the evaluable data in 3 groups: exercise and education (n⫽43), education only (n⫽14), and usual physical therapy (n⫽20) (Fig. 2). Of the 98 randomized participants, the majority were employed, had an income of ⬎$50,000, and attended at least some college. Overall, 53 (55%) of the participants were men, and the mean (⫾SD) age was 40⫾10 years across both sexes. Table 1 summarizes the demographic and clinical characteristics for the 98 randomized participants, stratified by intervention allocations. No statistically significant baseline differences were found among the 3 intervention groups (P⬎.05), nor were significant differences found across the 3 actual intervention groups (P⬎.05) at baseline. Postintervention Outcomes Analyses of evaluable data for the outcome measures for the 2-group allocation are summarized in Table 2. The ANCOVA results revealed a significant difference in the postintervention scores for the ODI November 2009

(P⫽.001) and the 5-Minute Walk Test (P⫽.024) between the 2 groups, with the improvements exhibited by the exercise and education group approximately twice the magnitude of those seen in the education-only group. The postintervention scores were not significantly different between groups for the 50-Foot Walk Test (P⫽.078) and the Repeated Sitto-Stand Test (P⫽.430). Analyses of data for the outcome measures for the actual intervention received are summarized in Table 3. The ANCOVA results revealed a significant difference in ODI scores among groups (P⫽.001). Post hoc comparisons showed most improvement in the exercise and education group (19.5%⫾13%) compared with both the education-only group (9.3%⫾11% improvement) (P⬍.016) and the usual physical therapy group (7.9%⫾11% improvement) (P⬍.003). No significant difference in postintervention scores was found between the education-only and usual physical therapy groups (P⫽.985). Postintervention scores were significantly different among groups for the 5-Minute Walk Test (P⫽.028) and the 50-Foot Walk Test (P⫽.010). The 5-Minute Walk Test post hoc comparisons revealed the exercise and education group showed significant improvement (293.0⫾277 ft improvement) compared with the usual physical therapy group (96.6⫾152 ft improvement) (P⫽.038) but not the education-only group (171.4⫾316 ft improvement) (P⫽.188). The 50-Foot Walk Test post hoc comparisons showed most improvement in the exercise and education group (⫺1.8⫾1.9 seconds) compared with both the educationonly group (⫺1.2⫾1.7 seconds) (P⫽.033) and the usual physical therapy group (⫺0.5⫾1.0 seconds) (P⫽.046). Between-group postintervention scores were not significantly different for the Repeated Sit-toStand Test (P⫽.053). Volume 89

Performance of the Back Extensors The exercise and education group was trained and assessed using the same apparatus; therefore, musculoskeletal performance of the back extensors was not included as an outcome measure. However, as a matter of interest, preintervention and postintervention extensor impulse during the modified Sorensen test procedure on a Roman chair was analyzed. In the 2-group analysis (Tab. 4), the ANCOVA results revealed a significant difference in postintervention scores between the 2 groups (P⬍.001). In the analysis of the 3 actual intervention groups (Tab. 5), the ANCOVA results also revealed a significant difference among groups (P⬍.001). Post hoc comparisons showed greater improvement in the exercise and education group (5,709⫾4,577 N䡠m䡠s improvement) compared with both the education-only group (860⫾3,054 N䡠m䡠s improvement) (P⬍.001) and the usual physical therapy group (1,650⫾3,002 N䡠m䡠s improvement) (P⫽.003). No significant difference in postintervention scores was found between the education-only and usual physical therapy groups (P⫽.693). Adverse Events Adverse events were monitored and reported according to the protocol approved by the PTClinResNet Safety Monitoring Board.26 There were 3 adverse events that were considered not related to the study (1 in the exercise and education group and 2 in the education-only group). Adverse events consisted of a second microdiskectomy for unrelenting sciatica, elevated blood pressure, and a severe bout of low back pain and leg numbness.

Discussion The purpose of this study was to examine the effectiveness of an interventional protocol26 to improve Number 11

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Intensive, Progressive Exercise Program for Patients After Single-Level Lumbar Microdiskectomy Table 1. Baseline Demographics, Primary Outcomes, and Participation Measures by Randomization Groups (N⫽98)a Variable

Exercise and Education Group (nⴝ51)

Education-Only Group (nⴝ47)

P

39.2 (10.2)

41.4 (9.9)

.90

29 (58%)

24 (50%)

.43

6 (12%)

9 (19%)

.35

Demographics Age (y) Sex Male Latino or Hispanic Race Black or African American

1 (2%)

1 (2%)

White

36 (71%)

33 (70%)

Unspecified or other

14 (27%)

13 (28%)

4 (9%)

9 (19%)

.14

6.7 (9.8)

5.9 (7.0)

.66

Time since first onset of low back pain (mo)

82.1 (93.3)

120.7 (125.3)

.12

Time since first onset of sciatica (mo)

33.1 (67.6)

38.7 (69.8)

.71

13 (32%)

16 (34%)

3–5

3 (7%)

5 (11%)

5–10

5 (12%)

3 (6%)

⬎10

13 (32%)

18 (38%)

7 (17%)

5 (11%)

L4/L5

19 (37%)

24 (51%)

L5/S1

31 (61%)

23 (49%)

L2/L3

1 (2%)

0 (0%)

29 (63%)

19 (45%)

.09

29.4 (15.4)

34.2 (16.2)

.15

1.00

Involved in a litigation process with workers’ compensation Medical history Duration of pain episode prior to surgery (mo)

No. of previous episodes ⬍3

.75

Unspecified Involved spinal level

.35

Positive passive straight leg raise Oswestry Disability Index (%) Physical function 5-Minute Walk Test (ft)

1,423.7 (310.6)

50-Foot Walk Test (s) Repeated Sit-to-Stand Test (s)

1,418.2 (277.1)

.93

9.9 (2.8)

9.9 (2.4)

.92

17.9 (7.7)

18.9 (7.0)

.53

5,825.3 (3,432.4)

4,604.9 (3,269.5)

.13

Modified Sorensen test Normalized (N䡠m䡠s) a

Values are mean (⫾SD) for continuous variables, frequency (%) for categorical variables. Chi-square tests were used for categorical variables, and one-way analyses of variance were used for continuous variables. Missing data for the following variables (exercise and education group, education-only group): involved in a litigation process with workers’ compensation (4, 0), duration of pain episode prior to surgery (10, 0), time since first onset of low back pain (10, 9), time since first onset of sciatica (12, 2), number of previous episodes (10, 0), positive passive straight leg raise (5, 5), physical function (0, 1), modified Sorensen test (2, 3).

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Intensive, Progressive Exercise Program for Patients After Single-Level Lumbar Microdiskectomy Table 2. Mean Change Score (Postintervention-Preintervention) and 95% Confidence Interval for Each Outcome Measure Based on 2-Group Analyses of Evaluable Dataa Outcome Measure

Exercise and Education Group (nⴝ45)

Education-Only Group (nⴝ32)

Pb

Oswestry Disability Index score (%)

⫺18.4 (⫺22.5 to ⫺14.3)

⫺9.4 (⫺13.0 to ⫺5.8)

⬍.001

5-Minute Walk Test (ft)

281.2 (199.1 to 363.3)

133.6 (53.5 to 213.7)

.024

50-Foot Walk Test (s)

⫺1.7 (⫺2.2 to ⫺1.2)

⫺0.9 (⫺1.5 to ⫺0.3)

.078

Repeated Sit-to-Stand Test (s)

⫺4.8 (⫺6.7 to ⫺2.9)

⫺4.3 (⫺6.7 to ⫺1.9)

.430

a

Missing data for the following variables (exercise and education group, education-only group): 5-Minute Walk Test (1, 5), 50-Foot Walk Test (1, 5), and Repeated Sit-to-Stand Test (2, 5). b The P value is a between-group comparison of the postintervention scores using an analysis of covariance (covariate⫽baseline/pretest).

Table 3. Mean Change Score (Postintervention-Preintervention) and 95% Confidence Interval for Each Outcome Measure Based on Actual Intervention Receiveda Outcome Measure

Exercise and Education Group (nⴝ43) c,d

Oswestry Disability Index score (%)

–19.5 (–23.4 to –15.6)

5-Minute Walk Test (ft)

293.0 (210.1 to 375.9)d

Education-Only Group (nⴝ14)

Usual Physical Therapy Group (nⴝ20)

⫺9.3 (⫺15.1 to ⫺3.5)

⫺7.9 (⫺12.9 to ⫺2.9)

.001

96.6 (29.9 to 163.3)

.028

171.4 (5.8 to 337.0)

Pb

50-Foot Walk Test (s)

–1.8 (–2.4 to –1.2)c,d

–1.2 (–2.1 to –0.3)

–0.5 (–0.9 to –0.1)

.010

Repeated Sit-to-Stand Test (s)

–5.7 (–8.0 to –3.4)

–3.2 (–5.6 to –0.8)

–3.1 (–5.1 to –1.1)

.053

a Missing data for the following variables (exercise and education group, education-only group, usual physical therapy group): 5-Minute Walk Test (2, 1, 3), 50-Foot Walk Test (2, 1, 3), and Repeated Sit-to-Stand Test (3, 1, 3). b The P value is a between-group comparison of the postintervention scores using an analysis of covariance (covariate⫽baseline/pretest). c Significant difference between postintervention scores using analysis of covariance for the exercise and education group and the education-only group from the post hoc analysis. d Significant difference between postintervention scores using analysis of covariance for the exercise and education group and the usual physical therapy group from the post hoc analysis.

functional outcomes in patients who have undergone a single-level lumbar microdiskectomy. In the 2-group analyses, the exercise and education group showed a significantly greater reduction in ODI scores immediately following the intervention (4.5 months postsurgery). The ODI scores were reduced in both groups, but only reached the level of clinical significance in the exercise and education group.37 A Cochrane review of 200238 concluded that there is strong evidence that intensive exercise is effective in restoring functional status in patients who have undergone lumbar diskectomy. In the studies cited, exercise groups experienced a greater reduction in disability following rehabilitation for single-level lumbar diskectomy.19,20,22 However, there were November 2009

several differences among these studies and the current study. The duration of the exercise intervention in these studies ranged from 4 to 8 weeks, whereas the duration of the intervention in the current study was 12 weeks. In addition, assessment time points differed among studies. Of these studies,19,20,22 only Danielsen et al20 reported a greater reduction in disability at the first postintervention assessment (6 months postsurgery). A significant reduction was not achieved in the other studies at earlier assessment times following the intervention, but only at follow-up times of 8 months22 and 12 months19 postsurgery. In the study by Danielsen et al, subjects who received an 8-week program of vigorous medical exercise therapy had a significantly greater reduction in disability than the control group. HowVolume 89

ever, in contrast to the current study, Danielsen et al examined the change in disability by subtracting the postintervention disability scores from the preoperative scores. Prior to surgery, subjects in the exercise group had significantly higher disability scores than the control group. Thus, similar within-group changes in disability scores following surgery but prior to the exercise intervention must be assumed in order to conclude that the exercise intervention was responsible for the greater reduction in disability in the exercise group. Since the Cochrane review,38 one study has shown a reduction in disability following a postsurgical exercise program in patients who had undergone a single-level lumbar microdiskectomy.21 In that study, the Number 11

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Intensive, Progressive Exercise Program for Patients After Single-Level Lumbar Microdiskectomy Table 4. Mean Change Score (Postintervention-Preintervention) and 95% Confidence Interval for Back Extensor Impulse Based on 2-Group Analyses of Evaluable Dataa

a b

Outcome Measure

Exercise and Education Group (nⴝ43)

Education-Only Group (nⴝ26)

Pb

Modified Sorensen test (N䡠m䡠s)

5,328.4 (3,948.6 to 6,708.2)

1,261.1 (1,148.6 to 2,407.4)

⬍.001

Missing data (exercise and education group, education-only group) for the modified Sorensen test (2, 8). The P value is a between-group comparison of the postintervention scores using an analysis of covariance (covariate⫽baseline/pretest).

Table 5. Mean Change Score (Postintervention-Preintervention) and 95% Confidence Interval for Back Extensor Impulse Based on Intervention Receiveda Outcome Measure

Exercise and Education Group (nⴝ43)

Education-Only Group (nⴝ26)

Usual Physical Therapy Group (nⴝ17)

Pb

Modified Sorensen test (N䡠m䡠s)

5,709.6 (4,341.5 to 7,077.7)c,d

860.4 (⫺739.5 to 2,460.3)

1,650.0 (334.2 to 2,965.8)

⬍.001

a

Missing data (exercise and education group, education-only group, usual physical therapy group) for the modified Sorensen test (4, 1, 3). The P value is a between-group comparison of the postintervention scores using an analysis of covariance (covariate⫽baseline/pretest). Significant difference between postintervention scores using analysis of covariance for the exercise and education group and the education-only group from the post hoc analysis. d Significant difference between postintervention scores using analysis of covariance for the exercise and education group and the usual physical therapy group from the post hoc analysis. b c

reduction in ODI scores in the group that received lumbar stabilization exercises was 27%, whereas the reduction in the current study was 18%. This difference may have been due to the difference in baseline ODI scores between the 2 studies. In the study by Yilmaz et al,21 the initial ODI score was 44%, whereas that of the current study was 31%. The higher baseline level of disability reported by Yilmaz et al may have allotted more potential improvement from their intervention than in the exercise and education group in the current study. The only functional performance measured in that study was lifting. The subjects in the exercise group improved their lifting performance significantly more than those in the control groups. The exercise intervention in the current study consisted of an intensive, graded strength and endurance training program targeting the trunk and lower-extremity musculature, with the spine maintained in a neutral position. None of the participants in the exercise and education group withdrew due to symptom exacer1154

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bation from the intervention. This finding is in agreement with those of other studies,18,22 indicating that early, intensive training of trunk muscles, initiated 4 to 6 weeks after lumbar diskectomy, can be a safe form of postoperative rehabilitation. Walking performance was not reported as an outcome measure in previous investigations studying the effects of exercise following lumbar diskectomy. In the 2-group analyses of the current study, the exercise and education group had a significantly greater improvement in 5-minute walk distance compared with the education-only group. The postintervention walking performance of the exercise and education group was similar to values of subjects who were healthy for both measures.35 This change in walking performance may have been the result of the intensive lower-extremity training performed in the current study. Lower-extremity training was a component of previous exercise protocols following microdiskectomy;17–20 however, measures of lower-extremity performance were

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not reported. A suspected benefit of lower-extremity training was a greater reduction in time to perform the 50-Foot Walk Test and the Repeated Sit-to-Stand Test. However, the time reduction of both tests in the exercise and education group was not significantly greater than that of the education-only group, which suggests a less-discriminating role for these tests. A unique comparison in our study was the analysis of the actual interventions received. Participants who opted out of their allocated intervention group to pursue physical therapy outside of the study agreed to remain in the study, allowing for inclusion of a third group in the analyses. The participants who received usual physical therapy care attended local physical therapy clinics where their intervention was determined by their physical therapists, rather than the USC Spine Exercise Program. The results of the analysis of the actual intervention received (3group analysis) showed a greater improvement in performance of the exercise and education group. The November 2009

Intensive, Progressive Exercise Program for Patients After Single-Level Lumbar Microdiskectomy improvement in ODI scores, 5-minute walk distance, and 50-foot walk time was significantly greater in those participants who received exercise and education compared with either the education-only group or the usual physical therapy group. These results suggest greater effectiveness of the current exercise program in reducing disability and improving walking performance than that expected from usual physical therapy. The volume and intensity of the interventions in the usual physical therapy group were lower than those of the USC Spine Exercise Program, perhaps reflecting caution when managing postsurgical cases. Inherent in the usual physical therapy group is a lack of standardized care procedures, resulting in high variability in both the durations and types of interventions received. The lack of standardization of care in the usual physical therapy group may have influenced the results. One limitation of this study was the large number of participants who chose not to adhere to the original allocation into the education-only group. This finding suggests that more participants preferred exercise as part of their intervention rather than education only. A selection bias of the participants can confound the interpretation of the results. For instance, more highly motivated participants in the education-only group may have withdrawn from the study, which may have led to poorer outcomes in that group. The intentionto-treat analysis is a strategy used to deal with participants who withdraw from a study. One common form of intention-to-treat analysis is the imputation of missing data by carrying the last observation forward. If applied to the current study, the preintervention score would be used again as the postintervention score. Because of the greater dropout rate in the education-only group, this analysis would clearly bias the November 2009

results in favor of the exercise and education group. Analysis of the evaluable data in the 2-group analysis resulted in more-conservative results, in that no data were carried forward from baseline and some participants received exercise in physical therapy clinics outside the study. A second limitation is that the exercise and education group received substantially more time with a physical therapist compared with the other groups. More time with the therapist may have influenced the measured outcomes. However, it should be noted that such time inequalities may not necessarily influence disability outcome measures. Three previous studies of intervention effects on disability from low back problems with disparate intervention durations showed no differences in the reduction in disability between these groups, although patient satisfaction was higher in the group that received more therapist attention.39 – 41 A third limitation involves the statistical analyses. Univariate analyses were performed on each of the outcome variables. As the multiple use of a univariate analysis raises the risk of a type I error, the results should be viewed with this fact in mind.

Conclusion The outcome of microdiskectomy for a lumbar disk herniation depends on the postoperative regimen offered. An intensive 12-week strength and endurance training program of the trunk and lower-extremity musculature is safe and results in a greater reduction in disability and a greater increase in walking performance immediately following the intervention. Because only the immediate effects of the exercise program were reported, long-term effects cannot be assumed.

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The authors’ contributions to this work were as follows. Concept/idea/research design: K.K., S.P.F., E.M.P., C.M.P., S.A., C.J.W., J.G., J.C.W. Writing: K.K., G.J.B., D.M.S., J.M.P. Jr, S.P.F., E.M.P., C.M.P., S.A. Data collection: K.K., G.J.B., D.M.S., J.M.P. Jr, E.M.P., K.A.Y., S.S., T.C.C., J.C.W. Data analysis: K.K., G.J.B., J.M.P. Jr, T.T. Ge, S.P.F., E.M.P., S.A., S.S., T.C.C. Project management: K.K., K.A.Y., C.J.W., J.G. Fund procurement: K.K., C.J.W., J.G. Providing participants: K.K., E.M.P., S.S., T.C.C., A.N.S., L.T.K., M.J.S., J.C.W. Providing facilities/equipment: K.K., G.J.B., E.M.P. Providing institutional liaisons: K.K., C.J.W., J.G., L.T.K. Clerical support: K.K., K.A.Y. Consultation (including review of manuscript before submission): K.K., J.M.P. Jr, S.P.F., E.M.P., C.M.P., C.J.W., J.G., L.T.K., M.J.S., J.C.W. Physical Therapy Clinical Research Network (PTClinResNet): Network Principal Investigator is Carolee J. Winstein, PT, PhD, FAPTA, and Co-Principal Investigator is James Gordon, PT, EdD, FAPTA (both at University of Southern California). Project Principal and Co-Principal Investigators are: David A. Brown, PT, PhD (Northwestern University); Sara Mulroy, PT, PhD, and Bryan Kemp, PhD (Rancho Los Amigos National Rehabilitation Center); Loretta M. Knutson, PT, PhD, PCS (University of Indianapolis); Eileen G. Fowler, PT, PhD (University of California at Los Angeles); and Sharon K. DeMuth, PT, DPT, Kornelia Kulig, PT, PhD, and Katherine J. Sullivan, PT, PhD (University Southern California). The Data Management Center is located at the University of Southern California and is directed by Stanley P. Azen, PhD. The 4-member Data Safety and Monitoring Committee are: Nancy Byl, PT, PhD, FAPTA, Chair (University of California at San Francisco), Hugh G. Watts, MD (Shriners’ Hospital for Children–LA Unit, Los Angeles, California), June Isaacson Kailes, MSW (Western University, Los Angeles, California), and Anny Xiang, PhD (University of Southern California). This study was approved by the Institutional Review Board of the University of Southern California. This study was funded by a grant from the Foundation for Physical Therapy. This article was received February 18, 2008, and was accepted July 21, 2009. DOI: 10.2522/ptj.20080052

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Intensive, Progressive Exercise Program for Patients After Single-Level Lumbar Microdiskectomy References 1 Andersson GB. Epidemiological features of chronic low-back pain. Lancet. 1999;354: 581–585. 2 Asch HL, Lewis PJ, Moreland DB, et al. Prospective multiple outcomes study of outpatient lumbar microdiscectomy: should 75% to 80% success rates be the norm? J Neurosurg. 2002;96:34 – 44. 3 Davis GW, Onik G. Clinical experience with automated percutaneous lumbar discectomy. Clin Orthop Relat Res. 1989; (238):98 –103. 4 Findlay GF, Hall BI, Musa BS, et al. A 10year follow-up of the outcome of lumbar microdiscectomy. Spine. 1998;23: 1168 –1171. 5 Goldstein TB, Mink JH, Dawson EG. Early experience with automated percutaneous lumbar discectomy in the treatment of lumbar disc herniation. Clin Orthop Relat Res. 1989;(238):77– 82. 6 Maroon JC, Onik G, Sternau L. Percutaneous automated discectomy: a new approach to lumbar surgery. Clin Orthop Relat Res. 1989;(238):64 –70. 7 Loupasis GA, Stamos K, Katonis PG, et al. Seven- to 20-year outcome of lumbar discectomy. Spine. 1999;24:2313–2317. 8 Weinstein JN, Tosteson TD, Lurie JD, et al. Surgical vs nonoperative treatment for lumbar disk herniation—the Spine Patient Outcomes Research Trial (SPORT): a randomized trial. JAMA. 2006;296: 2441–2450. 9 Osterman H, Seitsalo S, Karppinen J, Malmivaara A. Effectiveness of microdiscectomy for lumbar disc herniation: a randomized controlled trial with 2 years of follow-up. Spine. 2006;31:2409 –2414. 10 Barker KL, Shamley DR, Jackson D. Changes in the cross-sectional area of multifidus and psoas in patients with unilateral back pain: the relationship to pain and disability. Spine. 2004;29:E515–E519. 11 Mayer TG, Mooney V, Gatchel RJ, et al. Quantifying postoperative deficits of physical function following spinal surgery. Clin Orthop Relat Res. 1989;(244):147–157. 12 Dedering A, Harms-Ringdahl K, Nemeth G. Back extensor muscle fatigue in patients with lumbar disc herniation: pre-operative and post-operative analysis of electromyography, endurance time and subjective factors. Eur Spine J. 2006;15:559 –569. 13 Rantanen J, Hurme M, Falck B, et al. The lumbar multifidus muscle five years after surgery for a lumbar intervertebral disc herniation. Spine. 1993;18:568 –574. 14 Yoshihara K, Nakayama Y, Fujii N, et al. Atrophy of the multifidus muscle in patients with lumbar disk herniation: histochemical and electromyographic study. Orthopedics. 2003;26:493– 495.

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15 Dolan P, Adams MA. Repetitive lifting tasks fatigue the back muscles and increase the bending moment acting on the lumbar spine. J Biomech. 1998;31: 713–721. 16 Sihvonen T, Herno A, Paljarvi L, et al. Local denervation atrophy of paraspinal muscles in postoperative failed back syndrome. Spine. 1993;18:575–581. 17 Donaldson BL, Shipton EA, Inglis G, et al. Comparison of usual surgical advice versus a nonaggravating six-month gym-based exercise rehabilitation program postlumbar discectomy: results at one-year follow-up. Spine J. 2006;6:357–363. 18 Choi G, Raiturker PP, Kim MJ, et al. The effect of early isolated lumbar extension exercise program for patients with herniated disc undergoing lumbar discectomy. Neurosurgery. 2005;57:764 –772; discussion 764 –772. 19 Dolan P, Greenfield K, Nelson RJ, Nelson IW. Can exercise therapy improve the outcome of microdiscectomy? Spine. 2000; 25:1523–1532. 20 Danielsen JM, Johnsen R, Kibsgaard SK, Hellevik E. Early aggressive exercise for postoperative rehabilitation after discectomy. Spine. 2000;25:1015–1020. 21 Yilmaz F, Yilmaz A, Merdol F, et al. Efficacy of dynamic lumbar stabilization exercise in lumbar microdiscectomy. J Rehabil Med. 2003;35:163–167. 22 Manniche C, Skall HF, Braendholt L, et al. Clinical trial of postoperative dynamic back exercises after first lumbar discectomy. Spine. 1993;18:92–97. 23 Johannsen F, Remvig L, Kryger P, et al. Supervised endurance exercise training compared to home training after first lumbar diskectomy: a clinical trial. Clin Exp Rheumatol. 1994;12:609 – 614. 24 Kjellby-Wendt G, Styf J, Carlsson SG. Early active rehabilitation after surgery for lumbar disc herniation: a prospective, randomized study of psychometric assessment in 50 patients. Acta Orthop Scand. 2001;72:518 –524. 25 Brennan GP, Shultz BB, Hood RS, et al. The effects of aerobic exercise after lumbar microdiscectomy. Spine. 1994;19:735–739. 26 Selkowitz DM, Kulig K, Poppert EM, et al. The immediate and long-term effects of exercise and patient education on physical, functional, and quality-of-life outcome measures after single-level lumbar microdiscectomy: a randomized controlled trial protocol. BMC Musculoskelet Disord. 2006;7:70. 27 Physical Therapy Clinical Research network (PTClinResNet). Available at: http:// pt.usc.edu/clinresnet/. 28 Rhea MR, Alvar BA, Burkett LN, Ball SD. A meta-analysis to determine the dose response for strength development. Med Sci Sports Exerc. 2003;35:456 – 464.

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29 Biering-Sorensen F. Physical measurements as risk indicators for low-back trouble over a one-year period. Spine. 1984;9: 106 –119. 30 Flanagan SP, Kulig K. Assessing musculoskeletal performance of the back extensors following a single-level microdiscectomy. J Orthop Sports Phys Ther. 2007;37: 356 –363. 31 Kraemer WJ, Adams K, Cafarelli E, et al. American College of Sports Medicine position stand. Progression models in resistance training for healthy adults. Med Sci Sports Exerc. 2002;34:364 –380. 32 Willardson JM. A brief review: factors affecting the length of the rest interval between resistance exercise sets. J Strength Cond Res. 2006;20:978 –984. 33 Fritz JM, Irrgang JJ. A comparison of a modified Oswestry Low Back Pain Disability Questionnaire and the Quebec Back Pain Disability Scale. Phys Ther. 2001;81: 776 –788. 34 Harding VR, Williams AC, Richardson PH, et al. The development of a battery of measures for assessing physical functioning of chronic pain patients. Pain. 1994;58: 367–375. 35 Simmonds MJ, Olson SL, Jones S, et al. Psychometric characteristics and clinical usefulness of physical performance tests in patients with low back pain. Spine. 1998; 23:2412–2421. 36 Portney LG, Watkins MP. Foundations of Clinical Research: Applications to Practice. Englewood Cliffs, NJ: Prentice-Hall; 2000. 37 Ostelo RW, de Vet HC. Clinically important outcomes in low back pain. Best Pract Res Clin Rheumatol. 2005;19:593– 607. 38 Ostelo RW, de Vet HC, Waddell G, et al. Rehabilitation after lumbar disc surgery. Cochrane Database Syst Rev. 2002;4: CD003007. 39 Niemisto L, Rissanen P, Sarna S, et al. Costeffectiveness of combined manipulation, stabilizing exercises, and physician consultation compared to physician consultation alone for chronic low back pain: a prospective randomized trial with 2-year follow-up. Spine. 2005;30:1109 –1115. 40 Frost H, Lamb SE, Doll HA, et al. Randomised controlled trial of physiotherapy compared with advice for low back pain. BMJ. 2004;329:708. 41 Pengel LH, Refshauge KM, Maher CG, et al. Physiotherapist-directed exercise, advice, or both for subacute low back pain: a randomized trial. Ann Intern Med. 2007;146:787–796.

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Intensive, Progressive Exercise Program for Patients After Single-Level Lumbar Microdiskectomy Appendix. Characteristics of Usual Physical Therapy Care Received by the Participants Who Elected to Pursue Care Outside of the MUSSEL Project Characteristics of Clinical Physical Therapy Visits No. of visits attended Frequency of visits (per week or per month) Time in session (min)

Mode 12 3/wk 45

Range

Percentage

1–24 3/wk to 1/mo 30–120

Main reason for discontinuing care (% of total participants)

25 22 15 38

met physical therapy goals self-discharge insurance “ran out” other (plateau, no reason given)

Type of intervention Education

100

Modalities (ice, heat, electrotherapy)

100

Stabilization exercises

100

Stretching

80

Manual therapy

40

Exercise with back equipment

30

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Research Report

Physical Therapists’ Management of Patients in the Acute Care Setting: An Observational Study Diane U. Jette, Rebecca Brown, Nicole Collette, Wendy Friant, Lloyd Graves D.U. Jette, PT, DSc, is Professor and Chair, Department of Rehabilitation and Movement Science, University of Vermont, Rowell 305, 106 Carrigan Ave, Burlington, VT 05405 (USA). Address all correspondence to Dr Jette at: [email protected]. R. Brown, PT, DPT, was a student in the DPT program at the University of Vermont when this study was conducted. N. Collette, PT, DPT, is Staff Physical Therapist, Mount Auburn Hospital, Cambridge, Massachusetts. Dr Collette was a student in the DPT program at the University of Vermont when this study was conducted. W. Friant, PT, DPT, is Staff Physical Therapist, Cornerstone Physical Therapy, Williston, Vermont. Dr Friant was a student in the DPT program at the University of Vermont when this study was conducted. L. Graves, PT, DPT, is Staff Physical Therapist, Cayuga Medical Center, Ithaca, New York. Dr Graves was a student in the DPT program at the University of Vermont when this study was conducted. [Jette DU, Brown R, Collette N, et al. Physical therapists’ management of patients in the acute care setting: an observational study. Phys Ther. 2009;89:1158 –1181.]

Background. Previous literature has not fully described physical therapists’ management of patients across diagnoses in the acute care setting or how that management might vary by facility. Objective. The purposes of this study were to describe patient management by physical therapists in the acute care setting and to examine variations in patient management across facilities.

Design. This was an observational study. Methods. Fifty clinicians practicing at 3 academic medical centers in the northeastern United States agreed to participate. Over a 2-week period, clinicians completed checklists indicating the details of patient visits. Logistic analyses, controlling for patient age and diagnosis and accounting for clustering of data, were conducted to examine the odds of patients having several categories of examinations, goals, and interventions.

Results. Participants provided 2,364 visits to 896 patients. More than 75% of patients in each facility received examinations, goals, and interventions related to functional ability. Median number of visits per patient, duration of visits, and number of visits in which the patient was not treated varied across facilities. Patients with orthopedic conditions were more likely than those with medical/surgical conditions to receive several types of examinations, goals, and interventions. The odds of patients having examinations, goals, and interventions related to functional abilities were greater in facility 2 than in facility 1.

Limitations. Limitations include the convenience sample, use of an untested data collection tool, and use of only age and diagnosis to control for case mix. Conclusion. This study of physical therapist practice in 3 acute care facilities suggests that patient management focuses on functional activity. There was no clear pattern of examinations, goals, and interventions related to specific diagnoses. A small degree of variation was found in practice across the facilities.

© 2009 American Physical Therapy Association

Post a Rapid Response or find The Bottom Line: www.ptjournal.org 1158

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Physical Therapists’ Management of Patients in the Acute Care Setting

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n light of a renewed emphasis on health care reform in the United States, variations in clinical practice provide a focus for possible costcutting strategies. Efforts to reduce costs and variability have centered on evidence-based practices and use of clinical practice guidelines by physicians. Eddy stated that “uncertainty, biases, errors, and differences of opinions, motives, and values”1(p75) affect the decisions made by physicians in the management of patients. Clinical decisions also are affected by the state and strength of scientific evidence related to clinical practice, as well as the education and clinical expertise of the clinician and the practice setting.2 Recently, Sirovich et al3 reported that physicians in regions of the United States with higher health care spending levels differed from those in lower-cost areas largely on decisions that were considered discretionary, such as frequency of visits, ordering of tests, and referral to specialists, rather than on decisions informed by evidence. O’Neill and Kuder4 have suggested a model under which practitioners make decisions when faced with uncertainties. The model suggests a “baseline heuristic” that reflects the practitioner’s education, experience, and professional style. This heuristic is adapted to the practice environment and then further modified to reflect the specific situations

Available With This Article at www.ptjournal.org • The Bottom Line clinical summary • The Bottom Line Podcast • Audio Abstracts Podcast This article was published ahead of print on September 3, 2009, at www.ptjournal.org.

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of individual patients in decision making. Any of these sets of factors could result in different decisions about how to manage patients with similar conditions; these differences result in variations in practice across practitioners and practice settings. Findings reported in the physical therapy literature suggest that decisions about the physical therapists’ management of patients may be subject to the same sets of factors noted above.5,6 In one study, the choice of interventions in some situations was related to variables such as therapist caseload or patient reimbursement.4 The authors speculated that some of the variability in care may have been the result of professional uncertainty about diagnosis, as well as lack of evidence. A more recent study of physical therapists’ decisions regarding examination of balance noted that the choice of instrument was related to documentation requirements in some cases and discharge planning in other cases.5 The study also noted that physical therapists’ decisions appeared to rely on clinical experience with limited influence of research evidence. Applying the conclusions of the aforementioned studies to physical therapy in the acute care setting, it might be speculated that decisions about patient management could be related to physical therapists’ education and experience, the environment and resources of the facility, and the general characteristics of the patients treated at the facility. These factors could be related to differences in decisions about whether patients have impairments or limitations that require the skilled care of a physical therapist. Such determinations could vary depending on the tests and measures selected and the interpretation of the results. Variations in management also might result from decisions about which types of interventions would best adVolume 89

dress impairments and limitations identified by the tests. That is, for any particular condition, there is likely to be more than one intervention or combination of interventions that could benefit patients or to which patients will agree. Additionally, decisions about interventions may depend on many unique patient characteristics, including patients’ desired outcomes. Although little information exists as to the precise nature of physical therapists’ management of patients in the acute care setting, there is some evidence that there are variations related to the factors outlined above. Curtis and Martin7 reported results of a survey of physical therapists practicing in the acute care setting. They noted that participants’ responses were related to the size of the institution in which they practiced and their experience levels. Lopopolo8 described the changing role of physical therapists in one acute care setting following hospital restructuring. The therapists interviewed for this study believed that changes in the organization had led to increased focus on their productivity and increased use of support staff. In a study that included physical therapists from 60 acute care facilities in Australia, gait training and exercise were the only interventions cited by more than 50% of respondents for patients following total knee replacement.9 Factors cited as influencing therapists’ decisions included assumptions about the outcomes derived from various interventions, patient preferences, surgeon preferences, and established institutional practice. In a study of 60 patients undergoing abdominal surgery at 2 hospitals in Australia, variations in patient management between the hospitals included the number of physical therapist visits per patient and the amount of time spent by patients in physical therapy treatment.10 Number 11

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Physical Therapists’ Management of Patients in the Acute Care Setting Because variations in care may have implications for quality of care, cost of care, and disparities in care, there has been interest in reducing them.11 The first step in reducing variations is a description of practices and their variability across settings. The primary purposes of this study, therefore, were to describe the practice of physical therapy in 3 acute care settings and to examine differences in practice across the participating facilities.

Method Participants The rehabilitation services departments of 3 large academic medical centers providing tertiary care in the northeastern United States agreed to participate. Within those centers, 50 practitioners provided data: 45 physical therapists, 4 physical therapist assistants, and 1 individual who did not provide demographic data. The characteristics of the medical centers and physical therapy staffing are included in Table 1. The sample was one of convenience based on the principal investigator’s (D.U.J.) acquaintance with managers of the rehabilitation services departments at the facilities and the willingness of the managers to have their staff participate. With the approval of the managers, the principal investigator met with the staff to seek their voluntary participation and informed consent. Of the participants, 16% were male and 84% were female. The median number of years in practice was 5 (range⫽1–33), and the median number of years practicing in acute care was 5 (range⫽ 1–33). Procedure A data collection form (Appendix 1) was developed by the primary investigator using available literature on physical therapist practice in acute care and the Guide to Physical Therapist Practice.12 Drafts of the form 1160

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were shared with clinicians practicing in the settings in order to solicit feedback about completeness, clarity, and functionality. Feedback was incorporated into revisions of the form. Three rounds of feedback and revisions resulted in the final content and format of the data collection tool. Prior to the data collection period, training sessions were conducted by the principal investigator at each facility to enhance standardized data collection. These sessions were approximately 1 to 2 hours in length and allowed for a description of the study and data collection methods, definitions of terms used in the data collection instrument, and a question and answer period. Participants were provided with a set of precoded data collection forms and definitions for the examinations and interventions listed on the data collection form, which were consistent with the definitions provided in the Guide to Physical Therapist Practice (Appendix 2). Additionally, an online group listserv was made available to all participating therapists to allow for questions and answers during the data collection period. Participants were asked to complete a data collection form for each planned visit with all patients whose episodes of care were initiated during a 2-week period. Each facility was able to choose a 2-week period that was deemed manageable and that was not considered unusual (eg, contained a holiday). The data collection, therefore, occurred between the months of March and July 2008. A visit was defined as any planned encounter with the patient or any activity done on behalf of the patient, even if no face-to-face encounter took place. Therefore, a visit could comprise a planned visit in which the patient declined care, or only reading or documentation in

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the medical record was done. Therapists provided forms for varying numbers of patients (n⫽2–39). The data collection form comprised a checklist that was precoded for facility, patient, and primary therapist. In this way, the therapist and patient remained anonymous. Therapists were asked to keep a list of their patients with their study code numbers in order to facilitate accuracy; however, this list was not provided to the investigators. On each form, therapists were asked to indicate some demographic data about the patient; every examination, intervention, documentation, and communication activity performed on behalf of the patient for each visit; all goals they had for the patient for the visit; personnel present at each visit; and discharge destination, if they knew the visit was the last visit and the destination was known. There also were check boxes to indicate reasons for a planned visit being deferred. We, therefore, were able to distinguish visits in which patients had examinations and interventions and those in which there was neither. Therapists were instructed to indicate the total duration of a visit, including face-to-face encounters with the patient, record reading, verbal communication with team members, documentation, and so forth. Therapists were reminded that the data collection was not at all related to billing. Visits on weekends were recorded by having the primary therapist provide data collection forms for each of his or her patients to the therapists covering the weekend. If any patient for whom data were being collected remained in acute care 1 or 2 days longer than the designated 2-week period, therapists continued to complete data collection for each visit until discharge. If the hospital admission was prolonged beyond another 1 or 2 days, November 2009

Physical Therapists’ Management of Patients in the Acute Care Setting Table 1. Facility and Practitioner Characteristicsa Facility Variable

1

2

3

All

Size (licensed beds)

430

675

777

Average patient length of stay (d)

5.2

4.1

4.5

Weekday

14

19

13

Weekend

4

10

5

3 (17.6%)

4 (25%)

1 (6.3%)

8 (16.3%)

14 (82.4%)

12 (75%)

15 (93.7%)

41 (83.7%)

14 (84.4%)

15 (93.7%)

16 (100%)

45 (91.8%)

3 (17.6%)

1 (6.3%)

0

4 (8.2%)

3 (17.6%)

1 (6.3%)

0

4 (8.2%)

Baccalaureate

9 (52.9%)

1 (6.3%)

2 (12.5%)

12 (24.5%)

Master’s

4 (23.5%)

9 (56.2%)

11 (68.8%)

24 (48.9%)

DPT

1 (6.0%)

5 (31.2%)

3 (18.7%)

9 (18.4%)

Facility characteristicsb

Average daily FTEs (PT and PTA)

Practitioner characteristicsc Sex Male Female License PT PTA Entry-level degree Associate’s

Highest degree Associate’s

2 (11.8%)

1 (6.3%)

0

3 (6.1%)

Baccalaureate (not PT)

1 (5.8%)

0

0

1 (2.0%)

Entry-level PT

11 (68.7%)

34 (71.4%)

Advanced master’s

10 (58.8%) 2 (11.8%)

13 (81.1%) 0

1 (6.3%)

3 (6.1%)

Transitional DPT

2 (11.8%)

2 (12.6%)

3 (18.7%)

7 (14.4%)

Advanced doctorate

0

0

1 (6.3%)

1 (2.0%)

Specialty certification No

16 (94.1%)

14 (87.5%)

14 (87.5%)

44 (89.8%)

Yes

1 (5.9%)

2 (12.5%)

2 (12.5%)

5 (10.2%)

Years practicing Median

2

3.5

5

5–26

0.5–17

1–33

1–33

Median

9

2

2.75

5

Range

3–26

0.5–10

1–33

1–33

Range

10

Years practicing in acute care

Therapists’ hours worked per week Mean SD a b c

34.7

39.0

39.2

37.8

7.1

4.0

1.0

5.2

FTE⫽full-time equivalent, PT⫽physical therapist, PTA⫽physical therapist assistant, DPT⫽Doctor of Physical Therapy. Data reported by facility. Demographic and practice data are missing for 1 participating practitioner.

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Physical Therapists’ Management of Patients in the Acute Care Setting data collection ended for a patient at the end of the 2-week period. The therapists, however, did not begin data collection for any visits with new patients after the end of the 2-week period. The manager of the rehabilitation services department at each facility was asked to provide data about the facility’s number of beds and average length of stay, as reported by the institution. The manager also provided data about average staffing levels for weekdays and weekends. Data Analysis Summary statistics were used to describe the characteristics of the physical therapists, the characteristics of the patients they managed, and the characteristics of the visits they conducted. Depending on the distribution of data, we used chisquare analyses, analyses of variance, or Kruskal-Wallis analyses to compare facilities on various patient and visit characteristics. In order to compare facilities in terms of the examinations, goals, and interventions provided for patients, we used the generalized estimating equations module in SPSS for Windows, version 16.0.* This program allowed us to perform logistic regression analyses that controlled for therapist, accounting for the clustering of patients within therapists and therapists within facilities.13 Generalized estimating equations are a form of multilevel statistical modeling that addresses lack of independence of observations. Lack of independence, or clustering, refers in this study to the fact that patients whose care is managed by one therapist or therapists who practice in one facility may be similar on unknown or unmeasured characteristics. For example, patients may be seen by one physical therapist be* SPSS Inc, 233 S Wacker Dr, Chicago, IL 60606.

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cause of his or her expertise, and that therapist’s care may differ from that provided by less-expert therapists to other patients; therapists in one facility may provide similar care because many have been educated in the same 2 or 3 local universities. To control to some degree for case mix, we used patient age and diagnosis as factors in the models. In order to derive useful statistical models and reduce the number of statistical tests, data for patient age and diagnosis were collapsed into smaller numbers of categories. Data for discharge destination were categorized as home versus not home. Data regarding all examinations, goals, and interventions were dichotomized as present or absent across all visits for each patient. Categories then were created to represent body systems and functions in the following manner. Musculoskeletal. Examinations included those to determine strength (force-generating capacity), flexibility or range of motion, posture, joint integrity or mobility, anthropometrics, and pain. Goals included increasing strength and flexibility or range of motion, improving posture, and reducing pain. Interventions included flexibility or range of motion and strengthening exercises, manual therapy, thermal modalities, electrotherapy, and hydrotherapy. Neuromuscular. Examinations included those to determine arousal, balance, coordination, motor function, cranial and peripheral nerve integrity, neuromotor development, and reflex integrity. Goals included improving arousal, coordination, balance, motor control, and sensory awareness and reducing stress. Interventions included balance and relaxation exercises, motor control strategies, and neurodevelopmental and sensory or perceptual training.

