Physical Therapy- Journal of the APTA, Volume 90, Issue 5 (May 2010)

May 2010  Volume 90  Number 5

Research Reports 663

Particle Repositioning Maneuvers in the Treatment of Benign Paroxysmal Positional Vertigo

748

Dynamic Balance Measures and Functional Performance in Community-Dwelling Elderly People

679

Kinematics During Arm Elevation Following Mastectomy

761

Functional Gait Assessment in CommunityDwelling Older Adults

693

Acute Care Physical Therapists’ Discharge Recommendations

776

Validation of a New Device to Measure Postsurgical Scar Adherence

707

Effect of Analgesia on Ease of Care After Hip Arthroplasty

Case Reports

714

Exercise-Induced Analgesia

726

Exercise Habits of Physical Therapists, Physical Therapist Assistants, and Student Physical Therapists

735

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Access to Physical Therapy Services Among Medically Underserved Adults

784

Spondyloarthritis in a Patient With Unilateral Buttock Pain and Crohn Disease

793

Walking Recovery After Locomotor Training in a Child With Incomplete SCI

Perspective 803

Revised APTA Code of Ethics and Standards of Ethical Conduct for the Physical Therapist Assistant

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Next month—in PTJ or online at ptjournal.apta.org • Clinical Prediction Rules for Musculoskeletal Conditions

• Responsiveness of Shoulder CAT Measures

• Graded Activity and Graded Exposure for Persistent Nonspecific Low Back Pain

• Constrained Physical Therapist Practice

• Balance Exercise Program for Patients With Total Knee Arthroplasty • Home Program of Hip Abductor Exercises

• Implementation of Measurement Instruments • Creating an Interface Between the ICF and Physical Therapist Practice • And much more!

• Impact of Work-Related Pain on Therapists • Physical Performance Measures in Elderly African Americans

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

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Physical Therapy Journal of the American Physical Therapy Association

Editorial Office

Editor in Chief

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

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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

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

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

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

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

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

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Physical Therapy (PTJ) (ISSN 00319023) is published monthly by the American Physical Therapy Association (APTA), 1111 North Fairfax Street, Alexandria, VA 22314-1488, at an annual subscription rate of $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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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.

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Health Policy in Perspective Bundling Acute and Postacute Payment: From a Culture of Compliance to a Culture of Innovation and Best Practice Gerben DeJong

B

uried deep in the Patient Protection and Affordable Care Act (HR 3590; Pub L No. 111-148)1 are proposals to bundle acute and postacute payment into one payment for services provided to Medicare beneficiaries within the 30 days postdischarge from the acute care hospital. The concept of bundling payment appears to have gained sufficient traction that it will endure as a topic of debate.2,3

Bundling, or episode payment, has not been a part of the public debate about health care reform. Politicians rarely, if ever, mention it—in part because they know that the public is not easily engaged in technical issues of acute and postacute payment that are largely invisible to them. Yet, bundling acute and postacute payment represents one of the most far-reaching proposals for Medicare reform since 1983, when Congress authorized the use of diagnosis-related groups (DRGs) as the basis for classifying Medicare beneficiaries under a prospective payment system (PPS) for acute hospital care. Bundling promises to reshape the way we manage a patient’s care over a given episode of care. It offers enormous opportunities to enhance patient care while reducing costs, but it also poses significant design challenges that, if not handled correctly, can have unintended effects and undermine patient well-being. I will examine these opportunities and challenges primarily, but not solely, from the

perspective of postacute care, a major practice area for physical therapists. Most of the observations made here generalize to both the acute and postacute portions of an episode of care. In fact, with bundling, some of the distinctions between acute care and postacute care may begin to lose some of their meaning.

Growth of Postacute Care Bundling acute and postacute payment is not a new concept.4 The concept surfaced in the mid 1980s in the aftermath of the new DRGbased PPS for hospital care.5 The DRG-based PPS applied only to the acute hospital stay, and it “exempted” postacute providers, such as: •Rehabilitation hospitals and units, known as inpatient rehabilitation facilities (IRFs) in the parlance of the Centers for Medicare & Medicaid Services (CMS) •Skilled nursing facilities (SNFs) •Long-term care hospitals (LTCHs) •Home health agencies (HHAs) The exemption allowed postacute providers to continue to be paid on a cost basis, subject to certain limits. The exemption was meant to be only temporary, but it was not until the Balanced Budget Act of 1997 (BBA’97) that Congress authorized a PPS for postacute care and then went a step further by authorizing a separate PPS for each postacute venue to be phased in over several years (Tab. 1).

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The 1983 and 1997 legislation had 2 major unintended effects on postacute care. First, the 1983 DRG-PPS exemption led to a proliferation of postacute facilities and programs and made it one of the fastest growing portions of the Medicare program (Tab. 2). In FY2008, the fee-for-service portion of Medicare spent $50 billion for postacute care apart from outpatient care.6 Amounts spent under the auspices of the Medicare Advantage program, which now enrolls about 24% of Medicare beneficiaries,7 remains unknown. The physical therapy profession has grown accordingly. In short, the DRG-PPS helped create postacute care as we know it today. Second, as intended, BBA’97 initially curbed the growth of postacute care—especially SNF and home health care—and led to a decline in the demand for physical therapist services in the years immediately after BBA’97. Over the long term, however, BBA’97 hardened the distinctions between postacute settings by endowing them with their own patient assessment instruments and payment formulas. This has made it more difficult to serve patients seamlessly across settings as their needs change. It also has led to increased use of multiple postacute venues for the same episode of care because the payment clock starts anew with each new placement.8–10 Finally, it has resulted in more practice rules that limit the degrees of freedom that therapists have when trying

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Health Policy in Perspective Table 1. Prospective Payment Systems for Postacute Carea

Feature

a

Inpatient Rehabilitation Facilities (IRF-PPS)

Skilled Nursing Facilities (SNF-PPS)

Long-term Care Hospitals (LTCH-PPS)

Home Health Agencies (HHA-PPS)

Unit basis

Per diem

Per case/ per hospitalization

Per case/ per hospitalization

Per 60-day episode of care

Case-mix adjuster

Resource Utilization Groups III (RUGs III)

Function-related groups (FRGs) or case-mix groups (CMGs)

Diagnosis-related groups (DRGs) specific to LTCH patients

Home Health Resource Groups (HHRCs)

Number of case-mix groups

53

92 CMGs X 4 Comorbidity subgroups/ CMG = 368 groups

540

153

Patient assessment tool

Minimum Data Set (MDS)

Patient Assessment Instrument (IRF-PAI)

ICD-9-CM codes recorded on patient claims

Outcome & Assessment Information Set (OASIS)

PPS=prospective payment system.

to manage patients with complex problems creatively. These rules center on who may be admitted to certain settings; length-of-stay requirements; when therapy should be initiated; use of group therapy; utilization of therapy extenders; use of adjunct therapies; minimum number of therapy hours per day; and, above all, excessive documentation requirements to avert costly retroactive denials in the name of eliminating “waste, fraud, and abuse.” Although many of the rules have been created to restrain overutilization and inappropriate care, they also have created clinical straight jackets that limit creativity and innovation. Rules are rarely evidence-based; they have more to do with maintaining the artificial distinctions between settings of

care, and less to do with the merits of actual patient care. Across all settings of care, providers have viewed bundling with apprehension. Adapting to yet another payment regime seems daunting. Although the regulatory regime facing postacute providers has become increasingly complex over the years, providers have more or less adapted. They have trained staff in the art of compliance protocols and retooled their information systems around each new regulatory requirement. Providers have developed their clinical and business models accordingly, learning to live with the current regime and developing the workarounds where possible—and, by adaptation, have become invested in the system.

From a daily clinical perspective, institutionally based therapists and clinicians often chafe at the rules. They find themselves living in a “culture of compliance” where the focus has been on “compliance management” rather than “care management.” Managers and clinicians live in fear of retroactive denials and spend countless hours justifying placement decisions and past care decisions. They often feel shackled in providing what they believe is optimal care for the patient. It can be said that a culture of compliance suffocates; it removes the oxygen that care providers need in order to do what is best for the patient. Bundling payment provides an unusual opportunity to shift from a culture of compliance to one that liberates providers to work

Table 2. Number of Postacute Facilities, 1985–2009 (In 4-Year Increments)a Type Skilled nursing facilities Inpatient rehabilittion facilities Long-term care hospitals Home health agencies a

1985

1989

1993

1997

2001

2005

2009*

6,725

8,688

11,436

14,568

14,765

15,008

15,071

454

767

984

1,067

1,141

1,227

1,180

86

89

113

194

273

385

427

*

*

6,497

10,444

6,976

8,205

10,568

Sources: OSCAR database, Centers for Medicare and Medicaid Services, MedPAC. Computed by the NRH Center for Post-acute Studies, Washington, DC, March 2010. * = data not readily available.

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Health Policy in Perspective together to do what is best, to be creative and innovative, and to look forward rather than backward. I believe that bundling can help unleash clinical creativity and help discover best practice—and save costs in a way that cannot be done in the current payment environment.

Seven Key Elements We need to get bundling right— but how? Bundling entails 7 key policy choices11: 1. Scope of services to be bundled. Most bundling proposals would bundle both acute and postacute payment into one payment. Some have argued that combining both acute and postacute might be too “heavy a lift” at the outset and that we may need to go to full bundling in stages. There is a great deal to be gained by bundling postacute payment alone—at least at the outset. Most proposals to bundle acute and postacute payment, however, apply only to Medicare Part A services. Part B outpatient services need to be made part of the postacute bundle to avoid cost shifting from Part A to Part B. Moreover, once acute and postacute payment is bundled, Part B physician payment also should be included. 2. Duration. Most bundling proposals call for payments to be bundled for 30 days after discharge from an acute care hospital. I believe that the duration needs to vary somewhat with the type of health condition, otherwise it will be too easy to shift costs from one side of the 30-day window to the other side. 3. Method of patient assessment. A uniform patient assess-

ment system is needed across all acute and postacute venues. A uniform system is needed for postacute placement, clinical management, outcome measurement, and case-mix adjustment for both payment and outcome. A common language across all settings is needed to facilitate a common patient care culture across all settings. This will assist in communicating with patients and family members as well. If we want culture change and a shared patient culture, we need a common language.12 The CMS has commissioned the development of such a tool under the auspices of the Medicare postacute payment reform demonstration project13 that preceded the health care reform debate. The “CARE Tool” (Continuity Assessment Record and Evaluation), as it is known, remains the most promising step in this direction, but more is needed to make the tool less burdensome, more user friendly, and more precise across all levels of patient function. Computeradaptive technologies offer a promising approach in achieving these features.14 4. Method of payment and gain sharing. To work effectively, the payment system needs to (a) adjust for patient case-mix to avoid cherry picking (ie, selecting “easier,” lower-cost, higher-margin patients), and (b) include a significant pay-for-performance (P4P) component to avoid stinting (ie, short-changing services relative to patient need). A P4P component also will encourage upstream acute providers to work with downstream postacute providers. All providers need to have “skin in the game” for both payment and outcome. Financial gain sharing

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among providers can facilitate a shared stake in the patient’s outcome and foster mutual accountability. The payment system also should have an outlier payment policy to encourage providers to serve patients with unusual needs or unpredictable care trajectories. 5. Selection of bundler or accountable entity. A bundled payment system implies that there is an overarching entity that (a) will be accountable for payment and outcome and (b) is prepared to share gains and losses with all provider stakeholders. Such an entity needs to have several important capacities, that is, ability to provide or contract for services, go at risk for payment and outcome, develop clinical pathways including discharge planning, establish quality standards, provide information technology and decision-support systems, and coordinate with community services. 6. Choice of quality and outcome metrics. There are many quality and outcome metrics from which to choose, such as mortality, patient function, infection rates, medical complications, readmissions, discharge destination, and health-related quality of life. Some metrics apply to all patients, whereas others must be appropriate to the intervention and types of patients served. Regardless of the metrics chosen, they need to have adequate validity and reliability, offer precision at all ranges of illness and function, be feasible to collect, and be publicly available to all stakeholders, including patients, families, and healthplan subscribers. Ill-chosen and poorly-reported measures can have unintended effects. May 2010

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Health Policy in Perspective 7. Use of case-mix adjustment. As already suggested, casemix adjustment is needed for both payment and outcome. It is needed to create a level playing field and avert “gaming” by payers and providers (eg, selecting certain types of patients, selective reporting of patient outcomes that fail to reflect case-mix differences among payers and providers). Case-mix adjustment will make sure that high-need patients are well served and that payers and providers are not penalized for serving them well.

Regulatory Reform, Provider Autonomy, and Patient Choice Getting each of these elements right is essential to the overall success of a bundling regime. Success also requires a new regulatory framework to operationalize the bundling concept. This regime should not merely build on top of existing regulations. In fact, Congress and CMS should wipe the slate clean, considering what might be carried forward while avoiding the tendency to jerry-rig the old system with new rules that would make the system even more cumbersome. Congress and CMS should consider eliminating some of the distinctions that currently exist between levels of care. If providers are at risk for both payment and outcome, they should be free to determine how best to move the patient along a continuum of care. Providers should be allowed to modulate the level of care within settings, not just between settings. Congress should consider, for example, eliminating the artificial distinctions in hospital-level postacute care that now exist with IRFs, LTCHs, and hospital-based SNFs.

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Bundling payment is a game changer, and a key motivation for bundling is to save costs. The risk going forward is that each provider interest will hunker down to protect its turf in the name of preserving access for patients who need their services. This is understandable. The CMS track record of the last few decades has not been very good: policy changes have often been accompanied by a raft of regulations that have only limited the degrees of provider freedom. Regulatory changes that followed BBA’97, for example, have sought to more narrowly define each provider’s “sandbox.” Many regulatory changes have been blunt instruments that seek to accomplish what was not achieved with past payment reforms. A vexing issue for physical therapists is the matter of patient choice and access. In most of its forms, bundling means limiting patient choice to providers who are represented in the bundle, but patient choice already is limited. Edelman of the Center for Medicare Advocacy argues that “patient choice in [today’s] postacute care is often illusory” and that “patients and family often, if not usually, follow physician or discharge planner’s recommendation.”15 Postacute choices are often made under duress, and short lengths of stay in acute care give patients and family members very little time to make informed choices. In short, bundling will limit patient choice, but patient choice is already quite limited except in cases of elective procedures (eg, joint replacement), where postacute services can be selected in advance of the acute stay. Professional and trade associations are rightfully concerned that bundling may reduce the need

for their services and undermine their business models. But this overlooks the opportunities inherent in the bundling concept. Bundling actually could increase the demand for therapy services, for example, if a provider network is held accountable for outcomes that speak to therapy goals. More than likely, bundling will “squeeze out” unnecessary utilization and reduce the need for certain kinds of services within a given episode of care. But more important, if done right, bundling can restore provider autonomy that has gradually eroded as payers such as CMS have “squeezed” providers in the name of utilization and cost control. The key is whether CMS and other payers are willing to let go of their rules in exchange for a payment system in which incentives are better aligned to achieve real value.

Innovation and Best Practice If the incentives inherent in bundling are structured correctly—and that is a big IF—it should foster greater care coordination under the auspices of more integrated health systems. It also should unleash a race for best practice. Providers of all kinds will be strongly motivated to figure out what works and does not work and weed out interventions and care processes with little or no benefit; they will focus on resources that provide the highest probability of improving outcomes.16 Providers are smart and have learned to adapt their business models to any payment regime. Bundling offers the potential for a business model that is based not on market share, bed utilization, and cost recovery but on price, quality, and transparency—in short, a business model that is based on value. To comment, submit a Rapid Response to this article posted online at ptjournal.apta.org.

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Health Policy in Perspective I contend that a bundling regime that fosters competition on price, quality, and transparency is worth a thousand randomized controlled trials (RCTs) in the search for evidence-based practice. I say this because RCTs have a long gestation period, and there simply is not enough money in the entire federal health sciences budget to evaluate all the interventions and combinations of interventions now used or contemplated. One byproduct of a bundling regime will be more providersponsored research, because identifying what works and does not work is in the provider’s interest.

Grand Bargain Providers of all kinds, including physical therapists, should attempt to strike a grand bargain with government and payers: Eliminate much of today’s regulatory infrastructure that has clinicians tied up in knots, and, in return, hold providers accountable for price and outcome. Or, if this is too radical or risky, come up with a model in which risks are shared between provider and payer. Bundling acute and postacute payment offers a framework in which such a grand bargain can be made. The role of government and payers should not be to constrain provider behavior but to create new rules for a level playing field that competes on price and quality or outcome. For all its advantages, bundling is not a cure-all for containing the cost of acute care and postacute care. It contains costs within an episode of care. But bundling does not address whether a particular procedure is appropriate for a particular patient, and it will not automatically reduce the number of episodes. In fact, hospitals might try to “drive volume growth” by increasing the number of episodes.17

Fortunately, the Patient Protection and Affordable Care Act1 calls for a period of pilot testing and demonstrations prior to full implementation of a bundling regime. This is crucial, as the risk of unintended outcomes remains great. But the essentials of a bundling system are reasonably well understood, and it would behoove all stakeholders to take a step back to embrace the opportunities inherent in the bundling concept. My fear is that we will just muddle through, make compromises, and end up with a payment regime that could add to our health care system’s woes. Bundling represents one of the best opportunities to move the culture of health care from one of compliance to one of innovation and best practice, and it should be seized. G. DeJong, PhD, is Senior Fellow and Director, Center for Post-acute Studies, National Rehabilitation Hospital, Washington, DC. The author would like to acknowledge the many contributors who presented at the Conference on Bundling Post-acute Payment held on June 24, 2009, in Washington, DC. A copy of the conference report is available at www.postacuteconference.org. The views expressed are solely those of the author and do not necessarily reflect the views of the National Rehabilitation Hospital, MedStar Health, or any other organization with which the author is affiliated. DOI: 10.2522/ptj.2010.90.5.658

References 1 Patient Protection and Affordable Care Act, Pub L No. 111-148, 124 Stat 119. March 2010. 2 Center for Post-acute Studies. Bundling Payment for Post-acute Care: Building Blocks and Policy Options. Washington, DC: National Rehabilitation Hospital; 2009. Available at http://www.post-acute. org/bundling/Bundling%20Report%20 V15.pdf. Accessed February 2, 2010. 3 Whelan EM, Feder J. Payment Reform to Improve Health Care: Ways to Move Forward. Washington, DC: Center for American Progress; 2009. Available at http://www.americanprogress.org/ issues/2009/06/pdf/healthpaymentre form.pdf. Accessed February 2, 2010. 4 Welch WP. Bundled Medicare payment for acute and postacute care. Health Aff (Millwood). 1998;17:69–81.

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Neu CR, Harrison S. Prospective Payment for Medicare Posthospital Services: Some Empirical Considerations, R-3435HCFA. Santa Monica, CA: RAND; 1986.

6

MedPAC. Healthcare Spending and the Medicare Program: A Data Book. Washington, DC: Medicare Payment Advisory Commission; June 2009:125; chart 9–3.

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MedPAC. The Medicare Advantage program. In: Medicare Payment Policy. Report to the Congress. Washington, DC: Medicare Payment Advisory Commission; March 2010:261–262. Available at: http://www.medpac.gov/chapters/ Mar10_Ch04.pdf.

8

Kramer A, Holthaus D, Goodrish G, Epstein A. A Study of Stroke Post-acute Care Costs and Outcomes: Final Report. Washington, DC: Office of Disability, Aging, and Long-term Care Policy, US Department of Health and Human Services; 2006:51–70. Available at http:// aspe.hhs.gov/daltcp/reports/2006/ strokePAC.pdf. Accessed February 2, 2010.

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Gage B, Morley M, Spain P, et al. Examining Post Acute Care Relationships in an Integrated Hospital System. Washington, DC: Assistant Secretary for Planning and Evaluation, US Department of Health and Human Services; 2009. Available at http://aspe.hhs.gov/health/ reports/09/pacihs/report.shtml.

10 DeJong G, Wenqiang T, Smout RJ, et al. Use of rehabilitation and other health care services by patients with joint replacement after discharge from skilled nursing and inpatient rehabilitation facilities. Arch Phys Med Rehabil. 2009;90:1297–1305. 11 Center for Post-acute Studies. Bundling Payment for Post-acute Care: Building Blocks and Policy Options. Washington, DC: National Rehabilitation Hospital; 2009. Available at http://www.postacuteconference.org. Accessed February 1, 2010. 12 Warren R. Remarks made to the Conference on Bundling Post-acute Payment. Washington, DC: June 24, 2009. 13 Overview of the Medicare Post Acute Care Payment Reform Initiative. Available at: http://www.cms.hhs.gov/ DemoProj ectsEvalRpts/downloads/ PACPR_RTI_CMS_PAC_PRD_Overview. pdf. Accessed February 9, 2010. 14 Jette A. Remarks made to the Conference on Bundling Post-acute Payment. Washington, DC: June 24, 2009. 15 Edelman T. Remarks made to the Conference on Bundling Post-acute Payment. Washington, DC: June 24, 2009. 16 Luft HS. Economic incentives to promote innovation in healthcare delivery. Clin Orthop Relat Res. 2009;467:2497–2505. 17 The Health Industry Forum. ImplementingBundledPaymentsforHealthCare Services: Conference Report.Waltham,MA: Health Industry Forum, The Heller School forSocialPolicyandManagement,Brandeis University; 2009. Available at http://www. healthindustryforum.org.AccessedFebruary 2, 2010.

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Research Report Effectiveness of Particle Repositioning Maneuvers in the Treatment of Benign Paroxysmal Positional Vertigo: A Systematic Review Janet Odry Helminski, David Samuel Zee, Imke Janssen, Timothy Carl Hain

Background. Benign paroxysmal positional vertigo (BPPV) is the most common cause of vertigo.

Purpose. The purpose of this systematic review was to determine whether patients diagnosed with posterior canal (PC) BPPV, based on positional testing, and treated with a particle repositioning maneuver will show the resolution of benign paroxysmal positional nystagmus (BPPN) on the Dix-Hallpike Test performed 24 hours or more after treatment.

Data Sources. Data were obtained from an electronic search of the MEDLINE, EMBASE, and CINAHL databases from 1966 through September 2009. Study Selection. The study topics were randomized controlled trials (RCTs), quasi-RCTs, the diagnosis of PC BPPV, treatment with the particle repositioning maneuver, and outcome measured with a positional test 24 hours or more after treatment.

Data Extraction. Data extracted were study descriptors and the information used to code for effect size.

Data Synthesis. In 2 double-blind RCTs, the odds in favor of the resolution of BPPN were 22 times (95% confidence interval⫽3.41–141.73) and 37 times (95% confidence interval⫽8.75–159.22) higher in people receiving the canalith repositioning procedure (CRP) than in people receiving a sham treatment. This finding was supported by the results reported in 8 nonmasked quasi-RCTs. Studies with limited methodological quality suggested that a liberatory maneuver (LM) was more effective than a control intervention; there was no significant difference in the effectiveness of the LM and the effectiveness of the CRP; the self-administered CRP was more effective than the self-administered LM; and the CRP administered together with the selfadministered CRP was more effective than the CRP administered alone. The BrandtDaroff exercises were the least effective self-administered treatments.

J.O. Helminski, PT, PhD, is Associate Professor, Department of Physical Therapy, Midwestern University, 555 31st St, Downers Grove, IL 60515 (USA). Address all correspondence to Dr Helminski at: [email protected]. D.S. Zee, MD, is Professor, Departments of Neurology, Ophthalmology, Otolaryngology, and Pathology, School of Medicine, The Johns Hopkins University, Baltimore, Maryland. I. Janssen, PhD, is Assistant Professor, Department of Preventive Medicine, Rush University Medical Center, Chicago, Illinois. T.C. Hain, MD, is Professor, Departments of Physical Therapy and Human Movement Science, Otolaryngology, and Neurology, Northwestern University Medical School, Chicago, Illinois. [Helminski JO, Zee DS, Janssen I, Hain TC. Effectiveness of particle repositioning maneuvers in the treatment of benign paroxysmal positional vertigo: a systematic review. Phys Ther. 2010;90: 663– 678.] © 2010 American Physical Therapy Association

Limitations. The limitations included the methodological quality of the studies, the lack of quality-of-life measures, and confounding factors in reporting vertigo.

Conclusions. Randomized controlled trials provided strong evidence that the CRP resolves PC BPPN, and quasi-RCTs suggested that the CRP or the LM performed by a clinician or with proper instruction at home by the patient resolves PC BPPN. There were no data on the effects of the maneuvers on outcomes relevant to patients.

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B

enign paroxysmal positional vertigo (BPPV) is characterized by brief periods of vertigo triggered by a change in the position of a person’s head relative to gravity. In the general population, the lifetime prevalence of BPPV is 2.4%, and the 1-year incidence is 0.6%.1 It is the most common vestibular disorder, accounting for one third of vestibular diagnoses in the general population.1 Benign paroxysmal positional vertigo can affect the quality of life of elderly patients and is associated with reduced activities of daily living, falls, and depression.2 Patients with BPPV experience delays in diagnosis and treatment, the mean delay being 92 weeks, and they frequently are inappropriately treated with vestibular suppressant medications.3 Benign paroxysmal positional vertigo is caused by abnormal mechanical stimulation of 1 or more of the 3 semicircular canals within the inner ear (Fig. 1). The fluid-filled canals normally act to detect rotation of the head through the deflection of sensory hair cells embedded within a gelatinous membrane, the cupula. The weighted sensory membrane of the maculae normally acts to detect gravitational forces on the head. In BPPV, calcite particles (otoconia), which normally weight this membrane, become dislodged and sediment in the canals, changing the dynamics of the canals. There are 2 primary theories for the mechanism of BPPV. The first is cupulolithiasis,4 in which the dislodged otoconia di-

Available With This Article at ptjournal.apta.org • The Bottom Line • Audio Abstracts Podcast This article was published ahead of print on March 25, 2010, at ptjournal.apta.org.

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rectly attach to the cupula, weighting this membrane. Reorientation of the canal relative to gravity deflects the cupula, exciting or inhibiting the ampullary organ. The second is canalithiasis,5 in which the otoconia freely sediment in the canals. Reorientation of the canals causes the otoconia to move to the lowest part of the canals, creating a drag on the endolymph, resulting in fluid pressure on the cupula, and activating the ampullary organ. The Dix-Hallpike maneuver,6 referred to as the Dix-Hallpike Test (DHT) in this article, is the standard from which the diagnosis of posterior canal (PC) BPPV is made and differentiated from other conditions.7,8 The diagnostic criteria for PC BPPV are vertigo associated with characteristic ocular nystagmus that is torsional (toward the dependent ear) and directed upward, consistent with the excitation of the ampullary organ of the PC9; a 1- to 40-second latency before the onset of vertigo and nystagmus10 –12; and vertigo and nystagmus with a duration of less than 60 seconds.13 With repeated positioning, PC BPPV temporarily becomes less intense and disappears.13 For the DHT, the estimated sensitivity and specificity are 79% (95% confidence interval [CI]⫽65–94) and 75% (CI⫽33–100), respectively.14 The interrater reliability for interpreting the direction of eye movement ranges from a mean percentage of agreement of 43% (fair) to a mean percentage of agreement of 81% (substantial), depending on the level of expertise.15

Treatment of BPPV Once the involved canal is identified, BPPV often is treated with particle repositioning maneuvers. These maneuvers move otoconia out of the affected canal and back into the vestibule, where it is thought that the particles dissolve.16,17

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Historically, the first maneuvers used for BPPV were the Brandt-Daroff exercises,10 which were designed to habituate symptoms. The patient repeatedly moved from sitting at the edge of the bed to lying on the side (side lying) with the head rotated 45 degrees toward the ceiling. The patient alternated between left side lying and right side lying. The canalith repositioning procedure (CRP), developed by Epley18 (Fig. 2A), was designed to use gravity to treat canalithiasis of the PC. The clinician moves the patient through a series of 4 positions. With each position, the otoconia settle to the lowest part of the canal, move around the arc of the PC, and finally deposit in the vestibule. This procedure requires a 180-degree turn of the head19 –21 and a return to a sitting position from lying on the uninvolved side.21 To enable the otoconia to settle, each position is maintained for at least 30 seconds.20 Vibration applied to the mastoid process of the involved side does not affect the outcome of the procedure and is no longer considered necessary.22–24 The liberatory maneuver, developed by Semont et al25 (Fig. 2B), was designed to use inertia and gravity to treat cupulolithiasis of the PC. To evacuate the particles, the patient is rapidly swung from lying on the involved side to lying on the uninvolved side through a 180-degree cartwheel motion with a duration of less than 1.3 seconds.19 Both the CRP and the liberatory maneuver have been modified to enable a patient to self-treat. With the selfadministered CRP,26,27 the patient moves through the same positions as in the CRP, except that the head is extended over the edge of a pillow. With the self-administered liberatory maneuver,27 the patient performs the maneuver independently, with May 2010

Particle Repositioning Maneuvers in the Treatment of Benign Paroxysmal Positional Vertigo

Figure 1. Mechanisms of benign paroxysmal positional vertigo. Reprinted with permission from American Dizziness and Balance. Copyright 2007.

no other modifications. Both exercises are stopped when the patient has been vertigo free for at least 24 hours.26,27 The role of activity restrictions in the outcome of particle repositioning maneuvers remains uncertain. Postmaneuver activity restrictions did not improve the efficacy of treatment with the CRP28,29 or the liberatory maneuver,28 but patients with no activity restrictions required 1 or 2 more treatment sessions to achieve a successful outcome.30 The DHT is critical for determining the outcome of particle repositioning maneuvers.7,31 The absence of the characteristic nystagmus indicates the resolution of PC BPPV.32 The patient’s report of vertigo is more variable than the observation of the characteristic nystagmus on positional testing. Patients showing May 2010

The Bottom Line What do we already know about this topic? Randomized controlled trials (RCTs) suggest that the canalith repositioning procedure (CRP) is more effective than a sham treatment in the resolution of posterior canal benign paroxysmal positional nystagmus (PC BPPN).

What new information does this study offer? Evidence for the use of other particle repositioning maneuvers is weak due to the limited numbers of studies and no RCTs. There is no significant difference in the effectiveness of the CRP compared with the liberatory maneuver (LM). If properly instructed, self-administered CRP and LM are effective. The Brandt-Daroff habituation exercises are the least effective. The most effective treatment is a combination of the CRP and the selfadministered CRP.

If you’re a patient, what might these findings mean for you? The CRP and LM performed by a clinician or, with proper instruction, by the patient at home resolves PC BPPN.

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Figure 2. Particle repositioning maneuvers. (A) Canalith repositioning procedure illustrated for treatment of the right posterior canal. The clinician moves the patient through a series of 4 positions, starting with the placement of the involved canal in the head-hanging position of the Dix-Hallpike Test. To begin, the patient is positioned in the long sitting position (sitting on the treatment table with the legs extended). The patient’s head is rotated 45 degrees toward the right. The patient is then lowered into the supine position with the neck extended 20 degrees over the edge of the treatment table; this is the head-hanging position. The head is rotated through 90 degrees of motion, ending in 45 degrees of neck rotation toward the uninvolved side. This step is followed by rolling onto the uninvolved side while maintaining the head-on-trunk position and, finally, sitting up from lying on the uninvolved side. Each position is maintained for a minimum of 30 seconds or as long as the nystagmus lasts. The procedure is repeated 3 times. (B) Liberatory (Semont) maneuver illustrated for treatment of the right posterior canal. The patient sits on the edge of the treatment table. The clinician rapidly moves the patient to lying on the involved side with the head rotated 45 degrees toward the uninvolved side. While maintaining the head-on-trunk position, the clinician swings the patient from lying on the involved side to lying on the uninvolved side. The head then is gently tapped on the treatment table. Each position is maintained for 1.5 minutes. The procedure is repeated 3 times. Reprinted with permission from American Dizziness and Balance. Copyright 2007.

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Particle Repositioning Maneuvers in the Treatment of Benign Paroxysmal Positional Vertigo the resolution of positional nystagmus on the DHT may report vertigo if concurrent vestibular deficits exist.33 Patients with positive findings on the DHT may report no vertigo at the time of follow-up if provoking positions are avoided or if they have unrecognized BPPV (imbalance with no vertigo).2 Because of these confounding factors, the patient’s report of vertigo should not be the only outcome measure. The time interval between treatment and outcome assessment is critical. To separate the effects of active treatment from a fatigue response, outcome should be assessed 24 hours or more after treatment.32 Repeated positioning may cause a fatigue response that can mimic successful treatment.32 Within 7 days of PC BPPV symptom onset, 30% of patients will experience spontaneous remission.34 To minimize the possibility of spontaneous remission causing a false-negative particle repositioning maneuver outcome and to avoid a fatigue response, outcome ideally should be assessed 24 hours after treatment. Patients with BPPV experience a decrease in health-related quality of life, which is restored after successful remission of BPPV following treatment with a particle repositioning maneuver.35 However, health-related qualityof-life measures are not routinely used in treatment outcome studies. A published overview of the Cochrane Collaboration (search dates: 1966 – 2004)36 and 2 meta-analyses37,38 evaluated the effectiveness of the CRP in the treatment of BPPV but did not evaluate other maneuvers. Two recently published practice guidelines7,8 evaluated the effectiveness of the CRP, the liberatory maneuver, and the selfadministered variants. These publications included assessments of the methodological quality of the studies evaluated. A rigorous qualitative synMay 2010

thesis needs to include an evaluation not only of the methodological quality but also of the precise performance of the intervention and the validity, reliability, and responsiveness of the tests used in the studies.39 The purpose of this systematic review was to determine whether patients diagnosed with PC BPPV on positional testing and treated with a particle repositioning maneuver will show the resolution of benign paroxysmal positional nystagmus (BPPN) on the DHT performed 24 hours or more after treatment. A synthesis of methodological quality was performed. The standards of methodological quality for this systematic review were randomization,40 allocation concealment,41,42 masking,43 and sample size calculation.44 The CRP, the liberatory maneuver, and the self-administered variants were evaluated. The inclusion and exclusion criteria were based on the findings of the proposed mathematical models of the treatment of BPPV19 –21 with the particle repositioning maneuvers to take into account the quality of the performance of the intervention and were based on the performance of the DHT as an outcome measure to take into account the validity and reliability of the outcome. The responsiveness of the DHT has not been reported in the literature.

Method Data Sources and Searches An electronic literature search of the MEDLINE, EMBASE, and CINAHL databases for the period from 1966 through September 2009 was conducted with the medical subject heading term “vertigo.” In MEDLINE, to refine the search, the medical subject heading was combined with an “or” statement including “benign paroxysmal positional vertigo, BPPV, BPV, benign paroxysmal positional nystagmus, BPPN, or BPN.” The search was restricted to English (pos-

sibly introducing publication bias). In CINAHL, the search was replicated with the same terms. In EMBASE, because of more specific indexing, the search was performed with the medical subject heading “vertigo” and the subheadings “BPPV” and “therapy.” A published overview of the Cochrane Collaboration (search dates: 1966 –2004),36 2 metaanalyses37,38 of the treatment of PC BPPV, and 2 practice guidelines7,8 were also reviewed. Bibliographies of the identified articles were manually searched for any additional relevant articles. The results of the searches were compared, and duplicates were removed (Fig. 3). Study Selection Published studies that reported on the effectiveness of particle repositioning maneuvers in the treatment of PC BPPV were eligible for inclusion. The inclusion criteria (Tab. 1) were as follows: 1. The study design was a randomized controlled trial (RCT) or quasi-RCT. 2. Participants had a clinical diagnosis of unilateral typical BPPV (PC involvement) on the basis of the findings on the DHT.7,8 3. A manual particle repositioning maneuver was performed. If the CRP was used, it included all 4 positions described originally by Epley18 to optimize the removal of loose otoconia from the PC.19 –21 For the best outcome, simulated models of the CRP suggested from the initial headhanging position a full 180-degree turn of the head toward the uninvolved side and a return to the upright position from the uninvolved side.19 –21 Acceptable modifications to the original CRP included self-administration,26,27,45 performance of the procedure

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Particle Repositioning Maneuvers in the Treatment of Benign Paroxysmal Positional Vertigo Table 1. Inclusion and Exclusion Criteriaa

Parameter

Asawavichianginda et al55

⻫

⻫

⻫

⻫

⻫

⻫

⻫

⻫

⻫

⻫

⻫

⻫

⻫

⻫

⻫

⻫

⻫

⻫

⻫

⻫

⻫

⻫

⻫

⻫

⻫

⻫

⻫

⻫

⻫

⻫

⻫

⻫

⻫

⻫

⻫

⻫

⻫

⻫

⻫

⻫

⻫

⻫

⻫

⻫

⻫

⻫

⻫

⻫

⻫

⻫

⻫

⻫

⻫

Blakley56

Califano et al57

Cavaliere et al58

Chang et al59

Cohen and Kimball60

Angeli et al54

Froehling et al49

Li61

⻫

⻫

⻫

⻫

⻫

Lynn et al33

Inclusion criteria RCT, quasi-RCT Typical BPPV

⻫ ⻫

Intervention Manual particle repositioning maneuver CRP with positions described by Epley18 Administered by: Clinician Self Activity restrictions after treatment ⻫

Yes

⻫

No Outcome DHT or side-lying test to assess nystagmus

⻫

⻫

Outcome assessed ⱖ24 h and ⬍1 mo after treatment Proportion of participants who converted from positive to negative DHT results reported

⻫

⻫

⻫

⻫

⻫

Exclusion criteria Cohort, retrospective, case-control, or case study

⻫

⻫

No inclusion criteria Atypical BPPV ⻫

Bilateral PC BPPV Central nervous system dysfunction Intervention: CRP with modification of positions described by Epley18

⻫

⻫

⻫

Outcome: no DHT or side-lying test to assess nystagmus

⻫

⻫

a RCT⫽randomized controlled trial, BPPV⫽benign paroxysmal positional vertigo, CRP⫽canalith repositioning procedure, DHT⫽Dix-Hallpike Test, PC⫽posterior canal.

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Particle Repositioning Maneuvers in the Treatment of Benign Paroxysmal Positional Vertigo Table 1. Continued Massoud and Ireland28

Munoz et al62

Radtke et al26

Radtke et al27

Salvinelli et al50

Salvinelli et al51

RCT, quasi-RCT

⻫

⻫

⻫

⻫

⻫

⻫

Typical BPPV

⻫

⻫

⻫

⻫

⻫

⻫

⻫

Manual particle repositioning maneuver

⻫

⻫

⻫

⻫

⻫

⻫

⻫

CRP with positions described by Epley18

⻫

⻫

⻫

⻫

⻫

⻫

Parameter

Serafini et al63

Sherman and Massoud52

Soto Varela et al53

Sridhar et al64

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⻫

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⻫

⻫

⻫

⻫

⻫

Inclusion criteria

Intervention

Administered by: Clinician Self

⻫

⻫

⻫

⻫

⻫

⻫

Activity restrictions after treatment Yes

⻫

No

⻫

⻫

⻫

⻫

⻫

⻫

⻫

DHT or side-lying test to assess nystagmus

⻫

⻫

⻫

⻫

⻫

⻫

⻫

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⻫

⻫

Outcome assessed ⱖ24 h and ⬍1 mo after treatment

⻫

⻫

⻫

⻫

⻫

⻫

⻫

⻫

⻫

Proportion of participants who converted from positive to negative DHT results reported

⻫

⻫

⻫

⻫

⻫

⻫

⻫

⻫

⻫

Outcome

⻫

Exclusion criteria Cohort, retrospective, case-control, or case study

⻫

⻫

No inclusion criteria Atypical BPPV ⻫

Bilateral PC BPPV Central nervous system dysfunction Intervention: CRP with modification of positions described by Epley18 Outcome: no DHT or side-lying test to assess nystagmus

(Continued)

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Parameter

von Brevern et al32

Wolf et al65

Yimtae et al66

Inclusion criteria RCT, quasi-RCT

⻫

⻫

⻫

⻫

Typical BPPV

⻫

⻫

⻫

⻫

Manual particle repositioning maneuver

⻫

⻫

⻫

⻫

CRP with positions described by Epley18

⻫

⻫

⻫

Clinician

⻫

⻫

⻫

Self

⻫

Intervention

Administered by: ⻫

Activity restrictions after treatment ⻫

Yes ⻫

⻫

DHT or side-lying test to assess nystagmus

⻫

⻫

⻫

⻫

Outcome assessed ⱖ24 h and ⬍1 mo after treatment

⻫

⻫

⻫

⻫

Proportion of participants who converted from positive to negative DHT results reported

⻫

⻫

⻫

⻫

No

⻫

Outcome

without the use of vibration,22–24 no activity restrictions after the procedure,28 –30 and no premedication to avoid nausea. 4. The successful outcome of a particle repositioning maneuver was defined as the conversion of a positive DHT result to a negative DHT result or side-lying test result33 24 hours or more after the initial treatment procedure to avoid the fatiguing response32 but less than 1 month later to separate the effects of active treatment from natural history.34 5. The proportion of participants who showed conversion from nystagmus to no nystagmus on the DHT at the time of follow-up was reported. The exclusion criteria (Tab. 1) were as follows: 1. The study was a cohort study, a retrospective study, a casecontrol study, or a case study. 2. No inclusion described.

Exclusion criteria Cohort, retrospective, case-control, or case study

Atypical BPPV ⻫

Central nervous system dysfunction ⻫

Intervention: CRP with modification of positions described by Epley18 Outcome: no DHT or side-lying test to assess nystagmus

were

3. Participants had a clinical diagnosis of atypical BPPV (lateral canal or anterior canal involvement), bilateral PC BPPV due to confounding variables,46 or central vestibular deficit.

No inclusion criteria

Bilateral PC BPPV

criteria

4. The head positions of the CRP originally described by Epley18 were modified. The CRP was performed with less than 180 degrees of head rotation from the initial head-hanging position and a return to the upright position from the involved side.19 –21 5. The successful outcome of a particle repositioning maneuver was defined only as the resolution of vertigo.

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Figure 3. Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement flow diagram of the literature search.

6. A successful outcome was assessed less than 24 hours after treatment. 7. The proportion of participants who showed successful conversion from nystagmus to no nystagmus on the DHT at the time of follow-up was not documented. Data Extraction and Quality Assessment Abstracts were screened. If the study was an RCT or a quasi-RCT and the study population was diagnosed with PC BPPV, then the article was obtained and reviewed by 2 reviewers (J.O.H. and D.S.Z.). When discrepancies occurred, the reasons were identified, and a final decision was made on the basis of the unanimous agreement of the authors May 2010

(J.O.H., D.S.Z., and T.C.H.). The studies were stratified according to the particle repositioning maneuver. The methodological quality standards for this systematic review were randomization,40 allocation concealment,41,42 masking,43 and sample size calculation.44 Lack of randomization, allocation concealment, or masking could change the treatment effects, resulting in study selection and confounding biases. Lack of calculation of the sample size could result in a greater risk of a type II error.44 Data were extracted, and a data form was completed to evaluate the methodological quality and quality of the interventions, tests, and outcomes of

each study. The data collection form consisted of items compiled from a combination of instruments.39,47,48 Information was obtained on the setting, study design, patient selection process, masking, intervention, outcomes, and statistics to evaluate the components of internal validity (selection bias, performance bias, detection bias, and attrition bias) and external validity (patients, intervention, setting, and outcomes) for potential bias. In addition, we compiled the following variables: patient report and quantitative outcomes on positional testing at short-term follow-up (first follow-up session) and long-term follow-up (if multiple follow-up sessions, last session), complications, and postprocedure instructions. When studies used re-

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Particle Repositioning Maneuvers in the Treatment of Benign Paroxysmal Positional Vertigo peated follow-up periods, the shortest time between 1 and 30 days to follow-up was used to allow for the strongest association between treatment and outcome. Studies that met the inclusion criteria were stratified according to the study design and intervention. Data Synthesis and Analysis To assess the outcome of each study, the effect size was calculated. The successful outcome of a particle repositioning maneuver was defined as the conversion of a positive positional test to a negative positional test (no BPPN). The patient’s report of vertigo was not qualitatively analyzed. Two-by-two contingency tables were used to organize the outcome data. The odds ratio (OR) and the 95% CI were calculated to determine the odds of a successful outcome or a negative positional test. The OR measures the association between treatment and outcome. For quasi-RCTs comparing active treatments, the OR was calculated with the standard treatment (control) as the CRP. The CRP was selected as the standard of treatment because the 2 RCTs supported its effectiveness.32,33 Only trials in which randomized treatment assignments and a clearly defined control group were used were considered for inclusion in a meta-analysis. Because only 2 such trials existed, a meta-analysis was not performed. We included quasi-RCTs and nonmasked trials in the systematic review. We acknowledge that these studies may be biased and may overestimate treatment efficacy. Statistical analysis of the data was performed with SAS/STAT (version 9.1).* All tests of significance were performed at an ␣ level of .05.

* SAS Institute Inc, 100 SAS Campus Dr, Cary, NC 27513-2414.

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Results Initially, 868 records were identified through an electronic database search (Fig. 3). From these records, 24 fulltext articles were assessed for eligibility on the basis of their titles and abstracts. After complete articles were read, only 10 articles met the inclusion criteria,27,28,32,33,45,49 –53 and 14 met the exclusion criteria.26,54 – 66 The main reasons for exclusion were study design, inclusion criteria (no inclusion criteria discussed or bilateral PC BPPV included), modifications to the head position used in the CRP, outcome not measured with a positional test, outcome assessed less than 24 hours or more than 1 month after treatment, and inadequate statistics (Tab. 1). Of the 10 articles included in the qualitative synthesis, 2 studies used sealed envelopes with a computergenerated randomization code32 or a block randomization scheme (numbered, sealed envelopes containing treatment group assignments, prepared before the start of the study)33 to randomly allocate their participants to groups. Two studies quasirandomly allocated their participants to groups on the basis of the date of their first visit.51,52 Six studies stated that participants were randomly allocated to groups but did not describe the method of randomization.27,28,45,49,50,53 Masking of participants and outcome occurred in 3 studies.32,33,49 None of the studies reported calculation of the sample size.27,28,32,33,45,49 –53 Attrition was described but was not included in statistical calculations in 8 studies (intention-to-treat analysis)27,28,32,33,45,49,52,53 and was not addressed in the remaining 2 articles.50,51 A summary of the items included to assess the methodological quality of the studies is provided in Table 2. Two RCTs32,33 and 2 quasi-RCTs49,52 compared the effectiveness of the CRP without vibration and the effective-

Number 5

ness of a sham treatment.32,33,49,52 At short-term follow-up, the success rates for patients treated with the CRP were 67% to 95%,32,33,49,52 those obtained with the sham treatment were 10% to 38%,32,33,49,52 and that obtained with the control was 60%.52 The magnitude of the effect of the CRP compared with that of the sham treatment was significant in all 4 studies.32,33,49,52 Because of the small sample sizes and the wide confidence intervals, homogeneity could not be determined. The odds in favor of symptom resolution in the RCTs were 22 to 37 times higher in people receiving the CRP32,33 and were more variable in the quasi-RCTs (3–25 times higher).49,52 Two quasi-RCTs compared the liberatory maneuver and no treatment (control).50,51 At short-term followup, the success rates for patients treated with the liberatory maneuver were 80% to 85%, whereas spontaneous resolution in the control group was 35% to 38%. The odds in favor of symptom resolution were 7 to 10 times higher in patients receiving the liberatory maneuver than in the control group (Tab. 3). There may have been overlap of participants in these 2 studies because the data were collected over the same time periods by the same authors.50,51 Two quasi-RCTs compared the CRP and the liberatory maneuver.28,53 At short-term follow-up, the success rates were 71% to 93% for the CRP and 74% to 92% for the liberatory maneuver. To calculate the OR, the CRP was selected as the standard of treatment. The odds in favor of symptom resolution were 0.80 and 1.16 higher in participants using the CRP, and the 95% CIs included 1, suggesting no significant difference in effectiveness between the liberatory maneuver and the CRP.

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Particle Repositioning Maneuvers in the Treatment of Benign Paroxysmal Positional Vertigo Table 2. Summary of Methodological Qualitya Froehling et al49

Lynn et al33

Massoud and Ireland28

Radtke et al27

Salvinelli et al50

Salvinelli et al51

Sherman and Massoud52

Soto Varela et al53

Tanimoto et al45

von Brevern et al32

Setting

Urgent care/IM

Oto

OP

Oto/Neuro

Oto

Oto

BD

Oto

Oto

Oto/Neuro

Study design

Quasi-RCT

RCT

Quasi-RCT

Quasi-RCT

Quasi-RCT

Quasi-RCT

Quasi-RCT

Quasi-RCT

Quasi-RCT

RCT

Inclusion and exclusion criteria

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Method of randomization

No

Yes

No

No

No

No

No

No

No

Yes

Method of quasirandomization

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Method of randomization concealed

No

Yes

No

No

No

No

No

No

No

Yes

Baseline comparability

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Masking of participants

Yes

Yes

No

No

No

No

No

No

No

Yes

Masking of outcome

Yes

Yes

No

No

No

No

No

No

No

Yes

Treatment protocol adequately described

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Control or placebo adequate

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Testing of participant adherence to treatment protocol

No

Yes

No

Yes

No

No

No

No

Yes

No

Description of withdrawal and dropouts

NA

Yes

NA

Yes

No

No

Yes

Yes

Yes

Yes

Participant follow-up details reported

Yes

Yes

Yes

Yes

No

No

Yes

Yes

Yes

Yes

Follow-up period adequate

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Outcome measure described

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Relevant outcomes used

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Parameter

Participant selection

Masking

Intervention

Outcomes

(Continued)

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Particle Repositioning Maneuvers in the Treatment of Benign Paroxysmal Positional Vertigo Table 2. Continued Froehling et al49

Lynn et al33

Massoud and Ireland28

Radtke et al27

Salvinelli et al50

Salvinelli et al51

Sherman and Massoud52

Soto Varela et al53

Tanimoto et al45

von Brevern et al32

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Descriptive measures identified and reported for primary outcome

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Appropriate statistics used

Yes

Yes

Yes

Yes

No

Yes

Yes

Yes

Yes

Yes

Sample size calculation performed

No

No

No

No

No

No

No

No

No

No

Adequate sample size

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Intention-to-treat analysis used

NA

No

NA

No

No

No

No

No

No

No

Parameter Use of quantitative outcome measure Statistics

a IM⫽internal medicine, Oto⫽otolaryngology, OP⫽outpatient, Neuro⫽neurology, BD⫽balance and dizziness, RCT⫽randomized controlled trial, NA⫽not available.