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Cardiovascular/pulmonary. Examinations included those to determine aerobic capacity, circulation, respiration or ventilation, breathing pattern or effort, and swelling or edema. Goals included increasing aerobic capacity, improving airway clearance, and reducing edema, energy expenditure, and work of breathing. Interventions included endurance training, manual airway clearance, breathing exercises, and edema management strategies. Integumentary. Examinations included those to determine wound status and skin integrity. Goals included improved skin integrity and wound healing. Interventions included wound care. Functional. Examinations included those to determine use of assistive devices, bed mobility and positioning, gait or ambulation, environmental barriers, ergonomics, transfer ability, knowledge of self-care, orthotic or prosthetic fit, and wheelchair locomotion. Goals included improving bed mobility, gait or ambulation, self-care knowledge, safety in mobility, transfers, and function in activities of daily living and reducing the chance for falling. Interventions included training in the use of assistive devices, bed mobility, activities of daily living, gait or ambulation, fall prevention, wheelchair use, and prescription of assistive devices, prostheses, and orthoses. In addition, educational intervention included patient and family education and staff education. The goal of discharge to the appropriate level of care was kept as its original separate category. We thereby created 17 dichotomous variables: 5 representing examinations, 6 representing goals, and 6 representing interventions. Each of these 17 variables became dependent variables in separate logistic reNovember 2009

Physical Therapists’ Management of Patients in the Acute Care Setting Table 2. Patient Characteristics Facility Variable

1

2

3

All

231

273

392

896

1–20

12 (5.2%)

4 (1.5%)

6 (1.5%)

22 (2.5%)

21–40

16 (7.0%)

30 (11.1%)

25 (6.4%)

71 (8.0%)

41–60

54 (23.5%)

88 (32.6%)

110 (28.3%)

252 (28.3%)

61–80

86 (37.4%)

114 (42.2%)

162 (41.6%)

362 (40.7%)

81⫹

62 (27.0%)

34 (12.6%)

86 (22.1%)

182 (20.5%)

Medical/surgical

80 (37.7%)

87 (32.9%)

129 (37.0%)

296 (35.9%)

Cardiovascular

34 (16.0%)

49 (18.6%)

78 (22.3%)

161 (19.5%)

Orthopedic

39 (18.4%)

59 (22.3%)

87 (24.9%)

185 (22.4%)

Pulmonary

21 (9.9%)

2 (0.8%)

13 (3.7%)

36 (4.4%)

Neurological

35 (16.5%)

63 (23.9%)

39 (11.2%)

137 (16.6%)

3 (1.4%)

4 (1.5%)

3 (0.9%)

10 (1.2%)

3.0 (1–17)

2.0 (1–10)

2.0 (1–14)

2.0 (1–17)

34 (19.4%)

52 (27.8%)

96 (38.9%)

182 (29.9%)

8 (4.6%)

16 (8.6%)

Home with home health rehabilitation

44 (25.1%)

64 (34.2%)

69 (27.9%)

177 (29.1%)

Inpatient rehabilitation

15 (8.6%)

18 (9.6%)

21 (8.5%)

54 (8.9%)

Subacute or long-term care

46 (26.3%)

33 (17.6%)

35 (14.1%)

114 (18.7%)

Remains hospitalized

27 (15.5%)

3 (1.6%)

17 (6.9%)

47 (7.7%)

1 (0.6%)

1 (0.5%)

9 (3.6%)

11 (1.8%)

1.8 (1.3–2.7)

2.1 (1.3–3.4)

No. of patients Age (y)a

Diagnosis typea

Other No. of visitsb Median (range) Discharge destinationa Home without rehabilitation Home with outpatient rehabilitation

Deceased

0 (0%)

24 (3.9%)

Odds of being discharged home Odds ratio (95% confidence interval)

Reference

a

Chi-square test, P⬍.001; n varies due to incomplete data. b Kruskal-Wallis test, P⬍.001.

gression analyses. We determined the odds of patients having a particular type of examination, goal, or intervention within facility 2 or 3 as compared with facility 1, the arbitrary reference. The same analyses also allowed us to determine the odds of patients having particular types of examinations, goals, and interventions, given their diagnostic category. The general medical/surgical diagnostic category was used as the referent category. We used the same type of analysis to determine

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the odds of patients being discharged to home.

Results Patients Over a 2-week period, visits for 896 patients were recorded. The majority of patients were over 60 years of age. More than 60% of the patients fell into 2 diagnostic categories: orthopedic and general medical/surgical. Age (␹2⫽32.5, df⫽8, P⬍.001) and diagnosis (␹2⫽44.1, df⫽8, P⬍.001) varied across facilities. The

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median number of visits varied across facilities (P⬍.001), with facility 1 having 42% of patients with a median number of visits less than or equal to the overall median of 2, as compared with patients in facilities 2 and 3, where 66% and 60%, respectively, had a median of visits less than or equal to 2 (Tab. 2). Visits Over a 2-week period within each facility, 2,364 visits were recorded. Table 3 includes information about

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Physical Therapists’ Management of Patients in the Acute Care Setting Table 3. Visit Characteristicsa Facility Variable Total visitsb

1

2

3

All

833

599

932

2,364

No examination or intervention providedc Patient unavailable

92 (11.0%)

16 (2.7%)

18 (1.9%)

126 (5.3%)

Patient status or need for clarification

85 (10.2%)

49 (8.2%)

107 (11.5%)

241 (10.2%)

Patient declined

44 (5.3%)

29 (4.7%)

23 (2.5%)

95 (4.0%)

80 (9.6%)

52 (8.7%)

87 (9.3%)

219 (9.3%)

416 (50.0%)

437 (72.9%)

363 (38.9%)

1,216 (51.4%)

1 (0.1%)

1 (0.2%)

1 (0.1%)

3 (0.1%)

115 (13.8%)

14 (2.3%)

13 (1.4%)

142 (6.0%)

14 (1.7%)

3 (0.5%)

23 (2.5%)

40 (1.7%)

Visit in ICU

d

Personnel presente PT only PT with PTA PT with physical therapy aide PT with OT or SLP PT with SPT

0

37 (6.2%)

214 (23.0%)

251 (10.6%)

PT with nurse

8 (1.0%)

24 (4.0%)

18 (1.9%)

50 (2.1%)

PTA only

121 (14.5%)

17 (2.8%)

0

138 (5.8%)

PTA with aide

47 (5.6%)

1 (0.2%)

0

48 (2.0%)

PTA with nurse

3 (0.4%)

Other

8 (0.9%)

13 (2.4%)

14 (1.5%)

509 (61.1%)

417 (69.6%)

647 (69.4%)

1,573 (66.5%)

112 (13.4%)

160 (26.7%)

110 (11.8%)

382 (16.2%)

3 (0.4%)

58 (9.7%)

142 (15.2%)

203 (8.6%)

15 (1.8%)

4 (0.7%)

5 (0.5%)

24 (1.0%)

33.1 (16.5)

37.4 (13.9)

48.9 (29.5)

40.7 (23.4)

8.1 (4.4)

8.8 (4.8)

9.1 (7.2)

8.5 (5.5)

0

0

3 (0.1%) 35 (1.0%)

Communicationf Other team memberse Patients’ family or associates

e

Third-party payere Other agency or facility

g

Duration of visit (min) Examination or intervention provided, mean (SD)h No examination or intervention provided, mean (SD)d

a ICU⫽intensive care unit, PT⫽physical therapist, PTA⫽physical therapist assistant, OT⫽occupational therapist, SLP⫽speech-language pathologist, SPT⫽student physical therapist. b Percentages are of total N and may not add to 100% due to missing data. c Chi-square, P⬍.001, for frequency of sessions with vs without examination or intervention across facilities. d Analysis of variance, P⬎.05, for differences across facilities. e Chi-square, P⬍.001, for differences across facilities. f More than one type of communication could be indicated. g Chi-square, P⫽.017, for differences across facilities. h Analysis of variance, P⬍.001, for differences across facilities.

the visits. The mean duration of all visits in which some form of examination or intervention was recorded was 40.7 minutes (SD⫽23.4). The visit duration was different across all facilities (F⫽103.7, P⬍.001). Approximately 10% of visits were intended for patients for whom services were not indicated, usually because of medical status or determi1164

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nation that the care required was unskilled or because physicians’ referrals needed clarification. Nearly 10% of the visits were made to patients who were unavailable or declined treatment. The percentage of visits that resulted in no examination or intervention varied across facilities: 26.5%, 15.6%, and 15.9%, respectively (␹2⫽40.5, df⫽2, P⬍.001).

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Physical therapists spent an average of 8.5 minutes (SD⫽5.5) on planned visits where no examinations or interventions were conducted. The duration of these sessions was similar across facilities. The majority of the visits were conducted by physical therapists with or without other providers. Services were provided by physical therapist assistants alone or November 2009

Physical Therapists’ Management of Patients in the Acute Care Setting Table 4. Number (Percentage) of Patients With Examinations, Goals, or Interventions by Diagnostic Categorya Diagnostic Category Variable

Medical/Surgical

Neurological

Pulmonary

Orthopedic

Cardiovascular

Musculoskeletal

261 (88.2%)

124 (90.5%)

34 (94.4%)

179 (96.8%)

147 (91.8%)

Neuromuscular

256 (86.5%)

125 (91.2%)

34 (94.4%)

174 (94.0%)

146 (90.6%)

Cardiovascular/pulmonary

253 (85.5%)

106 (77.4%)

34 (94.4%)

167 (90.3%)

149 (92.5%)

84 (28.4%)

25 (18.2%)

10 (27.8%)

79 (42.7%)

66 (41.0%)

261 (88.2%)

124 (90.5%)

33 (91.7%)

180 (97.3%)

150 (93.2%)

Examinations

Integumentary Functional ability Goals Musculoskeletal

181 (61.1%)

81 (59.1%)

23 (63.9%)

153 (82.7%)

97 (60.2%)

Neuromuscular

214 (72.3%)

107 (78.1%)

26 (72.2%)

161 (87.0%)

118 (73.3%)

Cardiovascular/pulmonary

192 (64.9%)

76 (55.5%)

32 (88.9%)

129 (69.7%)

112 (69.6%)

33 (11.1%)

5 (3.6%)

4 (11.1%)

35 (18.9%)

29 (18.0%)

Functional ability

247 (83.4%)

118 (86.1%)

30 (83.3%)

180 (97.3%)

142 (88.2%)

Discharge

240 (81.1%)

98 (71.5%)

24 (66.7%)

146 (78.9%)

125 (77.6%)

133 (44.9%)

47 (34.3%)

18 (50.0%)

132 (71.3%)

75 (46.6%)

Integumentary

Interventions Musculoskeletal Neuromuscular

172 (58.1%)

88 (64.2%)

23 (63.9%)

147 (79.5%)

111 (68.9%)

Cardiovascular/pulmonary

165 (55.7%)

71 (51.8%)

29 (80.5%)

127 (68.6%)

123 (76.4%)

Integumentary

a

2 (0.7%)

0 (0.0%)

0 (0.0%)

0 (0.0%)

1 (0.6%)

Functional ability

245 (82.8%)

117 (85.4%)

30 (83.3%)

177 (95.7%)

141 (87.6%)

Education

236 (79.7%)

106 (77.4%)

28 (77.8%)

170 (91.9%)

145 (90.1%)

Patients could have more than one type of examination, goal, or intervention.

with providers other than physical therapists in less than 10% of visits. Personnel at visits varied across facilities (␹2⫽708.7, df⫽16, P⬍.001). Facility 3 did not employ physical therapist assistants at all. Examinations All of the examination methods listed on the data collection form were completed for at least one patient in each facility. More than 75% of patients in all diagnostic categories received examinations of functional activities and musculoskeletal, neuromuscular, and cardiovascular/ pulmonary systems (Tab. 4). Controlling for patients’ age and facility, patients with orthopedic conditions had greater odds of having musculoskeletal (odds ratio [OR]⫽4.8, 95% confidence interval [CI]⫽1.6 – November 2009

14.4), neuromuscular (OR⫽3.1, 95% CI⫽1.1– 8.3), integumentary (OR⫽ 2.1, 95% CI⫽1.2–3.6), and functional ability (OR⫽5.8, 95% CI⫽1.7–19.4) examinations than patients with general medical/surgical diagnoses (Tab. 5, Fig. 1). Across all facilities, 75% or more of patients received examinations of functional activities and musculoskeletal, neuromuscular, and cardiovascular/pulmonary systems (Tab. 6). Controlling for patients’ age and diagnostic category, the odds of patients receiving examinations of functional activities were greater in facility 2 (OR⫽2.7, 95% CI⫽1.1– 6.6) than in facility 1. There were no other differences across facilities (Tab. 7, Fig. 2).

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Goals All of the goals listed on the data collection sheet were identified for at least one patient at each facility. Goals related to improving functional ability were identified for more than 80% of patients in each diagnostic category (Tab. 4). Controlling for patients’ age and facility, the odds of patients having goals for functional abilities (OR⫽8.8, 95% CI⫽2.8 –27.4) and musculoskeletal (OR⫽3.6, 95% CI⫽1.6 – 8.2) and neuromuscular (OR⫽3.1, 95% CI⫽1.4 –7.1) systems were greater for patients with orthopedic conditions than for patients with medical/ surgical conditions. Patients with pulmonary conditions had greater odds of having goals related to cardiovascular/pulmonary system impairments (OR⫽4.4, 95% CI⫽1.3– Number 11

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Physical Therapists’ Management of Patients in the Acute Care Setting Table 5. Odds of Patients Having Examinations, Goals, or Interventions by Diagnosisa Diagnostic Category Neurological Variable

Medical/Surgical

Odds Ratio

Reference

1.5

Pulmonary

95% Cl

Odds Ratio

0.6–3.5

3.2

Orthopedic

95% Cl

Odds Ratio

0.8–12.1

4.8

Cardiovascular

95% Cl

Odds Ratio

95% Cl

1.6–14.4

1.4

0.4–4.1

Examinations Musculoskeletal Neuromuscular

Reference

2.0

0.8–5.1

3.3

0.9–12.9

3.1

1.1–8.3

1.4

0.5–4.0

Cardiovascular/pulmonary

Reference

0.7

0.3–1.6

3.7

0.8–16.8

1.8

0.7–4.7

2.1

0.7–5.8

Integumentary

Reference

0.7

0.3–1.2

0.8

0.3–2.0

2.1

1.2–3.6

1.7

0.9–3.2

Functional ability

Reference

1.6

0.7–3.7

2.1

0.5–8.3

5.8

1.7–19.4

1.7

0.6–5.3

Reference

0.9

0.5–1.6

1.0

0.4–2.3

3.6

1.6–8.2

1.0

0.5–1.7

Goals Musculoskeletal Neuromuscular

Reference

1.5

0.8–3.0

1.1

0.4–2.9

3.1

1.4–7.1

1.0

0.5–2.0

Cardiovascular/pulmonary

Reference

0.6

0.3–1.4

4.4

1.3–15.1

1.4

0.7–2.8

1.2

0.6–2.6

Integumentary

Reference

0.3

0.1–0.7

1.1

0.2–5.2

2.0

0.9–4.4

1.8

0.7–4.8

Functional ability

Reference

1.4

0.6–3.3

1.3

0.5–3.2

8.8

2.8–27.4

1.4

0.5–4.1

Discharge

Reference

0.8

0.4–1.5

0.5

0.2–1.1

0.4–2.5

0.8

0.4–1.7

Musculoskeletal

Reference

0.5

0.3–1.0

1.2

0.6–2.4

3.8

1.9–7.5

1.1

0.7–1.8

Neuromuscular

Reference

1.5

0.9–2.5

1.4

0.6–3.4

3.4

1.9–5.8

1.5

0.8–2.9

Cardiovascular/pulmonary

Reference

0.9

0.4–1.9

3.9

1.2–12.3

2.0

1.0–3.9

2.5

1.3–5.0

Functional ability

Reference

0.7

0.3–1.5

0.7

0.2–2.0

0.2

0.1–0.5

0.7

0.3–1.8

Education

Reference

1.0

0.5–2.0

1.2

0.5–3.3

3.1

1.1–8.5

2.3

1.0–5.2

10

Interventions

Integumentaryb a b

Controlled for patient age and facility. CI⫽confidence interval. Proportions too small for computation.

15.1) than those with medical/ surgical conditions, and patients with neurological conditions had lower odds of having goals related to the integumentary system (OR⫽0.3, 95% CI⫽0.1– 0.7) than patients with medical/surgical conditions (Tab. 5, Fig. 1). Goals related to improving functional ability and discharge to appropriate level of care were identified for 70% or more of patients at each facility (Tab. 6). Controlling for patients’ age and diagnostic category, the odds of patients having goals related to functional ability were greater in facility 2 (OR⫽2.7, 95% CI⫽1.3–5.6) than in facility 1, and the odds of patients having goals re1166

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lated to the musculoskeletal system were less in facility 3 (OR⫽0.5, 95% CI⫽0.3– 0.8) than in facility 1 (Tab. 7, Fig. 2). Interventions Several interventions listed on the data collection form were not provided to patients in at least one facility. These interventions included electrotherapy, hydrotherapy, manual therapy, wound care, and thermal modalities. Across all diagnostic categories, more than 80% of patients received training in functional abilities and more than 75% of patients received educational interventions (Tab. 4). Controlling for facility and patients’ age, patients with orthopedic conditions

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had greater odds of receiving musculoskeletal (OR⫽3.8, 95% CI⫽1.9 – 7.5), neuromuscular (OR⫽3.4, 95% CI⫽1.9 –5.8), and educational interventions (OR⫽3.1, 95% CI⫽1.1– 8.5) than patients with medical/surgical conditions. Patients with pulmonary conditions and cardiovascular conditions had greater odds of having cardiovascular/pulmonary interventions (OR⫽3.9, 95% CI⫽1.2– 12.3 and OR⫽2.5, 95% CI⫽1.3–5.0, respectively) than patients with general medical/surgical conditions (Tab. 5, Fig. 1). Interventions related to functional training were provided to more than 75% of patients at each facility (Tab. 6). Controlling for patients’ age November 2009

Physical Therapists’ Management of Patients in the Acute Care Setting and diagnostic category, the odds of patients having interventions directed at functional ability and education were greater in facility 2 (OR⫽3.0, 95% CI⫽1.4 – 6.4 and OR⫽2.9, 95% CI⫽1.6 –5.5, respectively) than in facility 1 (Tab. 7, Fig. 2). Discharge Overall, slightly more than 60% of patients were discharged to their homes. Controlling for patient age and diagnostic category, facilities 2 and 3 had greater odds of patients being discharged to home compared with facility 1 (OR⫽1.8, 95% CI⫽1.3–2.7 and OR⫽2.1, 95% CI⫽1.3–3.4, respectively) (Tab. 2).

Discussion To our knowledge, this study is the first to describe physical therapists’ management of patients in the acute care setting across patient diagnoses and facilities. Overall, examinations, goals, and interventions related to functional ability were used across the greatest percentage of patients. Examinations, goals, and interventions related to system impairments were used for fewer patients. These findings are consistent with those of other studies showing functional activities to be a priority of physical therapy in both acute care and acute rehabilitation settings. Previous findings suggest that understanding patients’ abilities in functional activities is important in making decisions about discharge from the acute care setting.14 In one study, 88% of physical therapists indicated that functional activities such as transfer training and gait training were either frequently or always a focus of acute care.7 In a study of patients immediately following total knee replacement, 95% had gait training.9 Jette et al15 found that 78% of physical therapy sessions for patients in acute rehabilitation settings following stroke included gait training, “prefunctional activities,” or transfer training. SimiNovember 2009

Figure 1. Percentages of patients with examinations, goals, and interventions by diagnostic category.

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Physical Therapists’ Management of Patients in the Acute Care Setting Table 6. Number (Percentage) of Patients With Examinations, Goals, Interventionsa Facility Variable

1

2

3

All

Musculoskeletal

190 (82.2%)

250 (91.6%)

333 (84.9%)

773 (86.3%)

Neuromuscular

190 (82.2%)

245 (89.7%)

327 (83.4%)

762 (85.0%)

Cardiovascular/pulmonary

181 (78.3%)

226 (82.8%)

329 (83.9%)

736 (82.1%)

84 (36.4%)

61 (22.3%)

128 (32.6%)

273 (30.5%)

188 (81.4%)

250 (91.6%)

335 (85.5%)

773 (86.3%)

Musculoskeletal

157 (68.0%)

193 (70.7%)

205 (52.3%)

555 (61.9%)

Neuromuscular

164 (71.0%)

218 (79.8%)

270 (68.9%)

652 (72.8%)

Cardiovascular/pulmonary

154 (66.7%)

193 (70.7%)

216 (55.1%)

563 (62.8%)

31 (13.4%)

46 (16.8%)

29 (7.4%)

106 (11.8%)

Functional ability

180 (77.9%)

247 (90.5%)

320 (81.6%)

747 (83.4%)

Discharge

166 (71.9%)

193 (70.7%)

295 (75.2%)

654 (73.0%)

126 (54.5%)

166 (60.8%)

127 (32.4%)

419 (46.8%)

Examinations

Integumentary Functional ability Goals

Integumentary

Interventions Musculoskeletal Neuromuscular

138 (59.7%)

189 (69.2%)

232 (59.2%)

559 (62.4%)

Cardiovascular/pulmonary

134 (58.0%)

181 (66.3%)

220 (56.1%)

535 (59.7%)

Integumentary

a

0 (0.0%)

2 (0.7%)

1 (0.2%)

3 (0.3%)

Functional ability

176 (76.2%)

245 (89.7%)

316 (80.6%)

737 (82.2%)

Education

159 (68.8%)

230 (84.2%)

325 (82.9%)

714 (79.7%)

Patients could have more than one type of examination, goal, or intervention.

larly, therapists interviewed by Lopopolo8 indicated that restructuring in their setting had increased focus on functional activities. Education also was a frequently provided intervention. This finding is consistent with those of Curtis and Martin,7 who found that nearly 70% of physical therapists in their sample indicated that patient and family education was done frequently or always. Although it might be expected that patients with various types of conditions would be more or less likely to have certain types of examinations, goals, and interventions, we found no clear pattern indicating this. For example, patients with cardiovascular/pulmonary conditions were no more likely than patients with medical/surgical conditions to have ex1168

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aminations related to the cardiovascular/pulmonary systems. Patients with those conditions, however, were more likely to receive cardiovascular/pulmonary interventions. Similarly, one study focusing on patients with abdominal surgery reported that nearly 100% of patients received interventions related to the pulmonary system.10 We found that patients with orthopedic conditions were more likely than patients with medical/surgical conditions to have had several types of examinations, goals, and interventions. It is possible that patients with orthopedic conditions have a wider range of impairments than those with medical/ surgical conditions, leading to the need for a variety of examinations, goals, and interventions. The design

Number 11

of this study did not allow such determinations. We identified some degree of variation in practice across the 3 facilities. In facility 2, patients were more likely than the referent facility to have examinations, goals, and interventions addressing functional activities. In addition, patients in facility 2 had nearly 3 times the likelihood of having an educational intervention. One general difference among the facilities was in duration of visits and median number of visits per patient. The factors associated with this variation are not clear. Physical therapist practice variations have been shown to be due, in part, to nonclinical factors such as therapists’ education.5 Freburger and Hurley16 reported differences associated with hospital November 2009

Physical Therapists’ Management of Patients in the Acute Care Setting Table 7. Odds of Patients Having Examinations, Goals, or Interventions by Facilitya Facility 2 1

Odds Ratio

Reference

2.6

Variable

3 95% Cl

Odds Ratio

95% Cl

1.0–6.5

1.8

0.7–4.2

Examinations Musculoskeletal Neuromuscular

Reference

1.9

0.8–4.4

1.3

0.5–3.2

Cardiovascular/pulmonary

Reference

1.4

0.5–3.8

1.9

0.8–4.9

Integumentary

Reference

0.4

0.2–1.0

0.8

0.4–1.7

Functional ability

Reference

2.7

1.1–6.6

2.1

0.8–5.8

Reference

1.0

0.6–1.8

0.5

0.3–0.8

Goals Musculoskeletal Neuromuscular

Reference

1.6

0.7–3.3

0.9

0.4–1.8

Cardiovascular/pulmonary

Reference

1.3

0.6–2.7

0.6

0.3–1.1

Integumentary

Reference

1.3

0.5–3.4

0.5

0.2–1.2

Functional ability

Reference

2.7

1.3–5.6

1.4

0.6–3.3

Discharge

Reference

0.8

0.3–2.1

1.3

0.5–3.4

Musculoskeletal

Reference

1.3

0.7–2.3

0.3

0.2–0.6

Neuromuscular

Reference

1.5

0.7–3.1

1.0

0.6–1.8

Cardiovascular/pulmonary

Reference

1.5

0.8–3.2

0.9

0.5–1.7

Functional ability

Reference

3.0

1.4–6.4

1.6

0.7–3.5

Education

Reference

2.9

1.6–5.5

2.3

0.9–5.8

Interventions

Integumentaryb a b

Controlled for age and diagnostic category. CI⫽confidence interval. Proportions too small for computation.

characteristics in the use of physical therapy services for patients with hip arthroplasty and stroke. Differences among the facilities in our study may include the philosophical approach to practice taken by the members of the physical therapy staff, common educational backgrounds of staff, productivity expectations, or other unmeasured factors. In facility 2, where patients had greater odds of having functionally related and educational interventions, a higher percentage of patients (⬃70%) were discharged to home compared with the other facilities. In exploring further, we found that patients with interventions related to functional activity were more likely November 2009

to be discharged to home than those without the intervention (OR⫽1.9, 95% CI⫽1.1–3.2). Short lengths of stay (mean of 4 –5 days reported by facilities for all patients), low number of visits (median⫽2–3), and a high likelihood of patients being discharged to home may necessitate physical therapists’ focusing examinations and interventions on patients’ ability to perform functional activities. A focus on functional activity may be more effective than addressing impairments in bodily functions such as strength, endurance, and range of motion that could take considerable time to influence in any meaningful way. Short hospital stays also may be reflected in the focus on appropriate level of discharge for paVolume 89

tients in our study. More than 70% of the patients had a goal related to discharge to the appropriate setting. Physical therapists interviewed by Lopopolo8 believed that hospital restructuring had led to their increased involvement in decision making related to patient discharge. In our study, nearly 70% of visits included communication with other health care team members. It might be expected that communication is essential in a setting in which patients’ medical status may change from moment to moment, where patients may be moved from one level of care to another quite rapidly, and where length of stay is short. A previous study of discharge decision Number 11

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Physical Therapists’ Management of Patients in the Acute Care Setting making by physical therapists in the acute care setting indicated that opinion sharing was an important aspect of determining appropriate discharge destination for patients, helping to refine and focus recommendations.14 Similarly, the therapists that Lopopolo8 interviewed indicated that with hospital restructuring, they had increased their interactions with other care providers, sharing knowledge and coordinating care. One interesting finding of our study was that nearly 20% of visits did not involve examinations or interventions. These sessions included visits to patients who were unavailable or inappropriate for treatment, as well as visits that involved only reading the medical record, communicating with team members, or completing various forms of documentation. We were able to show to some extent the potential effect of such visits on productivity, as these nonbillable visits averaged approximately 8 minutes each. This finding demonstrates some of the inherent inefficiencies of providing physical therapy treatment in the acute care setting.

Figure 2. Percentages of patients with examinations, goals, and interventions by facility.

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Limitations This study describes physical therapist practice at 3 academic medical centers in the northeastern United States. This small sample of convenience limits the ability to generalize the findings. For example, practice may be quite different in smaller community hospitals or in different regions of the country. The fact that all facilities were in one region of the country is likely to reduce the variability in practice, as practitioners, including physicians who refer patients and physical therapists who treat them, may come from a fairly small pool of education programs. Additionally, not all of the therapists at each site volunteered to collect data. Therefore, the data do not represent all the patients managed by physical therapists in each facility. Our November 2009

Physical Therapists’ Management of Patients in the Acute Care Setting ability to control for case mix was limited to patients’ ages and diagnostic categories. There is evidence that there are other variables that contribute to the case mix that we did not measure (eg, payer type).5,13 The reliability of the data collection instrument and the participants in terms of consistency in recording the contents of sessions was not formally tested. Although the same training method was used for all participating therapists and a definition of each technique was provided to the therapists, it is possible that different therapists interpreted the content of their sessions differently. In order to enhance consistency, we used the Guide to Physical Therapist Practice12 and had input from clinicians practicing in acute care in developing the tool. Because we relied on volunteer participation, and knowing how busy therapists can be, it is possible that some visits were not recorded, resulting in missing data and an underestimation of the proportion of patients receiving various examinations, interventions, or goals. We did attempt, however, to make the form fairly easy to complete while still being comprehensive. We did not collect information on the facilities’ philosophical approach to care in the acute care setting. We also do not know the proportion of all patients in each facility during the 2-week data collection period who were seen by physical therapists. Differences in referral patterns could be reflected in variations in care. Additionally, although the literature suggests that variations in care are related to differences in decision making, we did not try to determine the decision-making process and clinical judgment used by the physical therapists. Identifying examinations, interventions, and goals provided through a checklist cannot reflect the level of thinking and skill

November 2009

involved in care of patients who are acutely ill. Implications and Future Research This study provides a simple description of physical therapists’ management of patients in acute care and attempts to show variations across facilities. The findings may offer some basis for curriculum decisions in physical therapist education programs. For example, a focus of patient management was on functional activities, determining discharge destination, and education of patients and staff, suggesting that curricula should focus on these strategies as they relate to patient management in the acute care setting. Future research is needed on variations in practice across a greater diversity of facilities, including size, geographic location, and level of care. Future research might also seek to explain the type of decision making that is involved in acute care practice. We were unable to determine the relationship between patient management strategies and patient outcomes. Further research might examine this relationship; however, first there needs to be identification of the specific types of measures that therapists use to determine patients’ progress and outcomes in acute care. In a recent study, only 16% of physical therapists in the acute care setting used standardized outcomes measures.17 Should new health care reform measures include “bundled payments” (ie, combined reimbursement for hospitalization, inpatient rehabilitation, home health care, and outpatient follow-up into a single payment), there may need to be rethinking of the total physical therapy plan of care for patients who require such services. For example, such a system might emphasize the importance of determining the mosteffective combination of setting, freVolume 89

quency, intensity, and type of interventions for patients with conditions commonly managed by physical therapists. Additionally, there may be more impetus for developing outcome measures for the acute setting to enhance effectiveness research.

Conclusions This study of physical therapist practice in 3 acute care facilities suggests that patient management focuses on functional activity. There was no clear pattern of examinations, goals, and interventions related to specific diagnoses. Some degree of variation was found in practice across three facilities in the northeastern United States. All authors provided concept/idea/research design and writing. Dr Brown, Dr Collette, Dr Friant, and Dr Graves provided data collection. Dr Jette provided data analysis, project management, and institutional liaisons. The authors acknowledge the time and effort of their clinical colleagues and their managers at the 3 facilities at which data were collected. They appreciate their help in creating a useful protocol and the extra burden they assumed in the collection of data. The protocol for the study was approved by the University of Vermont Institutional Review Board and review boards of the participating facilities where required. This article was received October 24, 2008, and was accepted July 16, 2009. DOI: 10.2522/ptj.20080338

References 1 Eddy DM. Variations in physician practice: the role of uncertainty. Health Aff. 1984; 3:74 – 89. 2 Wennberg JE, Barnes BA, Zubkoff M. Professional uncertainty and the problem of supplier-induced demand. Soc Sci Med. 1982;16:811– 824. 3 Sirovich B, Gallagher PM, Wennberg DE, Fisher ES. Discretionary decision making by primary care physicians and the cost of US health care. Health Aff. 2008;27:813– 823. 4 O’Neill L, Kuder J. Explaining variation in physician practice patterns and their propensities to recommend services. Med Care Res Rev. 2005;62:339 –357. 5 Jette DU, Jette AM. Professional uncertainty and treatment choices by physical therapists. Arch Phys Med Rehabil. 1997; 78:3146 –3151.

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Physical Therapists’ Management of Patients in the Acute Care Setting 6 McGinnis PQ, Hack LM, Nixon-Cave K, et al. Factors that influence the clinical decision making of physical therapists in choosing a balance assessment approach. Phys Ther. 2009;89:233–247. 7 Curtis KA, Martin T. Perceptions of acute care physical therapy practice: issues for physical therapist preparation. Phys Ther. 1993;73:581–594; discussion 594 –588. 8 Lopopolo RB. The effect of hospital restructuring on the role of physical therapists in acute care. Phys Ther. 1997;77: 918 –936. 9 Naylor J, Harmer A, Fransen M, et al. Status of physiotherapy rehabilitation after total knee replacement in Australia. Physiother Res Int. 2006;11:35– 47.

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10 Mackay MR, Ellis E. Physiotherapy outcomes and staffing resources in open abdominal surgery patients. Physiother Theory Pract. 2002;18:75–93. 11 Nelson AR. Unequal treatment: report of the Institute of Medicine on racial and ethnic disparities in healthcare. Ann Thorac Surg. 2003;76:S1377–S1381. 12 Guide to Physical Therapist Practice. 2nd ed. Phys Ther. 2001;81:9 –746. 13 Resnik L, Liu D, Hart DL, et al. Benchmarking physical therapy clinic performance: statistical methods to enhance internal validity when using observational data. Phys Ther. 2008;88:1078 –1087. 14 Jette DU, Grover L, Keck CP. A qualitative study of clinical decision making in recommending discharge placement from the acute care setting. Phys Ther. 2003;83: 224 –236.

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15 Jette DU, Latham NK, Smout RJ, et al. Physical therapy interventions for patients with stroke in inpatient rehabilitation facilities Phys Ther. 2005;85:238 –248. 16 Freburger JK, Hurley RE. Ancillary service utilization in academic health center hospitals: use of physical therapy for the treatment of stroke and hip arthroplasty. J Clin Outcomes Manag. 2000;8:20 –26. 17 Jette DU, Halbert J, Iverson C, et al. Use of standardized outcome measures in physical therapist practice: perceptions and applications. Phys Ther. 2009;89:125–135.

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November 2009 䡺 21–30

Interventions (complete for each session)

䡺 61–70

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䡺 Wound care (including burns) 䡺 Other _______________

䡺 Hydrotherapy

䡺 Transfer training 䡺 Wheelchair training

䡺 Functional training (ADL, IADL) 䡺 Gait training 䡺 Manual airway clearance

䡺 Sensory/perceptual training 䡺 Thermal agents

䡺 Endurance training 䡺 Fall prevention

䡺 Strengthening exercises 䡺 ROM/flexibility exercises

䡺 Education of staff

䡺 Prosthetic or orthotic device training 䡺 Relaxation exercises/techniques

䡺 Edema/swelling management 䡺 Education of patient/family 䡺 Electrotherapeutic agents

䡺 Neurodevelopmental training 䡺 Prescription of assistive/adaptive devices

䡺 Bed mobility/positioning 䡺 Breathing exercises

䡺 Manual therapy/joint mobilization/manipulation 䡺 Motor control/motor learning

䡺 Assistive or adaptive device training

䡺 Record reading only

䡺 Joint integrity/mobility 䡺 Balance Training

䡺 Wounds/skin integrity 䡺 Other _______________

䡺 Flexibility/ROM 䡺 Gait/ambulation

䡺 Transfer ability 䡺 Wheelchair locomotion

䡺 Environmental barriers 䡺 Ergonomics or body mechanics

䡺 Self-care activities 䡺 Swelling/edema

䡺 Coordination 䡺 Cranial/peripheral nerve integrity

䡺 Reflexes 䡺 Respiration/ventilation (RR, SpO2, work of breathing)

䡺 Breathing pattern/effort 䡺 Circulation (HR, pulses, BP)

䡺 Pain 䡺 Posture

䡺 Balance 䡺 Bed mobility

䡺 Neuromotor development 䡺 Orthotic or prosthetic devices–need for or fit of

䡺 Arousal/attention/cognition

䡺 Patient declined

䡺 71–80

䡺 Assistive or adaptive devices–need for or fit of

䡺 Motor function (motor control/learning) 䡺 Muscle strength

䡺 Aerobic/endurance capacity or exercise response 䡺 Anthropometric measurements

Examination (history, tests, measures) (complete for each session)

䡺 Need to clarify orders

䡺 Medically inappropriate 䡺 No

䡺 Patient unavailable

䡺 Unskilled care

䡺 41–50 䡺 51–60

䡺 Yes

䡺 31–40

䡺 Session 3

Decision not to treat due to:

䡺 4–12 䡺 13–20

䡺 ⬎1

䡺 Session 2

Patient in ICU?

Patient age (y)

䡺 Session 1

䡺 1–3

Treating Therapist Code # ________

Patient Code # ______________________

Date ___________________________

Facility Code # ______________________

Primary Therapist Code # _____________

Data Collection Forma

Appendix 1.

䡺 81–90

(Continued)

䡺 ⬎90

Physical Therapists’ Management of Patients in the Acute Care Setting

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Communication/Discussion

䡺 Vascular (including related wounds) 䡺 Other________________

䡺 Oncological 䡺 Organ transplant

䡺 General medical

䡺 Pulmonary-medical

䡺 Improved skin integrity

䡺 PTA with nurse 䡺 session shortened

䡺 PT with nurse 䡺 full session completed

䡺 PT with physical therapy aide (#_____)

䡺 PTA alone

䡺 Remains in hospital but discontinued from physical therapy services 䡺 Deceased

䡺 Home with home health rehabilitation 䡺 Acute inpatient rehabilitation 䡺 Skilled nursing facility rehabilitation

䡺 Long-term care facility 䡺 Other acute care hospital

䡺 Home without follow-up rehabilitation

䡺 Other____________

䡺 Home with outpatient rehabilitation

䡺 PTA with physical therapy aide (#________)

䡺 PT with OT or SLP 䡺 PT with SPT

䡺 PT only

䡺 Other______________

䡺 Reduced work of breathing

䡺 Reduced pain

䡺 Reduced swelling/edema

䡺 Reduced stress/anxiety

䡺 Reduced energy expenditure

䡺 Reduced chance of falling

䡺 Improved wound healing/skin integrity

䡺 Improved transfer ability

䡺 Improved strength

䡺 PT with PTA

䡺 Improved posture

䡺 Improved motor control

䡺 Improved knowledge about condition and self-care

䡺 Improved ambulation or gait pattern

䡺 Improved function (ADL/IADL)

䡺 Improved flexibility/ROM

䡺 Improved coordination/dexterity

䡺 Improved bed mobility

䡺 Improved balance

䡺 Improved arousal/attention/cognition

䡺 Improved airway clearance and gas exchange

䡺 Improved safety in mobility 䡺 Improved sensory awareness

䡺 Discharge to appropriate level of care 䡺 Improved aerobic capacity/endurance (includes ambulation distance)

䡺 Pulmonary-surgical

䡺 Neurological-surgical 䡺 Ob-Gyn

䡺 Cardiac-surgical 䡺 General surgical

䡺 Orthopedic-surgical

䡺 Multi-trauma 䡺 Neurological-general

䡺 Burns

䡺 Orthopedic-general

䡺 Other

䡺 None

䡺 Other agencies or facilities

䡺 Third-party payer or case manager

䡺 Family/associates of patient

䡺 Other team members in-house

䡺 Cardiac-medical

䡺 Other

䡺 None

䡺 Patient instructions/home program

䡺 Discharge documents

䡺 In-house patient record (initial evaluation, progress or discontinue notes)

ICU⫽intensive care unit, HR⫽heart rate, BP⫽blood pressure, ROM⫽range of motion, RR⫽respiratory rate, SpO2⫽oxygen saturation, ADL⫽activities of daily living, IADL⫽instrumental activities of daily living, Ob-Gyn⫽obstetrics and gynecology, PT⫽physical therapist, PTA⫽physical therapist assistant, OT⫽occupational therapist, SLP⫽speech-language pathologist.

a

Discharge disposition (complete at final session only)

Duration of session in minutes _____________

Personnel during session (complete at each session)

(complete at each session)

Goals/expected patient outcomes

Classify primary problem (complete at initial session only)

Documentation (complete for each session)

Continued

Appendix 1. Physical Therapists’ Management of Patients in the Acute Care Setting

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Physical Therapists’ Management of Patients in the Acute Care Setting Appendix 2. Definitions of Tests and Measures and Definitions of Interventions12,a

Definitions of Tests and Measures If you are unsure of what to check on the data collection form, scan these definitions. Aerobic Capacity and Endurance ● Assessment of blood pressure, heart rate, respiratory rate, pulse oximetry, exertion, dyspnea, or angina during and after activity ● Use of standardized tests such as 6-minute walk, treadmill, or bike protocols ● General assessment of perceived exertion during activities, including bed mobility, ambulation, ADL Anthropometric Characteristics ● Measurement of body fat composition ● Measurement of height, weight, length, and girth Arousal, Attention, and Cognition ● Assessment of factors that influence motivation level ● Assessment of level of consciousness ● Assessment of level of recall (eg, short-term and long-term memory) ● Assessment of orientation to time, person, place, and situation ● Screening for cognition (eg, to determine ability to process commands, to measure safety awareness) ● Screening for gross expressive (eg, verbalization) deficits Assistive and Adaptive Devices (Including Crutches, Canes, Walkers, Wheelchairs, Reachers) ● Analysis of effects and benefits while patient/client uses device ● Analysis of patient/client or caregiver ability to use and care for device ● Assessment of alignment and fit of the device and inspection of related changes in skin condition ● Assessment of safety/proper use of device Balance (Both Static and Dynamic) ● Analysis of arthrokinematic, biomechanical, kinematic, and kinetic characteristics of balance, with and without the use of assistive, adaptive, orthotic, protective, supportive, or prosthetic devices or equipment ● Analysis of balance on various terrains, or in different physical environments ● Assessment of balance-related safety, including susceptibility to falling ● Identification and quantification of static and dynamic balance characteristics with or without standardized instruments Bed Mobility ● Assessment of ability to roll and move in bed and come to sitting on the edge of the bed Breathing Pattern/Effort ● Assessment of breathing patterns at rest or with activity, including use of accessory muscles, discoordination, etc Circulation ● Assessment of autonomic responses to positional changes ● Assessment of resting vital signs (HR, BP, pulses) ● Monitoring of circulatory status via telemetry or hard-wire monitoring ● Auscultation of the heart ● Claudication time tests (Continued)

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Physical Therapists’ Management of Patients in the Acute Care Setting Appendix 2. Continued

Coordination ● Assessment of gross and fine motor function related to coordination such as ataxia, eye-hand coordination, and other skilled movements Cranial/Peripheral Nerve Integrity ● Assessment of dermatomes ● Assessment of gag reflex ● Assessment of muscles innervated by the cranial and peripheral nerves ● Assessment of response to the following stimuli: auditory, gustatory, olfactory, visual, vestibular ● Assessment of swallowing ● Sensory testing such as 2-point discrimination, light touch, heat/cold, etc Environmental Barriers ● Analysis of physical space for current and potential barriers ● Measurement or physical inspection of physical space ● Analysis of safety issues in physical space ● Interview or other questionnaires conducted with patient/client and others regarding physical space and barriers Ergonomics or Body Mechanics ● Observation/analysis of preferred postures during performance of tasks and activities ● Determination of dynamic capabilities and limitations during specific activities ● Observation/analysis of performance of selected movements or activities Flexibility/ROM ● Analysis of functional ROM ● Analysis of active and passive ROM using goniometers, tape measures, flexible rulers, inclinometers ● Analysis of muscle length Gait/Ambulation ● Analysis of biomechanical, kinematic, and kinetic characteristics of gait, with and without the use of assistive, adaptive, orthotic, protective, supportive, or prosthetic devices or equipment ● Analysis of gait, on various terrains, or in different physical environments ● Identification and quantification of gait characteristics Joint Integrity/Mobility ● Joint play movements ● Assessment of joint hypermobility and hypomobility ● Assessment of response to manual provocation tests ● Assessment of soft tissue inflammation, or restriction ● Assessment of sprain Motor Function ● Analysis of head, trunk, and limb movement ● Analysis of locomotor activities appropriate for age (eg, walking, hopping, skipping, running, jumping) ● Analysis of stereotypic movements ● Assessment of dexterity and agility ● Assessment of sensorimotor integration ● Initiation, modification and control of movement patterns and voluntary movements and postures ● Analysis of voluntary and involuntary movement ● Assessment of motor function (motor control and motor learning) (Continued) 1176

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Physical Therapists’ Management of Patients in the Acute Care Setting Appendix 2. Continued