Three quasi-RCTs reported the results of self-administered maneuvers27,45,53 (Tab. 3). All of these studies compared 2 or more maneuvers. At 1 week, the success rates were 90% to 95% for the self-administered CRP or the CRP administered together with the selfadministered CRP,27,45 58% for the self-administered liberatory maneuver,27 and 24% for the Brandt-Daroff exercises.53 The low success rate for the Brandt-Daroff exercises in those studies was contrary to the high success rate (98%) originally described in a 2-week, nonrandomized trial with longer treatment durations.10 To calculate the OR, the CRP was selected as the standard of treatment. If CRP was not performed, then the self-administered CRP was selected. The odds in favor of symptom resolution were only 0.13 times higher in participants using the Brandt-Daroff exercises (OR⫽0.13, 95% CI⫽0.04 – 0.38) and 0.08 times higher in participants using the self-administered liberatory maneu674

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ver (OR⫽0.08, 95% CI⫽0.02– 0.38) (Tab. 3). The odds in favor of symptom resolution were 3.54 times higher (95% CI⫽1.02–12.30) with the CRP plus the self-administered CRP than with the CRP alone (Tab. 3), suggesting better outcomes with the performance of a combination of the CRP plus the selfadministered CRP. Two RCTs32,33 comparing the effectiveness of the CRP without vibration and the effectiveness of a sham treatment were eligible for quantitative synthesis. Because of the limited number of studies, a meta-analysis was not performed.

Discussion This systematic review evaluated the effectiveness of several particle repositioning maneuvers, namely, the CRP, the liberatory maneuver, and the self-administered variants, in the treatment of PC BPPV. The present systematic review is a qualitative syn-

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thesis of methodological quality. Our inclusion and exclusion criteria took into account the quality of the performance of the intervention and the appropriateness of the tests and measures used. Our inclusion and exclusion criteria were based on the findings of the proposed mathematical models for the treatment of BPPV19 –21 with the particle repositioning maneuvers. We excluded studies that included participants with bilateral BPPV to avoid confounding variables.56,64,65 We did not rate the methodological quality of the articles but provided a description of the quality because not all of the qualitative scales addressed the quality of the physical therapy interventions and the validity, reliability, and responsiveness of the outcomes used.39 Our results agree with those of earlier reviews7,8,36 –38—that the CRP is more effective than a control in the May 2010

Particle Repositioning Maneuvers in the Treatment of Benign Paroxysmal Positional Vertigo Table 3. Information Used to Code for Effect Size Outcome

No. of Participants/ Group

No. of Participants With Negative Dix-Hallpike Test Result

% of Participants Cured

CRP

18

16

89

Study

Group

Lynn et al33

Outcome Measures

Sham

15

4

27

Massoud and Ireland28,a

CRP

46

43

93

LM

50

46

92

Froehling et al49

CRP

24

16

67

Sham

26

10

38

CRP

33

27

82

Sham

13

2

15

Control

25

15

60

Brandt-Daroff exercises

29

7

24

LM

35

26

74

CRP

42

30

71

Sherman and Massoud52

Soto Varela et

al53,a

Salvinelli et al50

Radtke et al27,c

Salvinelli et al51

Tanimoto et al45,a

von Brevern et al32

LM

40

32

80

Control

40

15

38

Self-administered CRP

37

35

95

Self-administered LM

33

19

58

LM

52

44

85

Flunarizine

52

30

58

Control

52

18

35

CRP only

39

28

72

CRP and selfadministered CRP

40

36

90

CRP

35

28

80

Sham

31

3

10

Reported Level of Significance (P)

Odds Ratio (95% Confidence Interval)

Groups

⬍.001

CRP vs sham

⬎.2b

LM vs CRP

0.80 (0.17–3.79)

.046

CRP vs sham

3.20 (1.00–10.20)

.06

CRP vs sham

24.75 (4.31–142.02)

Brandt-Daroff exercises vs CRP

0.13 (0.04–0.38)

LM vs CRP

1.16 (0.42–3.18)

⬍.01

LM vs control

6.67 (2.44–18.21)

⬍.001

Self-administered LM vs selfadministered CRP

0.08 (0.02–0.38)

⬍.001

LM vs control

⬍.00001

.15315b

.048

22.0 (3.41–141.73)

Self-administered CRP vs CRP

⬍.001

CRP vs sham

10.39 (4.04–26.74)

3.54 (1.02–12.30)

37.33 (8.75–159.22)

a

Quasi-randomized controlled trial; standard treatment: canalith repositioning procedure (CRP). b No significance of comparison of liberatory maneuver (LM) and CRP. c Quasi-randomized controlled trial; standard treatment: self-administered CRP.

treatment of PC BPPV. On the basis of our inclusion and exclusion criteria, only 2 studies32,33 met the criteria for quantitative synthesis; therefore, a meta-analysis was not performed. The greater variability in the quasi-RCTs may have been due to May 2010

the clinical expertise of the study personnel49 or to a difference in the patient populations. Professionals were trained to evaluate ocular nystagmus during positional testing.49 The interrater reliability for interpreting the direction of eye move-

ment varied depending on the level of expertise.15 The low OR may reflect the lack of experience of the trained professionals in evaluating eye movements and may support the need for experienced professionals to treat BPPV to minimize delays in

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Particle Repositioning Maneuvers in the Treatment of Benign Paroxysmal Positional Vertigo treatment and reduce health care costs. The liberatory maneuver was effective in the treatment of PC BPPV, and the quasi-RCTs found that the liberatory maneuver was as effective as the CRP. However, RCTs need to be performed to determine whether the liberatory maneuver is more effective for PC BPPV than a sham treatment and whether there is a correlation between the speed at which the maneuver is performed and the success of the maneuver.19 The self-administered CRP was more effective than the self-administered liberatory maneuver in the treatment of PC BPPV. More patients performed the self-administered liberatory maneuver incorrectly than performed the self-administered CRP incorrectly. The Brandt-Daroff exercises had little or no effect on symptom resolution.53 Although this conclusion is based on a single randomized study, the low success rate of the Brandt-Daroff exercises was consistent with the findings of an earlier nonrandomized trial.26 Therefore, the self-administered CRP has the highest reported treatment efficacy, whereas the Brandt-Daroff exercises have the lowest reported efficacy. For this reason, the BrandtDaroff exercises are not recommended as an initial treatment maneuver. Patients should be physically and mentally screened to determine whether they are good candidates for instruction in and correct performance of self-administered maneuvers. To optimize outcomes, all patients should receive illustrated instructions with specific exercises for the affected ear, perform the exercises under the supervision of an experienced clinician, and be asked to perform the maneuver at the time of follow-up to assess the accuracy of performance.27

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Although these data demonstrate that the CRP, the liberatory maneuver, and the self-administered variant of the CRP are effective treatments for PC BPPV,27,28,32,33,45,49 –53,57 clinicians must recognize that with both of these maneuvers, there is a chance (2.5%– 6%) of causing a transient worsening of the patient’s condition through a “canal conversion” from the PC to the lateral canal.45,67 Because of this possibility, clinicians using these maneuvers should be able to recognize and treat lateral canal BPPV, although in most cases the complication resolves on its own. Patients performing selfadministered treatments should be educated about the possibility of a canal conversion. Unfortunately, RCTs regarding the treatment of lateral canal BPPV are not available. Limitations of Study/ Further Investigation Only 2 RCTs32,33 compared the effectiveness of the CRP and the effectiveness of a control in the treatment of PC BPPV. The limited number of studies prevented us from including the articles in a quantitative synthesis or meta-analysis. The methodological quality was low and the probability of bias was high in studies investigating the effectiveness of the liberatory maneuver and selfadministered variants. Therefore, interpretation of the data should be limited. Randomized controlled trials investigating the effectiveness of the liberatory maneuver and selfadministered variants need to be conducted. The CRP was designed to use the forces associated with gravity to treat canalithiasis of the PC,18 and the liberatory maneuver was designed to use both inertia and gravity to treat cupulolithiasis of the PC.25 The mechanism of BPPV may be determined on the basis of the characteristic nystagmus parameters of latency to onset, duration, and am-

Number 5

plitude. The nystagmus parameters were not reported for the particle repositioning maneuvers; therefore, correlations between the mechanism of BPPV and the outcome of the maneuvers could not be determined. Further research on this topic is needed. Two studies reported by the same authors attempted to evaluate quality-of-life measures before and after the treatment of PC BPPV with the liberatory maneuver.50,51 Information was insufficient to draw any conclusions. Further studies assessing the quality of life before and after the successful treatment of PC BPPV with particle repositioning maneuvers are needed. We did not qualitatively assess the outcome of the patient’s report of vertigo. The patient’s report of vertigo may be assessed during the DHT or with the patient’s daily routine (1 week before the follow-up appointment). The scales vary in that they use the frequency of reports of vertigo, the intensity of vertigo on an analog scale of 1 to 10, and categorization of the resolution of BPPV on the basis of a combination of subjective symptoms and findings on the DHT. There was considerable variability in the collection of the reports of vertigo. The resolution of vertigo was reported at follow-up during positional testing,32,49 within 1 week of follow-up during daily activities,33 at follow-up with the completion of a questionnaire (Vestibular Disorders Activities of Daily Living Scale68),50,51 through categorization of the resolution of both symptoms and nystagmus45,53 as first described by Epley,18 or no mention of symptoms.27,28,52 The development of a means for assessing the patient’s report of vertigo is indicated.

Conclusion Randomized controlled trials suggested that the CRP was more effecMay 2010

Particle Repositioning Maneuvers in the Treatment of Benign Paroxysmal Positional Vertigo tive than a control in the resolution of BPPN in patients with PC BPPV. The evidence for the use of other particle repositioning maneuvers in the treatment of PC BPPV was weak. There were limited numbers of studies and no RCTs. Individual results suggested that the liberatory maneuver was more effective than a control; there was no significant difference in the effectiveness of the liberatory maneuver and the effectiveness of the CRP; the self-administered CRP was more effective than the selfadministered liberatory maneuver; and the CRP administered together with the self-administered CRP was more effective than the CRP administered alone. The Brandt-Daroff exercises were the least effective selfadministered treatments. There were no data on the effects of the particle repositioning maneuvers on outcomes relevant to patients. Dr Helminski, Dr Zee, and Dr Hain provided concept/idea/research design and writing. Dr Helminski provided data collection and project management. Dr Helminski and Dr Janssen provided data analysis. Dr Hain provided consultation (including review of manuscript before submission). The authors acknowledge the assistance of Midwestern University’s librarian, Rebecca Caton, MLIS, who assisted with the electronic literature search, and Sandra Levi, PT, PhD, for her guidance in writing this systematic review. A poster presentation of data from this study was given at the Combined Sections Meeting of the American Physical Therapy Association; February 9 –12, 2009; Las Vegas, Nevada. This article was submitted March 10, 2009, and was accepted December 21, 2009. DOI: 10.2522/ptj.20090071

References 1 von Brevern M, Radtke A, Lezius F, et al. Epidemiology of benign paroxysmal positional vertigo: a population based study. J Neurol Neurosurg Psychiatry. 2007;78: 710 –715. 2 Oghalai JS, Manolidis S, Barth JL, et al. Unrecognized benign paroxysmal positional vertigo in elderly patients. Otolaryngol Head Neck Surg. 2000;122:630 – 634.

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3 Fife D, FitzGerald JE. Do patients with benign paroxysmal positional vertigo receive prompt treatment? Analysis of waiting times and human and financial costs associated with current practice. Int J Audiol. 2005;44:50 –57. 4 Schuknecht HF. Cupulolithiasis. Arch Otolaryngol. 1969;90:765–778. 5 Hall SF, Ruby RR, McClure JA. The mechanics of benign paroxysmal vertigo. J Otolaryngol. 1979;8:151–158. 6 Dix MR, Hallpike CS. The pathology, symptomatology, and diagnosis of certain common disorders of the vestibular system. Proc R Soc Med. 1952;45:341–354. 7 Bhattacharyya N, Baugh RF, Orvidas L, et al. Clinical practice guideline: benign paroxysmal positional vertigo. Otolaryngol Head Neck Surg. 2008;139(5 suppl 4): S47–S81. 8 Fife TD, Iverson DJ, Lempert T, et al. Practice parameter: therapies for benign paroxysmal positional vertigo (an evidencebased review): report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology. 2008; 70:2067–2074. 9 Aw ST, Todd MJ, Aw GE, et al. Benign positional nystagmus: a study of its threedimensional spatio-temporal characteristics. Neurology. 2005;64:1897–1905. 10 Brandt T, Daroff RB. Physical therapy for benign paroxysmal positional vertigo. Arch Otolaryngol. 1980;106:484 – 485. 11 Epley JM. New dimensions of benign paroxysmal positional vertigo. Otolaryngol Head Neck Surg. 1980;88:599 – 605. 12 Herdman SJ. Treatment of benign paroxysmal positional vertigo. Phys Ther. 1990; 70:381–388. 13 Baloh RW, Jacobson K, Honrubia V. Horizontal semicircular canal variant of benign positional vertigo. Neurology. 1993;43: 2542–2549. 14 Halker RB, Barrs DM, Wellik KE, et al. Establishing a diagnosis of benign paroxysmal positional vertigo through the DixHallpike and side-lying maneuvers: a critically appraised topic. Neurologist. 2008;14:201–204. 15 Blau P, Shoup A. Reliability of a rating scale used to distinguish direction of eye movement using infrared/video ENG recordings during repositioning maneuvers. Int J Audiol. 2007;46:427– 432. 16 Harada Y. Metabolic disorder, absorption area and formation area of the statoconia. J Clin Electron Microsc. 1982;18:1–18. 17 Lim DJ. Formation and fate of the otoconia: scanning and transmission electron microscopy. Ann Otol Rhinol Laryngol. 1973;82:23–35. 18 Epley JM. The canalith repositioning procedure: for treatment of benign paroxysmal positional vertigo. Otolaryngol Head Neck Surg. 1992;107:399 – 404. 19 Faldon ME, Bronstein AM. Head accelerations during particle repositioning manoeuvres. Audiol Neurootol. 2008;13: 345–356.

20 Hain TC, Squires TM, Stone HA. Clinical implications of a mathematical model of benign paroxysmal positional vertigo. Ann N Y Acad Sci. 2005;1039:384 –394. 21 Rajguru SM, Ifediba MA, Rabbitt RD. Three-dimensional biomechanical model of benign paroxysmal positional vertigo. Ann Biomed Eng. 2004;32:831– 846. 22 Hain TC, Helminski JO, Reis IL, Uddin MK. Vibration does not improve results of the canalith repositioning procedure. Arch Otolaryngol Head Neck Surg. 2000;126: 617– 622. 23 Macias JD, Ellensohn A, Massingale S, Gerkin R. Vibration with the canalith repositioning maneuver: a prospective randomized study to determine efficacy. Laryngoscope. 2004;114:1011–1014. 24 Motamed M, Osinubi O, Cook JA. Effect of mastoid oscillation on the outcome of the canalith repositioning procedure. Laryngoscope. 2004;114:1296 –1298. 25 Semont A, Freyss G, Vitte E. Benign paroxysmal positional vertigo and provocative maneuvers [in French]. Ann Otolaryngol Chir Cervicofac. 1989;106: 473– 476. 26 Radtke A, Neuhauser H, von Brevern M, Lempert T. A modified Epley’s procedure for self-treatment of benign paroxysmal positional vertigo. Neurology. 1999;53: 1358 –1360. 27 Radtke A, von Brevern M, Tiel-Wilck K, et al. Self-treatment of benign paroxysmal positional vertigo: Semont maneuver vs Epley procedure. Neurology. 2004;63: 150 –152. 28 Massoud EA, Ireland DJ. Post-treatment instructions in the nonsurgical management of benign paroxysmal positional vertigo. J Otolaryngol. 1996;25:121–125. 29 Roberts RA, Gans RE, DeBoodt JL, Lister JJ. Treatment of benign paroxysmal positional vertigo: necessity of postmaneuver patient restrictions. J Am Acad Audiol. 2005;16:357–366. 30 Cakir BO, Ercan I, Cakir ZA, Turgut S. Efficacy of postural restriction in treating benign paroxysmal positional vertigo. Arch Otolaryngol Head Neck Surg. 2006;132: 501–505. 31 Baarsma EA. Vestibular testing in Me´nie`re’s syndrome [in Dutch]. Acta Otorhinolaryngol Belg. 1979;33:254 –263. 32 von Brevern M, Seelig T, Radtke A, et al. Short-term efficacy of Epley’s manoeuvre: a double-blind randomised trial. J Neurol Neurosurg Psychiatry. 2006;77:980 –982. 33 Lynn S, Pool A, Rose D, et al. Randomized trial of the canalith repositioning procedure. Otolaryngol Head Neck Surg. 1995; 113:712–720. 34 Imai T, Ito M, Takeda N, et al. Natural course of the remission of vertigo in patients with benign paroxysmal positional vertigo. Neurology. 2005;64:920 –921. 35 Lopez-Escamez JA, Gamiz MJ, FernandezPerez A, Gomez-Finana M. Long-term outcome and health-related quality of life in benign paroxysmal positional vertigo. Eur Arch Otorhinolaryngol. 2005;262: 507–511.

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Particle Repositioning Maneuvers in the Treatment of Benign Paroxysmal Positional Vertigo 36 Hilton M, Pinder D. The Epley (canalith repositioning) manoeuvre for benign paroxysmal positional vertigo. Cochrane Database Syst Rev. 2004;2:CD003162. 37 Teixeira LJ, Machado JN. Maneuvers for the treatment of benign positional paroxysmal vertigo: a systematic review. Braz J Otorhinolaryngol. 2006;72:130 –139. 38 Woodworth BA, Gillespie MB, Lambert PR. The canalith repositioning procedure for benign positional vertigo: a meta-analysis. Laryngoscope. 2004;114:1143–1146. 39 Olivo SA, Macedo LG, Gadotti IC, et al. Scales to assess the quality of randomized controlled trials: a systematic review. Phys Ther. 2008;88:156 –175. 40 Chalmers TC, Celano P, Sacks HS, Smith H Jr. Bias in treatment assignment in controlled clinical trials. N Engl J Med. 1983; 309:1358 –1361. 41 Moher D, Cook DJ, Eastwood S, et al. Improving the quality of reports of metaanalyses of randomised controlled trials: the QUOROM statement. Quality of Reporting of Meta-analyses. Lancet. 1999; 354:1896 –1900. 42 Moher D, Cook DJ, Jadad AR, et al. Assessing the quality of reports of randomised trials: implications for the conduct of meta-analyses. Health Technol Assess. 1999;3:i–iv, 1–98. 43 Schulz KF, Chalmers I, Hayes RJ, Altman DG. Empirical evidence of bias: dimensions of methodological quality associated with estimates of treatment effects in controlled trials. JAMA. 1995;273:408 – 412. 44 Moher D, Dulberg CS, Wells GA. Statistical power, sample size, and their reporting in randomized controlled trials. JAMA. 1994; 272:122–124. 45 Tanimoto H, Doi K, Katata K, Nibu KI. Self-treatment for benign paroxysmal positional vertigo of the posterior semicircular canal. Neurology. 2005;65:1299 –1300. 46 Longridge NS, Barber HO. Bilateral paroxysmal positioning nystagmus. J Otolaryngol. 1978;7:395– 400. 47 Portney LG, Watkins MP. Foundations of Clinical Research: Applications to Practice. 3rd ed. Upper Saddle River, NJ: Pearson Prentice Hall; 2009.

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48 Sherrington C, Herbert RD, Maher CG, Moseley AM. PEDro: a database of randomized trials and systematic reviews in physiotherapy. Man Ther. 2000;5:223–226. 49 Froehling DA, Bowen JM, Mohr DN, et al. The canalith repositioning procedure for the treatment of benign paroxysmal positional vertigo: a randomized controlled trial. Mayo Clin Proc. 2000;75:695–700. 50 Salvinelli F, Casale M, Trivelli M, et al. Benign paroxysmal positional vertigo: a comparative prospective study on the efficacy of Semont’s maneuver and no treatment strategy. Clin Ter. 2003;154:7–11. 51 Salvinelli F, Trivelli M, Casale M, et al. Treatment of benign positional vertigo in the elderly: a randomized trial. Laryngoscope. 2004;114:827– 831. 52 Sherman D, Massoud EA. Treatment outcomes of benign paroxysmal positional vertigo. J Otolaryngol. 2001;30:295–299. 53 Soto Varela A, Bartual Magro J, Santos Pe´rez S, et al. Benign paroxysmal vertigo: a comparative prospective study of the efficacy of Brandt and Daroff exercises, Semont and Epley maneuver. Rev Laryngol Otol Rhinol (Bord). 2001;122:179 –183. 54 Angeli SI, Hawley R, Gomez O. Systematic approach to benign paroxysmal positional vertigo in the elderly. Otolaryngol Head Neck Surg. 2003;128:719 –725. 55 Asawavichianginda S, Isipradit P, Snidvongs K, Supiyaphun P. Canalith repositioning for benign paroxysmal positional vertigo: a randomized, controlled trial. Ear Nose Throat J. 2000;79:732–734, 736 –737. 56 Blakley BW. A randomized, controlled assessment of the canalith repositioning maneuver. Otolaryngol Head Neck Surg. 1994;110:391–396. 57 Califano L, Capparuccia PG, Di Maria D, et al. Treatment of benign paroxysmal positional vertigo of posterior semicircular canal by “Quick Liberatory Rotation Manoeuvre.” Acta Otorhinolaryngol Ital. 2003;23:161–167. 58 Cavaliere M, Mottola G, Iemma M. Benign paroxysmal positional vertigo: a study of two manoeuvres with and without betahistine. Acta Otorhinolaryngol Ital. 2005; 25:107–112.

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59 Chang AK, Schoeman G, Hill M. A randomized clinical trial to assess the efficacy of the Epley maneuver in the treatment of acute benign positional vertigo. Acad Emerg Med. 2004;11:918 –924. 60 Cohen HS, Kimball KT. Effectiveness of treatments for benign paroxysmal positional vertigo of the posterior canal. Otol Neurotol. 2005;26:1034 –1040. 61 Li JC. Mastoid oscillation: a critical factor for success in canalith repositioning procedure. Otolaryngol Head Neck Surg. 1995;112:670 – 675. 62 Munoz JE, Miklea JT, Howard M, et al. Canalith repositioning maneuver for benign paroxysmal positional vertigo: randomized controlled trial in family practice. Can Fam Physician. 2007;53:1049 –1053, 1048. 63 Serafini G, Palmieri AM, Simoncelli C. Benign paroxysmal positional vertigo of posterior semicircular canal: results in 160 cases treated with Semont’s maneuver. Ann Otol Rhinol Laryngol. 1996;105: 770 –775. 64 Sridhar S, Panda N, Raghunathan M. Efficacy of particle repositioning maneuver in BPPV: a prospective study. Am J Otolaryngol. 2003;24:355–360. 65 Wolf M, Hertanu T, Novikov I, Kronenberg J. Epley’s manoeuvre for benign paroxysmal positional vertigo: a prospective study. Clin Otolaryngol Allied Sci. 1999; 24:43– 46. 66 Yimtae K, Srirompotong S, Srirompotong S, Sae-Seaw P. A randomized trial of the canalith repositioning procedure. Laryngoscope. 2003;113:828 – 832. 67 Herdman SJ, Tusa RJ. Complications of the canalith repositioning procedure. Arch Otolaryngol Head Neck Surg. 1996;122: 281–286. 68 Cohen HS, Kimball KT. Development of the Vestibular Disorders Activities of Daily Living Scale. Arch Otolaryngol Head Neck Surg. 2000;126:881– 887.

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Research Report

Effects of Mastectomy on Shoulder and Spinal Kinematics During Bilateral Upper-Limb Movement Jack Crosbie, Sharon L. Kilbreath, Elizabeth Dylke, Kathryn M. Refshauge, Leslie L. Nicholson, Jane M. Beith, Andrew J. Spillane, Kate White

Background. Shoulder movement impairment is a commonly reported consequence of surgery for breast cancer.

Objective. The aim of this study was to determine whether shoulder girdle kinematics, including those of the scapula, spine, and upper limb, in women who have undergone a unilateral mastectomy for breast cancer are different from those demonstrated by an age-matched control group.

Design. An observational study using 3-dimensional kinematic analysis was performed.

Methods. Women who had a unilateral mastectomy on their dominant-arm side (n⫽29, mean [⫾SD] age⫽62.4⫾8.9 years) or nondominant-arm side (n⫽24, mean [⫾SD] age⫽59.8⫾9.9 years), as well as a control group of age-matched women without upper-limb, shoulder, or spinal problems (n⫽22, mean [⫾SD] age⫽58.1⫾11.5 years), were measured while performing bilateral arm movements in the sagittal, scapular, and coronal planes. All of the women were free of shoulder pain at the time of testing. Data were collected from the glenohumeral joint, the scapulothoracic articulation, and the spine (upper and lower thoracic and lumbar regions) using an electromagnetic tracking system.

Results. Women following mastectomy displayed altered patterns of scapular rotation compared with controls in all planes of movement. In particular, the scapula on the mastectomy side rotated upward to a markedly greater extent than that on the nonmastectomy side, and women following mastectomy displayed greater scapular excursion than controls.

Conclusions. The findings suggest that altered motor patterns of the scapula are associated with mastectomy on the same side. Whether these changes are harmful or not is unclear. Investigation of interventions designed to restore normal scapulohumeral relationships on the affected side following unilateral mastectomy for breast cancer is warranted.

J. Crosbie, MSc, PhD, GradDipPhys, DipTP, is Associate Professor, Clinical Rehabilitation Sciences Research Group, Discipline of Physiotherapy, Faculty of Health Sciences, University of Sydney, PO Box 170, East Street, Lidcombe, New South Wales 1825, Australia. Address all correspondence to Dr Crosbie at: [email protected]. S.L. Kilbreath, BSc, MClSci, PhD, is Associate Professor, Clinical Rehabilitation Sciences Research Group, Discipline of Physiotherapy, Faculty of Health Sciences, University of Sydney. E. Dylke, BSc, MPhys, is Research Physiotherapist, Clinical Rehabilitation Sciences Research Group, Discipline of Physiotherapy, Faculty of Health Sciences, University of Sydney. K.M. Refshauge, DipPhys, GradDip AppSci, MSc, PhD, is Professor, Clinical Rehabilitation Sciences Research Group, Discipline of Physiotherapy, Faculty of Health Sciences, University of Sydney. L.L. Nicholson, BAppSci, GradDip, PhD, is Senior Lecturer, Clinical Rehabilitation Sciences Research Group, Discipline of Physiotherapy, Faculty of Health Sciences, University of Sydney. J.M. Beith, MB, BS, FRACP, PhD, is Senior Staff Specialist, Sydney Cancer Centre, Royal Prince Alfred Hospital, Camperdown, North Sydney, New South Wales, Australia. A.J. Spillane, MB, BS, MD, is Visiting Medical Officer and Senior Lecturer, Northern Clinical School, Royal North Shore Hospital, Faculty of Medicine, University of Sydney. K. White, GNC, MNurs, PhD, is Professor and Director of Research, Faculty of Nursing, University of Sydney. [Crosbie J, Kilbreath SL, Dylke E, et al. Effects of mastectomy on shoulder and spinal kinematics during bilateral upper-limb movement. Phys Ther. 2010;90:679 – 692.] © 2010 American Physical Therapy Association

Post a Rapid Response to this article at: ptjournal.apta.org May 2010

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ollowing mastectomy for breast cancer, many women experience impairment in shoulder movements that can substantially affect their everyday function and quality of life.1 Although some symptoms, such as arm swelling due to lymphedema,2 are easily accounted for, other symptoms, such as chronic ache and pain,3,4 which women report in the shoulder and upper trunk months to years after surgery, are not always associated with their physical strength (force-generating capacity) or range of motion at the shoulder.5–7 The lack of a relationship between impairments and self-reported function suggests that other factors are likely to contribute to these persisting problems.

The residual effects of surgical scarring and fibrosis following radiotherapy4 could affect the mechanics of the shoulder region through tethering of soft tissue or pain-inhibited movement. The incidence of shoulder morbidity has been found to be significantly and substantially higher in women treated with postsurgical radiotherapy (17%) compared with a group of women who received no radiotherapy (2%).8 Additionally, women who undergo mastectomy are almost 6 times more likely to

Available With This Article at ptjournal.apta.org • eTable 1: Scapular Internal Rotation • eTable 2: Scapular Upward Rotation • eTable 3: Scapular Anterior Tilt • eTable 4: Spinal Motion • The Bottom Line Podcast • Audio Abstracts Podcast This article was published ahead of print on March 11, 2010, at ptjournal.apta.org.

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experience shoulder restriction9 and impairment10 than patients who undergo breast-conserving surgery, and, despite improved surgical techniques and postoperative care, pain and functional limitation continue to pose problems.11 The residual effects of surgery or radiotherapy also may affect the intricate shoulder girdle movements required for arm elevation. Normally, the humerus moves smoothly and in synchrony with respect to the scapula.12,13 This scapulohumeral rhythm is achieved through precise muscle firing of scapulothoracic and scapulohumeral musculature in response to complex proprioceptive information, maintaining the head of the humerus within the glenoid fossa throughout the movement.14,15 The asymmetry of both soft tissue motility and mass distribution across the chest wall that arises from loss of a breast potentially could affect upperlimb movements and contribute to trunk or arm symptoms. Previous research has identified that there can be changes in the size and activation of muscles around the upper trunk consequential to surgery for breast cancer,16 and soft tissue contracture may result from protective posture and movement.11 A recent study16 showed significant changes during unilateral arm elevation in scapular kinematics on the operated side following surgery for breast cancer. In that study, however, the sample included women who had undergone mastectomy with or without radiotherapy, wide local excision with or without radiotherapy, or chemotherapy. In addition, participants included women with coexisting shoulder pain on the side of surgery. An important confounder in understanding the mechanism underlying long-term shoulder pain in women following mastectomy is the relatively high incidence of idiopathic or posttraumatic shoulder disability

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that occurs in the same age group.17 Seventy percent of people with adhesive capsulitis are women,18 and the point prevalence of shoulder pain has been reported from large population surveys as affecting 8.2% or more of the population aged 45 to 54 years, rising to 13.2% for those aged 75 to 84 years.19,20 Sixty-five percent of women diagnosed with breast cancer are between 40 and 70 years of age.21,22 Thus, in exploring the kinematics of the shoulder complex in women following mastectomy, it is important to ensure that disturbances cannot be attributed to coexisting joint pathology. Our aim in this observational study was to determine whether glenohumeral, scapular, and spinal kinematics in women who had undergone a mastectomy, but who were asymptomatic with respect to shoulder pain, were different from those demonstrated by a control group. If there was a significant difference in the inherent movement patterns of the upper limb and trunk displayed by the women following mastectomy, this difference in movement patterns might be a source of potential impairment. Such subtle disturbances previously have been associated with shoulder tightness23 and idiopathic loss of shoulder range of motion.24 Single-arm elevation inevitably is associated with other movements designed to maintain postural equilibrium, as well as being synergic to the primary motion. We wanted to ensure that the movements demonstrated were limited to those required to achieve arm elevation. Therefore, in this study, we tested simultaneous, bilateral arm motion in 3 different planes of movement: sagittal (forward flexion), coronal (abduction), and scapular (approximately 30° forward from abduction). We compared participants’ performance with that of an age-matched May 2010

Kinematics During Arm Elevation Following Mastectomy control group. In particular, we sought insights into the effect of the mastectomy on intralimb kinematics.

Method Participants Fifty-three women, aged between 44 and 84 years, who had undergone a unilateral mastectomy at least 12 months previously, did not have lymphedema, and had no recent history of disorders affecting the upper limb or spine were recruited via newspaper advertisement. Within this cohort, 29 participants had undergone surgery on their dominant side (mastectomy dominant-side group), and 24 participants had undergone surgery on their nondominant side (mastectomy nondominant-side group). We also recruited an age-matched (43– 80 years) control group of women (n⫽22) who also had no upper-limb, shoulder, or spinal problems. Sample group sizes were determined from data previously reported for a similar activity25 and were based on the power (80%) required to detect a difference of 3 degrees in scapular upward rotation, which we determined as clinically significant. The target sample size was 22 participants in each group; however, convenience sampling provided slightly larger and less numerically balanced cohorts in the 2 mastectomy groups. We assessed the participants’ activity levels using the International Physical Activity Questionnaire (IPAQ) (1–3 scale)26 and their quality of life using the Medical Outcomes Study 36-Item Short-Form Health Survey questionnaire (SF-36) (0 –100 scale). We also assessed shoulder impairment with the Disabilities of the Arm, Shoulder, and Hand questionnaire (DASH),27 which has a maximum score of 100, indicating maximum disability. We collected and recorded general anthropometric and demographic data. All participants gave informed consent.

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Inclusion and Exclusion Criteria As simple screening instruments, we measured overall shoulder forward flexion range of motion using a digital inclinometer and shoulder flexor strength at 90 degrees of flexion using a handheld dynamometer. Any participant who was unable to achieve at least 150 degrees of sagittal-plane humeral elevation or who demonstrated asymmetrical weakness of the shoulder flexors, notionally defined as one side producing a maximum force of ⱕ80% of the other side, was excluded from the study. We established the presence of shoulder impingement (a common manifestation of dysfunctional shoulder motor control) using the dichotomous Hawkins-Kennedy28 and dynamic impingement29 tests. The Hawkins-Kennedy test, although widely used, is primarily a passive test of impingement, whereas the dynamic impingement test assesses impingement in the shoulder during dynamic active motion. Individuals who demonstrated a positive result on either test were excluded, as

were those who reported any existing or recent (previous 6 months) pain in the shoulder region, either at rest or during activity, or any history of surgery (apart from the mastectomy in the relevant groups) to the shoulder region. We determined the presence of lymphedema using single-frequency bioimpedance (Z) analysis.30 Participants were excluded on the presence of clinically significant lymphedema, as determined by the ratio: Zunaffected limb/Zaffected limb. A ratio of less than 1.139 on the dominant side or 1.066 on the nondominant side indicates absence of lymphedema.31 Protocol The women were required, while seated on a backless stool with both feet on the ground, to raise both their arms with elbows extended simultaneously as far overhead as they could. Seating the participants ensured that the movements were localized to the upper limbs and trunk, rather than permitting the lower limbs to contribute to the activity.

The Bottom Line What do we already know about this topic? It is logical that, following mastectomy for breast cancer, movement of the shoulder region on the operated side can be compromised. The extent and nature of alterations in shoulder kinematics are not known.

What new information does this study offer? After mastectomy, patterns of scapular movement are altered, particularly on the operated side, despite the absence of mechanical restriction. This suggests that there may be changes to the motor patterns of the scapula, perhaps as a learned behavior.

If you’re a patient, what might these findings mean for you? Closer attention to the restoration of more “normal” scapulohumeral rhythm may be warranted in the recovery period following mastectomy.

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Kinematics During Arm Elevation Following Mastectomy The order in which movements were completed was forward flexion, abduction, and movement in the scapular plane. For each movement, the women completed 3 repetitions. The movement commenced with the arm at the side, thumb pointing anteriorly, and this position was maintained throughout the movement. One cycle of movement took approximately 3 seconds. To collect kinematic data, we used a multi-sensor, 6-degree-of-freedom electromagnetic tracking device (Motion Star Wireless 2 system with an extended range transmitter).* Sensors were firmly attached on the skin overlying the superior acromial processes, first and sixth thoracic and first lumbar vertebral spinous processes, and the second sacral segment. The humeral sensors were attached to the skin on the lateral side of the arm below the deltoid muscle insertion. A ninth sensor, attached to a pointer, was used to manually digitize anatomical landmarks in the upper limbs, scapulae, and trunk. Calibration of the body segments adhered to a previously reported protocol.25 Following digitization and calibration, we collected kinematic data at 100 Hz. This protocol has been reported to have good in vivo reliability, with an intraclass correlation coefficient value of .91 for position and an accuracy of 1.2 degrees.25 Based on these data, standard error of measurement (SEM) values were calculated for each of the kinematic variables of interest following the approach described by Palombaro et al.32 Minimal detectable change (MDC) was computed as 1.96 ⫻ SEM and represents the 95% confidence interval for the SEM. Data processing and reduction were carried out using conventional biomechanical analysis by a researcher

* Ascension Technology Corp, 107 Catamount Dr, Burlington, VT 05468-3284.

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who was blinded to the group allocation of participants. The joint angle values obtained in the neutral posture were subtracted from the data for each participant, resulting in a starting position close to zero for each movement. Thus, movements are reported relative to the starting posture and are not absolute with respect to global or local coordinate systems. Each participant was instructed to rest with her arm hanging as close to vertical as possible. The starting positions were analyzed between groups and planes of motion to ensure that the movement patterns were not distorted by different offsets in any group or plane of motion. The kinematic data of interest were those of the humeral, scapulothoracic, and spinal joints. For the purpose of this analysis, humeral motion was defined with respect to the global vertical axis (humeral elevation). The 3 scapulothoracic movements assessed were upward/downward rotation, internal/external rotation, and anterior/posterior tilt (rotation about the longitudinal axis of the spine of the scapula) (Fig. 1). We subdivided the trunk into upper (T1–T6) and lower (T7–T12) thoracic and lumbar (L1–L5) regions using the spinous processes of relevant vertebrae as landmarks and recorded flexion and extension and lateral flexion and axial rotation motions of each spinal region. Upper and lower thoracic regions, defined here according to convenience, have been shown to behave differently from one another,33–35 probably because the upper segment is more closely tethered through the more rigid anterior articulation of the ribs with the sternum. Although the participants exhibited humeral elevation in excess of 90 degrees, particularly within the sagittal plane, we confined the analysis

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of scapular and thoracic movements to positions associated with 4 defined angles of humeral elevation in each movement plane: 0, 30, 60, and 90 degrees. The average values of the scapular and thoracic postures from the 3 repetitions at each of the noted angles were used for analysis. Data Analysis The primary focus of the investigation was to determine whether mastectomy affected scapular and thoracic kinematics during elevation of the arm. In particular, we were curious to establish whether asymmetry of scapular motion, notably upward rotation, as has been reported in women who had not undergone a mastectomy,25 was different in women following mastectomy. We also were interested in determining whether the scapular and spinal contributions to overall humeral elevation were incrementally and linearly related to the plane in which motion occurred and to the angle of humeral elevation. For the purpose of this study, we tested the primary hypotheses that there would be no difference: (1) among groups for 3-dimensional (3D) scapular and spinal contributions to overall movement at any of the designated humeral angles, (2) among the patterns of scapular and spinal motion in any of the 3 planes of motion, or (3) between dominantand nondominant-arm sides with respect to 3D scapular motion. Statistical analysis was carried out using PASW version 17 software.† A full factorial 3 ⫻ 4 ⫻ 3 ⫻ 2 repeatedmeasures analysis of variance (ANOVA) with planned contrasts was used to separately investigate scapular internal rotation, upward rotation, and anterior tilting on each of the dominant and nondominant † SPSS Inc, 233 S Wacker Dr, Chicago, IL 60606.

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Kinematics During Arm Elevation Following Mastectomy sides. The between-group factor was group (mastectomy dominant-side, mastectomy nondominant-side, and control), and the within-group factors were humeral elevation angle (0°, 30°, 60°, and 90°), plane of motion (sagittal, scapular, and coronal), and side (dominant and nondominant). Plane of motion was an important component of the analysis and was tested to establish whether the changes in scapular pattern were systematic and progressive with changing plane of humeral elevation. Repeated-measures contrasts were polynomial for plane and angle and difference for groups, which were treated in a pair-wise fashion. Body mass index (BMI) was included as a continuous covariate in all linear models, as we had determined that women in the control group had BMI values that were significantly lower than those in the mastectomy groups (F2,72⫽6.20; P⫽.003), although there was no significant difference between the 2 mastectomy groups (P⫽.916). A repeated-measures ANOVA also was used to investigate the relationships between spinal segment movements and arm elevation. For the purposes of this analysis, because arm motion was bilateral, lateral flexion and axial rotation of the spine would not be expected to occur to a significant extent. To investigate these out-of-plane movements, we calculated the summated root mean square value for lateral flexion and axial rotation for each participant at each discrete glenohumeral angle and in each plane and used this resultant as a single variable of convenience. Flexion and extension were recorded as a single variable at each interval in each test. Sphericity was tested in all cases using the Mauchley procedure, and the Greenhouse-Geisser correction was applied in all cases where sphericity was found to be significant. A one-way ANOVA was used to determine whether any differences exMay 2010

Figure 1. Kinematic conventions for local segmental coordinate system on the right scapula. The embedded axes follow the conventions of the International Society of Biomechanics. Anterior tilt is the clockwise rotation about the axis congruent with the spine of the scapula (Xs), and internal rotation is the clockwise rotation about the pseudo-vertical axis (Ys) perpendicular to Xs and in the plane of the body of the scapula. Upward rotation is the clockwise rotation about the posteriorly directed axis perpendicular to the body of the scapula (Zs) and to the other axes.

isted among groups for entry data such as age, available range of motion, and so on. Post hoc analysis used the Tukey test for pair-wise comparison of variables when significant differences were observed among groups. Interactions found to be significant (P⬍.05) are identified,

but nonsignificant interactions are not reported. Effect of Radiotherapy on Arm Elevation Half of the women in the mastectomy nondominant-side group had received radiotherapy as part of their

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Kinematics During Arm Elevation Following Mastectomy Table 1. Participant Characteristicsa

Characteristic Dominant side, right:left

Control Group (nⴝ22)

Mastectomy Dominant-Side Group (nⴝ29)

Mastectomy Nondominant-Side Group (nⴝ24)

19:3

27:2

21:3

Age (y)

58.1 (11.5)

62.4 (8.9)

59.8 (9.9)

Body mass (kg)

63.8 (9.4)

73.0 (17.0)

73.5 (16.8)

Height (m)

1.66 (0.07)

Body mass index (kg/m2)b

23.2 (2.6)

1.64 (0.08) 27.1 (5.1)

1.63 (0.06) 27.6 (5.4)

Radiotherapy, yes:no

0:22

6:23

12:12

Chemotherapy, yes:no

0:22

12:17

13:11

Axillary node dissection, yes:no

0:22

Lymphedema ratio

1.01 (0.04)

24:5

21:3

1.04 (0.05)

1.03 (0.06)

SF-36 physical component score

88.9 (10.0)

80.0 (17.8)

71.5 (18.5)

SF-36 mental component score

75.1 (12.2)

70.2 (15.3)

63.2 (15.7)

DASH score

3.29 (4.75)

10.12 (9.39)

12.97 (11.6)

IPAQ score

2.68 (0.48)

2.41 (0.83)

2.61 (0.58)

Strength, dominant side (N)

141.4 (21.1)

121.3 (25.1)

124.3 (34.1)

Strength, nondominant side (N)

142.0 (20.6)

116.1 (22.2)

118.5 (34.4)

Range of motion, dominant side (°)

172 (21)

169 (8)

177 (6)

Range of motion, nondominant side (°)

170 (22)

171 (7)

170 (11)

a Mean (SD) values are reported. SF-36⫽Medical Outcomes Study 36-Item Short-Form Health Survey questionnaire, DASH⫽Disabilities of the Arm, Shoulder, and Hand questionnaire, IPAQ⫽International Physical Activity Questionnaire. b Significant at P⬍.05

postoperative management, enabling an opportunistic secondary analysis to determine its effect on elevation of the arm. For each of the analyses described above, a secondary analysis was undertaken in which the between-group factor was replaced by whether or not the woman had received radiotherapy.

Results Participant Characteristics The participant characteristics are shown in Table 1. There was no significant difference in age among the groups (F2,72⫽1.22; P⫽.301). Apart from BMI, as previously noted, there were no significant differences among the groups for any of the general participant characteristics. Kinematic Variables Data for all 3D scapular angular measurements, corresponding to the val684

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ues at the predetermined humeral elevation angles, are presented in eTables 1, 2, and 3 (available at ptjournal.apta.org). Patterns of scapular rotations are illustrated in Figures 2, 3, and 4. Data for associated spinal motion are presented in eTable 4 (available at ptjournal. apta.org). Because average lumbar spine motion was less than 1 degree and, therefore, neither clinically important nor probably greater than measurement error, no further analysis will be reported. The SEM values for scapular rotations and thoracic flexion were determined and are indicated in each relevant table, along with calculated values for MDC. No significant differences were found among starting positions for the glenohumeral joint (with respect to the global coordinate system) for groups or planes of motion (F4,144⫽0.77; P⫽.549).

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Group Effects Significant effects were detected among groups, particularly for scapular upward rotation during humeral elevation in both the scapular and coronal planes (Tab. 2) and on both dominant and nondominant sides. In general, women in both mastectomy groups demonstrated significantly more upward rotation on both sides than did the control group. On the dominant side, both mastectomy groups demonstrated greater upward/downward rotation compared with the control group, but the 2 mastectomy groups did not differ significantly from one another. Upward/downward rotation on the nondominant side, however, also was significantly greater in the mastectomy nondominant-side group than in the mastectomy dominantside group (P⫽.036). The magnitudes of all of these significant differMay 2010

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Figure 2. Patterns of scapular internal rotation on the dominant and nondominant sides for the 3 groups during humeral elevation in the (A) sagittal plane, (B) scapular plane, and (C) coronal plane. Mean and 95% confidence interval values for each group are illustrated. Solid circles represent the values for the control group at the 4 humeral angles (0°, 30°, 60°, and 90°); open squares represent values for the mastectomy dominant-side group, and filled diamonds represent values for the mastectomy nondominant-side group. Values are deliberately offset (by ⫾2°) among groups for ease of representation. *⫽P⬍.05.

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Figure 3. Patterns of scapular upward rotation on the dominant and nondominant sides during humeral elevation in the (A) sagittal plane, (B) scapular plane, and (C) coronal plane. Symbols are as defined for Figure 2. *⫽P⬍.05, **⫽P⬍.001.

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Figure 4. Patterns of scapular anterior tilt on the dominant and nondominant sides during humeral elevation in the (A) sagittal plane, (B) scapular plane, and (C) coronal plane. Symbols are as defined for Figure 2.

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Kinematics During Arm Elevation Following Mastectomy Table 2. Group Effects for Scapular and Thoracic Motion During Humeral Elevation in 3 Planes Plane of Humeral Elevation Motion

Side

Sagittal

Scapular

Coronal

Dominant

F2,72⫽0.52; P⫽.6

F2,72⫽0.10; P⫽.902

F2,72⫽0.07; P⫽.93

Nondominant

F2,72⫽2.08; P⫽.112

F2,72⫽0.62; P⫽.538

F2,72⫽5.27; P⫽.007 Control group ⬍ mastectomy nondominant-side group (P⫽.006)

Dominant

F2,72⫽2.90; P⫽.062

F2,72⫽8.41; P⫽.001 Control group ⬍ mastectomy dominant-side group (P⫽.002) Control group ⬍ mastectomy nondominant-side group (P⫽.002)

F2,72⫽14.45; P⬍.001 Control group ⬍ mastectomy dominant-side group (P⬍.001) Control group ⬍ mastectomy nondominant-side group (P⬍.001)

Nondominant

F2,72⫽2.31; P⫽.107

F2,72⫽11.92; P⬍.001 Control group ⬍ mastectomy dominant-side group (P⫽.028) Control group ⬍ mastectomy nondominant-side group (P⬍.001) Mastectomy dominant-side group ⬍ mastectomy nondominant-side group (P⫽.036)

F2,72⫽25.65; P⬍.001 Control group ⬍ mastectomy dominant-side group (P⫽.023) Control group ⬍ mastectomy nondominant-side group (P⬍.001) Mastectomy dominant-side group ⬍ mastectomy nondominant-side group (P⬍.001)

Dominant

F2,72⫽0.82; P⫽.444

F2,72⫽0.84; P⫽.435

F2,72⫽2.74; P⫽.071

Nondominant

F2,72⫽0.44; P⫽.643

F2,72⫽0.74; P⫽.481

F2,72⫽0.41; P⫽.668

Upper thoracic flexion

F2,72⫽3.92; P⫽.047 Control group ⬍ mastectomy dominant-side group (P⫽.05)

F2,72⫽1.36; P⫽.262

F2,72⫽4.69; P⫽.012 Mastectomy nondominantside group ⬍ mastectomy dominant-side group (P⫽.01)

Lower thoracic flexion

F2,72⫽1.15; P⫽.322

F2,72⫽1.46; P⫽.239

F2,72⫽1.64; P⫽.201

Out-of-plane motion

F2,72⫽0.19; P⫽.828

F2,72⫽1.19; P⫽.309

F2,72⫽0.48; P⫽.621

Scapular internal rotation

Scapular upward rotation

Scapular anterior tilt

ences were in excess of 3 times the MDC (eTab. 2, available at ptjournal.apta.org). There was one significant difference noted for scapular internal/external rotation during humeral elevation in the coronal plane, with the mastectomy nondominant-side group demonstrating significantly more external rotation on the nondominant side than the control group (P⫽.006). Anterior tilt of the scapula did not demonstrate any significant effects for group in any plane of elevation. Upper thoracic flexion was significantly greater in the mastectomy dominant-side group than in the control group during humeral elevation 688

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in the sagittal plane (P⫽.05) and also greater than in the mastectomy nondominant-side group during humeral elevation in the coronal plane (P⫽.01). However, the amplitudes of these differences were marginal and less than the 3 degrees defined as clinically important. No significant group differences were detected for either lower thoracic flexion or outof-plane movements. Body mass index was not found to produce a significant effect in any comparison.

plane to the coronal plane. Scapular internal/external rotation was positive and linear in the sagittal plane, but became progressively more negative in association with the changing elevation plane. In addition, the scapular response became significantly more quadratic in pattern (P⫽.024); that is, maximum external rotation occurred around 60 degrees of humeral elevation, and then the scapula began to rotate internally once more (Fig. 2C).

Effect of Plane of Humeral Elevation Significant effects were detected for changes to scapular motion as humeral elevation progressed from the sagittal plane through the scapular

Upward/downward rotation was consistently linear across the discrete elevation angles and increased significantly from sagittal- to scapular- and coronal-plane motion (F2,72⫽4.32; P⫽.017). There was no

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Kinematics During Arm Elevation Following Mastectomy significant difference between scapular- and coronal-plane motion trends (P⫽.388). There were no significant linear or quadratic effects of changing the plane of humeral elevation on overall anterior tilt of the scapula (P⫽.65). Upper thoracic flexion became progressively greater as humeral elevation progressed from the sagittal plane to the coronal plane. This progression involved a significant quadratic trend (F1,72⫽8.51; P⫽.005); however, the magnitude of the difference did not substantially exceed MDC values. The lower thoracic region progressively and significantly extended in response to plane of motion. There was a significant linear increase in the spinal component as the humeral elevation moved from the sagittal plane to the coronal plane (F1,72⫽42.3; P⬍.001). The amplitude of the difference was more than 4 degrees, which was 10 times MDC values. Out-of-plane movements increased in a cubic trend, with progressive change in humeral plane (F1,72⫽ 9.39; P⫽.003); however, the amplitude of this change was less than could be considered clinically important. Effect of Side Significant effects were found between dominant- and nondominantside scapular motions during humeral elevation. The control group demonstrated significantly greater upward/downward rotation in both the scapular plane (P⫽.048) and the coronal plane (P⫽.043) but no other asymmetries. Women whose surgery affected their dominant side were significantly asymmetrical with respect to internal/external rotation in the sagittal plane (P⫽.004) and anterior/posterior tilt in the coronal plane (P⫽.049) but otherwise did not demonstrate significant siderelated differences. May 2010

The group of women whose mastectomy affected their nondominant side demonstrated significantly more scapular upward rotation on the affected side in the sagittal (P⫽.003), scapular (P⫽.001), and coronal (P⬍.001) planes. They also had more nondominant-side scapular external rotation (P⫽.012) and significantly less posterior tilt of the nondominant scapula (P⫽.003) during humeral elevation in the coronal plane. In all cases, these statistically significant differences exceeded MDC values.

total ranges for the instruments) were small, and there was no significant association between any of the kinematic variables and these selfreport variables. Similarly, the fact that the women in the mastectomy groups were more overweight compared with the control group did not appear to exert any influence on the outcomes of the study. The testing of individuals who were symptom-free meant that we anticipated subtle rather than obvious differences from control group.

Effect of Radiotherapy There were no significant differences for any scapular motion in any plane of glenohumeral elevation between the radiotherapy and nonradiotherapy subgroups of the mastectomy nondominant-side group. Equally, there were no statistically significant differences between the radiotherapy and nonradiotherapy subgroups for upper thoracic, lower thoracic, lumbar, or out-of-plane movements.

The results of our investigation indicate the rejection of all 3 of our primary hypotheses. There were significant differences among groups for the scapular and upper thoracic spine movements during humeral elevation, although the discrepancy was almost entirely limited to upward rotation of the scapula, which demonstrated systematic differences from the control group. The magnitude of the differences in upward rotation was substantially greater than the calculated error terms for the movements in question. Although there were spinal movements associated with the upper-extremity elevation trials, similar to patterns previously reported,25,35 the differences among the groups were small and did not indicate clinically meaningful changes. Women who had undergone a mastectomy demonstrated significant changes to the association between scapular upward rotation and glenohumeral motion compared with the women in the control group. Specifically, women who had undergone a mastectomy had a greater scapular contribution to the overall motion, particularly on the affected side. Although it has been reported that asymmetries in scapular motion occur naturally in individuals who are healthy, with the nondominant side tending to rotate upward more than the dominant side,25 a finding supported in this cohort with 13% greater upward ro-

Discussion We investigated the effect of mastectomy on upper-quadrant movement in women who reported no significant upper-limb or spinal symptoms, testing bilateral arm elevation in 3 planes of movement. The deliberate selection of participants who were no longer considered to be in the recovery phase after surgery and who had stable clinical presentations was designed to identify intrinsic changes in the kinematics of the shoulder girdle and upper trunk that might be ascribed to the consequences of their surgery and postoperative activity rather than to shoulder pathology that might have originated from surgery or from other causes. Although the women in the mastectomy groups reported slightly higher scores for DASH and lower scores for SF-36 assessments compared with the control group, the absolute values (relative to the

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Kinematics During Arm Elevation Following Mastectomy tation on the nondominant side at 90 degrees of humeral elevation in the coronal plane, the mastectomy nondominant-side group demonstrated a greater degree of asymmetry (29%) than the control group. Interestingly, the mastectomy dominant-side group demonstrated 14% more scapular upward rotation on their dominant, mastectomy side. Differences recently have been reported in side-to-side movement of the scapula during unilateral arm elevation in the plane of the scapula in women following breast cancer surgery.16 The researchers found that women whose surgery was on the left side demonstrated greater scapulohumeral dysfunction and had higher levels of pain, particularly the greater the time since surgery. In our study, the majority of participants in each group were right-side dominant (Tab. 1), so almost all of the women in the mastectomy nondominantside group were affected on their left side, and it was in this group that the most significant changes were identified, albeit without the presence of pain. As arm elevation progresses from the sagittal plane through the scapular plane to the coronal plane, there is a significant trend in the patterns of associated scapular motion. Although the movement patterns of the scapulae are somewhat complex, the changes are logical and consistent with the anatomical structures of the shoulder complex. Elevation in the sagittal plane places little constraint on a linear set of scapular rotations, but as the arm is moved toward the coronal plane, the anatomy of the head of the humerus in the glenoid fossa necessitates a nonlinear external rotation from the scapulae, peaking around 60 degrees of humeral elevation. This rotation appears to be associated with a progressive and linear increase in the extension of the lower thoracic spi690

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nal region. We find it interesting that the 3 groups demonstrated almost identical patterns and amplitudes of motion of scapular external rotation on their dominant side during coronal-plane elevation, but the mastectomy nondominant-side group exhibited a markedly increased amplitude compared with the other groups, although an identical pattern, on the nondominant side. Why the women in the mastectomy dominant-side group did not show a similar distortion on the affected side is not immediately apparent. Scapular and thoracic participation in upper-limb motion is a natural component of the kinematics of the shoulder girdle,35,36 and it frequently is altered in people with problems affecting the shoulder region.37 In our study, however, none of the women reported current shoulder symptoms, nor did they demonstrate positive shoulder impingement patterns. They had no significant difference in the range of shoulder elevation and, from the kinematics of the scapula recorded in the study, had no apparent limitation of scapular motion. We speculate that the reason for this altered scapular contribution may be a motor control adaptation arising from reduced frequency and amplitude of elevations of the arm following surgery and during everyday activities. The changes to scapulohumeral motion apparently were not attributable to actual shoulder pathology; therefore, the alteration is likely to arise through adaptive changes to motor patterns and learned usage. One explanation as to why the postmastectomy groups used adaptive strategies may be related to postoperative surgical management. Typically, a drain is inserted in the incision on the chest wall to enable drainage of any seroma.38 Women

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are encouraged not to elevate their arm above their head in the early postoperative period, as it can cause formation or production of serous fluid. Furthermore, even after drain removal, women are instructed to protect their affected limb to prevent lymphedema. The adaptive changes may simply be a consequence of fewer elevations of the arm past 90 degrees. An observational study of older participants who were healthy determined that their arm moved beyond this position 13 times per hour,39 which suggests that such movement may be necessary to maintain range and synchrony of movement. There is no clear causal evidence that altered scapular kinematics will lead to further shoulder impairment. The increased scapular upward rotation in particular, although consistent and quite dramatic on the operated side of those women in the postmastectomy groups, is not per se a symptom of shoulder dysfunction. In fact, evidence in the literature is divided regarding whether upward scapular rotation is implicated in symptomatic shoulder problems. Scapular upward rotation has been reported to be increased in people with adhesive capsulitis40,41 and in people with idiopathic shoulder restriction,24 reduced in people with multidirectional shoulder instability,42 and either reduced37 or not clearly differentiated43 in people with shoulder impingement. Nevertheless, significant changes in the kinematic patterns around the shoulder are worthy of notice and might be symptomatic of some mechanical anomaly, in the same way that a painless limp may indicate a mechanical gait dysfunction. Our postulation regarding “guarding” of the operated arm requires systematic investigation and warrants a prospective trial in which the unaffected arm is constrained May 2010

Kinematics During Arm Elevation Following Mastectomy and the arm on the operated side is used for most actions to determine whether shoulder kinematics could be maintained or restored to normal in the affected arm of women after mastectomy. Equally, it would be important to determine whether the same scapular kinematics are associated with the development of shoulder pain and impairment in women following mastectomy. From such an investigation, it might be possible to determine whether the altered kinematics we have observed are common to both people who are symptomatic and those who are asymptomatic. It has been suggested that the effects of radiotherapy are implicated in the alterations to upper-limb movement patterns.8 The finding that there were no significant differences for any of the scapular or thoracic movements in the women who had received radiotherapy following surgery compared with those who had not received radiotherapy was of some interest. The number of women who received radiotherapy in the mastectomy dominant-side group (n⫽6) was too small to draw clear inferences; however, the mastectomy nondominant-side group was evenly balanced between those who had and those who had not received radiotherapy. The lack of any substantial or significant differences in range of movement tends to contradict the suggestion that radiotherapy is a major cause of shoulder girdle dyskinesia.4,8 This finding tends to support the views of Lee and colleagues,44,45 who concluded that any change in the compliance of irradiated tissue was not a major factor in determining shoulder symptoms. Furthermore, if there is scarring or alteration in the compliance of the chest wall following radiotherapy, it did not appear to be influential in the altered scapular kinematics demonstrated in this study.

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Conclusions The findings of this study indicate complex kinematic distortions, particularly during abduction in the coronal plane, in which the relationships between scapular and glenohumeral movements are changed. Of note is the fact that the population we studied did not report shoulder symptoms. It is not known whether these small discontinuities and changes to the associations of scapular and humeral motion are prognostic of shoulder impingement or future development of symptoms. Previous interventions, administered at an early stage,46 have shown the benefits of physical therapy and patient education on recovery of shoulder mobility, but in that study the emphasis was on acute phase recovery of range of motion, rather than the development of skill, symmetry, and coordination. It would be interesting to investigate the early use of motor control techniques for the reestablishment of normal scapulohumeral coordination and whether they are associated with altering the incidence of shoulder symptoms following mastectomy. Furthermore, because this study placed no extra demand—in the form of load resistance—on the women during movement, it would be valuable to repeat the experiment with a controlled resistance to the movement to ascertain whether there are other kinematic changes that appear only in response to increased muscle activity. Dr Crosbie, Dr Kilbreath, Dr Refshauge, Dr Nicholson, Dr Beith, Dr Spillane, and Dr White provided concept/idea/research design. Dr Crosbie, Dr Kilbreath, Ms Dylke, Dr Refshauge, Dr Nicholson, and Dr Spillane provided writing. Dr Crosbie, Dr Kilbreath, Ms Dylke, Dr Refshauge, and Dr Nicholson provided data collection. Dr Crosbie, Dr Kilbreath, Ms Dylke, and Dr Beith provided data analysis. Dr Crosbie provided project management. Dr Crosbie, Dr Kilbreath, and Dr White provided fund procurement. Dr Beith and Dr Spillane provided participants.

Dr Crosbie and Dr Nicholson provided facilities/equipment. Dr Beith provided institutional liaisons. Dr Crosbie, Dr Nicholson, Dr Beith, and Dr Spillane provided consultation (including review of manuscript before submission). The authors acknowledge Sabine Giesebrecht, Sarah York, and Luise Hollmann for assistance with data collection and Dr Roger Adams for advice and assistance in statistical analyses. The study was approved by the Human Ethics Committee of the University of Sydney (protocol number 02–2006/3/8756). This project was supported by a grant from the National Breast Cancer Foundation of Australia. This article was received March 29, 2009, and was accepted December 21, 2009. DOI: 10.2522/ptj.20090104

References 1 Voogd AC, Ververs JM, Vingerhoets AJ, et al. Lymphoedema and reduced shoulder function as indicators of quality of life after axillary lymph node dissection for invasive breast cancer. Br J Surg. 2003;90:76 – 81. 2 Erickson VS, Pearson ML, Ganz PA, et al. Arm edema in breast cancer patients. J Natl Cancer Inst. 2001;93:96 –111. 3 Aitken DR, Monton JP. Complications associated with mastectomy. Surg Clin North Am. 1983;63:1331–1352. 4 Chiverton SG, Perry PM. Morbidity after surgery for breast cancer. Br J Surg. 1987; 74:1166. 5 Haid A, Ko ¨ berle-Wu ¨ hrer R, Knauer M, et al. Morbidity of breast cancer patients following complete axillary dissection or sentinel node biopsy only: a comparative evaluation. Breast Cancer Res Treat. 2002;73:31–36. 6 Al-Ghazal SK, Fallowfield L, Blamey RW. Comparison of psychological aspects and patient satisfaction following breast conserving surgery, simple mastectomy and breast reconstruction. Eur J Cancer. 2000; 36:1938 –1943. 7 Merchant CR, Chapman T, Kilbreath SL, et al. Decreased muscle strength following management of breast cancer. Disabil Rehabil. 2008;30:1098 –1105. 8 Højris I, Andersen J, Overgaard M, Overgaard J. Late treatment-related morbidity in breast cancer patients randomized to postmastectomy radiotherapy and systemic treatment versus systemic treatment alone. Acta Oncol. 2000;39:355–372. 9 Sugden EM, Rezvani M, Harrison JM, Hughes LK. Shoulder movement after the treatment of early stage breast cancer. Clin Oncol (R Coll Radiol). 1998;10: 173–181.

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Kinematics During Arm Elevation Following Mastectomy 10 Lauridsen MC, Torsleff KR, Husted H, Erichsen C. Physiotherapy treatment of late symptoms following surgical treatment of breast cancer. Breast. 2000;9: 45–51. 11 Cheville AL, Tchou J. Barriers to rehabilitation following surgery for primary breast cancer. J Surg Oncol. 2007;95:409 – 418. 12 Inman VT, Saunders JBdeCM, Abbot LC. Observations on the function of the shoulder joint. J Bone Joint Surg Am. 1944;26: 1–30. 13 McClure PW, Michener LA, Sennett BJ, Karduna AR Direct3-dimensional measurement of scapular kinematics during dynamic movements in vivo. J Shoulder Elbow Surg. 2001;10:269 –277. 14 Belling Sørensen AK, Jorgensen U. Secondary impingement in the shoulder: an improved terminology in impingement. Scand J Med Sci Sports. 2000;10:266 –278. 15 Warner JJ, Micheli LJ, Arslanian LE, et al. Scapulothoracic motion in normal shoulders and shoulders with glenohumeral instability and impingement syndrome: a study using Moire topographic analysis. Clin Orthop Relat Res. 1992;285:191–199. 16 Shamley D, Srinaganathan R, Oskrochi R, et al. Three-dimensional scapulothoracic motion following treatment for breast cancer. Breast Cancer Res Treat. 2009;118: 315–322. 17 Brue S, Valentin A, Forssblad M, et al. Idiopathic adhesive capsulitis of the shoulder: a review. Knee Surg Sports Traumatol Arthrosc. 2007;15:1048 –1054. 18 Sheridan MA, Hannafin JA. Upper extremity: emphasis on frozen shoulder. Orthop Clin North Am. 2006;37:531–539. 19 Badley EM, Tennant A. Changing profile of joint disorders with age: findings from a postal survey of the population of Calderdale, West Yorkshire, United Kingdom. Ann Rheum Dis. 1992;51:366 –371. 20 Allander E. Prevalence incidence and remission rates of some common rheumatic diseases or syndromes. Scand J Rheum. 1974;3:145–153. 21 Australian Institute of Health and Welfare. Available at: http://www.aihw.gov.au/ cancer/index.cfm. Accessed March 2009. 22 Cho OH, Yoo YS, Kim NC. Efficacy of comprehensive group rehabilitation for women with early breast cancer in South Korea. Nurs Health Sci. 2006;8:140 –146.

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23 Yang JL, Lu TW, Chou FC, et al. Secondary motions of the shoulder during arm elevation in patients with shoulder tightness. J Electromyogr Kinesiol. 2009;19:1035– 1042. 24 Rundquist PJ. Alterations in scapular kinematics in subjects with idiopathic loss of shoulder range of motion. J Orthop Sport Phys Ther. 2007;37:19 –25. 25 Crosbie J, Kilbreath SL, Hollmann L, York S. Scapulohumeral rhythm and associated spinal motion. Clin Biomech(Bristol, Avon). 2008;23:184 –192. 26 Craig CL, Marshall AL, Sjo ¨ strom M, et al. International physical activity questionnaire: 12-country reliability and validity. Med Sci Sports Exerc. 2003;35:1381–1395. 27 Hudak PL, Amadio PC, Bombardier C; for the Upper Extremity Collaboration Group. Development of an upper extremity outcome measure: the DASH (Disabilities of the Arm, Shoulder, and Hand). Am J Indust Med. 1996;29:602– 608. 28 Hawkins RJ, Kennedy JC. Impingement syndrome in athletics. Am J Sports Med. 1980;8:151–158. 29 Allingham C. The shoulder complex. In: Zuluaga M, Briggs C, Carlisle J, et al, eds. Sports Physiotherapy: Applied Science and Practice. Melbourne, Victoria, Australia: Churchill Livingstone; 1995:357– 406. 30 Hayes S, Cornish B, Newman B. Comparison of methods to diagnose lymphedema among breast cancer survivors: 6-month follow-up. Breast Cancer Res Treat. 2005; 89:221–226. 31 York SL, Ward LC, Czerniac S, et al. Single frequency versus bioimpedance spectroscopy for the assessment of lymphedema. Breast Cancer Res Treat. 2009;117: 177–182. 32 Palombaro KM, Craik RL, Mangione KK, Tomlinson JD. Determining meaningful changes in gait speed after hip fracture. Phys Ther. 2006;86:809 – 816. 33 Crosbie J, Vachalathiti R, Smith R. Patterns of spinal motion during walking. Gait Posture. 1997;5:6 –12. 34 Edmondston SJ, Singer KP. Thoracic spine: anatomical and biomechanical considerations for manual therapy. Man Ther. 1997;2:132–143. 35 Theodoridis D, Ruston S. The effect of shoulder movements on thoracic spine 3D motion. Clin Biomech (Bristol, Avon). 2002;17:418 – 421.

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36 Biryukova E, Roby-Brami A, Frolov AA, Mokhtari M. Kinematics of human arm reconstructed from spatial tracking recordings. J Biomech. 2000;33:985–995. 37 Ludewig PM, Cook TM. Alterations in shoulder kinematics and associated muscle activity in people with symptoms of shoulder impingement. Phys Ther. 2000; 80:276 –291. 38 Harmer V. The surgical management of breast cancer. Nurs Times. 2000;96(48): 34 –35. 39 Schurr K, Ada L. Observation of arm behaviour in healthy elderly people: implications for contracture prevention after stroke. Aust J Physiother. 2006;52:129 – 33. 40 Vermeulen HM, Stokdijk M, Eilers PH, et al. Measurement of three-dimensional shoulder movement patterns with an electromagnetic tracking device in patients with a frozen shoulder. Ann Rheum Dis. 2002;61:115–120. 41 Fayad F, Roby-Brami A, Yazbeck C, et al. Three-dimensional scapular kinematics and scapulohumeral rhythm in patients with glenohumeral osteoarthritis or frozen shoulder. J Biomech. 2008;41:326 –332. 42 Ogston JB, Ludewig PM. Differences in 3-dimensional shoulder kinematics between persons with multidirectional instability and asymptomatic controls. Am J Sports Med. 2007;35:1361–1370. 43 He´bert LJ, Moffet H, McFadyen BJ, Dionne CE. Scapular behavior in shoulder impingement syndrome. Arch Phys Med Rehabil. 2002;83:60 – 69. 44 Lee TS, Kilbreath SL, Refshauge KM, et al. Pectoral stretching program for women undergoing radiotherapy for breast cancer. Breast Cancer Res Treat. 2007;102: 313–321. 45 Lee TS, Kilbreath SL, Refshauge KM, et al. Prognosis of the upper limb following surgery and radiation for breast cancer. Breast Cancer Res Treat. 2008;110: 19 –37. 46 Box RC, Reul-Hirche HM, Bullock-Saxton JE, Furnival CM. Shoulder movement after breast cancer surgery: results of a randomized controlled study of postoperative physiotherapy. Breast Cancer Res Treat. 2002;75:35–50.

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Research Report Physical Therapists Make Accurate and Appropriate Discharge Recommendations for Patients Who Are Acutely Ill Beth A. Smith, Christina J. Fields, Natalia Fernandez

Background. Acute care physical therapists contribute to the complex process of patient discharge planning. As physical therapists are experts at evaluating functional abilities and are able to incorporate various other factors relevant to discharge planning, it was expected that physical therapists’ recommendations of patient discharge location would be both accurate and appropriate. Objective. This study determined how often the therapists’ recommendations for patient discharge location and services were implemented, representing the accuracy of the recommendations. The impact of unimplemented recommendations on readmission rate was examined, reflecting the appropriateness of the recommendations.

Design. This retrospective study included the discharge recommendations of 40 acute care physical therapists for 762 patients in a large academic medical center. The frequency of mismatch between the physical therapist’s recommendation and the patient’s actual discharge location and services was calculated. The mismatch variable had 3 levels: match, mismatch with services lacking, or mismatch with different services. Regression analysis was used to test whether mismatch status, patient age, length of admission, or discharge location predicted patient readmittance.

Results. Overall, physical therapists’ discharge recommendations were implemented 83% of the time. Patients were 2.9 times more likely to be readmitted when the therapist’s discharge recommendation was not implemented and recommended follow-up services were lacking (mismatch with services lacking) compared with patients with a match.

Limitations. This study was limited to one facility. Limited information about the patients was collected, and data on patient readmission to other facilities were not collected.

Conclusions. This study supports the role of physical therapists in discharge planning in the acute care setting. Physical therapists demonstrated the ability to make accurate and appropriate discharge recommendations for patients who are acutely ill.

B.A. Smith, PT, DPT, PhD, is Postdoctoral Fellow, Balance Disorders Laboratory, Departments of Neurology and Behavioral Neuroscience, Oregon Health and Science University, Portland, Oregon. During the data collection for this project, she was a PhD candidate in the Developmental Neuromotor Control Laboratory, School of Kinesiology, University of Michigan, and a per diem staff member, Division of Physical Therapy, University of Michigan Hospital, Ann Arbor, Michigan. Institutional mailing address: NSI, OHSU West Campus, 505 NW 185th Ave, Beaverton, OR 97006 (USA). Address all correspondence to Dr Smith at: smitbeth@ ohsu.edu. C.J. Fields, PT, MPT, is Physical Therapy Clinical Specialist, Cardiovascular Team, University of Michigan Hospital. N. Fernandez, PT, Master of Health Science (Physical Therapy), is Staff Physical Therapist, Cardiovascular Team, University of Michigan Hospital. [Smith BA, Fields CJ, Fernandez N. Physical therapists make accurate and appropriate discharge recommendations for patients who are acutely ill. Phys Ther. 2010; 90:693–703.] © 2010 American Physical Therapy Association

Post a Rapid Response to this article at: ptjournal.apta.org May 2010

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ischarge planning is the development of a discharge plan for follow-up services for a patient prior to leaving the hospital, with the aim of containing costs and improving patient outcomes.1 Discharge planning is a complex process, and many health care disciplines may contribute to the plan, including formal discharge planning coordinators, nurses, social workers, physical therapists, occupational therapists, and physicians. Reviews of discharge planning processes showed that they consistently involve the assessment of many factors, including cognitive, physical and social/financial status, environmental concerns, and access to formal and informal care.2,3 In an effort to assess these many factors, formal discharge planning in the United States often is practiced as a collaborative, multidisciplinary effort led by a case manager, particularly for patients identified as having an increased risk for poor outcomes.4,5 Although the shift toward collaborative discharge planning has improved patient outcomes, there remains room for further improvement. A study by Mamon and colleagues6 showed that multidisciplinary discharge planning efforts led by formal case managers appeared to be significantly more effective in arranging home nursing care and rehabilitation services than informal discharge planning; however,

Available With This Article at ptjournal.apta.org • Discussion Podcast: Participants to be determined. • The Bottom Line Podcast • Audio Abstracts Podcast This article was published ahead of print on March 18, 2010, at ptjournal.apta.org.

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patients still often reported these and other needs were unmet after discharge. The study did not examine how the discharge planning process failed to accurately identify or meet the needs of the patients, but as many health care professionals participate in the multifactorial process, the final decision on discharge placement may not take into consideration each professional’s recommendation. Important information from one discipline may be overlooked or excluded from the final discharge plan, leading to failure of the plan. Poor discharge planning and the failure to provide necessary services may have an impact at several levels: failure of the patient to reach optimal health and functional status, increased cost to the hospital and decreased resource availability to others due to increased length of stay and readmission, or possible adverse events or conditions causing harm to the patient.7 In an effort to better understand failure of the plan, several factors have been associated with poor postdischarge outcomes: aged 80 years and older; inadequate support system; multiple, active, chronic health problems; history of depression; moderate to severe functional impairment; multiple hospitalizations during the prior 6 months; hospitalization within the past 30 days; fair or poor self-rating of health; or history of nonadherence to the therapeutic regimen.7 It is clear from the large number and broad nature of factors associated with poor discharge outcomes that discharge planning is a complex process requiring the assessment and assimilation of multiple factors. Additional evidence of discharge planning as a complex process is the lack of use of standardized quantitative measures to determine discharge recommendations. Despite the validation of measures such as the Berg Balance Scale to predict

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discharge disposition,8 physical therapists and hospitals do not rely solely on standardized tests in regard to discharge planning.9,10 Standardized screening forms are often used to identify patients at high risk of poor outcomes in order to initiate the formal multidisciplinary discharge planning process, but they are not used to make the decision on discharge location and services.3,5,6,11 The need for comprehensive assessment of functional status is one factor in discharge planning that is directly related to the practice of physical therapy. One study quantified change in functional status, reporting that 35% of patients aged 70 years and older showed a decline in activities of daily living function between hospital admission and discharge.12 Patients experiencing a decline in functional status while in the hospital may no longer be able to function adequately in the environment they lived in prior to admission, and are less likely to recover baseline function and health status.13 There is an association between decreased functional status and transfers to and from acute care settings.14 There also is an association between decreased functional status and complicated posthospital care transitions.15 The studies described above show that level of functional ability is related to discharge location; however, other studies demonstrate that the relationship, consistent with the theme of discharge planning, is complex. Although patients returning home had a higher level of function than those who were discharged elsewhere, some patients who were significantly impaired returned home with family support. Patients who had family support but were discharged to facilities were the most impaired.8 Additionally, researchers studying the effect of functional level on length of hospital adMay 2010

Acute Care Physical Therapists’ Discharge Recommendations mission found that patients with a higher level of function demonstrated a shorter length of stay than average, but patients with a low level of function who were discharged to a supportive environment also had a shorter-than-average length of stay.16 These findings highlight the complex relationship between functional ability and discharge needs and further support physical therapist evaluation of functional abilities, assistance required for safety, and recommendations for discharge location based on what the patient requires and what is available to them. Physical therapists in the acute care setting play an important role in the multidisciplinary discharge planning process. “Discharge to the appropriate level of care” often is a goal in acute care physical therapy,17 and therapists routinely make recommendations regarding discharge placement and any continuing therapy services for patients. Due to short average lengths of admission in acute care, patients often need continued physical therapy services after leaving acute care, and therapists may recommend that continued services take place in the home, a skilled nursing facility (SNF), a rehabilitation center, or an outpatient setting.18 Although creating a discharge plan is a multidisciplinary process, physical therapists practicing in acute care are in a unique position to assess the discharge needs of a patient. This is well described within the scope of practice in the Guide to Physical Therapist Practice: “The plan of care identifies anticipated goals and expected outcomes, taking into consideration the expectations of the patient/client and appropriate others. . . . The plan of care includes the anticipated discharge plans. In consultation with appropriate individuals, the physical therapist plans for discharge and provides for appropriMay 2010

ate follow-up or referral.”19(p46) Furthermore, physical therapists are health care professionals who diagnose and treat individuals of all ages who have medical problems or other health-related conditions that limit their ability to move and perform functional activities in their daily lives,19 and the assessment of functional abilities is a particularly important and complex aspect in determining discharge needs. Having established that physical therapists are well qualified to participate in the complex discharge planning process, how do they come to a decision on a discharge recommendation? According to a qualitative study by Jette et al,9 physical therapists appeared to use a patient’s level of functioning and disability as the core dimension in their initial decision-making process. In general, they were guided by 4 constructs when making a discharge recommendation: patients’ functioning and

disability, patients’ wants and needs, patients’ ability to participate in care, and patients’ life context. The therapists gathered and integrated information from multiple constructs before making their discharge recommendation, showing consideration of what the patients required and what was available in their environment.9 Building upon previous descriptions of the complexities of the decisionmaking process and the idea that physical therapists are uniquely suited to contribute useful insight through their evaluation and assessment skills, we wanted to validate the participation of acute care physical therapists in the discharge planning process. Because we hypothesized that therapists are able to successfully incorporate all of the various factors involved in the discharge planning process and that there is value placed on the therapist’s recommendation by the final

The Bottom Line What do we already know about this topic? Acute care discharge planning is a complex process that involves clinicians from varied disciplines and the assessment of many factors. Physical therapists often are involved in discharge planning and make recommendations for follow-up services, but the accuracy and appropriateness of their recommendations have not been studied.

What new information does this study offer? This study indicates that physical therapists are able to integrate multiple patient factors to make accurate and appropriate discharge recommendations. When the physical therapist’s recommendation was not implemented and follow-up services were lacking, patients were more likely to be readmitted to the hospital.

If you’re a patient, what might these findings mean for you? If you are in the hospital and have any concern that you will not be fully functional at discharge, you should seek a physical therapist’s recommendation for the most appropriate discharge destination.

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Acute Care Physical Therapists’ Discharge Recommendations discharge plan decision maker, we anticipated that the therapist’s discharge recommendations for patients in the acute care setting would match the patient’s actual discharge location and services a majority of the time. Furthermore, supporting the idea that therapists are appropriate in their recommendations, we expected an increased likelihood of hospital readmissions when recommendations were not implemented.

Method The University of Michigan Hospital is a 700-bed acute care teaching hospital. Our facility is a level 1 trauma center offering and receiving helicopter transfers for patients from Michigan and its surrounding states who are in critical and complex situations; many of our patients are transferred from outside hospitals for ongoing care. Discharge Planning Process The discharge planning process in our facility occurs in a fairly, but not completely, standardized manner. The initial parts of the process are standard; practice management coordinators use a screening form based on the factors associated with poor discharge outcomes to screen all admitted patients and identify those who are at increased risk for poor discharge outcomes. Patients who are not identified as high risk by the screening process have discharge planning done by their staff nurse, unless formal discharge planning is later requested. For patients who are identified as high risk, formal discharge planning is initiated, with practice management coordinators taking the lead role in the discharge planning process. They read the documentation on discharge recommendations from the physical therapist evaluation and any subsequent physical therapist documentation and incorporate it into a multidisciplinary discharge planning process, including any documenta696

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tion they read from the medical/surgical team, unit nurses, and, when consulted, occupational therapists and social workers. In this basic process, the coordinator may or may not seek additional information from other members of the health care team. If a consensus has been identified, the coordinator proceeds to arrange insurance benefits and necessary services. If there is not a consensus, the coordinator will elicit additional information from the other members of the health care team, usually using the hospital alphanumeric paging and telephone systems. A lack of consensus can occur, for example, if the patient’s preferences change or if insurance benefits are not available. Physical therapist involvement in the discharge planning process starts when the medical/surgical team sends an electronic consult to the Division of Physical Therapy through our online medical charting system. The therapist does an initial evaluation, with the exact procedures varying according to the ability of the patient to participate. The overall process is best described in the Guide to Physical Therapist Practice: [Physical therapists] engage in an examination process that includes taking the patient/client history, conducting a systems review, and performing tests and measures to identify potential and existing problems. To establish diagnoses, prognoses, and plans of care, physical therapists perform evaluations, synthesizing the examination data and determining whether the problems to be addressed are within the scope of physical therapist practice. Based on their judgments about diagnoses and prognoses and based on patient/client goals, physical therapists provide interventions (the interactions and procedures used in managing and instructing patients/clients), conduct reexaminations, modify interventions as necessary to achieve anticipated goals and expected outcomes, and de-

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velop and plans.19(p21)

implement

discharge

The physical therapist documents his or her evaluation in the computerized patient medical record. At the top of every therapist evaluation and any subsequent documentation, information is highlighted that is particularly relevant to discharge recommendations, specifically therapist recommendations for discharge location, the amount of assistance required for patient safety, necessary assistive devices, and the need for ongoing physical therapy and the appropriate setting. This information is consistently provided by therapists, regardless of whether or not patients are receiving formal discharge planning. Follow-up physical therapy treatments are provided as appropriate throughout the patient’s acute care stay, and discharge recommendations are updated and documented each time a therapist works with the patient. Although all physical therapist recommendations are consistently documented in the medical record in a standard manner, the remaining discharge process varies in how communication is exchanged. Beyond the basic discharge planning process, some service areas of the hospital follow additional procedures that increase in-person communication between health care providers. Three of the services hold additional daily or weekly “discharge rounds” interdisciplinary meetings, attended by the resident physician, practice management coordinator, occupational therapist, physical therapist, and social worker. In addition, some coordinators work with 1 or 2 specific services and make it a point to meet in person with the therapists, whereas other coordinators float among services and do not do so. Data Collection To conduct our retrospective study of the outcomes of the discharge May 2010

Acute Care Physical Therapists’ Discharge Recommendations planning process, we obtained University of Michigan Privacy Board approval for waiver of informed consent to access patient medical records and institutional review board approval for the use of physical therapists as human participants. We accessed the medical records of all patients who received a physical therapist evaluation during our study period. We also collected data about career history from consenting therapists to further describe therapist practice at our facility. We created a secure database and separated identifying information about patients and therapists from de-identified, coded data collection forms. We selected one week (Sunday–Saturday) in each season of the preceding year. The weeks were in December 2007 and March, June, and September 2008 and did not include any holidays. Two research assistants were trained, using case studies, to access medical records and find the relevant information and enter it into the database. Information was collected primarily from physical therapist evaluations and treatment notes, physician discharge notes, and practice management coordinator evaluations and notes. Occasionally, data were found in emergency department documentation, physician admitting history and physical documents, social work notes, nursing notes, and outpatient or rehabilitation facility documentation from our health system. Any questions related to data collection were resolved by consensus of the 3 primary investigators (B.A.S., C.J.F, and N.F.). Variables and Inclusion Criteria We identified 51 physical therapists who were working in acute care during our selected weeks. Forty out of the possible 51 therapists consented to participate in our study. The 11 therapists who were not included May 2010

were those we could not contact, who were no longer employed at the university, or who were temporary staff who did not evaluate patients during the 4 weeks we analyzed. One of the 3 primary investigators discussed the study with each therapist before the informed consent form was signed. After consent, participating therapists were asked to provide the following background information: total months of practice as an acute care physical therapist, total months and setting of other, nonacute care physical therapist experience, and total months of practice as an acute care physical therapist at University of Michigan Hospital. We used hospital billing records to identify that 780 patients received a physical therapist evaluation during our specified 4 one-week periods, and we included all of them in our study. We specified the following operational definitions and collected the following data from patient medical records:

therapist who documented the final discharge recommendation. • Physical therapist discharge recommendation—the discharge location and services that were determined by the therapist as necessary to promote patient safety and any recovery, as based on the patient’s current level of function and available resources at discharge, coded as home without physical therapy, home with outpatient therapy, home with home therapist, subacute rehabilitation/SNF, acute rehabilitation, or extended care facility without therapy. • Match—when the actual discharge location and services were the same as the discharge recommendation in the final therapist documentation. • Mismatch—when the actual discharge location or services were not the same as the discharge recommendation in the final therapist documentation. 䡩 Mismatch with services lacking— the patient did not receive follow-up services when a home therapist was recommended. 䡩 Mismatch with different services than recommended or extra services—the patient received home physical therapy instead of recommended outpatient therapy or the patient received home therapy when no follow-up therapy was recommended.

• Age of patient, in years. • Patient’s primary service at discharge—service team of attending physician at the time of discharge, listed by abbreviation code. • Date of admission, in MM/DD/YYYY format. • Date of discharge, in MM/DD/YYYY format.

• Reason for mismatch, categorized as:

• Date of physical therapy evaluation, in MM/DD/YYYY format. • Discharge location—the physical location the patient was sent to at the end of the hospital admission, coded as home without physical therapy, home with outpatient therapy, home with home therapist, subacute rehabilitation/SNF, acute rehabilitation, extended care facility without therapy, or expired. • Physical therapist at discharge—physical therapist identifier code of the

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䡩 Patient refusal of placement—the therapist recommended placement or services, and the patient or his or her legal representative declined, 䡩 Insurance issues—the therapist recommended placement or services, and the patient did not receive them due to lack of insurance or insurance denial of services, 䡩 Medical complexity of the patient precludes placement—the patient is on a ventilator or receiving enteral/ parental feedings, for example, or 䡩 Other—any other reason.

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Acute Care Physical Therapists’ Discharge Recommendations Table 1. Patient Baseline Demographics Variable

X

SD

Range

Patient age (y)

63

17

0–83

Length of admission (d)

11

19

1–136

Time from admission to physical therapist evaluation (d)a

4

4

0–37

Time from physical therapist evaluation to discharge (d)

7

22

0–122

a Length of time to physical therapist evaluation was calculated from admission and did not take into consideration when the consult was sent.

Table 2. Mismatch Status by Discharge Location Discharge Location Home without physical therapy Home with outpatient physical therapy

Match

Mismatch

Total

275 (83%)

58 (17%)

333

13 (93%)

1 (7%)

14

Home with home physical therapy

150 (76%)

47 (24%)

197

Subacute rehabilitation/skilled nursing facility

129 (88%)

18 (12%)

147

Acute rehabilitation

42 (100%)

0 (0%)

42

Extended care facility, no physical therapy

10 (100%)

0 (0%)

10

124 (17%)

743

Total

619 (83%)

• Readmission—if the patient was admitted to our acute care facility within 30 days of discharge, a time period consistent with similar studies.11,20

which variables were associated with an increased risk of readmission. An alpha level of .05 was used for all hypothesis testing.

Data Analysis We used Microsoft Excel software (Microsoft Office 2007)* for database formation and SPSS software (versions 16.0 and 17.0)† for statistical analyses. We used descriptive statistics to summarize physical therapist and patient characteristics. We calculated the frequency of occurrence of patient discharge locations, mismatch, and readmission. Patients who expired were included in demographic and descriptive data but excluded from statistical analyses of mismatches or readmission. We used a general linear modeling technique, explained below, to determine

We did logistic regression analysis using generalized estimating equations to control for correlation of the outcomes by physical therapy and to predict the probability that a patient would be readmitted. The predictor variables we included in the model were mismatch status, patient age, length of admission, and discharge location. These are all of the variables we collected that could have had an effect on readmission. Patient age and length of admission were collapsed from continuous variables into categories to allow for more meaningful analysis. Age was categorized as ⱕ35 years, 36 to 55 years, 56 to 70 years, 71 to 84 years, and ⱖ85 years. Length of admission was categorized as less than 2 days, 2 to 4 days, 5 to 7 days, 8 to 10 days, 11 to

* Microsoft Corp, One Microsoft Way, Redmond, WA 98052-6399. † SPSS Inc, 233 S Wacker Dr, Chicago, IL 60606.

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14 days, and ⱖ15 days. Mismatch status and discharge location were categorized as previously defined. We used this analytic approach rather than the more common method of linear regression for 2 reasons. First, our response variable (readmission) is a dichotomous outcome. Second, it allowed us to control for the fact that each physical therapist made discharge recommendations for multiple patients and outcomes for a given therapist were not independent.21,22 Preliminary models tested for correlation of outcomes by physical therapy, but the observed correlation was not significant. The reported results specified an independent correlation structure.

Results Patient Demographics Of the 780 patients we identified as having received physical therapist evaluations in the specified 4 weeks, we successfully collected data from the medical records of 762 patients. Eighteen patients were excluded because their discharge location or the therapist recommendation could not be determined. This situation occurred when information was missing from the medical record or clerical errors led to an inability to locate the patient’s medical record. Of the 762 patients from whom we collected data, 743 were eventually discharged from acute care, and 19 expired. Patients tended to be older adults who were distributed across medical (48%), surgical (27%), neurology (7%) and trauma/orthopedic (18%) services. Although the ranges were broad, the patients had an average hospital admission of 11 days and were evaluated by a physical therapist around day 4 of their admission (Tab. 1). The discharge locations of the patients from whom we collected data were as follows: home without physical therapy (44%), home with home therapy May 2010

Acute Care Physical Therapists’ Discharge Recommendations Table 3. Reason for Mismatch by Discharge Location Discharge Location Home Without Physical Therapy

Home With Outpatient Physical Therapy

Home With Home Physical Therapy

Subacute Rehabilitation/Skilled Nursing Facility

Total

Patient refusal of placement

8 (57%)

0 (0%)

4 (29%)

2 (14%)

14

Insurance issues

2 (100%)

0 (0%)

0 (0%)

0 (0%)

2

40 (100%)

0 (0%)

0 (0%)

0 (0%)

40

Received home physical therapy without recommendation

0 (0%)

0 (0%)

32 (100%)

0 (0%)

32

Other

8 (22%)

1 (3%)

11 (31%)

16 (44%)

36

Total

58 (47%)

1 (1%)

47 (38%)

18 (15%)

124

Reason for Mismatch

Missing home physical therapy with recommendation

(26%), subacute rehabilitation/SNF (19%), acute rehabilitation (5.5%), expired (2.5%), home with outpatient therapy (2%), and extended care facility without therapy (1%). Mismatches There was a mismatch between physical therapist recommendation and patient discharge location in 124 of 743 cases, or 17% of the time. The breakdown by service groups was: neurology/neurosurgery, 21%; medicine, 19%; surgery, 16%; and trauma/ orthopedics, 7%. Mismatches are categorized by discharge location in Table 2 and by reason for mismatch in Table 3. The majority of mismatches occurred in patients who were discharged home. The most frequent reason for mismatch was patients who did not receive home therapy when recommended. The second largest group of mismatches were patients who received home therapy services that were not recommended, a condition that reflects

unnecessary use of resources. Patient refusal of placement or services was the third largest category, and lack of insurance or insurance denial of services caused very few mismatches. Although most mismatches occurred in patients who were ultimately discharged home, mismatches in the “other” category of reasons for mismatch did include patients who were subsequently discharged to a subacute rehabilitation facility or SNF. These cases were scenarios where no beds were available at the recommended level of care in the patient’s preferred geographical area or where patients were denied admittance to an acute rehabilitation facility despite the recommendation. Readmission As shown in Table 4, 139 patients (approximately 18% of our sample) were readmitted to our hospital within 30 days of their discharge.

Our overall readmission rate is consistent with that of other studies.20,23 In our logistic regression analysis to predict the probability that a patient would be readmitted, mismatch status, discharge location, and length of admission were significant predictor variables. Patient age was not a significant predictor variable. Table 5 shows the results of follow-up hypothesis testing. Holding all other variables constant, a patient was 2.9 times more likely to be readmitted when the therapist discharge recommendation was not implemented and services were lacking compared with patients with a match (mismatch with services lacking versus match, odds ratio [OR]⫽2.89, 95% confidence interval [CI]⫽1.57– 5.30). Patients whose therapist discharge recommendations were not implemented and who received different services or extra services were not significantly more likely to be readmitted than patients with a

Table 4. Patient Readmission by Mismatch Status Readmitted

Not Readmitted

Total

Odds Ratio (95% Confidence Interval)

103 (17%)

516 (83%)

619 (100%)

1

Mismatch: services lacking

22 (35%)

41 (65%)

63 (100%)

2.89 (1.57–5.30)a

Mismatch: different services

14 (23%)

47 (77%)

61 (100%)

1.42 (0.79–2.56)

Variable Match

a

Significantly different risk of readmission compared with match at P⬍.01.

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Acute Care Physical Therapists’ Discharge Recommendations Table 5. Odds of Readmission

Predictor Variables

Odds Ratio

95% Confidence Interval

Mismatch Match

Reference

Mismatch: services lackinga

2.89

1.57–5.30

Mismatch: different services

1.42

0.79–2.56

Discharge location Home without physical therapy

Reference

Extended care facility, no physical therapya

6.89

2.23–21.32

Home with outpatient physical therapy

1.36

0.45–4.13

Home with home physical therapy

1.21

0.74–1.98

Subacute rehabilitation/skilled nursing facility

1.22

0.72–2.07

Acute rehabilitation

0.41

0.16–1.02

Length of admission

a

0–1 d

Reference

2–4 d

0.89

0.32–2.46

5–7 d

1.50

0.56–3.99

8–10 d

2.55

0.87–7.51

11–14 d

0.91

0.26–3.15

ⱖ15d

0.85

0.33–2.20

Significant compared with reference at P⬍.05.

match (mismatch with different services versus match, OR⫽1.42, 95% CI⫽0.79 –2.56). Follow-up testing also revealed that patients discharged to an extended care facility were 6.9 times more likely to be readmitted (OR⫽6.89, 95% CI⫽2.23–21.32) as compared to patients discharged home without therapy. The results for patients discharged to an acute rehabilitation setting approached significance in the direction of lower risk of readmission (OR⫽0.41, 95% CI⫽0.16 – 1.02) as compared to patients discharged home without therapy. In Figure 1 we show the different readmission rates by discharge location. Physical Therapists The 40 therapists included in the sample had a mean of 110 months of total experience as a practicing physical therapist (range⫽3⫺354 months). As 23 of the physical therapists had career experience beyond the acute care setting, the range of acute care experience was the same; however, the mean was lower (mean of 57.5 months of acute care experience).

Discussion

Figure. Rate of readmission by discharge location. Overall readmission rate was 18%, and patients discharged to extended care facilities without physical therapy were significantly more likely to be readmitted to the hospital within 30 days.

Overall, patients were discharged in accordance with the physical therapist discharge recommendation 83% of the time. When the discharge recommendation was not implemented and recommended followup services were not received, patients were 2.9 times more likely to be readmitted to our hospital within 30 days of discharge. Together, these results indicate that therapists are able to integrate multiple factors contributing to the discharge needs of the patient to make accurate and appropriate discharge recommendations. An overall match rate of 83% between the therapist discharge recommendation and the patient’s actual discharge location and services

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Acute Care Physical Therapists’ Discharge Recommendations indicates therapists are able to successfully incorporate all of the various factors involved in the discharge planning process. This finding indicates that there is value placed on the therapist recommendation by the final discharge plan decision maker. It is possible, however, that in some cases the discharge recommendation happened to match the patient’s actual discharge location without actually influencing the decision making of the nurse or practice management coordinator making the final decision. It is difficult for us to explain the patients who did not receive home physical therapy when recommended or the patients who received home therapy services that were not recommended— by far the largest causes of a mismatch. Either situation is a poor outcome, as it leads to a patient lacking in necessary services or unnecessary use of limited resources. These cases ultimately reflect a lack of communication between the physical therapist and the practice management coordinator, even though the therapist recommendations were clearly documented in the electronic medical record. In the case of patients not receiving home physical therapy that was recommended, it is possible that the therapist documentation was not completed before the discharge plan was in place and no verbal exchange about the recommendation took place, or that the practice management coordinator did not value the information. Alternatively, it is possible that the patient was not receiving formal discharge planning and, despite the therapist identifying the patient’s need for services, no one followed up to set up home therapy services. Interestingly, Mamon et al6 reported a similar finding that 43% of patients over the age of 60 years who were discharged home reported that they had an unmet need for physical therapy or rehabilitation services. AlMay 2010

though physical therapist recommendations were not reported in their study, the findings indicate that there seem to be a number of patients being discharged with unmet needs. Perhaps practice management coordinators need to screen patients for formal discharge planning needs at discharge or after discharge, not just at admission. Patients lacking necessary follow-up services are a problem that needs to be addressed, as our findings show that when physical therapist discharge recommendations were not implemented and recommended follow-up services were not received, patients were 2.9 times more likely to be readmitted to our hospital. As the United States struggles to balance efficiency and quality of health care, the ability of physical therapists to provide accurate and appropriate discharge recommendations becomes even more important. Discharge planning is increasingly becoming part of an integrated package of health care, and even small reductions in readmission rates could free up capacity for subsequent admissions in a health care system where there is a shortage of acute hospital beds.1 Decreases in readmission rates, appropriate allocation of resources, and avoidance of unnecessary services can help contain escalating health care costs. Another aspect of containing health care costs relates to the employment of physical therapists in the acute care setting. Since the initiation of the Medicare prospective payment system and its use of diagnosisrelated groups, payments to hospitals have been determined based on the patient’s diagnosis, regardless of whether the patient receives services such as physical therapy. Acute care physical therapists have the challenge of justifying their salary cost to the hospital as outweighed by the benefit to the patient and the

hospital. This challenge is difficult for a number of reasons. Therapists often are consulted to work with the patients who are more medically and functionally compromised—patients who are more likely to have negative outcomes than their less compromised peers. In addition, therapists often are advocating for additional services for patients, such as discharge to a rehabilitation facility, and the patient’s length of stay often increases as he or she waits for admission to another facility. These findings demonstrate that therapists benefit both the patient and the hospital through their crucial role in the discharge planning process. When therapist discharge recommendations were implemented and recommended follow-up services were received, the patient and the hospital had an increased likelihood of positive outcomes through a decreased risk of readmission. In addition to whether or not the therapist recommendation was implemented, risk of readmission also was partially predicted by the patient’s actual discharge location. Patients discharged to an extended care facility without physical therapy were 6.9 times more likely to be readmitted, whereas patients discharged to acute rehabilitation approached a significantly lower risk of 0.4 times as likely to be readmitted. This finding probably reflects the nature of illness and reason for admission of these patients, and possibly reflects the quality of follow-up care they receive. Patients usually are discharged to an extended care facility without a recommendation for continued physical therapy because they are very ill with a poor prognosis for functional gains, whereas patients are discharged to an acute rehabilitation setting because it is believed that they will tolerate and benefit from at least 3 hours per day of interdisciplinary rehabilitation. Acute rehabilitation patients also continue

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Acute Care Physical Therapists’ Discharge Recommendations to receive 24-hour nursing care and the other benefits (and drawbacks) of a hospital setting, whereas patients discharged home do not. Patients discharged to subacute rehabilitation or an SNF also receive 24hour nursing care and daily rehabilitation, but, for a variety of reasons, have not been admitted to acute rehabilitation or discharged home. Further speculation on the relationship between discharge location and risk for readmission is beyond the scope and design of our study. Of further interest, although we acknowledge this information is specific to our facility, the frequency of mismatch was not evenly distributed across the different primary attending services that discharged the patients. Some services had a higher rate of mismatch than others. The rate was highest for neurology/neurosurgery and lowest for trauma/orthopedics. One contributing factor may be the nature of admissions; the orthopedic surgeons perform a high volume of planned surgeries compared with the trauma/orthopedics and neurology/neurosurgery services, which have a lesser volume of patients and larger proportion of unplanned admissions. Planned admissions allow patients adequate time to confirm insurance benefits and consider discharge needs ahead of time. Different frequency of mismatch also is likely related to the culture of each service and differential value placed on the physical therapist recommendation, as well as the slightly different processes by which communication is exchanged (eg, the presence or absence of formal interdisciplinary meetings). Within our 4 weeks of representative data, evaluations provided by each physical therapist were distributed across the different services, avoiding undue influence of this phenomenon on our final results but still reflecting the servicespecific rates of mismatch. 702

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Limitations and Further Questions The major limitation of our study is that it is unique to our facility and may have limited generalizability to other acute care settings. The large size of our hospital leads to many staff members in each discipline, each of whom practices in an individual manner within the community of their discipline and within the larger hospital community. Resident physicians and physical therapists rotate between service areas of the hospital, interacting with different members of the health care team and providing care to different types of patients within each area. As an academic medical center and level 1 trauma center, the facility tends to care for patients who are more severely ill and complex, which certainly influences discharge locations and readmission rates. In addition to the facility-specific aspects of our study, other limitations were that we collected limited information on the patients who received physical therapist evaluations. We did not address readmission of patients to hospitals other than our own and we did not assess the reason for readmission. We did not collect information on reason for admission, severity of illness, comorbidities, or functional level of the patients, which is information that would allow us to understand more about patterns of recommendation for discharge location or rates of readmission. In a cognizant effort to respect patient privacy, we did not collect information on patient sex, race, or ethnicity, as we felt a discussion of how these variables might relate to discharge location and readmission rates was beyond the scope of our report. In regard to tracking readmission only to our own hospital, our readmission rate reflects only readmission to our hospital and is likely

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lower than an overall readmission rate, as there are almost certainly patients discharged from our facility who were readmitted to facilities closer to their home. Although our readmission rate needs to be interpreted in context, the proportion of mismatches should be accurate. Patients who were part of a mismatch should have been equally likely to be readmitted to our hospital compared with an outside hospital. By not assessing the reason for readmission, we may have included patients who were readmitted for purely medical, and not functional, reasons. Overall, readmission for any reason reflects a failure of the discharge plan, which may have been avoided with proper supportive postdischarge care. A decline in physical function is known to contribute to emergency department visits in older adults.24 Future research, with a larger sample size, could investigate how clinical experience influences the accuracy of discharge recommendations of acute care physical therapists. We also think it would be interesting to follow up with patients and gather their perception of their recovery and functional status in relation to their discharge services and location. We are particularly interested in the patients who were functioning at a level where both subacute rehabilitiation/SNF and home with home physical therapy were viable options. In addition, we were not able to address how frequency of acute care physical therapist treatments influences discharge locations, which may be of particular relevance in these “borderline” situations.