Muscle Strength ● Dynamometry ● Manual muscle tests ● Assessment of functional strength of muscle groups Neuromotor Development ● Analysis of age-appropriate development, including gross and fine motor skills, oromotor function, phonation, and speech production ● Assessment of behavioral responses ● Infant and toddler neuromotor assessments Orthotic or Prosthetic Devices ● Analysis of ability to use and care for device independently ● Analysis of appropriate components of the device ● Analysis of effects and benefits with patient/client use of the device ● Analysis of movement while patient/client wears the device ● Analysis of practicality and ease of use of the device ● Assessment of alignment and fit of the device and inspection of related changes in skin condition ● Assessment of patient/client or caregiver ability to put on and remove the device and to understand its use and care ● Assessment of safety during use of the device Pain ● Analysis of pain behavior and reaction during specific movements and provocation tests ● Assessment of muscle soreness ● Assessment of pain and soreness with joint movement ● Assessment of pain perception (eg, phantom pain) ● Assessment of pain using pain ratings, questionnaires, graphs, visual analog scales, etc Posture ● Analysis of resting posture in any position, including postural alignment, symmetry deviations, etc ● Analysis of dynamic postures Reflexes ● Assessment of developmentally appropriate postural, equilibrium, righting reactions and reflexes over time ● Assessment of normal reflexes (eg, stretch reflex) ● Assessment of pathologic reflexes (eg, Babinski reflex, hypertonicity) Respiratory/Ventilation ● Assessment of pulmonary function ● Auscultation of lungs ● Measurement of SpO2 ● Monitoring of ventilator settings and weaning parameters ● Assessment of work of breathing at rest and during activity Self-Care Activities ● Assessment of ADL or IADL such as bathing, dressing, eating, toileting ● Analysis of environment and tasks ● Analysis of self-care and home management activities that are performed with or without assistive, adaptive, orthotic, protective, supportive, or prosthetic devices or equipment ● Assessment of safety in self-care and home management activities (Continued) November 2009

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Physical Therapists’ Management of Patients in the Acute Care Setting Appendix 2. Continued

Swelling/Edema ● Assessment of activities and postures that aggravate or relieve edema, lymphedema, or effusion ● Assessment of edema/soft tissue swelling through palpation and volume and girth measurements Transfer Ability ● Assessment of ability to move from one surface to another or one posture to another (eg, bed to chair, standing to toilet, sit to stand) ● Assessment of safety in moving from one surface to another or one posture to another Wheelchair Locomotion ● Assessment of ability to maneuver wheelchair ● Assessment of ability to use wheelchair safely and effectively Wounds/Skin Integrity ● Assessment for presence of blistering ● Assessment for presence of hair growth ● Assessment of activities, positioning, postures, and assistive and adaptive devices that may result in trauma to skin or wound ● Assessment of continuity of skin color ● Assessment of nail beds ● Assessment of skin temperature as compared with that of an adjacent area or an opposite extremity ● Assessment of tissue mobility, turgor, and texture ● Assessment for presence of dermatitis ● Assessment for signs of infection or trauma ● Assessment of bleeding ● Assessment of burn ● Assessment of ecchymosis ● Assessment of scar tissue ● Assessment of wound contraction, drainage, location, odor, shape, size, and depth ● Assessment of wound tissue, including epithelium, granulation, mobility, necrosis, slough, texture, and turgor Record Reading Only ● No observation, tests or measures were done in the presence of the patient. Examination included reading the patient’s record only. ● May be associated with a decision not to treat the patient at that time

Definitions of Interventions If you are unsure of what to check on the data collection form, scan these definitions. Assistive or Adaptive Device Training ● Training in how to appropriately use assistive gait devices, equipment used for assisting ADL units, CPM units, etc Balance Training ● Training that challenges balance ● Training that improves awareness of position in space (Continued)

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Physical Therapists’ Management of Patients in the Acute Care Setting Appendix 2. Continued

Bed Mobility/Positioning ● Training to roll in bed, come to sitting on side of bed, or otherwise reposition oneself in bed ● Training of family/associates to position or move patient in bed Breathing Exercises ● Training to improve breathing pattern to reduce energy consumption ● Training in deep breathing to improve ventilation and gas exchange ● Training in segmental breathing ● Training in use of incentive spirometer Edema/Swelling Management ● Use of any of the following to reduce swelling and edema – massage – taping and wrapping techniques – mechanical pumps – positioning Education of Patient/Family ● Teaching the patient and/or family or associates to manage various aspects of the patient’s care, including symptom recognition, safety, body mechanics, correct performance of exercises, risk factor reduction, etc Education of Staff ● Teaching nurses, aides, orderlies, and others on staff to manage various aspects of the patient’s care such as bed positioning, ambulation training, wound care, etc Electrotherapeutic Agents Application of ● TENS ● NMES ● FES ● High-voltage pulsed current Endurance Training ● Activities that are designed to improve endurance or aerobic capacity including walking and wheelchair propulsion ● The activities may serve other functions as well, such as improving balance or improving ADL ability, but they are being used to improve endurance Fall Prevention ● Activities that are designed to reduce the patient’s risk of falls, including changing the environment, improving balance, instructing in proper use of assistive device ● The activities also may be classified under interventions such as balance training Functional Training ● Activities that help the patient improve in ADL, IADL, task-specific body mechanics, etc Gait Training ● Training that focuses on improving gait pattern such as stride length, swing through, arthrokinematics during stance, etc (Continued)

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Physical Therapists’ Management of Patients in the Acute Care Setting Appendix 2. Continued

Hydrotherapy ● Use of water for reducing pain or improving movement ability Manual Airway Clearance ● Manual (percussion, vibration, shaking) or mechanical techniques to loosen secretions ● Breathing strategies such as autogenic drainage to loosen secretions ● Teaching/facilitating coughing or huffing ● Positioning to drain secretions ● Suctioning Manual Therapy/Joint Mobilization/Manipulation ● Mobilization/manipulation of joints and soft tissue ● Massage ● Manual traction Motor Control/Motor Learning ● Task-specific performance training to improve coordination, dexterity, motor planning, efficiency, etc ● Neuromuscular re-education ● Techniques to normalize tone or reduce spasticity ● Techniques for facilitation or inhibition of movements Neurodevelopmental Training ● Use of developmental activities and stimuli to improve motor function and physical performance and progress in developmental stage ● Movement pattern training Prescription of Assistive/Adaptive Devices ● Selecting or working with patient and family to select an appropriate device for improving patient’s function, including walker, cane, splint, AFO, reacher, wheelchair, etc Prosthetic or Orthotic Device training ● Training in care and use of devices such as upper- and lower-limb prostheses, AFOs, wrist splints, etc Relaxation Exercises/Techniques ● Techniques such as imagery, breathing strategies, superficial massage, etc designed to reduce patient’s anxiety and/or tension ROM/Flexibility Exercises ● Active, active assistive or passive exercises designed to improve flexibility of connective tissue of joints or to lengthen muscles ● Stretching exercises (Continued)

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Physical Therapists’ Management of Patients in the Acute Care Setting Appendix 2. Continued

Sensory/Perceptual Training ● Training designed to improve proprioception, light touch sensation, postural awareness, awareness of position in space, apraxias, etc ● Vestibular training Strengthening Exercises ● Active assistive, active, and resistance exercises, on land or in water, designed to improve patient’s muscular strength ● Resistance may be applied manually or using weights or machines ● Exercises may be isotonic, isometric, isokinetic, concentric, or eccentric Thermal Agents ● Use of hot packs, cold packs, ice, ultrasound, etc Transfer Training ● Activities designed to teach patients how to safely and effectively move from one surface to another or one position to another, including sit-to-stand, bed-to-chair, in and out of tub, etc Wheelchair Training ● Activities designed to teach patient the appropriate and safe use of a wheelchair, including propulsion, steering, removal of arms or leg rests Wound Care ● Debridement ● Application of dressings ● Application of topical agents ● Use of techniques such as hydrotherapy, hyperbaric oxygen to assist in debridement or healing ● Protection and prevention techniques to reduce chance of further injury, infection, etc ADL⫽activities of daily living, IADL⫽instrumental activities of daily living, HR⫽heart rate, BP⫽blood pressure, ROM⫽range of motion, SpO2⫽oxygen saturation, TENS⫽transcutaneous electrical nerve stimulation, NMES⫽neuromuscular electrical stimulation, FES⫽functional electrical stimulation, AFO⫽anklefoot orthosis, CPM⫽continuous passive motion. a

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Research Report Academic Difficulty and ProgramLevel Variables Predict Performance on the National Physical Therapy Examination for Licensure: A Population-Based Cohort Study Daniel L. Riddle, Ralph R. Utzman, Dianne V. Jewell, Stephanie Pearson, Xiangrong Kong D.L. Riddle, PT, PhD, FAPTA, is Otto D. Payton Professor, Department of Physical Therapy, Medical College of Virginia Campus, Virginia Commonwealth University, 1200 E Broad St, West Hospital Basement, Room 100, Richmond, VA 23298-0224. Address all correspondence to Dr Riddle at: [email protected]. R.R. Utzman, PT, PhD, MPH, is Associate Professor and Academic Coordinator of Clinical Education, Division of Physical Therapy, School of Medicine, West Virginia University, Morgantown, West Virginia. D.V. Jewell, PT, DPT, PhD, CCS, is Assistant Professor, Department of Physical Therapy, Medical College of Virginia Campus, Virginia Commonwealth University. S. Pearson, BS, is a doctoral student in the Department of Biostatistics, Virginia Commonwealth University. X. Kong, PhD, is Assistant Scientist, Department of Family Population and Reproductive Health, The Johns Hopkins University, Baltimore, Maryland. [Riddle DL, Utzman RR, Jewell DV, et al. Academic difficulty and program-level variables predict performance on the National Physical Therapy Examination for licensure: a population-based cohort study. Phys Ther. 2009;89: 1182–1191.]

Background. Several factors have been shown to influence first-time pass rates on the National Physical Therapy Examination (NPTE). It is unclear to what extent academic difficulty experienced by students in a physical therapist education program may affect NPTE pass rates. The effects of institutional status (public or private) and Carnegie Classification on NPTE pass rates also are unknown. Objective. The aim of this study was to quantify the odds of failure on the NPTE for students experiencing academic difficulty and for institutional status and Carnegie Classification.

Design. This investigation was a retrospective population-based cohort study. Methods. Quota sampling was used to recruit a random sample of 20 professional physical therapist education programs across the United States. Individual student demographic, preadmission, and academic performance data were collected, as were data on program-level variables and data indicating pass/fail performance on the NPTE. A generalized linear mixed-effects logistic regression model was used to adjust for confounding factors and to describe relationships among the key predictor variables—academic difficulty, institutional status, and Carnegie Classification—and the dependent variable, NPTE performance.

Results. Academic difficulty during a student’s professional training was an independent predictor for NPTE failure. The odds of students who had academic difficulty (relative to students who did not experience academic difficulty) failing the NPTE were 5.89 (95% confidence interval⫽4.06 – 8.93). The odds of NPTE failure also varied depending on institutional status and Carnegie Classification.

Limitations. The findings related to Carnegie Classification and institutional status should be considered preliminary. Conclusions. Student performance on the NPTE was influenced by multiple factors, but the most important, potentially modifiable risk factor for poor NPTE performance likely is academic difficulty during professional training.

© 2009 American Physical Therapy Association Post a Rapid Response or find The Bottom Line: www.ptjournal.org 1182

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Predicting Performance on the Licensure Examination

P

rofessional training for physical therapist students typically culminates with the National Physical Therapist Examination (NPTE) for licensure. A passing score on the NPTE is a requirement for entering practice in all 50 states.1 Given the essential role of the NPTE in a student’s professional career, identifying factors associated with performance on the NPTE is critical for both students and academic institutions. Pascarella and Terenzini2 suggested that success on standardized tests, such as the NPTE, is related to student-level factors and institutional factors. Student-level factors include demographic characteristics, past academic performance, and scores on standardized aptitude tests. Institutional factors can include withininstitution effects, such as class size and instructional approaches, and between-institution effects, such as institutional status (public or private), emphasis on research, and mission. Most recent studies of factors that may influence student success on the NPTE have relied on small samples from single schools or have focused only on student- or institution-level variables. Studying both student-level and institutionlevel factors related to success on the NPTE is a logistical and statistical challenge, a fact that may explain why so few studies with large samples have been conducted.2 In 4 recent studies, student-level predictors of performance on the NPTE

Available With This Article at www.ptjournal.org • Audio Abstracts Podcast This article was published ahead of print on September 17, 2009, at www.ptjournal.org.

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were examined,3– 6 and 3 of these studies relied on relatively small samples (n⫽107,3 n⫽92,4 and n⫽1225) from individual physical therapist education programs. Utzman et al6 collected data on 3,365 students from 20 physical therapist education programs for the purpose of identifying preadmission predictors of NPTE performance. Key preadmission predictors of NPTE pass rates were undergraduate grade point average (uGPA), scores on the verbal and quantitative sections of the Graduate Record Examination (GRE), and race or ethnicity variables. Because their study focused on data gathered only during the admissions process, Utzman et al did not examine the effects of student performance during the professional physical therapist education program or specific institutional characteristics on NPTE performance.6 Mohr et al7 conducted the only recent study to examine the relationship between characteristics of physical therapist education programs and NPTE performance. They surveyed program directors from 132 professional (entry-level) physical therapist education programs with regard to program characteristics and compared these characteristics with each program’s NPTE pass rate. However, because data were collected at the level of academic programs and not at the student level, the authors were unable to control for differences in student characteristics. No other studies examining the role of institutional characteristics in physical therapist student academic or NPTE performance were found. Researchers in other fields have studied relationships between student academic and licensure performance and student and institutional factors. For example, Mitchell8 found that undergraduate institutional quality rankings were related to medical stuVolume 89

dent performance on national licensure examinations. Anaya9 examined data from 495 premedical students from across the United States and found that Medical College Admission Test performance was related to several variables, including score on the Scholastic Aptitude Test, sex, ethnicity, and institutional status. There are a variety of reasons for hypothesizing that institutional characteristics may influence NPTE pass rates. For example, the Carnegie Classification* may influence pass rates because the academic preparation of faculty and students in doctoral institutions may differ from those in master’s degree or medical or health science institutions. Institutions that are less focused on research, for example, may have fewer faculty members with doctoral degrees and may have different philosophical approaches guiding professional education. Institutional status may also influence pass rates because public and private institutions attract students with different racial or ethnic,10 sociodemographic,10 and geographic11 backgrounds. The purpose of this study was to determine whether student- and program-level variables predict the odds of students failing the NPTE. Specifically, our first purpose was to determine whether academic difficulty encountered during a professional physical therapist education program is predictive of NPTE failure. Our second purpose was to determine whether the odds of NPTE failure are affected by public or private institutional status or by Carnegie Classification when student demographics, admissions scores, and academic difficulty are controlled for. We hypothesized that academic difficulty during physical therapist * The Carnegie Foundation for the Advancement of Teaching, 51 Vista Ln, Stanford, CA 94305.

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Predicting Performance on the Licensure Examination professional education would increase the odds of NPTE failure. Because recent evidence on the potential role of institutional status or Carnegie Classification is lacking, we considered our second purpose to be exploratory in nature.

Methods Methods for recruitment and data collection are thoroughly described in a recent publication.6 We briefly summarize these methods here. Participating Programs Physical therapist education programs were recruited by quota sampling. First, all accredited physical therapist education programs in the United States were stratified by geography and degree level. Geographic regions, as designated by the US Census Bureau, were West, Midwest, Northeast, and South. Programs were categorized by the degree offered during the period from 2000 through 2004: doctoral degree in physical therapy, master’s degree (master of physical therapy or master of science in physical therapy), or transition (ie, a program offered the master’s degree some years and the doctoral degree other years). Within each geographic region and degree level, programs were randomized and invited to participate in the study. Programs that did not use the GRE for admissions or that admitted fewer than 30 students per year were excluded. The programs recruited were reasonably representative of the population of programs in the United States that met the inclusionary criteria. The original recruitment plan included 12 physical therapist education program strata based on 4 geographic regions (ie, Northeast, South, Midwest, and West) and 3 degree levels (ie, doctoral degree, master’s degree, and programs transitioning from master’s degree to doctoral degree). For 2 of these 1184

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strata, there were no data (ie, 2 geographic regions had no physical therapist education programs at certain degree levels); therefore, the final analysis was based on 10 strata. Only one program in our dataset was classified by The Carnegie Foundation for the Advancement of Teaching as “health sciences”; therefore, we deleted the data for this program (164 students) from our data set. Participating programs provided data on students who were originally admitted to the cohorts expected to graduate in the years 2000 through 2004. A total of 23 programs were originally recruited; 3 of those programs later withdrew because of time constraints. A database of accredited programs12 was used to determine the degrees offered by the programs as well as institutional status (public or private) and Carnegie Classification. It is important to note the Carnegie Classification is a university-level classification system and not a departmental or program degree classification. We recruited 20 programs because, at the time of the study, 95 programs in the United States met the inclusion criteria. We believed that if we were able to randomly select and recruit approximately 20% of the 95 programs of interest, our findings would be reasonably reflective of the population of physical therapist students in the United States. The data in our study were generally representative of the population of 95 physical therapist education programs with regard to geographic region, degree level, institutional status, and Carnegie Classification.13 The age and uGPA of the students in our sample were representative of those of the entire population of US physical therapist students. Our student sample had slightly smaller proportions of female, African American, and Hispanic students than the population

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of students enrolled in all accredited programs at the time of the study. The total sample size was 3,585 students. The NPTE results were not available for 171 students, 143 of whom were dismissed or withdrew from their education programs. Data for these 171 students were excluded from the analysis. A total of 11 students completed the NPTE but did not earn their degree at the institution recruited for the study. Another 173 students were excluded because of missing data for the predictor variables. Because of missing data (n⫽355) and elimination of health sciences program data (n⫽164), the final analysis was conducted on data from 3,066 students. The characteristics of the student sample are shown in Table 1, and the program characteristics are shown in Table 2. Data Collection Physical therapist education programs provided data regarding students’ demographic characteristics (age at admission, sex, and racial or ethnic category), cohort, uGPA, and scores on the verbal GRE (vGRE) and quantitative GRE (qGRE). They also provided categorical data about whether each student encountered academic difficulty. Academic difficulty was defined as failing a course or unit or being placed on academic suspension or probation. These data were collected on a spreadsheet and given to the investigators. Each program then sent a list of student identifiers to the Federation of State Boards of Physical Therapy (FSBPT). Using a spreadsheet, the FSBPT then recorded whether each student failed the NPTE one or more times. We chose to collect categorical (pass/fail) information on NPTE performance rather than raw NPTE scores because passing is the primary concern for physical therapist students and faculty. All states now have a uniform passing score threshNovember 2009

Predicting Performance on the Licensure Examination old.1 The Commission on Accreditation in Physical Therapy Education requires programs to report their first-time and overall pass rates, rather than raw scores, for each graduating cohort of students.14

Table 1. Characteristics of Student Sample Characteristic

Value (Range)

Median age, y

23 (18–50)

Sex, % women

66

Race or ethnicity, %

After deleting students’ identifying information, the FSBPT sent the NPTE performance data to the investigators. The investigators used randomized matching codes on the spreadsheets to match data sent by the academic programs with data sent by the FSBPT. At no time did the investigators have access to students’ personal identifying information, thus protecting student anonymity. Data Analysis The data structure comprised 3 levels. The first level consisted of data collected on individual students, such as GRE scores, age, and sex. The second level was the program level and consisted of 19 programs. Program was treated as a randomeffects variable in our analysis because the programs were randomly selected from the population of 95 physical therapist education programs to represent all programs in the population. By treating program as a random-effects variable, we were able to account for correlations among students in individual programs and to generate estimates that could reasonably be applied to the entire population of 95 programs. The third level comprised the Carnegie Classification (ie, doctoral degree, master’s degree, or medical degree) and institutional status (public or private). Carnegie Classification and institutional status variables represented a third level because each of these categories of variables comprised multiple programs and there might be correlations among programs in each Carnegie Classification and institutional status category that would need to be accounted for in the model. The Figure illustrates the multilevel structure of the data and November 2009

African American

2.7

Asian or Pacific Islander

6.3

Hispanic

2.6

White, non-Hispanic

85.7

Other

2.7

Mean undergraduate grade point average

3.43 (2.10–4.00)

Mean verbal Graduate Record Examination (GRE) score

470 (240–800)

Mean quantitative GRE score

600 (200–800)

Students who had academic difficulty during a professional physical therapist education program, % Students who failed the National Physical Therapy Examination 1 or more times, %

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Table 2. Characteristics of Participating Programs No. of Programs

Characteristic Geographic region Northeast

4

South

7

Midwest

5

West

3

Institutional status Private

8

Public

11

Carnegie Classification of institution Doctoral, extensive or intensive

7

Master’s

9

Medical

3

Institutional status by Carnegie Classification Public doctoral

5

Private doctoral

2

Public master’s

3

Private master’s

6

Public medical

1

Private medical

2

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Predicting Performance on the Licensure Examination examined predictor variables of academic difficulty, institutional status, and Carnegie Classification. A thorough description of the roles of the other covariates is provided in our earlier article.6

Figure. Multilevel structure of the data as well as the dependent variable and other covariates. DPT⫽doctoral degree in physical therapy, GPA⫽grade point average, GRE⫽Graduate Record Examination, NPTE⫽National Physical Therapy Examination, PT⫽physical therapy.

the variables corresponding to each level. The key predictors of interest were academic difficulty, institutional status (public or private), and Carnegie Classification. Several confounding factors were assessed in our previous study, and these variables were adjusted for in the current analysis.6 Potential confounding factors were test version (ie, an older version of an examination taken during the first half of the study versus a newer version of the examination taken during 1186

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the second half of the study), student cohort (ie, 2000, 2001, 2002, 2003, and 2004), degree (ie, master’s degree and doctoral degree), age, sex, ethnicity, uGPA, vGRE score, and qGRE score. For example, in our previous study, test version was shown to be highly predictive of NPTE failure. After adjustment for covariates, the odds of failure for students who took the newer version of the examination were 8 times higher than those for students taking the older version of the examination. The focus of the present study is the newly

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To account for the multilevel data structure, we used the generalized linear mixed-effects model. Specifically, the log odds of NPTE failure were modeled as a linear function of the confounding factors, the predictors of interest, and the programlevel variable that was modeled as a random effect. Given the multilevel nature of the data, we conducted preliminary analyses of 2 scenarios of the random program effect. In one scenario, the program effect had heterogeneous variability in the different categories cross-classified by institutional status and Carnegie Classification. Essentially, this model tested whether the effects of the program-level variable differed across Carnegie Classification and institutional status categories. In the other scenario, the program effect had homogeneous variability in the different categories. In other words, this model assumed that the effects of the program-level variable were the same across different categories of Carnegie Classification and institutional status variables. The model-building procedure started with the inclusion of all potential confounding factors, the predictors of interest and their 2-way interaction effects, and the random program effect. The significance of the heterogeneity of the random program effect was then tested with the likelihood ratio test. Only confounding factors having a P value of less than .10 were retained in the model. The interactions between the significant confounding factors and the predictors of interest also were included to test whether the confounding factors were effect modifiers, and only significant confounding November 2009

Predicting Performance on the Licensure Examination effects (P⬍.10) were retained in the final model. The final model also contained the predictors of interest and their significant 2-way interaction effects. Model diagnostics were performed by exploring the correlations between the predictor variables and the model fit statistics. All of the regression analyses were conducted by use of SAS 9.2 with PROC GLIMMIX.† A heterogeneous random program effect in the different groups crossclassified by Carnegie Classification and institutional status was found not to be significant (P⫽.18) in a comparison with a model with a homogeneous random program effect. However, a homogeneous random program effect was found to be significant (P⬍.001) in a comparison with a model without a random program effect, that is, a model assuming that the scores obtained from all of the students were independent of one another. These preliminary test results indicated that there were significant correlations among students in the same program as well as significant variability among programs. However, the variability among programs cross-classified by Carnegie Classification and institutional status was not significantly different. These analyses indicated that it was not necessary to account for the correlation structure of variables at the third level (Carnegie Classification and institutional status) but that the variable at the second level (program) introduced significant correlations among subjects and needed to be accounted for in the final analysis. Role of the Funding Source This work was funded, in part, by the FSBPT. Data provided by the FSBPT were used for this study. However, the ideas and conclusions drawn from the data are those of the † SAS Institute Inc, 100 SAS Campus Dr, Cary, NC 27513-2414.

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authors and do not necessarily represent the views of the FSBPT.

Results In the final model, the significant confounding factors were test version, cohort, ethnic group, uGPA, and vGRE and qGRE scores. The interaction between the vGRE score and the Carnegie Classification was determined to be significant on the basis of our criterion P value of .10 (P⫽.08). These data suggested that the association of the school’s Carnegie Classification with students’ NPTE performance varied according to the vGRE score. The variables age, sex, and degree were not significant predictors and were not included in the final model. The findings related to age, sex, and degree were consistent with those of our previous work6 in that none of these variables was a significant predictor of NPTE failure after adjustment for other covariates. The odds ratios corresponding to each significant covariate are shown in the Appendix. For the predictors of interest, academic difficulty was found to be a significant predictor of NPTE failure. The odds of failure were 5.89 times higher for students who had academic difficulty in the professional program (95% confidence interval⫽4.06 – 8.93) than for students who did not have academic difficulty, after all other variables in the model were accounted for. After adjustment for confounding factors, institutional status (public or private) and Carnegie Classification showed a significant interaction effect (P⫽.09). These data suggested that the odds of NPTE failure for public and private institutions depended on the Carnegie Classification. The parameter estimates and odds ratios for the key predictor variables are summarized in Table 3. We did not report the interactions for medical degree programs because data from only 3 programs were represented in Volume 89

the study and we were concerned that these data could not be extrapolated to other medical degree programs in the United States.

Discussion The results of the present study extend the findings of our previous report on the influence of preadmission variables on NPTE performance.6 Specifically, in the present study, we quantified the predictive power of academic difficulty during professional education for increasing the odds of students failing the NPTE. In addition, the odds of NPTE failure were related to institutional status and Carnegie Classification. In the present study, the odds of NPTE failure for students who encountered academic difficulty were almost 6 times higher than those for students who had no academic difficulty. This finding supports those of other authors3,5 who conducted studies with small samples and found that academic performance during professional physical therapist education programs was related to NPTE performance. We studied data from more than 3,000 students in different categories of programs and controlled for important covariates in the analysis; our results suggested that academic difficulty is a generalizable and powerful independent predictor of NPTE failure. We believe that this information should be useful for students and faculty. Students who encounter academic difficulty during their training should seek tutoring and other examination preparation assistance before taking the NPTE. Faculty should develop strategies to potentially increase the likelihood of NPTE success for students who experience academic difficulty because they are at the highest risk for NPTE failure. Future investigations should identify reasons why some students struggle academically and have difficulty Number 11

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Predicting Performance on the Licensure Examination Table 3. Parameter Estimates, Odds Ratios, and 95% Confidence Intervals for the Key Predictor Variables in the Mixed-Effects Model After Adjustment for Significant Covariatesa 95% Confidence Interval Variable

Odds Ratio

Lower Limit

Upper Limit

1.77 (0.19)

5.89

4.06

8.53

Estimate (SE)

Academic difficulty Institutional status by Carnegie Classificationb Public doctoral vs public master’s

0.68 (0.50)

1.97

0.74

5.26

Private doctoral vs private master’s

⫺0.57 (0.53)

0.57

0.20

1.61

Private doctoral vs public doctoral

⫺0.22 (0.54)

0.80

0.28

2.32

Private master’s vs public master’s

1.02 (0.48)

2.78

1.09

7.10

Private doctoral vs public master’s

0.46 (0.61)

1.58

0.48

5.21

Public doctoral vs private master’s

⫺0.34 (0.40)

0.71

0.32

1.55

a

Covariates were test version, cohort, ethnicity, undergraduate grade point average, verbal Graduate Record Examination (GRE) score, and quantitative GRE score. These estimates were based on a fixed verbal GRE mean score of 470 because the verbal GRE score also was found to interact with the Carnegie Classification in the prediction of failure on the National Physical Therapy Examination. b

passing the NPTE. Research also needs to examine educational interventions designed to enhance students’ academic program performance and NPTE performance. The second purpose of the present study was to explore relationships among institutional characteristics of physical therapist education programs and NPTE failure. Although we were surprised to find little research examining this issue in the medical and allied health literature, theoretical arguments can be made for why institutional status and Carnegie Classification might influence NPTE performance. For example, as determined on the basis of the Carnegie Classification, institutions with doctoral degree programs generally have a stronger research emphasis than institutions with master’s degree and medical degree programs, and this stronger emphasis might influence the way in which programs prepare students. Evidence also suggests that there are sociodemographic and geographic differences between students in public institutions and those in private institutions,10,11 and these differences could affect NPTE performance. 1188

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Our results indicated that institutional status and Carnegie Classification were related to student performance on the NPTE. However, these relationships were complex. The association between Carnegie Classification and NPTE failure changed according to institutional status. When fixing the vGRE score (because it also is related to Carnegie Classification), institutional status and Carnegie Classification did not influence pass rates individually but rather interacted to influence the odds of NPTE failure. As shown in Table 3, the only significant interaction was between private master’s degree and public master’s degree programs. The odds of NPTE failure for students in private master’s degree programs were, on average, 2.78 times higher than those for students in public master’s degree programs, after all other confounding variables in the model were accounted for. The 95% confidence interval for this point estimate ranged from 1.09 to 7.10, indicating that the point estimate was somewhat lacking in precision. Public doctoral degree programs also had higher rates of failure than public master’s degree programs (odds ratio⫽1.97, 95% confi-

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dence interval⫽0.74 –5.26). Although the 95% confidence interval for this point estimate included 1 (indicating that the point estimate was not statistically significant at P⫽.05), the data suggested that a larger sample of programs might better clarify whether there are significantly higher rates of failure in public doctoral degree programs than in public master’s degree programs. Public master’s degree programs generally had lower rates of failure than other types of programs, but, in most cases, these differences were not statistically significant. The reasons for these variations in NPTE pass rates in different institutional classifications are unclear from the present study. Perhaps the most likely reason is that the curricular approaches used in public master’s degree programs better prepare students for success on the NPTE. We did not collect data on teaching philosophies and strategies; therefore, we cannot provide evidence-based explanations for why students in public master’s degree programs had lower NPTE failure rates than students in private master’s degree programs. However, our data provide the strongest evidence to date that there may be differences November 2009

Predicting Performance on the Licensure Examination in NPTE pass rates among public and private institutions and institutions in various Carnegie Classification categories. The Carnegie Classification is an institution-level variable and does not necessarily reflect the degree offered by the physical therapy program.

tutional support for teaching versus research. More research is needed to determine whether institutional status and Carnegie Classification variables explain the differences in the programs or whether there are other, as-yet-unidentified variables that better explain the findings.

We found another significant interaction: between the vGRE score and the Carnegie Classification. The vGRE score interacted with the Carnegie Classification such that the vGRE score had a more powerful protective effect against NPTE failure (ie, an odds ratio of significantly ⬍1) for doctoral degree and master’s degree programs than for medical degree programs. Preadmission verbal skills appeared to play a more important role in NPTE performance for students entering institutions offering a doctoral or master’s degree than for students entering institutions offering a medical degree (according to Carnegie Classification categories). The reasons for these variable effects of the Carnegie Classification and the vGRE score on the odds of NPTE failure are speculative. Perhaps the curricula in medical degree programs provide better training in verbal and communication skills and are not as dependent on students’ verbal skills at program admission. More research clearly is needed.

As noted by Pascarella and Terenzini,2 institutions differ in their missions and resources. These variations are reflected in the compositions of their applicant pools, student bodies, and overall achievements of students. Programs in different institutional status and Carnegie Classifications categories likely vary with respect to faculty credentials, workloads, and focus on research and scholarly activity. Curriculum design, instructional methods, and student support resources may also vary. As a result of these differences, some programs may be more or less effective in preparing students.

The variables institutional status and Carnegie Classification are well defined but may actually serve as surrogate measures for other constructs not measured in the present study. For example, it is possible that public master’s degree programs have generally lower failure rates than other types of programs not because of their Carnegie Classification or institutional status but because of some other, unmeasured variable. We have mentioned several potential candidates, including faculty training, emphasis on teaching, and instiNovember 2009

Our examination of the potential role of institutional status and Carnegie Classification was exploratory in nature. There is little evidence for the potential role of these institutionlevel variables in NPTE performance. We suspect that this is the case because studies designed to examine these issues require very large samples from multiple schools. This aspect of our study will likely raise more questions than it answers, but we believe that the potential implications are important. If NPTE pass rates are shown in future research to vary according to institutional status or Carnegie Classification, should the profession address the issue? Can other, more modifiable measures related to Carnegie Classification or institutional status be identified? More research is needed to begin to understand whether these complex relationships can be consistently demonstrated and, if so, whether they should be addressed by institutions or the profession. Volume 89

Limitations Our original sampling strategy was not designed to capture a large number of programs representing all Carnegie Classification and institutional status permutations. For example, there were no health science programs in our final dataset, and we recruited only 3 programs in the medical category of the Carnegie Classification (Tab. 2). Our sample comprised 5 public doctoral degree programs for physical therapy, 2 private doctoral degree programs, 3 public master’s degree programs, and 6 private master’s degree programs. A study with a larger and, perhaps more representative, sample of programs from each of these categories might result in conclusions different from those presented here. Readers should exercise caution when interpreting the results regarding multiple program-level characteristics and NPTE failure. We collected data over a 5-year period (2000 –2004). We used this strategy to increase the likelihood that the results would be generalized over multiple years, but the data might not apply to current or future student academic or NPTE performance. We did not include a measure of undergraduate institution selectivity, a measure of the degree to which some undergraduate programs produce better-prepared students than other institutions. Researchers in other fields8,9,15 have included such measures in their studies to control for differences in preadmission grades from different undergraduate institutions. Future studies in physical therapist education may benefit from the inclusion of undergraduate institution selectivity in their analyses. Data for 212 students who completed their programs were missing from our sample, and we cannot rule out the possibility that these missing data influenced our findings. Finally, our study included only students Number 11

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Predicting Performance on the Licensure Examination who successfully completed their physical therapist education programs and took the NPTE. Some students have academic difficulty to the extent that they do not complete their professional training, and our results cannot be extrapolated to these students.

Conclusion Academic difficulty during professional academic training is one of the most powerful predictors of NPTE failure. Academic difficulty also appears to be one of the most likely variables to target in attempts to improve students’ chances of passing the NPTE. Institutional factors also appear to influence NPTE pass rates, through an interaction between institutional status and Carnegie Classification. Because the institutionlevel analyses were exploratory in nature, our study should be replicated with a larger sample to assess the validity of these findings. Dr Riddle, Dr Utzman, and Dr Jewell provided concept/idea/research design. All authors provided writing. Dr Utzman provided data collection. Dr Riddle, Ms Pearson, and Dr Kong provided data analysis. Dr Riddle and Dr Utzman provided fund procurement and institutional liaisons. Dr Riddle, Dr Utzman, Ms Pearson, and Dr Kong provided consultation (including review of manuscript before submission). The authors thank Dr Christine M. Schubert for her guidance with the data analysis.

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This work was completed in partial fulfillment of the requirements for Dr Utzman’s PhD in Health-Related Sciences, Medical College of Virginia Campus, Virginia Commonwealth University. The study was approved by the institutional review board at Virginia Commonwealth University on the basis of exemption criteria. This work was funded, in part, by the Federation of State Boards of Physical Therapy (FSBPT). Data provided by the FSBPT were used for this study. However, the ideas and conclusions drawn from the data are those of the authors and do not necessarily represent the views of the FSBPT. This article was submitted December 16, 2008, and was accepted July 13, 2009. DOI: 10.2522/ptj.20080400

References 1 2005 NPTE Candidate Handbook for the National Physical Therapy Examinations: PT, PTA. Alexandria, VA: Federation of State Boards of Physical Therapy; 2005. 2 Pascarella ET, Terenzini PT. How College Affects Students: Findings and Insights From Twenty Years of Research. San Francisco, CA: Jossey-Bass Publishers; 1991. 3 Dockter M. An analysis of physical therapy preadmission factors on academic success and success on the National Licensing Examination. J Phys Ther Educ. 2001;15:60 – 64. 4 Kosmahl EM. Factors related to physical therapist licensure examination scores. J Phys Ther Educ. 2005;19:52–56. 5 Thieman TJ, Weddle ML, Moore MA. Predicting academic, clinical, and licensure examination performance in a professional (entry-level) master’s degree program in physical therapy. J Phys Ther Educ. 2003;17:32–37.

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6 Utzman RR, Riddle DL, Jewell DV. Use of demographic and quantitative admissions data to predict performance on the National Physical Therapy Examination. Phys Ther. 2007;87:1181–1193. 7 Mohr T, Ingram D, Hayes SH, Du Z. Educational program characteristics and pass rates on the National Physical Therapy Examination. J Phys Ther Educ. 2005;19: 60 – 66. 8 Mitchell KJ. Traditional predictors of performance in medical school. Acad Med. 1990;65:149 –158. 9 Anaya G. Correlates of performance on the MCAT: an examination of the influence of college environments and experiences on student learning. Adv Health Sci Educ Theory Pract. 2001;6:179 –191. 10 Cooper RA. Impact of trends in primary, secondary, and postsecondary education on applications to medical school, II: considerations of race, ethnicity, and income. Acad Med. 2003;78:864 – 876. 11 Barzansky B, Etzel SL. Educational programs in US medical schools, 2004 –2005. JAMA. 2005;294:1068 –1074. 12 Commission on Accreditation in Physical Therapy Education. Accredited Physical Therapy Programs. Available at: http:// www.apta.org/Education/accreditation/ dir_acc_PT_ed_prog. Accessed May 2, 2004. 13 Utzman RR, Riddle DL, Jewell DV. Use of demographic and quantitative admissions data to predict academic difficulty among professional physical therapist students. Phys Ther. 2007;87:1164 –1180. 14 Commission on Accreditation in Physical Therapy Education. Evaluative Criteria for Accreditation of Education Programs for the Preparation of Physical Therapists. Alexandria, VA: American Physical Therapy Association; 2006. 15 Huff KL, Fang D. When are students most at risk of encountering academic difficulty? A study of the 1992 matriculants to U.S. medical schools. Acad Med. 1999;74: 454 – 460.

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Predicting Performance on the Licensure Examination Appendix. Odds Ratios and 95% Confidence Intervals for the Significant Covariates in the Final Modela 95% Confidence Interval Parameter

Reference Group

Other Group

Odds Ratio

Lower Limit

Upper Limit

Test version by cohortb

2002 old

2002 new

6.82

3.92

11.88

Race or ethnicity

African American

Asian or Pacific Islander

0.97

0.47

2.00

Hispanic

Asian or Pacific Islander

2.33

0.92

5.91

Other

Asian or Pacific Islander

1.23

0.54

2.78

White non-Hispanic

Asian or Pacific Islander

1.93

1.19

3.13

Hispanic

African American

2.41

0.89

6.54

Other

African American

1.26

0.51

3.11

White non-Hispanic

African American

1.99

1.12

3.53

Other

Hispanic

0.52

0.18

1.55

White non-Hispanic

Hispanic

0.83

0.36

1.93

White non-Hispanic

Other

1.58

0.77

3.24

Mean undergraduate GPA

3.4

3.5

0.88

0.85

0.92

Mean qGRE score

600

610

0.97

0.95

0.98

Mean vGRE score by doctoral institution (Carnegie Classification)

470

480

0.91

0.89

0.94

Mean vGRE score by master’s institution (Carnegie Classification)

470

480

0.94

0.92

0.97

Mean vGRE score by medical institution (Carnegie Classification)

470

480

0.97

0.93

1.00

a The reference groups for the continuous variables were their mean observed levels. GPA⫽grade point average, qGRE⫽quantitative Graduate Record Examination, vGRE⫽verbal Graduate Record Examination. b Test version and cohort were addressed in the following way. Because no student took the old version of the examination in 2003 and 2004, some cells in the analysis of cohort by test version were empty. We, therefore, created dummy variables (not shown in the Appendix) that reflected the cohort from which the students came and whether they took the new or the old version of the examination. To reflect the relationship between test version and cohort, we report the interaction of test version and cohort for 2002, the year in which approximately half of the students took the old version of the National Physical Therapy Examination and half took the new version. In the final model, we adjusted for test version and cohort by using the dummy variables.

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Research Report A Conceptual Model of Optimal International Service-Learning and Its Application to Global Health Initiatives in Rehabilitation Celia M. Pechak, Mary Thompson C.M. Pechak, PT, PhD, MPH, is Assistant Professor, Physical Therapy Program, College of Health Sciences, University of Texas at El Paso, 1101 N Campbell St, El Paso, TX 79902-0581 (USA). She is vice-chair of the American Physical Therapy Association’s Cross Cultural and International Special Interest Group. Address all correspondence to Dr Pechak at: [email protected]. M. Thompson, PT, PhD, GCS, is Professor and Coordinator of PostProfessional Studies, School of Physical Therapy, Texas Woman’s University, Dallas, Texas. [Pechak CM, Thompson M. A conceptual model of optimal international service-learning and its application to global health initiatives in rehabilitation. Phys Ther. 2009;89:1192–1204.] © 2009 American Physical Therapy Association

Background. There is growing involvement by US clinicians, faculty members, and students in global health initiatives, including international service-learning (ISL). Limited research has been done to examine the profession’s increasing global engagement, or the ISL phenomenon in particular, and no research has been done to determine best practices. This study was intended as an early step in the examination of the physical therapy profession’s role and activities in the global health arena within and beyond academics. Objectives. The purposes of this study were: (1) to identify and analyze the common structures and processes among established ISL programs within physical therapist education programs and (2) to develop a conceptual model of optimal ISL within physical therapist education programs.

Design. A descriptive, exploratory study was completed using grounded theory. Methods. Telephone interviews were completed with 14 faculty members who had been involved in international service, international learning, or ISL in physical therapist education programs. Interviews were transcribed, and transcriptions were analyzed using the grounded theory method.

Results. Four major themes emerged from the data: structure, reciprocity, relationship, and sustainability. A conceptual model of and a proposed definition for optimal ISL in physical therapist education were developed. Seven essential components of the conceptual model are: a partner that understands the role of physical therapy, community-identified needs, explicit service and learning objectives, reflection, preparation, risk management, and service and learning outcome measures. Essential consequences are positive effects on students and community.

Conclusions. The conceptual model and definition of optimal ISL can be used to direct development of new ISL programs and to improve existing programs. In addition, they can offer substantive guidance to any physical therapist involved in global health initiatives.

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A Conceptual Model of Optimal International Service-Learning

G

rowth in the number of people with disabilities worldwide and unmet needs for rehabilitation challenge the physical therapy profession to expand its involvement in global rehabilitation efforts. The World Health Organization estimates that there are 650 million people with disabilities, and most live in developing countries with little or no access to rehabilitation.1

Although physical therapists have the knowledge and skills to make significant contributions to global rehabilitation efforts,2,3 the physical therapy profession has had a limited role in the global health arena to date.3 Given that Vision 2020 includes the expectation that physical therapists will be prepared for autonomous and collaborative practice in all settings,4 a trend toward increased global health involvement by physical therapists might be expected and perhaps encouraged by the profession. Although sources of data are limited, it does appear that clinicians, faculty members, and students in the United States are increasingly involved in global health initiatives5–7 and related activities such as promoting cultural competency. Membership in the American Physical Therapy Association’s Cross Cultural and International Special Interest Group has grown by 316.7% in the past 4 years to 225 members (Robin Childers, personal communication, April 28, 2009). The physical therapy division of Health Volunteers Overseas is

Available With This Article at www.ptjournal.org • Audio Abstracts Podcast This article was published ahead of print on September 10, 2009, at www.ptjournal.org.