Conclusions Overall, our data strongly support the role of physical therapists in discharge planning in acute care. Physical therapists demonstrated the ability to make accurate discharge recommendations for patients with complex clinical presentations who May 2010

Acute Care Physical Therapists’ Discharge Recommendations are acutely ill; these patients were discharged in accordance with the therapist discharge recommendation 83% of the time. More important, we showed that the therapist discharge recommendations were appropriate, as patients were 2.9 times more likely to be readmitted when the discharge recommendations were not implemented and recommended follow-up services were lacking. All authors provided concept/idea/research design, writing, data collection, and consultation (including review of manuscript before submission). Dr Smith and Ms Fields provided data analysis. Dr Smith provided project management. Ms Fields provided participants. Dr Smith and Ms Fernandez provided clerical support. The authors thank the physical therapy staff at the University of Michigan Hospital for their participation and support, particularly Casandra Redmon and Lauren Lobert for data collection. They also thank Diane Jette, PT, DSc, for her comments on the initial idea. A poster presentation of this research was given at the Combined Sections Meeting of the American Physical Therapy Association; February 17–20, 2010; San Diego, California. This publication was made possible with support from the Oregon Clinical and Translational Research Institute; grant UL1 RR024140 01 from the National Center for Research Resources, a component of the National Institutes of Health (NIH); and the NIH Roadmap for Medical Research. Dr Smith is supported by a National Institute of Aging Institutional Training Grant to Jeri Janowsky (principal investigator). During her PhD studies, she was supported by grant H424C010067 from the US Office of Special Education and Rehabilitative Services to Dale Ulrich (principal investigator).

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This article was received May 22, 2009, and was accepted January 3, 2010. DOI: 10.2522/ptj.20090164

References 1 Shepperd S, Parkes J, McClaran JJ, Phillips C. Discharge planning from hospital to home. Cochrane Database Syst Rev. 2003;3:CD000313. 2 Jackson MF. Discharge planning: issues and challenges for gerontological nursing: a critique of the literature. J Adv Nurs. 1994;19:492–502. 3 Haddock KS. Characteristics of effective discharge planning programs for the frail elderly. J Gerontol Nurs. 1991;17:10 –14. 4 Hickey ML, Cook EF, Rossi LP, et al. Effect of case managers with a general medical patient population. J Eval Clin Pract. 2000;6:23–29. 5 Naylor M, Brooten D, Jones R, et al. Comprehensive discharge planning for the hospitalized elderly: a randomized clinical trial. Ann Intern Med. 1994;120:999 –1006. 6 Mamon J, Steinwachs DM, Fahey M, et al. Impact of hospital discharge planning on meeting patient needs after returning home. Health Serv Res. 1992;27:155–175. 7 Bowles KH, Naylor MD, Foust JB. Patient characteristics at hospital discharge and a comparison of home care referral decisions. J Am Geriatr Soc. 2002;50: 336 –342. 8 Wee JY, Wong H, Palepu A. Validation of the Berg Balance Scale as a predictor of length of stay and discharge destination in stroke rehabilitation. Arch Phys Med Rehabil. 2003;84:731–735. 9 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. 10 Potthoff S, Kane RL, Franco SJ. Improving hospital discharge planning for elderly patients. Health Care Financ Rev. 1997;19: 47–72. 11 Haddock KS. Collaborative discharge planning: nursing and social services. Clin Nurse Spec. 1994;8:248 –252. 12 Gill TM, Williams CS, Tinetti ME. The combined effects of baseline vulnerability and acute hospital events on the development of functional dependence among community-living older persons. J Gerontol A Biol Sci Med Sci. 1999;54:M377–M383.

13 Boyd C, Landefeld CS, Counsell S, et al. Recovery of activities of daily living in older adults after hospitalization for acute medical illness. J Am Geriatr Soc. 2008; 56:2171–2179. 14 Covinsky KE, Palmer RM, Fortinsky RH, et al. Loss of independence in activities of daily living in older adults hospitalized with medical illnesses: increased vulnerability with age. J Am Geriatr Soc. 2003;51: 451– 458. 15 Coleman EA, Min SJ, Chomiak A, Kramer AM. Posthospital care transitions: patterns, complications, and risk identification. Health Serv Res. 2004;39: 1449 –1465. 16 Ensberg MD, Paletta MJ, Galecki AT, et al. Identifying elderly patients for early discharge after hospitalization for hip fracture. J Gerontol. 1993;48:M187–M195. 17 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. 18 Curtis KA, Martin T. Perceptions of acute care physical therapy practice: issues for physical therapist preparation. Phys Ther. 1993;73:581–594; discussion 594 –598. 19 Guide to Physical Therapist Practice. 2nd ed. Phys Ther. 2001;81:9 –746. 20 Einstadter D, Cebul RD, Franta PR. Effect of a nurse case manager on postdischarge follow-up. J Gen Intern Med. 1996;11: 684 – 688. 21 Pagano M, Gauvreau K. Principles of Biostatistics. Florence, KY: Wadsworth Publishing Co; 1993. 22 Resnik L, Liu D, Hart DL, Mor V. Benchmarking physical therapy clinic performance: Statistical methods to enhance internal validity when using observational data. Phys Ther. 2008;88:1078 –1087. 23 Bowles KH, Ratcliffe SJ, Holmes JH, et al. Post-acute referral decisions made by multidisciplinary experts compared to hospital clinicians and the patients’ 12-week outcomes. Med Care. 2008;46:158 –166. 24 Wilber ST, Blanda M, Gerson LW. Does functional decline prompt emergency department visits and admission in older patients? Acad Emerg Med. 2006;13: 680 – 682.

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Invited Commentary

Cynthia Coffin-Zadai

Smith and colleagues1 have studied a timely and extremely relevant topic, as the US health care system focuses reform efforts toward patients receiving “the right care, in the right service location, at the right time.” This study, which examined the impact of the physical therapist’s consultation, evaluation, and professional decision making during acute care discharge planning, both highlights the process and validates the physical therapist’s skill by examining an outcome: patient readmission rate. According to Kramer and Holtaus, editors of the report titled Uniform Patient Assessment for Post-Acute Care prepared for the Centers for Medicare and Medicaid Services in 2006, “Care fragmentation, unsafe care transitions, and the inability to determine the most cost-effective settings for patients discharged to post-acute care (PAC) are all compounded by lack of a Uniform Patient Assessment.”2(p1) This detailed report was prepared by 7 PAC experts, including 3 physicians and 2 physical therapists well versed in the assessment tools available for determining an appropriate PAC level and measurement of functional assessment domains. The report aims were to review existing PAC assessment tools and to consider the viability and utility of creating a uniform tool that would address the varied and necessary domains of patient assessment for discharge planning in this complex patient population. The report2 recommends the development of an inclusive instrument that attempts to quantify and qualify the broad array of data and integrate the myriad factors considered during the challenging process associated with discharge planning. The authors highlight the significant time, effort, and

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expenditures that have been directed toward accurately assessing patients in acute care settings and appropriately moving them across the continuum of care. Some studies have shown that effective evaluation and planning can decrease costs and improve functional prognosis and outcome.3,4 Smith et al have nicely demonstrated in their study that physical therapists practicing in the acute care setting have an integral role in both evaluating patient functioning and making prognostic decisions about discharge destination and likely outcome of care. In the absence of any inclusive uniform assessment tool, the physical therapists at this level 1 trauma/acute care institution evaluated and suggested appropriate PAC recommendations, as evidenced by the discharge planners’ decisions to send patients to the destination recommended by the physical therapist and the additional interesting variable of readmission rate for the discharged patients. Earlier qualitative and quantitative studies have illustrated that the PAC discharge planning process is commonly a multidisciplinary activity and that the final destination decision may or may not be made by a licensed clinician.4 –7 Most of these studies discussed the importance of multiple factors in determining PAC destination, such as age, pathology, comorbidities, functional status prior to and during hospitalization, caregiver support, living conditions, and finances. Although all of these factors may be important, Smith and colleagues’ work begins to suggest that some prognostic factors evaluated and considered by physical therapists specifically may be more important than others in determining the most efficient (time spent and cost) and ef-

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fective (functional outcome achieved) discharge destination. A qualitative study by Jette et al in 2003 first described the discharge decision-making process used by physical therapists to include “4 constructs: patients’ functioning and disability, patients’ wants and needs, patients’ ability to participate in care, and patients’ life context.”5(p224) The University of Michigan Hospital discharge planning process described by Smith et al varies as to whether a physical therapist’s consultation is formally requested or considered, and no specific time line or standardized steps for the process were described. However, it appears that the physical therapist’s consultation notes do specifically indicate the patient’s functioning and disability, the patient’s ability to participate in care (amount of assistance required for safety or use of devices), and the patient’s need for a physical therapist in a subsequent setting. It was presumably this set of information evaluated and reported by the physical therapists that was used as the basis for their discharge recommendation and the rationale to support their decision. This physical therapist consultation information was subsequently available in the medical record and may, or may not, have been used by the discharge decision maker. As the health care reform initiatives are debated in this country, it is essential that we continue to support the search for evidence that quantitatively assesses the value of each and every component of service. In the process of clinical practice, it is quite challenging to design studies that measure the impact or outcome of a clinical recommendation. This study presents an interesting model for analysis of the

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Acute Care Physical Therapists’ Discharge Recommendations physical therapist’s consultation. By retrospectively assessing the frequency of adherence to a recommendation, we can infer that the recommendation had some influence on the decision. The inference is possibly strengthened by the frequency of adherence. Most interesting in this study are the rate of adherence and the consequence of nonadherence. Although the limitations of the study design and the impracticality of collecting more exhaustive data precluded the authors from drawing stronger conclusions, it is quite compelling to consider both a frequency match of 83% for discharge recommendation and destination and a tracked probability of readmission rate of 2.9 times more likely when the physical therapist’s recommendation was not followed. These data have real and practical clinical implications when considering the study construct. This was an exhaustive sample of 762 patients who were referred to physical therapists in each of the 4 weeks surveyed. The patients were admitted to any of the inpatient services, and they were evaluated by more than 40 physical therapists with a range of experience described as 3 to 354 months. The sample and practice are consistent with the types of patients evaluated and the decisions being made by many physical therapists practicing in acute care settings across the United States. Therefore, the method could be replicated in a multi-institutional setting, and it has good potential for generalizability.

Author Response We thank Coffin-Zadai for her insightful commentary1 on our article.2 She has thoughtfully expanded on

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The authors’ study design, methods, and discussion placed an emphasis not just on the PAC discharge destination, but also on the patient’s need and recommendation for follow-up services. Although this is an important and interesting aspect of the study, because there is so little descriptive information about the patient sample, I believe it is difficult to analyze or draw conclusions about this aspect of the study. I do agree that this is an interesting observation to explore further because the significant readmission rate was associated with the mismatched group for whom services were lacking, whereas the next lower, but nonsignificant, readmission rate was for the mismatched patients who received more services than were recommended. In summary, this research report identifies one model for investigating issues related to the practice patterns, decision making, and outcomes associated with physical therapists’ consultation services. The study sample included the wide range of patients being managed in and transferred from an acute care setting, but the method could be very useful to carefully describe and track prognostic indicators in subsets of patients in this setting and in other settings as well. Additionally, the findings suggest that a more detailed description of the patient sample or other subsets of the sample could be useful for identifying the indicators that physical therapists and others could and should rely on as sensitive and specific for discharge planning and determining the most efficient and effective services or setting

that would be associated with improved function and decreased disability. Cynthia Coffin-Zadai, PT, DPT, CCS, FAPTA, is Coordinator, Transitional DPT Program, MGH Institute of Health Professions, Charlestown Navy Yard, 36 1st Ave, Boston, MA 02129. Address all correspondence to Dr Coffin-Zadai at: [email protected]. DOI: 10.2522/ptj.20090164.ic

References 1 Smith BA, Fields CJ, Fernandez N. Physical therapists make accurate and appropriate discharge recommendations for patients who are acutely ill. Phys Ther. 2010;90:693–703. 2 Kramer A, Holthaus D, eds. Uniform Patient Assessment for Post-Acute Care (Executive Summary). Report prepared by the Division of Health Care Policy and Research, University of Colorado at Denver and Health Sciences Center, for the Centers for Medicare and Medicaid Services and the Iowa Foundation for Medical Care, January 25, 2006. 3 Potthoff S, Kane RL, Franco SJ. Improving hospital discharge planning for elderly patients. Health Care Financ Rev. 1997;19:47– 83. 4 Unsworth CA. Selection for rehabilitation: acute care discharge patterns for stroke and orthopedic patients. Int J Rehabil Res. 2001;24:103–114. 5 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. 6 Baum MC, Edwards DF. Documenting productive behaviors: using the functional behavior profile to plan discharge following stroke. J Gerontol Nurs. 2000;26:34 – 43. 7 Volland PJ. Model for decision making in the discharge planning process. In: Volland PJ, ed. Discharge Planning: An Interdisciplinary Approach to Continuity of Care. Baltimore, MD: National Health Publishing Div, Williams & Wilkins; 1988:279 –300.

Beth A. Smith, Christina J. Fields, Natalia Fernandez

and reinforced important aspects of our article, highlighting the overall difficulty that the US health care sys-

tem experiences with discharge planning. She also has nicely described some relevant next steps for

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Acute Care Physical Therapists’ Discharge Recommendations physical therapist’s consultation. By retrospectively assessing the frequency of adherence to a recommendation, we can infer that the recommendation had some influence on the decision. The inference is possibly strengthened by the frequency of adherence. Most interesting in this study are the rate of adherence and the consequence of nonadherence. Although the limitations of the study design and the impracticality of collecting more exhaustive data precluded the authors from drawing stronger conclusions, it is quite compelling to consider both a frequency match of 83% for discharge recommendation and destination and a tracked probability of readmission rate of 2.9 times more likely when the physical therapist’s recommendation was not followed. These data have real and practical clinical implications when considering the study construct. This was an exhaustive sample of 762 patients who were referred to physical therapists in each of the 4 weeks surveyed. The patients were admitted to any of the inpatient services, and they were evaluated by more than 40 physical therapists with a range of experience described as 3 to 354 months. The sample and practice are consistent with the types of patients evaluated and the decisions being made by many physical therapists practicing in acute care settings across the United States. Therefore, the method could be replicated in a multi-institutional setting, and it has good potential for generalizability.

Author Response We thank Coffin-Zadai for her insightful commentary1 on our article.2 She has thoughtfully expanded on

May 2010

The authors’ study design, methods, and discussion placed an emphasis not just on the PAC discharge destination, but also on the patient’s need and recommendation for follow-up services. Although this is an important and interesting aspect of the study, because there is so little descriptive information about the patient sample, I believe it is difficult to analyze or draw conclusions about this aspect of the study. I do agree that this is an interesting observation to explore further because the significant readmission rate was associated with the mismatched group for whom services were lacking, whereas the next lower, but nonsignificant, readmission rate was for the mismatched patients who received more services than were recommended. In summary, this research report identifies one model for investigating issues related to the practice patterns, decision making, and outcomes associated with physical therapists’ consultation services. The study sample included the wide range of patients being managed in and transferred from an acute care setting, but the method could be very useful to carefully describe and track prognostic indicators in subsets of patients in this setting and in other settings as well. Additionally, the findings suggest that a more detailed description of the patient sample or other subsets of the sample could be useful for identifying the indicators that physical therapists and others could and should rely on as sensitive and specific for discharge planning and determining the most efficient and effective services or setting

that would be associated with improved function and decreased disability. Cynthia Coffin-Zadai, PT, DPT, CCS, FAPTA, is Coordinator, Transitional DPT Program, MGH Institute of Health Professions, Charlestown Navy Yard, 36 1st Ave, Boston, MA 02129. Address all correspondence to Dr Coffin-Zadai at: [email protected]. DOI: 10.2522/ptj.20090164.ic

References 1 Smith BA, Fields CJ, Fernandez N. Physical therapists make accurate and appropriate discharge recommendations for patients who are acutely ill. Phys Ther. 2010;90:693–703. 2 Kramer A, Holthaus D, eds. Uniform Patient Assessment for Post-Acute Care (Executive Summary). Report prepared by the Division of Health Care Policy and Research, University of Colorado at Denver and Health Sciences Center, for the Centers for Medicare and Medicaid Services and the Iowa Foundation for Medical Care, January 25, 2006. 3 Potthoff S, Kane RL, Franco SJ. Improving hospital discharge planning for elderly patients. Health Care Financ Rev. 1997;19:47– 83. 4 Unsworth CA. Selection for rehabilitation: acute care discharge patterns for stroke and orthopedic patients. Int J Rehabil Res. 2001;24:103–114. 5 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. 6 Baum MC, Edwards DF. Documenting productive behaviors: using the functional behavior profile to plan discharge following stroke. J Gerontol Nurs. 2000;26:34 – 43. 7 Volland PJ. Model for decision making in the discharge planning process. In: Volland PJ, ed. Discharge Planning: An Interdisciplinary Approach to Continuity of Care. Baltimore, MD: National Health Publishing Div, Williams & Wilkins; 1988:279 –300.

Beth A. Smith, Christina J. Fields, Natalia Fernandez

and reinforced important aspects of our article, highlighting the overall difficulty that the US health care sys-

tem experiences with discharge planning. She also has nicely described some relevant next steps for

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Acute Care Physical Therapists’ Discharge Recommendations using subsets of the sample to identify indicators that physical therapists and others could and should rely on as sensitive and specific for discharge planning. Our sample was a broad overview of the wide range of patients admitted to a large acute care hospital, reflecting a wide variety of need for skilled physical therapist evaluation and treatment. Starting to define when and for whom acute care physical therapist involvement is most critical and effective is an important next step. Coffin-Zadai writes that the Uniform Patient Assessment for Post-Acute Care3 report recommends the development of an inclusive instrument that attempts to quantify and qualify the broad array of data and integrate the varied factors considered during the challenging process associated with discharge planning. Although we believe that this is exactly the skilled decision making that acute care physical therapists are performing, we also recognize the strength of using standardized, quantitative measures and believe the formation of an evidence-based quantitative measure would be beneficial. We especially think it would be beneficial to practitioners new to acute care. We attempted to compare the rate of mismatch of physical therapists new to acute care with that of physical therapists with more acute care experience, but did not have a sufficient number of evaluations performed by therapists new to acute care to be able to draw conclusions. Based on the preliminary data, which were underpowered, we speculate that physical therapists with less than 6 months of acute care experience had a higher rate of mismatch than their more experienced peers. A quantitative measure for dis-

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charge planning would help clinicians new to acute care to identify relevant factors to consider in their decision-making process. We also would like to address CoffinZadai’s comment on our lack of formal guidelines or timelines for physical therapy consultation for discharge planning, as we believe many acute care settings find this difficult to address. Our institution does define guidelines for when a physical therapy consultation is appropriate and recommended; however, there still exists much variation hospitalwide in terms of when a consult is sent. It seems to reflect the culture of the admitting service or physical location of the patient, despite our best efforts to educate all providers on appropriate consultation practices. For example, our Cardiovascular Center Surgical Intensive Care Unit has recently started consulting physical therapists at admission for every patient. Although we appreciate the opportunity to follow the patients and identify their need for physical therapy and any discharge needs as early as possible, this also introduces the burden of time spent monitoring and triaging a large number of patients. On the other hand, we have all had the experience of not being consulted until the day of discharge, when we could have identified and prevented problems had we been consulted earlier. Different models of practice might include having a physical therapist triage all newly admitted patients and identify their need for physical therapist evaluation of treatment and discharge planning needs or the creation of concise, detailed guidelines of when a consultation is appropriate and cueing physicians through the electronic medical records system. The

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trade-off between time spent triaging versus time spent evaluating and treating patients is important to consider; however, eliminating inappropriate or “too late” consultations also can improve efficiency of care. In a large academic medical center such as ours, we have a high rate of rotation or turnover of health care providers in all areas. As diligently as we try to define our unique role as acute care physical therapists and show that our skilled involvement early in the care process is beneficial to the outcomes of the patient, we still have to continually educate clinicians and patients about our role. We also struggle with defining ideal physical therapist involvement in patient care versus the real-world constraints of prioritizing patient treatments in response to fluctuating levels of patients needing skilled physical therapist and staffing levels. Continuing to define, test, and converse about how to effectively and efficiently deliver care in the acute care setting and beyond is important to physical therapy and to health care in general. DOI: 10.2522/ptj.20090164.ar

References 1 Coffin-Zadai C. Invited commentary on “Physical therapists make accurate and appropriate discharge recommendations for patients who are acutely ill.” Phys Ther. 2010;90:704 –705. 2 Smith BA, Fields CJ, Fernandez N. Physical therapists make accurate and appropriate discharge recommendations for patients who are acutely ill. Phys Ther. 2010;90:693–703. 3 Kramer A, Holthaus D, eds. Uniform Patient Assessment for Post-Acute Care (Executive Summary). Report prepared by the Division of Health Care Policy and Research, University of Colorado at Denver and Health Sciences Center, for the Centers for Medicare and Medicaid Services and the Iowa Foundation for Medical Care, January 25, 2006.

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Research Report Physical Therapists’ Perceptions of Ease of Care in Patients Receiving 2 Forms of Analgesia After Total Hip Arthroplasty

M.H. Bourne, MD, is Chairman, Division of Orthopaedic Surgery, Salt Lake Orthopaedic Clinic, St Mark’s Hospital, 1160 E 3900 South, Suite 5000, Salt Lake City, UT 84124 (USA). Address all correspondence to Dr Bourne at: [email protected].

Michael H. Bourne, Jacques E. Chelly, C.V. Damaraju, Winnie W. Nelson, Jeff R. Schein, David J. Hewitt

Background. Pain management modalities that facilitate patient mobility may contribute to recovery after total hip replacement (THR) surgery. Objective. The aim of this study was to evaluate the impact of morphine intravenous (IV) patient-controlled analgesia (PCA) and the fentanyl iontophoretic transdermal system (fentanyl ITS) on physical therapists’ ability to complete care tasks for patients after THR.

Design. The data were from an open-label, randomized, multicenter, activecontrol phase IIIb clinical trial.

Methods. The settings were 52 US-based teaching and community hospitals. The

patients were ⱖ18 years of age (mean [SEM]: 62.8 [0.6] years in the fentanyl ITS group and 62.9 [0.6] years in the morphine IV PCA group); had an American Society of Anesthesiologists physical status of I, II, or III; and were scheduled to undergo primary unilateral THR surgery. The patients were randomized to receive analgesia for up to 72 hours via the fentanyl ITS (40 ␮g of fentanyl over 10 minutes for up to 6 doses per hour for 24 hours or 80 doses per system, whichever occurred first) or morphine IV PCA (1-mg bolus doses [with a 5-minute lockout interval between doses] for up to 10 doses per hour for 24 hours). All patients received the usual treatment administered by physical therapists. After each therapy session, physical therapists completed a validated Physical Therapist Ease-of-Care Questionnaire, which included time efficiency and convenience subscales (lower scores indicated more positive responses) and a satisfaction subscale (a higher score indicated a more positive response). Therapists whose average scores were ⱕ2 on all items of the time efficiency and convenience subscales or ⱖ4 on both items of the satisfaction subscale were considered responders.

Results. Higher percentages of physical therapists were responders for the fentanyl ITS than for morphine IV PCA on the subscales that assessed time efficiency (84.9% and 59.1%, respectively), convenience (86.6% and 71.2%, respectively), and satisfaction (54.3% and 30.5%, respectively). Higher percentages of physical therapists favored the fentanyl ITS than favored morphine IV PCA.

Limitations. The trial was limited by its open-label design, and physical therapists were more familiar with IV PCA than with the fentanyl ITS.

J.E. Chelly, MD, PhD, MBA, is Professor of Anesthesiology and Orthopedic Surgery, Vice Chair of Clinical Research, Director of the Regional and Orthopedic Fellowships, and Director of the Division of Acute Interventional Perioperative Pain and Regional Anesthesia, Department of Anesthesiology, University of Pittsburgh Medical Center; Director of Orthopedic Anesthesia, UPMC Shadyside Hospital; and Director of Acute Interventional Perioperative Pain, UPMC Presbyterian-Shadyside Hospitals, Pittsburgh, Pennsylvania. C.V. Damaraju, PhD, is Director, Biostatistics, Ortho-McNeil Janssen Scientific Affairs, LLC, Raritan, New Jersey. W.W. Nelson, PharmD, MS, is Director, Health Economics and Outcomes Research, Ortho-McNeil Janssen Scientific Affairs, LLC. J.R. Schein, DrPH, MPH, is Senior Director, Health Economics and Outcomes Research, Ortho-McNeil Janssen Scientific Affairs, LLC. D.J. Hewitt, MD, is Senior Director, Clinical Neuroscience, Merck Research Laboratories, Merck & Co Inc, North Wales, Pennsylvania. [Bourne MH, Chelly JE, Damaraju CV, et al. Physical therapists’ perceptions of ease of care in patients receiving 2 forms of analgesia after total hip arthroplasty. Phys Ther. 2010;90:707–713.] © 2010 American Physical Therapy Association

Conclusions. The findings demonstrate benefits to physical therapists of using the fentanyl ITS over morphine IV PCA in terms of time efficiency, convenience, and satisfaction.

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Effect of Analgesia on Ease of Care After Hip Arthroplasty

T

otal hip replacement (THR) is a common procedure; approximately 234,000 THRs are performed annually in the United States.1 Patient-controlled analgesia (PCA) is a valuable treatment option for managing acute pain after THR. Studies have shown that patients prefer PCA to clinician-controlled forms of analgesia administration2 for several reasons, including greater control over pain management,3 a sense of better pain relief,4 and the feeling of not being overdosed.4 Patientcontrolled analgesia modalities allow patients to self-administer analgesia in small, fixed doses according to their individual requirements. Additionally, there are fewer gaps in pain relief with PCA than with nurseadministered, intermittent dosing strategies.5 The doses of opioids administered with PCA modalities are sufficient to reach the minimum effective analgesic threshold but small enough to avoid some of the adverse events associated with nurseadministered bolus doses of opioids.6 Intravenous (IV) PCA is commonly and effectively used to manage acute postoperative pain.7 However, IV PCA has several limitations, including the requirement for IV access and the associated risks of needlerelated complications; the need for manual programming of the PCA pump and the associated risks of programming errors; the requirement for substantial staff time to set up, maintain, and program the PCA pump; and the need for patients to be attached to IV tubing and a PCA

Available With This Article at ptjournal.apta.org • Audio Abstracts Podcast This article was published ahead of print on March 18, 2010, at ptjournal.apta.org.

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apparatus, which may impede their mobility. It is well established that the initiation of physical therapy and patient mobility is an important determinant of postoperative outcomes and the prevention of morbidity after surgery,8 –11 particularly after joint replacement.12,13 Therefore, the implementation of postoperative pain management modalities that enhance patient mobility may improve the quality of patient care after THR. The fentanyl HCl iontophoretic transdermal system (fentanyl ITS; IONSYS*) is a novel PCA delivery system. This compact, self-contained, needle-free system delivers fentanyl via iontophoresis, a process by which a lowintensity electrical current is used to transport ionized fentanyl molecules across intact skin and into the bloodstream, thus providing systemic analgesia. The system is applied to the upper outer arm or chest and delivers a preprogrammed dose (40 ␮g) of fentanyl upon patient demand. Activation of the dosing button on the fentanyl ITS results in the absorption of 39.5 ␮g of fentanyl, with a maximum concentration of 1.954 ␮g/L and a time to maximum concentration of 23.427 hours.14 The efficacy and safety of the fentanyl ITS have been established in several placebo-control and activecontrol (IV PCA with morphine) clinical trials.15–19 Although fentanyl is approximately 75 to 125 times more potent than morphine,20 a pooled analysis21 of data from 3 active-control trials indicated that the relative dosing ratio of fentanyl administered via the fentanyl ITS to morphine administered intravenously was approximately 30:1. This ratio was lower than the ratio expected for fentanyl administered intravenously. * Ortho-McNeil Inc, 1000 US Highway 202 South, Raritan, NJ 08869.

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A phase IIIb clinical trial was conducted to evaluate the efficacy and safety of the fentanyl ITS and of morphine IV PCA in patients who underwent THR.22 The results of that trial demonstrated that the fentanyl ITS and morphine IV PCA are comparable methods of pain control after THR, as indicated by statistically equivalent ratings of success on a patient global assessment of the method of pain control23 and mean last pain intensity scores in the first 24 hours. Separate validated questionnaires regarding ease of care24,25 were completed during that study by nurses, physical therapists, and patients to assess the time efficiency, convenience, and satisfaction associated with each modality. The purpose of the present investigation was to evaluate the impact of each modality on the completion of physical therapy tasks after THR from the perspective of the physical therapist.

Method Design Overview The method of the clinical trial from which data for the present analysis were obtained has been published elsewhere22 and is described briefly here. Settings and Patients The data were from an open-label, randomized, multicenter, activecontrol phase IIIb clinical trial; patients in that trial were 18 years of age or older; had an American Society of Anesthesiologists physical status of I, II, or III26; and were scheduled to undergo primary unilateral THR surgery. All patients provided informed written consent, were expected to be hospitalized, and were expected to experience moderate or severe pain requiring parenteral opioids for 24 hours or longer after surgery. Randomization and Intervention A computer-generated randomization schedule was used to randomly May 2010

Effect of Analgesia on Ease of Care After Hip Arthroplasty assign patients 1:1 to receive analgesia via the fentanyl ITS or morphine IV PCA for up to 72 hours. Preprogrammed fentanyl ITS treatment delivered a 40-␮g dose of fentanyl over 10 minutes for up to 6 doses per hour for 24 hours or a maximum of 80 doses per system (whichever occurred first), after which a new system was applied, if needed. Drug delivery was activated when patients double-clicked the recessed on-demand dose activation button. An audible beep signaled the initiation of drug delivery, and a red light-emitting diode was illuminated continuously until delivery of the dose was completed. During drug delivery, the system could not be activated to deliver another dose. Morphine IV PCA treatment was delivered in 1-mg bolus doses (with a 5-minute lockout interval between doses) for a maximum of 10 doses per hour for 24 hours (up to a maximum of 240 doses). After surgery, patient comfort was achieved with IV opioids (morphine, hydromorphone, fentanyl, sufentanil, or alfentanil) as needed. Patients were included in the trial if they were awake; alert; breathing spontaneously, with a respiratory rate of 8 to 24 breaths per minute and an arterial oxygen saturation (which was not obtained for room air) of at least 90%; and comfortable, with a pain intensity score of 4 or less on a verbal numerical rating scale that ranged from 0 (no pain) to 10 (worst possible pain) for 30 minutes or longer in the postanesthesia care unit. Trial initiation occurred upon the first application of the fentanyl ITS or activation of the IV PCA pump. Supplemental IV opioids were allowed for 3 hours after surgery and disallowed thereafter. Patients in the fentanyl ITS group received IV fentanyl, whereas patients in the morphine IV PCA group received IV morphine; however, patients in either May 2010

group could receive fentanyl or morphine if delivery of the specified analgesic agent was not possible. When the trial was initiated, multimodal treatment with the cyclooxygenase-2 inhibitor rofecoxib was included. Thus, patients who were enrolled before the withdrawal of rofecoxib from the market (approximately half of the enrolled patients) were scheduled to receive 25 mg of oral rofecoxib 2 to 4 hours before surgery and 25 mg each day after surgery while enrolled in the trial. Outcomes and Follow-up The Physical Therapist Ease of Care (EOC) Questionnaire was developed with input from physical therapists and included items pertaining to the time efficiency, convenience, satisfaction, and overall ease of completing tasks with patients whose postoperative pain was being managed with PCA systems; these tasks included transfer from the bed to a chair, ambulation in the room, and ambulation outside the room. The questionnaire previously was shown to have content and psychometric validity.24 Physical therapists completed the questionnaire at the end of each physical therapy session for each patient. The Physical Therapist EOC Questionnaire consisted of 22 items grouped in 3 subscales (Appendix): time efficiency was assessed with the 10-item “time-consuming” subscale; convenience was assessed with the 10-item “bothersome” subscale; and satisfaction was assessed with the 2-item “satisfaction” subscale. Items that assessed time efficiency and convenience were scored on a 6-point Likert scale from 0 (not at all) to 5 (a very great deal); lower scores indicated more positive results. Items that assessed satisfaction were scored on a 6-point Likert scale from 0 (extremely dissatisfied) to 5 (extremely satisfied).

Data Analysis Differences in responses on the Physical Therapist EOC Questionnaire were assessed by use of mean scores. Mean subscale and overall scale scores were better for the fentanyl ITS than for morphine IV PCA (P⬍.001 for all comparisons).27 However, analyses of mean scores are not suitable for comparing discrete response variables or ordered categorical data. A more appropriate way to analyze ordered response data is to consider the inherent ordering of responses. For simplicity and ease of interpretation, the ordered response categories were dichotomized as “responders” and “nonresponders.” Because a physical therapist might have completed multiple questionnaires, the mean score from all questionnaires filled out by an individual physical therapist was used to determine his or her responder status. On the time efficiency and convenience subscales, a responder was defined as a physical therapist whose average score was 2 or lower on all items in each respective subscale; a lower score indicated a more positive response. Because the satisfaction subscale had an implicit neutral point in its response options and because a higher score indicated a more positive response, a responder on the satisfaction subscale was defined as a physical therapist whose average score was 4 or higher on both subscale items. Statistical significance for the difference in the proportion of responders between analgesia treatment groups was determined with the Fisher exact test. Analyses of dichotomized data included responses from physical therapists who had experience with one or both treatment modalities. The percentages of physical therapists who favored one modality over the other were evaluated for physical therapists who conducted ses-

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Effect of Analgesia on Ease of Care After Hip Arthroplasty On the Brief Pain Inventory, which was administered before surgery, the mean scores for “worst pain in the past week” were higher (indicating more preoperative pain) in the fentanyl ITS group (7.3) than in the morphine IV PCA group (7.0) (P⫽.0376); however, the mean pain intensity scores before randomization were the same in the analgesia groups (2.8 on an 11-point numerical rating scale). Most patients underwent at least 1 physical therapy session (fentanyl ITS, 98.5%; morphine IV PCA, 98.3%). Figure 1. Physical therapist responders on subscales that measured time efficiency, convenience, and satisfaction. Higher percentages of physical therapists were responders for the fentanyl iontophoretic transdermal system (ITS) (n⫽184) than for morphine intravenous (IV) patient-controlled analgesia (PCA) (n⫽178) on subscales that measured time efficiency, convenience, and satisfaction. *P⬍.001.

A total of 252 physical therapists at 50 sites participated in the study. Analyses of ease of care were based on responses from 184 (fentanyl ITS) and 178 (morphine IV PCA) questionnaires.

it was set to 400 to account for the small proportion of patients whose data could not be evaluated.

The results from the completed Physical Therapist EOC Questionnaire indicated that there were higher percentages of responders for the fentanyl ITS than for morphine IV PCA on the subscales that assessed time efficiency (84.9% and 59.1%, respectively), convenience (86.6% and 71.2%, respectively), and satisfaction (54.3% and 30.5%, respectively) (P⬍.001 for all comparisons) (Fig. 1).

sions with patients from both treatment groups by use of the mean score for each subscale (nonmissing responses to items in each respective subscale). For example, a physical therapist whose mean score on the time efficiency subscale was lower for patients who received analgesia via the fentanyl ITS than for patients who received analgesia via morphine IV PCA was considered to have favored the fentanyl ITS over morphine IV PCA. If the scores for the treatment groups were the same, then the physical therapist was considered to be neutral regarding the modality. Statistical significance was determined with a sign test. The sample size of the overall trial was calculated to achieve a power of 80% while controlling the type I error rate at .05 by use of a 2-sided confidence interval procedure with an equivalence margin of .10. The sample size also depended on a success rate (␲), which was assumed to be .75 in both groups on the basis of the results of a previous study.16 These assumptions yielded a required sample size of 395 per group; 710

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Role of the Funding Source Ortho-McNeil Inc was the sponsor of the original clinical trial from which data for the present analysis were obtained.

Results The baseline demographic characteristics of the patients were previously described and did not differ between the treatment groups.22 The mean (SEM) ages of the patients were 62.8 (0.6) years in the fentanyl ITS group and 62.9 (0.6) years in the morphine IV PCA group; the mean (SEM) body mass indexes for patients in the fentanyl ITS and morphine IV PCA groups were 29.8 (0.3) and 29.2 (0.3) kg/m2, respectively; and the majority of patients (⬎90%) in both groups were white.22 There were no significant differences in hip operated on, duration of surgery, or surgical site information between the analgesia groups.

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The percentages of physical therapists who responded with each of the 3 most positive responses to the items that assessed mobility-related tasks (transfer to chair, ambulation in room, and ambulation outside room) on the subscales that measured time efficiency and convenience for the fentanyl ITS and morphine IV PCA are shown in Figures 2A and 2B, respectively. For the fentanyl ITS, higher (P⬍.05) percentages of physical therapists responded with 1 of the 3 most positive responses for the item “ambulation in room” on both subscales and for the item “ambulation outside room” on the subscale that measured convenience. Although numerical difMay 2010

Effect of Analgesia on Ease of Care After Hip Arthroplasty ferences that favored the fentanyl ITS were also observed for the item “ambulation outside room” on the subscale that measured time efficiency and for the item “transfer to chair” on both subscales, these differences were not statistically significant. Higher percentages of physical therapists who treated patients receiving analgesia via the fentanyl ITS and patients receiving analgesia via morphine IV PCA favored the fentanyl ITS than favored morphine IV PCA on subscales that assessed time efficiency (71.0% and 24.3%, respectively), convenience (75.0% and 18.5%, respectively), and satisfaction (63.6% and 25.5%, respectively) (P⬍.001 for all comparisons) (Fig. 3).

Discussion The results of the present study indicated that significantly higher percentages of physical therapists perceived their interventions to be more time efficient and convenient and were more satisfied with their delivery of care for patients receiving analgesia via the fentanyl ITS than for patients receiving analgesia via morphine IV PCA. These findings support the hypothesis that, from the perspective of the physical therapist, the systemic delivery of fentanyl via the fentanyl ITS would provide better ease of care than would morphine IV PCA, as indicated by the significant mean score differences.27 Other responder data from the openlabel, active-control trial22 and responder data from a similar trial with patients who underwent abdominal or pelvic surgeries18 also indicated that the fentanyl ITS was superior to morphine IV PCA in terms of ease of care from the perspectives of patients and nurses as well as physical therapists. Physical therapists who treated patients with both modalities favored the fentanyl ITS over morphine IV PCA. This finding is important beMay 2010

Figure 2. Physical therapist responses to mobility-related items. The percentages of physical therapist responses for the 3 most positive choices (“not at all,” “a little bit,” and “somewhat”) for 3 mobility-related items on subscales that measured time efficiency (A) and convenience (B) are shown (for the fentanyl iontophoretic transdermal system [ITS], n⫽184; for morphine intravenous [IV] patient-controlled analgesia [PCA], n⫽178). Values represent percentages of responses out of all possible choices. *P⬍.05.

cause patients recovering from major orthopedic surgery require the completion of physical therapy for optimal recovery.13 After surgery, physical therapy is important for reducing the risk of several complications, including deep vein thrombosis and pulmonary embolism,10 pressure ulcers (pressure sores),9 and pneumonia.8

The compact, needle-free, selfcontained design of the fentanyl ITS allows ease of movement, with no bulky apparatus. This fact may explain why physical therapists favored the fentanyl ITS over morphine IV PCA. Because the use of IV PCA requires an IV connection along with its accompanying tubing and IV stand, transfer to a chair re-

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Figure 3. Percentages of physical therapists who favored each modality. Higher percentages of physical therapists who treated patients in both treatment groups favored the fentanyl iontophoretic transdermal system (ITS) than favored morphine intravenous (IV) patientcontrolled analgesia (PCA) on subscales that measured time efficiency (n⫽107), convenience (n⫽108), and satisfaction (n⫽110). *P⬍.001.

quires pivoting around the apparatus, and ambulation requires securing and transporting the tubing and stand. In addition, the multiple components of the IV PCA system may present a safety concern because patients can trip over the tubing and fall. In contrast, the fentanyl ITS is self-contained, and physical therapists’ favorable ratings of its time efficiency suggest that they may be able to spend more time working with an individual patient or may be able to work with more patients. A potential limitation of the trial was its open-label design. However, a masked study would not have been feasible given the very different physical features of IV PCA and the fentanyl ITS. Another limitation was that physical therapists were more familiar with IV PCA than with the fentanyl ITS.

Conclusion The fentanyl ITS offers physical therapists more convenience and ease of patient care than morphine IV PCA, perhaps because of its preprogrammed, needle-free, compact, selfcontained design. In particular, the findings demonstrate the potential benefits of using the fentanyl ITS in terms of time efficiency, convenience, and satisfaction from the perspective of the physical therapist.

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Dr Bourne, Dr Chelly, Dr Schein, and Dr Hewitt provided concept/idea/research design. Dr Bourne, Dr Schein, and Dr Hewitt provided writing. Dr Bourne, Dr Chelly, and Dr Schein provided data collection. Dr Bourne, Dr Damaraju, Dr Nelson, Dr Schein, and Dr Hewitt provided data analysis. Dr Hewitt provided project management. Dr Bourne and Dr Chelly provided participants and facilities/equipment. Dr Chelly provided institutional liaisons. Dr Bourne, Dr Chelly, Dr Nelson, and Dr Schein provided consultation (including review of manuscript before submission). The authors thank the following physical therapists for their help in conducting this study and for providing editorial assistance: Gina Rose, Jim Swinyard, Marcus Schellenburg, and Garth Dunford. Editorial assistance was provided by Ashley O’Dunne, PhD, of MedErgy and was funded by Johnson & Johnson Pharmaceutical Services, LLC. The authors were not compensated and retained full editorial control over the content of the article. Institutional review board approval was obtained at each of the 52 trial sites. Ortho-McNeil Inc was the sponsor of the original clinical trial from which data for the present analysis were obtained. This article was submitted October 7, 2008, and was accepted December 21, 2009. DOI: 10.2522/ptj.20080323

References 1 DeFrances CJ, Podgornik MN. 2004 National Hospital Discharge Survey. Advance Data From Vital and Health Statistics; no. 371. Hyattsville, MD: National Center for Health Statistics; 2006. 2 Lehmann KA. Patient-controlled analgesia: an efficient therapeutic tool in the postoperative setting. Eur Surg Res. 1999;31:112–121.

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3 Ballantyne JC, Carr DB, Chalmers TC, et al. Postoperative patient-controlled analgesia: meta-analyses of initial randomized control trials. J Clin Anesth. 1993;5:182–193. 4 Chumbley GM, Hall GM, Salmon P. Why do patients feel positive about patientcontrolled analgesia? Anaesthesia. 1999; 54:386 –389. 5 Carr DB, Reines HD, Schaffer J, et al. The impact of technology on the analgesic gap and quality of acute pain management. Reg Anesth Pain Med. 2005;30:286 –291. 6 Etches RC. Patient-controlled analgesia. Surg Clin North Am. 1999;79:297–312. 7 Grass JA. Patient-controlled analgesia. Anesth Analg. 2005;101(suppl 5):S44 –S61. 8 Markey DW, Brown RJ. An interdisciplinary approach to addressing patient activity and mobility in the medical-surgical patient. J Nurs Care Qual. 2002;16:1–12. 9 Nixon J, Brown J, McElvenny D, et al. Prognostic factors associated with pressure sore development in the immediate post-operative period. Int J Nurs Stud. 2000;37:279 –289. 10 Ramzi DW, Leeper KV. DVT and pulmonary embolism, part I: diagnosis. Am Fam Physician. 2004;69:2829 –2836. 11 Weill-Engerer S, Meaume S, Lahlou A, et al. Risk factors for deep vein thrombosis in inpatients aged 65 and older: a casecontrol multicenter study. J Am Geriatr Soc. 2004;52:1299 –1304. 12 Munin MC, Rudy TE, Glynn NW, et al. Early inpatient rehabilitation after elective hip and knee arthroplasty. JAMA. 1998; 279:847– 852. 13 Roos EM. Effectiveness and practice variation of rehabilitation after joint replacement. Curr Opin Rheumatol. 2003;15: 160 –162. 14 Sathyan G, Jaskowiak J, Evashenk M, Gupta S. Characterisation of the pharmacokinetics of the fentanyl HCl patientcontrolled transdermal system (PCTS): effect of current magnitude and multipleday dosing and comparison with IV fentanyl administration. Clin Pharmacokinet. 2005;44(suppl 1):7–15. 15 Chelly JE, Grass J, Houseman TW, et al. The safety and efficacy of a fentanyl patient-controlled transdermal system for acute postoperative analgesia: a multicenter, placebo-controlled trial. Anesth Analg. 2004;98:427– 433. 16 Viscusi ER, Reynolds L, Chung F, et al. Patient-controlled transdermal fentanyl hydrochloride vs intravenous morphine pump for postoperative pain: a randomized controlled trial. JAMA. 2004;291:1333–1341. 17 Viscusi ER, Reynolds L, Tait S, et al. An iontophoretic fentanyl patient-controlled analgesic delivery system for postoperative pain: a double-blind, placebo-controlled trial. Anesth Analg. 2006;102:188 –194. 18 Minkowitz HS, Rathmell JP, Vallow S, et al. Efficacy and safety of the fentanyl iontophoretic transdermal system (ITS) and intravenous patient-controlled analgesia (IV PCA) with morphine for pain management following abdominal or pelvic surgery. Pain Med. 2007;8:657– 668.

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Effect of Analgesia on Ease of Care After Hip Arthroplasty 19 Grond S, Hall J, Spacek A, et al. Iontophoretic transdermal system using fentanyl compared with patient-controlled intravenous analgesia using morphine for postoperative pain management. Br J Anaesth. 2007;98:806 – 815. 20 Austrup ML, Korean G. Analgesic agents for the postoperative period: opioids. Surg Clin North Am. 1999;79:253–273. 21 Viscusi ER, Siccardi M, Damaraju CV, et al. The safety and efficacy of fentanyl iontophoretic transdermal system compared with morphine intravenous patientcontrolled analgesia for postoperative pain management: an analysis of pooled data from three randomized, activecontrolled clinical studies. Anesth Analg. 2007;105:1428 –1436. 22 Hartrick CT, Bourne MH, Gargiulo K, et al. Fentanyl iontophoretic transdermal system for acute-pain management after orthopedic surgery: a comparative study with morphine intravenous patientcontrolled analgesia. Reg Anesth Pain Med. 2006;31:546 –554. 23 Rothman M, Vallow S, Damaraju CV, Hewitt DJ. Using the patient global assessment of the method of pain control to assess new analgesic modalities in clinical trials. Curr Med Res Opin. 2009;25:1433– 1443. 24 Harding G, Vallow S, Leidy NK, et al. Ease of care with patient controlled analgesia systems: questionnaire development and validation. J Adv Nurs. 2007;59:530 –541. 25 Harding G, Vallow S, Leidy NK, et al. Development of an instrument to capture ease-of-care outcomes in patients treated with PCA delivery systems [abstract PPN11]. Value Health. 2004;7:728. 26 American Society of Anesthesiologists. ASA physical status classification system. Available at: www.asahq.org/clinical/ physicalstatus.htm. Accessed September 2008. 27 Phillips S, Vallow S, Gargiulo K, Hewitt D. Ease of care of postoperative pain management following total hip replacement: fentanyl HCl patient-controlled transdermal system (PCTS) versus morphine intravenous patient-controlled analgesia (IV PCA) [abstract A22]. Reg Anesth Pain Med. 2005;30.

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Appendix. Physical Therapist Ease of Care Questionnairea “Time-consuming” subscale 1. Completing physical therapy session at bedside 2. Transfer to chair 3. Ambulation in room 4. Ambulation outside room (hallway, stairs) 5. Rearranging medical devices, machines, or furniture to start physical therapy session 6. Waiting for assistance for problems related to the pain management device 7. Waiting for assistance for problems related to patient medical problems (pain, nausea, dizziness, hypotension) 8. Addressing patient concerns related to doing physical therapy with pain management device 9. Educating/reinstructing patient on how to use device 10. Attaining session goals “Bothersome” subscale 11. Completing physical therapy session at bedside 12. Transfer to chair 13. Ambulation in room 14. Ambulation outside room (hallway, stairs) 15. Rearranging medical devices, machines, or furniture to start physical therapy session 16. Waiting for assistance for problems related to the pain management device 17. Waiting for assistance for problems related to patient medical problems (pain, nausea, dizziness, hypotension) 18. Addressing patient concerns related to doing physical therapy with pain management device 19. Educating/reinstructing patient on how to use device 20. Attaining session goals “Satisfaction” subscale 21. How satisfied were you with the pain control by the device? 22. Please rate your overall satisfaction with the device. a

Adapted with permission from Harding G, Vallow S, Leidy NK, et al. Ease of care with patient controlled analgesia systems: questionnaire development and validation. J Adv Nurs. 2007;59:530 –541. Copyright 2007, Blackwell Publishing Ltd.

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Research Report Aerobic Exercise Alters Analgesia and Neurotrophin-3 Synthesis in an Animal Model of Chronic Widespread Pain Neena K. Sharma, Janelle M. Ryals, Byron J. Gajewski, Douglas E. Wright N.K. Sharma, PT, PhD, is Research Assistant Professor, Department of Physical Therapy and Rehabilitation Science, University of Kansas Medical Center, Mail Stop 2002, 3901 Rainbow Blvd, Kansas City, KS 66160 (USA). Address all correspondence to Dr Sharma at: [email protected]. J.M. Ryals, BS, is Research Assistant, Department of Anatomy and Cell Biology, University of Kansas Medical Center. B.J. Gajewski, PhD, is Associate Professor, Department of Biostatistics, University of Kansas Medical Center. D.E. Wright, PhD, is Associate Professor, Department of Anatomy and Cell Biology, University of Kansas Medical Center. [Sharma NK, Ryals JM, Gajewski BJ, Wright DE. Aerobic exercise alters analgesia and neurotrophin-3 synthesis in an animal model of chronic widespread pain. Phys Ther. 2010;90:714 –725.] © 2010 American Physical Therapy Association

Background. Present literature and clinical practice provide strong support for the use of aerobic exercise in reducing pain and improving function for individuals with chronic musculoskeletal pain syndromes. However, the molecular basis for the positive actions of exercise remains poorly understood. Recent studies suggest that neurotrophin-3 (NT-3) may act in an analgesic fashion in various pain states. Objective. The purpose of the present study was to examine the effects of moderate-intensity aerobic exercise on pain-like behavior and NT-3 in an animal model of widespread pain.

Design. This was a repeated-measures, observational cross-sectional study. Methods. Forty female mice were injected with either normal (pH 7.2; n⫽20) or acidic (pH 4.0; n⫽20) saline in the gastrocnemius muscle to induce widespread hyperalgesia and exercised for 3 weeks. Cutaneous (von Frey monofilament) and muscular (forceps compression) mechanical sensitivity were assessed. Neurotrophin-3 was quantified in 2 hind-limb skeletal muscles for both messenger RNA (mRNA) and protein levels after exercise training. Data were analyzed with 2-factor analysis of variance for repeated measures (group ⫻ time). Results. Moderate-intensity aerobic exercise reduced cutaneous and deep tissue hyperalgesia induced by acidic saline and stimulated NT-3 synthesis in skeletal muscle. The increase in NT-3 was more pronounced at the protein level compared with mRNA expression. In addition, the increase in NT-3 protein was significant in the gastrocnemius muscle but not in the soleus muscle, suggesting that exercise can preferentially target NT-3 synthesis in specific muscle types.

Limitations. Results are limited to animal models and cannot be generalized to chronic pain syndromes in humans. Conclusions. This is the first study demonstrating the effect of exercise on deep tissue mechanical hyperalgesia in a rodent model of pain and providing a possible molecular basis for exercise training in reducing muscular pain.

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hronic widespread pain is complex and poorly understood and affects about 12% of the adult population in developed countries.1–3 Many laboratory animal models of pain have been produced to mimic human painful conditions. The acid model used in the present study is a noninflammatory muscle pain model and is considered to mirror some aspects of human fibromyalgia and other related syndromes that display referred hypersensitivity to mechanical stimuli. Acidic saline produces mechanical hypersensitivity of cutaneous,4 –9 visceral,10 and muscular tissue11,12 that lasts up to 3 to 4 weeks. It is suggested that the influx of acid stimulates the acidsensing ion channel-3 (ASIC3) receptors expressed by muscle afferent sensory fibers, resulting in increased nociceptive input to the spinal cord. Convergent input in the spinal cord from both muscle and paw sensory axons and receptive field plasticity of wide dynamic range (WDR) spinal neurons are believed to cause and maintain widespread secondary hyperalgesia (widespread hypersensitivity).4,6 No muscle tissue damage or gross motor/sensory loss is associated with this model of pain,4 thus allowing the investigation of exercise effects on widespread pain-like behavior. Management of chronic pain syndromes poses challenges for health care practitioners, and pharmacological interventions offer limited efficacy.13,14 Exercise training has been long suggested to reduce pain and improve functional outcomes.13,15–20 Surprisingly, the current literature is mainly limited to human studies where the molecular basis for exercise training cannot be easily determined. Relatively few animal studies have addressed the effects and mechanisms of exercise on sensory modulation of chronic pain. These studies demonstrate that exercise training is capable of reducing or reMay 2010

versing hypersensitivity associated with chronic pain in various animal models.21,22 However, they are limited to examining cutaneous sensation and have not investigated the effects of exercise on deep tissue pain, which is a major clinical complaint of many people with chronic pain syndromes. To date, no animal studies have evaluated the effect of exercise on muscular hypersensitivity. Pain states are influenced by members of the nerve-growth factor (NGF) family of neurotrophins, which include brain-derived neurotrophic factor (BDNF), neurotrophin-3 (NT-3), and neurotrophin-4 (NT-4). These neurotrophins support sensory neurons during development and continue to modify their function, particularly related to nociception in adulthood.23 The concept of exerciseinduced analgesia via modulation of neurotrophins has only recently emerged. Studies by Go ´ mez-Pinilla and colleagues24 –27 have shown that various exercise regimens (voluntary or forced) increase neurotrophins at central and peripheral sites in healthy and injured animals. However, these studies were largely limited to biochemical approaches, and studies correlating behavioral improvements, neurotrophin production, and exercise are lacking. In recent years, evidence has emerged concerning the role of NT-3 as a pain modulator for thermal,28,29 mechanical,9 and inflammatory30 hyperalgesia. Previous studies from our laboratory revealed that increased levels of NT-3 (either genetically overexpressed or delivered intramuscularly) abolished mechanical hypersensitivity that developed in response to intramuscular acid injections.9 If exercise increases NT-3 synthesis and NT-3 reduces cutaneous and thermal hyperalgesia, the next logical step is to test whether exercise-induced analgesia can be

achieved in a muscular pain model. Thus, the goals of the present study were: (1) to examine the effect of exercise training on widespread hypersensitivity (cutaneous and muscular) in a mouse model of chronic muscle pain and (2) to test whether exercise induces an increase in muscle-derived NT-3 synthesis.

Method Animals All experiments were approved by the Institutional Animal Care and Use Committee of the University of Kansas Medical Center and adhered to the university’s animal care guidelines. Forty CF-1 female mice* (weight⫽25 g) were used to examine the effects of moderately intense exercise on primary (muscular) and secondary (cutaneous) hyperalgesia and NT-3 synthesis. Because women develop widespread pain syndromes at a greater rate than age-matched men,31–33 hyperalgesia was induced in female mice. The mice were exposed to a 12-hour light/dark cycle and had access to food and water ad libitum. The mice received two 20 ␮L injections of either acidic saline (mean [⫾SD] pH⫽4.0⫾0.1) or normal saline (mean [⫾SD] pH⫽7.4⫾0.1) 2 days apart into the right gastrocnemius muscle to induce chronic widespread hyperalgesia or pain-like behavior.4,6 – 8 The acid-pain model injections were made with a 1-mL syringe† in 10-␮L increments, as previously reported.9,12 * Charles River Laboratories International Inc, 251 Ballardville St, Wilmington, MA 01887. † Becton Dickinson, 1 Becton Dr, Franklin Lakes, NJ 07417.

Available With This Article at ptjournal.apta.org • Audio Abstracts Podcast This article was published ahead of print on March 25, 2010, at ptjournal.apta.org.

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Exercise-Induced Analgesia Experimental Design Initially, the mice were randomly assigned to either the acidic saline injection (experimental) group or the normal saline injection (placebo) group. Five days after inducing hyperalgesia with acidic saline injections into the right limb, the animals were further assigned to either exercise or no-exercise groups, as follows: experimental with exercise group (n⫽10), experimental without exercise group (n⫽10), placebo with exercise group (n⫽10), and placebo without exercise group (n⫽10). The assignment to exercise or no-exercise groups was stratified within each group (acidic versus normal saline) based on the animals’ postinjection mechanical hypersensitivity, as they displayed some variability in their cutaneous paw sensitivity both before and after injection. Thus, all groups contained a range of mechanical hyperalgesia, from mild to high levels, to ensure that the groups were not biased in relation to their mechanical sensitivity. Exercise Training Two 6-lane, motorized treadmills‡ were used for exercise training. The exercise training was conducted 5 days per week for 3 weeks. The desired speed and exercise duration were gradually increased over the 3-week period, as follows: 13 m/min for 30 minutes during the first week, 14 m/min for 40 minutes during the second week, and 15 to 16 m/min for 45 minutes during the third week. The exercise protocol included 2 to 3 minutes of warm-up and 3 minutes of cool-down. Although treadmill running in rodents is considered forced activity,34,35 we observed that most animals ran for the majority of the exercise period without any encouragement. The animals did not appear overly fatigued, which is an important consideration, ‡ Columbus Instruments, 950 N Hague Ave, Columbus, OH 43204.

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as exhaustive exercise training may alter the levels of lactic acid36,37 and cause fatigue that may increase pain sensitivity.11 All mice were acclimated and trained for 3 days on the treadmill at 13 m/min before being assigned to an experimental or placebo group. After exercise training, all mice were tested for cutaneous and muscular mechanical sensitivity and then killed to quantify NT-3 levels in the soleus and gastrocnemius muscles. The investigator (N.S.) carrying out the behavioral and biochemical assessments was blinded to group assignments. Behavioral Testing Animals were acclimated for 3 days to the behavioral testing paradigms (2 times per day for von Frey monofilament and 3 times per day for muscle squeeze testing) at each time point of the behavior testing. For acclimation, the animals were brought to the testing laboratory and placed under the testing environment without actually conducting the test. For cutaneous testing, the animals were placed under a plastic chamber for 20 minutes for each acclimation period. For the muscle squeeze test, they were placed in a customized holder and remained in the holder for 5 minutes for each acclimation period. All exercise sessions were conducted between 4 and 6 PM toward the end of the animals’ sleep cycle. Behavioral testing was always conducted between 7 and 10 AM to avoid potential confounding factors such as stress-induced antinociception or acute effects of exercise training. Behavior testing was conducted at baseline (before injection), following the second acidic saline injection (1 day after injection for von Frey monofilament and 3 days after injection for muscle squeeze) and every week thereafter, alternating with cutaneous and deep tissue tests to avoid excessive animal handling and overstimulation.

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Mechanical testing of cutaneous sensitivity. Mechanical hyperalgesia to an innocuous stimulus was assessed using von Frey monofilaments. Clear plastic chambers (3 ⫻ 8 ⫻ 12 cm) were placed in an inverted position on a wire-mesh tabletop. The mice were placed under the plastic chambers and allowed to acclimate for 20 minutes prior to each test. A single von Frey monofilament§ of 1.0g bending force was applied to the plantar surface of each foot. A positive response to the von Frey stimulus was defined as a retraction of paw with or without licking. Three trials, each consisting of 5 applications (each 30 seconds apart) of the von Frey monofilament to the plantar surface of the ipsilateral and the contralateral hind paws, were conducted. The percent response for each hind limb was obtained by determining the number of withdrawals out of 5 monofilament applications. For statistical analysis, percent responses were averaged to obtain group means. Mechanical testing of muscle sensitivity. The mice were placed in a customized holder, and deep tissue mechanical sensitivity to a noxious stimulus was tested with a forceps compression device similar to the apparatus described by Yu et al.38 A modified version of the device was built internally at the University of Kansas Medical Center Neuromuscular Research Laboratory to accommodate the small size of the mice. The device is described elsewhere.12 In brief, the device consisted of a forceps, a pressure sensor (LCKD subminiature compression load cells㛳) attached to the inner tip flat surface of the forceps, a signal amplifier, and a laptop computer. A manual force was applied to each gastrocnemius §

Stoelting Co, Ste A, 620 Wheat Ln, Wood Dale, IL 60191. 㛳 Omega Engineering Inc, PO Box 4047, Stamford, CT 06907-0047.

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Exercise-Induced Analgesia muscle from a marked area on the forceps by an examiner who was blinded to group assignment. The signal from the load cells was amplified, digitized, and stored in a laptop computer. The recorded signal from the pressure sensor was analyzed with a custom-written Matlab computer program (Matlab 6.5).# The loading period and peak threshold level were recorded for each hind limb. The loading period was defined as the total time from the beginning of the loading to the peak withdrawal force. The peak threshold level was defined as the peak force and demonstrated by withdrawal response or vocalization upon compression. Three consecutive squeezes on the right and left sides were conducted on each mouse. A total of 3 trials were performed. The mean of 9 force peaks over 3 trials was calculated for each hind limb. Only force peaks with a loading time period of less than 1.0 second were used for the final calculation. Biochemical Assays Levels of NT-3 messenger RNA (mRNA) and protein in skeletal muscles were measured using standard measures of quantitative, real-time polymerase chain reaction (PCR) and enzyme-linked immunosorbent assay (ELISA), respectively. After the completion of 3 weeks of exercise training, mice from all groups were killed 24 hours after the last exercise session. The gastrocnemius and soleus muscles were removed separately and frozen at ⫺80°C. The soleus muscle often is chosen in rat studies because of its high level of recruitment during treadmill training.24,25,27 In our previous study using NT-3 to reduce acid-induced mechanical sensitivity, we chose the gastrocnemius muscle.9 We included both muscles in the present study. Five animals # The MathWorks Inc, PO Box 845428, Boston, MA 02284-5428.

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from each group were randomly chosen for biochemical analysis. The tissue samples from the remaining 5 animals were fixed for future analysis and were not included in this study. Two to 3 independent NT-3 real-time PCR and protein assays per animal were conducted. NT-3 mRNA. Total RNA was isolated using Trizol reagent** as per the manufacturer’s protocol. Frozen tissue samples of the right gastroctrocnemius muscle and the right soleus muscle were homogenized separately in 1 mL of Trizol reagent and precipitated with isopropanol. RNA pellets were washed with 75% ethanol and resuspended in deionized diethylpyrocarbonate water. The RNA concentration was determined using a BioRad spectrophotometer.†† Samples were tested for the quality of RNA using an electrophoretic separation technique (Agilent 2100 bioanalyzer‡‡ tracer with Eukaryote total RNA nano assay) prior to realtime PCR analysis.39 Following the assessment of RNA quality, 0.653 ␮g of RNA was reverse transcribed to complementary DNA (cDNA) using the iScript cDNA synthesis kit.§§ The thermal cycling conditions for reverse transcription were programmed such that each sample cycled at 25°C for 5 minutes, at 42°C for 30 minutes, and at 85°C for 5 minutes for cDNA synthesis. Real-time PCR amplification of NT-3 cDNA was performed using 0.2 ␮g of total cDNA (from 0.653 ␮g reverse-transcribed cDNA) and SYBR green master mix (BioRad iCycler§§). The thermal cycling conditions for real-time PCR were set at 95°C and

** Sigma-Aldrich Corporate Offices, 3050 Spruce St, St Louis, MO 63103. †† Biocompare, 395 Oyster Point Blvd, #405, South San Francisco, CA 94080. ‡‡ Quantum Analytics Inc, 363 Vintage Park Dr, Foster City, CA 94404. §§ Bio-Rad Laboratories, 1000 Alfred Nobel Dr, Hercules, CA 94547.

60°C for 40 cycles (MyiQ real-time PCR detection system§§). Glyceraldehyde 3-phosphate dehydrogenase (GAPDH) was used as a reference gene.24,26,27,40 The primer sequences used for real-time PCR were as follows: NT-3 forward: 5⬘AACGGACACAGAGCTACTACG-3⬘ NT-3 reverse: 5⬘CCATTAGGTATAAGGGAGGGGG-3⬘ GAPDH forward: 5⬘AGGTCGGTGTGAACGGATTTG-3⬘ GAPDH reverse: 5⬘TGTAGACCATGTAGTTGAGGTCA-3⬘ Samples were run in triplicate, and control reactions were run with each amplification series. Control reactions were derived from the gastrocnemius muscle from a mouse that genetically overexpressed NT-3 levels in skeletal muscles. Threshold cycle (CT) values were averaged, and relative changes in RNA levels were determined by subtracting sample CT values from the reference gene CT values (⌬CT). The ⌬CT values were averaged to obtain group means. A higher average CT value suggests that a larger number of cycles were needed to obtain a defined threshold level, indicating less mRNA in the sample. NT-3 protein analysis. The left gastrocnemius and left soleus muscles were used to assess NT-3 protein levels. Frozen sections of samples were separately homogenized in buffer consisting of 20 mM Tris-HCl (pH 8.0), 137 mM NaCl, 1% NP40, 1 mM PMSF, 10% glycerol, 10 ␮g/mL aprotinin, 1 ␮g/mL leupeptin, 0.5 mM sodium vanadate, and 4% Triton X-100 using electrical homogenizers. The homogenates were centrifuged, and supernatants were collected. The total protein concentration was measured using the Bradford method

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Exercise-Induced Analgesia (Bio-Rad protein reagent). The NT-3 protein was quantified using an ELISA kit (NT-3 Emax immunoassay system kit㛳㛳).26,27 Equal amounts of protein extracts from each group were used to quantify NT-3 protein levels (10 ␮g for the soleus muscle and 5 ␮g for the gastrocnemius muscle per well) and were analyzed in duplicate using the manufacturer’s instructions. Data Analysis All data were analyzed using SPSS 15.0 for Windows.## Hypersensitivity following acidic saline injections and the effect of exercise on behavioral measures initially were analyzed using repeated-measures analysis of variance (ANOVA) on the ipsilateral and contralateral sides separately. In addition, a one-way ANOVA was conducted to examine the group differences related to cutaneous and muscle hyperalgesia at different time points when interactions (time ⫻ hypersensitivity or time ⫻ exercise) were significant. The Fisher least significant difference post hoc analysis of behavioral measures was used to conduct pairwise comparisons when groups were significantly different using ANOVA. Comparison between experimental and placebo groups (acidic versus normal saline) was used to indicate hypersensitive status of the mice. Comparison between both experimental groups (with and without exercise) was used to indicate the effect of exercise training. The NT-3 mRNA measurements were analyzed with the Pair-Wise Fixed Reallocation Randomization Test (Pfaffl method) to determine pair-wise comparisons between animals from different groups.41 The Pair-Wise Fixed Reallocation Randomization Test is a nonparametric test similar to the 㛳㛳 Promega Corp, 2800 Woods Hollow Rd, Madison, WI 53711-5399. ## SPSS Inc, 233 Wacker Dr, Chicago, IL 60606.

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Mann-Whitney U test and was used for mRNA analysis because our data were derived from ratios (NT-3 ⫺ GAPDH). In the Pair-Wise Fixed Reallocation Randomization Test, various data points are randomly selected from samples and repeatedly analyzed (random sampling) for effect size (expression of ratio is based on mean values of reference and target genes within control and intervention groups) with mathematical analysis. The NT-3 protein levels were analyzed with one-way ANOVA for group differences. Values were considered significant at an alpha level of ⬍.05. Role of the Funding Source This study was funded by National Institutes of Health/National Institute of Neurological Disorders and Stroke grant R01NS43314 and a Foundation for Physical Therapy Research PODS II scholarship.

crease in withdrawal response was significant for the ipsilateral and contralateral sides (P⬍.05) from before injection to 1 day after acidic saline injection. The withdrawal response remained increased on both sides in the experimental group of mice that did not exercise. In comparison, our post hoc analysis showed that the experimental group of mice that exercised showed a significant decrease in withdrawal response on the ipsilateral side at 1 week and 3 weeks of exercise training (Fig. 1A; P⬍.05). The effect of exercise training on the contralateral side was not significant at any time points (Fig. 1B; P⬎.05). Overall, these results indicate that intramuscular acidic saline injection induced secondary hyperalgesia bilaterally in the hind paws of the mice. Furthermore, moderate-intensity exercise training significantly reduced the cutaneous hypersensitivity on the ipsilateral side.

Results Behavioral Assessments Changes in scores of cutaneous and muscle hyperalgesia were calculated by subtracting the mean value of each time point from the preinjection (baseline) value and are presented in Figures 1 and 2. The actual mean scores and 95% confidence intervals are presented in Tables 1 and 2. Cutaneous mechanical hypersensitivity. The withdrawal responses remained relatively unaffected on the ipsilateral and contralateral sides in both placebo groups of mice that received normal saline injections (Fig. 1), suggesting that neither normal saline injection nor exercise influenced mechanical sensitivity. In contrast, the percentage of withdrawal increased in both experimental groups of mice that received acidic saline injections on the ipsilateral and contralateral sides, consistent with mechanical secondary hyperalgesia (Tab. 1, Fig. 1). The in-

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Muscular mechanical hypersensitivity. Following acidic saline injections, the mice displayed bilateral muscle hyperalgesia that lasted up to 2 weeks, and exercise decreased muscle hyperalgesia (Tab. 2, Fig. 2). The muscle withdrawal threshold increased on the ipsilateral and the contralateral sides 2 weeks following normal saline injections in both placebo groups of mice. These results suggest that the saline-injected mice became acclimated to the muscle compression test and were able to tolerate greater compression over time. In contrast, muscle withdrawal thresholds decreased after acidic saline injections in both experimental groups of mice. In the experimental group that did not exercise, ipsilateral muscle withdrawal thresholds decreased from preinjection to postinjection levels and remained decreased 2 weeks later. The muscle withdrawal threshold on the conMay 2010

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Figure 1. Effect of moderately intense exercise on cutaneous hyperalgesia. Acidic saline injections significantly increased cutaneous withdrawal responses on the ipsilateral and contralateral sides. (A) Moderately intense exercise significantly decreased withdrawal responses at 1-week and 3-week time points on the ipsilateral side (P⬍.05). (B) A similar effect of exercise was noted on the contralateral side, but it was not significant (P⬎.05) at any time points. The thin black arrow indicates the injection of acidic or normal saline. The larger, open arrow indicates the initiation of exercise training. Data are represented as change in mean score from before injection to each time point; error bars indicate standard error of the mean. * denotes status of hypersensitivity and P⬍.05 for difference between experimental and placebo groups (acidic versus normal saline) at the postinjection time points. # denotes effects of exercise training and P⬍.05 for difference between exercise and no-exercise groups at the postexercise time points.

tralateral side also decreased from preinjection to postinjection levels and returned to baseline values 2 weeks later. In the experimental group that exercised, ipsilateral muscle withdrawal thresholds also decreased from preinjection to postinjection testing, but then increased after 2 weeks of exercise training (Tab. 2, Fig. 2A; P⬍.05). Muscle withdrawal thresholds on the contralateral side also decreased from preinjection to postinjection testing but then increased beyond baseline after 2 weeks of exercise training (Fig. 2B; P⬍.05). These results indicate that acidic saline significantly induced bilateral muscular hyperalgesia in the hind limbs of the mice and that exercise training significantly reduced the muscular hypersensitivity on the ipsilateral and contralateral sides. Thus, exercise May 2010

training increased muscle withdrawal thresholds in an animal model of chronic pain. Biochemical Assessments NT-3 mRNA. The NT3 mRNA data are presented in CT values, where a larger number indicates less mRNA in the tissue samples (Fig. 3). Our results show that exercise training had no effect on NT-3 mRNA levels in the soleus muscle (Fig. 3A; P⬎.05), but a trend for increased levels of mRNA (1.7-fold increase; P⫽.06) was noted in the gastrocnemius muscle when comparing both placebo groups of mice (Fig. 3B). In addition, no significant differences in NT-3 mRNA levels were observed between both experimental groups in either the soleus or gastrocnemius muscle. Interestingly, acidic saline injection increased NT-3 mRNA in

the gastrocnemius muscle when NT-3 levels were compared between the 2 groups of mice that did not exercise (Fig. 3B; P⬍.05), suggesting that acidic saline itself may affect NT-3 mRNA levels. NT-3 protein. In contrast to mRNA, a significant increase in protein levels was noted following 3 weeks of moderate-intensity exercise training in the mice. In the soleus muscle, a trend for increased levels of protein was noted in both exercise groups, but it was not significant (Fig. 3C; P⬎.05). However, the protein level of the gastrocnemius muscle was significantly upregulated. Both exercise groups had significantly greater amounts of NT-3 protein compared with the placebo group that did not exercise (Fig 3D; P⬍.05). These results indicate that

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Figure 2. The effect of moderately intense exercise on muscle hyperalgesia. Acidic saline injections significantly decreased muscle withdrawal thresholds on the ipsilateral and contralateral sides. Moderately intense exercise training significantly increased the muscle withdrawal thresholds of both hind limbs (A and B, P⬍.05). The thin black arrow indicates the injection of acidic or normal saline. The larger, open arrow indicates the initiation of exercise training. Data are represented as change in mean score from before injection to each time point; error bars indicate standard error of the mean. * denotes P⬍.05 for difference between experimental and placebo status (acidic versus normal saline) at the postinjection time point. # denotes P⬍.05 for difference between exercise and no exercise at the postexercise time point.

exercise training can increase NT-3 abundance, as reported previously.25–27 Additionally, it appears that exercise can differentially increase NT-3 protein levels in muscles with different properties of fiber types.

Discussion Because most animal studies related to exercise and chronic pain have evaluated cutaneous sensation in neuropathic pain models, there is a significant gap in our knowledge about how exercise alters deep tissue hypersensitivity in a chronic muscular pain model. Here, we analyzed the effect of moderate-intensity exercise training on widespread cutaneous and muscle hyperalgesia induced by acidic saline injection. We further examined a possible molecular correlate (NT-3 synthesis) that could explain the changes in skeletal muscles. The findings of our study suggest that exercise training at720

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tenuates acidic saline-induced cutaneous and muscle hypersensitivity in both limbs. In addition, our findings suggest that moderately intense treadmill running can increase musclederived NT-3 protein levels in mice and that this effect is selective to the gastrocnemius muscle. Overall, these results show, for the first time, that exercise decreases chronic muscle hyperalgesia in rodents, supporting the growing literature indicating the role of NT-3 in pain modulation and providing a potential molecular correlate for exercise-induced analgesia in chronic muscular pain. Aerobic Exercise Decreases Mechanical Hyperalgesia Associated With Intramuscular Acidic Saline Injection Clinical studies using various types of exercise interventions for people with chronic pain syndromes are in-

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creasing.13,15–19,42 These human experiments provide insight into important treatment avenues, but it is clear that additional animal studies are needed to extend our knowledge about exercise-induced analgesia and its mechanisms. A limited number of animal studies have attempted to address this issue. Bement and Sluka21 recently reported that lowintensity treadmill training (3.05 m/min for 30 minutes) for 5 days reversed acid-induced cutaneous mechanical allodynia via an opioidbased mechanism in rats. However, their study examined an immediate effect of exercise, as seen in most animal studies.43 Another study22 demonstrated a decrease in pain responses following 9 days of swimming exercise, yet it was limited to assessing cutaneous sensation. The primary goal of the present study was to examine the long-term effect May 2010

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30.0 (15.9, 44.1)

Experimental with exercise

50.0 (33.1, 66.9)

a

17.3 (9.0, 25.6) 51.3 (38.9, 63.8)

b

22.7 (9.6, 35.8)

68.0a (57.9, 78.1)

45.3a (26.3, 64.4)

Week 1 21.3 (11.4, 31.2)

Postinjection 22.0 (11.3, 32.7)

b

41.3 (30.7, 52.0)

b

18.7 (9.0, 28.4)

60.3a (52.4, 68.3)

129.4 (108.6, 150.1) 102.1 (90.1, 114.1) 98.6 (86.2, 111.1)

Placebo with exercise

Experimental with exercise

Ipsilateral Side

171.8 (155.9, 187.7) 123.1b (108.9, 137.4)

53.9 (44.6, 63.3)

67.6 (57.9, 77.3)

63.4 (50.1, 76.7)

74.6 (60.7, 88.6)

Week 2 97.7 (86.8, 108.7) 61.1a (53.6, 68.6) 99.3 (88.4, 110.1) 75.6b (66.6, 84.7)

59.9 (49.9, 69.9) 36.4a (30.8, 42.0) 58.9 (45.0, 72.9) 38.5a (29.7, 47.3)

43.3a (30.7, 56.0)

Postinjection

Contralateral Side

44.3 (25.9, 62.8)

48.7 (41.9, 55.4)

20.0 (10.3, 29.7)

a

20.7 (12.5, 28.8)

a

21.3 (12.2, 30.4)

52.7a (41.1, 64.3)

60.7a (51.0, 70.3)

Week 3 20.0 (8.6, 31.4)

46.0a (33.8, 58.2)

Week 1 27.3 (16.4, 38.3)

Postinjection

Contralateral Side

34.0 (20.7, 47.3)

Preinjection

26.7 (12.0, 41.4)

27.3 (11.1, 43.6)

21.3 (13.3, 29.3)

114.7 (99.3, 130.1)

103.5a (91.5, 115.5)

Preinjection 28.0 (20.3, 35.7)

69.2a (57.6, 80.8)

170.3 (160.4, 180.1)

118.86 (97.7, 140.0)

Week 2

71.6a (64.0, 79.2)

Postinjection

P⬍.05 for experimental group mice that developed muscle hyperalgesia following acidic saline injections. P⬍.05 for exercise group mice compared with their no-exercise counterparts.

99.6 (82.4, 116.7)

Experimental without exercise

Preinjection

Placebo without exercise

Group

Mean Scores and 95% Confidence Intervals for the Muscle Behavioral Test

a

Week 3 20.7 (12.1, 29.3)

P⬍.05 for experimental group mice that developed cutaneous hyperalgesia following acidic saline injections. P⬍.05 for exercise group mice compared with their no-exercise counterparts.

26.7 (16.2, 37.2)

Placebo with exercise

Table 2.

b

a

22.7 (12.3, 33.0)

Experimental without exercise

Preinjection

17.3 (6.1, 28.6)

Group

Placebo without exercise

Ipsilateral Side

Mean Scores and 95% Confidence Intervals for the Cutaneous Behavioral Test

Table 1.

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of exercise training on muscle hypersensitivity, which is the predominant complaint in people with various chronic pain syndromes.44 Our results are consistent with those of previous studies21,22,25 and suggest that moderate-intensity exercise can be effective in reducing widespread hyperalgesia that is chronic in nature, potentially by modulating NT-3 levels.

Moderately Intense Exercise Training Can Induce NT-3 Synthesis In adulthood, NT-3 is primarily synthesized in skeletal muscles, within muscle spindles and smooth muscles surrounding the arterial supply (unpublished observations and Wright et al45). The exact mechanism by which exercise induces NT-3 synthesis is unknown. However, it is possible that the ability of exercise to increase levels of NT-3 may be associated with potentially increased muscle spindle activity or increased in muscle perfusion from exercise training. Some studies24,25,27 have shown that exercise training can induce NT-3 synthesis. Various types of exercise training, such as treadmill training,24 general physical activity of swimming or hind-paw standing,25 and voluntary wheel running,27 have increased peripheral or spinal NT-3 synthesis. In a spinal cord injury model, 28 days of wheel running was required to stimulate NT-3 synthesis.25 Our results are consistent with those of these studies and demonstrate that moderately intense exercise training was sufficient to abolish muscle-originated hyperalgesia. Activity-dependent changes in muscle may have a strong effect on NT-3 levels via activation of proprioceptive and muscle afferents that could result in exercise-induced analgesia. Muscle activity provides signals to innervating neurons and can alter the synthesis of neurotrophic factors.24 –26,46,47

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Figure 3. Effect of exercise on neurotrophin-3 (NT-3) messenger RNA (mRNA) and protein synthesis. Moderately intense exercise training did not change NT-3 mRNA expression in the soleus or gastrocnemius muscle (A and B, P⬎.05). In contrast, the effect of exercise training did increase NT-3 protein levels (C and D). The increased NT-3 protein levels were not significant in the soleus muscle (C, P⬎.05) but were significant in the gastrocnemius muscle (D, P⬍.05). The NT-3 mRNA data (A and B) are represented in threshold cycle (CT) value, where lower values indicate a higher amount of mRNA in the sample. In addition, comparisons between groups (B) are indicated by fold change (2⌬CT-⌬CT). Data represented as mean scores; error bars indicate standard error of the mean. Group comparisons with P⬍.05 are denoted with asterisk (*), indicating that both exercise groups of mice were different from the placebo group of mice that did not exercise (D).

One surprising finding from this study was that we observed significant exercise-induced increases in NT-3 only in the gastrocnemius muscle. We did observe a trend in increased NT-3 protein in the soleus muscle, consistent with previous rat 722

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studies.24 –27 The functions of the soleus and gastrocnemius muscles are different, and these muscles are composed of very different fiber types. The soleus muscle consists of both type I and type II fibers, whereas the gastrocnemius muscle has predomi-

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nantly type II muscle fibers.48,49 It is not known whether NT-3 is preferentially expressed more in slowtwitch fibers or in fast-twitch fiber types under normal conditions, but our studies suggest that this possibility could account for the differences May 2010

Exercise-Induced Analgesia in NT-3 expression between gastrocnemius and soleus muscles in rodents. Neurotrophin-3 has been shown to favorably improve reinnervation of fast-twitch muscles (gastrocnemius and extensor digitorum longus muscles) over slow-twitch muscles (soleus muscle),50 and myogenic and transgenic mice that overexpress NT-3 and develop excessive muscle spindles do so only in the gastrocnemius muscle and not in the soleus muscle.45 Collectively, these data suggest that NT-3 is differentially synthesized in select muscle fiber types, and our results suggest that aerobic exercise training may be associated with this differential increase in NT-3 levels. Antinociceptive Effects of NT-3 on Chronic Pain Neurotrophin-3 is an antinociceptive molecule and a biomarker for testing activation of large beta and proprioceptive fibers. Once, NT-3 is synthesized in peripheral tissues, it preferentially binds to its receptors located on about 75% of muscle afferents30 and is retrogradely transported to cell bodies of the dorsal root ganglia.30,51–53 Given its anatomical location and ability to be altered under physiological stress (ie, exercise), NT-3 is positioned to influence afferent input associated with chronic pain, in terms of both peripheral afferent activity and modulation of spinal neurons. In addition, the effects of NT-3 are not restricted to largediameter afferent fibers, as C-fibers and A␦-fibers also are known to respond to NT-3.9,29 Therefore, NT-3 is capable of modulating different sensory fiber types after certain injuries.29,54 Neurotrophin-3 also has been shown to reduce the expression of tyrosine kinase A receptors for nerve growth factor and substance P in dorsal root ganglion neurons, both of which are involved in inflammatory pain.28 The antagonistic role of NT-3 on secondary hyperalgesia has been tested in many pain May 2010

models. Intrathecal administration of NT-3 prevents thermal hyperalgesia and suppresses the injury-induced overexpression of these receptors in the dorsal root ganglia and the spinal cord of rats receiving a sciatic nerve injury.29 A single systemic dose of NT-3 into hyperalgesic rats results in mechanical but not thermal hypoalgesia 24 hours following its administration.30 Either overexpression of NT-3 or intramuscular injection of NT-3 decreases mechanical hyperalgesia from acid injection.9 Collectively, these findings strengthen the role of NT-3 as an antinociceptive neurotrophin in treating muscle pain and provide further support for exercise training as a therapeutic intervention for the field of pain medicine. Limitations The duration of the exercise training and lack of frequent behavioral testing may be a limitation of this study and should be considered in future studies. To comprehend the full effect of exercise training on chronic pain, future studies should consider extending exercise training for longer periods and conducting frequent behavioral measures. This study demonstrated a possible correlation between NT-3 synthesis and decrease in muscle and cutaneous hyperalgesia from exercise training in a muscle pain model. Future studies could be conducted by blocking the NT-3 receptor tyrosine kinase C to establish a mechanism of exerciseinduced analgesia via NT-3 synthesis. Demonstration of actions of exercise on neurotrophin levels has been restricted to animal models and it may be difficult to relate the results of the study to clinical syndromes of chronic pain in humans. However, the study provides a possible physiological correlate for exerciseinduced relief of muscle pain reported in clinical studies. It will be interesting to find out whether these

observations hold true in human studies. Blood samples and muscle biopsies following exercise training might provide some insight into possible exercise effects on select neurotrophins in human experiments. Clinical Significance The mechanisms of exercise-induced analgesia in patients with chronic pain are poorly understood. Two possible mechanisms have been reported. The most widely accepted explanation involves modulation of central opioid receptors.17,21,55,56 Alternatively, activation of muscle and proprioceptive afferents may affect descending inhibitory pathways and central sensitization.39,57 The theory of activation of proprioceptive input to override pain has gained interest in physical therapy rehabilitation. Our results provide a possible correlation between activity-related NT-3 synthesis (presumably through activation of muscle afferent fibers from exercise training) and an exerciseinduced decrease in hyeralgesia. The correlation of pain modulation and NT-3 changes through exercise training can provide support for exercise prescriptions. It is important to determine the intensity of exercise training required to activate muscle afferents and synthesize neurotrophins. Although more studies are needed to examine this issue further, our results suggest that moderate-intensity exercise training is sufficient to induce NT-3 synthesis. Human studies provide similar evidence for exercise training for people with fibromyalgia. Longterm aerobic training at a moderate level (50%– 60% of maximum heart rate) with gradual progression from pool walking to land jogging for 30 minutes, 3 to 5 times per week, decreases symptom severity and improves physical function and aspects of self-care in individuals with fibromyalgia.15,16,18

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Conclusion We have demonstrated that moderate-intensity exercise training did not cure but significantly reduced cutaneous and deep tissue mechanical hypersensitivity induced by acidic saline injection. This finding is consistent with the findings of human studies, as exercise does not reverse the painful condition but rather decreases pain and improves function. The data also demonstrate an increase in activity-dependent NT-3 levels in selected peripheral tissues. Based on emerging views about the analgesic properties of NT-3, it is plausible to suggest that the decrease in mechanical hypersensitivity following exercise may be due, in part, to elevated levels of NT-3 protein. However, the mechanism by which NT-3 modulates mechanoreceptors is still unknown and remains to be investigated. Dr Sharma and Dr Wright provided concept/ idea/research design, writing, project management, and fund procurement. Dr Sharma and Ms Ryals provided data collection. Dr Sharma and Dr Gajewski provided data analysis. Dr Wright provided facilities/equipment. Ms Ryals provided clerical support. The authors thank Megan Johnson and Karra Muller for helpful comments on the manuscript and Jennifer Koch, Elizabeth Phelps, and Melissa Sindt for helping with exercise training. A poster presentation of this work was given at the Combined Sections Meeting of the American Physical Therapy Association; February 9 –12, 2009; Las Vegas, Nevada. This study was funded by National Institutes of Health/National Institute of Neurological Disorders and Stroke grant R01NS43314 and a Foundation for Physical Therapy Research PODS II scholarship. This article was received May 25, 2009, and was accepted January 17, 2010. DOI: 10.2522/ptj.20090168

References 1 Gran JT. The epidemiology of chronic generalized musculoskeletal pain. Best Pract Res Clin Rheumatol. 2003;17:547–561.

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2 Neumann L, Buskila D. Epidemiology of fibromyalgia. Curr Pain Headache Rep. 2003;7:362–368. 3 Rohrbeck J, Jordan K, Croft P. The frequency and characteristics of chronic widespread pain in general practice: a case-control study. Br J Gen Pract. 2007; 57:109 –115. 4 Sluka KA, Kalra A, Moore SA. Unilateral intramuscular injections of acidic saline produce a bilateral, long-lasting hyperalgesia. Muscle Nerve. 2001;24:37– 46. 5 Sluka KA, Rohlwing JJ, Bussey RA, et al. Chronic muscle pain induced by repeated acid Injection is reversed by spinally administered mu- and delta-, but not kappa-, opioid receptor agonists. J Pharmacol Exp Ther. 2002;302:1146 –1150. 6 Sluka KA, Price MP, Breese NM, et al. Chronic hyperalgesia induced by repeated acid injections in muscle is abolished by the loss of ASIC3, but not ASIC1. Pain. 2003;106:229 –239. 7 Skyba DA, King EW, Sluka KA. Effects of NMDA and non-NMDA ionotropic glutamate receptor antagonists on the development and maintenance of hyperalgesia induced by repeated intramuscular injection of acidic saline. Pain. 2002;98:69 –78. 8 Hoeger-Bement MK, Sluka KA. Phosphorylation of CREB and mechanical hyperalgesia is reversed by blockade of the cAMP pathway in a time-dependent manner after repeated intramuscular acid injections. J Neurosci. 2003;23:5437–5445. 9 Gandhi R, Ryals JM, Wright DE. Neurotrophin-3 reverses chronic mechanical hyperalgesia induced by intramuscular acid injection. J Neurosci. 2004;24:9405–9413. 10 Miranda A, Peles S, Rudolph C, et al. Altered visceral sensation in response to somatic pain in the rat. Gastroenterology. 2004;126:1082–1089. 11 Yokoyama T, Lisi TL, Moore SA, Sluka KA. Muscle fatigue increases the probability of developing hyperalgesia in mice. J Pain. 2007;8:692– 699. 12 Sharma NK, Ryals JM, Liu H, et al. Acidic saline-induced primary and secondary mechanical hyperalgesia in mice. J Pain. 2009;10:1231–1241. 13 Goldenberg DL, Burckhardt C, Crofford L. Management of fibromyalgia syndrome. JAMA. 2004;292:2388 –2395. 14 Wang LX, Wang ZJ. Animal and cellular models of chronic pain. Adv Drug Deliv Rev. 2003;55:949 –965. 15 Meiworm L, Jakob E, Walker UA, et al. Patients with fibromyalgia benefit from aerobic endurance exercise. Clin Rheumatol. 2000;19:253–257. 16 Gowans SE, deHueck A. Effectiveness of exercise in management of fibromyalgia. Curr Opin Rheumatol. 2004;16:138 –142. 17 Hoffman MD, Shepanski MA, Ruble SB, et al. Intensity and duration threshold for aerobic exercise-induced analgesia to pressure pain. Arch Phys Med Rehabil. 2004;85:1183–1187. 18 Whiteside A, Hansen S, Chaudhuri A. Exercise lowers pain threshold in chronic fatigue syndrome. Pain. 2004;109:497– 499.

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19 Redondo JR, Justo CM, Moraleda FV, et al. Long-term efficacy of therapy in patients with fibromyalgia: a physical exercisebased program and a cognitive-behavioral approach. Arthritis Rheum. 2004;51: 184 –192. 20 Mannerkorpi K. Exercise in fibromyalgia. Curr Opin Rheumatol. 2005;17:190 –194. 21 Bement MK, Sluka KA. Low-intensity exercise reverses chronic muscle pain in the rat in a naloxone-dependent manner. Arch Phys Med Rehabil. 2005;86:1736 –1740. 22 Kuphal KE, Fibuch EE, Taylor BK. Extended swimming exercise reduces inflammatory and peripheral neuropathic pain in rodents. J Pain. 2007;8:989 –997. 23 Pezet S, McMahon SB. Neurotrophins: mediators and modulators of pain. Annu Rev Neurosci. 2006;29:507–538. 24 Go ´ mez-Pinilla F, Ying Z, Opazo P, et al. Differential regulation by exercise of BDNF and NT-3 in rat spinal cord and skeletal muscle. Eur J Neurosci. 2001;13: 1078 –1084. 25 Hutchinson KJ, Go ´ mez-Pinilla, Crowe MJ, et al. Three exercise paradigms differentially improve sensory recovery after spinal cord contusion in rats. Brain. 2004; 127(pt 6):1403–1414. 26 Ying Z, Roy RR, Edgerton VR, Go ´ mez-Pinilla. Exercise restores levels of neurotrophins and synaptic plasticity following spinal cord injury. Exp Neurol. 2005; 193: 411– 419. 27 Ying Z, Roy RR, Edgerton VR, Go ´mez-Pinilla. Voluntary exercise increases neurotrophin-3 and its receptor TrkC in the spinal cord. Brain Res. 2003;987:93–99. 28 Gratto KA, Verge VM. Neurotrophin-3 down-regulates trkA mRNA, NGF highaffinity binding sites, and associated phenotype in adult DRG neurons. Eur J Neurosci. 2003;18:1535–1548. 29 Wilson-Gerwing TD, Dmyterko MV, Zochodne DW, et al. Neurotrophin-3 suppresses thermal hyperalgesia associated with neuropathic pain and attenuates transient receptor potential vanilloid receptor-1 expression in adult sensory neurons. J Neurosci. 2005;25:758 –767. 30 Watanabe M, Endo Y, Kimoto K, et al. Inhibition of adjuvant-induced inflammatory hyperalgesia in rats by local injection of neurotrophin-3. Neurosci Lett. 2000;282: 61– 64. 31 Gran JT. The epidemiology of chronic generalized musculoskeletal pain. Best Pract Res Clin Rheumatol. 2003;17 547–561. 32 Yunus MB. The role of gender in fibromyalgia syndrome. Curr Rheumatol Rep. 2001;3:128 –134. 33 Yunus MB. Gender differences in fibromyalgia and other related syndromes. J Gend Specif Med. 2002;5:42– 47. 34 Aguiar AS Jr, Tuon T, Pinho CA, et al. Intense exercise induces mitochondrial dysfunction in mice brain. Neurochem Res. 2008;33:51–58. 35 Burghardt PR, Fulk LJ, Hand GA, Wilson MA. The effects of chronic treadmill and wheel running on behavior in rats. Brain Res. 2004;1019:84 –96.

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Exercise-Induced Analgesia 36 Sastre J, Asensi M, Gasco E, et al. Exhaustive physical exercise causes oxidation of glutathione status in blood: prevention by antioxidant administration. Am J Physiol. 1992;263(5 pt 2):R992–995. 37 Billat VL, Mouisel E, Roblot N, Melki J. Inter- and intrastrain variation in mouse critical running speed. J Appl Physiol. 2005; 98:1258 –1263. 38 Yu YC, Koo ST, Kim CH, et al. Two variables that can be used as pain indices in experimental animal models of arthritis. J Neurosci Methods. 2002;115:107–113. 39 Schroeder A, Mueller O, Stocker S, et al. The RIN: an RNA integrity number for assigning integrity values to RNA measurements. BMC Mol Biol. 2006;7:3. 40 Mahoney DJ, Carey K, Fu MH, et al. Realtime RT-PCR analysis of housekeeping genes in human skeletal muscle following acute exercise. Physiol Genomics. 2004; 18:226 –231. 41 Pfaffl MW. A new mathematical model for relative quantification in real-time RT-PCR. Nucleic Acids Res. 2001;29:e45. 42 Droste C. Transient hypoalgesia under physical exercise: relation to silent ischaemia and implications for cardiac rehabilitation. Ann Acad Med Singapore. 1992; 21:23–33. 43 Koltyn KF. Analgesia following exercise: a review. Sports Med. 2000;29:85–98.

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44 Borg-Stein J. Management of peripheral pain generators in fibromyalgia. Rheum Dis Clin North Am. 2002;28:305–317. 45 Wright DE, Zhou L, Kucera J, Snider WD. Introduction of a neurotrophin-3 transgene into muscle selectively rescues proprioceptive neurons in mice lacking endogenous neurotrophin-3. Neuron. 1997; 19:503–517. 46 Molteni R, Zheng JQ, Ying Z, et al. Voluntary exercise increases axonal regeneration from sensory neurons. Proc Natl Acad Sci USA. 2004;101:8473– 8478. 47 Xie K, Wang T, Olafsson P, et al. Activitydependent expression of NT-3 in muscle cells in culture: implications in the development of neuromuscular junctions. J Neurosci. 1997;17:2947–2958. 48 Burkholder TJ, Fingado B, Baron S, Lieber RL. Relationship between muscle fiber types and sizes and muscle architectural properties in the mouse hindlimb. J Morphol. 1994;221:177–190. 49 Ashmore CR, Doerr L. Comparative aspects of muscle fiber types in different species. Exp Neurol. 1971;31:408 – 418. 50 Simon M, Terenghi G, Green CJ, Coulton GR. Differential effects of NT-3 on reinnervation of the fast extensor digitorum longus (EDL) and the slow soleus muscle of rat. Eur J Neurosci. 2000;12:863– 871.

51 Wright DE, Williams JM, McDonald JT, et al. Muscle-derived neurotrophin-3 reduces injury-induced proprioceptive degeneration in neonatal mice. J Neurobiol. 2002;50:198 –208. 52 Malcangio M, Garrett NE, Cruwys S, Tomlinson DR. Nerve growth factor- and neurotrophin-3-induced changes in nociceptive threshold and the release of substance P from the rat isolated spinal cord. J Neurosci. 1997;17:8459 – 8467. 53 Munson JB, Johnson RD, Mendell LM. Neurotrophin-3 and maintenance of muscle afferent function. Prog Brain Res. 1999;123:157–163. 54 Saragovi HU, Gehring K. Development of pharmacological agents for targeting neurotrophins and their receptors. Trends Pharmacol Sci. 2000;21:93–98. 55 Goldfarb AH, Jamurtas AZ. Beta-endorphin response to exercise: an update. Sports Med. 1997;24:8 –16. 56 Schwarz L, Kindermann W. Changes in beta-endorphin levels in response to aerobic and anaerobic exercise. Sports Med. 1992;13:25–36. 57 Farrell PA, Gustafson AB, Morgan WP, Pert CB. Enkephalins, catecholamines, and psychological mood alterations: effects of prolonged exercise. Med Sci Sports Exerc. 1987;19:347–353.

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Research Report Do As I Do: Exercise Habits of Physical Therapists, Physical Therapist Assistants, and Student Physical Therapists Julia Chevan, Esther M. Haskvitz J. Chevan, PT, PhD, MPH, OCS, is Professor of Physical Therapy, Department of Physical Therapy, Springfield College, 263 Alden St, Springfield, MA 01109 (USA). Address all correspondence to Dr Chevan at: [email protected]. E.M. Haskvitz, PT, PhD, ATC, is Associate Professor, Physical Therapy Department, The Sage Colleges, Troy, New York. [Chevan J, Haskvitz EM. Do as I do: exercise habits of physical therapists, physical therapist assistants, and student physical therapists. Phys Ther. 2010;90:726 –734.] © 2010 American Physical Therapy Association

Background. Physical therapy practitioners are among the many health care professionals who can counsel their patients to address the public health care concern of physical inactivity. Health care providers who are physically active themselves are more likely to counsel patients on the benefits of activity. Objective. The purposes of this study were: (1) to examine the leisure-time physical activity habits of physical therapists, physical therapist assistants, and student physical therapists in the United States using Centers for Disease Control and Prevention and American College of Sports Medicine (CDC-ACSM) recommendations and (2) to compare these habits with those of the general population and other health care professionals.

Design. A cross-sectional survey design was used. Methods. There were 2 data sources. A random sample of American Physical Therapy Association members completed an online survey that included questions about physical activity habits worded in same manner as the leisure-time activities section of the 2005 National Health Interview Survey (NHIS). The final study sample comprised 1,238 participants: 923 physical therapists, 210 student physical therapists, and 105 physical therapist assistants. The 2005 NHIS public use data files were the source for the same information about the general US population and for a subset of health care professionals. Rates of participation in vigorous and moderate physical activity were analyzed.

Results. Physical therapists, physical therapist assistants, and student physical therapists exercised at higher rates than adults and health-diagnosing professionals in the 2005 NHIS.