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now the organization’s second largest of 14 branches, with 298 members. It has experienced an 81.7% growth in the number of volunteers since 2004 and had 57 volunteers serve in 2008 (Barbara Edwards, personal communication, April 27, 2009). Research regarding the growing involvement of the physical therapy profession in global health initiatives has been limited in scope. Most studies have focused on the involvement of faculty members and students in global health activities, such as international service-learning (ISL). Service-learning is “a structured learning experience that combines community service with explicit learning objectives, preparation, and reflection.”8(p274) Service-learning describes not only a type of program, but also a philosophy of education that “emphasizes active, engaged learning with the goal of social responsibility.”9(p22) A reflective component is purposively incorporated in service-learning to cultivate student learning about the greater social issues creating the need that the service seeks to alleviate. Reciprocity is the underlying premise that both the needs of the server and those being served must be addressed.8,9 Interest in and research about service-learning in higher education have been growing since the 1980s and in physical therapist education in particular since the 1990s. Similar to researchers throughout higher education,10 physical therapist educators have promoted service-learning as an effective method for students to garner real-world learning, enhance students’ knowledge and attitudes related to professional issues, and foster commitment to service while offering meaningful service to their communities.11–15 Interest in ISL and related international service or learning activities in Volume 89

physical therapist education has increased over the last decade.7,16 –19 International service-learning is a service-learning opportunity that occurs outside of the country where the education program is located.7 There is a dearth of literature related to ISL in physical therapist education. In a 2006 survey of physical therapist education programs in the United States and Canada, 27.6% (n⫽24) of the US survey respondents and 50% (n⫽4) of the Canadian respondents reported using ISL in the previous 10 years. Of those US and Canadian programs without ISL, 14.9% specified a plan to incorporate ISL in the following 2 years.7 Examining the effects on physical therapist student participants in an individual ISL program in Guatemala, Dockter16 noted an increased score on a subscale that measures social justice attitudes. The study supported the use of service-learning as a pedagogical tool if students are provided with adequate preparation and guidance related to realistic goal setting. Other researchers have examined related global health activities with physical therapist students, including a medical mission,17 an international clinical education experience,18 and a research and study abroad program.19 They noted positive effects that included improved critical thinking and problem solving, greater cultural sensitivity, and an expanded worldview. The rising trend toward including international educational activities is evident in medical education as well.20 –22 Recognizing the farreaching effects of rapid globalization on health care, medical educators increasingly advocate for global health education in all medical schools23–25 and call for international clinical experiences to be offered routinely.23 Some authors have presented guidance on how to impleNumber 11

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A Conceptual Model of Optimal International Service-Learning Table 1. Operational Definitions Term

Definition

Service-learning

is “a structured learning experience that combines community service with explicit learning objectives, preparation, and reflection.”8(p274) Also, “[u]nlike practica and internships, the experiential activity in a service-learning course is not necessarily skill-based within the context of professional education.”28(p222)

International servicelearning (ISL)

is a service-learning opportunity that occurs outside of the country where the education program is located.7

Established ISL program

is a program that had been in existence for at least 2 years and was in existence at the time of data collection.

International service

includes opportunities primarily focused on service activities that occur outside of the country where the physical therapist education program is situated, that faculty offer to or organize with students, and that do not meet the above-defined criteria for service-learning.

International learning

includes opportunities primarily focused on learning activities that occur outside of the country where the physical therapist education program is situated, that faculty offer to or organize with students, and that do not meet the above-defined criteria for service-learning.

International service and/or learning

is an umbrella term that includes ISL, international service, and international learning.

ment training programs in medical schools and residency programs.24 –26 Although the medical education literature may offer some direction, physical therapist educators have the responsibility to chart their own course for future global health training. No previous study has examined how global health training should be carried out in physical therapist education. As its prevalence is expected to grow and because it is a common model for global health engagement in physical therapist education,7 ISL was specifically chosen for investigation in the current study. The purposes of this study were: (1) to identify and analyze the common structures and processes among established ISL programs within physical therapist education programs and (2) to develop a conceptual model of optimal ISL within physical therapist education programs. Although focused on the academic segment, this study was intended as an early step in the examination of the physical therapy profession’s role and activities in the

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global health arena within and beyond academics.

Method Grounded theory, as described by Strauss and Corbin,27 was the qualitative research method used for this study because of the usefulness of their method in the analysis of the relatively unknown and complex phenomenon of ISL. The operational definitions are shown in Table 1. The definition of ISL was based on the literature, and we determined the other definitions. We focused on established ISL programs, defined as in existence at least 2 years, based on the assumption that this time period would allow some degree of faculty reflection and program evaluation. We believed that informed participants engaged in such programs would yield rich data required for model development. Participants Potential participants were identified by a 2006 survey of all US physical therapist education programs.7 The intent of the pilot study survey was to determine whether ISL was a

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phenomenon that justified in-depth exploration as a dissertation topic and, if so, to identify possible future informants. Faculty members from 87 US physical therapist education programs responded and, of these, 36 reported some sort of ISL or other volunteer service within the past 10 years, 16 of whom provided contact information for the qualitative study. Although the research questions involved ISL rather than international service or international learning, participants who were currently involved in international service or learning in physical therapist education were included to assist us in delineating the edges of the ISL phenomenon. From the group of 16 faculty members, 3 were eliminated because they were no longer involved in an ISL program in a physical therapist education program and 2 did not respond to an e-mail requesting participation in the study. Therefore, 11 of the original 16 faculty members from the pilot study were eligible and agreed to be interviewed. In addition, the primary researcher (C.M.P.) recruited an acquaintance with ISL expertise who had not responded to the original survey. We also asked participants and potential participants to suggest other participants, resulting in a 13th faculty member. Lastly, a 14th participant was recruited after one of the researchers met her at a professional meeting. Thus, purposive and snowball selection29 were used to recruit 14 participants. Consistent with qualitative methods, sample size adequacy was dependent upon the point when saturation had been reached, that is, when additional data collection did not add unique or significant information.27 All major themes emerged by the 12th interview. The 13th participant was recruited to maximize the geographic variation of participants, and no new theme was uncovered in that interview. Lastly, the 14th particiNovember 2009

A Conceptual Model of Optimal International Service-Learning pant was recruited after she had verbalized a unique condition in her program to the researcher in casual conversation. After a formal interview, this condition did not change the developing conceptual model. Therefore, further recruitment ceased. Data Collection and Analysis As data collection and analysis occur simultaneously in a qualitative study, procedures for data collection and analysis will be combined in the following discussion. Telephone interviews were arranged over a 3-month period in 2007. The length of the initial interview varied from 40 to 90 minutes. Follow-up communication, for purposes of clarification or elaboration, was accomplished by e-mail, as needed. Follow-up e-mails were printed and saved. The interview format was semistructured. All data were gathered by the principal investigator. Demographic data were obtained from all participants, which included the number of years each participant had been a physical therapist and a part-time or full-time core faculty member. Information regarding the university and physical therapist education program that each participant represented, which included university name, location, public versus non– faith-affiliated private versus faithaffiliated private university, and professional (entry-level) degree offered, also was gathered. Guiding questions (Appendix) were used to direct the interview, but questions changed within and between interviews as data accumulated, analysis was performed, and the conceptual model evolved. The operational definition of service-learning for this study was not provided to the participants during the interviews. This omission was by design for 2 reasons. First, there is no broadly accepted definition of service-learning.30 Second, due to the exploratory nature of this study, we sought to discover November 2009

whether the participants categorized their projects as service-learning, without the influence of the study definition. For the purpose of triangulation, other data were gathered. In addition to audiotaping the interviews, notes were taken by the primary researcher during and after each interview. Notes focused on key phrases stated by the participants, possible concepts emerging from the data, and additional questions to pursue in future interviews. The researcher requested that the participant provide a copy of the ISL syllabus and any other ISL-related documentation. Six participants provided documents, and 4 participants referred the researcher to a Web site. Information from syllabuses and Web sites allowed verification of some of the faculty and university characteristics. Initial themes were identified through the interview notes. The audiotapes were transcribed by 1 of 3 independent transcriptionists. After receiving the transcript, the principal investigator listened to the entire interview and compared it with the written transcript to ensure accuracy. If the participant chose the option on the consent form to review the transcript, then the researcher waited at least 4 weeks for the reviewed transcript to be returned. Seven participants elected to review their transcripts; 5 of the 7 participants returned the transcript to the researcher, all with minor changes that did not affect data analysis. Their reviewed transcripts were used for coding and analysis. All interview notes and transcripts were imported into QSR NVivo7* qualitative software for data management. The principal investigator used this same software for subsequent coding and annotations. * QSR International Inc, 90 Sherman St, Cambridge, MA 02140.

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Line-by-line analysis was completed to identify concepts, and the concepts were grouped into categories and subcategories described by properties and dimensions. Analysis occurred at 2 levels: the participants’ verbatim words and the researcher’s conceptualization of these words.27 As part of the open coding process, relevant portions of the transcribed interview were linked to a growing list of codes, and annotations were made directly on the transcript using the NVivo 7 software. Annotations were used as mini-memos that were connected to specific portions of the transcript, rather than referring to the entire transcript. Full memos also were written and were linked to entire transcripts or emerging concepts. Diagrams were used to capture the emerging themes and begin to develop the conceptual model. With the goal to fill out the dimensions of categories and subcategories, highly purposive sampling was used to optimize opportunities for comparative analysis during the next phase. As early participants tended to represent faith-affiliated schools, subsequent participants who represented public and non–faith-affiliated private universities were specifically chosen. Sampling also was performed to fill out the dimensions of categories and subcategories to increase density and seek negative cases. For example, early participants tended to refer to faith as a strong motivating force for students to participate in ISL. Additional sampling revealed that faith seemed to play no part in student motivation at some universities. Thus, both ends of the spectrum of faith as a motivating factor were sampled. After initial concepts and their categories emerged from the data, the data were examined for relationships. The questions of “who, what, when, where, why, how, and with Number 11

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A Conceptual Model of Optimal International Service-Learning what consequences” were asked and answered to describe the complexity and dynamism of the phenomenon.27(p127) During the final phase of analysis, the primary researcher provided an early version of the optimal ISL model to 3 participants with requests for comment for validation; 2 participants offered feedback. Model content was not substantively changed based on their input, but the illustration was revised for clarity. One participant reviewed an earlier definition of optimal ISL and did not suggest changes. Various methods were used to ensure methodological rigor.31 The principal investigator performed all data collection and coding to ensure consistency. However, the second researcher (M.T.), who had extensive experience in qualitative methods, reviewed portions of the first 2 transcripts and the primary investigator’s coding prior to the principal investigator proceeding with coding additional transcripts. Triangulation was used through sampling a variety of participants, asking the same questions in different ways and analyzing transcripts, interview notes, Web sites, and course documents. Additionally, purposive sampling was used to enhance validity and relevance by deliberately obtaining data from a diverse group of programs to reflect variation found in ISL in physical therapist education programs. Role of the Funding Source The Texas Physical Therapy Foundation funded this study through a research grant. It had no role in the design, conduct, or reporting of this study.

Results The 14 participants used a wide array of terms to label their international programs during the interview and in the provided supplementary 1196

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documents, and these terms did not always directly correspond to each other. Triangulation was used to determine whether the program met the operational definition of an established ISL program.

apist education programs granted entry-level doctorates at the time that the interviews were conducted, and the last program was in the process of transitioning to an entry-level doctorate.

Three categories of groups emerged from the data. All programs shared the common characteristic of being related to international service and/or learning in physical therapist education. The first and largest group (n⫽8) met the operational definition of established ISL in physical therapist education. Second, the quasiestablished ISL programs (n⫽3) were very closely related to the first group but lacked a defining characteristic (eg, they were not in existence for 2 or more years or they did not have explicit learning objectives). Third, the international service or learning programs (n⫽3) were primarily focused on service or learning but not both service and learning relatively equally. Analysis of data from all participants revealed how indistinct the edges of the phenomena can be in practice. However, only data from the established ISL group were used to identify and analyze the commonalities that existed among established ISL programs within physical therapist education programs in terms of structures and processes and to develop a conceptual model of and proposed definition for optimal ISL.

The demographics of established ISL, quasi-established ISL, and international service or learning programs were examined separately. When looking at established ISL programs only, the most notable differences were the greater proportion of participants from private faith-based universities and the lack of representation from universities in Western states compared with all participants. When the established ISL programs were combined with the quasi-established ISL programs, however, public and private universities were more closely balanced, and only the Western US region was not represented.

Participant and University Characteristics Fourteen physical therapists with a broad range of experience as physical therapist educators and in established ISL programs, quasi-established ISL programs, or international service or learning programs provided data for this study (Tab. 2). Participants represented public, faithaffiliated private, and non–faithaffiliated private universities that were located across the United States. Thirteen of the physical ther-

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Phases of Establishing an Optimal ISL Program Five phases in the overall process of establishing an optimal ISL program emerged from the data (Figure). The development phase involved laying the early groundwork for a program. A committed faculty member and an appropriate community partner were essential elements of this phase. One participant highlighted the importance of a committed faculty member, stating, “I am completely dedicated to this project. That has got to be a huge part of it.” Characteristics of an appropriate community partner include established connections to the local community, reliability, and understanding of what service-learning is. Having had a bad experience with her first community partner, one participant said, “Their perception of service-learning was that the Americans would come and bring them things. The money.”

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A Conceptual Model of Optimal International Service-Learning Table 2. Participant Demographic and University Characteristics by Program Type

Characteristic

Established International Service-Learning (ISL) Programs

Participants

8

Quasi-Established ISL Programs

International Service or Learning Programs

3

3

All Programs 14

Years as a physical therapist, X (range)

23 (9–39)

24 (20–27)

23 (10–37)

23 (9–39)

Years as a physical therapist educator,a X (range)

11 (2–28)

12 (6–16)

8 (3–11)

11 (2–28)

7 (2–10)

8 (2–13)

6 (4–8)

7 (2–13)

Years with international service or learning, X (range) University type Public

3

2

2

7

Faith-affiliated private

5

0

1

6

Non–faith-affiliated private

0

1

0

1

Northeastern

3

2

0

5

Midwestern

4

0

0

4

Western

0

0

2

2

Southern

1

1

1

3

University locationb

a b

Data reflect how long participants had been in full-time or part-time core faculty positions, not adjunct faculty positions. Regions defined according to US Census Bureau32 regions.

Although part of the community partner’s role in service-learning is to identify community needs, the faculty member usually had to educate the partner as to what physical therapy is and what it could offer. A participant explained, “At first, you’re kind of in the spirit of discovery; we’re going to learn about each other a little bit more. It was really exciting for them to see what we could do as physical therapists because at first they kept calling us ‘nurses.’” In the design phase (Figure), operational decisions were made in 5 key areas: placing the program in the curriculum, structuring the international service and learning components, choosing students, making logistical plans, and funding the program. Again, a committed faculty member was the essential element and was primarily responsible for designing all facets of the ISL program.

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Explicit learning objectives were determined in this phase. The key activities of the implementation phase (Figure) were performing the service-learning and keeping the team safe and healthy. A committed faculty member, an established and appropriate community partner, and students were essential elements of this phase. Although not playing an essential role in other phases, students consistently were key players in the implementation phase. Common activities included collecting wheelchairs and other equipment prior to departure for the international site, providing direct care to patients, and training and educating family members and nonprofessional caregivers. Reflection, preparation, and risk management emerged as essential components of the implementation phase. Most programs used a combi-

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nation of individual journaling and informal verbal reflection as a group. One program used daily reflective readings as the framework for reflection, whereas another program used the Preparation, Action, Reflection, and Evaluation (PARE) model33 to guide reflection activities. A participant who described a one-credit class that prepares students for the international experience, stated, “They [students] each have some type of presentation that they have to do; one is on culture, one is on language, one is related to travel, one is basic travel— getting a passport, international safety and travel.” The fourth phase was evaluation (Figure). Temporally, it partially overlapped the preceding phase of implemention. Key activities included assessing outcomes related to the student, department, and university and assessing community outcomes. A committed faculty

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A Conceptual Model of Optimal International Service-Learning

Figure. Conceptual model of optimal international service-learning in physical therapist education. The conceptual model was included in the American Physical Therapy Association’s Cross Cultural and International Special Interest Group’s Resource Guide for International Service-Learning in Physical Therapy Education. This guide is available on the Section on Health Policy and Administration Web site to members only.

member, an established and appropriate community partner, and students were essential elements, and learning outcome measures were essential components. A faculty member stated, “We took the CPI [Clinical Performance Instrument], and we looked at, in our program, where we were falling short or maybe not touching upon enough skills, and our clinical educator came up with a tool for the clinician, the PT [physical therapist], to use when supervising the student [at the international site].” In regard to community outcomes, participants were more likely to provide anecdotes of patient improvement or general statements such as, “I think the program [at the international site] benefits from the input of the teaching that we can do.” One faculty member said, “This year I am just trying to become more structured about reporting what we have done and what we accomplished. We assess the students; we 1198

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always do that before and after. As far as the community itself, that is not something that we have formally done.” The final phase, enhancement (Figure), centered primarily on the faculty member; however, communication and coordination with the community partner were essential. The key activities included improving the original program and expanding the program. One participant described an effort to improve evaluation, stating, “This year, though, we have started for the first time doing an outcome measure with all of our students, the Tulane questionnaire.” Another participant described plans for shifting the focus of her program, saying, “What we want to do is spend more time with the university students [at the international site]. We want to have a cultural and professional education exchange.”

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Major Themes Four major themes were identified throughout the 5 phases of the overall process of establishing ISL: structure, reciprocity, relationship, and sustainability. These themes were interwoven throughout the common structures and processes discussed previously. Structure. The concept of structure (Figure) was the underpinning of establishing ISL. In general, structure among all key players corresponded with larger and seemingly better-implemented programs. The faculty members of the largest programs attributed their programs’ effectiveness, in part, to the structure that they had created. One participant from a large and organized program described clear learning objectives and outcome measures, tight daily schedules, and structured reflection. She emphasized, “It is structured so that it is a learning experiNovember 2009

A Conceptual Model of Optimal International Service-Learning ence. I tell the students that we are not going to Cancun; this isn’t a vacation.” Another participant stated, “I think the more I get it structured around the things that I am finding out each time I go, the better it is going to get.” Community partners that were better organized were stronger partners, including being able to provide significant assistance with logistical support. Reciprocity. The theme of reciprocity (Figure) emerged repeatedly from the data. Participants described the imperative of developing a reciprocal relationship with the community partner and the community. First, the community identified its own needs, usually through the community partner. Second, although the community members received service and often teaching from the faculty-student team, the participants acknowledged the community members’ roles in teaching the team. One participant said, “It’s got to be this reciprocity that is give-and-take between the person served and the person serving such that those lines are blurred; both are served and both are serving.” Relationship. In addition to the importance of establishing a reciprocal relationship as described above, participants discussed the long-term personal and professional relationships that were formed or further developed after sharing intense international experiences (Figure). Participants also described how students gained a new appreciation for the value of relationships. A participant explained that the students “talked a lot about how much they learned from the people there, who really seemed to have nothing, but they had so much in terms of relationships.” Sustainability. Although participants did not always use the term “sustainability” specifically, they ofNovember 2009

ten described the concept as a goal for their programs (Figure). The concept of sustainability applied, in part, to the long-term existence of the ISL program within the university as well as the program’s efforts at the international site. A faculty member explained, “The other thing that is successful is the longevity, the ongoing relationship, and to watch PT [physical therapist] practice improve in a developing country is just a remarkable thing.” Similarly, the programs were intended to produce enduring changes in the students and the community. Participants routinely reported effects on students that were described as life-changing and transformative. One participant summarized the students’ feedback: They all say it was both professionally and personally life changing. I think it is that they have to really think flexibly, that they have to work in a challenging way with patients . . . the problems are more . . . they all say it makes them think differently about people and about money, and about culture and how you meet people’s needs and our own presumptions about what people need.

Some participants also highlighted the importance of being a part of a larger rehabilitation effort that continued even after the faculty-student team returned to the United States. Conceptual Model of Optimal ISL A conceptual model of optimal ISL (Figure) was developed after analyzing the common structures and processes of established ISL and the major themes that emerged from the data. The basic tenets found in the service-learning literature8,9,34 and the principles of good practices for ISL found in the literature35 also were considered as we reflected on potential missing elements or inconsistencies.

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Definition of Optimal ISL Based on the conceptual model, a definition for optimal ISL emerged. Optimal ISL in physical therapist education is defined as a structured program of service and learning experiences at an international site that includes preparation, reflection, and explicit service and learning objectives. The service is performed in partnership with an established community partner that understands the role of physical therapy to address community-identified needs, with the goal of creating sustainable change in the community. Program evaluation with service and learning components is integrated into the design of the program and enhances ongoing program improvement for the benefit of the students and community.

Discussion “Optimal” was specifically chosen as the adjective to describe the model, as it conveys the idea that the level of practice is achievable. No ISL program in the study possessed all of the elements described in the model, and thus the model has the potential to inform both new and existing programs. The following discussion will focus on the essential elements that were particularly variable or absent in the ISL programs, as well as their applicability to physical therapists’ participation in global health initiatives in general. Each ISL program had a community partner, but the apparent fit and effectiveness of the community partner with the ISL program varied. Partner organizations with an ongoing rehabilitation effort in the community or at least a clear understanding of what services physical therapists have to offer appear to be the most effective partners. Although some participants described a rushed effort to find a community partner, the study results highlight the importance of taking the time to Number 11

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A Conceptual Model of Optimal International Service-Learning find the right partner. In the best cases, the faculty completed a site assessment prior to taking students with them. Contrasting the limited resources of the physical therapy profession against the unlimited need for rehabilitation services in underserved populations worldwide, the importance of carefully selecting an effective partner organization is applicable to educational programs and clinicians alike.

was part of a larger effort with greater potential to make a difference.

States should address health and safety issues as part of the preparation.

Sustainability is a consideration for any physical therapist involved in global health initiatives. Given the significant time, effort, and financial commitment that global health engagement involves, physical therapists may want to consider a project that includes training and education in addition to direct service.

Closely related to this topic is the essential element of sustainability. Faculty members often struggled with several issues related to sustainability, some of which are similar to those discussed in the medical literature.26 Given limited to no funding and lack of student and faculty time, how can the ISL program continue within the physical therapist education program from year to year? Even with annual visits by the facultystudent team, can the rehabilitation efforts in the community be sustained in their absence? Can sustainable outcomes be achieved for the students and community in the typical 1- to 2-week period that physical therapist faculty-student teams are at an international site? Can the faculty member collaborate with other educational programs in order to develop continuity for the service to the community? Should the faculty member find a more suitable community partner or site?

Although explicit learning objectives were a component of the operational definition of service-learning and, therefore, were present in all of the ISL programs, service objectives were notably absent. Reciprocity is a central tenet of service-learning8,9,34 and requires that the needs of the server and served must be addressed. Therefore, we deemed both service and learning objectives to be essential elements of the model. Similarly to ensure adequate program evaluation, service and outcome measures were determined to be essential. The importance of program evaluation for both student and community components of global health programs has been raised in the medical literature.26 However, there has been a tendency to focus on student over community outcomes across the general service-learning literature.10

In addition to risk management for the students, attention to risk management for the community is needed. Despite the best intentions, there is potential for unintended harm to the community partner and its clients in ISL and other global health activities.39 The partner organization may expend already limited resources to host the faculty-student team without reaping significant benefit from the team’s stay. A UStrained physical therapist on the team may overstep cultural boundaries by interacting more assertively with a local physician than is acceptable and negatively affect the long-term relationship between the physician and local physical therapists. Ultimately, the principle of nonmaleficence should guide all physical therapists involved in global health initiatives.

Some participants did not mention sustainability as related to the rehabilitation efforts or community outcomes until the primary researcher initiated discussion. However, a participant from a quasi-established ISL program specifically stressed, “One of the huge advantages, and I hope this can emphasized somehow in your research, is that our site is ongoing.” This aspect of sustainability was advantageous for the community, but also it was beneficial for students to know that their service 1200

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Risk management was not consistently addressed by the participants. Specifically, programs did not routinely encourage or require emergency health and evacuation insurance, register with the local US embassy, or have any formal plans in case of emergency. Given risks related to high rates of traffic-related injuries and death,36 potential exposure to infectious diseases,37 and possible civil unrest38 in the lowincome countries in which ISL is typically carried out,7 the need for risk management cannot be overstated. Similarly, any physical therapist involved in work outside of the United

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Recent commentary in the medical literature has highlighted the importance of explicitly addressing ethical considerations such as nonmaleficence for short-term global health experiences.39 The conceptual model for and definition of optimal ISL may offer a launching point for this discussion in physical therapist education. Limitations and Future Research The results of the study will best inform physical therapist education programs with contexts similar to those sampled. A wide diversity of contexts was deliberately sampled, however, to increase the applicability of the model within and beyond physical therapy academia. Research into physical therapy’s role in the global health arena is in its infancy, leaving limitless possibilities for further examination across the spectrum of global health activities. In ISL, research is particularly November 2009

A Conceptual Model of Optimal International Service-Learning indicated in the area of service outcome measures and community benefits. Should global health education be a standard component of physical therapist education, and, if so, is ISL the best model? Looking more broadly, how can the physical therapy profession most effectively and ethically expand its role in the global health arena in order to significantly improve the lives of millions of people with disabilities?

Conclusion This study was the first investigation of the emerging phenomenon of ISL in physical therapist education in depth and breadth, just one dimension of the even larger phenomenon of the growing involvement of the physical therapy profession in global health initiatives. As the physical therapy profession matures, it increasingly is shaped by evidencebased practice and guided by best practices. Physical therapists’ involvement in global health initiatives, too, should be influenced by research and best practices. The conceptual model of and proposed definition for optimal ISL can be used to direct development of new ISL programs in physical therapist education and to improve existing programs. In addition, they can offer substantive guidance to any physical therapist with present or future involvement in global health initiatives. Both authors provided concept/idea/research design, writing, data analysis, and consultation (including review of manuscript before submission). Dr Pechak provided data collection, project management, fund procurement, and clerical support. This study was completed in partial fulfillment of Dr Pechak’s doctoral dissertation at Texas Woman’s University, 2007. This study was approved by the Texas Woman’s University Institutional Review Board. A description of the conceptual model was included in a presentation at the Combined Sections Meeting of the American Physical

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Therapy Association; February 6 –9, 2008; Las Vegas, Nevada. The Texas Physical Therapy Foundation provided funding for this study. The authors thank the Foundation for its support. This article was received November 28, 2008, and was accepted July 20, 2009. DOI: 10.2522/ptj.20080378

References 1 Concept Paper: World Report on Disability And Rehabilitation. World Health Organization Web site. Available at: http:// www.who.int/disabilities/publications/ dar_world_report_concept_note.pdf. Accessed October 20, 2008. 2 Kay E, Kilonzo C, Harris MJ. Improving rehabilitation services in developing nations: the proposed role of physiotherapists. Physiotherapy. 1994:80:77– 82. 3 Alappat C, Siu G, Penfold A, et al. Role of Canadian physical therapists in global health initiatives: SWOT analysis. Physiother Can. 2007;59:272–285. 4 APTA Vision Statement for Physical Therapy 2020: Elements of Vision 2020. American Physical Therapy Web site. Available at: http://www.apta.org/AM/Template. cfm?Section⫽Vision_20201&Template⫽ /TaggedPage/TaggedPageDisplay.cfm& TPLID⫽285&ContentID⫽32061. Accessed October 20, 2008. 5 Peteet J. CCISIG member shares resources with Guatemalan colleagues. HPA Resource. 2008;8(3):1, 3. 6 Do S. Global partnerships in Africa. HPA Resource. 2008;8(3):3– 4. 7 Pechak CM, Thompson M. International service-learning and other international volunteer service opportunities in physical therapist education programs in the USA and Canada. J Phys Ther Educ. 2009; 28:69 –77. 8 Seifer SD. Service-learning: communitycampus partnerships for health professions education. Acad Med. 1998;73: 273–277. 9 Kendall JCE. Combining service and learning: an introduction. In: Kendall JCE, ed. Combining Service and Learning: A Resource Book for Community and Public Service. Vol I. Raleigh, NC: National Society for Experiential Education; 1990:1–33. 10 Eyler JS, Giles DE, Stenson CM, Gray CJ. At a Glance: What We Know About the Effects of Service-Learning on College Students, Faculty, Institution and Communities, 1993–2000: Third Edition. Campus Compact Web site. Available at: http:// www.compact.org/resources/downloads/ aag.pdf. Published August 31, 2001. Accessed October 20, 2008. 11 Beling J. Impact of service learning on physical therapist students’ knowledge of and attitudes toward older adults and on their critical thinking ability. J Phys Ther Educ. 2004;18:13–21.

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12 Reynolds PJ. Service learning: What is it? Why is it important? HPA Resource. 2005; 5(4):1, 3–5. 13 Reynolds PJ. How service-learning experiences benefit physical therapists’ professional development: a grounded theory study. J Phys Ther Educ. 2005;19:41–54. 14 Romani WA, Holbert RL. A wellness service-learning project improves the perception of professional empowerment in physical therapist students. J Phys Ther Educ. 2007;21:73–78. 15 Brosky JA Jr, Deprey SM, Hopp JF, Maher EJ. Physical therapist student and community partner perspectives and attitudes regarding service-learning experiences. J Phys Ther Educ. 2006;20:41– 48. 16 Dockter MK. An International ServiceLearning Experience for Physical Therapy Students: Its Meaning and Effect on Civic Engagement and Leadership Skills [dissertation]. Grand Forks, ND: University of North Dakota; 2004. 17 Utsey C, Graham C. Investigation of interdisciplinary learning by physical therapist students during a community-based medical mission trip. J Phys Ther Educ. 2001; 15:53–59. 18 Sawyer KL, Lopopolo R. Perceived impact on physical therapist students of an international pro bono clinical education experience in a developing country. J Phys Ther Educ. 2004;18:40 – 47. 19 Ekelman B, Bello-Hass VD, Bazyk J, Bazyk S. Developing cultural competence in occupational therapy and physical therapy education: a field immersion approach. J Allied Health. 2003; 32:131–137. 20 Nelson BD, Lee AC, Newby KB, et al. Global health training in pediatric residency programs. Pediatrics. 2008;122: 28 –33. 21 Ozgediz D, Wang J, Jayaraman S, et al. Surgical training and global health: initial results of a 5-year partnership with a surgical training program in a low-income country. Arch Surg. 2008:143:860 – 865. 22 Thompson MJ, Huntington MK, Hunt DD, et al. Educational effects of international health electives on U.S. and Canadian medical students and residents: a literature review. Acad Med. 2004;78: 342–347. 23 Drain PK, Primack A, Hunt DD, et al. Global health in medical education: a call for more training and opportunities. Acad Med. 2007;82:226 –230. 24 Evert J, Mautner D, Hoffman I. Developing Global Health Curricula: A Guidebook for US Medical Schools. Ride for World Health Web site. Available at: http:// rideforworldhealth.org/pdfs/Intl_Health_ Curr_Guide.pdf. Published March 20, 2006. Accessed November 16, 2008. 25 Houpt ER, Pearson RD, Hall TL. Three domains of competency in global health education: recommendations for all medical students. Acad Med. 2007;82:222–225. 26 Evert J, Bazemore A, Hixon A, Wright K. Going global: considerations for introducing global health into family medicine training programs. Fam Med. 2007;39: 659 – 665.

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A Conceptual Model of Optimal International Service-Learning 27 Strauss A, Corbin J. Basics of Qualitative Research Techniques and Procedures for Developing Grounded Theory: Techniques and Procedures for Developing Grounded Theory. 2nd ed. Thousand Oaks, CA: Sage Publications; 1994. 28 Bringle RG, Hatcher JA. Implementing service learning in higher education. J Higher Educ. 1996;67:221–239. 29 Portney LG, Watkins MP. Foundations of Clinical Research: Applications to Practice. 2nd ed. Upper Saddle River, NJ: Prentice-Hall Inc; 2000. 30 What Is Service-Learning? Learn and Serve America’s National Service-Learning Clearinghouse Web site. Available at: http://www.servicelearning.org/what_is_ service-learning/service-learning_is/index. php. Accessed April 17, 2009.

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31 Mays N, Pope C. Qualitative research in health care: assessing quality in qualitative research. BMJ. 2000;320:50 –52. 32 2007 Economic Census Regions and Divisions. US Census Bureau Web site. Available at: http://www.census.gov/econ/ census07/www/geography/012144.html. Accessed November 16, 2008. 33 Commuter Affairs and Community Service, University of Maryland. Faculty Handbook for Service-Learning. University of Maryland Web site. Available at: http:// www.cls.umd.edu/faculty_staff/Service Learning.pdf. Published 1999. Accessed August 16, 2009. 34 Jacoby B. Service-learning in today’s higher education. In: Jacoby B, ed. ServiceLearning in Higher Education. San Francisco, CA: Jossey-Bass Inc; 1996:3–25. 35 Tonkin H, Deeley SJ, Pusch M, et al. Service-Learning Across Cultures: Promise and Achievement. New York, NY: The International Partnership for ServiceLearning and Leadership; 2004.

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36 World Report on Road Traffic Injury Prevention: Summary. World Health Organization Web site. 2004. Available at: http:// whqlibdoc.who.int/publications/2004/ 9241562609.pdf. Accessed November 16, 2008. 37 Travelers’ Health. Centers for Disease Control and Prevention Web site. Available at: http://wwwn.cdc.gov/travel/. Accessed October 20, 2008. 38 International Travel. US Department of State Web site. Available at: http://travel. state.gov/travel/travel_1744.html. Accessed October 20, 2008. 39 Crump JA, Sugarman J. Ethical considerations for short-term experiences by trainees in global health. JAMA. 2008;300: 1456 –1458.

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A Conceptual Model of Optimal International Service-Learning Appendix. Semistructured Interview Questions and Probing Questions

1. You have been invited to participate in this project because of your involvement in international service-learning or other international volunteer opportunities in physical therapist education. Will you describe for me your involvement in these activities? ● If you have been involved in more than one program or project, please choose the one in which you are currently involved. If there is time, we can discuss the other(s). 2. If you are the person responsible for starting this international program or project, will you explain why, when, and how you initiated the program or project? If you are not the person responsible for starting this international program or project, can you provide details as to why, when, and how the program or project was initiated, to the best of your knowledge, and how you became involved? 3. Would you categorize your international program or project as “service-learning” or in some other way? Please explain. 4. What were the primary driving external or internal forces for initiating this international program or project? 5. What are your professional and personal motivations for participating in this international program or project? 6. How was the relationship established between your physical therapist program/school and the international community partner? ● Will you describe the formal and informal processes for establishing and maintaining the relationship? 7. How were the community needs identified? ● Will you describe the formal or informal processes for needs assessment? 8. Did you have support from your institution to start this international program or project? ● Will you describe the process for securing support? ● Do you have ongoing support? 9. Did you have support from your program director to start this international program or project? ● Will you describe the process for securing support? ● Do you have ongoing support? 10. Did you have support from other faculty to start this international program or project? ● Will you describe the process for securing support? ● Do you have ongoing support? 11. What were the primary barriers within your institution or physical therapist program to initiating this international program or project? ● What barriers continue to negatively influence the ongoing running of the international program or project? 12. What were the primary driving forces within your institution or physical therapist program in support of initiating this international program or project? ● What driving forces support the continuance of the international program or project? 13. What are your goals and objectives for the international program or project? ● How do you ensure that these goals and objectives are met? 14. How are students chosen to participate in this international program or project? ● Why do you think students choose to participate? (Continued)

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15. Do students receive academic credit for participating? ● Is this international program or project part of a course? 16. What activities are completed to prepare students to participate in this international program or project? 17. How is travel paid for the faculty and students? ● Are there any fund-raising activities? 18. Who is responsible for travel arrangements? ● Do students purchase travel insurance? ● What are the emergency contingency plans? 19. Are students encouraged to or required to take leadership roles in before, during, or after the international travels? 20. Will you explain the process of getting faculty and students to and from the international site and for securing room and board at the site? 21. Will you explain what service activities faculty and students do while at the international site? 22. Do students participate in reflective activities? Please explain. 23. What barriers do you encounter to success in providing effective service to the community? ● What support is in place to ensure that your service is effective? 24. How do you assess if community needs are met? 25. How do you evaluate the outcomes of the international program or project after you have returned from the international site? 26. Whether or not you have formally completed a program evaluation, what do you perceive are the most important outcomes of this international program or project? 27. Would you describe your international program or project as successful? Please explain why or why not. 28. Realistically, what could you do to improve your international program or project? ● Ideally, what would you do to improve your international program or project? 29. Is there anything else about your international program or project that you would like to share with me? 30. Are you aware of other physical therapist program educators who are involved in international service-learning or other international volunteer service with their students who may be willing to be interviewed for this study?

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Research Report Comparison of Gluteus Medius Muscle Electromyographic Activity During Forward and Lateral Step-up Exercises in Older Adults Vicki Stemmons Mercer, Michael T. Gross, Subhashini Sharma, Erin Weeks

Background. Step-up exercises often are suggested for strengthening the hip abductor muscles and improving balance in older adults. Little is known, however, about whether the forward or lateral version of these exercises is best for activating the hip abductor muscles. Objective. The purpose of this study was to examine the electromyographic (EMG) amplitude of the gluteus medius (GM) muscles bilaterally during forward and lateral step-up exercises.

Design. The study design involved single-occasion repeated measures. Methods. Twenty-seven community-dwelling adults (7 men and 20 women) with a mean (SD) age of 79.4 (8.0) years performed forward and lateral step-up exercises while the surface EMG activity of the GM muscles was recorded bilaterally. Pressure switches and dual forceplates were used to identify the ascent and descent phases. Subjects were instructed to lead with the right lower extremity during ascent and the left lower extremity during descent. Differences in normalized root-mean-square EMG amplitudes with exercise direction (forward versus lateral) and phase (ascent versus descent) were examined by use of separate repeated-measures analyses of variance for the right and left lower extremities. The alpha level was set at .05.

Results. Gluteus medius muscle EMG activity was significantly greater for lateral than for forward step-up exercises for the left lower extremity during the ascent phase and for both lower extremities during the descent phase. In addition, right GM muscle EMG activity was significantly greater during ascent than during descent for both exercise directions.

Limitations. Study limitations include use of a convenience sample and collec-

V.S. Mercer, PT, PhD, is Associate Professor, Division of Physical Therapy, Department of Allied Health Sciences, University of North Carolina at Chapel Hill, CB #7135, Bondurant Hall, Suite 3022, Chapel Hill, NC 275997135 (USA). Address all correspondence to Dr Mercer at: [email protected]. M.T. Gross, PT, PhD, FAPTA, is Professor, Program in Human Movement Science, Division of Physical Therapy, Department of Allied Health Sciences, University of North Carolina at Chapel Hill. S. Sharma, PT, MPT, is Staff Physical Therapist, Sports & More Physical Therapy Inc, Cary, North Carolina. E. Weeks, PT, MPT, is Staff Physical Therapist, Carolinas Rehabilitation (Main), Charlotte, North Carolina. [Mercer VS, Gross MT, Sharma S, Weeks E. Comparison of gluteus medius muscle electromyographic activity during forward and lateral step-up exercises in older adults. Phys Ther. 2009;89:1205–1214.] © 2009 American Physical Therapy Association

tion of limited information about participants.

Conclusions. Step-up exercises are effective in activating the GM muscle, with lateral step-up exercises requiring greater GM muscle activation than forward step-up exercises. Further study is needed to determine whether exercise programs for hip abductor muscle strengthening in older adults should preferentially include lateral over forward step-up exercises.

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

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ompared with younger adults, older adults have greater difficulty maintaining and recovering postural stability, particularly in the frontal plane.1–3 One likely cause of this difficulty is weakness of the hip abductor muscles and other muscles that control frontal-plane or “lateral” stability.4,5 Step-up exercises have been suggested for strengthening the hip abductor muscles and improving balance in older adults.6,7 Step-up exercises often are incorporated into health promotion and fall prevention programs delivered in community contexts.8,9 The benefits of multidisciplinary, communitybased fall prevention programs are well documented, both for unselected populations of older people and for those selected because they have reported concerns about their balance abilities or have a history of falling or other known risk factors.10 Interventions that include strengthening and balance exercises can be effective for fall prevention whether delivered in a group format or as part of an individually prescribed home exercise program.10 –13 As noted by Wang et al,14 step-up exercises may be especially appropriate for older adults because they involve movement patterns similar to those of daily functional activities, such as climbing stairs or negotiating curbs; they can be performed safely in a variety of settings, including the home; and they can be modified for

Available With This Article at www.ptjournal.org • The Bottom Line clinical summary • The Bottom Line Podcast • Audio Abstracts Podcast This article was published ahead of print on September 24, 2009, at www.ptjournal.org.

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different levels of ability simply by varying the step height. Step-up exercises may be more feasible when performed with a step-bench instead of a flight of stairs because many older adults do not have stairs in their homes.14 The step-bench can be placed in front of the individual for forward step-up exercises or to the side for lateral step-up exercises. Sims and Brauer15 demonstrated that forward step-up exercises challenge lateral stability. In a comparison of forward step-up exercises, walking, and chair sit-stand-sit activities in older adults who were sedentary, Wang and colleagues16 reported that the forward step-up exercises generated the greatest overall dynamic hip moments. In addition, the hip moments generated during the forward step-up exercises were strongly correlated with hip bone mass in women but not in men in that study. Hip abduction moments explained up to 88% of the variance in bone mineral content and bone mineral density at the femoral neck and proximal femur in women. Unfortunately, little is known about whether the forward or the lateral step-up exercise is the preferred exercise for activating the hip abductor muscle groups in older adults. Wang and colleagues14 used an inverse dynamics approach to determine peak net joint moments at the hip, knee, and ankle during forward and lateral step-up activities. These researchers concluded that frontal-plane hip moments were similar for the 2 step-up directions. No previous researchers, however, made direct comparisons of the exercises in terms of gluteus medius (GM) muscle activation. The purpose of this study was to examine the electromyographic (EMG) amplitude of the GM muscles bilaterally during forward and lateral step-up exercises. We hypothesized that GM muscle EMG amplitudes

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would be greater during lateral than during forward step-up exercises because of the greater movement of the center of mass in the frontal plane during lateral step-up exercises. We also hypothesized that for both exercises, GM muscle EMG amplitudes would be greater during the ascent phase than during the descent phase because ascent involves more concentric muscle contraction, which has been associated with higher levels of EMG activity.17

Method Participants Participants in the study were 28 community-dwelling older adults. The study was powered by the ability to detect a 10% difference in mean EMG amplitudes between lateral and forward step-ups. On the basis of data from previous studies,15,17 an estimated sample size of 27 was needed to provide a power of .80 at an alpha level of .05. Participants were recruited through a mass e-mail at the University of North Carolina at Chapel Hill (UNCCH) campus, presentations at senior centers and continuing care retirement communities, and posting of flyers. Potential participants were screened by telephone interview. Inclusion criteria were an age of 65 years or older, the ability to read and speak English, the ability to ambulate independently in the community (including up and down curbs), the ability to follow instructions and perform all experimental procedures, normal or corrected-to-normal vision and hearing (by self-report), and a reported preference for using the right lower extremity for skilled movement (in response to the question, “Which foot would you use to kick a ball?”). Volunteers were excluded if they had a diagnosed neurological disease or disorder (eg, stroke, Parkinson disease), pain when ascending or descending curbs or stairs (by self-report), acute back or November 2009

EMG Activity During Step-up Exercises in Older Adults lower-extremity musculoskeletal problems (eg, strain, sprain, fracture), or medical conditions that might make step-up exercises unsafe (eg, unstable angina, myocardial infarction within the preceding 6 months, congestive heart failure within the preceding 12 months, unstable chronic obstructive disease requiring 2 or more hospitalizations within the preceding 12 months, uncontrolled hypertension, uncontrolled diabetes mellitus). Thirty-nine people volunteered for the study and completed the telephone screening. The 28 volunteers who remained eligible for the study after the telephone screening were scheduled for a single testing session at the Center for Human Movement Science at UNC-CH. Written informed consent was obtained at the start of the laboratory test session with forms and procedures approved by the UNC-CH Biomedical Institutional Review Board. Each participant’s ability to perform the exercises with appropriate sequencing and timing was determined by asking him or her to complete 3 or 4 practice attempts for each exercise. One participant was unable to perform the exercises without assistance and, therefore, was excluded from further participation in the study. The characteristics of the remaining 27 participants are shown in Table 1. Data Collection EMG set-up. Each participant’s height and weight were measured and recorded. A 16-channel telemeter EMG system* was used to record GM muscle activity bilaterally. The skin over the posterolateral gluteal region was cleansed with alcohol. Active surface electrodes (Neuroline†; pregelled, silver-silver chlo-

* Konigsberg Instruments Inc, 2000 E Foothill Blvd, Pasadena, CA 91107. † Ambu Inc, 740 Baymeadow Dr, Glen Burnie, MD 21060.