Limitations. The study may be limited by sampling and response bias. Conclusions. This study identified that physical therapists, physical therapist assistants, and student physical therapists are meeting CDC-ACSM physical activity guidelines at higher rates than the US adult population and health-diagnosing professionals. These rates exceed the physical activity targets set for adults in Healthy People 2010. Post a Rapid Response to this article at: ptjournal.apta.org 726

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hysical activity is an important component of a healthy lifestyle to reduce a person’s risk of developing disease and subsequent disability.1,2 Physical inactivity is a growing public health concern. Among adults 18 years of age and older in the United States, the rate of inactivity remained steady at 40% from 1998 to 2005.3 This concern is being addressed by many professional organizations, including the American Medical Association, the American College of Sports Medicine (ACSM),4 and the American Physical Therapy Association (APTA).5,6 The APTA has provided guidance to physical therapists about their role in promoting physical activity through the development of a plan for physical fitness for special populations, as well as statements on the role of physical therapists in promoting health, wellness, physical education, and physical conditioning.5–7 The Guide to Physical Therapist Practice specifically states that physical therapists are expected to “promote health, wellness, and fitness.”8 Physical therapists are well suited to provide counseling to patients and clients about the need to participate in physical activity. Current recommendations for physical activity advocated by the ACSM and the American Heart Association are that “all healthy adults aged 18 to 65 need moderate-intensity aerobic physical activity for a minimum of 30 minutes, 5 days each week or vigorous-intensity aerobic activity for a minimum of 20 minutes, 3 days each week.”9(p1425) The majority of US adults do not meet these guidelines, with 31.6% reporting regular leisure-time physical activity and 38% reporting never engaging in physical activity during leisure time.3,10 Improving levels of physical activity participation in the United States will require effective dissemination of May 2010

guidelines and acceptance of the importance of physical activity for disease prevention and health enhancement.11 Although the evidence of the effects of behavioral counseling on physical activity is mixed,12 physician and other professional organizations,4 including APTA,7 have developed programs urging professionals to counsel patients about regular physical activity. These professionals also need to be physically active themselves, not only for their own benefit, but also because of their position as role models. The endorsement of an active lifestyle is more credible coming from a professional who is physically active.11 Surveys of physicians and medical students have shown that those who are physically active are more likely to counsel their patients on the benefits of activity.13–15 Estimates of the proportion of physicians who participate in leisure-time physical activity have been documented in a number of studies, and these estimates fall in a broad range from 27% to 73%.13,15–17 Physical activity participation rates among hospital employees, nursing students, and medical students also have been studied.18 –22 We were unable to find published studies documenting the physical activity habits of physical therapists. Physical therapists are trained to be authorities on exercise. Williford et al23 found that when physicians recommended an exercise program to a patient, a physical therapist was the most likely health care professional to whom referral was made. Rea et al24 found that the health-promoting behavior that received the greatest attention from physical therapists was the promotion of physical activity to their patients. Because physicians and medical students who were physically active were more likely to counsel their patients on the benefits of activity than their sedentary counterparts,13–15 knowledge of the physical activity habits of physi-

cal therapists may be an important indicator of their willingness to engage in counseling activities. In addition to physical therapists, physical therapist assistants are engaged in direct patient care with a potential to counsel. Student physical therapists’ physical activity behaviors may provide an indicator for the future of physical activity among those in the profession or a gauge of the level of self-selection of active people into the profession. The purposes of this study were: (1) to develop an estimate of the rate of participation in leisure-time physical activities among physical therapists, physical therapist assistants, and student physical therapists and (2) to compare these estimates to rates of physical activity among US adults and health care professionals identified in the 2005 National Health Interview Survey (NHIS).

Method Data Sources We compiled data from 2 sources for this study. The 2005 NHIS was used to assess the physical activity habits of all US adults and of people classified as “health professionals.” A selfdesigned survey of activity with questions derived from the leisuretime activities portion of the NHIS was administered to a randomly selected sample of APTA members who were physical therapists, physical therapist assistants, and student physical therapists to gather data on their personal exercise habits. The 2005 NHIS was selected as the comparator data source to match the

Available With This Article at ptjournal.apta.org • Audio Abstracts Podcast This article was published ahead of print on March 18, 2010, at ptjournal.apta.org.

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Exercise Habits of Physical Therapists, Physical Therapist Assistants, and Student Physical Therapists year of administration of the selfdesigned survey. NHIS. The NHIS is a populationbased, nationally representative survey conducted annually by the National Center for Health Statistics (NCHS) of the Centers for Disease Control and Prevention (CDC). The NHIS is one of the tools used to study and measure the health status and health behaviors of the civilian, noninstitutionalized population of the United States. The survey consists of a core module, which includes a family core survey, a survey of a sample adult randomly selected from each household, and a survey of a sample child randomly selected from each household. Public use files are released annually and made available via the CDC Web site. Detailed information about the NHIS and the method used in data collection may be found at the NCHS Web site25 or in published literature.26,27 The 2005 NHIS sample adult data file (SADF) was used to extract data on physical activity for adults and for that subpopulation classified as a health care professional. The subpopulation of health care professionals was selected as the group that would most closely match physical therapists in their occupation, educational background, and social status. The SADF included demographic information and contained variables that documented responses to the survey questions asked about leisure-time activities related to exercise (Appendix). The SADF also contained weighting, primary sampling unit, and strata variables to account for the complex design of the NHIS. These variables are needed to develop national estimates and to enable population-based estimates. The SADF from 2005 contained 31,428 people aged18 years or older. In the SADF, 735 people were identified as unable to exercise in any 728

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fashion; these people were dropped from the base population for our analysis. Health care professionals were identified from a set of variables that described a person’s industry and occupation. Because broad categories are used for the occupation variables, we used the category of “health-treating and -diagnosing professionals.” Among those professionals included in that category are physical therapists, physicians, nurses, and physician assistants. The SADF contained 706 people identified as “health-treating and -diagnosing professionals.” Due to privacy restrictions on public data files, further breakdown of the specific professions associated with these people is not available. Among the SADF respondents who were able to exercise, the mean (SD) age was 45.2 (17.4) years and 47.4 (14.7) years for the healthtreating and -diagnosing professionals. The percentage of women among the SADF respondents able to exercise was 56%, whereas for the health care professionals it was 78%. Survey of Leisure-Time Activities for Physical Therapists. The selfdesigned Survey of Leisure-Time Activities for Physical Therapists (SLTAPT) was administered using the SurveyMonkey online survey tool. The survey consisted of 5 background demographic questions followed by sections asking about vigorous activities, moderate activities, and strengthening activities done during leisure time. All of the vigorous, moderate, and strength activities questions were asked using definitions and phrasing identical to the 2005 NHIS (Appendix). By using NHIS phrasing for the survey, we could be sure that we were using questions that previously had been field tested, validated, and assessed for their reliability. All estimates of levels of physical activity in this article and associated statistics presented follow the NCHS guidelines for reliability of data and have a rel-

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ative standard error of 30% or less (personal communication with NCHS). The SLTAPT was available online from October 2005 until December 2005. Potential participants were contacted by notices that were posted on physical therapy e-mail listservs for APTA sections or through a direct contact e-mail that contained the link to the survey. Our intent was to generate a representative 1% sample of the APTA membership list, which numbered 69,994 at the time of our study. The Figure shows the flow of respondents in the study. A random selection algorithm using the entire APTA membership list was applied for the direct contact e-mails, resulting in 2,960 e-mail notices sent. In the algorithm, a random number generator was used to generate a 3-digit number that was matched to letters of the alphabet (eg, A⫽1, B⫽2, and so on). Then, all members whose last name started with these 3 letters were sent an e-mail invitation to participate, until 2,960 e-mails were sent by the computer program that was monitoring response rate at the survey Web site. From these e-mails, 466 were returned due to having undeliverable e-mail addresses. We were unable to determine how many of the e-mails actually reached the intended recipients. A follow-up reminder e-mail notice was sent 4 to 6 weeks after the initial e-mail or listserv notice was sent. At the end of the survey period, data were downloaded for 1,352 survey respondents from the SurveyMonkey Web site. Inclusion criteria for participating in the survey were that respondents must have been currently practicing physical therapy in the United States, have direct patient care, and have billable patient hours. We excluded 114 respondents from May 2010

Exercise Habits of Physical Therapists, Physical Therapist Assistants, and Student Physical Therapists the database for not meeting inclusion criteria or for not providing complete information. The final study sample consisted of 1,238 respondents: 923 physical therapists, 105 physical therapist assistants, and 210 student physical therapists. The ages of the physical therapists, physical therapist assistants, and student physical therapists in our sample appear to be representative of the entire membership of APTA. The mean (SD) age of our student sample was 24.9 (10.7) years compared with 25.2 (4.1) years for the APTA membership. The mean (SD) age of the physical therapists was 40.5 (10.3) years compared with 42.4 (12.3) years for the membership, and the mean (SD) age for the physical therapist assistants was 38.6 (11.2) years compared with 38.7 (10.8) years for the membership. The mean (SD) age in our total sample was 37.7 (11.6) years. Women comprised 73% of our sample compared with 65% of the APTA membership (personal communication, APTA). Variables Variables to analyze exercise frequency were constructed for both the SADF and the SLTAPT data. Duration of vigorous and moderate leisure-time activities was converted to minutes. We identified a respondent as meeting the guidelines using a moderate level of activity if he or she participated in at least 30 minutes of moderate activity, 5 or more days of the week. A respondent met the vigorous exercise guidelines if he or she participated in at least 20 minutes of vigorous activity, 3 or more days of the week. To meet the guidelines through a combination of moderate and vigorous activity, a respondent had to be engaged in physical activity for at least 5 days of the week, with the vigorous activities encompassing 20 minutes and the moderate activities encompassing 30 minutes. A respondent met the curMay 2010

Figure. Flow diagram for respondents to the survey of leisure-time activities for physical therapists. APTA⫽American Physical Therapy Association.

rent guidelines for strength training if activities were carried out on at least 2 days of the week. Data Analysis Weighted frequencies, percentages, confidence intervals, and standard errors were calculated to examine exercise frequency among all the groups of interest. Tests of proportions were used to compare results among the subgroups. We were most interested in our primary comparison, which was between the physical therapy practitioner groups and the US population. After examining that comparison, we compared the physical therapy practitioner groups with the subpopulation of health care professionals identified in the NHIS data. All data were analyzed using Stata/SE 9.2 for Windows.* Stata survey commands were used to account for the complex survey design. * Stata Corp LP, 4905 Lakeway Dr, College Station, TX 77845.

Wave analysis28 was used to estimate nonresponse bias comparing the earlier and later respondents on both the demographic and exercise frequency variables. Accordingly, both t tests and chi-square analysis were used to compare age, sex, and exercise frequency between people who responded to the survey in the first 2 weeks of survey availability (n⫽457) and those who responded to the survey in the last 2 weeks of availability (n⫽47).

Results Physical therapists, physical therapist assistants, and student physical therapists are all exercising at higher rates than the US noninstitutionalized adults in the 2005 NHIS survey, as well as those identifying themselves as health-diagnosing and -treating professionals. The proportions of those exercising at the ACSM-recommended level are shown in the Table. The rates of activity were significantly different for

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Exercise Habits of Physical Therapists, Physical Therapist Assistants, and Student Physical Therapists Table. Physical Activity Comparisons Among Physical Therapists, US Adults, and Health-Diagnosing and -Treating Professionalsa Meets Recommendation With a Combination of Moderate and Vigorous Activity

Strength Training

Any Physical Activity at Recommendation Level

Meets Recommendation With Moderate Activity Only

Meets Recommendation With Vigorous Activity Only

Physical therapists (n⫽923)

67.0% (63.9, 70.0)

15.2% (12.9, 17.5)

51.7% (48.5, 54.9)

9.4% (7.5, 11.3)

59.1% (55.9, 62.3)

Physical therapist assistants (n⫽105)

63.8% (54.6, 73.1)

17.1% (9.9, 24.4)

46.7% (37.1, 56.3)

12.4% (6.0, 18.7)

59.6% (50.3, 69.0)

Student physical therapists (n⫽210)

72.4% (66.3, 78.4)

18.6% (13.3, 23.8)

58.1% (51.4, 64.8)

9.0% (5.2, 12.9)

55.8% (49.0, 62.7)

Adults in 2005 NHIS (n⫽30,693)

36.1% (35.2, 36.9)

16.5% (15.9, 17.0)

24.3% (23.5, 25.0)

3.4% (3.2, 3.7)

20.2% (19.6, 20.9)

Health-diagnosing and -treating professionals in 2005 NHIS (n⫽706)

44.5% (40.2, 48.8)

19.2% (16.1, 22.3)

32.9% (28.5, 37.3)

3.2% (1.7, 4.8)

30.5% (26.3, 34.7)

Variable

a Percentage reflects proportion of respondents within each category; values in parentheses are 95% confidence intervals. NHIS⫽National Health Interview Survey.

physical therapists than those from the 2 samples of the NHIS when any physical activity and when vigorous activity were considered (P⬍.05). The rates of activity also differed significantly when physical therapist assistants and student physical therapists were compared with the 2 samples from the NHIS (P⬍.05). The rate of moderate activity at the ACSM-recommended level was similar across all study samples. Physical therapists also engaged in strength training at rates that exceeded those of adults and health-diagnosing and -treating professionals in the 2005 NHIS (P⬍.05).

Discussion Physical therapists, physical therapist assistants, and student physical therapists all appear to follow the ACSM recommendations for physical activity at rates higher than those of both the general public and other health care professionals. The higher rates emanate from the high percentage of physical therapists, physical therapist assistants, and student physical therapists who maintain a program of vigorous physical activity. Frank et al22 found that medical students also preferred strenuous ex730

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ercise as modality of choice for physical activity. One benefit of a program of vigorous activity is that a busy professional can meet the recommendations with only 3 days of activity. Among those we surveyed who met the recommendations, the most frequently reported number of days on which activity was performed was 3 (38.1%), 4 (23.6%), or 5 (16.4%) days. Jones et al29 found that the prevalence of adults meeting the CDCACSM guidelines decreased with age. Our results support that finding. We acknowledge that there are age differences between the sample of therapists and the 2 NHIS samples; however, the 5- to 7-year difference, on average, between the 2 groups would not account for the substantial difference in exercise rates. Jones et al29 showed the greatest reduction in meeting guidelines occurred after the age of 65 years. Among our respondents, student physical therapists had the highest percentage of meeting the recommendations at any activity level. The higher level of physical activity among students may be an indicator of a bias among those who exercise

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and their occupational preference. We were unable to find any studies that examined this theory. Level of education also appears to be a factor in engagement in leisuretime physical activity. Research has shown that the prevalence of meeting the CDC-ACSM guidelines is greater with increased educational attainment.29,30 Our results are consistent with those findings. In the studies by Jones et al29 and Brownson et al,30 education level was defined as attaining more or less than 12 years of education. Because physical therapists complete a graduate program and physical therapist assistants complete an associate’s degree, they are engaged in educational activities beyond the typical 12 years of secondary education. However, that does not explain why the physical activity rates for physical therapists are higher than those of other health care professionals. Education has been hypothesized to be an important social influence on health31,32 and likely improves the ability to obtain and interpret healthrelated information. Perhaps the education related to the benefits of May 2010

Exercise Habits of Physical Therapists, Physical Therapist Assistants, and Student Physical Therapists exercise that physical therapists, physical therapist assistants, and student physical therapists receive positively influences their exercise behavior. Another explanation may be that those individuals drawn to the physical therapy profession are inclined to be more active. Because movement plays a central role in the profession of physical therapy,8 individuals drawn to the profession may be more active by nature. Also, those who are active at work are more likely to be active in leisure-time activities.33 The exercise recommendations from the ACSM and American Heart Association include aerobic and muscle strengthening activities. Strength training activities should be performed a minimum of 2 nonconsecutive days each week.9 The Healthy People 2010 target is for 30% of adults aged 18 years and older to be engaged in strength training activities.34 The physical therapists in our survey far exceed this target, with 59.1% participating in strength training activities a minimum of 2 days per week. The 2005 NHIS data indicate that adults are short of the target, with only 20.2% engaged in strength training activities, and that the health-diagnosing and -treating professionals in the 2005 NHIS data are on target with 30.5% engaged. The strongest determinant of participation in strength training is participation in other aerobic activities.35 Our results support that finding. The physical therapists we surveyed had higher rates of participation in both aerobic and strength training exercise compared with adults and health-diagnosing and -treating professionals surveyed in the 2005 NHIS. A 1% sample of the APTA membership represents a sufficiently large sample on which to base an estimate. However, several limitations May 2010

exist in this study, including the potential for sampling and response bias. Sampling APTA members may impart bias because these individuals may be people who are not only more active in their profession but also more active in other venues of their lives. Although response and nonresponse are difficult to track with an electronic survey delivered via e-mail, we dealt with the issue of bias by conducting a wave analysis of early and late responders to the survey.28 These 2 waves did not differ significantly on any demographic or activity variables, mitigating concerns about response bias. Physical activity has been recognized as an important means to help curb chronic disease and provide substantial health benefits. Recently, the US government issued its first Physical Activity Guidelines for Americans.36 These guidelines are intended to promote physical activity as a preventative measure. Physical therapists can play an important role in helping to promote the benefits of physical activity by counseling their patients to increase their participation.

Conclusion Based on our sample, most physical therapists appear to be good role models. This finding may have clinical implications related to their counseling of patients about the importance of physical activity. Further research is needed to determine the relationship between personal exercise habits and counseling practices of physical therapists. Both authors provided concept/idea/research design, writing, data analysis, and project management. Dr Chevan provided data collection, fund procurement, and facilities/equipment. The authors thank Adam Oyola, Katie Wilby, and Amanda Smith for assistance with data collection. A poster presentation of this research was given at the Combined Sections Meeting of the American Physical therapy Association; February 6 –9, 2008; Nashville, Tennessee.

This study was funded by the Springfield College Research Fund. This article was received April 3, 2009, and was accepted December 21, 2009. DOI: 10.2522/ptj.20090112

References 1 Warburton DE, Nicol CW, Bredin SS. Health benefits of physical activity: the evidence. CMAJ. 2006;174:801– 809. 2 Bauman AE. Updating the evidence that physical activity is good for health: an epidemiological review 2000 –2003. J Sci Med Sport. 2004;7(1 suppl):6 –19. 3 Health, United States, 2007 With Chartbook on Trends in the Health of Americans. Hyattsville, MD: National Center for Health Statistics; 2007. 4 Exercise is Medicine. Available at: http:// www.exerciseismedicine.org/. Accessed November 24, 2008. 5 American Physical Therapy Association. Physical therapists and physical therapist assistants as promoters and advocates for physical activity/exercise. HOD P06 – 08 – 07– 08. Available at: http://www.apta.org/ AM/Template.cfm?Section⫽Home&TEM PLATE⫽/CM/ContentDisplay.cfm&CON TENTID⫽52475. Accessed November 24, 2008. 6 American Physical Therapy Association. Physical activity advocacy. HOD P06 – 05– 19 – 09. Available at: http://www.apta.org/ AM/Template.cfm?Section⫽Home&TEM PLATE⫽/CM/ContentDisplay.cfm&CON TENTID⫽25459. Accessed November 24, 2008. 7 American Physical Therapy Association. Plan to describe, communicate and reinforce the role of physical therapy in providing services that positively impact physical fitness in two priority populations. BOD 03– 06 –17– 41. Available at: http://www.apta.org/AM/Template.cfm? Section⫽Home &TEMPLATE⫽/CM/Content Display.cfm&CONTENTID⫽34423. Accessed August 3, 2009. 8 Guide to Physical Therapist Practice. Phys Ther. 1997;77:1163–1650. 9 Haskell WL, Lee IM, Pate RR, et al. Physical activity and public health: updated recommendation for adults from the American College of Sports Medicine and the American Heart Association. Med Sci Sports Exerc. 2007;39:1423–1434. 10 Adams PF, Schoenborn CA, Health behaviors of adults: United States, 2002– 04. Vital Health Stat 10. 2006(230):1–140. 11 Pate RR, Pratt M, Blair SN, et al. Physical activity and public health. a recommendation from the Centers for Disease Control and prevention and the American College of Sports Medicine. JAMA. 1995;273: 402– 407. 12 Eden KB, Orleans CT, Mulrow CD, et al. Does counseling by clinicians improve physical activity? A summary of the evidence for the U.S. Preventive Services Task Force. Ann Intern Med. 2002;137: 208 –215.

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Exercise Habits of Physical Therapists, Physical Therapist Assistants, and Student Physical Therapists 13 Abramson S, Stein J, Schaufele M, et al. Personal exercise habits and counseling practices of primary care physicians: a national survey. Clin J Sport Med. 2000;10: 40 – 48. 14 Frank E, Carrera JS, Elon L, Hertzberg VS. Predictors of US medical students’ prevention counseling practices. Prev Med. 2007; 44:76 – 81. 15 Frank E, Bhat Schelbert K, Elon L. Exercise counseling and personal exercise habits of US women physicians. J Am Med Women’s Assoc. 2003;58:178 –184. 16 Wells KB, Lewis CE, Leake B, Ware JE Jr. Do physicians preach what they practice: a study of physicians’ health habits and counseling practices. JAMA. 1984;252: 2846 –2848. 17 Gaertner PH, Firor WB, Edouard L. Physical inactivity among physicians. CMAJ. 1991;144:1253–1256. 18 Irazusta A, Gil S, Ruiz F, et al. Exercise, physical fitness, and dietary habits of firstyear female nursing students. Biol Res Nurs. 2006;7:175–186. 19 Shriver CB, Scott-Stiles A. Health habits of nursing versus non-nursing students: a longitudinal study. J Nurs Educ. 2000;39: 308 –314. 20 Drummond JL, Hagan L. Leisure-time physical activity and self-perceived fitness of hospital employees. Percept Mot Skills. 1998;87:1256 –1258.

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21 Frank E, Galuska DA, Elon LK, Wright EH. Personal and clinical exercise-related attitudes and behaviors of freshmen U.S. medical students. Res Q Exerc Sport. 2004;75: 112–121. 22 Frank E, Carrera JS, Elon L, Hertzberg VS. Basic demographics, health practices, and health status of U.S. medical students. Am J Prev Med. 2006;31:499 –505. 23 Williford HN, Barfield BR, Lazenby RB, Olson MS. A survey of physicians’ attitudes and practices related to exercise promotion. Prev Med. 1992;21:630 – 636. 24 Rea BL, Hopp Marshak H, Neish C, Davis N. The role of health promotion in physical therapy in California, New York, and Tennessee. Phys Ther. 2004;84:510 –523. 25 National Center for Health Statistics. National Health Interview Survey (NHIS). Available at: http://www.cdc.gov/nchs/ nhis.htm. Accessed November 24, 2008. 26 Gentleman JF, Pleis JR. The National Health Interview Survey: an overview. Eff Clin Pract. 2002;5(3 suppl):E2. 27 Botman SL, Moore TF, Moriarty CL, Parsons VL. Design and estimation for the National Health Interview Survey, 1995– 2004. Vital Health Stat 2. 2000;(130): 1–31. 28 Fowler FJ. Survey Research Methods. Vol 1. 4th ed. Thousand Oaks, CA: Sage Publications; 2009:201.

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29 Jones DA, Ainsworth BE, Croft JB, et al. Moderate leisure-time physical activity: who is meeting the public health recommendations: a national cross-sectional study. Arch Fam Med. 1998;7:285–289. 30 Brownson RC, Boehmer TK, Luke DA. Declining rates of physical activity in the United States: what are the contributors? Annu Rev Public Health. 2005;26: 421– 443. 31 Mirowsky J, Ross CE. Education, Social Status, and Health. New York, NY: A. de Gruyter; 2003:242. 32 Marshall SJ, Jones DA, Ainsworth BE, et al. Race/ethnicity, social class, and leisuretime physical inactivity. Med Sci Sports Exerc. 2007;39:44 –51. 33 Barnes PM, Schoenborn CA. Physical activity among adults: United States, 2000. Adv Data. 2003;333:1–23. 34 US Department of Health and Human Services. Healthy People 2010. 2nd ed. Washington, DC: US Government Printing Office; 2000. 35 Chevan J. Demographic determinants of participation in strength training activities among U.S. adults. J Strength Cond Res. 2008;22:553–558. 36 Physical Activity Guidelines for Americans. Available at: http://www.health.gov/ PAGuidelines/. Accessed November 24, 2008.

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Exercise Habits of Physical Therapists, Physical Therapist Assistants, and Student Physical Therapists Appendix. Questions and Definitions Used in the Surveys National Health Interview Survey (NHIS) Sample Adult Questionnaire No similar content in NHIS

Survey of Leisure-Time Exercise Activities for Physical Therapists Section 1: Introduction Thank you for agreeing to be a participant in our research project. This survey should take 5 minutes or less of your time. The purpose of this study is to examine the personal exercise habits of US physical therapists. By completing this survey, you are agreeing to participate in this study and, therefore, have implied your consent. Please complete this survey only one time. If you have already completed this survey, please close the browser window you have just opened. The data collected will be kept confidential, reported in aggregate, and used for statistical research purposes only. If you have any questions about this project, please contact us.

No similar content in NHIS

Section 2: Consent This survey includes basic demographic information and incorporates the leisure-time physical activity questions from the NHIS of the Centers for Disease Control and Prevention/National Center for Health Statistics. By providing responses to this survey, I certify that I understand the nature of this study, I willingly consent to participate, and I will answer the questions to the best of my knowledge.

Adult Identification and Adult Sociodemographic Sections Question ID: AID.040_00.000 Are you male or female? Question ID: AID.050_00.000 How old are you? Question ID: ASD.060_00.000 What is your correct working status? Question ID: ASD.080_00.000 What kind of business or industry was this? Question ID: ASD.090_00.000 What kind of work were you doing?

Section 3: Demographic Information 1. I am: Male Female 2. What is your current age (in years)? 3. Are you a: Physical therapist Student physial therapist Physical therapist assistant Student physical therapist assistant Physical therapy aide Other (please specify) _____________ 4. Are you current employed in a setting in which you have direct patient/ client care interactions? (By “interactions,” we mean activities in which you would have the opportunity to provide a clinical intervention to a person or group of people.) Yes No 5. If you said no, please describe your current physical therapy-related work:

Adult Health Behaviors Section: Leisure-Time Physical Activity The next questions are about physical activities (eg, exercise, sports, physically active hobbies) that you may do in your leisure time.

Section 4: Vigorous Activities These questions are about physical activities (eg, exercises, sports, physically active hobbies) that you may do in your leisure time.

Question ID: AHB.090_01.000 How often do you do vigorous leisure-time physical activities for at least 10 minutes that cause heavy sweating or large increases in breathing or heart rate? (Read if necessary: How many times per day, per week, per month, or per year do you do these activities?)

Vigorous activities are those that cause heavy sweating or large increases in breathing or heart rate. 6. On how many days each week do you typically do vigorous activities for at least 10 minutes that cause heavy sweating or large increases in breathing or heart rate. 0 1 day/week 2 days/week 3 days/week 4 days/week 5 days/week 6 days/week 7 days/week Unable to do this type of activity 7. On average, for how many minutes do you do these vigorous activities each time?

Question ID: AHB.100_01.000 About how long do you do these vigorous leisure-time physical activities each time?

(Continued)

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Exercise Habits of Physical Therapists, Physical Therapist Assistants, and Student Physical Therapists Appendix. Continued National Health Interview Survey (NHIS) Sample Adult Questionnaire

Survey of Leisure-Time Exercise Activities for Physical Therapists

Question ID: AHB.110_01.000 How often do you do light or moderate leisure-time physical activities for at least 10 minutes that cause only light sweating or a slight to moderate increase in breathing or heart rate? (If necessary, prompt with: How many times per day, per week, per month, or per year do you do these activities?)

Section 5: Moderate Activities

Question ID: AHB.120_01.000 About how long do you do these light or moderate leisure-time physical activities each time?

8. On how many days each week do you typically do light or moderate activities for at least 10 minutes that cause only light sweating or a slight to moderate increase in breathing or heart rate. 0 1 day/week 2 days/week 3 days/week 4 days/week 5 days/week 6 days/week 7 days/week Unable to do this type of activity 9. On average, for how many minutes do you do these light or moderate activities each time?

Question ID: AHB.130_01.000 How often do you do leisure-time physical activities specifically designed to strengthen your muscles, such as lifting weights or doing calisthenics? Include all such activities even if you have mentioned them before. (Read if necessary: How many times per day, per week, per month, or per year do you do these activities?)

Section 6: Strengthening Activities

These questions are about physical activities (eg, exercises, sports, physically active hobbies) that you may do in your leisure time. Moderate activities are those that cause only light sweating or a slight to moderate increase in breathing or heart rate.

These questions are about physical activities (eg, exercises, sports, physically active hobbies) that you may do in your leisure time. Activities specifically designed to strengthen your muscles include lifting weights or doing calisthenics. Please include all such activities, even if you have mentioned them before. 10. On how many days each week do you typically do physical activities specifically designed to strengthen your muscles such as lifting weights or doing calisthenics? 0 1 day/week 2 days/week 3 days/week 4 days/week 5 days/week 6 days/week 7 days/week Unable to do this type of activity

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Research Report

Access to Physical Therapy Services Among Medically Underserved Adults: A Mixed-Method Study Christine A. McCallum

Background and Objectives. This mixed-method case study examined access issues related to physical therapy services among medically underserved adults within an Ohio community. Design. Three community health care clinics served as the units of analysis. Methods. Eleven health care providers and 110 patients participated in the study, and documents from local, state, and national resources were reviewed.

Results. Results revealed that structural, utilization of care, and outcome barriers existed. A lack of accessible physical therapy providers for medically underserved adults and a lack of standardized screening or assessment processes to identify physical mobility problems among people with chronic health conditions were found. Inadequate knowledge about the full scope of physical therapist practice existed, which may impede access to those individuals most in need of services.

C.A. McCallum, PT, PhD, GCS, is Clinical Associate Professor and Director of Clinical Education, Division of Physical Therapy, Walsh University, 2020 E Maple St, North Canton, OH 44720 (USA). Address all correspondence to Dr McCallum at: [email protected]. [McCallum CA. Access to physical therapy services among medically underserved adults: a mixedmethod study. Phys Ther. 2010;90: 735–747.] © 2010 American Physical Therapy Association

Conclusions. Opportunities are present for physical therapist involvement in screening, wellness and prevention, consultation, education, and program development among medically underserved adults. However, challenges exist due to a lack of human and financial resources and the current structure of our health care system, which focuses on acute and chronic care rather than prevention.

Post a Rapid Response to this article at: ptjournal.apta.org May 2010

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Access to Physical Therapy Services Among Medically Underserved Adults

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lthough the United States boasts the most advanced health care system in the world, millions of Americans continue to lack adequate health care each year. Those especially affected are the medically underserved populations who reside in every community. Medically underserved individuals are described as those who need assistance with improving their health as a result of limited access to health care due to lack of health insurance and low income.1,2 They cross all levels of education and age; however, social and economic factors are key predictors of an individual having health care coverage.3–5 As a result, underinsured and uninsured individuals are medically vulnerable, meaning they experience greater difficulty accessing health care services of any kind and have a greater likelihood of negative health care outcomes as they age.3,4 The Institute of Medicine defined access to health care as: The timely use of personal health services to achieve the best possible health outcomes. Importantly, this definition relies on both the use of health services and health outcomes to provide yardsticks for judging whether access have been achieved.6(p29)

Many indicators have been used to identify barriers and facilitators to accessing care.7 Four themes identified in the literature that measure access to health care are: structural factors, patient perception issues, Available With This Article at ptjournal.apta.org • The Bottom Line Podcast • Audio Abstracts Podcast This article was published ahead of print on March 25, 2010, at ptjournal.apta.org.

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utilization of care issues, and outcome measures.7,8 Structural factors include environmental issues such as health insurance and population characteristics such as education and age variables.7,8 Patient perception issues involve patient satisfaction with quality and quantity of services, which are predisposing factors to health. Utilization of care issues include having a usual source of care, entry into the system, preventative service, and emergency service use. Outcome measures include health behaviors and health status.7,8 Thus, when examining health care access in the United States, populationbased and individual characteristics, services, and outcomes all affect a person’s ability to receive care. Environmental characteristics, a structural factor, has been shown to be a major barrier to health care access. The environmental characteristics of health insurance coverage and utilization control issues dramatically affect the type and quality of health care services that individuals receive.8,9 Health insurance is both an enabling factor in access to health care and a function of health policy.8 As such, health insurance is targeted as one of the most important measures in accessing health care services.8,9 Generally, medically underserved individuals lack many benefits of health insurance, specifically a structure for obtaining care when it is needed the most. Many consequences of being uninsured exist, including a lack of a usual source of care; fewer referrals for specialty services, including physical therapy; less access to preventative health services and health education; and less use of interventions for chronic illnesses.2,10 –13 Often, the end results of these consequences are a greater risk of poorer health outcomes and higher morbidity and mortality rates.12,14 Poor health outcomes frequently are measured by

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the presence of chronic health conditions such as musculoskeletal disorders, cardiorespiratory conditions, neurological conditions, and diabetes. These conditions are found among the uninsured populations and are known to increase risk factors associated with development of disabling physical mobility problems with age.15–18 Unfortunately, chronic health conditions often are left untreated, as uninsured individuals often delay or avoid seeking help because of their inability to pay for services, leading to adverse health outcomes and increased health care costs. Even when primary care is sought, referral to specialists is limited because of the structural barriers these individuals face. Physical therapy services are part of the specialty health care system many medically underserved individuals are unable to access. Physical therapists’ expertise in movement and exercise and their in-depth knowledge of the pathophysiology of acute and chronic diseases and injuries make them an obvious choice to address health care needs of the adult population in the United States.19 However, the role of physical therapy in community health care is essentially unknown, as no existing literature discusses access to physical therapy services for medically underserved individuals. Therefore, the purpose of this study was to describe access issues related to physical therapy among medically underserved adults within a community.

Method Unit of Analysis This research study used a mixedmethod, sequential, exploratory20 case-study approach.21 The units of analysis were 3 Ohio-based community health care clinics (CHCs) that provided care to medically underserved adults. A community health care clinic is defined as a private, not-for-profit organization that provides a wide range of primary health care services to medically underMay 2010

Access to Physical Therapy Services Among Medically Underserved Adults served populations within a community, as it accepts patients who lack health insurance and have limited means to pay for services.22 Criteria for choosing the clinics included (1) being geographically located in a community, (2) serving medically underserved adults, and (3) being granted permission to participate in the study. All 3 of the CHCs available to residents within the community agreed to participate in the study. Participants Two sets of participants were involved in this research study. First, 11 health care providers (HCPs) who worked within the 3 CHCs were recruited by telephone for participation. The selection process was purposeful to include the HCPs who provided consistent care in these clinics. The executive directors for all chosen health care clinics first were contacted to obtain permission to complete the study at their respective clinic and for the names of other HCPs who were available and willing to participate in an interview. At a minimum, requested HCP participants included the medical director, the executive director or other designee, and a nurse who primarily worked directly with the patients of the clinic. The goal of the selection process was to ensure a broad category of HCPs who serve medically underserved individuals and those who were decision-makers in the care provided to the patients served. Participants’ years of service ranged from 6 months to 10 years, with a mean of 2.8 years. Ten of the 11 participants were paid employees of the clinics. Informed consent was obtained from each HCP participant prior to each interview session. The second set of participants was a total of 110 medically underserved adults who were receiving treatment at the CHCs during the time of the study. The patient participants were recruited voluntarily by clinic perMay 2010

sonnel to complete a patient questionnaire during the last week of August 2004. The clinic staff obtained informed consent from all patient participants. Completion of the patient survey served as consent for participation. The distribution of patient participants across the clinics was: (1) clinic A, n⫽38; (2) clinic B, n⫽47; and (3) clinic C, n⫽25. The totals represented 75% of the patients treated at 2 of the 3 medical clinics during the selected week of study. Clinic C did not provide a total for the number of patients treated during the week of the study; therefore, the overall percentage of participants was not available. Data Collection Data from the 3 CHCs were collected and analyzed individually and were aggregated to present a community perspective. Data from 3 sources— interviews, document review, and

patient survey responses—were collected during the summer of 2004. Interviewing. Semistructured interviews23,24 were completed as one of the primary means of data collection. Topical questions were developed based upon a review of the literature of medically underserved populations and scope of physical therapist practice. The research concepts also followed the Institute of Medicine’s25 Conceptual Framework for Evaluating Uninsurance, including resources, characteristics, and needs. An interview guide developed for the study (available upon request) outlined topical questions as well as cues and probes that assisted me in probing for more information from the HCP participants. The primary strength of this data collection strategy was my ability to understand the unique experiences and perspectives of the HCP participants without limiting their responses through closedended questions.23,26 A pilot inter-

The Bottom Line What do we already know about this topic? Underinsured and uninsured individuals experience more difficulty accessing health care services of any kind when a need exists. Many lack a usual source of care, have less medical visits, and receive fewer referrals to specialty services when needed.

What new information does this study offer? This was the first study that examined physical therapy access issues for medically underserved individuals. The results reveal that individuals experience access barriers to physical therapy services. Physical therapy can be included in the list of specialty services out of reach for many medically underserved patients.

If you’re a patient, what might these findings mean for you? Individuals who do not have comprehensive health care insurance may lack access to physical therapy services if they are in need of these services. These individuals may need to advocate for themselves to receive appropriate care.

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Access to Physical Therapy Services Among Medically Underserved Adults view with a health care practitioner previously associated with a free medical clinic was completed prior to use of the guide and showed the interview plan to be appropriate. All interviews took place during the final 2 weeks of July 2004. I completed all interviews, which were audiotaped using reliable equipment. I took notes during each interview to prevent data loss in the event of malfunctioning equipment. The tapes were transcribed following each interview session. Data mining. The second method of data collection used in this study was data mining. Data mining is the process of extracting data from numerous written documents.23,27 Documents from 3 constituencies— the clinics, the local community, and state and national records—were analyzed. Archival records in the form of service records, organizational records, and maps and charts were analyzed to gather data on communitylevel characteristics such as community health indicators, community demographics, and social and economic information. Information also was extracted from organizational administrative documents such as proposals, progress reports, and other documents central to the medical conditions addressed and medical care delivered at each center. Review of other formal studies (grant applications) or evaluations of the sites provided by clinic administration were used. Data from community-wide reports, such as census data, health and human services reports, and other vital statistics, also were examined. This method of data collection helped to answer questions about “who,” “what,” “where,” “how much,” and “how many” in regard to medically underserved adults within the community and questions regarding access issues pertaining to physical therapy services.

and patient participants. First, a HCP demographic questionnaire was used to collect background data (eg, health care specialty, years employed) on the HCP participants interviewed. Next, a patient questionnaire (available upon request) was used to assess characteristics and needs of the actual patients who receive care at the CHCs. The survey was developed specifically for this study. The patient questionnaire was divided into 3 content areas: basic demographic data (6 items), medical history (2 items in “check all that apply” format), and self-reported health care needs about physical mobility problems and access to physical therapy services (6 items). The first 2 content areas (demographics and medical history) were adapted from the American Physical Therapy Association’s Documentation Template for Physical Therapist Patient/ Client Management.28 The third area was developed to provide information about the patients’ views of their needs for and knowledge about physical therapy services in the community. Prior to dissemination of the questionnaire, face validity was assessed by 2 physical therapists who reviewed the instrument, and a pilot study of the instrument was conducted on 10 patients selected at one CHC. Reliability of the instrument was checked using intraclass correlation coefficient (3,1), a single measure of average scores, and found to be .75. Distribution of the questionnaire to patients who sought health care services during the data collection period was provided by an individual identified at each clinic. Each clinic was provided with a selfaddressed, stamped envelope to return the completed questionnaires to the planner at the end of the week. The questionnaires were coded according to the clinic; otherwise, all information was kept confidential.

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Data Analysis: Building a Chain of Evidence Data collection and analysis were not mutually exclusive processes, as I worked back and forth between the data and conclusions drawn. A process of data triangulation19,26,29,30 was used during the analysis phase. The 3 sources of data—transcribed interviews, document data, and survey results—were analyzed using a constant-comparative method21 to develop themes and patterns, which provided for meaningful interpretation of the community needs regarding access to physical therapy services. Data verification was offered to each HCP participant through member checking23; however, participants either declined to review transcribed interview sessions or failed to respond to requests for review. Content analysis and data reduction30 were completed by coding data based upon theoretical themes and concepts identified in the literature. A patternmatching process was used for this method of analysis, whereby a theoretical pattern and an observed pattern are linked by arrangement to provide new conclusions.31,32 Data conclusion followed the Institute of Medicine’s framework for examining community characteristics, resources, and needs.25

Results A comprehensive analysis of the data is presented that describes: (1) the characteristics of the community, (2) the characteristics of patients who sought treatment at the CHCs, (3) resources available to the medically underserved community, and (4) knowledge of the scope of physical therapist practice. General Community Characteristics Three medical clinics serve medically underserved adults in the community. The clinics are separated May 2010

Access to Physical Therapy Services Among Medically Underserved Adults geographically and are located in the southern, eastern, and western sections of the county. The community has both urban and rural sections; however, the community clinics are located close to the downtown urban areas. Two of the 3 geographic areas are designated medically underserved areas and health professional shortage areas. All 3 clinics are located near residential neighborhoods and some local businesses and churches; however, these neighborhoods appear to be of lower socioeconomic status. The clinics are on local bus routes; but the HCPs reported some patients continue to have difficulty with transportation. Contrary to clinic personnel perception, patient responses from survey data do not indicate transportation is a major barrier for seeking services from these clinics, as only 8% (n⫽9) of 110 patients reported transportation as an issue.

Table 1. Community and Clinic Demographics Community Population (Nⴝ378,000)

Patient Responses (Nⴝ110)

%

%a

Race White

90.3

73

African American

7.5

19

Hispanic

1.5

2

Asian

0.5

0

American Indian

0.2

6

Male

49.2

40

Female

50.8

60

Sex

Age (y) ⬍18

24.8

18–24

0

8.3

6.4

25–34

12

11.8

35–44

15.8

24.5

45–54

12

29.0

55–64

12

22.0

⬎65

15.1

4.5

⬍High school

16.5

32.8

High school diploma

41.2

32.7

Some college

18.9

26.4

College degree or higher

23.3

4.5

7

10–80

6

7–10

Educational attainment

The 2000 US census reported the community population is roughly 378,000, with 2 main metropolitan cities within its proximity. The racial makeup of the county is rather homogenous, with 90% of the population being white, 7.5% African American, 1.1% Hispanic, 0.5% Asian, and 0.2% American Indian. The age demographics for the county are diverse, with 24.8% under the age of 18 years, 8.3% aged 18 to 24 years, 27.8% aged 25 to 44 years, 24% aged 45 to 64 years, and 15% aged 65 years or older. The median age is 38 years. Women outnumber men (ie, 100 females for every 92.4 males). Unemployment rates in the county are higher than statewide averages, with 5.8% of the population unemployed in October 2004. The cities where the health care clinics are located report higher averages in unemployment, ranging from a high of 9.5% (clinic B) to a low of 7.3% (clinic C). A trend in manufacturing plant closings within the county over the past few years has driven May 2010

Poverty level

b

100%–200% FPL Unemployment a

For patient responses, age was unreported for 1.8% of the patients and educational attainment was unreported for 3.6% of the patients. b 100% of federal poverty level (FPL) in 2005 was $19,350 for a family of 4.31

this growth in unemployment. This trend, in turn, has impaired economic growth within the community and negatively affected the socioeconomic status of community members. Poverty levels are high in the areas surrounding the clinics as a result of the hardships associated with unemployment. Approximately 7% of the county’s adult population falls between 100% and 200% of the federal poverty level, which was $19,350 for a family of 4 in 2005.33 Rates in the communities where the clinics exist, however, are higher. Clinic A reports

that in 1 census track (out of 7 it services), the poverty level is 80%, whereas clinic B’s poverty level is around 41% and clinic C’s poverty level is 11%. Table 1 provides demographic data on the community. A 2001 community needs survey, the most current information at the time of the study, revealed that the uninsured and underinsured population and the low income population of this county were in need of additional resources to address health and wellness needs, as services and resources were seriously

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Access to Physical Therapy Services Among Medically Underserved Adults lacking. The high cost of health insurance premiums and insurance coverage expenses were some of the most pressing issues that affected this population. The high poverty rate, the high unemployment rate, and insufficient access to health care services all contributed to adverse health conditions. Health indicators that were measured consistently throughout the county and state reveal this Ohio community ranked higher than average for people with diabetes, heart disease, respiratory infections, and overall mortality rate. The overall death rate in the county exceeded state standards, reaching 10.4 per 1,000 people, compared with 9.6 in Ohio. The Patient Population General patient characteristics. The target population for the 3 clinics was primarily adult men and women who lived and worked in the communities where the clinics are located. Clinics A and C were classified as free clinics, and clinic B was a federally qualified health care center.34 Individuals were required to show proof of income below a predetermined level to qualify for free medical services at the clinics. Clinic personnel described their patient population as uninsured and unemployed or holding low-paying jobs that did not qualify them for health insurance benefits. Physician A reported, We are seeing more and more people that have lost their jobs or their medical insurances have been cut, so there has been more of an increase in those types of people, where the economic impact has hit them.

Clinic reports and interviews revealed most individuals lived in private or public housing; however, clinic C provided countywide services for homeless individuals through its mobile health van. Health care provid740

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ers who worked at these clinics across the county similarly classified the patients who sought medical care as either the working poor or the indigent poor (ie, below the federal poverty level). Neither of these groups had access to health insurance, nor did they have a usual HCP beyond the clinic doors and, therefore, used the services of the CHCs. Resources Health care providers and services offered. The clinics were staffed with a combination of medical and administrative personnel. Medical personnel who provided periodic health care services included: internal medicine physicians, family practitioners, cardiologists, chiropractors, counselors, dentists, medical interns and residents, nurse practitioners, and physician assistants; however, the extent to which they are available at the clinics varied. In regard to physical therapy services, only one clinic had access to one volunteer physical therapist on a limited basis. Two clinics reported utilizing a free physical therapy clinic once housed in a local community college’s physical therapist assistant program; however, the clinic closed in 2004 due to a lack of operational funding. The HCPs were not aware of other physical therapy providers who accepted patients from or provided consistent physical therapy care to this population. The common structural barrier was the inability of the patient to pay for these services and the inability of the providers to accept many patients who are unable to pay for services. As a result, patient referrals to physical therapy services were severely limited. One HCP reported, We don’t offer PT [physical therapy] services because we haven’t found a physical therapist willing to work with underprivileged [people]. That’s our biggest problem here . . . finding

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area providers that we can refer patients to.”

Health Status Prevalent conditions. The 3 CHCs offered care for a variety of medical problems, with the most common problems categorized as chronic health conditions. Patients were described in interviews as having multiple health issues, including physical mobility problems. The 3 chronic medical conditions most frequently mentioned by HCPs and in clinic documents were hypertension, diabetes, and high cholesterol. Patient self-reports revealed hypertension as the most common medical diagnosis treated at the clinics, followed by arthritis and being overweight. Table 2 provides the distribution of medical diagnoses self-reported by patients. Accessible services. Medical management of the patients served by these clinics was similar across the community; the specific needs of the individual guided interventions. Table 3 outlines the common services provided. A pattern found across all 3 CHCs related to the lack of identification of impairments or functional limitations that may impede current or future function of the patients they treated. Nurse A reported: I would probably send [those with chronic health conditions] earlier; however, I have to recommend to the doctor first. I’m not allowed to do that. He [the physician] thinks he has to do all the diagnosing and referring. It’s a very fine line.

Although more than 35% of the patients surveyed reported problems with physical mobility, the CHCs did not follow a standardized screening program to identify impairments or functional limitations. Instead, HCPs relied on patient self-reports during an examination to ascertain whether physical mobility problems were a

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Access to Physical Therapy Services Among Medically Underserved Adults Table 2.

were most frequently referred for services. The most often mentioned candidates for physical therapy services were those with musculoskeletal injuries such as sprains, strains, arthritis, or spinal injuries to the neck or low back. A few references to people with neurological disorders such as stroke, multiple sclerosis, or Parkinson disease were found, but there was no mention of patients with cardiovascular, pulmonary, or integument problems who would need physical therapy services. Nurse B stated:

Aggregate Health Conditions Reported: Self-Reportsa Patients (%)

Reported (n)

Hypertension

41.8

46

Overweight

36.4

40

Arthritis

34.5

30

Diabetes

17.3

19

Heart disease

13.6

15

Lung problems

12.7

14

Head injury

10.9

12

8.2

9

Cancer Stroke

7.3

8

Rheumatoid arthritis

7.3

7

Spinal cord Injury

6.4

3

Osteoporosis

3.6

4

Multiple sclerosis

0.9

1

Parkinson disease

0

0

My weakness lies in orthopedics, because I don’t have a very strong background in it. If they [the patients] have a weakness or a pain that limits mobility and range of motion, I would be more inclined to refer for physical therapy than if it seems nerve oriented. I don’t know whether I’m right or not [in her decision-making process about what type of patients to refer for physical therapy].

a

Patients were able to report more than one diagnosis; therefore, the total number of diagnoses may be greater than the number of patients surveyed.

cause for concern. Physician A reported: [w]e don’t usually assess functional mobility, except, of course, for those who come in with musculoskeletal problems, low back pain, or neck problems. Then we go through the range of motion, the usual things we do. It is not as extensive as a physical therapist would do. We only have limited personnel and limited time to deal with problems.

One health care practitioner specifically mentioned reliance on other medical or rehabilitative specialists, such as physical therapists, to identify these problems areas; however, a concern existed, as most patients were referred to specialists only if

a problem was detected during a scheduled patient visit. Table 4 outlines patient self-reports on select impairments and functional limitations. Entry Into the System Knowledge of the scope of physical therapist practice. Three themes emerged that described the scope of physical therapist practice as known by the population studied: (1) the type of patients whom physical therapists treat, (2) the services provided by physical therapists, and (3) the process for accessing physical therapy services once a need is identified. First, interview data suggested the scope of physical therapy was defined by the type of patients who

Second, the types of interventions provided by physical therapists were similarly described in HCP interviews and written comments from patients. Interventions pertaining to exercise prescription focused on stretching and strengthening the body, and pain reduction modalities such as ice or heat were cited most frequently. One health care provider interviewed used the broad word “rehabilitation” to describe what physical therapists do; however, no other specific interventions were stated. Patient comments included, “flexibility and

Table 3. Common Medical Services Provided by Community Health Clinics Primary Medical Care

Specialty Services

Diagnostic Studies

Education and Wellness

Heart disease Diabetes Obesity Cancer Respiratory infection Musculoskeletal disorders

Internal medicine Podiatry Gynecology Pharmacology

Glucose Urinalysis Hemoglobin Foot examinations Electrocardiograms

Diabetes Hypertension Nutrition Social services Medication Substance abuse

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Access to Physical Therapy Services Among Medically Underserved Adults Table 4. Self-Reported Impairments and Functional Limitationsa Patients (%)

Reported (n)

Muscle aches

63.6

70

Headaches

37.3

41

Numbness

33.6

37

Weakness overall

33.6

37

Loss of balance

30.9

34

Impairments

Loss of motion

28.2

31

Coordination problems

11.8

13

35.5

39

Difficulty with transfers

34.5

38

Difficulty lifting

30.0

33

Difficulty with instrumental ADL

22.7

25

9.1

10

Functional limitations Difficulty walking

Difficulty with ADL a

Patients were able to report more than one impairment or functional limitation; therefore, the total number of diagnoses may be greater than the number of patients surveyed. ADL⫽activities of daily living.

strengthening exercises” and “things to help me walk correctly and stand up correctly.”

done from a physical therapy standpoint. That’s a little discouraging from a nurse’s standpoint.