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Table 1. Participant Characteristics Characteristic

No. (%)

Age, y

X (SD)

Range

79.4 (8.0)

65–97

Sex Women Men

20 (74) 7 (26)

Weight (kg)

68.7 (13.7)

Height (cm)

166.9 (9.5)

ride, bipolar disposable electrodes) were attached to the skin over the GM muscle belly 2 to 3 cm distal to the midpoint of the iliac crest.18 The electrodes were configured parallel to the GM muscle fibers. Each electrode surface was 15 mm in diameter, and the interelectrode distance, from center to center, was 20 mm. A common reference electrode was placed on the skin overlying the anteromedial aspect of the proximal right tibia. Electrode placements were verified by manual muscle testing techniques to minimize cross talk. Wires from the electrodes were connected to a small transmitter that was carried on the participant’s back. The differential amplifier of the EMG system had an input impedance of greater than 1.0 M⍀, a common-mode rejection ratio of greater than 90 dB, and a signal-tonoise ratio of greater than 50 dB. The raw analog signals were band-pass filtered from 10 to 1,000 Hz before output to a 16-bit analog-to-digital converter. The signals were sampled at 1,000 Hz per channel and recorded with Peak Motus‡ software.§ ‡ Peak Performance Technologies, 7388 S Revere Pkwy, Suite 603, Englewood, CO 80112. § To ensure that aliasing of the EMG signals did not occur during data collection for this study, we performed additional testing with 1 participant under experimental conditions identical to those used in the original study. During this testing, the GM muscle EMG signal was sampled at 2,000 Hz and then resampled at 1,000 Hz. Root-mean-square amplitudes were computed from both sets of data and were virtually identical, with a mean difference between the 2 data sets of only 0.2%.

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49.9–97.5 149.9–188.0

EMG normalization. Because of the repeated-measures design of the study, with contrasts being made on the same day and on the same muscle without removal of the electrodes, normalization of the EMG data was not required. Nevertheless, we chose to normalize the data to allow comparisons with similar data from other studies and to provide a basis for interpretation of the relative amount of muscle activation.19 For the normalization procedure, participants were asked to lie on one side on a padded high-low table. The participant raised the upper lower extremity so that the extremity was level with the lateral aspect of the trunk and the hip joint was in approximately 0 degrees of abduction; this position was maintained against gravity for 8 seconds while GM muscle EMG activity for that extremity was recorded. The knee joint was extended, and the hip joint was maintained in a neutral position with respect to flexion/extension and medial (internal) rotation/lateral (external) rotation during the normalizing muscle contraction. This procedure was repeated with the other lower extremity. Submaximal muscle contractions similar to the normalizing muscle contraction are considered by some authors to be more reliable and accurate as a means of normalization than maximal muscle contractions.15,20 –22 Step-up exercises. A step measuring 90 cm wide, 21.5 cm high, and

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EMG Activity During Step-up Exercises in Older Adults sure switches secured to the step were used to record the contact of each foot with the step.

Figure 1. Representative data for a single participant performing lateral step-up exercises. Traces from top to bottom are as follows: pressure-switch data indicating contact of the right (R) foot with the step; pressure-switch data indicating contact of the left (L) foot with the step; vertical ground reaction forces under the right foot (Fz1), indicating contact of the right foot with the floor; vertical ground reaction forces under the left foot (Fz2), indicating contact of the left foot with the floor; raw electromyographic (EMG) data from the right gluteus medius (RGM) muscle; and raw EMG data from the left gluteus medius (LGM) muscle. The dashed vertical lines indicate a single step-up, including the ascent phase (from A to B) and the descent phase (from B to C).

29.5 cm deep was used for the step-up exercises. The order of performance of the exercises (forward versus lateral) was randomized. For both exercises, the participant stood on separate side-by-side forceplates㛳 embedded in the floor. Each of the 2 forceplates measured 40 cm (in the medial-lateral direction) by 60 cm (in the anterior-posterior direction), with combined forceplate dimensions of 80 by 60 cm. The participant stood at the juncture of the 2 forceplates, with 1 foot on each forceplate. The participant stepped up onto the step (which was not in contact with the forceplates) with the right foot leading and then stepped back down onto the forceplates with the left foot leading. The participant maintained the same starting position on the forceplates for both ex㛳

Bertec Corp, 6171 Huntley Rd, Suite J, Columbus, OH 43229.

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ercises, but the step was moved in front of or to the right side of the participant for forward and lateral step-up exercises, respectively. The step was positioned just in front of the forceplates for forward step-ups and straddling the forceplates in an anterior-posterior direction for lateral step-ups. For forward step-ups, participants positioned themselves behind the step at whatever distance was comfortable for them. They could move within the 60-cm anterior-posterior dimension of the forceplates. For lateral step-up exercises, the step was positioned only far enough to the participant’s right side to allow room for the right foot to come down (on the right forceplate) and the left foot to come down (on the left forceplate) at a normal stance width. The forceplates were used to record ground reaction forces under each foot separately, and pres-

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For each exercise, the researchers demonstrated the required movements, and participants practiced until they reported being comfortable with the exercise. Participants were instructed to lead with the right lower extremity during ascent and the left lower extremity during descent for both exercises. A metronome set at 66 beats per minute was used to pace the participants’ movements, with movement of 1 foot per beat (right foot up, left foot up, left foot down, right foot down). Participants performed 3 sets of 8 repetitions for each exercise, with rest periods of approximately 2 minutes between sets and 5 minutes between exercises. One additional set of 8 repetitions was performed if a participant stepped with the wrong sequence or experienced a visible loss of balance requiring assistance from a spotter. Forceplate and pressureswitch signals were sampled along with the raw EMG signals at 1,000 Hz. Data Reduction Data were exported from Peak Motus software and imported to DATAPAC 2K2# software for reduction. Pressure-switch and vertical ground reaction force data were used to identify the beginning and end of each movement component (Fig. 1). The ascent phase was defined as the time from right foot contact with the floor (forceplate) to left foot contact with the step (pressure switch). The descent phase was defined as the time from left foot contact with the step to right foot contact with the floor. From the 24 steps (3 sets ⫻ 8 repetitions per set⫽24) of each exercise performed by each participant, 6 to 12 steps were selected for # RUN Technologies, 22702 Via Santa Maria, Mission Viejo, CA 92691.

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EMG Activity During Step-up Exercises in Older Adults analysis. The middle 4 of the 8 steps in each set were selected, unless participant foot placement or movement artifacts reduced the clarity of the force platform, pressure-switch, or EMG signals. In these situations, the step(s) closest in time to the deleted step(s) was (were) selected. The mean (SD) numbers of steps included in the analysis per participant were 10.0 (2.2) steps for forward step-up exercises and 9.9 (2.4) steps for lateral step-up exercises. The durations of the ascent and descent phases of each step were determined. The EMG signals recorded for the left and right GM muscles during stepup exercises and during the standard submaximal contraction were smoothed by use of a root-meansquare (RMS) envelope with a time constant of 30 milliseconds. The RMS EMG amplitudes of the left and right GM muscles were then calculated for the ascent and descent phases of each step as well as for the middle 5 seconds of the 8-second standard submaximal contraction. The mean RMS values for the forward and lateral step-up trials for each participant were normalized by dividing them by the RMS values obtained for that participant during the submaximal contraction of the respective GM muscle (left or right). Consequently, the EMG amplitude was expressed as a percentage of the standard submaximal contraction for each muscle. Data Analysis Statistical analyses were completed with SYSTAT** version 5.0 software. Descriptive statistics were calculated for phase durations and RMS EMG values for the right and left GM muscles. Because many fewer men (n⫽7) than women (n⫽20) participated in this study, we examined the ** SYSTAT Inc, 1800 Sherman Ave, Evanston, IL 60201.

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Figure 2. Mean durations of ascent and descent phases during forward and lateral step-up exercises. Error bars represent 1 standard deviation.

data for any obvious differences in GM muscle activation between these 2 groups. We calculated the means for each EMG measure by sex and determined the rank ordering of these means. An intraclass correlation coefficient (ICC [3,6])23 and the standard error of measurement (SEM)24 were used to examine the within-subject reliability of the EMG amplitudes. The form of the ICC used in this analysis (ICC [3,k]) is appropriate because of the need to determine the withinsubject reliability of the EMG data for this particular study only (ICC model 3) and the use of a mean of 6 to 12 steps for each participant for each EMG measure (form k, in which the designation of k equals the number of values used to obtain the mean).23,24 Because data for at least 6 steps were available for all participants, the ICC (3,6) was used. The ICC (3,6) calculation was based on the first 6 (of up to 12) steps of each exercise selected for each participant. The SEM was estimated by mulVolume 89

tiplying the standard deviation of the EMG amplitudes for each exercise by the square root of 1 minus the ICC (3,6).24 To compare EMG amplitudes by exercise direction and phase, we entered mean normalized RMS EMG values for each participant into a 2 ⫻ 2 (step-up direction ⫻ phase) repeated-measures analysis of variance (ANOVA). Separate ANOVAs were performed for the right and left GM muscles. The level of significance was set at an ␣ value of .05.

Results Phase durations were similar for ascent and descent for both directions of the step-up exercises (Fig. 2). This timing is consistent with the metronome pacing which, if followed precisely, would have produced stepups lasting 3,600 milliseconds, with ascent and descent phases of 1,800 milliseconds each. The ICC (3,6) and SEM values for the EMG amplitudes are shown in Number 11

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EMG Activity During Step-up Exercises in Older Adults Table 2. Repeatability of Measurements of Gluteus Medius (GM) Muscle Electromyographic (EMG) Amplitudesa EMG Amplitude of: Left GM Muscle Exercise (Phase)

Right GM Muscle

ICC (3,6)

SEM

ICC (3,6)

SEM

Forward step-up (ascent)

.96

14.12

.97

11.13

Forward step-up (descent)

.99

7.81

.98

6.79

Lateral step-up (ascent)

.99

7.80

.99

7.62

Lateral step-up (descent)

.99

7.75

.97

8.56

a

ICC⫽intraclass correlation coefficient, SEM⫽standard error of measurement, expressed as a percentage of the standard submaximal contraction.

Table 2. The ICC (3,6) values ranged from .96 to .99 for the forward step-up exercises and from .97 to .99 for the lateral step-up exercises. The SEM was less than 15% for all EMG variables and was particularly low (⬍7%) for the right GM muscle during the descent phase of the forward step-up exercises and both phases of the lateral step-up exercises. The results of the ANOVAs for EMG amplitudes generally supported our hypotheses that the values would be greater for lateral than for forward step-up exercises and greater for the ascent phase than for the descent phase. Because the normalization procedure involved dividing the RMS EMG values by a muscle-specific constant (the normalization value) for each participant, the results of the ANOVAs were the same for nonnormalized and normalized EMG values. Only the results obtained with the normalized data are presented.

For the right GM muscle, the mean (SD) EMG amplitudes ranged from 108.0% (43.8%) to 157.7% (64.4%) of the standard submaximal contraction (Tab. 3). A significant interaction effect (F1,26⫽9.65, P⫽.005) was found. Tests of simple main effects revealed that normalized right GM muscle EMG amplitudes were greater for lateral than for forward step-up exercises, but only during the descent phase (F1,52⫽9.81, P⫽.003). Normalized right GM muscle EMG amplitudes were greater during the ascent phase than during the descent phase for both directions of step-up exercises (F1,52⫽69.08 for forward step-ups, F1,52⫽37.56 for lateral step-ups; P⬍.001). For the left GM muscle, the mean (SD) EMG amplitudes ranged from 128.9% (82.3%) to 147.0% (71.2%) of the standard submaximal muscle contraction (Tab. 3). A main effect of exercise direction was found

Table 3. Normalized Root-Mean-Square (RMS) Electromyographic (EMG) Amplitudes of Gluteus Medius (GM) Muscles During Step-up Exercises X (SD) RMS EMG Amplitude of: Left GM Muscle

Right GM Muscle

Forward step-up (ascent)

131.4 (68.9)

154.6 (65.4)

Forward step-up (descent)

128.9 (82.3)

108.0 (43.8)

Lateral step-up (ascent)

147.0 (71.2)

157.7 (64.4)

Lateral step-up (descent)

138.3 (77.5)

123.3 (53.1)

Exercise (Phase)

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(F1,26⫽7.59, P⫽.011), but the main effect of phase and the interaction between phase and step-up direction were not statistically significant. Muscle activation was greater during lateral step-ups than during forward step-ups for both exercise phases. Although the mean EMG amplitudes appeared to be lower for men than for women by visual inspection, the rank ordering of the means for each combination of exercise direction and phase was the same for both sexes for the right and left GM muscles. For the right GM muscle, the mean (SD) EMG amplitudes were lowest during the descent phase of the forward step-up exercise, measuring 88.0% (42.1%) in men and 115.1% (43.2%) in women, and highest during the ascent phase of the lateral step-up exercise, measuring 141.3% (68.7%) in men and 163.4% (63.6%) in women. For the left GM muscle, the mean (SD) EMG amplitudes ranged from lows of 89.3% (32.8%) in men and 142.7% (90.3%) in women during the descent phase of forward step-ups to highs of 121.3% (31.8%) in men and 156.0% (79.3%) in women during the ascent phase of lateral step-ups.

Discussion In the present study, we found greater GM muscle activity during lateral than during forward step-up exercises in older adults. The ICC (3,6) values indicated that our participants had relatively consistent levels of GM muscle activation across repetitions of step-up exercises. These results have implications for exercise recommendations, as the torquegenerating capabilities of the GM muscles appear to be critical for the maintenance and recovery of balance under a variety of circumstances.25,26 Several researchers have suggested that the hip abductor muscles should be critical targets for assessment and, if indicated, resistance November 2009

EMG Activity During Step-up Exercises in Older Adults strength (force-generating capacity) training in older adults.27–29 Physical therapists may prescribe step-up exercises for hip abductor muscle strengthening in a variety of contexts, ranging from the development of individualized exercise programs for people with known balance difficulties to the design of communitybased fall prevention programs. The amount of GM muscle activation displayed by our participants varied from approximately 108% to 158% of that required to hold the limb against gravity in a side-lying position. The external torque applied during this normalizing muscle contraction was relatively large, equaling the gravitational force of the lower extremity (approximately 16% of body mass) times the external moment arm, which is appreciably longer in a sidelying position than in a standing position.30 In a study of young adults who were healthy, Bolgla and Uhl30 reported right GM muscle EMG amplitudes for exercises involving right hip abduction during side lying and abduction of the left hip during standing on the right lower extremity. These exercises were performed with an ankle cuff weight equal to 3% of the body mass on the moving limb and produced mean (SD) EMG activity levels ranging from 42% (23%) to 46% (34%) of the maximum voluntary isometric contraction (MVIC). In a study of 30 subjects ranging in age from 19 to 58 years, Ekstrom et al31 reported mean (SD) GM muscle EMG activity levels of 39% (17%) of the MVIC for active hip abduction during side lying and 43% (18%) of the MVIC for lateral step-up exercises. The GM muscle EMG signal amplitudes reported for these hip abduction exercises in young and middle-aged adults approached 45% of the MVIC, a level that has been suggested to represent a sufficient

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stimulus for strength gains in some people.31 Because the level of maximum muscle strength is lower in older adults than in younger adults,32–34 older adults must use a larger percentage of their neuromuscular capacity for daily tasks.29,35 This fact was shown specifically for the GM muscle in a study by Hahn et al,29 in which older adults displayed normalized EMG activation percentages that were approximately twice those of younger adults for level walking and for obstacle negotiation at most obstacle heights tested. This fact makes it likely that the GM muscle is activated at proportionally higher levels in older adults than in younger adults during both weight-bearing and non–weight-bearing hip abductor muscle exercises. Depending on their initial strength level, some older adults may need to add ankle cuff weights or similar resistance during hip abductor muscle exercises to obtain a strengthening response.31 For symmetrical strengthening, logic would dictate that step-up exercises be performed on both sides instead of only on the right, as in the present study. In both forward and lateral step-up exercises, the GM muscles either moved or stabilized the hip and pelvis in the frontal plane during the performance of each movement phase.15,30 Activation of the GM muscle on the side of the lower extremity that is to be lifted from the support surface has been shown to contribute to the acceleration of the body’s center of mass toward the upcoming stance limb.36 – 40 Subsequent activation of the GM muscle on the side of the stance limb helps to control the extent of this lateral weight shift36 –38 and, especially if the leading limb is being placed on a step or other higher level, to elevate the pelvis on the swing side.41 Because of the greater frontal-plane Volume 89

movement associated with lateral than with forward step-up exercises, we expected greater GM muscle activation in lateral step-up exercises; our results were consistent with this expectation. The significant interaction observed between step-up direction and phase for the right GM muscle in the present study may be explained by the different biomechanical demands placed on the 2 lower extremities during the ascent and descent phases. We offer the following as a possible explanation of this interaction effect, although we do not have kinematic data to support it. Much of the control of lateral displacement of the center of mass may be accomplished by the left GM muscle during ascent.36 – 40 The right GM muscle may play a similar role during ascent in both exercise directions by helping to control pelvic position as the center of mass moves upward and over the right foot.42 During descent, however, unilateral stance is maintained on the right lower extremity as the left foot is lowered to the floor. Because of the more lateral placement of the left foot during lateral than during forward step-up exercises, the right GM muscle theoretically must generate a larger internal torque to counterbalance the mass of the head, arms, trunk, and more abducted left lower extremity30 and to assist with the greater lateral displacement of the body’s center of mass.37,43 We suggest that internal frontalplane hip moments may be greater in lateral than in forward step-up exercises because of the greater lateral excursion of the center of mass during the former exercise. Our finding of greater GM muscle activity during lateral step-up exercises is consistent with this suggestion. In a direct comparison of forward and lateral step-up exercises, however, Wang et al14 reported that peak net hip moments in the frontal plane did not Number 11

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EMG Activity During Step-up Exercises in Older Adults differ between step-up conditions or movement phases. A possible explanation for these conflicting results is that Wang et al14 allowed subjects to use upper-extremity support from a “safety bar,” which was monitored for vertical but not lateral forces and which may have limited the requirements for frontal-plane stabilization. Another possibility is that subjects in that study were stepping closer to the step during lateral step-up exercises, as subject foot placement was not constrained by the size of the forceplates, as in the present study. In addition, subjects in the study of Wang et al14 were instructed not to push off with the trailing leg during ascent, whereas subjects in the present study were not given specific instructions about movement strategies. Wang et al14 did not consider exercise speed, number of repetitions to be performed, or coactivation of antagonistic muscle groups in their investigation. Right GM muscle EMG amplitudes were greater overall during ascent than during descent. This finding is consistent with our expectation of greater concentric GM muscle activity during ascent41 and with previous reports of greater EMG amplitudes during concentric than during eccentric muscle contractions.44 – 46 However, it is important to recognize that the relationship between EMG activity and muscle force is not linear.44 This relationship is affected by factors such as muscle length, recruitment patterns, and rate of contraction. Consequently, comparisons of normalized EMG activity across types of contraction should be interpreted with caution.46 The elastic properties of the right GM muscle may have contributed to the torque generated during descent and may have decreased the amount of EMG activity required.47,48 The present study had several limitations. We used a sample of conve1212

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nience and did not collect detailed information about medical history, fall history, physical activity level, or other participant characteristics. We would describe our participants as healthy, active, independent community dwellers who, admittedly, may have differed in important respects from people likely to seek intervention for balance concerns. Also, our sample included only a small number of male participants. We had no reason to expect that the pattern of results would differ according to sex, however, and our visual inspection of the data confirmed the same rank ordering of the means for both men and women in our sample. Another methodological limitation was that we did not perform repeat testing of the normalization contraction; therefore, we were unable to measure its test-retest reliability. Although this limitation may affect the interpretation of the absolute muscular effort expressed as a percentage of the standard submaximal contraction, the within-subject design of our study provided a solid basis for comparisons of muscular effort among exercise conditions. Additional methodological considerations were the strategies used by our participants and the environmental constraints that may have affected these strategies. To more closely approximate exercise performance in nonlaboratory settings, we specifically avoided giving subjects instructions about positions or movements to use or not use when performing the exercises. Although we did not observe any deviations in trunk or lowerextremity alignment as our participants performed the exercises, these variables were not measured. On the other hand, the location of the step relative to the 2 forceplates during lateral step-up exercises may have produced lateral steps larger than those that would occur typically in nonlaboratory settings. Differences in strategies for dealing with task de-

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mands may have contributed to the between-subject variability observed in GM muscle EMG amplitudes. Our results indicate that step-up exercises produce bilateral GM muscle activation but do not address the benefits of other exercises or training in other aspects of muscle force generation, such as rate of force development. Other types of training, especially balance training, have been effective in reducing fall risk in older adults.49 –51 In addition, we did not investigate other muscles (besides the GM muscles) that control frontal-plane motion. Other researchers have reported that activation of the hip adductor muscle37,40 and the superior portion of the gluteus maximus muscle,52 as well as passive restraint by the iliotibial tract,53 may contribute to frontal-plane postural control.

Conclusion Lateral step-up exercises are associated with greater GM muscle activity than forward step-up exercises in older adults. This result holds true for the trailing extremity during the ascent phase and for both lower extremities during the descent phase. Further study is needed to determine whether exercise programs incorporating lateral step-up exercises are more beneficial for hip abductor muscle strengthening in older adults than programs incorporating forward step-up exercises or other types of exercises. Dr Mercer provided concept/idea/research design, project management, and facilities/ equipment. Dr Mercer, Dr Gross, and Ms Sharma provided writing. Dr Mercer, Ms Sharma, and Ms Weeks provided data collection and subjects. All authors provided data analysis. Dr Gross provided consultation (including review of manuscript before submission). This study was approved by the Biomedical Institutional Review Board at the University of North Carolina at Chapel Hill. This research was presented at the Combined Sections Meeting of the American

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EMG Activity During Step-up Exercises in Older Adults Physical Therapy Association; February 6 –9, 2008; Nashville, Tennessee. This article was submitted July 29, 2008, and was accepted July 20, 2009. DOI: 10.2522/ptj.20080229

References 1 Maki BE, Holliday PJ, Topper AK. A prospective study of postural balance and risk of falling in an ambulatory and independent elderly population. J Gerontol. 1994; 49:M72–M84. 2 McIlroy WE, Maki BE. Age-related changes in compensatory stepping in response to unpredictable perturbations. J Gerontol A Biol Sci Med Sci. 1996;51:M289 –M296. 3 McIlroy WE, Maki BE. The control of lateral stability during rapid stepping reactions evoked by antero-posterior perturbation: does anticipatory control play a role? Gait Posture. 1999;9:190 –198. 4 Maki BE, Edmondstone MA, McIlroy WE. Age-related differences in laterally directed compensatory stepping behavior. J Gerontol A Biol Sci Med Sci. 2000;55: M270 –M277. 5 Rogers MW, Mille ML. Lateral stability and falls in older people. Exerc Sport Sci Rev. 2003;31:182–187. 6 Sherrington C, Lord SR, Herbert RD. A randomized controlled trial of weight-bearing versus non-weight-bearing exercise for improving physical ability after usual care for hip fracture. Arch Phys Med Rehabil. 2004;85:710 –716. 7 Steadman J, Donaldson N, Kalra L. A randomized controlled trial of an enhanced balance training program to improve mobility and reduce falls in elderly patients. J Am Geriatr Soc. 2003;51:847– 852. 8 Bean JF, Herman S, Kiely DK, et al. Increased velocity exercise specific to task (InVEST) training: a pilot study exploring effects on leg power, balance, and mobility in community-dwelling older women. J Am Geriatr Soc. 2004;52:799 – 804. 9 Shaw JM, Snow CM. Weighted vest exercise improves indices of fall risk in older women. J Gerontol A Biol Sci Med Sci. 1998;53:M53–M58. 10 Gillespie LD, Gillespie WJ, Robertson MC, et al. Interventions for preventing falls in elderly people. Cochrane Database Syst Rev. 2003;(4):CD000340. 11 Banez C, Tully S, Amaral L, et al. Development, implementation, and evaluation of an interprofessional falls prevention program for older adults. J Am Geriatr Soc. 2008;56:1549 –1555. 12 Day L, Fildes B, Gordon I, et al. Randomised factorial trial of falls prevention among older people living in their own homes. BMJ. 2002;325:128. 13 Robitaille Y, Laforest S, Fournier M, et al. Moving forward in fall prevention: an intervention to improve balance among older adults in real-world settings. Am J Public Health. 2005;95:2049 –2056.

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14 Wang MY, Flanagan S, Song JE, et al. Lower-extremity biomechanics during forward and lateral stepping activities in older adults. Clin Biomech (Bristol, Avon). 2003;18:214 –221. 15 Sims KJ, Brauer SG. A rapid upward step challenges medio-lateral postural stability. Gait Posture. 2000;12:217–224. 16 Wang MY, Flanagan SP, Song JE, et al. Relationships among body weight, joint moments generated during functional activities, and hip bone mass in older adults. Clin Biomech (Bristol, Avon). 2006;21: 717–725. 17 Kellis E, Baltzopoulos V. Muscle activation differences between eccentric and concentric isokinetic exercise. Med Sci Sports Exerc. 1998;30:1616 –1623. 18 Leis AA, Trapani VC. Atlas of Electromyography. New York, NY: Oxford University Press; 2000. 19 Soderberg GL, Knutson LM. A guide for use and interpretation of kinesiologic electromyographic data. Phys Ther. 2000;80: 485– 498. 20 Kollmitzer J, Ebenbichler GR, Kopf A. Reliability of surface electromyographic measurements. Clin Neurophysiol. 1999;110: 725–734. 21 Yang JF, Winter DA. Electromyography reliability in maximal and submaximal isometric contractions. Arch Phys Med Rehabil. 1983;64:417– 420. 22 Sims KJ, Richardson CA, Brauer SG. Investigation of hip abductor activation in subjects with clinical unilateral hip osteoarthritis. Ann Rheum Dis. 2002;61:687– 692. 23 Shrout PE, Fleiss JL. Intraclass correlations: uses in assessing rater reliability. Psych Bull. 1979;86:420 – 428. 24 Portney LG, Watkins MP, eds. Foundations of Clinical Research: Applications to Practice. 2nd ed. Upper Saddle River, NJ: Prentice-Hall Inc; 2000. 25 Rogers MW, Hedman LD, Johnson ME, et al. Lateral stability during forwardinduced stepping for dynamic balance recovery in young and older adults. J Gerontol A Biol Sci Med Sci. 2001;56:M589 – M594. 26 Maki BE, McIlroy WE. Control of rapid limb movements for balance recovery: age-related changes and implications for fall prevention. Age Ageing. 2006; 35(suppl 2):ii12–ii18. 27 Chang SH, Mercer VS, Giuliani CA, Sloane PD. Relationship between hip abductor rate of force development and mediolateral stability in older adults. Am Phys Med Rehabil. 2005;86:1843–1850. 28 Hilliard MJ, Martinez KM, Janssen I, et al. Lateral balance factors predict future falls in community-living older adults. Am Phys Med Rehabil. 2008;89:1708 –1713. 29 Hahn ME, Lee HJ, Chou LS. Increased muscular challenge in older adults during obstructed gait. Gait Posture. 2005;22:356 – 361. 30 Bolgla LA, Uhl TL. Electromyographic analysis of hip rehabilitation exercises in a group of healthy subjects. J Orthop Sports Phys Ther. 2005;35:487– 494.

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31 Ekstrom RA, Donatelli RA, Carp KC. Electromyographic analysis of core trunk, hip, and thigh muscles during 9 rehabilitation exercises. J Orthop Sports Phys Ther. 2007;37:754 –762. 32 El Haber N, Erbas B, Hill KD, Wark JD. Relationship between age and measures of balance, strength and gait: linear and nonlinear analyses. Clin Sci (Lond). 2008;114: 719 –727. 33 Johnson ME, Mille ML, Martinez KM, et al. Age-related changes in hip abductor and adductor joint torques. Am Phys Med Rehabil. 2004;85:593–597. 34 Frontera WR, Hughes VA, Fielding RA, et al. Aging of skeletal muscle: a 12-yr longitudinal study. J Appl Physiol. 2000;88: 1321–1326. 35 Landers KA, Hunter GR, Wetzstein CJ, et al. The interrelationship among muscle mass, strength, and the ability to perform physical tasks of daily living in younger and older women. J Gerontol A Biol Sci Med Sci. 2001;56:B443–B448. 36 Brunt D, Santos V, Kim HD, et al. Initiation of movement from quiet stance: comparison of gait and stepping in elderly subjects of different levels of functional ability. Gait Posture. 2005;21: 297–302. 37 Kirker SG, Simpson DS, Jenner JR, Wing AM. Stepping before standing: hip muscle function in stepping and standing balance after stroke. J Neurol Neurosurg Psychiatry. 2000;68:458 – 464. 38 Mercer VS, Sahrmann SA. Postural synergies associated with a stepping task. Phys Ther. 1999;79:1142–1152. 39 Rogers MW, Pai YC. Organization of preparatory postural responses for the initiation of lateral body motion during goal directed leg movements. Neurosci Lett. 1995;187:99 –102. 40 Rogers MW, Pai YC. Dynamic transitions in stance support accompanying leg flexion movements in man. Exp Brain Res. 1990;81:398 – 402. 41 Nadeau S, McFadyen BJ, Malouin F. Frontal and sagittal plane analyses of the stair climbing task in healthy adults aged over 40 years: what are the challenges compared to level walking? Clin Biomech (Bristol, Avon). 2003;18:950 –959. 42 McFadyen BJ, Winter DA. An integrated biomechanical analysis of normal stair ascent and descent. J Biomech. 1988;21: 733–744. 43 Mickelborough J, van der Linden ML, Tallis RC, Ennos AR. Muscle activity during gait initiation in normal elderly people. Gait Posture. 2004;19:50 –57. 44 Solomonow M, Baratta R, Shoji H, D’Ambrosia R. The EMG-force relationships of skeletal muscle; dependence on contraction rate, and motor units control strategy. Electromyogr Clin Neurophysiol. 1990;30:141–152. 45 Selseth A, Dayton M, Cordova ML, et al. Quadriceps concentric EMG activity is greater than eccentric EMG activity during the lateral step-up exercise. J Sport Rehabil. 2000;9:124 –134.

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EMG Activity During Step-up Exercises in Older Adults 46 Brask B, Lueke RH, Soderberg GL. Electromyographic analysis of selected muscles during the lateral step-up exercise. Phys Ther. 1984;64:324 –329. 47 Thys H, Faraggiana T, Margaria R. Utilization of muscle elasticity in exercise. J Appl Physiol. 1972;32:491– 494. 48 Komi PV, Linnamo V, Silventoinen P, Sillanpaa M. Force and EMG power spectrum during eccentric and concentric actions. Med Sci Sports Exerc. 2000;32: 1757–1762.

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49 Gillespie LD, Gillespie WJ, Robertson MC, et al. Interventions for preventing falls in elderly people. Cochrane Database Syst Rev. 2001;(3):CD000340. 50 Nitz JC, Choy NL. The efficacy of a specific balance-strategy training programme for preventing falls among older people: a pilot randomised controlled trial. Age Ageing. 2004;33:52–58. 51 Sihvonen S, Sipila S, Taskinen S, Era P. Fall incidence in frail older women after individualized visual feedback-based balance training. Gerontology. 2004;50:411– 416.

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52 Lyons K, Perry J, Gronley JK, et al. Timing and relative intensity of hip extensor and abductor muscle action during level and stair ambulation: an EMG study. Phys Ther. 1983;63:1597–1605. 53 Evans P. The postural function of the iliotibial tract. Ann R Coll Surg Engl. 1979; 61:271–280.

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Research Report

Associations of Supported Treadmill Stepping With Walking Attainment in Preterm and Full-Term Infants Hong-Ji Luo, Pei-Shan Chen, Wu-Shiun Hsieh, Kwan-Hwa Lin, Tung-Wu Lu, Wei J. Chen, Suh-Fang Jeng

Background. Treadmill training in supported stepping has been used as part of rehabilitation programs for children with neurodevelopmental problems to facilitate earlier onset of walking. However, information concerning the developmental continuity between supported stepping and walking is limited. Objective. The aims of this study were to longitudinally examine supported stepping in preterm and full-term infants and to explore the step parameters associated with walking attainment.

Design. A cohort study with a longitudinal follow-up design was used. Methods. Twenty-nine preterm infants and 20 full-term infants were examined bimonthly with supported stepping on a treadmill from 7 months of age until walking attainment or 18 months of corrected age. The associations between step variables and walking outcome were examined using Cox proportional hazard regression and logistic regression.

Results. Walking attainment for preterm infants was later than for full-term infants (median⫽12.8 versus 11 months, respectively). The percentage of alternating steps, hip-knee correlation, hip-ankle correlation, and asymmetry ratio (AR) of stance time of stepping movement from 7 to 9 months of corrected age were found to be associated with age of walking attainment in all infants. Manifestation of at least 3 of 4 step features (ie, ⱖ80% alternating steps, ⱕ.37 hip-knee correlation, ⱖ.73 hip-ankle correlation, and ⱕ1.40 AR of stance time) at 7 months predicted walking attainment prior to 11 months of corrected age (accuracy⫽75%–77%). Failure to achieve such competencies at 7 or 9 months of corrected age was predictive of failure in walking attainment by 15 months (accuracy⫽72%–98%).

Limitations. The limitations of this study included a small sample size and commencement of stepping assessment as early as 7 months of corrected age.

Conclusions. The emergence of walking may involve cooperation of alternating pattern generation, interjoint coordination, and interlimb coordination in supported stepping in preterm and full-term infants. The identified step predictors may assist clinicians in designing appropriate treadmill training programs for those infants with delayed walking.

H.-J. Luo, PT, MS, is a doctoral student, School and Graduate Institute of Physical Therapy, National Taiwan University College of Medicine, Taipei, Taiwan, and Lecturer, Department of Physical Therapy, Hungkuang University, Taichung, Taiwan. P.-S. Chen, PT, MS, is Physical Therapist, Department of Physical Medicine and Rehabilitation, National Taiwan University Hospital. W.-S. Hsieh, MD, is Associate Professor, Department of Pediatrics, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan. K.-H. Lin, PT, PhD, is Professor, School and Graduate Institute of Physical Therapy, National Taiwan University College of Medicine, and Physical Therapist, Physical Therapy Center, National Taiwan University Hospital. T.-W. Lu, DPhil, is Professor, Institute of Biomedical Engineering, National Taiwan University. W.J. Chen, MD, ScD, is Professor, Graduate Institute of Epidemiology, College of Public Health, National Taiwan University. S.-F. Jeng, PT, ScD, is Professor, School and Graduate Institute of Physical Therapy, National Taiwan University College of Medicine, and Director, Physical Therapy Center, National Taiwan University Hospital, Taipei 100, Taiwan. Address all correspondence to Dr. Jeng at: [email protected]. [Luo H-J, Chen P-S, Hsieh W-S, et al. Associations of supported treadmill stepping with walking attainment in preterm and fullterm infants. Phys Ther. 2009; 89:1215–1225.] © 2009 American Physical Therapy Association

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Supported Treadmill Stepping and Walking Attainment in Preterm and Full-Term Infants

I

nfants born prematurely enter this world with a disadvantage and face many challenges when they are most fragile. Preterm infants who survive sustain an increased risk of neurodevelopmental sequelae compared with infants born with normal birth weight.1 Among the wide range of functional skills learned in infancy, independent walking expands mobility and the ability of a child to explore the environment, which allows for experiences that broaden cognitive, social, and motor functioning.2 Preterm infants tend to attain walking ability at older ages3,4 and exhibit poorer quality of walking movement than full-term infants.5–7 Surveillance and enhancement of functional skills have become the major goals in the clinical management of preterm infants. Spontaneous kicking and supported stepping are early leg movements proposed as the precursory patterns for independent walking because of the similarity in spatiotemporal organization to the features of mature adult walking.8,9 Our recent observation regarding the associations of certain kicking variables with age of walking attainment in preterm and full-term infants has provided evidence to support the functional importance of spontaneous kicking.10 Treadmill training of stepping movement has been used as part of rehabilitation programs in children with or at risk for neurodevelopmental

Available With This Article at www.ptjournal.org • Audio Abstracts Podcast This article was published ahead of print on September 17, 2009, at www.ptjournal.org.

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problems to facilitate earlier onset of walking.11–17 However, information concerning the developmental continuity between supported stepping and walking is limited. Scrutiny of the developmental process of stepping movement and the identification of step predictors for walking attainment, therefore, are important in providing valuable clues for the genesis of walking disorders and to assist in the design of rehabilitation programs. Longitudinal studies illustrate that full-term infants who take steps on a treadmill from the first month after birth produce coordinated, alternating, adult-like steps by 7 months of age.8,18 Treadmill training of stepping movement in 3- to 7-month-old infants leads to the transition from multiple step patterns to more alternating steps.19 Furthermore, infants show adjustment of the step cycle in response to changes in treadmill speed18,20 and maintenance of a reciprocal pattern under split-belt treadmill conditions, much like mature walkers.21 A follow-up study showed that preterm infants without severe neonatal disease exhibited alternating steps on a treadmill at 1, 6, and 9 months of age (corrected for prematurity).22 Although previous studies8,18,20 have demonstrated similarities between supported stepping and walking in the global configuration and the response to contextual changes, the specific step features that may relate to walking attainment remain unclear. The development of leg movement may be influenced by an individual child’s characteristics, such as anthropometry and neuromotor function. Prior studies on preterm and full-term infants showed that a lower proportion of fat in body composition, a lower gain in leg volume, and higher motor function are associated with more alternate steps.18,22,23 Incorporation of potential influencing

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factors for supported stepping thus is crucial to help understand the roles of such factors in the development of leg movement. The purpose of this study, therefore, was to prospectively examine supported stepping in preterm and full-term infants on a treadmill from 7 months of age until walking attainment or 18 months of corrected age, and to explore the step parameters associated with age of walking attainment. Potential influencing factors of supported stepping such as anthropometry and gross motor function also were examined in this study.

Method Participants This study included 29 preterm infants and 20 full-term infants born at the National Taiwan University Hospital, Taipei, Taiwan, from 2000 to 2002. The inclusion criteria for preterm infants were: gestational age of ⬍37 weeks and absence of congenital abnormalities. The selection criteria for full-term infants were gestational age within 38 to 42 weeks and absence of perinatal complications. Preterm infants were lighter (mean birth weight⫽1.2 kg, SD⫽0.6 kg, versus mean birth weight⫽3.4 kg, SD⫽0.5 kg) and less mature (mean gestational age⫽29 weeks, SD⫽4 weeks versus mean gestational age⫽39 weeks, SD⫽1 week) at birth than full-term infants (F⫽188.17 for birth weight and F⫽151.35 for gestational age, both P⬍.05). Seven preterm infants (24%) had periventricular leukomalacia (PVL), as diagnosed using brain ultrasonography,24 and 9 (31%) had chronic lung disease (CLD), as defined by oxygen requirement at or beyond the postnatal age of 36 weeks.25 Of these infants, 4 (13%) had both PVL and CLD. The groups were comparable in sex and parental education. Informed consent was obtained from the parents.

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Supported Treadmill Stepping and Walking Attainment in Preterm and Full-Term Infants Testing Procedure and Measurements Infants were examined bimonthly for supported stepping on a treadmill, anthropometry, and gross motor function from 7 months of age until walking attainment or 18 months of corrected age. Age of walking attainment and neurological status were determined when infants approached 18 months of corrected age. Each infant wore black shorts to reveal the anatomical landmarks of the mid-trunk, greater trochanter, lateral femoral condyle, lateral malleolus, and fifth metatarsal head on the right side. One examiner was trained to identify children’s anatomical landmarks and to place reflective, ball-shaped markers with a diameter of 0.7 to 1 cm at these landmarks to respectively define the hip, knee, and ankle angles. The children were supported under the arms by an examiner and stepped for 2 minutes at 0.2 m/s on a treadmill (Woodway Reha K1*).18 Step movements were recorded using 2 synchronized 60-Hz video cameras (Panasonic WVCL350†) to construct a 3-dimensional analysis (calibration errors ⬍0.5%). Each camera was connected to a videocassette recorder (Panasonic SVHS AG-1960†), a time code generator (SDR-50‡), and a video monitor (Sony PVM-1341§). Infants subsequently were examined for anthropometry (ie, weight, height, leg length and circumference, and skinfold thickness) and gross motor function. Leg length was measured from the greater trochanter to the sole of the foot; leg circumference was measured as the average of the circumference of the mid-

* Woodway, Steinackerstrasse 20, D-79576 Weil an Rhein, Germany. † Panasonic Corporation of North America, One Panasonic Way, Secaucus, NJ 07094 ‡ Horita Co Inc, PO Box 3993, Mission Viejo, CA 92690. § Sony Corp, 1–7-1 Konan, Minato-ku, Tokyo 108-0075, Japan.

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thigh and the mid-shank area. Leg volume was calculated as the product of leg length and leg circumference. Skinfold thickness was measured at the anatomical locations of the biceps, triceps, sub-scapulae, suprailiac, anterior and posterior aspects of the thigh, and lateral aspect of the shank using a caliper. Percentage of total body fat was calculated from the skinfold thickness data using Pediatric Anthropo-Plicometry software.㛳 Gross motor function was examined using the Alberta Infant Motor Scale (AIMS), which has acceptable levels of reliability and validity for Taiwanese infants.26 A physical therapist with pediatric experience of 1 year served as the examiner. She underwent training on the use of the AIMS and practiced on 10 preterm and fullterm infants aged 6 to 15 months. Her measurements on another 10 preterm infants achieved a high level of agreement (⬎90%) comparable to that of an experienced examiner (S.F.J.) before she conducted the examinations in this study. Age of walking attainment was defined as the time when the children began taking 5 successive steps without support.3,10 A research assistant made biweekly telephone calls to parents regarding age of walking. The data were recorded by means of chronological age for full-term infants and corrected age for preterm infants. Walking outcome was classified into early (walking attainment prior to 11 months of corrected age), normal (walking attainment between 11 and 15 months of corrected age), and late walking attainment (failure to attain walking prior to 15 months of corrected age).10 Infants’ neurologic status was diagnosed by a pediatric neurologist for 㛳

Dietosystem MediGroup, Viale Monza, 13320125 Milano, Italy.

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the presence of cerebral palsy and psychomotor retardation. A 20-second segment of recorded videotape was selected for each child per assessment age during which he or she took consecutive steps and showed no emotional irritability.18,22 Children took an average of 6 to 8 steps during the 20-second segments. The videotape data were analyzed using the Motus version of the 3.01 Peak Performance Motion Analysis System# with a fourth-order Butterworth filter with a filtering rate of 6 Hz. The events of feet contacting and leaving the ground in step cycles were coded by the same examiner with a coding error of ⬍.017 seconds. The linear and angular displacement data together with the event information were used to calculate the kinematic variables using a customized program written with Matlab software version 5.3.** Steps were categorized into alternating and nonalternating modes, with the former defined as when the steps were initiated within 20% to 80% of a step cycle on the opposite leg18 and expressed as a percentage of the 20-second period. Kinematic analysis was performed for alternating steps to obtain spatiotemporal organization, interjoint coordination, and interlimb coordination. Spatiotemporal organization included the stance and swing time (expressed as a percentage of the stride time) and the right hip, knee, and ankle angle at foot contact (a smaller value, indicating more flexion). Interjoint coordination was measured by means of pair-wise cross-correlation of the right joint angles during the swing time that were transformed into Fisher z scores.27 # Peak Performance Technologies, 7388 S Revere Pkwy, #901, Centennial, CO 80112. ** The MathWorks Inc, 3 Apple Hill Dr, Natick, MA 01760.