Finally, the common mechanism used within the community health care system to identify patients who would benefit from physical therapy services, if accessible, was physician clinical judgment. All of the physician extenders (nurses and medical assistants) and administrative staff interviewed reported they rely on physicians to decide whether a patient should be referred for physical therapy services. Two nurses reported instances when they identified possible physical therapy candidates; however, the referral was not made because a physician did not recommend it. Nurse A reported:

Knowledge of Ohio legislation that permits direct access to physical therapy services was lacking. Clinic personnel at only one site were familiar with the law that allows patients to seek services by physical therapists without the need for physician referral. Even with this knowledge, however, these HCPs indicated they would still rely on a physician referral versus discussing this option with patients. The patient questionnaire did not ask about knowledge of direct access or other processes to access physical therapy services; therefore, patient knowledge about the processes of accessing physical therapy is unknown. Data reveal, however, that 31.8% (n⫽35) of the patients surveyed reported they were not referred for physical therapy services when a self-identified need was expressed. Another nurse shared:

Some of the physicians aren’t highly educated in that regard [in reference to a patient who fell and was in need of physical therapy], and sometimes even if you suggest it, they can shoot you down. We have a lot of volunteer docs, and generally they’re older. I don’t think they’re up on what can be

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[i]f there was anything I could say about the field of physical therapy and particularly with the new regulations [in Ohio], [it] is that we need more educational opportunities for nurses [about what physical therapists do] because we are the front line. We don’t generally come in contact with them [physical therapists]. I mean, I do here, but we don’t usually, as a general rule, in outpatient. If you worked for [a cardiovascular group in the county], those nurses see their patients all the time, and they get to know them very well, and they may be seen for cardiology issues; however, they see them one day coming in and then 3 months later they come in for a checkup, and they’re hobbling; they should be able [to refer patients for physical therapy], and they’re front line, they shouldn’t just be limited to the heart. . . . We’re generally the first line of contact, and the community, I don’t think, some of them would, but most of them wouldn’t [refer them for physical therapy].

These results indicate that access barriers to physical therapy services exist for medically underserved adults who sought care at community health clinics.

Discussion The purpose of this study was to describe issues that affect access to physical therapy services by medically underserved adults. Currently, there are few published reports on demographic or clinical characteristics of free clinic patients,35,36 and to date there are no published reports on access to physical therapy services for medically underserved adults. This study, therefore, brings physical therapy into the discussion on access issues for medically underserved adults. An examination of community, clinic, and patient characteristics, resources, and needs provided the basis for analysis. The results revealed 3 primary themes in regard to gaps in

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Access to Physical Therapy Services Among Medically Underserved Adults access to physical therapy services: (1) a lack of physical therapy providers for medically underserved adults, (2) inadequate knowledge by HCPs and patients about the scope of physical therapy services, and (3) a lack of standardized screening or assessment processes related to physical mobility problems for patients with chronic health conditions. These gaps indicate structural, utilization of care, and outcome measure barriers exist (Tab. 5). Each thematic gap is addressed in the context of this study. First, structural factors, such as population characteristics that inhibit individuals from obtaining a needed service, were found to be similar to those in national reports.6 Medically underserved adults within this study were described as the poor or working poor who did not have access to health insurance. These individuals did not have the financial means to obtain needed health care services, including physical therapy. In this study, 54% of the patients reported they could not afford physical therapy services if a need was present. It is well documented in the literature that referrals to medical specialists for uninsured patients is problematic as the result of a patient’s inability to pay for services and a lack of providers willing to accept little to no reimbursement for services delivered.2,13 It appears that physical therapy services can be included in the list of specialty services out of reach for many medically underserved patients who receive care at CHCs. All 3 clinics involved in this study struggled to provide referrals to those individuals in need of physical therapy services. This situation is in sharp contrast to that of individuals with access to public or private health care insurance plans offering physical therapy as a common benefit and living in communities with available and accessible providers. The difference for individuals who sought services at the CHCs is a lack of health May 2010

Table 5. Access Barriers to Physical Therapy Services Structural

Utilization of Care

Outcome Measures

Population characteristics Poor/working poor

Entry into system Lack of physical therapy providers Dependent upon physician referral Incomplete knowledge of scope of physical therapist practice

Health status Chronic health conditions Impairments and functional limitations Risk of physical mobility problems

Environmental characteristics Uninsured Lack of financial means to pay for services

Preventative services Lack of early screenings for functional mobility problems

insurance benefits and being at risk for health-related problems as they age.9,16,17,37,38 Second, access barriers were noted with utilization of care measures. Barriers existed at numerous levels involving entry into a system and availability of preventative services for medically underserved adults. First, an absence of available and accessible physical therapy providers existed within the community. Clinic HCPs reported that the most significant gap in service was the absence of physical therapy providers available within the community. It was found that a shortage of physical therapists who provided pro bono care existed and a lack of knowledge of community-based physical therapists who would accept a limited number of patients on a pro bono or sliding scale basis was present. Five percent (n⫽5) of the patients surveyed reported that they could not find a physical therapist for treatment, and 32% reported they had not been referred for physical therapy when a self-reported need was detected. At the time of the study, only one volunteer physical therapist in the county provided limited services at one CHC. With the closing of the local community college’s physical therapy clinic run by the physical therapist assistant education program, the community does not have a “go to” place to refer patients in need of physical rehabilitative services.

Although the limited availability of physical therapists hampered the ability to refer patients, the data suggest that when a need was identified, the primary mechanism for patients to access physical therapy services would be through physician judgment, rather than a direct access process. Some physician extenders reported they discussed possible needs for referrals with physicians; however, many times action was not taken, and others relied solely on physician judgment concerning needs of the patients. Reliance on physicians as the sole decisionmakers regarding the need for physical therapy services may prevent some referrals for therapy if physicians have limited knowledge of the scope of physical therapist practice. Although referrals for physical therapy services for medically underserved adults appear to be minimal, it is important to note that factors other than the availability of providers also may have an impact. Clinic HCPs and patients treated both appear to have only basic knowledge of the services provided by physical therapists, and a comprehensive understanding of physical therapist scope of practice is lacking. Similar to Foster and Tilse’s39 research, clinical factors such as the type and severity of disease and degree and type of impairment were mentioned in reference to candidates for physical therapy services. As expected, referrals for physical

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Access to Physical Therapy Services Among Medically Underserved Adults therapy services for chronic health conditions were not as commonly cited as musculoskeletal conditions. The results revealed musculoskeletal conditions were the most common conditions considered for physical rehabilitation, which is consistent with Sheppard’s40 findings. The results also suggest physical therapy is referenced by the type of interventions provided, with prescription of exercise programs for stretching and strengthening purposes and pain relief as the most commonly mentioned. Little reference by HCPs in this study was found about the need for physical therapy services for people with functional mobility problems related to difficulty walking or transferring or impairments such as impaired balance, which may affect the mobility problems. The scope of physical therapy was viewed mostly as a curative service or more commonly categorized as secondary and tertiary prevention, whereas restoration of function is used for people with short-term functional problems as the result of an injury or illness. Results indicate the physical therapist’s role in primary care or primary prevention is not as well understood. Health care providers reported physical therapists can play a role in educating patients in risk-factor management, such as exercise prescription for patients with chronic health conditions; however, referral for patients with these types of conditions was not ascertained in this study. Lack of referral to physical therapists for prevention and wellness services could be related to the current practice of medicine, where prevention and wellness services are not commonly reimbursable by third-party payers, or it could be related to a lack of understanding of the full scope of current physical therapist practice. 744

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The physicians interviewed in this study treated patients in both a thirdparty sector and the free care sector; therefore, referral patterns may be similar among these physicians in both practices, although this question was not directly asked. According to Ryan et al,41 most physicians do not have formal training about the practice of physical therapy or the advancements that occur in the field; however, they are expected by third-party payers to oversee the services provided to patients. This situation could leave patients untreated for various physical mobility problems, especially if referrals for physical therapy are not made because of a lack of understanding about physical therapist practice or because of cost constraints. It could be hypothesized that HCPs may not even consider physical therapy as an option for these patients seeking care at the community clinics because they do not have the financial means to pay for services, although this question was not directly investigated. Also absent were screening services to identify functional mobility problems for people who may be at risk for disability or for those who may already experience mobility problems and may need rehabilitation services. No formal systems existed in any of the clinics to identify such individuals. Some educational handouts on disease processes, health risks, dietary guidelines, and exercise guidelines were used within the clinics, but limited time with individual patients prevented in-depth education in any one area. Survey results revealed 19% of patients reported a physical mobility problem that was not being addressed. Patient data on self-reported impairments and functional limitations (Tab. 5) appeared to indicate a large number of patients with chronic health conditions. Assessing the need for services to address these issues, however, was outside the scope of this study.

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The utilization of care results is consistent with research documenting the needs of medically underserved individuals.12,42 Uninsured individuals are more likely to receive fragmented health care, with less focus on tests and screening for disease and health promotion/disease prevention activities to improve or maintain current health status.2,36,43,44 Although screening programs to identify functional mobility programs are limited in the sample studied, a true comparison to similar services offered to insured individuals cannot be made, as literature to describe such services is lacking. A large amount of literature is available, however, that describes specific tools that can be used to measure functional mobility problems in the adult population.15,45 Overall, it appears a need exists across the community to help identify medically underserved adults who may have early risk behaviors and factors associated with functional mobility problems that can lead to longterm health problems. Finally, the outcome measures available for analysis in this study revealed negative health outcomes for many of the medically underserved individuals. Chronic health conditions and associated impairments and functional limitations were present among the sample population studied. Similar to the National Academy on an Aging Society’s46 report on common chronic health care conditions, illnesses or injuries stemming from the musculoskeletal, cardiorespiratory, and neurological systems were prevalent among the patients. The presence of these conditions should be a concern, as individuals with chronic health conditions, such as those identified in this study, have a greater likelihood of developing related mobility disability as they age.15–17 Although the focus of this study did not address the correlation of adults with chronic health conditions and related functional mobility problems, it was noted that a number of people identified impairments and May 2010

Access to Physical Therapy Services Among Medically Underserved Adults functional limitations as a problem (Tab. 4). These individuals may be at risk for developing further mobility problems as they age as a result of the early presence of chronic health conditions and a lack of medical and rehabilitative providers to address problem areas. Overall, it appears a need exists across the community to help identify medically underserved adults who may have early risk behaviors and factors associated with functional mobility problems that can lead to long-term health problems. Physical therapists are prime HCPs to give direction to this movement. Andrulis47 reported a combination of uninsurance and access issues significantly contributed to adverse health outcomes among medically underserved populations. It appears the medically underserved adults in the community studied are at similar risk for such adverse health outcomes. Prevalence of physical mobility disability is predicted to increase with advanced age and for people who experience periods of uninsurance.48 Many times, declines in physical mobility go unnoticed until the progression of disease impairs overall function.17 When this occurs, tertiary care is needed to prevent further decline, which is more costly than primary preventative care. A better process is needed that would be an incentive to enhance primary care. Mobility is a critical aspect of maintaining functional independence throughout a person’s lifetime, and chronic health conditions such as heart disease, diabetes, and osteoarthritis increase the risk of occurrence of physical mobility disability.49,50 Access to physical therapy providers, who are specialists in the examination and treatment of problems that affect individuals’ ability to move and function to their maximum potential, may help alleviate some current mobility problems and prevent future physical mobility disability. Access could improve May 2010

if opportunities are provided to integrate screening and prevention services into contemporary physical therapist practice. Challenges exist, however, as financial resources are lacking in the current health care system to provide preventative services overall, let alone to the underserved populations. Consideration should be given to expanding the role of physical therapists in our health care system to be primary care providers to help identify individuals most at risk for mobility disability associated with chronic health conditions. Study Limitations A few limitations should be considered when interpreting the results of this study. First, CHCs are dynamic in nature due to funding and staffing issues and simply because of the nature of the services provided. The results of this study were based upon the views and beliefs of the HCPs who provided consistent services within the 3 CHCs during July and August 2004. Staffing or other internal clinic changes may have occurred since this time, and these views and beliefs may not be representative of those of all HCPs who work with medically underserved adults. Second, self-report studies have some limitations related to the truthfulness of responses. It is assumed the HCPs interviewed and the patients surveyed responded to questions openly and honestly; however, true prevalence is not known. Third, only the needs of medically underserved adults who sought health care services at CHCs were focused on in this study. There may be a population of medically underserved adults within the community who did not seek health care services at these clinics, or at all; therefore, the results may not be representative of all medically underserved adults in the community. Finally, generalization of the results to other communities should be done with caution. Although the results re-

vealed some relationship to national data on patient characteristics, resources, and needs, many variables may account for differences or similarities in other communities.

Conclusion As a result of this study, it is apparent that access barriers exist for medically underserved individuals in need of physical therapy services. Access to physical therapy services within the community studied can be measured by the gaps in services provided and the barriers that impede access to the services that exist. Access to physical therapy services by medically underserved adults within a community were limited by: (1) an absence of available and accessible physical therapy practitioners to provide services; (2) insufficient knowledge of the full scope of physical therapist practice; and (3) inadequate screening programs to identify functional mobility problems within the population, especially for individuals with chronic health conditions. As a result, unmet needs of medically underserved adults within the community existed. Physical therapists can play a larger role in meeting the needs of medically underserved adults, especially within the Ohio community studied. Opportunities exist for physical therapist involvement in screening, wellness and prevention, consultation, education, and program development; however, challenges also exist, as resources are lacking. Future consideration should be given within the health care system to utilize physical therapists for screening individuals for functional mobility problems and for treating people with chronic health care conditions who exhibit potential for development of mobility disability, especially among medically vulnerable populations. The author thanks the community clinic health care providers and patients who took

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Access to Physical Therapy Services Among Medically Underserved Adults part in this study. Their willingness to participate allowed the author to gain insight into their world and the needs of those who are less fortunate than others. This study was completed in partial fulfillment of the requirements for the author’s Doctor of Philosophy degree in the College of Education at the University of Akron. This study was approved by the Institutional Review Board for Protection of Human Subjects at the University of Akron. A Health Care Policy and Administration Section platform presentation of this research was given at the Combined Sections Meeting of the American Physical Therapy Association; February 9 –12, 2009; Las Vegas, Nevada. This article was received July 20, 2009, and was accepted January 19, 2010. DOI: 10.2522/ptj.20090242

References 1 Agency for Healthcare Research and Quality, US Department of Health and Human Services. National healthcare disparities report. Publication 09-0002. Available at: http://www.ahrq.gov/qual/nhdr08/Key.htm. Updated March 2009. Accessed December 14, 2009. 2 Kessler T, Alverson E. Health concerns and learning styles of underserved and uninsured clients at a nurse managed center. J Community Health Nurs. 2003;20:81–92. 3 Broyles R, Narine L, Brandt E. The temporarily and chronically uninsured: does their use of primary care differ? J Health Care Poor Underserved. 2002;13:95–111. 4 Cable G. Income, race, and preventable hospitalizations: a small area analysis in New Jersey. J Health Care Poor Underserved. 2002;13:66 – 80. 5 Chronic Disease in Adults. Publication 02M026. Rockville, MD: Agency for Healthcare Research and Quality, US Department of Health and Human Services; 2002. 6 Institute of Medicine. Coverage Matters: Insurance and Health Care. Washington, DC: National Academies Press; 2001. 7 Ricketts TC, Goldsmith LJ. Access in health services research: the battle of the frameworks. Nurs Outlook. 2005;53:274 –280. 8 Mascarenhas A, Pathak D, Salsberry P. Association Between Poor Health Care Access and Population Characteristics. The Center for Health Outcomes, Policy, and Evaluation Studies. Columbus, OH: The Ohio State University; 2001. 9 Aday L, Anderson R. Equity of access to medical care: a conceptual and empirical overview. Med Care. 1981;19:4 –27. 10 Bartman B, Moy E, D’Angelo L. Access to ambulatory care for adolescents: the role of a usual source of care. J Health Care Poor Underserved. 1997;8:214 –226.

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11 Berk M, Schur C. Access to care: how much difference does Medicaid make? Health Aff (Millwood). 1998;17:169 –180. 12 Earnest M, Morris J, Eberhardt M, Sands G; Task Force on Access to Health Care of the American Academy of Neurology. Report of the AAN task force on access to health care: the effect of no personal health insurance on health care for people with neurologic disorders. Neurology. 1996;46: 1471–1480. 13 Haas J, Goldman L. Acutely injured patients with trauma in Massachusetts: differences in care and mortality by insurance status. Am J Public Health. 1994;84: 1605–1608. 14 Brown M, Bindman A, Lurie N. Monitoring the consequences of uninsurance: a review of methodologies. Med Care Res Rev. 1998;55:177–210. 15 Fried LP, Bandeen-Roche K, Chaves PH, Johnson, BA. Preclinical mobility disability predicts incident mobility disability in older women. J Gerontol A Biol Sci Med Sci. 2000;55:M43–M52. 16 Houston DK, Ding J, Nicklas BJ, et al. Overweight and obesity over the adult life course and incident mobility limitation in older adults: the health, aging and body composition study. Am J Epidemiol. 2009; 169:927–936. 17 Melzer D, Gardener E, Guralink JM. Mobility disability in the middle-aged: cross sectional associations in the English longitudinal study of ageing. Age Ageing. 2005; 34:594 – 602. 18 Goldman DP, Zheng Y, Girosi F, et al. The benefits of risk factor prevention in Americans aged 51 years and older. Am J Public Health. 2009;99:2096 –2101. 19 Wilson M. Meeting new epidemics head on. PT Magazine. 2002;10(5):24 –29. 20 Rauscher L, Greenfiled BH. Advancements in contemporary physical therapy research: use of mixed-method designs. Phys Ther. 2009;89:91–100. 21 Stake R. Case studies. In: Denzin NK, Lincoln YS, eds. Handbook of Qualitative Research. 2nd ed. Thousand Oaks, CA: Sage Publications; 2000:435– 439. 22 National Association for Free Clinics. What is a free clinic? Available at: http://www. freeclinics.us/AboutUs/WhatisaFreeClinic/ tabid/63/Default.aspx. Accessed September 12, 2007. 23 Merriam SB. Qualitative Research and Case Study Application in Education. San Francisco, CA: Jossey-Bass; 2001. 24 Fontana A, Frey JH. Survey research. In: Denzin NK, Lincoln YS, eds. Handbook of Qualitative Research. 2nd ed. Thousand Oaks, CA: Sage Publications; 2000:648 – 649. 25 Institute of Medicine. Hidden costs, value lost: uninsurance in America. Washington, DC: National Academies Press; 2003. 26 DeSilets L. Needs assessments: an array of possibilities. J Contin Educ Nurs. 2007;38: 107–112. 27 Patton MQ. Qualitative Evaluation and Research Methods. 2nd ed. Newbury Park, CA: Sage Publications; 1990.

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28 Guide to Physical Therapist Practice. Rev 2nd ed. Alexandria, VA: American Physical Therapy Association; 2003. 29 Janesick VJ. The choreography of qualitative research design. In: Denzin NK, Lincoln YS, eds. Handbook of Qualitative Research. 2nd rev ed. Thousand Oaks, CA: Sage Publications; 2000:391. 30 Miles M, Huberman M. Qualitative Analysis: An Expanded Sourcebook. Thousand Oaks, CA: Sage Publications; 1994. 31 Yin R. Case Study Research: Design and Methods. 2nd ed. Thousand Oaks, CA: Sage Publications; 1994. 32 Web Center for Social Research. Research methods-knowledge base: pattern matching for construct validity. Available at: http://www.socialresearchmethods.net/kb/ pmconval.php. Accessed December 14, 2009. 33 US Census Bureau. Poverty thresholds 2005. Available at: http://www.census.gov/ hhes/www/poverty/threshld/thresh05.html. Accessed December 14, 2009. 34 Centers for Medicare and Medicaid, Medicare Learning Network. Federally qualified health center fact sheet. April 2009. Available at: http://www.cms.hhs.gov/MLN Products/downloads/fqhcfactsheet.pdf. Accessed December 14, 2009. 35 Nadkarni M, Philbrick J. Free clinics and the uninsured: the increasing demands of chronic illness. J Health Care Poor Underserved. 2003;14:165–174. 36 O’Malley A, Mandelblatt J. Delivery of preventative services for low-income persons over age 50: a comparison of community health clinics to private doctors’ offices. J Community Health. 2003;28:185–197. 37 Hoffman C, Wang M. Health Insurance Coverage in America: 2001 Data Update. Report 4070. Washington, DC: The Kaiser Commission on Medicaid and the Uninsured; 2003. 38 Picavet HS, van den Bos G. The contribution of six chronic conditions to the total burden of mobility disability in the Dutch population. Am J Public Health. 1997;87: 1680 –1682. 39 Foster M, Tilse C. Referral to rehabilitation following traumatic brain injury: a model for understanding inequities in access. Soc Sci Med. 2003;56:2201–2210. 40 Sheppard L. Changing the public perception of physiotherapeutic treatment. Health Mark Q. 1994;12:77–95. 41 Ryan G, Greathouse D, Mastui I, Murphy B. Introduction to primary care medicine. In: Boissonnault W, ed. Primary Care for the Physical Therapists: Examination and Triage. St Louis, MO: Elsevier Saunders, 2005:3–17. 42 Iezzoni LI, McCarthy EP, Davis, RB, Siebens H. Mobility impairments and use of screening and preventative services. Am J Public Health. 2000;90:955–961. 43 Mathiowetz V. Role of physical performance component evaluations in occupational therapy functional assessment. Am J Occup Ther. 1993;47:225–230.

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Access to Physical Therapy Services Among Medically Underserved Adults 44 Stewart AL. Greenfield S, Hays RD, et al. Functional status and well-being of patients with chronic health conditions: results from the medical outcomes study. JAMA. 1989:262:907–913. 45 Whitney SL, Poole JL, Cass SP. A review of balance instruments for older adults. Am J Occup Ther. 1998;52:666 – 671. 46 National Academy on an Aging Society. Chronic conditions: a challenge for the 21st century. Washington, DC; No. 1; November 1999. Available at: http://www. agingsociety.org.

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47 Andrulis DP. Access to care is the centerpiece in the elimination of socioeconomic disparities in health. Ann Intern Med. 1998;129:412– 416. 48 Mendes de Leon C, Guralnik J, BandeenRoche K. Short-term change in physical function and disability: the women’s health and aging study. J Gerontol B Psychol Sci Soc Sci. 2002;57:S355–S365. 49 Guralnik J. Preserving functional independence: state of the art. Paper presented at: Symposium on Functional Independence: Applying Theory to Practice; April 2000; Northeast Ohio College of Medicine, Ravenna, Ohio.

50 Melzer D, Izmirlian G, Leveille S, Guralnik J. Educational differences in the prevalence of mobility disability in old age: the dynamics of incidence, mortality and recovery. J Gerontol B Psychol Sci Soc Sci. 2001;56:S294 –S301.

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Research Report Relationship Between Dynamic Balance Measures and Functional Performance in Community-Dwelling Elderly People Ankur Desai, Valerie Goodman, Naaz Kapadia, Barbara L. Shay, Tony Szturm A. Desai, BPT, MSc (Medical Rehabilitation), is Professional Practice Leader–Physiotherapy, Scarborough General Hospital, Toronto, Ontario, Canada.

Background. Poor balance control, mobility restrictions, and fall injuries are serious problems for many older adults.

V. Goodman, BPT, is Staff Physical Therapist (retired), Geriatric Day Hospital, Riverview Health Centre, Winnipeg, Manitoba, Canada.

balance assessment test for identifying individuals at risk for falling in a group of community-dwelling older adults.

N. Kapadia, BPT, MSc (Medical Rehabilitation), is Research Coordinator and Physiotherapist, Toronto Rehabilitation Institute, Toronto, Ontario, Canada. B.L. Shay, PhD, MPT, BMR(PT), is Associate Professor, Department of Physical Therapy, University of Manitoba, Winnipeg, Manitoba, Canada. T. Szturm, BSc (Biology), BSc(PT), PhD (Neuroscience), is Associate Professor, Department of Physical Therapy, School of Medical Rehabilitation, University of Manitoba, R106 –771 McDermot Ave, Winnipeg, Manitoba R3E 0T6, Canada. Address all correspondence to Dr. Szturm at: ptsturm@ cc.umanitoba.ca. [Desai A, Goodman V, Kapadia N, et al. Relationship between dynamic balance measures and functional performance in communitydwelling elderly people. Phys Ther. 2010;90:748 –760.] © 2010 American Physical Therapy Association

Objective. The purpose of this study was to evaluate a new dynamic standing

Design. This was a cross-sectional observational study of 72 community-dwelling older adults who were receiving rehabilitation in a geriatric day hospital.

Method. A Dynamic Balance Assessment (DBA) test protocol was developed based on the concept of the Sensory Organization Test and the Clinical Test of Sensory Interaction and Balance. The DBA consists of 6 tasks performed on a normal floor surface and repeated on a sponge surface. A flexible pressure mat was used to record the foot’s center of pressure (COP) on both surfaces, and loss of balance was recorded. Balance performance also was evaluated using the Berg Balance Scale, the Timed “Up & Go” Test, gait speed, and the Six-Minute Walk Test. Participants were classified as “fallers” or “nonfallers” based on a self-report.

Results. No significant differences were noted between the faller group (n⫽47) and the nonfaller group (n⫽25) for demographic variables or medications. The DBA composite scores, which were derived from analysis of COP excursions of the 6 tasks performed on the sponge surface, were able to distinguish between fallers and nonfallers. Of the clinical tests, only the Timed “Up & Go” Test was able to differentiate between the faller and nonfaller groups. Limitations. A prospective study is needed to confirm the current findings and to expand testing to a larger and more diverse sample. Conclusions. The findings indicate that analysis of the extent and amount of COP displacements during selected tasks and under different surface conditions is an appropriate method to assess dynamic standing balance controls and can discriminate between fallers and nonfallers among community-dwelling elderly people.

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eclines in self-efficacy, increased susceptibility to falls, and reduced mobility are serious problems facing many older adults. Balance impairment and fear of falling can occur following singular events1,2 or can have an insidious onset, with the problem or source found in multiple predisposing factors, such as the decline of musculoskeletal, cardiovascular, respiratory, or neural fitness.3,4 Maintaining stability during movements in standing and walking and restoring balance following sudden disturbances or stumbles depend on the integration of multiple sources of spatial information, including visual, vestibular, proprioceptive, and cutaneous sensations from both internal and external frames of reference.5– 8 Feed-forward predictive control is required for preparatory postural adjustments to maintain stability during any voluntary movement. Feedback control is essential for responding in a timely fashion to unexpected disturbances or for correcting movement errors. Sensing the “state” of balance or the “threat” to balance and timely selection of feed-forward and feedback motor actions are determined by both the goal of the task (degrees of freedom and difficulty) and the demands of the environment in which it is being performed.9 Individuals manage reasonably well in their home, where they are able to control tasks, arrange environmental elements, and use assistive devices that compensate for either perceived or real instability. However, it is not always possible to predict the surface characteristics of outdoor terrains (uneven, compliant, and slippery) and to be prepared for other disruptive environmental conditions. Many older adults experience a substantial decrease in physical activity and a greater fear of falling, particularly when walking outdoors in the winter. Careful consideration, therefore, needs to be given to May 2010

the impact of “uncertainty” on stability.10 –13 The detection of changes in balance performance is a critical part of evidence-based practice in rehabilitation. Screening tools for early detection of physical decrements can allow for implementation of preventive measures and an appropriate treatment plan to minimize the development of secondary problems, such as reduced confidence and reduced physical activity. Valid outcome measures also are required for evaluation of treatment efficacy, in both the short term and the long term. Measurement of physical performance in selected tasks has been reported to predict declines in physical function or dependence.14,15 Low scores on the Berg Balance Scale (BBS),16,17 high scores on the Timed “Up & Go” Test (TUG),18 –21 shorter distance walked on the SixMinute Walk Test (6MWT),22 and slower self-selected gait speed23,24 can indicate the likelihood of falling. These tests are commonly used in daily clinical practice and incorporate a range of postures, voluntary movements, and stepping activities. Scores have been used to evaluate effects of interventions. However, most of these tests are self-paced and conducted in a predictable environment. Therefore, their ability to evaluate balance control and causes of the performance deficit is limited. Tests such as the Sensory Organization Test (SOT) and the Limits of Stability Test (LOS) provide quantitative information on biomechanical changes relevant to balance control.25–29 However, they are expensive commercial products and require special training to administer. Shumway-Cook and Horak30 developed a less expensive test based on the same principles as the SOT, known as the Clinical Test of Sensory Interaction and Balance (CTSIB). The CTSIB uses a compliant sponge pad

as an unstable support surface to emulate the SOT in terms of somatosensory distortion, with an added advantage that it is not limited to the pitch plane (ie, the disturbance could be multidirectional).31 The use of a compliant surface can modify the ground reaction forces under the feet (ie, the compliant surface cannot completely reciprocate the normal body forces beneath the feet as the body’s center of mass [COM] moves). This change in ground reaction forces can increase the magnitude and frequency of body sway. To prevent a fall, the individual must be able to sense and respond to this sway. Thus, increased demand on whole-body balance reactions and continuous automatic postural adjustments are required to maintain stability. Performance on the CTSIB is quantified by recording the amount of time the participant can maintain standing balance. However, peak excursions and amount of body sway are not recorded; thus, the CTSIB cannot provide quantification of the quality of movement.32,33 Several studies have used a sponge pad as a compliant surface and biomechanical forceplates (underneath the sponge pad) to record the foot’s center of pressure (COP) to quantify the amount of body sway and balance control as a more comprehensive balance assessment tool.12,32,34 However, as the sponge pad distorts ground reaction forces, it also distorts and damps the COP position signals. The COP signals recorded

Available With This Article at ptjournal.apta.org • The Bottom Line Podcast • Audio Abstracts Podcast This article was published ahead of print on March 11, 2010, at ptjournal.apta.org.

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Dynamic Balance Measures and Functional Performance in Community-Dwelling Elderly People from the bottom of the sponge pad are found to be different from and nonlinearly related to those of the top of the sponge pad.35 In addition, variations in the protocol and analysis used in different studies make it difficult to draw definitive conclusions.36 Although performance-based clinical balance tests such as the BBS and TUG are able to provide an indication of balance abilities, they cannot detect subtle changes in postural stability. Laboratory-based assessments can provide information regarding control processes and physiological changes relevant to balance; however, high costs limit their use in the clinical environment. There is a need for further development of clinically based balance assessments that in-

corporate dynamic balance assessment under both self-generated and unexpected or externally generated perturbations. It also is important to recognize factors influencing balance (ie, environmental interactions), its level, and its association with fall risk. In the present study, a new balance assessment tool—the Dynamic Balance Assessment (DBA)—was used to evaluate balance in communitydwelling older adults. The test incorporates features of the modified CTSIB (mCTSIB).33,37,38 In addition to standing with eyes open and closed, the DBA includes 4 additional tasks: head rotation (large gaze shifts), lifting arms, trunk rotation, and forward trunk bending. Execution of these voluntary movements displaces the body’s COM, which requires preparatory postural adjust-

The Bottom Line What do we already know about this topic? Poor balance control (leading to fear of falling), mobility restrictions, and fall injuries are common in older adults and people with neurological disorders. Test protocols and data analysis methods for daily clinical use have been developed to quantify a patient’s capacity to adapt balance and gaze stability to a few altered sensory conditions and tasks (eg, Timed “Up & Go” Test, Berg Balance Scale, modified Clinical Test of Sensory Interaction and Balance).

What new information does this study offer? This work established electronic records and used quantitative data analysis methods to quantify and track performance-based measures of dynamic standing balance during altered sensory conditions and during a variety of standardized tasks, which included trunk movements and gaze or head shifts. Additional relevant tasks and dual-task conditions during stepping and walking should also be evaluated.

If you’re a patient, what might these findings mean for you? The tracking of balance performance will shed light on the general mechanisms that contribute to limitations in mobility and will increase our understanding of fall risk. The assessment outcomes would provide a rationale for targeted interventions designed to improve balance and mobility.

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ments to maintain balance. The DBA uses a flexible pressure mapping system to record COP signals and a sponge pad as a compliant surface to distort the spatial information provided by the cutaneous sensors of the feet. These features enhance the portability of the system, yet allows a quantitative measure of balance control.35 The first objective of this study was to determine whether COP measurements (excursions and total resultant sway path length) on the DBA could differentiate fallers from nonfallers in a group of community-dwelling elderly people aged 65 years or older. Studies have used various measures of COP displacement during standing activities to index balance performance,25,27–29 and an increase in COP displacement is directly related to the amount of muscle activity during a disturbance.39 The second objective of this study was to examine whether the DBA COP measures are correlated to results from other functional balance tests assumed to measure the same construct.

Method Participants The participants in this study were 72 community-dwelling elderly people aged 65 years or older who attended a geriatric day hospital once a week and who received a rehabilitation program provided by physical therapists for clients identified with balance impairment. The program consisted of individual strengthening and balance exercises done in standing and sitting positions and a gait re-education program. Along with these exercises, there was an assessment of the use of walking aids. The inclusion criteria were: (1) age 65 years or older, (2) a Mini-Mental State Examination score greater than 24, (3) ability to speak English, (4) ability to understand the nature of the study and provide informed consent, (5) ability to stand for 2 minutes without May 2010

Dynamic Balance Measures and Functional Performance in Community-Dwelling Elderly People any gait aids, and (6) ability to walk 3.048 m (10 ft) with or without gait aids. Individuals with vertigo or any medical condition or disability that could prevent them from participating in routine clinical balance tests (eg, BBS, TUG) were excluded. The treating nurse or physical therapist informed patients of the study and completed a preliminary assessment to determine eligibility. Once a patient expressed willingness to take part in the study, we obtained informed consent. Participants were classified as fallers or nonfallers based on a self-report of one or more falls within the year prior to the study. A fall was defined as any event that led to an unplanned, unexpected loss of balance and contact with a supporting surface.28 Test Protocol Each participant completed 4 clinical tests (BBS,16 TUG,18 6MWT,22,40 and gait speed41,42) in the first session. The BBS consists of 14 common movement tasks, which are graded on a 5-point ordinal scale (0 – 4), where a score of 0 indicates an inability to perform the task and a score of 4 indicates that the patient performs the task independently, needs no cues, and meets time or distance criteria. The total score ranges from 0 to 56. The TUG measures the time to complete a 3-m walk. The test requires the participant to get up from a regular armchair, walk for 3 m, turn, walk back to the chair, and sit down. The 6MWT was used to measure the maximum distance that a person could walk in 6 minutes. Average gait speed over a 25-m walk distance was recorded for each participant. The DBA was performed on a separate visit within 1 week of the clinical tests. The DBA test conditions were as follows: 1. Quiet standing on a firm surface with eyes open. May 2010

2. Quiet standing on a firm surface with eyes closed. 3. Standing on a firm surface and performing cyclic, rhythmic, left and right head rotation to visual targets placed 120 degrees apart. Large letter T’s clearly visible to all participants were used as the visual targets. The targets’ width and height were 14 cm, and line thickness was 3 cm. The distance from the targets to the head of the participants was 120 to 140 cm. 4. Standing while performing a cyclic, rhythmic arm lifting and lowering task and while holding on to a 50-cm lightweight wooden pole, 1.91 cm in diameter, with both hands kept shoulder width apart and elbows extended. The pole was raised to shoulder level and then lowered to the legs. 5. Standing while performing cyclic, rhythmic horizontal trunk rotations to 45 degrees in each direction. 6. Standing while performing cyclic, rhythmic forward trunk bending and extension to return to the upright (erect) standing position. The amplitude of the trunk bending was about 30 degrees. For all tasks (except arm lift), the participants were instructed to keep their arms at their side. For tasks 1 and 2, the participants were instructed to stand still. The cyclic movements of tasks 3 to 6 were paced by a metronome set at 0.5 Hz or one complete movement cycle every 2 seconds. After a rest period of 2 to 3 minutes, participants repeated the 6 tasks while standing on a 50.8⫻ 50.8- ⫻ 10.16-cm sponge pad (compliant surface). A 25.4- ⫻ 40.64⫻ 1.91-cm wooden board was placed on top of the sponge pad to distribute the forces equally. Two grades of sponge were used to coun-

terbalance the effect of differences in body weight in compressing the sponge pads.35 A low-support (50.8⫻ 61- ⫻ 10.16-cm) sponge pad, with a density of 16.016 kg/m3 and a 25% indentation force deflection (IFD) of 6.82 kg, was used for people who weighed less than 55 kg. A mediumsupport (50.8- ⫻ 61- ⫻ 10.16-cm) sponge pad, with a density of 22.66 kg/m3 and a 25% IFD of 13.64 kg, was used for people who weighed more than 55 kg. Each task was performed for 20 seconds with a high table (chest height) in front of the participant (within arm’s length) and a physical therapist positioned immediately behind the participant to offer assistance, if required. Stance width was adjusted to shoulder width, and participants wore their usual footwear. The 6 tasks were presented in the same order for each participant. If a participant was unable to complete a task, then the trial was recorded as a loss of balance (LOB) and the participant advanced to the next task. A loss of balance was defined as the participant’s inability to complete the task due to the need for external support to prevent a fall. A force sensor array (FSA) pressuresensing mat* was used to compute vertical foot COP position for all tasks. The FSA pressure mats are constructed of thin, flexible piezoresistive material and thus can be placed on top of different types of support surfaces, including sponge pad surfaces.35 The FSA mat consists of an array of 256 piezo-resistive sensors (16 ⫻ 16), and each sensor covers a surface area of 2.8 cm2. Each sensor was sampled at 15 Hz, from which the vertical COP in the anterior-posterior (AP) and mediallateral (ML) directions were calculated by summing the contact forces * Verg Inc, Unit 3–55, Henlow Bay, Winnipeg, Manitoba, Canada R3Y 1G4.

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Dynamic Balance Measures and Functional Performance in Community-Dwelling Elderly People recorded from the sensor array; the equation for COP calculation is provided in the FSA user manual. Because the whole contact area is covered, the COP estimation becomes a function of the force resolution of the individual sensor. The sensors are calibrated to 300 mm Hg with a resolution of 4,096 levels (ie,12-bit). Figure 1 presents typical plots of AP-ML COP position during 2 different tasks recorded simultaneously from: (1) an AMTI-OR6 forceplate† (top trace in each panel, sampled at 100 Hz) and (2) an FSA mat secured directly on top of the AMTI forceplate (bottom trace in each plot, sampled at 15 Hz). The tasks included: (1) large AP body shifts from heels to toes and (2) large, complete ML body shifts from left foot to right foot. The movements were performed for 20 seconds and paced by a metronome set at 0.5 Hz, as per DBA tasks. As evident in Figure 1, the COP position signals obtained from the forceplate and FSA mat were virtually identical. A power-spectrum analysis also was performed on the COP position signals of the 6 DBA tasks while participants stood on the AMTI forceplate. This analysis was performed on 6 participants. For all tasks, 99% of the total power was between 0 and 1.0 Hz. This finding indicates that a sampling rate of 15 Hz would be sufficient to capture the signal content of COP displacements for the 6 DBA tasks. Participants were instructed to stand still for the eyes-open and eyesclosed conditions, and data recording was started within 2 seconds of the command. For the 4 movement tasks, data recording was started within one movement cycle. The following information also was obtained from each participant or retrieved from his or her medical † Advanced Mechanical Technology Inc, 176 Waltham St, Watertown, MA 02472-4800.

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Figure 1. Plots of anterior-posterior (AP) and medial-lateral (ML) center-of-pressure (COP) position obtained from synchronous recordings of: AMTI forceplate (top trace in each panel) and force sensor array pressure mat (bottom trace in each panel).

chart: age, sex, residential status, medical history, self-reported history of falls, use of assistive device for ambulation, whether walking outdoors for 0.5 mile (0.8 km) regularly (2–3 times per week), amount of home care assistance (frequency of days per week), and current number of prescription medications. This information was used to characterize the demographics and general health status of participants in the study.

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Data Analysis Peak-to-peak COP excursions in the AP and ML directions and total AP-ML resultant sway path length (SPL) over the 20-second time period were computed for each successful task. Increased COP excursion and total resultant SPL have been interpreted as decreased stability or reduced dynamic balance.10,26,38,43,44

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Dynamic Balance Measures and Functional Performance in Community-Dwelling Elderly People The following tests were performed to determine the capability of the DBA, clinical, and functional measures to distinguish between faller and nonfaller groups: 1. Independent t tests were performed for the normally distributed variables, including age, gait speed, and 6MWT score.

Figure 2. Total number of loss of balance (LOB) occurrences for each task and surface condition. EO⫽eyes open, EC⫽eyes closed, HR⫽head rotation, AL⫽arm lift, TB⫽trunk bending, TR⫽trunk rotation.

Composite scores for the 6 tasks performed on a fixed floor surface and on a sponge surface were calculated for each COP dependent variable. First, for each 12 tasks (6 floor surface tasks and 6 sponge surface tasks), quartile ranges were determined for the group values, peak-topeak AP-ML COP excursions, and SPL. Second, participants were assigned a score from 0 to 4, as follows: (1) a score of 0 if the value was within the lowest quartile (0%–25%), (2) a score of 1 if the value was within the second quartile (26%–50%), (3) a score of 2 if the value was within the third quartile (51%–75%), (4) a score of 3 if the value was within the upper quartile (76%–100%), and (5) a score of 4 if the task was not completed (ie, LOB). The total composite score, or sum of the scores of the 6 tasks, then was computed for each surface condition. A score of zero represented the best performance, and a score of 24 represented the worst performance. Composite scores for the eyes-open and eyes-closed conditions on both floor and sponge surfaces also were May 2010

computed to represent mCTSIB conditions.37,38

the

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An analysis of variance (ANOVA) was used to determine the effect of task condition on COP excursion and SPL. This analysis was performed for normal surface only, as there were a large number of tests on the sponge surface with LOB and thus many trials with no COP data. The Cochrane Q test was computed to determine the effect of task condition on LOB frequency. The McNemar test was used to determine the effects of surface conditions (fixed floor versus sponge) on LOB frequency.

2. Mann-Whitney U tests were performed for the non–normally distributed variables, including TUG score, BBS score, total number of prescribed medications, level of home care assistance, LOB frequency, and composite DBA scores. 3. Chi-square tests were performed for the following binomial variables: sex, use of walking aids, and the activity of walking 0.5 mile. Spearman correlation analysis was used to examine convergent validity among DBA and clinical tests assumed to measure a similar construct. All statistical analyses were performed using the SPSS statistical package for Windows, Release 10.0.‡ For all descriptive statistics, means and standard deviations were calculated for the normally distributed ‡ SPSS Inc, 233 S Wacker Dr, Chicago, IL 60606.

Figure 3. X-Y plots of center-of-pressure (COP) position (20 seconds’ duration) for selected tasks on fixed floor surface (F) and sponge surface (S). Vertical is anterior-posterior COP displacement, and horizontal is medial-lateral COP displacement. Top row of traces are for a representative participant from the nonfaller group, and bottom row of traces are for a representative participant from the faller group. EO⫽eyes open, EC⫽eyes closed, HR⫽head rotation, TB⫽trunk bending, and TR⫽trunk rotation, LOB⫽loss of balance.

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Figure 4. Group mean and standard error of mean (SEM) of: (A) peak-to-peak anterior-posterior (AP) center-of-pressure (COP) excursion, (B) peak-to-peak medial-lateral (ML) COP excursion, and (C) COP sway path length (SPL) for each task and 2 surface conditions. EO⫽eyes open, EC⫽eyes closed, HR⫽head rotation, AL⫽arm lift, TB⫽trunk bending, TR⫽trunk rotation.

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Dynamic Balance Measures and Functional Performance in Community-Dwelling Elderly People variables. Median and interquartile range were computed for non– normally distributed variables.

Table 1. Demographic and Clinical Data, Mean (SD) or Median (IQR)a Variable

Figure 3 presents representative X-Y plots of AP-ML COP position for selected tasks performed on the normal fixed floor and sponge surfaces. There was a progressive increase in COP excursion with increasing task demand on the compliant sponge surface. Group means and standard error of the mean (SEM) of peak-topeak COP excursion in the AP and ML directions and SPL are presented in Figure 4. Except for the trunkbending task, peak excursions were approximately 2 times greater when performed on the compliant sponge surface than on the normal floor surface. The SPL was 3 times greater when tasks were performed on the compliant sponge surface than on the normal floor surface, except for trunk rotation and trunk-bending tasks, for which the SPL was approximately twice as great on the compliMay 2010

Fallers (nⴝ47)

79.4 (5.48)

81.5 (6.87)

Age (y), X (SD)

Results Figure 2 presents the LOB frequency for each task and surface condition. There was a substantial increase in LOB frequency while performing the 6 tasks on the compliant sponge surface compared with the normal floor surface (McNemar test, P⬍.0001). There was a total of 16 LOB on the normal surface and 205 LOB on the compliant surface. There was no significant effect of task conditions on LOB frequency when the tasks were performed on the normal floor surface (Cochrane Q test, P⫽.14). However, a significant effect of task condition on LOB frequency was noted when the tasks were performed on the sponge surface (Cochrane Q test, P⬍.0001). Fifty-three out of 72 participants had LOB on the compliant surface during the eyes-closed condition. A high incidence of LOB on the sponge surface also was noted for the tasks that involved trunk flexion (47/72) and trunk rotation (41/72).

Nonfallers (nⴝ25)

Sex, n Male

8

23

17

24

None

28%

26%

Cane/walker

72%

74%

Female Assistive device

No. of prescribed medications, median (IQR)

8 (3.5)

8 (4)

Home care/assistance (d), median (IQR)

2 (6.5)

2 (7)

Walk 0.5 mile

a

Yes

28%

40%

No

72%

60%

IQR⫽interquartile range.

Table 2. Results of Independent t Test and Mann-Whitney U Test Comparing Faller and Nonfaller Groups for Dynamic Balance Assessment and Clinical Measuresa Variable Gait speed (m/s), X (SD)

Nonfallers

Fallers

0.75 (0.26)

0.72 (0.27)

P .8

6MWT (m), X (SD)

220 (90)

216 (82)

.9

BBS, median (IQR)

47 (12)

44 (8.5)

.3

TUG (s), median (IQR)

13 (7.5)

17 (10)

⬍.05

cAP COP, normal surface, median (IQR)

16.5 (7)

15.7 (8)

.6

cML COP, normal surface, median (IQR)

12 (8)

13.5 (7)

.6

cSPL, normal surface, median (IQR)

13 (7)

12.5 (7)

.7

cAP COP, sponge surface, median (IQR)

17.2 (7)

23.5 (6)

⬍.05

cML COP, sponge surface, median (IQR)

18.6 (7.5)

24.3 (6.5)

⬍.05

cSPL, sponge surface, median (IQR)

19.1 (7.1)

24.1 (6)

⬍.05

cAP COP, CTSIB conditions, median (IQR)

13 (4)

12.5 (4.5)

.9

cML COP, CTSIB conditions, median (IQR)

12.5 (4)

12.5 (5.1)

.9

cSPL, CTSIB conditions, median (IQR)

12.1 (3.5)

12 (5)

.9

LOB frequency, both surfaces, median (IQR)

2.4 (1.8)

3.5 (2.1)

⬍.05

a

6MWT⫽Six-Minute Walk Test, BBS⫽Berg Balance Scale, TUG⫽Timed “Up & Go” Test, IQR⫽interquartile range, AP⫽anterior-posterior, ML⫽medial-lateral, COP⫽center of pressure, SPL⫽sway path length, CTSIB⫽Clinical Test of Sensory Interaction and Balance, LOB⫽loss of balance. cAP, cML, and cSPL are composite scores (maximum⫽24).

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Dynamic Balance Measures and Functional Performance in Community-Dwelling Elderly People ant sponge surface compared with the normal floor surface. Analysis of variance showed significant effects of task condition on AP COP peakto-peak excursions (P⬍.0001), ML COP peak-to-peak excursions (P⬍.0001), and SPL (P⬍.0001). Twenty-five older adults were classified as nonfallers, and 47 older adults were classified as fallers. Table 1 summarizes the demographics, use of assistive devices, amount of home care (assistance), medication use, and the activity of walking 0.5 mile for both fallers and nonfallers. No statistical difference was found between these 2 groups for any of these variables. Clinical performance-based test scores and the DBA scores for nonfaller and faller groups are presented in Table 2. No significant difference was found between nonfallers and fallers for all clinical tests, except the TUG. The DBA composite scores for COP excursions and SPL obtained from tasks performed on the sponge surface and LOB frequency were able to distinguish between the nonfaller and faller groups. However, the DBA composite scores obtained from the normal fixed floor surface or the composite scores based on the mCTSIB conditions (eyes open and eyes closed on both floor and sponge surfaces) did not differentiate between nonfaller and faller groups. Spearman correlation coefficients among the DBA and clinical measures are presented in Table 3. Moderate to high (.58 –.83) correlations were found among clinical performance-based test scores (BBS, 6MWT, TUG, and gait speed). Low correlations (.10 –.31) were found between clinical tests and composite scores based on the COP position and LOB.

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Table 3. Spearman Correlation Coefficients for Comparisons Between Composite Dynamic Balance Assessment and Clinical Measuresa Variable Gait speed 6MWT

Gait Speed

6MWT

TUG

BBS

cAP

cML

cSPL

LOB

.83

⫺.69

.58

.14

.12

.11

.19

.59

.21

⫺.11

⫺.10

⫺.15

⫺.62

.10

.16

.18

.26

⫺.31

⫺.23

⫺.25

.29

⫺.72

TUG BBS a

6MWT⫽Six-Minute Walk Test, TUG⫽Timed “Up & Go” Test, BBS⫽Berg Balance Scale, cAP⫽composite anterior-posterior (AP) center-of-pressure (COP) excursion for sponge surface, cML⫽composite medial-lateral (ML) COP excursion for sponge surface, cSPL⫽resultant AP-ML COP path sway length for sponge surface.