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Figure 1. Kaplan-Meier plot of distributions of age of walking attainment for preterm and fullterm infants.

Interlimb coordination was measured using an asymmetry ratio (AR) for the stance and swing time, and each was calculated by dividing the larger value of the 2 limbs’ parameter by the smaller one.28 An AR of 1 indicates perfect symmetry, and an AR of ⬎1 indicates less symmetry. Data Analysis The distributions of age of walking attainment for preterm and full-term infants were estimated using the Kaplan-Meier method and were compared using the log-rank test. Perinatal data were examined for full-term and preterm infants among the 3 walking outcome categories (ie, normal, early, and late walking attainment) using analysis of variance for continuous variables and the chisquare test for categorical variables. Cox proportional hazard regression analysis was used to explore the potential step predictors in 7- and 9-month trials for the age of walking attainment of preterm and full-term infants. Logistic regression analysis subsequently was used to examine the predictive values of the identified step variables on clinically significant walking outcome (ie, early and 1218

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late walking attainment). Each step variable of the 7- and 9-month trials was scored as 1 (competent) versus 0 (incompetent) according to a cutoff point based on the mean and standard deviation of the same variable of the 9-month trial in infants with early walking attainment. The cutoff was calculated to be 1 standard deviation below the mean for the variables showing an incline in the magnitude from 7 to 9 months of corrected age; whereas the cutoff was 1 standard deviation above the mean for those variables exhibiting a decline. The step scores then were added into a composite score at each age to indicate the overall competency. The range of the composite scores was 0 to 4, with a high composite score indicating high competency and a low composite score indicating low competency. Predictive indexes of sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and ratio of likelihood of positive results (LR⫹) were calculated for each cutoff. An LR⫹ of ⬎10 generates large changes in probability from pretest to posttest; an LR⫹ of 5 to 10 generates moderate shifts in probability; an LR⫹ of 2 to 5 generates small

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shifts in probability; and for an LR⫹ of 1–2, change in probability is small and is rarely important.29 Anthropometry and gross motor function at 7 and 9 months of corrected age were compared among infants who had early, normal, and late walking attainment using an analysis of variance for repeated measures. The relationships of infant characteristics (perinatal factors, anthropometry, and gross motor function) with step parameters were examined using Pearson correlation analysis for preterm and full-term infants. All statistical analyses were performed using the SAS program†† with the alpha value set at .05 and adjusted to .017 (.05/3) or .008 (.05/6) for Tukey post hoc tests. Role of the Funding Source Dr Jeng received funding from the National Science Council (NSC 952314-B-002-218-MY3), and Ms Chen received funding from the National Taiwan University Hospital (96S634).

Results Age of Walking Attainment The distributions of age of walking attainment for full-term and preterm infants are depicted in Figure 1. The log-rank test revealed that preterm infants attained walking ability at older ages (median⫽12.8 months, range⫽9.8 to ⬎18 months) than fullterm infants (median⫽11 months, range⫽10 –14.5 months) after correction for prematurity (␹2⫽10.83, P⬍.05). Five preterm infants (17%) showed early walking attainment, 19 infants (66%) exhibited normal walking attainment, and 5 infants (17%) showed late walking attainment. Eight full-term infants (40%) showed early walking attainment, and 12 infants (60%) exhibited normal walking attainment. Developmental disorders were noted in 2 preterm infants ††

SAS Institute Inc, PO Box 8000, Cary, NC 27513.

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Supported Treadmill Stepping and Walking Attainment in Preterm and Full-Term Infants who failed to walk at 18 months of corrected age (1 with spastic diplegic cerebral palsy and 1 with psychomotor retardation).

Table 1. Cox Proportional Hazard Regression Analysis for the Relationships of Individual Stepping Variables With Age of Walking Attainment in All Infantsa 7 Months RR (95% CI)b

9 Months RR (95% CI)b

1.01 (0.99–1.02)

1.03 (1.01–1.05)c

Stance time (per % increase)

1.03 (0.98–1.08)

1.00 (0.94–1.06)

Swing time (per % increase)

0.97 (0.92–1.03)

1.00 (0.95–1.07)

Hip (per ° increase)

1.01 (0.99–1.03)

1.02 (0.99–1.05)

Knee (per ° increase)

1.01 (0.99–1.04)

1.01 (0.99–1.04)

Ankle (per ° increase)

1.01 (0.99–1.02)

1.01 (0.99–1.03)

Hip-knee coupling (per 1 increase)

0.89 (0.56–1.42)

0.44 (0.22–0.87)c

Hip-ankle coupling (per 1 increase)

2.38 (1.22–4.64)c

1.78 (1.01–3.23)c

Knee-ankle coupling (per 1 increase)

0.74 (0.44–1.24)

0.65 (0.39–1.09)

AR of stance time (per 1 increase)

0.49 (0.19–1.25)

0.28 (0.07–0.99)c

AR of swing time (per 1 increase)

0.45 (0.18–1.15)

0.42 (0.12–1.52)

Variable

Among full-term infants, early walkers (mean gestational age⫽40 weeks, SD⫽1 versus mean gestational age⫽39 weeks, SD⫽1) were more mature at birth than normal walkers (F⫽5.67, P⬍.05). Among preterm infants (excluding the 2 preterm infants with developmental disorders), early walkers were more mature (mean gestational age⫽34 weeks, SD⫽2 versus mean gestational age⫽29 weeks, SD⫽3 versus mean gestational age⫽26 weeks, SD⫽3) and heavier (mean birth weight⫽2.1 kg, SD⫽0.6 versus mean birth weight⫽1.1 kg, SD⫽0.4 versus mean birth weight⫽0.9 kg, SD⫽0.2) at birth than normal walkers (F⫽3.90 for gestational age and F⫽4.80 for birth weight, both P⬍.017) and late walkers (F⫽3.89 for gestational age and F⫽3.85 for birth weight, both P⬍.017). Furthermore, late walking attainment was associated with higher incidences of PVL (67% versus 16% versus 0%) and CLD (100% versus 26% versus 0%) than normal (␹2⫽7.90 for PVL and ␹2⫽4.87 for CLD, both P⬍.05) and early walking attainment (␹2⫽4.44 for PVL and ␹2⫽8.00 for CLD, both P⬍.05). Of the 4 infants who had both PVL and CLD, 3 showed late walking attainment, 1 showed normal walking attainment, and none showed early walking attainment. Of the 3 preterm infants who had PVL but no CLD, 1 showed late walking attainment, 2 showed normal walking attainment, and none showed early walking attainment. Of the 5 preterm infants who had CLD but no PVL, 1 showed late walking attainment, 4 showed normal walking attainment, and none showed early walking attainment.

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Alternating steps (per % increase) Spatiotemporal organization

Joint angle at foot contact

Interjoint coordination

Interlimb coordination

a

RR⫽rate ratio, CI⫽confidence interval, AR⫽asymmetry ratio. An RR of greater than 1 indicates that the level under consideration may lead to an increased rate of walking attainment; an RR of less than 1 indicates that the level under consideration may result in a decreased rate of walking attainment. b RR was adjusted for the effect of birth status (preterm vs full-term). c P⬍.05.

Step Variables for Age of Walking Attainment Cox univariate proportional hazard regression analysis for the relationships between step variables and age of walking attainment in preterm and full-term infants revealed similar patterns of association among groups. The data of all infants, therefore, were pooled for univariate regression analysis with correction of prematurity. The results showed that a high hip-ankle correlation at 7 months of corrected age was associated with an increased rate of walking attainment (P⬍.05) (Tab. 1). Furthermore, a high percentage of alternating steps, a low hip-knee correlation, a high hip-ankle correlation, and a low AR of stance time at 9 months of corrected age were associated with an increased rate of walking attainment (all P⬍.05).

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Developmental Pattern of Step Variables Based on the mean and standard deviation of the identified step variable in the 13 early walkers at 9 months of corrected age, the cutoffs calculated for the percentage of alternating steps, hip-knee correlation, hipankle correlation, and AR of stance time were 80%, .37, .73, and 1.40, respectively. During the period of study, infants with early and normal walking attainment showed an increase in the percentage of alternating steps, a decrease in the hip-knee correlation, a consistently high hipankle correlation, and a decrease in the AR of stance time (Figs. 2A, C, E, and G). Infants with late walking attainment manifested fluctuations in the step variables at various ages (Figs. 2B, D, F, and G).

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Supported Treadmill Stepping and Walking Attainment in Preterm and Full-Term Infants

Figure 2. Illustration of means and standard deviations for 4 step parameters—percentage of alternating steps, hip-knee coordination, hip-ankle coordination, and asymmetry ratio of stance time—in early and normal walkers (A, C, E, and G) and means and individual data for step parameters in late walkers (B, D, F, and H) during the study period.

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Supported Treadmill Stepping and Walking Attainment in Preterm and Full-Term Infants Table 2. Logistic Regression Analysis for the Relationships of the Step Composite Score With Early Walking Attainment (Walking Attainment Prior to 11 Months of Corrected Age) and Late Walking Attainment (Failure to Attain Walking by 15 Months of Corrected Age) in All Infantsa N (%) Passing Cutoff

Step Composite Scoreb and Cutoffs

Early and Normal Walking Attainment Accuracy

Sen

Spe

PPV

NPV

LRⴙ

Late Walking Attainment Accuracy

Sen

Spe

PPV

NPV

LRⴙ

7 months of corrected age (n⫽47)c Cutoff⫽1 (ⱖ1 vs 0)

45 (96)

32

100

6

29

100

1.06

92

98

25

93

50

1.31

Cutoff⫽2 (ⱖ2 vs ⬍2)

32 (68)

51

85

38

34

87

1.37

72

72

75

97

20

2.88

Cutoff⫽3 (ⱖ3 vs ⬍3)

15 (32)

75

62

79

53

84

2.95

40

35

100

100

13

4 (9)

77

23

97

75

77

7.67

17

9

100

48 (100)

25

100

0

25

1.00

90

100

0

Cutoff⫽4 (4 vs ⬍4) 9 months of corrected age (n⫽48)

9

c

Cutoff⫽1 (ⱖ1 vs 0)

90

1.00

Cutoff⫽2 (ⱖ2 vs ⬍2)

41 (85)

40

100

19

29

100

1.23

83

88

40

93

29

Cutoff⫽3 (ⱖ3 vs ⬍3)

29 (60)

60

92

50

38

95

1.84

71

67

100

100

26

Cutoff⫽4 (4 vs ⬍4)

17 (35)

65

50

69

35

81

1.61

46

40

100

100

16

1.47

a

Sen⫽sensitivity, Spe⫽specificity, PPV⫽positive predictive value, NPV⫽negative predictive value, LR⫹⫽likelihood ratio of a positive test result. b Composite score indicates the number of step variables that fulfilled the following criteria of competency: high percentage of alternating steps (ⱖ80%), low hip-knee correlation (ⱕ.37), high hip-ankle correlation (ⱖ.73), and low AR of stance time (ⱕ1.40). c Missing data were noted in 2 infants at 7 months of corrected age because 1 infant did not return for assessment and 1 infant did not show alternating steps; missing data were noted in 1 infant at 9 months of corrected age because of problems in video recording.

Prediction of Step Composite Score With Early and Late Walking Attainment The predictive accuracy of the 7- and 9-month step composite scores for early walking attainment gradually increased as the number of step variables increased (Tab. 2). Acceptable levels of accuracy were found for the 7-month step composite scores of

ⱖ3 (75%) and 4 (77%). The former was associated with more satisfactory predictive indexes than the latter was, including sensitivity (62% versus 23%), specificity (79% versus 97%), PPV (53% versus 75%), and NPV (84% versus 77%). Furthermore, the LR⫹ for the 7-month step composite scores of ⱖ3 (2.95) and 4 (7.67) for early and normal walking

outcome were small to moderate changes. However, the accuracy values for the 9-month step composite scores were all lower than 70% and the LR⫹ values were all small (⬍2). The predictive accuracy of the 7- and 9-month step composite scores on late walking attainment gradually decreased as the number of step vari-

Table 3. Two-Way Analysis of Variance for Repeated Measures for Anthropometry and Gross Motor Function Over Age (7 and 9 Months of Corrected Age) and Across Groups (Early, Normal, and Late Walking Attainment)a Early Walking Attainment (nⴝ13) Variable

Normal Walking Attainment (nⴝ31)

7 Months of Corrected Age

9 Months of Corrected Age

7 Months of Corrected Age

8.0 (0.7)b

8.7 (0.8)b

7.7 (1.3)b

69 (2)b

72 (2)b

68 (3)b

Late Walking Attainment (nⴝ5)

9 Months of Corrected Age

7 Months of Corrected Age

9 Months of Corrected Age

8.4 (1.3)b

6.8 (1.2)b

7.3 (1.0)b

71 (4)b

66 (4)b

68 (3)b

Anthropometry Weight (kg) Height (cm) 3

b,c

1,093 (193)

b,c

895 (234)

b

1,034 (270)

b

707 (185)

b,c

792 (178)b,c

Leg volume (cm )

994 (132)

Total body fat (%)

15 (4)

18 (3)

18 (4)

19 (4)

21 (1)

21 (1)

39 (8)b,d

51 (2)b,d

31 (5)b,d

44 (6)b,d

24 (3)d

30 (4)d

Gross motor function AIMS score (points) a

Data are presented as mean (SD). AIMS⫽Alberta Infant Motor Scale. Significant age effect at P⬍.05. Late walking attainment ⬍ early or normal walking attainment, P⬍.008, with Tukey post hoc tests. d Late walking attainment ⬍ normal walking attainment ⬍ early walking attainment, P⬍.008, with Tukey post hoc tests. b c

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Supported Treadmill Stepping and Walking Attainment in Preterm and Full-Term Infants Table 4. Pearson Correlation Analysis for the Relationships of Anthropometry and Gross Motor Function With Significant Stepping Variables at 7 and 9 Months of Corrected Age in All Infantsa Leg Volume (cm3) Variable

Total Body Fat (%)

AIMS Score (Points)

7 Months

9 Months

7 Months

9 Months

7 Months

9 Months

Alternating steps (%)

⫺.003

⫺.04

⫺.37b

⫺.16

Hip-knee coupling (z score)

⫺.16

⫺.13

.16

.04

⫺.22

⫺.06

Hip-ankle coupling (z score)

.14

.05

⫺.03

⫺.01

.18

.22

⫺.19

⫺.28

7 months of corrected age

AR of stance time

b

.40

b

.33b

.06

.13

.41

.21

.19

.19

.07

Hip-knee coupling (z score)

⫺.13

⫺.14

.09

.11

⫺.12

Hip-ankle coupling (z score)

.09

.10

⫺.01

.01

.16

.18

⫺.36

.33b

9 months of corrected age Alternating steps (%)

AR of stance time a b

⫺.12

.03

.12

.47b

.54b ⫺.20 .32b

b

⫺.26

Data are presented as correlation coefficient (r). AIMS⫽Alberta Infant Motor Scale, AR⫽asymmetry ratio. P⬍.05.

ables increased. The accuracy values of the 7-month composite scores of ⱖ1 (92%) and ⱖ2 (72%) were acceptable, and the LR⫹ values were in the range of rare and small changes (1.31 and 2.88, respectively). Furthermore, the predictive accuracy of the 9-month composite scores of ⱖ1 (90%) and ⱖ2 (83%) was acceptable, and the LR⫹ values were in the range of rare change (1 and 1.47, respectively).

walking attainment than in those with normal (F⫽4.36 for 7 months and F⫽3.38 for 9 months, both P⬍.008) and late (F⫽5.18 for 7 months and F⫽7.21 for 9 months, both P⬍.008) walking attainment at both ages. A higher AIMS score also was noted in infants with normal walking attainment compared with those with late walking attainment (F⫽2.81 for 7 months and F⫽5.55 for 9 months, both P⬍.008).

Relationship of Infant Characteristics With Step Predictors From 7 to 9 months of corrected age, all infants exhibited an increase in weight (F⫽9.98, P⬍.05), height (F⫽11.79, P⬍.05), and leg volume (F⫽5.36, P⬍.05) (Tab. 3). Tukey post hoc tests revealed that infants with late walking attainment had smaller leg volumes than infants with early walking attainment (F⫽2.81, P⬍.008). There was an increase in the AIMS score in infants with early (F⫽7.82, P⬍.008) and normal (F⫽13.99, P⬍.008) walking attainment, but no change in the AIMS score in infants with late walking attainment. Moreover, a higher AIMS score was found in infants with early

Correlation analyses for the relationships of total body fat, leg volume, and gross motor score with significant step variables showed similar correlation patterns in preterm and full-term infants. Their data, therefore, were pooled for analysis and presentation (Tab. 4). At both 7 and 9 months of corrected age, the AIMS score had positive associations with the percentage of alternating steps (r⫽.33–.54, all P⬍.05). The AIMS score at 7 months of corrected age had a negative association with the AR for stance time at 9 months of corrected age (r⫽⫺.36, P⬍.05). Furthermore, the AIMS score at 9 months of corrected age had a positive association with the hip-ankle correlation at 9 months of corrected

age (r⫽.32, P⬍.05). The percentage of total body fat at 7 months of corrected age had a negative relationship to the percentage of alternating steps at 7 months of corrected age (r⫽⫺.37, P⬍.05) and positive associations with the AR for stance time at both 7 and 9 months of corrected age (r⫽.41 and .40, both P⬍.05). The leg volume, however, had no association with any step variables.

Discussion

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The results of this study showed early or normal walking attainment in all full-term infants. Most preterm infants (83%) attained walking ability within early to normal range, but a few preterm infants (17%) exhibited late walking attainment. The results indicate that preterm infants with older gestational ages and heavier birth weights can achieve onset of walking similar to full-term infants. Nevertheless, small preterm infants who experienced severe neonatal diseases (eg, cystic periventricular leukomalacia and CLD) had an increased risk of late walking attainment. Cox proportional hazard analysis revealed the percentage of alternating November 2009

Supported Treadmill Stepping and Walking Attainment in Preterm and Full-Term Infants steps, hip-knee correlation, hip-ankle correlation, and AR of stance time during 7 to 9 months of corrected age as the potential step predictors for age of walking attainment in preterm and full-term infants. Subsequent logistic regression analysis demonstrated that the manifestation of at least 3 of the 4 step features— high percentage of alternating mode (ⱖ80%), low hip-knee correlation (ⱕ0.37), high hip-ankle correlation (ⱖ0.73), and low AR of stance time (ⱕ1.40)—at 7 months of corrected age predicted walking attainment prior to 11 months of corrected age. Failure to achieve such competencies at 7 or 9 months of corrected age, however, was predictive of difficulty in reaching walking attainment by 15 months of corrected age. Our findings indicate that the emergence of walking may involve the cooperation of alternating pattern generation, interjoint coordination, and interlimb coordination in leg movement. Clinicians could use the identified step predictors (ie, alternating step pattern, dissociated hipknee coupling together with associated hip-ankle coupling during swing time, and symmetrical stance time) as treatment goals when designing treadmill training programs. The significance and implication of these step predictors are delineated as follows. A high percentage of alternating steps at 7 and 9 months of corrected age was associated with an increased rate of walking attainment in all infants. Early and normal walkers manifested such an increased preference for alternating mode that it accounted for more than 80% of stepping in most infants at 9 months of corrected age. In contrast, late walkers did not produce more alternating steps from 7 to 9 months of corrected age. Alternating steps did not become their dominant pattern until 13 to 15 months of corrected age. The alternating mode has been conNovember 2009

sidered a necessity for balance control and weight shifting in walking.30 The development of more alternating steps when approaching walking attainment has previously been demonstrated for full-term infants18 and preterm infants16,22 in treadmill stepping. Our results suggest that the increasing dominance of alternating steps from 7 to 9 months of corrected age is crucial for walking attainment in full-term and preterm infants. A lower percentage of alternating steps was found to associate with a lower gross motor score at 7 and 9 months of corrected age and with a higher percentage of total body fat at 7 months of corrected age in all infants. A low gross motor score may reflect inadequate neuromotor maturation31 to generate leg movements and to maintain posture during upright locomotion. A high percentage of total body fat may indicate that low lean muscle mass23 is disadvantageous for strength generation. The lack of a significant association between the percentage of alternating steps and the percentage of total body fat at 9 months of corrected age may relate to different rates of change in these variables over time. From 7 to 9 months of corrected age, both the percentage of alternating steps and the gross motor score showed a gradual incline, whereas the body fat composition remained essentially constant. The body fat composition thus may play a minor role in the changes of percentage of alternating steps. Our observation concerning the positive relationship between the percentage of alternating steps and the gross motor function was consistent with Thelen and Ulrich’s18 report on full-term infants. However, our findings stand in contrast to the data on preterm infants provided by Davis et al,22 which showed a relationship between alternating steps and leg volVolume 89

ume only. The discrepancy might be due to the inclusion of preterm infants with a wider range of gestational ages and physiological conditions in the current study. A low hip-knee correlation at 9 months of corrected age and a high hip-ankle correlation from 7 to 9 months of corrected age also were related to an increased rate of walking attainment in all infants. From 7 to 9 months of corrected age, early and normal walkers manifested a decline in hip-knee correlation together with a persistently high hipankle correlation in stepping. In contrast, some late walkers did not exhibit such features until older ages and others never did. Infant stepping has been characterized by a tight synchrony in the interjoint coordination in the newborn period,27,32 and a gradual individualization of joint action prior to walking (hip-knee correlation from .85 to .60 and hip-ankle correlation from .70 to .15).27 Adult walking has been shown to feature a low hip-knee correlation (r near 0) and a moderate hip-ankle correlation (r⫽.60).27 Our early and normal walkers manifested constraint in hipankle coupling and dissociation in hip-knee coupling during the swing phase of stepping that allows for foot clearance and subsequent foot contact.33 The unfavorable relationship of deviated interjoint coordination in early leg movement (ie, spontaneous kicking) with poor neurodevelopmental outcome has been documented previously for preterm infants with PVL34 and CLD.10 The majority of our late walkers had PVL (80%) or CLD (80%). Further investigation is needed to determine whether neurologic or respiratory disease may influence the interjoint coordination in supported stepping and subsequent walking attainment. A high degree of symmetry of stance time from 7 to 9 months of corrected age was associated with an increased Number 11

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Supported Treadmill Stepping and Walking Attainment in Preterm and Full-Term Infants rate of walking attainment in all infants. Early and normal walkers demonstrated a slight decline in the AR of stance time in stepping from 7 to 9 months of corrected age, whereas late walkers exhibited fluctuation in the AR of stance time. The interlimb coordination of stepping in full-term infants has been found to achieve a fairly symmetric pattern at 4 months, followed by a refinement of variability.18 Symmetry plays a key role in locomotion, as it allows for simplification of neural control,35 maintenance of balance,35 and conservation of energy.36 The observed associations of gross motor score and percentage of total body fat with the AR of stance time in stepping imply that more mature neuromotor function together with sufficient lean muscle mass may produce the force required for symmetric limb support in locomotion. This study had some limitations that should be considered. First, the number of infants was relatively small. Thus, the information obtained should be considered preliminary. Further validation of our data with a larger case number is necessary. Second, the initial assessment of supported treadmill stepping was scheduled in preterm and full-term infants at 7 months of corrected age. Whether step parameters at earlier ages predict walking attainment also warrants investigation. Third, the step variables identified for age of walking attainment in preterm and full-term infants were explored in the context of treadmills in this study. The generalizability of findings to supported floor stepping remains to be determined.

Conclusion We conclude that preterm infants had an increased risk of late walking attainment compared to their fullterm counterparts. Early, normal, and late walkers manifested differences in alternating pattern genera1224

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tion, interjoint coordination, and interlimb coordination during supported stepping on a treadmill from 7 to 9 months of corrected age. These results underscore the need to investigate the causes responsible for altered step features in preterm infants. All authors provided concept, design, data analysis and interpretation, and manuscript preparation. Mr Luo and Dr Jeng provided data collection and project management. Dr Jeng and Ms Chen were responsible for fund procurement. Mr Luo and Ms Chen recruited participants and provided clerical support. Dr Chen, Dr Hsieh, Dr Lin, and Dr Lu provided technical support and consultation, and reviewed the manuscript before submission. The authors acknowledge the participation of the infants and their parents in this study. This study was approved by the Committee of Ethics of National Taiwan University Hospital and the Institutional Review Board of Mackay Memorial Hospital. Dr Jeng received funding from the National Science Council (NSC 95-2314-B-002-218MY3), and Ms Chen received funding from the National Taiwan University Hospital (96-S634). This article was received November 20, 2008, and was accepted July 20, 2009. DOI: 10.2522/ptj.20080369

References 1 Hack M, Fanaroff AA. Outcomes of children of extremely low birth weight and gestational age in the 1990s. Early Hum Dev. 1999;53:193–218. 2 Campos JJ, Anderson DI. Travel broadens the mind. Infancy. 2000;1:149 –219. 3 Jeng SF, Yau KI, Liao HF, et al. Prognostic factors for walking attainment in very lowbirth-weight preterm infants. Early Hum Dev. 2000;59:159 –173. 4 Vohr BR, Wright LL, Dusick AM, et al. Neurodevelopmental and functional outcomes of extremely low birth weight infants in the National Institute of Child Health and Human Development Neonatal Research Network, 1993–1994. Pediatrics. 2000;105: 1216 –1226. 5 Cioni G., Duchini F, Milianti B, et al. Differences and variations in the patterns of early independent walking. Early Hum Dev. 1993;35:193–205.

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6 de Groot L, de Groot CJ, Hopkins B. An instrument to measure independent walking: are there differences between preterm and full-term infants? J Child Neurol. 1997;12:37– 41. 7 Jeng SF, Lau TW, Hsieh WS, et al. Development of walking in preterm and term infants: age of onset, qualitative features and sensitivity to resonance. Gait Posture. 2008;27:340 –346. 8 Forssberg H. Ontogeny of human locomotor control, I: infant stepping, supported locomotion and transition to independent locomotion. Exp Brain Res. 1985;57:480 – 493. 9 Thelen E. Development of locomotion from a dynamic systems approach. In: Forssberg H, Hirschfeld H, eds. Movement Disorders in Children. Basel, Switzerland: S Karger AG, Medical and Scientific Publishers; 1992:169 –173. 10 Jeng SF, Chen LC, Tsou KI, et al. Relationship between spontaneous kicking and age of walking attainment in preterm infants with very low birth weight and full-term infants. Phys Ther. 2004;84:159 – 172. 11 Angulo-Barroso RM, Wu J, Ulrich DA. Long-term effect of different treadmill interventions on gait development in new walkers with Down syndrome. Gait Posture. 2008;27:231–238. 12 Ulrich DA, Ulrich BD, Angulo-Kinzler RM, et al. Treadmill training of infants with Down syndrome: evidence-based developmental outcomes. Pediatrics. 2001;108:E84. 13 Wu J, Looper J, Ulrich BD, et al. Exploring effects of different treadmill interventions on walking onset and gait patterns in infants with Down syndrome. Dev Med Child Neurol. 2007;4911:839 –945. 14 Schindl MR, Forstner C, Kern H, et al. Treadmill training with partial body weight support in nonambulatory patients with cerebral palsy. Arch Phys Med Rehabil. 2000;81:301–306. 15 Begnoche DM, Pitetti KH. Effects of traditional treatment and partial body weight treadmill training on the motor skills of children with spastic cerebral palsy: a pilot study. Pediatr Phys Ther. 2007;19: 11–19. 16 Bodkin AW, Baxter RS, Heriza CB. Treadmill training for an infant born preterm with a grade III intraventricular hemorrhage. Phys Ther. 2003;83:1107–1118. 17 Ulrich DA, Lloyd MC, Tiernan CW, et al. Effects of intensity of treadmill training on developmental outcomes and stepping in infants with Down syndrome: a randomized trial. Phys Ther. 2008;88:114 –122. 18 Thelen E, Ulrich BD. Hidden skills: a dynamic systems analysis of treadmill stepping during the first year. Monogr Soc Res Child Dev. 1991;56:1–104. 19 Vereijken B, Thelen E. Training infant treadmill stepping: the role of individual pattern stability. Dev Psychobiol. 1997;30: 89 –102. 20 Yang JF, Lam T, Pang MY, et al. Infant stepping: a window to the behaviour of the human pattern generator for walking. Can J Physiol Pharmacol. 2004;82:662– 674.

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Supported Treadmill Stepping and Walking Attainment in Preterm and Full-Term Infants 21 Thelen E, Ulrich BD, Niles D. Bilateral coordination in human infants: stepping on a split-belt treadmill. J Exp Psychol Hum Percept Perform. 1987;13:405– 410. 22 Davis DW, Thelen E, Keck J. Treadmill stepping in infants born prematurely. Early Hum Dev. 1994;39:211–223. 23 Thelen E, Fisher DM, Ridley-Johnson R. et al. Effects of body build and arousal on newborn infant stepping. Dev Psychobiol. 1982;15:447– 453. 24 Papile LA, Burstein J, Burstein R, et al. Incidence and evolution of subependymal and intraventricular hemorrhage: a study of infants with birth weights less than 1,500 gm. J Pediatr. 1978;92:529 –534. 25 Shennan AT, Dunn MS, Ohlsson A. Abnormal pulmonary outcomes in premature infants: Prediction from oxygen requirement in the neonatal period. Paediatrics. 1988;82:1061–1076. 26 Jeng SF, Yau KIT, Chen LC, et al. Alberta Infant Motor Scale: Reliability and validity when used on preterm infants in Taiwan. Phys Ther. 2000;80:168 –178.

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27 Thelen E, Cooke DW. Relationship between newborn stepping and later walking: a new interpretation. Dev Med Child Neurol. 1987;29:380 –393. 28 Jeng SF, Holt KG, Fetters L, et al. Selfoptimization of walking in nondisabled children and children with spastic hemiplegic cerebral palsy. J Mot Behav. 1996; 28:15–27. 29 Jaeschke R, Guyatt G, Sackett DL. Users’ guides to the medical literature, III: how to use an article about a diagnostic test, A: Are the results of the study valid? Evidence-Based Medicine Working Group. JAMA. 1994;5:389 –391. 30 Shumway-Cook A, Woollacott M. A life span perspective of mobility. In: Shumway-Cook A, Woollacott M, eds. Motor Control: Translating Research Into Clinical Practice. Philadelphia, PA: Williams & Wilkins; 2007: 330 –358 31 Darrah J, Piper M, Watt MJ. Assessment of gross motor skills of at-risk infants: Predictive validity of the Alberta Infant Motor Scale. Dev Med Child Neurol. 1998; 40:485– 491.

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32 Domello ¨ f E, Ro ¨ nnqvist L, Hopkins B. Functional asymmetries in the stepping response of the human newborn: a kinematic approach. Exp Brain Res. 2007;177: 324 –335. 33 Clark JE, Phillips SJ. A longitudinal study of intralimb coordination in the first year of independent walking: a dynamical systems analysis. Child Dev. 1993;64:1143–1157. 34 Vaal J, van Soest AJ, Hopkins B, et al. Development of spontaneous leg movements in infants with and without periventricular leukomalacia. Exp Brain Res. 2000;135: 94 –105. 35 Raibert MH. Symmetry in running. Science. 1986;231:1292–1294. 36 Inman VT. Conservation of energy in ambulation. Arch Phys Med Rehabil. 1967; 48:484 – 488.

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Research Report The Patient Goal Priority Questionnaire Is Moderately Reproducible in People With Persistent Musculoskeletal Pain Pernilla Åsenlo¨f, Kim Siljeba¨ck P. Åsenlo¨f, PT, PhD, is Assistant Professor, Department of Neuroscience, Section of Physiotherapy, Uppsala University, Entrance 15, Akademiska Sjukhuset, S-75185 Uppsala, Sweden. Address all correspondence to Dr Åsenlo¨f at: [email protected]. K. Siljeba¨ck, PT, MSc, is Physical Therapist, reAgera Clinics, Huddinge, Stockholm, Sweden. [Åsenlo¨f P, Siljeba¨ck K. The Patient Goal Priority Questionnaire is moderately reproducible in people with persistent musculoskeletal pain. Phys Ther. 2009;89: 1226 –1234.] © 2009 American Physical Therapy Association

Background. The Patient Goal Priority Questionnaire (PGPQ) is a patient-specific measure for identification of behavioral goals and evaluation of clinically significant changes. The use of such a measure in clinical settings and research requires that identified goals be consistent over time. Self-reports of behaviors related to the goals should be reliably estimated. Objective. The purpose of this study was to estimate chance-corrected agreement and test-retest reliability of the PGPQ. Chance-corrected agreement between the PGPQ and a similar therapist-guided goal identification tool, the Patient Goal Priority List (PGPL), also was estimated.

Design. A correlative and prospective design with 3 measurement points (M1, M2, and M3) was used in the study.

Methods. Fifty-four people who consulted physical therapists in primary care for persistent musculoskeletal pain were included in the study. Analyses of chancecorrected agreement and test-retest reliability of the PGPQ were done at M1 and M2. Chance-corrected agreement between procedures (PGPQ and PGPL) also was analyzed at M1 and M3.

Results. The percentage of agreement on content of the priority lists of the PGPQ at M1 and M2 was 52%. Cohen kappa values for agreement of rankings ranged between .47 and .64. Test-retest reliability coefficients for the self-report scales of the PGPQ ranged from .35 to .81. Chance-corrected agreement decreased when physical therapists were involved in the goal identification process using the PGPL (kappa⫽.08 –.46).

Limitations. Varying item content and a small, heterogeneous sample possibly increased variation and the standard error of measurements. The feasibility of using traditional approaches to psychometric evaluation of patient-specific measures is questionable. Conclusions. Chance-corrected agreement and test-retest reliability of the PGPQ were moderate. Involving a physical therapist in the goal identification procedure possibly introduced further bias. The size of the measurement error must be taken into account when using the PGPQ for estimations of clinically important changes. Post a Rapid Response or find The Bottom Line: www.ptjournal.org 1226

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Use of the Patient Goal Priority Questionnaire in People With Persistent Musculoskeletal Pain

A

sound research protocol should entail complementary dimensions of outcome measures that reflect the different perspectives of the individual, subgroups of patients, significant others, and society.1 Established recommendations for core outcome domains within the field of chronic pain clinical trials suggest inclusion of the following domains in the protocol2: (1) pain, (2) physical functioning, (3) emotional functioning, (4) participant ratings of global improvements and satisfaction with treatment, (5) reports of symptoms and adverse events, and (6) participant disposition. Recently, 19 aspects of daily living that patients with chronic pain regarded as important outcome domains were presented. They included pain-related symptoms, physical activities, family life, social and recreational activities, and emotional well-being.3 Currently, there is no absolute gold standard of outcome measures corresponding to the above-mentioned domains, but recommendations of core outcome measures to be considered when designing clinical trials of chronic pain treatments are available.4

lished generic measures and diseasespecific measures do not necessarily reflect the clinical significance of the outcomes, that is, whether treatments have a positive impact on individuals’ everyday lives.5 Kazdin5 questioned current means of operationalization of clinical significance, contending that a majority of outcome measures do not reflect the original construct of important changes in everyday life. Measures of symptom remissions (eg, pain intensity changes) are the most commonly applied, and measures based on patients’ views of what constitutes a successful outcome have not gained enough attention.

The importance of evaluation of clinically significant changes, or the clinical effectiveness of treatments, is a complementary topical issue. It emanates from the fact that estab-

According to Kazdin,5 a more valid strategy would be to tie measures of clinical significance to the presented clinical problem or to individual treatment goals. Patient-specific measures capable of reflecting perspectives of each individual may respond to this challenge. In a review from 2005, Jolles and colleagues6 identified 9 patient-specific outcome measures for musculoskeletal disorders covering various aspects of symptoms, activity, psychosocial well-being, and participation. Typically, these measures involve individuals generating their own items relevant for evaluation, but instructions given to patients for eliciting items differ. Some questionnaires (eg, Canadian Occupational Performance Measure [COPM]7) predefine outcome domains, whereas others

Available With This Article at www.ptjournal.org • eAppendix: Patient Goal Priority Questionnaire: Baseline, Followup, and Revision • The Bottom Line clinical summary • The Bottom Line Podcast • Audio Abstracts Podcast This article was published ahead of print on September 10, 2009, at www.ptjournal.org.

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Standardized and generic properties of available outcome measures possibly jeopardize the validity of research reports on clinical effectiveness. We must question whether the original construct of important individual changes in everyday life is correctly mirrored when conclusions are based on standardized, generic measures originally developed for evaluation and comparisons on a group level.

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(eg, Patient-Specific Functional Scale [PSFS]8) ask for a list of items without predefinition. Some questionnaires (eg, McMaster-Toronto Arthritis Questionnaire [MACTAR]9) are closely tied to current state of disease, whereas others (eg, Schedule for the Evaluation of Individual Quality of Life–Direct Weighting version [SEIQoL-DW]10) are closely tied to functioning in important life areas. For an excellent overview of contemporary patient-specific indexes, the reader is referred to Jolles et al.6 The MACTAR and the PSFS are 2 patient-specific questionnaires primarily used for evaluation of pain treatments and musculoskeletal disorders within physical therapy settings. Both measures assess disabilities and difficulties due to disease (eg, arthritis in the MACTAR9) or current state of musculoskeletal disorders (eg, PSFS11–13). They focus on identification of most urgent problem areas of each individual. However, patients’ problems and concerns may not agree with prioritized goals for treatment and related outcome expectations. Furthermore, patients’ problems and concerns are not obviously behavioral. As a consequence, we developed a patientspecific measure to help in exploring individual behavioral goals and evaluating the clinical effectiveness of physical therapy treatments with a behavioral medicine approach. In 2004, we presented the first version of a patient-specific questionnaire, the Patient Goal Priority Questionnaire (PGPQ), aimed at behavioral goal assessment in patients with persistent pain.14 The PGPQ differed from the MACTAR and the PSFS in that it took into account a behavioral and goal-directed starting point for physical therapy treatment by asking individuals to list their everyday life activities affected by pain, but at the same time most important to achieve as a result of Number 11

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Use of the Patient Goal Priority Questionnaire in People With Persistent Musculoskeletal Pain priority list of the PGPQ (priority list self-reported by the patient) and the similar clinical tool, the PGPL (priority list developed with guidance from a physical therapist).

Method

Figure 1. Study design and accompanying analyses. M1, M2, and M3⫽measurement points; PGPQ⫽Patient Goal Priority Questionnaire; PGPL⫽Patient Goal Priority List.

physical therapy treatment. An initial study of agreement between the single activity item in the first version of the PGPQ and a standardized, generic measure of disability (the Pain Disability Index) indicated that the PGPQ had patient- and activityspecific properties.14 Since then, the PGPQ has been further developed to cover evidence-based, cognitivebehavioral predictors of activity. Three items have been added to cover functional self-efficacy, fear of activity, and readiness to make everyday life changes. Items were formulated in accordance with their respective theoretical construct, meaning that questions are direct and patient and behavior specific. Items were tested on patients in primary care in a pilot study before applying the PGPQ in a recent randomized controlled trial.15,16 There are currently inquiries about using the PGPQ in research, clinical guidelines (New Zealand and Sweden), and clinical settings, which motivates further studies of measurement properties. Because the PGPQ is intended mainly for research and evaluation purposes, we also developed an independent clinical tool for physical 1228

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therapists to use in treatment: the Patient Goal Priority List (PGPL). The PGPL is a systematic method for physical therapists to use when supporting patients to elicit behavioral goals for treatment and to determine a behavioral starting point for current treatment. The PGPL is similar to the PGPQ in respect to listing and ranking important activities that the patient wants to affect with physical therapy. However, in the PGPL, the number of activities is not restricted, and the patient’s goal identification and priority ranking are guided by the physical therapist. More-detailed descriptions of the PGPQ and the PGPL are provided in the “Method” section. The purpose of this study was to estimate measurement properties of the PGPQ in patients consulting physical therapists in primary care due to persistent musculoskeletal pain. More specific aims were: (1) to estimate agreement, chancecorrected agreement, test-retest reliability, and smallest change possible to detect when applying the PGPQ on 2 occasions before the initial physical therapy assessment and (2) to estimate agreement and chancecorrected agreement between the

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Design Overview An overall correlative and prospective design with 3 measurement points was applied. The PGPQ was administered twice: at the first measurement point (M1, n⫽54) and at the second measurement point (M2, n⫽43), 3 weeks and 1 week before the initial physical therapy consultation, respectively. The PGPL was administered at the third measurement point (M3, n⫽38) at the patients’ first physical therapy consultation. Thirty-two patients completed the survey at all 3 measurement points. Eight patients completed the PGPL at M1 and M2 only, and 4 patients completed the PGPL at M1 and M3, but not at M2. All physical therapists were masked to the patients’ listing and ranking of goals at M1 and M2 (Fig. 1). Setting and Participants Between November 2007 and May 2008, participants were recruited consecutively at 6 physical therapy departments within the reAgera clinics in primary health care, Stockholm, Sweden. The inclusion criteria were: (1) over 18 years of age; (2) previous consultation with physical therapists due to subacute or chronic (⬎4 weeks) musculoskeletal pain; and (3) without any established inflammatory, neurological, or cancer diagnosis. Swedish language skills sufficient to fill out questionnaires independently were required. A total of 68 people were asked to participate in the study. Sixty-six people agreed to participate, and 2 individuals declined participation. Seven people were excluded due to language difficulties, and another 5 people withdrew before the start of the study (ie, did not send in quesNovember 2009

Use of the Patient Goal Priority Questionnaire in People With Persistent Musculoskeletal Pain tionnaires at M1). The sample size was dependent on a predetermined time limit of the study, set by the clinical organization. Measures Patient Goal Priority Questionnaire. The PGPQ is a patientspecific measure originally designed to collect data concerning patients’ behavioral goal priorities and for use as a proximal outcome measure when evaluating the clinical effectiveness of tailored pain management interventions.14 –16 The questionnaire consists of 2 sections. In the first section, the patient reports 1 to 3 activities that he or she: (1) is unable to perform or has difficulty performing due to pain and (2) wants to affect with physical therapy. The relative importance of the activities is ranked by the patient, with 1 representing the most important activity and 2 and 3 representing the next most important activities (referred to as priorities 1, 2, and 3 in this article). Domains covered are everyday life activity and participation. The concept being measured is the patient’s current priority of most important activities to achieve by means of physical therapy treatment. Patients are encouraged to specify each activity in as much detail as possible and to tie the activities to situations in everyday life. In the second section of the PGPQ, the patient scores current level of: (1) activity/behavioral performance on a numerical rating scale (NRS), with scores ranging from 0 to 10 (high scores⫽severe activity limitations); (2) frequency of behavioral performance during the past week on an ordinal scale with 5 grades (0⫽never, 1⫽once, 2⫽twice, 3⫽3 to 5 times, 4⫽more than 5 times); (3) satisfaction with current level of behavioral performance on an NRS, with scores ranging from 0 to 10 November 2009

(high score⫽high satisfaction); (4) self-efficacy for behavioral performance on an NRS, with scores ranging from 0 to 10 (high score⫽high confidence); (5) fear of behavioral performance on an NRS, with scores ranging from 0 to 10 (high score⫽ high fear level); (6) readiness to adopt new behaviors to attain expectations of behavioral performance on an NRS, with scores ranging from 0 to 10 (high score⫽high readiness); and (7) expectations of future behavioral performance as a result of treatment on an NRS, with scores ranging from 0 to 10 (high score⫽severe limitations). These items are scored separately with regard to each of the 3 ranked goals (eAppendix; available at: www.ptjournal.org). The patient is instructed to complete the PGPQ independently, without any involvement from the physical therapist or researcher. It takes less than 10 minutes to complete. The PGPQ is intended for evaluation of within-individual changes at the item level only. Comparisons of scale means and summed scores between groups, therefore, are not feasible. A previous study, using the Jacobson and Truax method to determine clinical significance of pain treatments, showed that an approximate 3-point difference in either positive or negative direction was required to make reliable changes in activity/behavioral performance.16 Patient Goal Priority List. The PGPL is similar to the PGPQ with respect to listing and ranking activities that the patient is unable to perform or has difficulty performing due to pain and wants to affect with physical therapy. However, in the PGPL, the number of activities is not restricted. A separate ranking of relative importance is introduced. Patients also are asked to estimate the frequency of activity performance during a day, week, or month and to judge the relative difficulty of perVolume 89

formance related to all listed activities (ie, to rank priorities according to self-efficacy magnitude)17 (Fig. 2). An important difference from the PGPQ is that the PGPL is administered by a physical therapist during consultation. The physical therapist guides the patient in the goal identification process but still empowers the patient to list and rank activities that are most important to him or her. The starting point for the coming treatment is determined by: (1) perceived difficulty (self-efficacy magnitude), (2) priority ranking (top 4 –5), and 3) frequency (must occur several times a week to be included in a behavioral skills training program). For research purposes, the PGPL has been used by physical therapists in tailored behavioral treatment protocols in primary care.15,18 Procedure The study followed the principles outlined in the Declaration of Helsinki. In addition, the study protocol was reviewed and agreed upon by an examiner of master’s theses, which is the customary procedure in Sweden for studies performed in postgraduate education programs at the master’s level. Patients referred for physical therapy contacted the physical therapy clinics by telephone and were registered in a computer-based booking system, ordinarily used at the clinics. One of the authors (K.S.) screened the computer register every other day and contacted those patients who fulfilled the inclusion criteria by telephone. After verbal information about the study was given and preliminary informed consent was obtained from potential participants, written information about the study was given and the PGPQ was administered by regular mail (M1). One reminder was sent to those patients who failed to return the PGPQ within 1 week. Another PGPQ was Number 11

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Figure 2. Excerpt from the Patient Goal Priority List (PGPL), a clinical tool for behavioral goal identification.

sent to participants 1 week before the initial physical therapy assessment (M2). The completed questionnaires from M2 were sent to administrative staff at the physical therapy clinics before the first consultation. Six physical therapists administered the PGPL at the first physical therapy consultation (M3). The PGPL was administered in the beginning of the session, before customary history taking and any possible standardized tests and physical assessments. Before the start of study, the physical therapists were trained to systematically administer the PGPL according to the manual. Data Analysis No substitutions were made for missing PGPQ data because the aim of this measure is to obtain goalspecific and patient-specific data. Behavioral goals listed in the PGPQ were grouped into 8 nominal categories according to a coding 1230

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scheme previously developed for management of PGPQ data. Categories included 8 domains of social role functioning, originally adopted from the Pain Disability Index.19 The chance-corrected agreement of coding was found acceptable (Cohen kappa⫽.86).14 Percentage of agreement and Cohen kappa were used for analysis of agreement and chance-corrected agreement of the content and ranking of the priority lists at M1 and M2 (PGPQ versus PGPQ) and at M1 and M3 (PGPQ versus PGPL). The Cohen kappa was the analysis of choice because data were nominal and all misclassifications were considered equally important. The reliability analyses were done for scales where priorities agreed between M1 and M2. Intraclass correlation coefficients (ICC [rxx]; 2-way random effects, absolute agreement, single measures)20 were calculated

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to study the test-retest reliability of the NRS scores for the PGPQ at M1 and M2. An exception was made for the 5-point ordinal scales of activity performance (item 1–3 b), which were analyzed using quadratic weighted kappa.21 Standard errors of measurement (SEM⫽ 公residual mean error term) were calculated. Additionally, the smallest change possible to detect with 95% confidence that observed change is real and not caused by measurement error was calculated (1.96 ⫻ 公2 ⫻ SEM), as proposed by Ostelo and de Vet.22 Most analyses were done using SPSS version 16.0 for Windows. The weighted kappa analyses were calculated on VassarStats.23 Role of the Funding Source The study, including administrative costs (eg, stamps and telephone calls), was financially supported by reAgera Clinics, Stockholm. Working November 2009

Use of the Patient Goal Priority Questionnaire in People With Persistent Musculoskeletal Pain Table 1. Patients’ Ranking of Behavioral Goals for Physical Therapy According to the Patient Goal Priority Questionnaire (PGPQ) at Measurement 1 (M1) and Measurement 2 (M2) and the Patient Priority List (PGPL) at Measurement 3 (M3)a Priority 1 Goal Category Family and home responsibilities Recreation and hobbies Social activity

M1

Priority 2 M1

Priority 3

M2

M3

M2

M3

M1

M2

M3

5 (9%)

6 (15%)

4 (11%)

5 (9%)

3 (7%)

4 (11%)

6 (11%)

5 (13%)

6 (16%)

12 (23%)

10 (25%)

8 (21%)

23 (43%)

20 (50%)

9 (24%)

17 (32%)

12 (30%)

8 (21%)

1 (2%)

0 (0%)

0 (0%)

2 (3%)

1 (3%)

1 (2%)

2 (4%)

1 (2%)

2 (5%)

15 (28%)

9 (22%)

4 (11%)

5 (9%)

4 (10%)

4 (11%)

1 (2%)

5 (12%)

3 (8%)

Sexual behavior

0 (0%)

0 (0%)

0 (0%)

0 (0%)

0 (0%)

0 (0%)

0 (0%)

0 (0%)

0 (0%)

Self-care

3 (5%)

5 (13%)

5 (14%)

4 (8%)

3 (7%)

4 (11%)

3 (5%)

2 (5%)

0 (0%)

Occupation and education

Life-support activity Functional ability Missing priority

b

3 (5%)

3 (8%)

3 (5%)

1 (1%)

0 (0%)

0 (0%)

2 (4%)

0 (0%)

1 (3%)

13 (24%)

7 (17%)

12 (33%)

9 (18%)

6 (15%)

13 (36%)

13 (24%)

8 (20%)

12 (32%)

2 (4%)

0 (0%)

2 (5%)

5 (9%)

3 (7%)

3 (5%)

10 (18%)

7 (18%)

6 (15%)

a

Priorities 1, 2, and 3⫽first, second, and third ranks. b Basic life-supporting behaviors such as eating, sleeping, and breathing.

hours in the project for Ms Siljeba¨ck and the participating physical therapists also were provided.

Results Participants A total of 54 participants (37 women, 17 men) were enrolled in the study. Their mean age was 55 years (SD⫽16, range⫽87). Thirtyseven participants were married or cohabitants. Average pain duration of current condition was 5.9 years (SD⫽9.9, range⫽50). Reported pain conditions were: lumbar pain (n⫽9), neck pain (n⫽2), shoulder pain (n⫽3), headache (n⫽1), lowerextremity pain (n⫽9), and pain in other part of body (n⫽3). Pain in more than 2 body locations was reported by 26 participants. Data were missing for 1 participant. Ten participants were on sick leave or were receiving compensation. Participants’ prioritized behavioral goals at the 3 measurement points are presented in Table 1. Note that priorities were elicited using the PGPQ at M1 and M2, whereas the PGPL was used at M3.

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Chance-Corrected Agreement and Test-Retest Reliability of the PGPQ on 2 Occasions Before Consulting a Physical Therapist The content of the priority list of the PGPQ, irrespective of ranking order, agreed in 21 out of 40 participants (raw percentage of agreement⫽ 52%). The chance-corrected agreement of priority 1 at M1 and M2 was: kappa⫽.64 (95% confidence interval [CI]⫽⫺.46 to .82), standard error (SE)⫽.09 (95% CI⫽⫺.09 to .27). Corresponding figures for priorities 2 and 3 were: kappa⫽.55 (95% CI⫽ ⫺.33 to .77), SE⫽.10 (95% CI⫽⫺.10 to .23) and kappa⫽.47 (95% CI⫽ ⫺.25 to .69), SE⫽.11 (95% CI⫽⫺.10 to .23) respectively. Thus, the chance-corrected agreement of patients’ priorities at M1 and M2 was moderate.

Chance-Corrected Agreement of Priority List of the PGPQ and Priority List of the PGPL The content of the priority list of the PGPQ at M1, irrespective of ranking order, and the content of the priority list of the PGPL at M3 agreed in 5 out of 36 participants (raw percentage of agreement⫽14%). The chancecorrected agreement of priority 1 at M1 and M3 was: kappa⫽.46 (95% CI⫽⫺.24 to .68), SE⫽.11 (95% CI⫽ ⫺.10 to .32). Corresponding figures for priorities 2 and 3 were: kappa⫽.36 (95% CI⫽⫺.11 to .60), SE⫽.12 (95% CI⫽⫺.12 to .36) and kappa⫽.08 (95% CI⫽0 to .35), SE⫽.13 (95% CI⫽⫺.12 to .38), respectively. Thus, the agreements of patients’ independently performed rankings at M1 and the therapistguided rankings at M3 were modest.

The reliability analyses were done for scales where priorities agreed between M1 and M2. The test-retest reliability of the self-report NRS in the PGPQ was estimated by calculating ICC and weighted kappa coefficients. The ICCs ranged from .35 to .81. Statistics are reported in Table 2, together with smallest change possible to detect for the current sample.

Discussion

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The purpose of this study was to estimate measurement properties of the second version of the PGPQ on patients consulting physical therapists in primary care due to persistent musculoskeletal pain. Chancecorrected agreement and test-retest reliability of the PGPQ were estimated on 2 occasions before an ini-

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a ICC⫽intraclass correlation coefficient, CI⫽confidence interval, SEM⫽standard error of measurements (公residual mean square error term), SCPD⫽smallest change possible to detect with 95% confidence that observed change is real and not caused by measurement error (1.96 ⫻ 公2 ⫻ SEM). b Items are numerical rating scales, with scores ranging from 0 to 10, except for “Activity frequency,” which is scored on a 5-category ordinal scale. c Weighted kappa coefficient.

3.9

2.9 1.1 (⫺1.0 to 3.2)

2.0 (⫺1.9 to 5.9) .48 (.17 to .70) 3.9

3.4

2.0 (⫺1.9 to 5.9) .52 (.24 to .72) 3.9

3.6

.55 (.28 to .73)

.64 (.40 to .80)

Readiness to change to improve activity

Expected level of future activity

1.7 (⫺1.6 to 5.0)

.45 (.15 to .67)

1.9 (⫺1.8 to 5.6)

.74 (.53 to .86)

1.5 (⫺1.4 to 4.4)

.81 (.64 to .90)

3.6

4.2 2.3 (⫺2.2 to 6.8)

1.7 (⫺1.6 to 5.0) .64 (.36 to .81)

.54 (.24 to .74)

3.6

3.9

1.7 (⫺1.6 to 5.0)

2.0 (⫺1.9 to 5.9) .61 (.35 to .78)

.42 (.11 to .66) 3.7

4.3

.57 (.31 to .75) Self-efficacy for activity

1.8 (⫺1.7 to 5.3)

3.7

Fear of activity

2.4 (⫺2.4 to 7.1)

3.7

0.78 0.08 (⫺0.08 to 0.96)

1.8 (⫺1.7 to 5.3)

1 .74 (.49 to .99) 0.78

3.7 .48 (.20 to .69)

0.08 (⫺0.08 to 0.96) .77 (.62 to .93)

Satisfaction with activity

c

Activity frequency

1.8 (⫺1.7 to 5.3)

c

.35 (.02 to .61)

0.13 (⫺0.25 to 0.38)

.45 (.12 to .69)

.69 (.53 to .84)

3.6

1.8 (⫺1.7 to 5.3)

c

1.7 (⫺1.6 to 5.0)

SEM (95% CI) ICC (95% CI)

.55 (.25 to .76) 3.9

SEM (95% CI)

2.0 (⫺1.9 to 5.9) .40 (.08 to .65)

ICC (95% CI) SCPD

3.7 1.8 (⫺1.7 to 5.3)

SEM (95% CI) ICC (95% CI) Item

b

Priority 1

Physical Therapy

.51 (.31 to .67)

Priority 2

SCPD

f

Test-Retest Reliability of the Self-Report Scales of the PGPQ on 2 Occasions Before Meeting a Physical Therapista

Table 2. 1232

Activity performance

Priority 3

SCPD

Use of the Patient Goal Priority Questionnaire in People With Persistent Musculoskeletal Pain tial physical therapy consultation to get an indication of the stability of the content of the patient-generated items of the measure. The results showed that the overall content of the priority lists in the first part of the PGPQ agreed in about one half of the sample, and the actual ranking of priorities 1, 2, and 3 showed a similar moderate agreement. The test-retest reliability coefficients of the self-report scales in the second part of the PGPQ ranged from .35 to .81, indicating moderate to good test-retest reliability of the measure.24 These results indicate either that the priority list of the PGPQ is not highly reliable in its present format or that the current sample was not sufficiently stable in priorities of goals for treatment to draw firm conclusions about test-retest reliability. We found that little effort hitherto has been aimed at examining the consistency of patient-generated items over time. One study dealing with the COPM and its interrater agreement regarding identified problems in 2 separate interviews was identified. The study showed that 80% of the problems identified with the COPM in the first interview agreed with problems prioritized in the second interview with a different interviewer.25 An important distinction from the current use of the PGPQ is that problems identified with the COPM were elicited during an interview performed by a trained occupational therapist. Consequently, the relatively high interrater agreement found in that study reflected the consistency of problems identified under guidance from a therapist and not the consistency of problems or goals as prioritized by the individual alone. Interestingly, the present study showed that when examining the consistency of patient-generated items at M1 (PGPQ; patient alone) and M3 (PGPL; guidance from physical therapist), agreement rates decreased markedly. November 2009

Use of the Patient Goal Priority Questionnaire in People With Persistent Musculoskeletal Pain Possibly, some potential biases were introduced by involving a physical therapist in the goal identification process. Patients want to present socially desirable goals, and possible embarrassment about preferences should be considered when interpreting the results. Another issue is patients’ desire to please the physical therapist by adhering to his or her points of view. The results show that patients gave highest priority to activities concerning occupation and education at M1 and to recreation at M2. At M3, when physical therapists were involved in the item generation, general functional abilities (eg, sitting, standing, walking) were most salient. It is important to emphasize this finding in terms of the construct that is supposed to be measured and evaluated by the PGPQ and its corresponding clinical tool, the PGPL: namely, most important behavioral goals from the view of each patient. General functional abilities are not behavioral because they are not explicitly activity related and lack situational specificity. The PGPQ and the PGPL were developed to secure such a behavioral starting point for physical therapy. Treatment evaluations regarding the clinical importance of treatment effects are thereby tied to what each individual deems highly relevant in his or her specific everyday life context.14,16 The results indicate that this underlying assumption of the methods is compromised when therapists are involved in the item generation. However, given the limitations of this study and the moderate reliability of the PGPQ, systematic replications are needed before it is possible to draw firm clinical conclusions. The SEMs and the smallest change possible to detect for the present sample resulted in a rather conservative interpretation of how large a change is needed for a reliable and clinically important change. Suppose 2 patients are measured with the November 2009

PGPQ before and after a 6-week treatment period. Patient A reports a 2-point improvement on the activity/ behavioral performance scale connected to her highest prioritized behavioral goal. We can conclude with 95% confidence that this improvement, given the measurement error associated with the PGPQ, is not reliable. On the contrary, patient B, who reports a pretreatmentposttreatment change of 4 points, has reliably improved according to the results of the current study. Thus, the measurement error connected to the PGPQ decides whether the change is reliable, and on a patient-specific level, whether it is clinically significant. An important challenge for future clinical studies is to ask individuals with different magnitudes of change on the PGPQ about the relevance of these changes in everyday life. Such studies are needed to circumvent problems associated with the use of traditional approaches for studies appraising psychometric properties of patient-specific measures with varying item content.6 With traditional approaches of test-retest reliability, the therapist or researcher might consider grouping items with similar content instead of testing priorities with varying content. The 10point NRS scales also would be candidates for refinements regarding number of scale points and anchors. Application of the PGPQ to larger and more homogenous groups of patients would allow researchers to detect whether measurement error is associated with item generation and scaling or with inter-individual variation. Furthermore, this study did not provide information about the PGPQ’s sensitivity of change compared with external global improvement criteria or established generic measures. Such a study is planned with prospective data from participants in 2 recent randomized controlled trials. Volume 89

A limitation of the present study was the relatively small sample and the fact that not all included participants completed all measurements. We planned initially for including at least 60 participants in each analysis to obtain variation and normal distributions. Due to organizational agreements, we had to stop inclusion at a stipulated time point, which prevented us from continuing to recruit participants to cover for the dropouts. We performed complementary analyses including only participants who completed all measurements to determine whether using all available data introduced any serious bias. However, the size of the coefficients was in concordance with the results presented. In conclusion, psychometric properties of the second version of the PGPQ, in terms of agreement and chance-corrected agreement of the priority list, and related goal ranking were moderate in a sample with persistent musculoskeletal pain. Consistency of goals and ranking decreased further when physical therapists were involved in the goal identification procedure by use of the PGPL. Test-retest reliability of the rating scales of the PGPQ was moderate to good. However, the feasibility of using traditional approaches to psychometric evaluation of patient-specific measures must be questioned. Future studies should involve replications in larger samples to estimate whether reported inconsistencies were dependent on the actual reliability of the measure or instability of the present sample. Dr Åsenlo¨f provided concept/idea/research design, writing, and project management. Ms Siljeba¨ck provided data collection and consultation (including review of manuscript before submission). Both authors provided data analysis. The authors thank the patients, the physical therapists, and the head administration of the reAgera clinics, Stockholm, for making this study possible.

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Use of the Patient Goal Priority Questionnaire in People With Persistent Musculoskeletal Pain The study, including administrative costs (eg, stamps and telephone calls), was financially supported by reAgera Clinics, Stockholm. Working hours in the project for Ms Siljeba¨ck and the participating physical therapists also were provided. This article was received February 1, 2009, and was accepted July 30, 2009. DOI: 10.2522/ptj.20090030

References 1 Kazdin AE. The meanings and measurement of clinical significance. J Consult Clin Psychol. 1999;67:332–339. 2 Turk D, Dworkin R, Allen R, et al. Core outcome domains for chronic pain clinical trials: IMMPACT recommendations. Pain. 2003;106:337–345. 3 Turk D, Dworkin R, Revivki D, et al. Identifying important outcome domains for chronic pain clinical trials: an IMMPACT survey of people with pain. Pain. 2008; 137:276 –285. 4 Dworkin R, Turk D, Farrar J, et al. Topical review and recommendations— core outcome measures for chronic pain clinical trials: IMMPACT recommendations. Pain. 2005;113:9 –19. 5 Kazdin AE. Almost clinically significant (p⬍.10): current measures may only approach clinical significance. Clinical Psychology: Science and Practice. 2001;8: 455– 462. 6 Jolles M, Buchbinder R, Beaton D. A study compared nine patient-specific indices for musculoskeletal disorders. J Clin Epidemiol. 2005;58:791– 801.

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7 Law M, Babtiste S, McColl M, et al. The Canadian Occupational Performance Measure: an outcome measure for occupational therapy. Can J Occup Ther. 1990; 57:82– 87. 8 Stratford PW, Gill C, Westaway MD, Binkley JM. Assessing disability and change on individual patients: a report of a patientspecific measure. Physiother Can. 1995; 47:258 –263. 9 Tugwell P, Bombardier C, Buchannan W, et al. The MACTAR patient preference disability questionnaire: an individualized functional priority approach for assessing improvement in physical disability in clinical trials in rheumatoid arthritis. J Rheumatol. 1987;14:446 – 451. 10 Browne J, O’Boyle C, McGee H, et al. Development of a direct weighting procedure for quality of life domains. Qual Life Res. 1997;6:301–309. 11 Westaway MD, Stratford PW, Binkley JM. The Patient-Specific Functional Scale: validation of its use in persons with neck dysfunction. J Orthop Sports Phys Ther. 1998;27:331–338. 12 Chatman AB, Hyams SP, Neel MJ, et al. The Patient-Specific Functional Scale: measurement properties in patients with knee dysfunction. Phys Ther. 1997;77:820 – 829. 13 Cleland J, Fritz J, Whitman J, Palmer J. The reliability and construct validity of the Neck Disability Index and Patient-Specific Functional Scale in patients with cervical radiculopathy. Spine. 2006;31:598 – 602. 14 Åsenlo ¨ f P, Denison E, Lindberg P. Behavioural goal assessment in patients with persistent musculoskeletal pain. Physiother Theory Pract. 2004;20:243–254. 15 Åsenlo ¨ f P, Denison E, Lindberg P. Individually tailored treatment targeting activity, motor behavior, and cognition reduces pain-related disability: a randomized controlled trial in patients with musculoskeletal pain. J Pain. 2005;6:588 – 603.

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16 Åsenlo ¨ f P, Denison E, Lindberg P. Idiographic outcome analyses of the clinical significance of two interventions for patients with musculoskeletal pain. Behav Res Ther. 2006;44:947–965. 17 Bandura A. Self-efficacy: The Exercise of Control. New York, NY: WH Freeman & Co; 1997. 18 Åsenlo ¨ f P, Denison E, Lindberg P. Individually tailored treatment targeting motor behavior, cognition, and disability: 2 experimental single case studies of patients with recurrent and persistent pain in primary health care. Phys Ther. 2005;85: 1061–1077. 19 Chibnall JT, Tait RC. The Pain Disability Index: factor structure and normative data. Arch Phys Med Rehabil. 1994;75: 1082–1086. 20 Lexell J. How to assess the reliability of measurements in rehabilitation. Am J Phys Med Rehabil. 2005;84:719 –723. 21 Jakobsson U, Westergren A. Statistical methods for assessing agreement for ordinal data. Scand J Caring Sci. 2005;19: 427– 431. 22 Ostelo R, de Vet H. Clinically important outcomes in low back pain. Best Pract Res Clin Rheumatol. 2005;19:593– 607. 23 VassarStats. Available at: http://faculty. vassar.edu/lowry/kappa.html. Accessed June 26, 2009. 24 Domholdt E. Rehabilitation Research. Principles and Applications. 3rd ed. St Louis, MO: Elsevier Saunders; 2005. 25 Verkerk G, Wolf M, Louwers A, et al. The reproducibility and validity of the Canadian Occupational Performance Measure in parents of children with disabilities. Clin Rehabil. 2006;20:980 –988.

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The Best We Can Be Is Yet to Come Carolee J. Winstein C.J. Winstein, PT, PhD, FAPTA, is Professor and Director of Research, Division of Biokinesiology and Physical Therapy at the School of Dentistry, and Associate Professor, Department of Neurology, Keck School of Medicine, University of Southern California, Los Angeles, CA 90033 (USA). Address all correspondence to Dr Winstein at: [email protected]. [Winstein CJ. 40th Mary McMillan Lecture: The best we can be is yet to come. Phys Ther. 2009;89: 1236 –1249.] © 2009 American Physical Therapy Association

Dr Winstein is recognized for her outstanding achievements in research, administration, and education. She has been dedicated to finding solutions to the problems that physical therapists face in the clinic and improving the lives of patients with neurological disorders, significantly in the area of motor learning and rehabilitation of patients poststroke. Internationally recognized as a leader for her research in the area of motor learning and neuroscience, Dr Winstein has had great success in funded research in particular, which is considered unusual for the physical therapy profession. She has received 25 research awards, cumulatively totaling more than $15 million. Dr Winstein is a member of the Research and Neurology sections of the American Physical Therapy Association. She has served as a guest editor for Physical Therapy and co-chaired the program committee for III STEP, a conference sponsored by the Neurology and Pediatric sections in 2005. Between 2002 and 2005, she was instrumental in helping to establish and direct the first clinical research network in physical therapy (PTClinResNet), funded in part through a grant from the Foundation for Physical Therapy. She has given more than 100 invited presentations over the course of her career, both nationally and internationally. Dr Winstein’s record of publication is further proof of the impact of her contributions to the science of motor control and learning for neurorehabilitation. She has authored 55 publications in peer-reviewed journals, with 18 as first author, and 73 published abstracts. She has authored 10 chapters in refereed volumes, another 5 in non-refereed texts, and 6 invited commentaries. In her 36-year career, Dr Winstein has been honored with some of the most prestigious awards in the physical therapy profession, including the Research Award from the Neurology Section, the Eugene Michels New Investigator Award, the Marian Williams Award for Research, and the John Maley Lecture Award. She was elected a Catherine Worthingham Fellow in 2003.

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hank you for giving me this tremendous honor. I have to confess that over the past year, I have found the preparation of this lecture to be one of the most daunting tasks I have ever engaged in. Those of you who have visited us at the University of Southern California [USC] know that there are 2 large portraits hanging in the main hallway— one of Helen Hislop and the other of Jacquelin Perry. Every day on my way into my office, I pass these portraits, and their eyes follow me, and I hear, “How much are you going to get done on your McMillan Lecture today?” When I leave, their eyes follow me in the other direction, and I hear, “What did you accomplish today on your McMillan Lecture?” In fact, there were times when I almost gave up and in my head had half-drafted the letter of what I would say. It went something like this: “Dear Scott, Because of extenuating circumstances, utter paralysis, and a complete tangle, I will be unable to deliver the McMillan Lecture this year. Can I take a rain check?”

In parallel with “daunting,” it has been one of the most exhilarating experiences of my life. How could that be? I’ll focus on the exhilarating part. After all, how often do we indulge ourselves in reflection, in taking the time to read about our founders and about the incredible individuals who have given so much to advance our profession? I want to thank you for giving me that opportunity—the opportunity to learn from many of the people who have come before me, many I never had an opportunity to know, and others, many of whom are sitting here in front of me today. I especially want to thank Helen Hislop, not only for her vision, but also for supporting me and my career at USC. When I re-read the 10th McMillan Lecture, “The Not-So-Impossible Dream,”1 it inspired my title, “The Best We Can November 2009

and then I want you to dig down deep and ask yourself, today, in 2009, how can our profession achieve its full potential? That is the question I asked myself in preparing my words for today.

Figure 1. Dr Winstein presenting the 40th Mary McMillan Lecture.

Be Is Yet to Come.” I want to publicly thank Helen for that. I too have a dream, which I will share today, some 30 years later (Fig. 1). Before I go there, would you all indulge me in a little mind exercise? I got this idea after I heard the Dalai Lama speak at the Society for Neuroscience meeting several years ago (Fig. 2). Somehow, he managed to create a situation in which literally tens of thousands of people in several large ballrooms felt that they were engaged in an intimate fireside chat in his living room. I can see some of you getting nervous. Don’t worry, we’re not all going to break out singing “Kumbaya” or “We Shall Overcome.” It is true that, despite all the differences we can point to among the educators, the clinicians, and the researchers gathered among us— or between those who work in the various specialty areas—we all have one thing in common, one thing that brought us into this profession, and it is likely the same reason that keeps us doing what we do. What is it? I don’t think I have to remind you. It is the patients we touch and care for. Everyone here has a story of someone whose life was touched during a time of need. This experience was likely mutually beneficial—not a one-way street— because we are a caring profession, and we always will be. I want you to remember that, Volume 89

If I let myself imagine what our profession would look like, I imagine a time when our profession displays more self-confidence than arrogance. A time when we can anticipate change and seek opportunities with nimbleness rather than with rigidity and isolation. I imagine a time when we are secure enough to seek advice and guidance from outside, and even from our competition, and not only from those who agree with our position. A time when we meet new knowledge and advances in science and health care with a willingness to learn, and engage in discussion and collaborate, instead of resisting or obstructing informing dialogue. Finally, I imagine a time when educators, practitioners, and researchers are valued equally for what they do, as long as the highest standards of excellence are what guide their efforts. I see 2 important objectives to achieving our full potential. The first objective is to invest in building strong academic centers in physical therapy. The second objective is to have a uniform commitment to setting the highest standards of excellence for our education, our research, and our practice. I will build an argument for the necessity of these objectives using evidence and Available With This Article at www.ptjournal.org • Audio Podcast: Listen to the 40th Mary McMillan Lecture delivered by Carolee J. Winstein, PT, PhD, FAPTA, at PT 2009 in Baltimore, Maryland.

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Figure 2. Quotation from the Dalai Lama’s speech at the Society for Neuroscience Congress; November 2005; Washington, DC.

through a few stories that come from my personal journey. I do not suggest these objectives lightly. I fully acknowledge that taking this course will not be easy; it will take considerable effort, but it will be worth every second of it. There certainly will be resistance along the way, and there will be many competing goals, some very practical and others motivated by the usual suspects, including fear, greed, power, and selfish motivations. We must resist the temptation to compromise and keep our ship sailing high in what stands to be one of the most challenging times that we have ever experienced for our profession and the health care system in which we function. I strongly believe that the necessary integration of education, research, and practice is possible only if we shore up our academic foundations. I will offer some suggestions for how we might accomplish this long-range objective in strategic and incremen1238

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tal steps. The good news is that we already have an excellent start, with a dozen or more programs from across the country leading the way— one, for example, right here in Baltimore at the University of Maryland— but where we go next is critical, especially at this time in our history.

A Few Disclaimers First, I feel compelled to reveal a few disclaimers and confessions about my own experiences that have helped to shape my thinking on this subject. After all, these days we strive for as much transparency as possible, don’t we? Well, not complete transparency, or I would have had to come out here wrapped in cellophane . . . and that would have been a little overboard, don’t you think? My California, flower child, anti-war, hippie days can’t be completely forgotten, I am afraid. There is this impression people have of Californians—that we are all “loose,” pot-smoking, party animals. Well, it’s true. . . .

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I have never owned my own physical therapist practice, I have never chaired a physical therapist education program, I have never put together an entire curriculum for a highly ranked professional [entrylevel] education program, and I have never managed a physical therapy service in a hospital or outpatient setting. What this should tell you is that I know where my strengths and weaknesses lie. My strengths lie in the ability to think; to analyze problems; and to recognize quality, sound thinking, and scholarship. And those skills have definitely shaped my vision and how I conduct my research and teaching, almost to a fault— sometimes, even over-thinking the problem (Fig. 3). A long time ago, I realized that there are many others who are much more capable than I of providing leadership in these other areas. In each case, I have tremendous respect for the people who have led these charges and particularly those who have done them well. I can only hope that my remarks will resonate equally well with them. On the other hand, it is true that I have had the privilege of spending the majority of my professional life in an academic setting, both in research and in education. So at least part of my perspective comes not from just academic physical therapy, but from playing a small part in the workings of a major research I institution and one that is currently engaged in its own new strategic planning process. I might add that, in addition to strategic planning, USC has just purchased 2 hospitals and is creating the USC Academic Medical Center. The future of physical therapy in this Academic Medical Center is not altogether clear. I believe this example from my own institution is a real manifestation of a much bigger problem that will require our focused attention.

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Figure 3. “The Thinker.” From The World of Richard Stine, published by Welcome Books, art copyright © 1994 Richard Stine. Reprinted with permission of the artist.

I am particularly fortunate in that my academic experiences have been molded by the quality and high standards of the institutions where I studied and worked. Similarly, most of my clinical experience has been influenced significantly by the quality of one of the major free-standing rehabilitation hospitals in the country, Rancho Los Amigos National Rehabilitation Hospital. Having said that, I must emphasize that it is not the “buildings,” even though they might be named the Jacquelin Perry Institute at Rancho Los Amigos, that molded my experience, but rather the quality and high standards embodied and exemplified through the colleagues and others I have had the good fortune to work with along the way. I have had the tremendous fortune and pleasure of working with a group of extremely talented individuals over my career in these 3 settings and across the country through November 2009

many different collaborations. Many of you are here today. I think you know who you are. You have had and will continue to have a tremendous impact on my vision for physical therapy. You could argue that my academic experience outweighs my clinical experience, and my comments, therefore, are biased toward the thing I know best. Certainly, there have been tremendous changes in the practice arena since I left it fulltime in 1982. I would simply respond to this by saying that I have not closed my eyes to clinical practice over the past 27 years. I teach professional Doctor of Physical Therapy students who go out into the practice environment and who come back to tell me about it, and I listen to them carefully. I conduct my own clinical trial research in neurorehabilitation in a network of outpatient Volume 89

practice settings across the nation, making me acutely aware of the inconsistencies in practice standards and the downright chaos that exists in reimbursement. I provide continuing education to experienced practicing clinicians in neurological physical therapy. And at my young age, I also see physical therapist clinical practice from the perspective of the consumer, both for myself and for my family and friends. These activities keep me informed and provide a reliable thermostat of the state of clinical practice today in the United States and Canada and how it is viewed from the outside. I have learned over many years of experience in academia and during my former life in clinical practice that good things take time and that nothing good comes easily or without effort. But I also have learned that if you keep your eye on the ball, Number 11

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40th Mary McMillan Lecture tations for excellence in the context of the randomized controlled trial. You might have expected some resistance from this group of experienced professionals. After all, they are well-respected experts in their practice setting. This has not been the case, however. In fact, all of our physical therapist colleagues have embraced the feedback and shown a sincere interest in demonstrating the excellence deemed necessary for trial initiation. I think this is largely because we have a grounding of mutual respect and we value what each brings to the table. That is the foundation for our academic-clinical partnership. Figure 4. “Man Stretching the Limits of His Own Mind.” From The World of Richard Stine, published by Welcome Books, art copyright © 1994 Richard Stine. Reprinted with permission of the artist.

have faith in your abilities, and— most importantly—strive for excellence using quality metrics, you will ultimately succeed. It might take several tries, but in the process, you have stretched your capacity, and, best of all, you did it without lowering your standards of excellence (Fig. 4). The benefits that emerge from this approach are contagious and attractive to all stakeholders, both inside and out; to consumers; to other health care providers; to students; to colleagues; and to educators and researchers.

Setting High Standards— An Example I’ll give you a recent example from my own work in connection with the implementation of a principlebased, complex intervention of stroke rehabilitation, in the context of the Interdisciplinary Comprehensive Arm Rehabilitation Evaluation (ICARE) trial.2 We are fortunate to be working with very experienced therapists who have either specialty 1240

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certification in neurological physical therapy or extensive clinical experience in neurological rehabilitation in the outpatient setting where the trial takes place. In several cases, on the first try, our very experienced clinicians have not met the 90% criterion level for standardization of the intervention protocol. Although their performance was more than acceptable for the natural clinical setting, it did not meet the high bar we set for the clinical trial. Our decision to request a second set of standardization materials will certainly delay the initiation of patient enrollment for several of our sites. However, the trade-off is a no-brainer. We believe the benefits of focusing on excellence far outweigh the detriments: in fact, (1) it allowed us to engage in a mutually beneficial dialogue with our clinical colleagues, (2) we seized the opportunity to develop an advanced training module to further refine and clarify details of the protocol, and, most importantly, (3) it served to calibrate our clinical colleagues to the expec-

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This is one example where establishing expectations for excellence can and will benefit not only the controlled trial but also the profession. In the context of our clinical research, we are setting a standard of care that should and will influence our practice. I have tremendous respect for and confidence in our clinical colleagues and know they can and will take responsibility to meet this new and exciting challenge.

Values and Attitude There is no place for divisiveness, unhealthy competition, or devaluation— every aspect of what we do is of value and necessary for our profession to reach its full potential. Nor is there room for an elitist attitude. In my book, what the successful clinical practitioner does is of equal value to what the long-time educator or National Institutes of Health–funded basic scientist does, as long as it fulfills a need and accomplishes its goals with excellence and integrity. We are equal partners in our quest for excellence—we may differ in our approach and skills, but we are much stronger when we embrace the differences and direct them toward a common goal. I am proud to know members of my profession November 2009

40th Mary McMillan Lecture who have chosen a career in clinical practice. All I ask is that in some way you share your vast clinical expertise and that you seek opportunities to collaborate with an academic center through research and teaching. With these kinds of connections, we all develop and grow, and it ensures that the 3 pillars of the physical therapy profession— education, research, and practice—are more strongly integrated. I believe that the development of strong academic-clinical partnerships is essential for advancing the research and clinical education agenda of the profession. Such partnerships are certainly one of the benefits of having strong academic centers of physical therapy. The Foundation for Physical Therapy saw the potential for this well before most when, in 2001, they offered a competition for the first clinical research network in physical therapy. In 2002, they funded PTClinResNet, with a grant to USC of $1.5 million over 3 years. We provided the network leadership, study-specific leadership, and much of the research resources, including data management and additional monetary support. Our partner academic institutions— Northwestern University, Southwest Missouri State University, and the University of California at Los Angeles—along with our clinical research partners at Rancho Los Amigos provided study-specific leadership that allowed for the successful completion of 3 phase I and 1 phase II randomized controlled trials across a diversified set of disability conditions, including adult stroke, cerebral palsy, chronic spinal cord injury, and low back pain. I bring this up here because I believe the network model is an excellent example of a true academic-clinical partnership. However, without an adequate research infrastructure and financial support provided by the academic center, PTClinResNet never would have sucNovember 2009

ceeded. Indeed, successful clinical research programs without academic center backing are rarely possible today, as they were when the intellectual strongholds for physical therapy were found in clinical settings at the premier rehabilitation centers around the country. The network model has been embraced successfully by our neighbors in Canada, and to a far greater extent than it has been in the United States. Carol Richards can attest to that. I believe this model should be explored further, especially as a particularly efficient means to conduct multi-site clinical trial research in physical therapy. The academic center can provide the core leadership, and the participating clinical sites can do what they are good at—implementing focused interventions. It is a win-win arrangement— one that benefits both sides in the process. The old notion that the academic center is an island—an ivory tower isolated from the clinical practice world—is completely shattered by the partnership model. In fact, by investing in the development of strong academic centers of physical therapy, we would be well positioned for achieving Vision 2020.3 Using one of Covey’s 7 habits of highly effective people,4 we must “Begin With the End in Mind.” We will need to shore up our image and reputation from outside the profession, and if we want to be, as Vision 2020 suggests, “recognized by consumers and other health care professionals and agencies as the practitioners of choice for the diagnosis of, interventions for, and prevention of impairments, functional limitations, and disabilities related to movement, function, and health,”3 we will need to get to work!

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Personal Journey— To Provide an Important Context for My Vision I have been a physical therapist for 36 years. I am very proud of that claim and proud of my profession and how far it has come since I began as a practitioner in 1973. In one sense, my career in physical therapy has come full circle— having cut my clinical teeth at Rancho Los Amigos, where I held my first job in physical therapy. I worked at Rancho Los Amigos for 3 years as a staff therapist on the neurology service until I left for Great Britain, where I practiced at King’s College Hospital for 6 months in what they called the Annex. This was where most of the patients with neurologic disorders were sent for rehabilitation. King’s College Hospital was one of the meccas for the Bobath—not neurodevelopmental treatment—approach to stroke rehabilitation. I’ll tell you one story to illustrate how far we have come from that era in our practice . . . or not. Mind you, I had just come from Rancho Los Amigos, where Dr Perry’s observational gait analysis was born and the key to proper gait alignment and limb progression was this concept of “roll-off” (not push-off) afforded by proper alignment, strength, and timing of the plantarflexor muscles. Of course, most patients with hemiparesis did not have adequate plantar-flexor control, so we usually provided them with an ankle-foot orthosis. By contrast, at King’s College Hospital, any device or equipment was strictly forbidden in the treatment gym. The idea was that if the therapist had proper “handling” skills, this would be more than sufficient for achieving optimal motor control and learning. On this particular afternoon, one of my American colleagues who worked there went into one of the locked storage closets and found a quad cane for her

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40th Mary McMillan Lecture patient. She gleefully brought it out and handed it to her patient, instructed her in its use, and began walking with her across the gym. All of a sudden, in a loud scream from the other side of the room, I heard one of the British supervisors boom, “WHAT ARE YOU DOING?” My American colleague had sinned and violated the doctrine of the purest Bobath approach to patient care. At that moment, I realized how fortunate I had been to have my initial clinical experience at Rancho Los Amigos, where we were encouraged to be independent thinkers, to question existing dogma, to evaluate our outcomes, to engage in our own problem solving, and to always seek improved approaches to rehabilitation. I went back to Rancho Los Amigos after my time in England and traveling around Europe visiting various physical therapy centers in France and Germany. It was after that period, away from the United States, that I realized what a unique opportunity Rancho Los Amigos offered across the board for education, research, and practice. At that time in the United Kingdom, and still today in certain countries in Europe, physical therapists—a.k.a. physiotherapists—were and continue to be viewed as technicians, following physician orders, but not functioning as full-fledged health care providers. I distinctly remember being advised by the senior leadership at Rancho Los Amigos that I would need to put my independent spirit in check when in the United Kingdom and learn to obey the physician’s orders—after all, they followed a more hierarchal medical model where the physical therapist was relatively low in the pecking order and certainly not capable of translating the science into a reasoned practice decision. In sharp contrast, my Rancho Los Amigos experience was one of equal collaboration with the physi1242

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cian and therapy team—I had been treated as an equal during our team meetings and was expected to demonstrate expertise in clinical decision making for the good of the patient. I distinctly remember the experience of presenting the physical therapy findings on rounds to Dr Perry and the physician team she led. I don’t know if it is still done this way today, but we would briefly present the evaluation findings and then demonstrate the patient’s functional capability—walking, in this case—to Dr Perry and the entire rehabilitation team. I remember how important it was to justify my treatment plan with evidence—not only the reported evidence, but also the demonstration. People talked about how nervous they were to present their patient in front of Dr Perry. I remember one of the occupational therapists being so nervous that she presented the “good” arm while the affected arm hung lifeless in the mobile arm support. What I remember was that Dr Perry treated the therapists with the same expectations and respect as she treated the physician residents and fellows. She did not tolerate a poorly presented case or response from anyone. These weekly rounds were a rigorous exercise, but one that we all benefited from, in large part because of the high expectations on the one hand and the tremendous mutual respect on the other hand. The whole experience is captured well by Maya Angelou’s words: “I’ve learned that people will forget what you said, people will forget what you did, but people will never forget how you made them feel.”5 I returned to Rancho Los Amigos after my United Kingdom experience because I realized there was no better place to be and accepted a job as the clinical instructor on the adult

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neurology service. It was there that I had the good fortune to work side by side with a talented and dedicated physical therapist, Jacqueline Montgomery. At the time, Jacque was the physical therapy supervisor for adult neurology. She was a superb role model who intuitively knew how to challenge and at the same time nurture the clinical careers of her staff. She did so by giving me a number of opportunities and challenges, but mostly by believing in me, even when I had my own doubts. She had an innate sense of how to effectively grow careers and to mentor junior clinicians to their full potential. This was clearly a turning point in my career, and I will be forever indebted to her for the critical experience she facilitated at a critical time in my professional development. I left Rancho Los Amigos in 1982, after nearly 10 years of clinical experience, to follow my yearning for science, and I went back to the university environment in pursuit of the skills that would enable a research career in physical therapy. At the time, putting “physical therapy” and “research” together would almost qualify as an oxymoron. When I spoke to Helen Hislop this past November, she reminded me that even Mary McMillan was an evidencebased practitioner—it is just that there was very little evidence in those days to support what physical therapists did. I have Ann VanSant to thank for pointing me to the work of Richard Schmidt, a behavioral movement scientist who had recently moved to UCLA. I went to study with Dick and spent the first year explaining to him why it might be important for a physical therapist to learn the science behind movement control and learning. He thought physical therapy dealt only with “hardware” problems, as he called them— broken bones and torn nerves. He had no idea that we also dealt with “software” problems, including November 2009

40th Mary McMillan Lecture movement planning and learning. It was a rude awakening when I got to UCLA for graduate work and realized that very little of my professional physical therapist education or even my advanced Master of Science degree in physical therapy from USC would count toward my PhD in kinesiology. It was around this critical period of focused academic work, during my doctoral studies at UCLA and a 2-year postdoctoral fellowship in behavioral neuroscience at the University of Wisconsin, when the stage was set for the opportunities and challenges that lay ahead. Although I had to take a leave from any clinical work during that period, except for a small stint doing home health and seeing one private patient, I was fortunate to receive a doctoral scholarship award from the Foundation for Physical Therapy to support me during the last few years of my doctoral studies. I am thankful to the Foundation for that early investment in my training. I would say that they made a reasonably good investment, particularly given that I am standing here before you now some 23 years later, articulating a vision for our profession. It says something about the commitment our profession has to the academic enterprise and to training the next generation of researchers in physical therapy. Many of my own PhD students have benefited from the Foundation’s Promotion of Doctoral Studies (PODS) mechanism that allowed them to focus full-time on their studies. This investment has already begun to bear fruit, as evidenced by a new breed of researchers such as Amy Bastian, Edelle FieldFote, Chris Powers, and John Buford, whose work has led to new understandings with important implications for therapy. There were a number of my colleagues around the period when I finished postdoctoral studies who, November 2009

upon completing rigorous academic degrees in related fields, could not see their way back to academic programs in physical therapy, and many decided to leave the profession altogether. Others found their way back, but were not provided with the necessary resources or had not been sufficiently prepared to grow their research careers or to participate in the development of academic physical therapy. Instead, they were faced with the choice to abandon their hard-earned research skills for faculty positions in institutions with a strong emphasis on professional education and few opportunities for research. I am sad to say that this problem has not gone away. Only recently, I learned that one of our PhD programs was restricted by the dean from enrolling any new students. Apparently, the faculty members, most of whom had obtained advanced doctoral degrees from the same institution and program—the “grow your own” approach—were considered insufficiently prepared. Neither was there any research infrastructure to support a PhD program. In this case, not only do the faculty suffer, but the program suffers, and the reputations of our academic programs and our profession suffer. It is my belief that part of the brain drain now and during earlier periods in our academic development relates to the paucity of academic institutions capable of supporting the research enterprise of the profession. As a result, a few of our distinguished researchers have their primary appointments in research centers outside of physical therapy or receive their salaries from non–physical therapist programs. Good examples are Fay Horak and Steve Wolf. At the most, some would take courtesy appointments in physical therapy, if such a program existed at their institution, but generally, in these cases, the physical therapist program could Volume 89

not provide the infrastructure needed to support a vigorous research program. The good news is that this situation is improving, and it is certainly better than it was when I finished my postdoctoral training in 1989. National Institutes of Health funding for rehabilitation has increased, and although the exact number is hard to extract from the CRISP database, there appears to be more physical therapists garnering NIH training and research grants than ever before. The problem, of course, is that only recently has physical therapy been viewed on a par with many of the other health care professions such as pharmacy, dentistry, and nursing. And only recently have we established a culture of academic program leaders who understand what is required to build high-quality academic programs of physical therapy and to be successful members of the universities within which they reside. I am convinced that the single most important aspect for the survival of the profession of physical therapy and for its external reputation is going to be the quality of its academic programs. Without such programs, we will be unable to keep up with the increasing demands to develop the evidence for our practice. Our profession has grown and has begun to mature, as evidenced by the previous analysis, but its success and prosperity are not guaranteed. We have seen a proliferation of professional education programs. As of today, there are 211 accredited programs in the United States, 196 of which are approved to offer the DPT (Fig. 5). Of these 196 accredited programs, 135 granted the degree in 2008. There also are 5 programs in active development, and an unknown number being considered by Number 11

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40th Mary McMillan Lecture important clinical and research collaborations inside and outside the institution. The biokinesiology program and its interdisciplinary collaborations serve to a large degree to strengthen the academic arm of our profession. Furthermore, we have identified a niche for the development of clinical research programs of nonpharmacologic complex interventions. There are multiple areas of funded clinical trial research programs involving stroke, Parkinson disease, cerebral palsy, aging, anterior cruciate ligament injury, tendinopathy, low back pain, aerobic fitness in children, and influence of hormone replacement therapy on skeletal muscle, to name a few. Figure 5. Accredited physical therapist programs, 1979 –2008.

institutions; all will offer the DPT [Mary Jane Harris, APTA; personal communication, December 2008].* The relevant question for the future is: How many of these programs can support our research enterprise? Suzann Campbell warned of this problem in her McMillan Lecture 10 years ago in 1999. She said, To look at the big picture of physical therapy research, we should consider the institutional settings needed to support our burgeoning research enterprise. In professions such as medicine and nursing, the faculties in major research universities produce a constant stream of data in support of practice and development of new approaches to patient care. Physical therapy programs in such research universities may become an endangered species as academic administrators reflect on our changing job market, the quality and quantity of our science, and their efforts to * Currently, there are 212 accredited programs, of which 201 are approved by the Commission on Accreditation in Physical Therapy Education to offer the DPT; there are now 8 developing programs.

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deal with the limitations of funding for higher education, especially when they are faced with APTA’s position on proliferation of education programs.6(p1061)

At that time, we did not have the financial crisis that we have today, and that has significant implications for our professional education programs. After completing postdoctoral studies, I was fortunate in finding my way back to physical therapy at one of the strongest academic programs in the country. It was Lucinda Baker, chair of the physical therapy department, who offered me a faculty position and gave me start-up funds to build my laboratory. It is in large part because of the tremendous vision, academic prowess, and strong leadership of Helen Hislop before and Jim Gordon now that the USC Division of Biokinesiology and Physical Therapy not only has survived in a research I university but also has been able to nurture the careers of its talented faculty and to develop

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Most of these programs have been successful in garnering grant support from NIH or various foundations, but without the substantial investment by our division in building a culture of clinical research and a research infrastructure, none of these programs would be possible. There is no doubt in my mind that were it not for the unique coalition of the academic and professional programs at USC, my research and teaching career would not have been possible. This is likely the same for many of my USC colleagues as well. In this environment, I have been and continue to be surrounded by incredible people, from whom I am continually challenged to think in new ways and consider new approaches and from whom I continue to learn. I am so grateful for this opportunity and for the wisdom and effort our academic leadership has extended.

Current Challenges and Opportunities In reading the compendium of previous McMillan Lectures, I was struck by the tremendous range of messages from the last 39 years. In most cases, the message was pertinent and shaped by the contextual issues confronting the profession November 2009

40th Mary McMillan Lecture and the person at that time. You could claim that, as a profession, we have come a long way since 1964 when Mildred Elson gave the first McMillan Lecture.7 However, we have spent considerable time focused inward on self-identity, selfdevelopment, and self-assessment (Fig. 6). Although this approach has been important for our own growth and development, it is now the time to make a concerted effort to turn the lens outward and ask how we are viewed from the outside. Many of the same conditions that drove Mary McMillan to found our profession in 1921 have come back, wearing a more modern face represented by the ravages of a much more sophisticated war that saves many more lives than in all previous wars but, by contrast, leaves them shattered from blast injuries to the head, amputations, and the elusive posttraumatic stress disorder. At the same time, the incidence of chronic health conditions such as diabetes, obesity, and stroke also is on the rise. The current generation of retirees is already the healthiest, longest lived, best educated, and most affluent in America’s history. Between the years 2000 and 2030, the number of Americans over 65 years of age will more than double, from 35 million to 71.5 million. By 2030, 1 in 4 Americans will be over age 65.8 Beyond a doubt, the most important concern today is the miserably fractured health care system in the United States—one that is embarrassingly inadequate for a nation that once set the standard for health care quality in the world. In 2001, the Institute of Medicine’s Committee on Quality of Healthcare in America published a report titled “Crossing the Quality Chasm: A New Health Care System for the 21st Century.”9 In it were recommendations for a new health system for the 21st century. They called for all health care November 2009

Figure 6. “Inner Stuff Dictating a Limit to Personal Vision.” From The World of Richard Stine, published by Welcome Books, art copyright © 1994 Richard Stine. Reprinted with permission of the artist.

organizations, professional groups, and private and public purchasers to pursue 6 major aims: specifically that health care should be safe, effective, patient-centered, timely, efficient, and equitable. The US health system spends a higher portion of its gross domestic product on health care than any other country but ranks only 37th out of 191 countries according to its performance.10 The challenge is to develop a system that will improve performance and reduce costs. Are we positioned to do this? Can we provide data on the degree to which physical therapists deliver care that is safe, effective, patient-centered, timely, efficient, and equitable? I am afraid that we have not even considered looking at these outcomes, let alone measuring them. I hope I am wrong about this. Given that health care reform was not considered an important enough Volume 89

item on the agenda for the previous White House administration, little has changed during the last 8 years since the Institute of Medicine’s report was published. If anything, the situation has gotten even worse, to the point where we have one of the highest infant mortality rates in the world.11 The good news is that under the current administration, we expect massive changes beginning with proposals to Congress as early as next week. This presents both an opportunity and a challenge to our profession. We must be smart and seize the opportunities and meet the challenges if we are to survive the changes and become part of the solution. Some of the opportunities that I hope we will embrace include telehealth, advanced technologies using remote communication, and novel health care delivery systems. Last year, John Wallace wrote a compelling piece on the need for outcome-based compensation.12 He argued eloquently for better alignNumber 11

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40th Mary McMillan Lecture ment between the payment for our practice and the patient’s goals. Wallace cited the work of DiPiero and Sanders13 to provide evidence that paying health care providers for their success in treating patients better aligns clinical performance with patient goals than do traditional salary and pay for production methods. This gets back to the idea of standards of excellence in clinical practice. Paying for quality and outcomes, rather than for the number of services or the amount of time spent treating, will entail a tremendous cultural shift for physical therapists— but I believe it will be necessary to achieve the goals of Vision 2020. We have advocated strongly for evidence-based practice, we have begun to see the rewards of this movement as we integrate this model into our education programs, and we have developed new clinical research models at the phase III clinical trial level in our unique area of expertise—that of complex behavioral interventions aimed to enhance recovery and effect rehabilitation, return to work, and the meaningful activities that define a high quality of life. I believe we still have a ways to go to make our practice more patient centered. There is considerable literature on behavioral change and eliciting self-management strategies through collaboration and problem solving that has only begun to be tapped in the context of physical therapy. On a parallel front, the basic scientists among us have made inroads into the traditionally sacred community that once was reserved for bench scientists from biology and the physical sciences but that now includes social scientists. We have seen the traditional walls crumbling between the parent disciplines of chemistry, physics, and physiology and the emergence of new interdisciplinary fields such as social1246

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cognitive-neuroscience. Our profession is represented on advisory boards, think tanks, and prestigious review panels. Some have gone on to top-level administrative positions as deans and university administrators. But these advances are not uniform across the health care professions. I have been surprised by the various battles that have arisen around the idea that a physical therapist (c’est moi) is leading a national multi-site controlled trial concerned with recovery of the arm and hand after stroke. To me, this concern only makes sense if we tear the body apart, as happens when you enter a black hole (Fig. 7)! Just like this. OK, you get the arm, and I will take the leg. Where does the trunk go? And, who gets the heart? More importantly, who gets the brain? I promised Chris Powers he could have the patella. Actually, nothing ever gets out of the black hole, I am told, and so, in the end, nobody gets anything. Kidding aside, you can see that this is a pointless argument, and yet it continues, in large part, because of professional insecurities. In the end, we are all in this for the good of the patient. In my view, these childish battles may serve only to compromise our reputation as we embark on a period of significant health care reform. Here’s a short story to illustrate the territorial problem in real life. The wife of a good friend of mine recently broke her radius when a biker ran over her. In addition, she sustained a rotator cuff tear in the same accident. She started seeing a hand therapist for rehabilitation after the wrist fracture healed, and they began working on her forearm in connection with the wrist injury, but they told her it was her choice to stay there or go over to physical therapy to get her shoulder treated! She was told that they both “do” the shoulder.

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The approach we have chosen is to reach across the aisle and provide leadership for developing interdisciplinary education programs focused on clinical trial research in rehabilitation. Clearly, these models have worked in the area of pediatrics, so there is some precedence already. We are working with our colleagues in occupational therapy on a proposal for the 2010 American Occupational Therapy Association meeting. Our hope is that demonstrating a successful collaboration in rehabilitation science will help us move past the fractured body problem to a focus on meaningful outcomes for the whole patients we treat. I see the opportunities ahead as those that will allow us to focus on what is important—the whole person—and to identify what will improve the patient’s health and quality of life, whether that might involve us or not. In fact, this is the focus of our recently funded Rehabilitation Engineering Research Center from the National Institute on Disability and Rehabilitation Research, involving people aging with or into disability. This is a partnership between Rancho Los Amigos and USC. The research and development activities represent a true collaborative effort among biomedical engineering, physical therapy, occupational therapy, gerontology, information technology, and the Institute for Creative Technologies that includes virtual reality systems. We have taken a leadership role in creating this center and in the integration of several emerging technologies that can be developed to benefit those who are aging with a disability. The research infrastructure of our academic center in physical therapy had an enabling influence on the development of these interdisciplinary collaborations and the creation of the Rehabilitation Engineering Research Center. I point this out as another benefit of having strong academic centers for November 2009

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Figure 7. Illustration shows the stretching and squeezing experienced when sucked into a black hole. Used with permission of Kip S. Thorne.

physical therapy—they can serve as a nexus for interdisciplinary collaborations that benefit health care.

Why Does Our Survival Hinge on the Quality of Our Academic Programs? Starting last November, I conducted a series of interviews in connection with the preparation for this lecture. I asked the same questions during each interview. One of my questions was: How would you rank the relative importance of each of the 3 pillars of the physical therapy profession— education, practice, and research? Most of the executive leadership I interviewed at APTA headquarters thought they were equally important and that you could not really have one without the other. Rob November 2009

Batarla, APTA’s Chief Financial Officer, was an exception. He said it was a no-brainer— education is the most important, with practice and research tied for second place. He argued that without practice, you do not know what is going on, and without research, you do not know what will be going on. Yet when you examine the recent strategic plan for APTA,14 the objectives for education are almost entirely focused on clinical education and postprofessional clinical residencies and fellowship programs. There was only one objective to “assess the current and projected needs in physical therapy academic education.” It is concerning when the group of academic administrators is organized

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as a special interest group—and considered primarily a forum or venue for networking and exchange of ideas, but not for strong leadership. I am aware that there is a proposal to form a new organization of academic physical therapist programs that wishes to take a strong and active leadership role in setting the agenda for improving the profession. I am encouraged by this proposal and consider that it will become even more important for giving guidance as we navigate through the impending health care reform. It was Jim Gordon who articulated the best answer to my 3-pillar question. He said,

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40th Mary McMillan Lecture physical therapy—this is essential if we want to be “recognized by consumers and other health care professionals and agencies as the practitioners of choice” for what we do. Second, we must build effective academic-clinical partnerships within the profession. This could be done initially by using the strongest academic programs to either singly or jointly lead the effort. PTClinResNet was an example. We should look to our neighbors in Canada for current models of effective networks. Finally, we must acknowledge the complexity of the problem and develop effective interdisciplinary collaborations outside the profession with engineering, medicine, behavioral scientists, and other health care professionals, all with common but unique strengths. Let’s stop pulling the patient into parts. We can step up to the plate and take a leadership role in this process. Remember, we are change agents; this is what we do with our patients, and we are passionate about our profession and its future.

Figure 8. “Star Reach.” From The World of Richard Stine, published by Welcome Books, art copyright © 1994 Richard Stine. Reprinted with permission of the artist.

This is a trick question, of course. I wouldn’t think of these as separate and distinct pillars. The overall purpose of our profession is to better the health of humans, and, of course, clinical practice is where that happens. But sound clinical practice rests on a foundation that includes research (evidence) and education (professional and postprofessional). Without this foundation, our practice is no more than quackery. Furthermore, both research and education depend on welltrained and dedicated physical thera-

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pist faculty members with access to adequate resources. These can only exist within strong academic physical therapy programs at universities that are committed to research and professional education.

So How Can Our Profession Achieve Its Full Potential? I propose 3 initiatives for our profession to achieve its full potential (Fig. 8). First, we must invest in building strong academic centers in

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Acknowledgments I want to acknowledge a few members of my family and long-time close friends who have joined us today. My partner in life, my husband, Kip Thorne, who not only gave me the black hole slide but has been a source of continuous inspiration and moral support for the past 26 years. My good friend, Margo Musante, who took time away from her busy schedule to come to Baltimore to be surrounded by a group of physical therapists. Beth Fisher, both a longtime special friend and now colleague at USC. Susan Waranch, a practicing physical therapist and dear friend here in Baltimore, who I met in the late 1970s at USC when we were both studying for our advanced master’s degree in physical therapy. November 2009

40th Mary McMillan Lecture A few people are not physically here today, but I know they are here in spirit. My parents, Saul and Sylvia Winstein, who were always a source of strength and encouragement. My brother, Bruce, and his family—my sister-in-law, Joan, and my niece and nephew, Allison and Keith. They stayed behind in Chicago to support my brother who is battling an aggressive cancer. Finally, I want to thank my colleagues from USC who are here to support me. You are a tremendous source of intellectual stimulation and make every day at USC an enriched experience. And last, but not least, I want to thank Steve Wolf for his mentorship in my career and for being a very special friend. The 40th Mary McMillan Lecture was presented at the Opening Ceremonies of PT

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2009: The Annual Conference and Exposition of the American Physical Therapy Association; June 10, 2009; Baltimore, Maryland. DOI: 10.2522/ptj.2009.mcmillan.lecture

References 1 Hislop HJ. Tenth Mary McMillan Lecture: The not-so-impossible dream. Phys Ther. 1975;55:1069 –1080. 2 National Center for Medical Rehabilitation Research (NCMRR) Supported Projects for 2008. NIH/NINDS/NICHD 1U01NS056256. Available at: http://www.nichd.nih.gov/ about/org/ncmrr/projects.cfm?fiscal_year ⫽2008&nihorg⫽HNT8. 3 Vision 2020. Available at: http://www.apta. org/AM/Template.cfm?Section⫽Vision_ 20201&Template⫽/TaggedPage/ TaggedPageDisplay.cfm&TPLID⫽285& ContentID⫽32061. 4 Covey SR. The 7 Habits of Highly Effective People. New York, NY: Fireside, Simon & Schuster Inc; 1989. 5 QuotationsBook. Available at: http:// quotationsbook.com/quote/46468/. 6 Campbell SK. Thirtieth Mary McMillan Lecture: PT 2000: nurturing the profession. Phys Ther. 1999;79:1058 –1068.

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7 Elson MO. The legacy of Mary McMillan. Phys Ther. 1964;44:1067–1072. 8 National Center for Health Statistics. Health, United States, 1999. Hyattsville, MD: US Department of Health and Human Services; 1999. 9 Institute of Medicine. Crossing the Quality Chasm: A New Health Care System for the 21st Century. Washington, DC: National Academy Press; 2001. 10 OECD Health Data, 2000: A Comparative Analysis of Twenty-Nine Countries. Paris, France: Organization for Economic Cooperation and Development; 2000. 11 US Department of Health and Human Services. Preventing Infant Mortality, 1997 and 2001. Available at: http://www.hhs. gov/news/factsheet/infant.html. 12 Wallace J. Your patients, your practice, your business: the need for outcome based compensation. Board Perspective. PT Magazine. 2008;16(1):46 – 47. 13 DiPiero A, Sanders D. Condition-based payment: improving care of chronic illness. BMJ. 2005;330:654 – 657. 14 APTA Strategic Plan. Available at: http:// www.apta.org/AM/Template.cfm?Section⫽ Home&Template⫽/CM/HTMLDisplay.cfm &ContentID⫽56233.

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2009 APTA Presidential Address

We Must See the Possibilities R. Scott Ward R.S. Ward, PT, PhD, is Professor and Chair, Department of Physical Therapy, College of Health, University of Utah, 520 Wakara Way, Salt Lake City, UT 84108-1213 (USA). Address all correspondence to Dr Ward at: scott.ward@ hsc.utah.edu. [Ward RS. 2009 APTA Presidential Address: We must see the possibilities. Phys Ther. 2009;89: 1250 –1252.] © 2009 American Physical Therapy Association

“T

hat moment changed my life. It was then up to me to define whether that change would be positive or negative. I was not sure if I would survive, let alone did I think I had much of a future.”

Around 20 years ago, an icon of mine, a patient, was burned in an industrial explosion, and these were some of the thoughts he commonly expressed to me. His survival of a mainly full-thickness, 68% body surface area burn was remarkable. For months, we worked hard together to help him overcome the several physical impairments he faced. Acute and ongoing mobility and strength deficits were paramount. Loss of distal digits on both hands and changes in his cosmetic appearance added both physical and psychological challenges to his recovery. Along the course of our work together, he declared something very simple and very consequential to me that shaped the work I have done since then as a physical therapist. He said, “Thanks for helping me see my possibilities!” Now, I was humbled by his comment, that he would assume it was me that was showing what was possible for him. I had worked with this patient and watched as he fought to recover when others might have fought against being revived. I had worked with him while he fought his fears with his own powerful doses of everincreasing determination. And, we had worked together to achieve milestones in his performance, from the simplest of routine activities of daily living, progressing to directed tasks of some level for his goal of returning to work. I was grateful that after returning to his home and some light-duty work, he continued to share with me his ongoing progress as he navigated his way through additional schooling and later to a more substantial return to work. He now continues his employment as a safety advisor and industrial counselor at the very industry where he was injured. He is a devoted father who has spent many hours of his personal time over the years at soccer and baseball games, school assemblies and graduations, and family gatherings and vacations. He has volunteered as a counselor for summer “burn camps” for children and river trips for adults who have survived burn injuries. He says he volunteers for his own therapy—but I know it has been more his own selfless motivation. I am honored that he felt I saw possibilities for him, and I am awed at how he saw even more possibilities for himself.

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With all the differences in our professional lives in physical therapy, we have this one thing in common: the essence of our profession is focused on seeing possibilities and

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2009 APTA Presidential Address helping those we work with to do the same. We spend our days— whether they are in the clinic, the classroom, the laboratory, or elsewhere, such as in our management or counseling roles—either identifying potential or helping others to see their own potential. We are continuously engaged in divining ways to help those with whom we work to achieve more than what they thought might be conceivable. At times, it is hard to believe how fortunate we are to be in the profession that we find ourselves. Our capacity to influence others at vulnerable moments has the potential to change lives for the better and to offer practical hope to those with whom we interact (Figure). With this capacity to help influence people’s potential comes clear responsibility as well. That responsibility is to honor possibilities, not to prejudicially limit them. Sometimes present-day society works to convince us that there are conspiracies and forces that will encourage us to narrow our thinking about possibility. We are time and again exposed to any number of pundits’ declarations of their personal perceptions, even their precision of view; of the black and white of every issue. These pundits, furthermore, believe that their viewpoint is always the right one. We need to be careful to avoid the dangerous effects of assuming someone else’s or, worse yet, our own omniscience.

Available With This Article at www.ptjournal.org • Audio Podcast: Listen to the 2009 APTA Presidential Address delivered by APTA President R. Scott Ward, PT, PhD, at PT 2009 in Baltimore, Maryland.

Figure. R. Scott Ward, PT, PhD, APTA President.

People talk about complex issues as if they are simple and the solutions are obvious. Of course, those who simplify an issue are clear that their resolution is the right one and cannot understand why others have such trouble comprehending their wisdom. This kind of dogmatism is a common theme on extreme sides of any issue. The unfortunate casualty here is that civil discourse often is not considered as a part of the conversational equation. We must always be on the alert for collegial conversational ground and ways that we can contribute to meaningful dialogue. A current issue of impressive importance to each of us and our society is the struggle to restructure the delivery of our country’s health care system. This challenge has prompted extremists to peddle their proposed system as simple to develop and better than any other, and then to make it someone else’s fault that nothing is being done to implement their magic. With this, as with many of our professional issues, we should be a part of careful thinking and of rational debate that seeks to include several options. In the case of health care reform, we must rise above dogma and actively seek to be a part of sensible solutions to treat the sickness in the system. We must see the possibilities.

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Issues with the reform of our health care delivery system include availability and access to care, cost of care, promotion of health and prevention, and returning a sense of “community” to health care in lieu of its current sense of “corporatization.” As health care delivery is revised, our challenge is to make sure that our patients and clients have— and know that they have—direct access to our services. Our patients and clients should be ensured, by law, that when they receive physical therapy care, it will not be a generic service but will be delivered by conscientious, well-prepared, licensed physical therapists and physical therapist assistants! We offer cost-effective access to and delivery of care. We promote health through the clinical prescription of directed, goal-oriented activity, exercise, and engagement in society. We provide broad prevention efforts throughout the care spectrum, from primary through tertiary prevention. We offer a very real “community” in our care because we connect directly with our patients and clients through the use of our hands as well as technology, and through the use of our minds by delivering our services with evidence-based clinical decision making. In physical therapy, we contribute great possibilities to health care reform. The American Physical Therapy Association is a part of the current discourse on health care reform; we are a part of the ongoing conversation. We will rise above the dogma and participate in the resolution, which is likely to be incremental and may at times even appear experimental. Because of that likelihood, we will remain diligently and intelligently engaged in the ongoing discussion of what health care delivery is today and what it will become, knowing that a specific endpoint is hard to predict. Number 11

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2009 APTA Presidential Address We also must realize that there is more for us to discover, and the possibilities for improving our care are exciting. For example, although the survival of the patient I referred to earlier was remarkable, it was not as astounding at that time in burn care as it might have been 20 years earlier. Clearly, his chances of survival were better in the 1980s than they would have been in the 1960s. And his chances of survival today would be even greater than they would have been in the 1980s, thanks to the many advances in knowledge and practice that we have seen over 40 years. In the 1960s, it is likely that my patient would have been in static splints in his bed for days or even weeks following his injury. Twenty years ago, our physical therapy care included limited use of static splints

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and required that the patient be an active participant in rehabilitation. Today, the level of patient involvement in rehabilitation in our burn center is even greater and more focused than it was 20 years ago. The potential for ongoing improvements in the care of any of our patients is ever present. Although the negative pull of society might be great, we must resist it. Society is looking for a profession like ours. We must do what we have always done well in this profession; that is, to instill in those we serve a pragmatic and very real hope. Without knowing it, Woodrow Wilson provided us with an admirable way to guide the profession of physical therapy when he said, “We are here to enrich the world, and we

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impoverish ourselves and others if we forget this errand.” In a world that often focuses on limiting possibilities, we should remember our daily opportunities to focus on the positive potential for those with whom we have the good fortune to work. Cherish your unique promise of helping others see their possibilities. You and those you work with—your patients and clients and your colleagues—deserve nothing less, and we all will be the better for it. The 2009 APTA Presidential Address was presented at the Opening Ceremonies of PT 2009: The Annual Conference and Exposition of the American Physical Therapy Association; June 10, 2009; Baltimore, Maryland. DOI: 10.2522/ptj.2009.presidential.address

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Letters to the Editor On “Manual therapy, exercise, and traction for patients with cervical radiculopathy…” Young IA, et al. Phys Ther. 2009;89:632–642. I appreciate the discussion in the article by Young et al1 that focused on the meaning and precision of confidence intervals regarding effect sizes seen in the study. This focus on the meaning of the data is extremely useful. However, it would have been more helpful if the confidence intervals had “fit” the point estimates for the Numeric Pain Rating Scale (NPRS) and the Neck Disability Index (NDI). Unfortunately, the point estimates given for the NPRS and the NDI are not at the midpoint of the confidence intervals (CIs)—a necessary requirement of CIs of mean differences. After looking at them carefully, it is fairly easy to guess that the CIs were probably constructed around a negative value for the point estimates (negative differences between group means), rather than the positive value given. It appears that this mistake also might have been repeated with 8 of the 32 CIs in Table 3. A second type of error (or conflict) in the data is in the 4-week unadjusted mean difference between groups for the PatientSpecific Functional Scale and the Global Rating of Change Scale. The intervals stated do not include the value “0” and, therefore, indicate that the differences are significant. However, the associated P value clearly indicates that the differences are not statistically significant. I suspect that the lower limit value for the CI may have been negative rather than positive.

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Donna L. Thorpe D.L. Thorpe, PT, DrPH, is Assistant Professor, Loma Linda University. This letter was posted as a Rapid Response on July 31, 2009, at www.ptjournal.org.

Reference 1 Young IA, Michener LA, Cleland JA, et al. Manual therapy, exercise, and traction for patients with cervical radiculopathy: a randomized clinical trial. Phys Ther. 2009;89:632–642. [DOI: 10.2522/ptj.2009.89.11.1253.1]

L.A. Michener, PT, PhD, ATC, SCS, is Associate Professor, Department of Physical Therapy, Virginia Commonwealth University–Medical College of Virginia Campus. J.A. Cleland, PT, PhD, OCS, FAAOMPT, is Associate Professor, Department of Physical Therapy, Franklin Pierce University, Concord, New Hampshire; Physical Therapist, Rehabilitation Services, Concord Hospital, Concord, New Hampshire; and Faculty, Regis University Manual Therapy Fellowship Program, Denver, Colorado. A.J. Aguilera, MD, is Neurologist, Neurology Associates, Fredericksburg, Virginia. A.R. Snyder, PhD, ATC, is Assistant Professor, Athletic Training Program, A.T. Still Univeristy, Mesa, Arizona.

Author Response We thank Dr Thorpe1 for bringing up a few very important issues with Table 3 in this article.2 She was correct in her assumptions about the nonsymmetrical 95% confidence intervals (CIs). Please refer to revised Table 3 (page 1255) where the corrections address transposition errors, inconsistent use of 100th versus 10th decimal points that are now consistent, and incorrect calculation of 95% CIs. All values and 95% CIs have been verified for accuracy, and the correct values appear in the revised Table 3. The 95% CIs for adjusted effect sizes at 4 weeks were reported incorrectly in the text. The corrected Results section appears on page 1254.

This letter was posted as a Rapid Response on October 15, 2009, at www.ptjournal.org.

Reference 1 Thorpe DL. Letter to the editor on “Manual therapy, exercise, and traction for patients with cervical radiculopathy: a randomized clinical trial.” Phys Ther. 2009;89:1253. 2 Young IA, Michener LA, Cleland JA, et al. Manual therapy, exercise, and traction for patients with cervical radiculopathy: a randomized clinical trial. Phys Ther. 2009;89:632–642. [DOI: 10.2522/ptj.2009.89.11.1253.2]

In addition, because of the changes to the 95% CIs, the second paragraph in the Discussion section— on precision of point estimates— has changed. The corrected paragraph appears on page 1254. Ian A. Young, Lori A. Michener, Joshua A. Cleland, Arnold J. Aguilera, Alison R. Snyder I.A. Young, PT, MS, OCS, SCS, CERT MDT, is Physical Therapist, Spine and Sport, Savannah, Georgia, and Affiliate-Associate Professor, Department of Physical Therapy, Virginia Commonwealth University–Medical College of Virginia Campus.

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Corrections Young IA, et al. “Manual therapy, exercise, and traction for patients with cervical radiculopathy…” Phys Ther. 2009;89:632–642. Errors1,2 were found in Table 3 in this article, and these errors required changes to the narrative as well. The revised Table 3 contains corrections that address transposition errors, inconsistent use of 100th versus 10th decimal points that are now consistent, and incorrect calculation of 95% confidence intervals (CIs). All values and 95% CIs have been verified for accuracy, and the correct values appear in the revised Table 3 (next page). The 95% CIs for adjusted effect sizes at 4 weeks were reported incorrectly in the text. The Results section, with corrections in bold, appears below. In addition, because of the changes to the 95% CIs, the second paragraph in the Discussion section—on precision of point estimates—has changed. The rewritten paragraph appears below. The authors regret the errors. Results Patients (N=121) were screened for eligibility, and 81 patients were eligible and agreed to participate (Fig. 1). Twelve patients (n=6 in each group) were lost to follow-up between baseline (pretreatment) measures and the 4-week follow-up. Baseline demographics and data for outcome measures are listed in Table 2. No significant interaction or main effects of group were found for the primary or secondary outcome measures (Tab. 3). There was a significant main effect (P<.05) of time for the NPRS [Numeric Pain Rating Scale], PSFS [Patient-Specific Functional Scale], NDI [Neck Disability Index], and body diagram, indicating there were significant improvements in pain, function, disability, and symptom distribution regardless of group assignment (MTEX [sham intermittent cervical traction] versus MTEXTraction [intermittent cervical traction]) from baseline to the 4-week follow-up. The adjusted effect size at 4 weeks from the mixed-models analysis for each of the primary outcomes was small (NDI=1.5, 95% confidence interval [CI]=−3.8 to 6.8; PSFS=0.3, 95% CI=−1.2 to 1.8; and NPRS=0.5, 95% CI=−1.0 to 2.1). Discussion (paragraph 2) Although there were no significant differences between groups with any of the outcome measures, the estimates of the treatment effects were imprecise, and this uncertainty needs to be considered when interpreting the trial results. At the 2-week follow-up, the upper boundary of the adjusted 95% CI for the NDI was 7.0 (Tab. 3). This value meets the threshold for meaningful clinically important change of the NDI (7.0), suggesting that we cannot exclude the possibility of harm in the MTEXTraction group relative to the MTEX group. Similarly, at the 4-week follow-up, the upper boundaries of the adjusted and unadjusted 95% CIs for the NPRS were 2.1 and 1.7, respectively (Tab. 3). These values exceed the threshold for meaningful clinically important change of the NPRS (1.3) and also indicate that we cannot exclude the possibility of harm in the MTEXTraction group. In addition, at the 2-week follow-up, the lower boundaries of the adjusted and unadjusted 95% CIs for the NPRS were −2.1 and −1.6, respectively (Tab. 3). These values, which are greater than the threshold for minimal clinically important difference (MCID), suggest that we cannot exclude the possibility of a clinically important benefit of the MTEXTraction group relative to the MTEX group for the NPRS variable at this specific time point. References 1 Thorpe DL. Letter to the editor on “Manual therapy, exercise, and traction for patients with cervical radiculopathy: a randomized controlled trial.” Phys Ther. 2009;89:1253. 2 Young IA. Author response to letter to the editor on “Manual therapy, exercise, and traction for patients with cervical radiculopathy: a randomized controlled trial.” Phys Ther. 2009;89:1253.

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Corrections Table 3 (Revised).

Results of Analysis Comparing Outcomes Between Treatment Groupsa Unadjusted Mean (SD) for Each Group Outcome Measure

MTEXTraction Group

Adjusted Mean (SD) for Each Groupb

MTEX Group

Unadjusted Mean Difference Between Groups (95% CI)

P

MTEXTraction Group

MTEX Group

Adjusted Mean Difference Between Groupsb (95% CI)

P

Neck Disability Index

c

2 wk

15.0 (8.2)

13.1 (7.1)

1.9 (−1.5 to 5.3)

.31

14.0 (12.3)

12.2 (11.8)

1.8 (−3.5 to 7.0)

.34

4 wk

12.1 (9.0)

10.9 (7.8)

1.2 (−2.6 to 5.0)

.56

11.1 (12.3)

9.6 (14.1)

1.5 (−3.8 to 6.8)

.42

2 wk

5.1 (2.5)

5.2 (2.4)

−0.1 (−1.2 to 1.0)

.91

5.3 (3.8)

5.6 (3.8)

−0.3 (−1.7 to 1.2)

.66

4 wk

6.6 (2.4)

6.3 (2.5)

.66

7.0 (3.8)

6.7 (4.3)

0.3 (−1.2 to 1.8)

.57

Patient-Specific Functional Scaled

0.3 (−0.8 to 1.4)

Numeric Pain Rating Scale

e

2 wk

4.5 (2.3)

5.1 (2.4)

−0.6 (−1.6 to 0.4)

.24

4.2 (3.0)

4.8 (3.0)

−0.6 (−2.1 to 0.9)

.25

4 wk

3.7 (2.7)

3.2 (2.5)

0.5 (−0.7 to 1.7)

.38

3.3 (3.1)

2.8 (3.4)

0.5 (−1.0 to 2.1)

.33

2 wk

17.8 (12.5)

16.4 (12.2)

1.4 (−4.1 to 6.9)

.60

16.5 (31.4)

16.6 (30.7)

−0.1 (−8.1 to 8.0)

.98

4 wk

15.2 (13.8)

12.8 (13.5)

2.4 (−3.7 to 8.5)

.46

13.1 (31.7)

12.7 (34.7)

0.4 (−7.7 to 8.6)

.87

Physical activity subscaleh

16.4 (7.5)

18.1 (6.0)

−1.7 (−4.8 to 1.4)

.31

15.5 (10.4)

17.0 (10.5)

−1.5 (−6.2 to 3.3)

.37

Work subscalei

21.9 (18.4)

20.3 (17.2)

1.6 (−6.7 to 9.6)

.71

16.8 (28.3)

15.1 (28.2)

1.7 (−9.2 to 12.6)

.65

Physical activity subscale

14.0 (7.8)

15.3 (7.9)

−1.3 (−4.8 to 2.2)

.38

12.4 (10.5)

14.2 (11.9)

−1.8 (−6.6 to 3.0)

.29

Work subscale

18.5 (16.9)

17.8 (16.8)

0.7 (−6.8 to 8.2)

.87

14.5 (28.3)

11.6 (31.7)

2 wk

5.5 (3.0)

5.6 (2.5)

−0.1 (−1.3 to 1.1)

.83

6.1 (4.5)

6.2 (4.6)

−0.1 (−1.5 to 1.2)

.85

4 wk

6.8 (3.0)

6.9 (3.0)

−0.1 (−1.4 to 1.2)

.83

7.1 (4.6)

7.5 (5.2)

−0.4 (−1.8 to 0.9)

.52

2 wk

9.7 (2.2)

9.6 (1.9)

0.1 (−0.8 to 1.0)

.76

10.1 (3.4)

10.0 (3.4)

0.1 (−0.8 to 1.1)

.74

4 wk

10.8 (2.0)

10.5 (2.4)

0.3 (−0.7 to 1.3)

.65

11.1 (3.3)

10.8 (3.9)

0.3 (−0.7 to 1.2)

.58

Body diagram (symptom distribution)f

Fear-Avoidance Beliefs Questionnaireg 2 wk

4 wk 2.9 (−8.1 to 13.9)

.44

Satisfaction ratingj

Global Rating of Change Scalek

Improved at 4 wk (%)

68

69

a Values are mean (SD) unless otherwise stated. MTEXTraction group=patients who receive manual therapy, exercise, and intermittent cervical traction; MTEX group=patients who receive manual therapy, exercise, and sham intermittent cervical traction; CI=confidence interval. b Adjusted values from mixed-models analysis. c Range of scores=0–50; higher scores represent higher levels of disability. d Range of scores=0–10; higher scores represent greater levels of function. e Range of scores=0–10, where 0=”no pain.” f Range of scores=0–44; higher scores represent greater area of symptom distribution. g Range of scores=0–30; higher scores represent higher levels of fear avoidance. h Range of scores=0–66; higher scores represent higher levels of fear avoidance. i 2 categories: deep tendon reflexes and myotome assessment. j Range of scores=0–10, where 10=”completely satisfied.” k Range of scores=0–13; scores ≥10 signify clinically meaningful improvement.

[DOI: 10.2522/ptj.20080283.cx]

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Scholarships, Fellowships, and Grants News from the Foundation for Physical Therapy Welcome to the New Members of the Scientific Review Committee The Foundation extends a warm welcome to the newest members of the Scientific Review Committee: Diane Borello-France, PT, PhD, Duquesne University; Rose Marie Rine, PT, PhD, University of North Florida; and Deborah Thorpe, PT, PhD, University of North Carolina at Chapel Hill. Each will serve a 3-year term beginning January 1, 2010, reviewing and scoring the scholarship and grant applications that are submitted for Foundation funding. The Foundation thanks them in advance for their commitment to the scientific review process and looks forward to working with them. Profiles of these newest members will be featured in upcoming Foundation publications. The Foundation will be seeking nominations again in 2010 for skilled reviewers to join the Scientific Review Committee. Criteria for membership are posted at the Foundation’s Web site (www. FoundationforPhysicalTherapy. org) under Program Information.

PhD, OCS, was a 1996 Doctoral Training Research Grant winner as well as the winner of the 2000 Research Grant funded by APTA’s Orthopaedic Section. “Effects of Physical Guidance on Short-Term Learning of Walking on a Narrow Beam” by Domingo A and Ferris DP was published eletronically in Gait Posture on August 10, 2009. Antoinette Domingo, PT, MPT, was the Marylou Barnes 2007 PODS II scholarship winner. “The Effects of a Secondary Task on Forward and Backward Walking in Parkinson’s Disease” by Hackney ME and Earhart GM was published electronically in Neurorehabilitation and Neural Repair on August 12, 2009. Gammon Earhart, PT, PhD, received a 1999 PODS II scholarship.

Recent Publications by Foundation-Funded Researchers

“First Item Response Theory Analysis on Tampa Scale for Kinesiophobia (Fear of Movement) in Arthritis” by Mielenz TJ, Edwards MC, and Callahan LF was published electronically in the Journal of Clinical Epidemiology on September 4, 2009. Thelma Mielenz, PT, PhD, OCS, won the 2003 New Investigator Fellowship Training Initiative (NIFTI).

“Development of Active Hip Abduction as a Screening Test for Identifying Occupational Low Back Pain” by Nelson-Wong E, Flynn TW, and Callaghan JP appeared in the Journal of Orthopediac & Sports Physical Therapy (2009;39[9]:649–657). Erika NelsonWong, PT, DPT, PhD, received a 2005 Kendall Scholarship as well as a 2006 PODS I scholarship and a 2008 PODS II scholarship from the Foundation. Timothy Flynn, PT,

“Effects of Fatigue and Recovery on Knee Mechanics during SideStep Cutting” by Tsai LC, Sigward SM, Pollard CD, Fletcher MJ, and Powers CM was published electronically in Medicine and Science in Sports and Exercise on September 2, 2009. Susan Sigward, PT, PhD, received a 2001 PODS I scholarship, and Christopher Powers, PT, PhD, received the MiamiMarquette Challenge Research Grant in 2001.

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Applications Still Being Accepted for PODS I and II Scholarships and NIFTI-HSR The Foundation is still accepting applications for the Promotion of Doctoral Studies (PODS) scholarships and the New Investigator Fellowship Training Initiative– Health Services Research (NIFTI– HSR) award. Please visit the Foundation at www.Foundation forPhysicalTherapy.org for more information and guidelines. Applications will be accepted until noon, January 26, 2010.

Foundation Accepting Applications in 2010 for $300,000 Research Grant The Foundation for Physical Therapy will begin accepting proposals in 2010 for a 2-year, $300,000 award that will focus on the topic “Physical Therapy Exercise Interventions to Reduce Activity Limitations and Improve Community Participation in Older Adults with Multiple Chronic Conditions.” This funding opportunity is intended

Foundation’s Online Auction The Foundation’s 4th Annual Online Auction closes Tuesday, December 1. Donated items are still needed to build our online catalog. To donate an item, register, and bid, visit www. Foundation4PT.cmarket.com. Proceeds support the Foundation’s mission of advancing the physical therapy profession through doctoral scholarships and clinical research. For more information, contact Ken Corch at 800/875-1378, or by e-mail at [email protected].

November 2009

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Scholarships, Fellowships, and Grants to support innovative research focused on physical therapy exercise interventions to improve activity and participation in older adults with multiple chronic conditions. The target of this funding mechanism is towards those projects that are considered high-impact and high-risk/high-reward applications. The Foundation encourages multidisciplinary teams to apply for this funding opportunity.

Keep Up With Research News From the Foundation PTJ readers are encouraged to subscribe to the Foundation’s monthly e-Newsletter and FPT Research Alerts. Not only will subscribers receive alerts when the Foundation’s online grant application system is open, they will also be “in the know” about key Foundation

New in Open Door:

events and activities and will be able view the latest researcher profiles. Subscribe at www.Foundationfor PhysicalTherapy.org, and click on “Join Our Email List.” [DOI: 10.2522/ptj.2009.89.11.1256]

www.apta.org/opendoor

Medcom Video Training Programs Collection ProQuest now provides access to Medcom’s video training collection of 75 health care topics important to practitioners. Topics include: safe lifts, falls prevention, wound care, body mechanics, pressure ulcers, documentation, patient safety, HIPAA, medical errors, and more. Each topic contains a series of short presentations (1-5 minutes). View one part of the series, or all, as your time allows. Watch the videos inside the ProQuest interface, or download the files into QuickTime or .mp4 formats.

How do you access the Medcom Video Training Programs Collection? Go to Open Door, access ProQuest, click on the “Browse” tab (third from the left), and select “Video Training Programs” under the “Competency and Training Resources” section. A list of the available video topics appears. Access videos from this page. Bookmark www.apta.org/opendoor for online access to vital clinical research, whenever and wherever you need it. Visit often for full-text access to research and articles from more than a thousand leading clinical and academic publications on topics critical to clinical practice.

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

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