Discussion Falls in older adults are known to be multifactorial, and fall risk is dependent on a combination of factors (peripheral/central, neurological, musculoskeletal, cardiorespiratory), which can differ substantially from individual to individual. The primary aim of this study was to evaluate whether indexes of balance performance obtained from a set of select tasks performed on both fixed and compliant support surfaces could differentiate between fallers and nonfallers in a sample of communitydwelling older adults. The secondary aim was to determine the strength of association among the composite DBA scores and performance-based clinical tests of balance and walking functions. The main findings of this study revealed that the composite DBA scores for a sponge surface did discriminate between a group of people with a history of falling and a group of people who had not reported a fall in the previous year. Composite DBA scores for a normal floor surface or based on the mCTSIB conditions did not distinguish between nonfaller and faller groups. Performancebased tests commonly used in daily clinical practice (ie, BBS, 6MWT, and gait speed) did not differentiate the 2 groups. The one exception was the TUG, which did discriminate the faller group from the nonfaller

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group. The results showed weak correlations of the DBA composite scores to the BBS, TUG, 6MWT, and gait speed scores. No differences in demographic variables were noted between the faller and nonfaller groups. A number of demographic and health covariates have been examined to predict fall risk. In addition, studies have combined performancebased balance tests scores and demographic variables to predict the fall risk in community-dwelling older adults.45– 47 Although general trends have been established with factors such as age, walking distance, numbers of medications, and social support, their predictive capacity is relatively low. These variables provide little information about the reasons for the falls or balance difficulties and limitations in mobility.45– 49 There have been mixed results in studies that used the BBS to predict fall risk in samples of communitydwelling older adults who differed in age and mobility limitations.50 –52 It should be noted that in the current study, the BBS scores (including those of the group with no fall history) were considerably lower than those reported in above-mentioned studies. No significant differences were noted between the nonfaller and May 2010

Dynamic Balance Measures and Functional Performance in Community-Dwelling Elderly People faller groups for gait speed and 6MWT scores. The faller subgroup showed an average (⫾SD) gait speed of 0.72⫾0.27 m/s. These values were similar to those reported by Maki23 for fearful fallers (0.66⫾0.19 m/s), but higher than those reported by VanSwearingen et al53 for frail community-dwelling older adults with history of 2 or more falls in the previous year (0.50⫾0.24 m/s). People in the faller group had an average walking distance of 215⫾81 m for the 6MWT, which was considerably lower than the walking distance reported by Cho et al22 for communitydwelling older adults with balance impairments (333⫾110 m). The gait speed test and the 6MWT are simple timed tasks that look at only one aspect of self-paced walking function on a predictable solid indoor surface. There also is a need to evaluate other aspects of gait requirements, such as stability and adaptability over different support surfaces and environmental conditions, that could lead to stumbles, resulting in a fall.54 Consistent with the findings of our study, previous studies20,21,49 have shown that the TUG can discriminate between fallers and nonfallers. However, the cutoff scores of the time taken to complete the task did vary significantly. Shumway-Cook et al20 reported a cutoff score of 13 seconds to differentiate between independently living, communitydwelling elderly people who had no falls and those who reported more than 2 falls in the previous 6 months. Chiu et al55 reported a cutoff score of 20 seconds to separate one-time fallers from nonfallers. In the current study, the TUG was able to differentiate between fallers (median⫽17 seconds) and nonfallers (median⫽13 seconds). Further analysis of the data revealed that 10 participants (3 nonfallers and 7 fallers) took at least 30 seconds to complete the TUG; 9 of them were using gait aids.

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The correlation analysis revealed weak associations between the DBA composite scores and scores on the performance-based clinical tests (ie, BBS, TUG, 6MWT, and gait speed). This finding is consistent with the findings of Hughes et al.56 These findings suggest that the DBA test protocol (derived from COP outcomes and LOB frequency) and performance-based clinical tests evaluate different components of dynamic standing balance control. Many of the participants were unable to adapt their balance and complete the 20-second tasks when the compliant standing surface and eyesclosed conditions were used. The findings demonstrate that body sway indicators and frequency of LOB depend on vision, large gaze shifts, predictable surface characteristics, and motor demands of the task (ie, multisegmental, anti-phase movements of upper- and lower-body segments). Seventy-three percent of the participants experienced LOB on the compliant surface in the eyes-closed condition compared with only 16% on the compliant surface in the eyesopen condition. In addition, when vision was eliminated and cutaneous information was distorted on the compliant surface, there was a substantial increase in body sway parameters (both peak excursion and SPL) for participants who were able to complete the tasks. The findings of this study demonstrate that elimination or distortion of one sensory input, such as surface or vision independently, is not sufficient to highlight differences in balance performance or LOB. Other studies also have shown that exclusion or disruption of only one sensory input is not sufficient to disrupt quiet standing balance in participants who are healthy57 and in older adults.10,13 Similarly, results of the composite DBA scores based on the mCTSIB conditions (ie, 3 of the 4 quiet stand-

ing tasks, which included distortion or elimination of only one sensory input) did not distinguish between nonfaller and faller groups. The same finding has been reported by Anacker and Di Fabio.37 Other studies have examined the maintenance of standing balance under altered sensory conditions and shown that when there is an elimination or distortion of 2 sensory inputs, such as using a sponge surface and eyesclosed condition12,25 or conditions 5 and 6 of the SOT,27–29 significant increases in body sway and LOB become evident. Performance on the SOT has been demonstrated to deteriorate with increasing age, which is reflected by an increase in body sway and loss of balance.25,29 Performance on the SOT, particularly during altered sensory conditions (sway stabilization and eyes closed), also has been demonstrated to distinguish between fallers and nonfallers in community-dwelling older adults.26,28 Although COP excursion and LOB frequency increased when vision was eliminated and as task demands increased, the present findings demonstrated that composite DBA scores of the 6 tasks when performed on a fixed floor surface also did not distinguish between nonfaller and faller groups. Ability to produce preparatory postural adjustments and to detect and correct balance disturbances while performing movements such as large gaze shifts and trunk movements is necessary in many activities of daily living. These tasks involving cyclic, rhythmic arm lifting and trunk motions paced by a metronome are similar to those of laboratory studies that used predictive sinusoidal platform motion paradigms to assess the feed-forward mechanism of balance control.58,59 These studies demonstrated that after 1 or 2 cycles, the participant could predict the forward/backward movements of the platform and pre-

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Dynamic Balance Measures and Functional Performance in Community-Dwelling Elderly People pare the necessary balance adjustments in advance of the platform turning points. A similar mechanism is required to ensure stability while performing voluntary movements on a fixed surface. However, the predictive process of preparatory balance adjustments is more difficult when performing the task on an “unpredictable” compliant surface. Planning errors can occur on the compliant surface, which can cause a sudden loss of balance. Rapid detection of disturbances and corrections, therefore, are required to maintain balance. This multidimensional approach is very important when assessing functional ability during basic and instrumental activities of daily living, both indoors and outdoors. Thus, the task protocol in the DBA performed on the sponge surface assesses both feed-forward preparatory balance control and timely sensory feedback controls required to deal with unpredictable conditions (compliant surface with and without vision). Interestingly, the majority of participants were able to perform the cyclic arm lift task while standing on both the fixed floor and compliant surfaces. Lifting the arms requires preparatory postural control but not trunk motion or antiphase lower-body motion. Furthermore, the head was stationary, and thus no large gaze shifts to new locations were required. The current findings suggest that the inability to maintain standing balance and adapt to unpredictable surface conditions significantly increases fall risk. These findings shed light on the general physiological mechanisms that contribute to falls and declining performance, thus providing a rationale for targeted interventions designed to improve balance and mobility function. The findings also are consistent with recent findings demonstrating that improvements in balance and mobility in

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older adults appear to be training specific.60 The fallers in this study reported being more physically active (walking 0.5 mile) than the nonfallers. However, we are not sure whether the perception of a half mile is consistently correct among all participants. Furthermore, we did not collect information about participants’ perception of their balance. A test such as the Activities-specific Balance Confidence (ABC) Scale could have established the participants’ perceived level of balance confidence. One limitation of this study is that fall history relied on participant recall. We attempted to control for recall bias by having a family member present for confirmation. In addition, the clinical information (medical, balance, mobility, and cognitive status) collected at the time of study may have been different from that at the time of fall. Predictive validity of the composite DBA scores has to be examined prospectively. The test must be administered at baseline in a cohort of older adults who subsequently fall (recorded and verified). Further research is needed to examine a larger sample of people who are at risk for falling and those who fall to better optimize composite scoring methods, including weighting of LOB occurrence. This procedure also would need to be repeated for other populations (eg, people with peripheral vestibular disorders, stroke, traumatic brain injury, or Parkinson disease). Future work is needed to obtain normative data for comparison. It should be noted that the psychometric properties of any new instrument must be established before bringing it into broad usage, and work is needed to examine testretest reliability of the composite DBA protocol. Another limitation of the study is that our sample may not be representative of the general population of older adults, because they

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were participating in a rehabilitation program at a geriatric day hospital due to balance and mobility limitations.

Conclusion The DBA examines people’s ability to maintain balance while performing graded motor tasks with alteration of sensory inputs. Measures of COP excursions for the tasks in which people maintain their balance provide further insight into performance abilities of individuals compared with simply recording the frequency of LOB. Both the DBA and the TUG can be recommended as measures to identify communitydwelling elderly people who are at risk of falling. Although the TUG may be more useful as a quick screening tool, the DBA includes multiple tasks that target both predictive and unpredictive aspects of balance control and thus is a useful indicator of sensorimotor impairment. Mr Desai and Dr Szturm provided concept/ idea/research design. Mr Desai, Ms Kapadia, Dr Shay, and Dr Szturm provided writing and data analysis. Mr Desai, Ms Goodman, and Dr Szturm provided data collection and project management. Dr Szturm provided fund procurement. Ms Goodman and Dr Szturm provided facilities/equipment and institutional liaisons. Ms Goodman provided clerical support. All authors provided consultation (including review of manuscript before submission). Ethical approval for this study was obtained from the Riverview Health Research Foundation Research Ethics Board, University of Manitoba. This work was supported by a grant from the Riverview Health Research Foundation, Winnipeg, Manitoba, Canada. This article was received March 26, 2009, and was accepted January 4, 2010. DOI: 10.2522/ptj.20090100

References 1 Guccione AA, Felson DT, Anderson JJ, et al. The effects of specific medical conditions on the functional limitations of elders in the Framingham Study. Am J Public Health. 1994;84:351–358.

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Dynamic Balance Measures and Functional Performance in Community-Dwelling Elderly People 2 Moore EG, Rosenberg MW, Fitzgibbon SH. Activity limitation and chronic conditions in Canada’s elderly, 1986 –2011. Disabil Rehabil. 1999;21:196 –210. 3 Tinetti ME, Williams TF, Mayewski R. Fall risk index for elderly patients based on number of chronic disabilities. Am J Med. 1986;80:429 – 434. 4 Gijsen R, Hoeymans N, Schellevis FG, et al. Causes and consequences of comorbidity: a review. J Clin Epidemiol. 2001;54:661– 674. 5 Creath R, Kiemel T, Horak F, Jeka JJ. Limited control strategies with the loss of vestibular function. Exp Brain Res. 2002;145: 323–333. 6 Peterka RJ. Sensorimotor integration in human postural control. J Neurophysiol. 2002;88:1097–1118. 7 Szturm T, Fallang B. Effects of varying acceleration of platform translation and toes-up rotations on the pattern and magnitude of balance reactions in humans. J Vestib Res. 1998;8:381–397. 8 van der Kooij H, Jacobs R, Koopman B, van der Helm F. An adaptive model of sensory integration in a dynamic environment applied to human stance control. Biol Cybern. 2001;84:103–115. 9 Horak FB, Nashner LM, Diener HC. Postural strategies associated with somatosensory and vestibular loss. Exp Brain Res. 1990;82:167–177. 10 Brooke-Wavell K, Perrett LK, Howarth PA, Haslam RA. Influence of the visual environment on the postural stability in healthy older women. Gerontology. 2002; 48:293–297. 11 Hay L, Bard C, Fleury M, Teasdale N. Availability of visual and proprioceptive afferent messages and postural control in elderly adults. Exp Brain Res. 1996;108: 129 –139. 12 Teasdale N, Stelmach GE, Breunig A. Postural sway characteristics of the elderly under normal and altered visual and support surface conditions. J Gerontol. 1991; 46:B238 –B244. 13 Redfern MS, Moore PL, Yarsky CM. The influence of flooring on standing balance among older persons. Hum Factors. 1997; 39:445– 455. 14 Topper AK, Maki BE, Holliday PJ. Are activity-based assessments of balance and gait in the elderly predictive of risk of falling and/or type of fall? J Am Geriatr Soc. 1993;41:479 – 487. 15 Tiedemann A, Shimada H, Sherrington C, et al. The comparative ability of eight functional mobility tests for predicting falls in community-dwelling older people. Age Ageing. 2008;37:430 – 435. 16 Berg KO, Wood-Dauphine´e SL, Williams JI, Maki B. Measuring balance in the elderly: validation of an instrument. Can J Public Health. 1992;83(suppl 2):S7–S11. 17 Shumway-Cook A, Baldwin M, Polissar NL, Gruber W. Predicting the probability for falls in community-dwelling older adults. Phys Ther. 1997;77:812– 819.

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18 Podsiadlo D, Richardson S. The timed “Up & Go”: a test of basic functional mobility for frail elderly persons. J Am Geriatr Soc. 1991;39:142–148. 19 Gunter KB, White KN, Hayes WC, Snow CM. Functional mobility discriminates nonfallers from one-time and frequent fallers. J Gerontol A Biol Sci Med Sci. 2000; 55:M672–M676. 20 Shumway-Cook A, Brauer S, Woollacott M. Predicting the probability for falls in community-dwelling older adults using the Timed Up & Go Test. Phys Ther. 2000; 80:896 –903. 21 Morris R, Harwood RH, Baker R, et al. A comparison of different balance tests in the prediction of falls in older women with vertebral fractures: a cohort study. Age Ageing. 2007;36:78 – 83. 22 Cho BL, Scarpace D, Alexander NB. Tests of stepping as indicators of mobility, balance, and fall risk in balance-impaired older adults. J Am Geriatr Soc. 2004;52: 1168 –1173. 23 Maki BE. Gait changes in older adults: predictors of falls or indicators of fear. J Am Geriatr Soc. 1997;45:313–320. 24 Woo J, Ho SC, Lau J, et al. Age-associated gait changes in the elderly: pathological or physiological? Neuroepidemiology. 1995; 14:65–71. 25 Cohen H, Heaton LG, Congdon SL, Jenkins HA. Changes in sensory organization test scores with age. Age Ageing. 1996;25:39 – 44. 26 Melzer I, Benjuya N, Kaplanski J. Postural stability in the elderly: a comparison between fallers and non-fallers. Age Ageing. 2004;33:602– 607. 27 Simmons RW, Richardson C, Pozos R. Postural stability of diabetic patients with and without cutaneous sensory deficit in the foot. Diabetes Res Clin Pract. 1997;36: 153–160. 28 Wallmann HW. Comparison of elderly nonfallers and fallers on performance measures of functional reach, sensory organization, and limits of stability. J Gerontol A Biol Sci Med Sci. 2001;56:M580 –M583. 29 Whipple R, Wolfson L, Derby C, et al. Altered sensory function and balance in older persons. J Gerontol. 1993;48(Spec No):71–76. 30 Shumway-Cook A, Horak FB. Assessing the influence of sensory interaction of balance: suggestion from the field. Phys Ther. 1986;66:1548 –1550. 31 Allum JH, Zamani F, Adkin AL, Ernst A. Differences between trunk sway characteristics on a foam support surface and on the Equitest ankle-sway-referenced support surface. Gait Posture. 2002;16:264 – 270. 32 El-Kashlan HK, Shepard NT, Asher AM, et al. Evaluation of clinical measures of equilibrium. Laryngoscope. 1998;108: 311–319. 33 Cohen H, Blatchly CA, Gombash LL. A study of the clinical test of sensory interaction and balance. Phys Ther. 1993;73: 346 –351.

34 Creath R, Kiemel T, Horak F, et al. A unified view of quiet and perturbed stance: simultaneous co-existing excitable modes. Neurosci Lett. 2005 Mar 29;377:75– 80. 35 Betker AL, Moussavi ZM, Szturm T. On modeling center of foot pressure distortion through a medium. IEEE Trans Biomed Eng. 2005;52:345–352. 36 Piirtola M, Era P. Force platform measurements as predictors of falls among older people: a review. Gerontology. 2006;52: 1–16. 37 Anacker S, Di Fabio RP. Influence of sensory inputs on standing balance in community-dwelling elders with a recent history of falling. Phys Ther. 1992;72:575– 584. 38 Loughran S, Tennant N, Kishore A, Swan IRC. Interobserver reliability in evaluating postural stability between clinicians and posturography. Clin Otolaryngol. 2005; 30:255–257. 39 Nakamura H, Tsuchida T, Mano Y. The assessment of posture control in the elderly using the displacement of the center of pressure after forward platform translation. J Electromyogr Kinesiol. 2001; 11:395– 403. 40 Guyatt GH, Sullivan MJ, Thompson PJ, et al. The 6-minute walk: a new measure of exercise capacity in patients with chronic heart failure. Can Med Assoc J. 1985;132: 919 –923. 41 Hageman PA, Blanke DJ. Comparison of gait of young women and elderly women. Phys Ther. 1986;66:1382–1387. 42 Ostrosky KM, VanSwearingen JM, Burdett RG, Gee Z. A comparison of gait characteristics in young and old subjects. Phys Ther. 1994;74:637– 646. 43 Amiridis IG, Hatzitaki V, Arabatzi F. Ageinduced modifications of static postural control in humans. Neurosci Lett. 2003; 350:137–140. 44 Lord SR, Ward JA. Age-associated differences in sensori-motor function and balance in community dwelling women. Age Ageing. 1994;23:452– 460. 45 Boulgarides LK, McGinty SM, Willett JA, Barnes CW. Use of clinical and impairment-based tests to predict falls by community-dwelling older adults. Phys Ther. 2003;83:328 –339. 46 Hoeymans N, Feskens EJ, Kromhout D, van den Bos GA. Ageing and the relationship between functional status and selfrated health in elderly men. Soc Sci Med. 1997;45:1527–1536. 47 Thomas JI, Lane JV. A pilot study to explore the predictive validity of 4 measures of falls risk in frail elderly patients. Arch Phys Med Rehabil. 2005;86:1636 –1640. 48 Barker AL, Nitz JC, Low Choy NL, Haines T. Measuring fall risk and predicting who will fall: clinimetric properties of four fall risk assessment tools for residential aged care. J Gerontol A Biol Sci Med Sci. 2009; 64:916 –924. 49 Tiedemann A, Shimada H, Sherrington C, et al. The comparative ability of eight functional mobility tests for predicting falls in community-dwelling older people. Age Ageing. 2008;37:430 – 435.

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Dynamic Balance Measures and Functional Performance in Community-Dwelling Elderly People 50 Brauer SG, Burns YR, Galley P. A prospective study of laboratory and clinical measures of postural stability to predict community-dwelling fallers. J Gerontol A Biol Sci Med Sci. 2000;55:M469 –M476. 51 Bogle Thorbahn LD, Newton RA. Use of the Berg Balance Test to predict falls in elderly persons. Phys Ther. 1996;76:576 – 583. 52 Muir SW, Berg C, Chesworth B, Speechley M. Use of the Berg Balance Scale for predicting multiple falls in communitydwelling elderly people: a prospective study. Phys Ther. 2008;88:449 – 459. 53 VanSwearingen JM, Paschal KA, Bonino P, Chen TW. Assessing recurrent fall risk of community-dwelling, frail older veterans using specific tests of mobility and the physical performance test of function. J Gerontol A Biol Sci Med Sci. 1998;53: M457–M464.

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54 Shumway-Cook A, Guralnik JM, Phillips CL, et al. Age-associated declines in complex walking task performance: the Walking InCHIANTI toolkit. J Am Geriatr Soc. 2007;55:58 – 65. 55 Chiu AY, Au-Yeung SS, Lo SK. A comparison of four functional tests in discriminating fallers from non-fallers in older people. Disabil Rehabil. 2003;25:45–50. 56 Hughes MA, Duncan PW, Rose DK, et al. The relationship of postural sway to sensorimotor function, functional performance, and disability in the elderly. Arch Phys Med Rehabil. 1996;77:567–572. 57 Fransson PA, Gomez S, Patel M, Johansson L. Changes in multi-segmented body movements and EMG activity while standing on firm and foam support surfaces. Eur J Appl Physiol. 2007;101:81– 89.

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58 Dietz V, Trippel M, Ibrahim IK, Berger W. Human stance on a sinusoidally translating platform: balance control by feedforward and feedback mechanisms. Exp Brain Res. 1993;93:352–362. 59 Corna S, Tarantola J, Nardone A, et al. Standing on a continuously moving platform: is body inertia counteracted or exploited? Exp Brain Res. 1999;124: 331–341. 60 Silsupadol P, Siu KC, Shumway-Cook A, Woollacott MH. Training of balance under single- and dual-task conditions in older adults with balance impairment. Phys Ther. 2006;86:269 –281.

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Research Report Functional Gait Assessment: Concurrent, Discriminative, and Predictive Validity in CommunityDwelling Older Adults Diane M. Wrisley, Neeraj A. Kumar

Background. The Functional Gait Assessment (FGA) is a reliable and valid measure of gait-related activities. Objective. The purpose of this study was to determine the concurrent, discriminative, and predictive validity of the FGA in community-dwelling older adults.

Design. This was a prospective cohort study. Methods. Thirty-five older adults aged 60 to 90 years completed the Activitiesspecific Balance Confidence Scale (ABC), Berg Balance Scale (BBS), Dynamic Gait Index (DGI), Timed “Up & Go” Test (TUG), and Functional Gait Assessment (FGA) during one session. Falls were tracked by having participants complete a monthly fall calendar for 6 months. Spearman correlation coefficients were used to determine concurrent validity among the ABC, BBS, TUG, DGI, and FGA. To determine the optimum scores to classify fall risk, sensitivity (Sn), specificity (Sp), and positive and negative likelihood ratios (LR⫹ and LR⫺) were calculated for the FGA in classifying fall risk based on the published criterion scores of the DGI and TUG and for the FGA, TUG, and DGI in identifying prospective falls. Receiver operator curves with area under the curve were used to determine the effectiveness of the FGA in classifying fall risk and of the DGI, TUG, and FGA in identifying prospective falls.

D.M. Wrisley, PT, PhD, NCS, is Assistant Professor, Department of Rehabilitation Science, State University of New York, University at Buffalo, 515 Kimball Tower, 3435 Main St, Buffalo, NY 14214 (USA). Address all correspondence to Dr Wrisley at: [email protected]. N.A. Kumar, PT, PhD, is Assistant Professor, Department of Rehabilitation Science, Texas Tech University Health Sciences Center, Odessa, Texas. [Wrisley DM, Kumar NA. Functional gait assessment: concurrent, discriminative, and predictive validity in communitydwelling older adults. Phys Ther. 2010;90:761–773.] © 2010 American Physical Therapy Association

Results. The FGA correlated with the ABC (r⫽.053, P⬍.001), BBS (r⫽.84, P⬍.001), and TUG (r⫽⫺.84, P⬍.001). An FGA score of ⱕ22/30 provides both discriminative and predictive validity. The FGA (scores ⱕ22/30) provided 100% Sn, 72% Sp, LR⫹ of 3.6, and LR⫺ of 0 to predict prospective falls. Limitations. The study was limited by the length of time of follow-up and the small sample size that did not allow for evaluation of criterion scores by decade.

Conclusions. The FGA with a cutoff score of 22/30 is effective in classifying fall risk in older adults and predicting unexplained falls in community-dwelling older adults.

Post a Rapid Response to this article at: ptjournal.apta.org May 2010

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alling in older adults is among the top public health issues in the United States. Approximately 35% of adults over the age of 65 years fall each year, and the risk of falling increases to 50% in adults over the age of 70 years.1–3 Falls in elderly people have been associated with significant decline in function and increased mortality and morbidity.4 –7 Many factors may contribute to falling in elderly people, including lower-extremity weakness, balance disorders, functional and cognitive impairments, visual deficits, polypharmacy, and environmental factors.8 Postural instability and gait abnormalities are strongly associated with falling in elderly people. Frequently, older adults are not aware of their risks of falling and do not report these issues to the health care professionals who care for them.8 Consequently, opportunities for prevention of falls often are overlooked, with the risk of falling evident only after injury and disability have occurred.9 –11 Recognition of older adults at risk for falls is an important task for physical therapists, as there is increasing evidence that frequency and consequences of falls can be decreased through interventions.12–15 The development and use of tools that screen for fall risk are useful to identify those older adults who require evaluation as to the cause of falling in order to prescribe the appropriate intervention. Several fall risk screening tools have been developed for and tested with older adults.16 –20 These tools include the

Available With This Article at ptjournal.apta.org • Audio Abstracts Podcast This article was published ahead of print on April 1, 2010, at ptjournal.apta.org.

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Timed “Up & Go” Test (TUG),18 the Berg Balance Scale (BBS),16,21 the Performance-Oriented Mobility Assessment (POMA),20 and the Dynamic Gait Index (DGI).19 The specificity (SP) and sensitivity (Sn) of these tools to identify individuals at risk for falls range from 59% to 89%,7,17,22–26 yet the majority of these tools were validated by their ability to discriminate between those with a history of falling and those who had not fallen.17,20,22,24 The gold standard is to validate the tools prospectively to determine whether the clinical performance tool can determine who will fall within a specified period of time. Many of these clinical performance tests, such as the POMA,20 BBS,25 and DGI,27 appear to have a ceiling effect in communityliving older adults and are not sensitive to minor differences among individuals that may indicate risk for falls and may direct intervention. The Functional Gait Assessment (FGA)28 is a modification of the DGI19 that was developed to improve the reliability of the DGI and to reduce the ceiling effect seen with the DGI in patients with vestibular disorders.27 The FGA is a 10-item clinical gait test during which participants are asked to perform the following gait activities: walk at normal speeds, at fast and slow speeds, with vertical and horizontal head turns, with eyes closed, over obstacles, in tandem, backward, and while ascending and descending stairs.28 The FGA is scored on a 4-level (0 –3) ordinal scale; scores range from 0 to 30, with lower scores indicating greater impairment. In adults with vestibular disorders, the interrater reliability of the FGA was reported as r⫽.86 (intraclass correlation coefficient [ICC (2,1)]) and intrarater reliability as r⫽.74 (ICC [2,1]).28 Individual FGA item interrater and intrarater reliability ranged from r⫽.16 to r⫽.83 (kappa). Walker et al29 found the interrater reliability

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of the FGA to be r⫽.93 (ICC [2,1]) in community-dwelling adults following a training session of the raters. In people with vestibular and balance disorders, the FGA correlated with the Activities-specific Balance Confidence Scale (ABC) (r⫽.64), the Dizziness Handicap Inventory (r⫽⫺.64), perceived symptoms of dizziness (r⫽⫺.70), number of falls in the previous 6 months (r⫽⫺.66), the TUG (r⫽ ⫺.50), and the DGI (r⫽.80).28 The FGA eliminated the ceiling effect in the DGI seen when testing people with vestibular dysfunction.28 Walker et al29 provided reference group data for the FGA in community-dwelling adults in decades from age 20 to 90 years. They found that total FGA scores decreased by decade over the age of 60 years, with adults over the age of 80 having significantly lower scores. For adults up to the age of 60 years, the normal score on the FGA would be considered ⬎27/30; for adults from ages 60 to 80 years, the normal score on the FGA would be considered ⬎24/30; and for adults over the age of 80 years, the normal score would be considered ⬎19/30.29 However, no protocol was included that would ensure that the participants’ balance abilities were normal, and there was no significant history of falls. This is especially important when considering the normative scores for older adults above 80 years. Due to the range of clinical gait activities within the FGA, we believe that it may be a more useful assessment tool to guide intervention to decrease fall risk in communityliving older adults than currently used clinical measures such as the POMA, TUG, BBS, and DGI. However, the clinical usefulness of a test increases when clinicians know its concurrent, discriminative, and predictive validity. Discriminative and predictive validity may provide indications of which scores are within normal limits and which correctly May 2010

Functional Gait Assessment in Community-Dwelling Older Adults Table 1. Participant Demographic Informationa All Participants

Nonfallers

Fallers

Significance (P Value)

Age (y)

72.9 (7.8)

71.5 (7.2)

77.7 (7.8)

.14b

⫺.47 P⫽.005

Sex

18 F, 17 M

14 F, 15 M

4 F, 2 M

.95c

⫺.09 P⫽.603

Variable

Correlation With FGA

b

⫺.02 P⫽.93

Height (cm)

166.1 (10.7)

166.9 (10.7)

165.6 (11.9)

.90

Weight (kg)

75.3 (15.6)

73.5 (14.2)

86.4 (19.6)

.16b

⫺.08 P⫽.66

b

.26 P⫽.13

MMSE ABC, range Berg Balance Scale, range

28.7 (1.5)

28.9 (1.2)

28.7 (2.0)

.89

90.5 (9.3), 64.4–100.0

91.2 (9.1), 64.4–100.0

86.5 (11.6), 66.3–95.0

.31c

.53 P⬍.001 c

.84 P⬍.000

52.7 (4.0), 38–56

53.8 (2.9), 46–56

47.8 (5.3), 38–54

.003

10.9 (4.1), 7.2–32.2

9.8 (1.6), 7.2–13.0

15.8 (8.2), 9.5–32.2

.001b

⫺.84 P⬍.000

Dynamic Gait Index, range

20.8 (3.4), 8–24

21.9 (2.3), 15–24

16.5 (4.6), 8–20

.001c

.94 P⬍.000

Functional Gait Assessment, range

23.3 (5.3), 9–30

24.9 (4.2), 15–30

16.2 (4.4), 9–20

.000c

Timed “Up & Go” Test, range

a

Reported values are mean (SD), unless otherwise indicated. Nonfallers⫽participants who did not experience an unexplained fall in the 6 months following testing. Fallers⫽participants who experienced 1 or more unexplained falls in the 6 months following testing. An explained fall was defined as a fall that was unavoidable due to medical, environmental, or task-related causes. Unexplained falls are all other falls. M⫽male, F⫽female, MMSE⫽Mini-Mental State Examination, ABC⫽Activities-specific Balance Confidence Scale. Correlations with Functional Gait Assessment performed using Spearman correlation coefficient. b Difference between fallers and nonfallers calculated using independent t test. c Difference between fallers and nonfallers calculated using Mann-Whitney U test.

classify fall risk. The determination of a cutoff score for the FGA that classifies individuals who are at increased risk of falls would provide clinicians with an additional screening tool. Discriminative validity is determined by evaluating how well a tool differentiates between 2 groups. For assessment tools that screen for fall risk, the older adults are frequently divided into groups based on history of falls. As the participants of this study did not have a history of falls, they were classified as having an increased risk of falls using the previously published criteria of the TUG and DGI. The discriminative validity of the FGA was determined by how well it identified those older adults classified as having increased fall risk. The optimum cutoff score was selected based on the FGA score with the highest sensitivity and lowest negative likelihood ratio, as it would identify the fewest false negatives. The predictive validity of the FGA was determined by how well the proposed cutoff score, established during the evaluation of discriminative validity, identified older adults who fell in the following 6 May 2010

months. Therefore, the purpose of this study was to determine: (1) the concurrent validity of the FGA with the ABC, BBS, and TUG, and (2) the discriminative and predictive validity of the FGA in classifying fall risk in older adults.

Method Participants Thirty-eight older adults were recruited as part of a larger study on the effect of age and functional level on balance. Demographic data are listed in Table 1. All participants met the following inclusion criteria: aged between 60 and 90 years; lived independently in the community; were able to stand independently longer than 1 minute; and had a Mini-Mental State Examination score of greater than 24. Participants were excluded if they had a history of osteoporosis, recent fractures, or lower-extremity surgery; had a history of progressive neuromuscular disorder; had a history of whiplash, neck injury, or current complaints of neck pain; had a history of unstable angina or uncontrolled cardiorespiratory problems; were taking any medications (eg,

benzodiazepines, antidepressants, hypnotics) that might affect balance; had a history of any falls in the previous 6 months and more than one fall in the last year; had pain in any segment greater than 2/10 on a 10point verbal analog scale (0⫽“no pain,” 10⫽“worst pain imaginable”); or did not return the monthly fall calendar. Three participants were excluded because they did not return their monthly fall calendars. We estimated that 30 participants were needed for a power of 92% using a conservative estimate of 65% positive predictive value and 90% negative predictive value for the chi-square analysis. The actual power of the chisquare analysis with the 35 participants included was 92% for the FGA versus prospective falls, 99% for the FGA versus the TUG (using ⬎11.1 seconds as the cutoff), and 91% for the FGA versus the DGI. The inclusion of human participants in this study was approved by the Health Science Institutional Review Board of the University at Buffalo. All participants provided informed consent prior to the beginning of the study.

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Functional Gait Assessment in Community-Dwelling Older Adults Procedure During the same session, participants completed the following assessment in the order listed: TUG, BBS, DGI, and FGA. All tests were administered by the same rater (N.A.K.), a physical therapist with 8 years of experience, who was trained in the administration of the tests by the other author (D.M.W.), a physical therapist with extensive experience using the tests in the evaluation and treatment of patients with balance dysfunction and one of the developers of the FGA. The test items on the BBS, DGI, and FGA were administered in their published order.16,18,19,28 Participants completed the ABC30,31 to quantify their confidence in the ability to maintain balance. The ABC was completed during breaks between the other tests. The ABC is a 16-item self-efficacy scale that is scored on a 10-point ordinal scale.30,31 Participants rate their confidence in maintaining their balance while performing 16 activities of daily living (ADL). Test-retest reliability of the ABC completed by 60 communitydwelling older adults over a 2-week period was reported as r⫽.92 using the Spearman correlation coefficient.31 Scores on the ABC range from 0, indicating no confidence in the patient’s ability to maintain balance while completing the activity, to 100, indicating complete confidence. The ABC correlates with physical function level in older adults: scores of ⬍50 indicate a low level of functioning seen with adults receiving home care, scores between 50 and 80 indicate a moderate level of functioning seen in older adults with chronic health problems or living in retirement centers, and scores greater than 80 indicate high functioning seen in physically active older adults.32 Activitiesspecific Balance Confidence Scale scores of ⱕ67 indicate increased risk of falls.33 764

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Participants completed the BBS as a means to quantify balance function. Although the BBS has a ceiling effect in community-dwelling older adults, it was included to provide a description of the participant sample and to illustrate the difference between those who prospectively experienced an unexplained fall and those who did not. The BBS is a 14-item clinical balance test that quantifies a person’s ability to perform various sitting and standing activities such as standing from a chair, standing with feet together, reaching forward, and standing on one foot.16,17 The test is scored on a 4-level ordinal scale, with lower scores indicating greater impairment. The test has interrater reliability of r⫽.98 (ICC)16 and r⫽.88 (Spearman rho)25 and correlates with the POMA (Pearson r⫽.91)21 and the TUG (Pearson r⫽.76). Scores of less than 46/56 have been interpreted to indicate increased risk for falls in communitydwelling older adults, with a sensitivity (Sn) range of 64% to 82.5%, a specificity range of 90% to 94%, a positive likelihood ratio (LR⫹) of 6.1, and a negative likelihood ratio (LR⫺) of 0.4.25,26,33 Scores of ⬍50/56 have an LR⫹ of 3.1 and an LR⫺ of 0.2 in community-dwelling older adults.26

pa⫽.64 when the test was used in patients with vestibular disorders27 and r⫽.98 (ICC) in people with multiple sclerosis when videotaped.34 The DGI correlates with the BBS (r⫽.67), the use of an assistive device (r⫽⫺.44), a history of imbalance (r⫽⫺.46), and the Balance SelfPerceptions Test (r⫽.76).24 The DGI discriminates between older adults and individuals with vestibular disorders with and without a history of falling, with scores of 19 or less indicating an increased risk of falls.35 The ability of the DGI to classify older adults at risk for falls with scores of ⱕ19/24 has been reported with an Sn of 59% and an Sp of 64%.24 Due to the similarity of the tests, the DGI and FGA were performed concurrently. Items on the DGI and FGA that are similar were performed once and scored according to their published criteria. The DGI and FGA were performed in the published order of the tests. Participants were provided with the standard instructions for each item and with a demonstration of the item, if needed. A maximum of 2 opportunities were provided to complete each task. A participant received a score of 0 if he or she was unable to perform a task as per the instructions of the DGI and FGA.

The DGI19 is a clinical gait test that was developed to assess fall risk in community-dwelling older adults. It is an 8-item test, rated on a 4-level ordinal scale, with lower scores indicating greater impairments. The DGI includes the activities of walking at normal speeds, walking at fast and slow speeds, walking with horizontal and vertical head turns, walking over and around obstacles, and ascending and descending stairs. The reliability of the DGI was .96 (using a ratio of subject variability to total variability) in community-dwelling older adults when the raters were trained by the developer of the test.24 Interrater reliability was kap-

The TUG is a modification of the Get Up and Go test.18 For the TUG, participants are timed as they stand up from a chair with arms, walk 3 m (9.84 ft) at their self-selected gait speed, turn around, come back to the chair, and sit down. For this study, participants were allowed 1 trial for practice and then performed 3 trials. The average of the 3 trials was used for analysis. The TUG has test-retest reliability of r⫽.99 (ICC [2,1])18 and correlates with gait speed (r⫽⫺.81), with the BBS (r⫽ ⫺.81), and with ADL function (Barthel Index, r⫽.78).18 Validity indexes for the TUG appear to be population dependent. Scores ranging from 10

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Functional Gait Assessment in Community-Dwelling Older Adults to 30 seconds have been suggested to classify fall risk in communitydwelling older adults.18,22,36,37 Podsiadlo and Richardson18 suggested that scores of ⬍11 seconds indicated a low risk for falls, whereas scores of ⬎19 seconds indicated a moderate to high risk for falls.38 ShumwayCook et al22 found that scores on the TUG of ⬎13.5 seconds classified fall risk with an Sn and Sp of 87% in community-dwelling older adults,22 whereas Rose and Jones36 found that scores of ⬎10 seconds classified older adults with a history of falling with an Sn of 71% and an Sp of 89%. If a score of ⬎13.5 seconds had been used by Rose and Jones,36 only 30% of those with a history of falling would have been identified. Trueblood et al37 found that scores of ⬎20 seconds resulted in an Sn of 10% and an Sp of 95% in classifying community-dwelling older adults who fell in the ensuing 6 months. They suggested that a TUG score of ⬎10 to 12 seconds would be a more appropriate cutoff score to classify older adults who are at risk for falling. Scores of ⬎11.1 seconds on the TUG were found to be more sensitive (80%) and specific (56%) in classifying adults with vestibular and balance dysfunction who had fallen (mean age⫽60 years).23 Scores of ⬎7.95 seconds were found to have an Sn of 30% and an Sp of 93% in classifying people with Parkinson disease (mean age [SD] for “fallers” [people with a history of falling]⫽73 [8.6] years; mean age [SD] for “nonfallers” [people without a history of falling]⫽66 [9.9] years),39 and scores of ⬎15.0 seconds resulted in an Sn of 96% and an Sp of 36% in classifying falls in older adults in a residential care facility.40 The cutoff score of ⱖ11.0 seconds, as suggested by Podsiadlo and Richardson18 and Trueblood et al,37 was used to determine discriminative and predictive validity. As our particiMay 2010

pants closely resemble the participants included by Trueblood et al37 and were classified as fallers versus nonfallers by prospective falls, a cutoff score within the suggested range was appropriate. To test the predictive validity of the FGA in identifying older adults who fell in the ensuing 6 months, all participants were provided with 6 months’ worth of postage-paid fall calendar postcards and were asked to return them monthly.41 Participants completed the calendar on a daily basis. If a fall occurred, a separate postcard was completed, providing details of the fall. The postcards were mailed back monthly, and if not received by the 10th of the following month, participants were contacted to remind them to return the cards. If participants returned a postcard indicating they had fallen, they were contacted via telephone or e-mail for additional details. Falls were defined as unintentionally coming in contact with any surface lower than the participant’s height. Falls were further classified as explained or unexplained. A fall was considered explained if there was a medical, environmental, or task-related explanation for the fall that was unavoidable (eg, falling while skiing, slipping on ice, falling on stairs while moving furniture, a reaction to medication).42 An unexplained fall was all other falls. Falls were classified by an investigator (D.M.W.) who was blinded to the participant’s clinical test performance prior to the clinical test data being added to the falls database. Data Analysis The Spearman correlation coefficient was calculated between the TUG, ABC, and BBS to determine concurrent validity of the FGA. The discriminative validity of the FGA in classifying older adults who were at increased risk for falls by the TUG (scores ⱖ11.0 seconds)18,37 and DGI

(scores ⱕ19)24 was determined using receiver operator curves (ROCs) with the area under the curve (AUC). The AUC was used to evaluate the effectiveness of the FGA in classifying fall risk. The greater the AUC, the better the test is in classifying fall risk. An area of 1 indicates 100% ability to classify fall risk, and an area of 0.5 indicates a 50% chance of correctly classifying fall risk. The determination of the optimum cutoff score for the FGA in correctly classifying fall risk in older adults was determined by calculating the Sn, Sp, LR⫹, and LR⫺. The scores with the highest Sn and lowest LR⫺ were identified as the optimum cutoff scores for the FGA. The predictive validity of the FGA, TUG, and DGI in identifying future falls was determined using ROCs with the AUC. The AUCs of the tests were compared to determine which test was best in identifying future falls. The determination of the optimum cutoff score for the FGA, TUG, and DGI in correctly identifying future falls in older adults was determined by calculating the Sn, Sp, LR⫹, and LR⫺. The scores with the highest Sn and lowest LR⫺, therefore yielding the fewest number of false negatives, were determined to be the optimum cutoff scores for the FGA, TUG, and DGI. All statistics were performed using SPSS software, version 15.* Role of the Funding Sources This work was supported by New York Physical Therapy Association Research Designated Funds and University at Buffalo’s Mark Diamond Research Fund.

Results Thirty-five participants (92%) returned their fall calendars and were included in the study. The 3 participants who did not return their fall calendars and were not included in * SPSS Inc, 233 S Wacker Dr, Chicago, IL 60606.

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Functional Gait Assessment in Community-Dwelling Older Adults the study did not respond to the telephone or e-mail reminders. There was no difference in demographics between those who returned their fall calendars and those who did not. Participant demographics are listed in Table 1. Concurrent Validity The FGA significantly correlated with the BBS, TUG, and ABC. Correlation coefficients and significance levels are listed in Table 1. Discriminative Validity Thirteen older adults were classified as at risk for falls based on the TUG (scores ⱖ11.0 seconds). The discriminative validity of the FGA is shown in Figure 1. The ROC for the FGA using the TUG scores for classification of fall risk is displayed in Figure 2A. The AUC was 0.87, indicating that the FGA correctly classified fall risk based on the TUG 87% of the time. The metrics for various values of the FGA to classify fall risk as indicated by TUG score are displayed in Table 2A. The optimum validity indexes are obtained with an FGA criterion score of ⱕ22, which results in an Sn of 91%, an Sp of 85%, an LR⫹ of 5.96, and an LR⫺ of 0.09. Individuals who score ⱕ22/30 on the FGA are 6 times more likely to be classified as having an increased risk of falling (based on the TUG) than those who score ⬎22/30. The metrics of the proposed cutoff score for the FGA (ⱕ22/30) to classify risk for falls as determined by scores on the TUG are presented in Table 3A.

Figure 1. Discriminative validity of the Functional Gait Assessment (FGA). (A) Relationship between FGA scores and Timed “Up & Go” Test (TUG) scores in community-dwelling older adults. The horizontal thick line is the published cutoff score for the TUG of ⱖ11 s.18,37 The vertical thick line is the proposed cutoff score for the FGA of ⱕ22/30. (B) Relationship between the FGA scores and Dynamic Gait Index (DGI) scores in community-dwelling older adults. The horizontal thick line is the published cutoff score for the DGI of ⱕ19/24.24 The vertical thick line is the proposed cutoff score for the FGA of ⱕ22/30. Note that there are overlapping data points, so the number of visible points on the graph may not equal the number of participants in each group.

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Eight older adults were classified as being at risk for falls based on the DGI (scores ⱕ19/24 indicate increased risk of falls). The ROC for the FGA using the fall risk classification of the DGI is displayed in Figure 2A. The AUC was 0.93, indicating that the FGA correctly classified fall risk based on the DGI 93% of the time. The metrics for various values of the FGA to classify fall risk as inMay 2010

Functional Gait Assessment in Community-Dwelling Older Adults dicated by the DGI are displayed in Table 2B. As with the TUG, the optimum validity indexes are obtained with an FGA criterion score of ⱕ22, resulting in an Sn of 100%, an Sp of 78%, an LR⫹ of 4.5, and an LR⫺ of 0. Individuals who score ⱕ22/30 on the FGA are 4.5 times more likely to be at increased risk of falling (based on the DGI) than those who score ⬎22/30. The metrics of the proposed cutoff score for the FGA (ⱕ22/30) to classify fall risk as determined by scores on the DGI are presented in Table 3A. Predictive Validity Seventeen participants (49%) reported 18 falls over the 6 months. Of these, 6 participants (17%) reported 7 unexplained falls. The conditions of the explained falls were medication reaction (n⫽1), slipping on ice (n⫽5), ascending stairs or curbs while carrying objects (n⫽2), moving furniture (n⫽1), slipping on wet rocks at the beach (n⫽1), and missing a hidden step behind a door (n⫽1). No participants sustained a serious injury from a fall or obtained medical attention following a fall. Participants who reported unexplained falls differed significantly from those who did not report unexplained falls in the BBS, TUG, DGI, and the FGA but not in age, sex, height, weight, Mini-Mental State Examination score, or ABC (Tab. 1). Based on their mean scores, the older adults with unexplained falls would be classified as at risk for falls based on the published cutoff scores for the BBS, TUG, FGA, and DGI. The FGA correctly identified all 6 of the participants who fell in the 6 months following the testing, whereas the TUG identified only 5 participants who fell (83%) and the DGI identified only 4 participants who fell (67%). The ROCs for the FGA, DGI, and TUG versus prospective falls are displayed in Figure 2B. The AUCs were 0.92 for the FGA, May 2010

Figure 2. Receiver operator curve analyses for discriminative and predictive validity of the Functional Gait Assessment (FGA). (A) Receiver operator curve for the FGA’s ability to classify fall risk in community-dwelling older adults based on Timed “Up & Go” Test (TUG) (participants with scores of ⱖ11 s classified as having increased risk for falls)18,37 and the Dynamic Gait Index (DGI) (participants with scores of ⬍19/24 classified as having increased risk for falls).24 The area under the curve is 0.87 for the TUG and 0.96 for the DGI. The larger gray points indicate the optimum cutoff score for the FGA of 22/30. (B) The receiver operating curve for the ability of the FGA, TUG, and DGI to predict prospective falls in community-dwelling older adults. The area under the curve is 0.92 for the FGA, 0.91 for the DGI, and 0.89 for the TUG. The larger black points are the optimum cutoff scores for the FGA, DGI and TUG to predict prospective falls. The larger gray points are the proposed cutoff score for the FGA and the published cutoff scores for the DGI and TUG.

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Functional Gait Assessment in Community-Dwelling Older Adults Table 2. Metrics of Individual Scores of the Functional Gait Assessment (FGA) for Classifying Increased Fall Riska A. Metrics of Individual Scores of the FGA for Classifying Increased Risk of Falls as Determined by Timed “Up & Go” Test Scores of >11.0 s FGA (Abnormal < Score)

Sensitivity

30

100.0%

29 28

LRⴙ

LRⴚ

True Positive

False Positive

False Negative

0.0%

1.00

NaN

13

0

22

0

100.0%

18.0%

1.22

0.00

100.0%

36.0%

1.57

0.00

13

4

18

0

13

8

14

0

26

92.0%

41.0%

1.56

0.19

25

92.0%

64.0%

2.54

0.12

12

9

13

1

12

14

8

1

24

85.0%

68.0%

2.66

23

85.0%

73.0%

3.10

0.23

11

15

7

2

0.21

11

16

6

2

22

85.0%

86.0%

21

77.0%

86.0%

6.21

0.18

11

19

3

2

5.64

0.27

10

19

3

3

20

62.0%

19

54.0%

86.0%

4.51

0.45

8

19

3

5

91.0%

5.92

0.51

7

20

2

6

18 17

31.0%

96.0%

6.77

0.73

4

21

1

9

23.0%

96.0%

5.08

0.81

3

21

1

10

15

15.0%

100.0%

NaN

0.85

2

22

0

11

12

8.0%

100.0%

NaN

0.92

1

22

0

12

8

0.0%

100.0%

NaN

1.00

0

22

0

13

Specificity

True Negative

B. Metrics of Individual Scores of the FGA for Classifying Increased Fall Risk as Determined by Scores of <19 on the Dynamic Gait Index

a

FGA (Abnormal < Score)

Sensitivity

30

100.0%

29 28

LRⴙ

LRⴚ

True Positive

False Positive

False Negative

0.0%

1.00

NaN

8

0

27

0

100.0%

14.8%

1.17

0.00

100.0%

29.6%

1.42

0.00

8

4

23

0

8

8

19

0

26

100.0%

37.0%

1.59

25

100.0%

55.6%

2.25

0.00

8

10

17

0

0.00

8

15

12

0

24

100.0%

63.0%

23

100.0%

66.7%

2.70

0.00

8

17

10

0

3.00

0.00

8

18

9

0

22

100.0%

21

87.5%

75.8%

4.50

0.00

8

21

6

0

75.8%

3.94

0.16

6

21

6

2

20

87.5%

85.2%

5.91

0.15

6

23

4

2

19

87.5%

92.6%

11.81

0.14

6

25

2

2

18

62.5%

100.0%

NaN

0.38

5

27

0

3

16

50.0%

100.0%

NaN

0.50

3

27

0

5

14

25.0%

100.0%

NaN

0.75

2

27

0

6

11

12.5%

100.0%

NaN

0.88

1

27

0

7

8

0.0%

100.0%

NaN

1.00

0

27

0

8

Specificity

True Negative

LR⫹⫽positive likelihood ratio, LR⫺⫽negative likelihood ratio. Optimal cutoff scores are indicated in bold type.

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Functional Gait Assessment in Community-Dwelling Older Adults Table 3. Metrics of the Functional Gait Assessment (FGA) to Classify Increased Risk of Falls and Predict Prospective Fallsa A. Metrics of the FGA Using a Cutoff Score of 22/30 to Classify Increased Risk of Falls as Determined by the Timed “Up & Go” Test (TUG) and Dynamic Gait Index (DGI) DGI

TUG

ⱕ1924

ⱖ11 s37

ⱕ22

ⱕ22

Sensitivity

100% (100%–100%)

85% (65%–104%)

Specificity

78% (62%–94%)

86% (72%–101%)

Score that indicates increased risk for falls FGA criterion score that indicates increased risk for falls

Positive likelihood ratio

4.5 (2.2–9.1)

6.2 (2.1–18.2)

Negative likelihood ratio

0 (0–NaN)

Positive predictive value

57% (31%–83%)

79% (57%–100%)

100% (100%–100%)

91% (75%–105%)

⬁

35.8

Negative predictive value Odds ratio

␹

2

0.2 (0.05–0.6)

5.13 (P⬍.001)

16.66 (P⬍.001)

B. Metrics of Proposed Cutoff Scores for the FGA and Published Cutoff Scores for the DGI and TUG to Predict Prospective Falls in Community-Dwelling Older Adults FGA

FGA

DGI

TUG

ⱕ20

ⱕ22

ⱕ1924

ⱖ11 s37

Sensitivity

100% (100%–100%)

100% (100%–100%)

67% (29%–104%)

83% (54%–113%)

Specificity

83% (69%–97%)

72% (56%–89%)

86% (74%–99%)

72% (56%–89%)

Score that indicates increased risk for falls

Positive likelihood ratio

5.8 (2.6–12.88)

Negative likelihood ratio

0.0 (0–NaN)

Positive predictive value Negative predictive value

a

4.78 (1.66–14.11)

3.0 (1.5–6.0)

0 (0–NaN)

0.4 (0.21–1.21)

58% (30%–86%)

43% (17%–69%)

50% (15%–85%)

39% (12%–65%)

100% (100%–100%)

100% (100%–100%)

93% (74%–111%)

96% (84%–107%)

⬁

Odds ratio

␹2

3.6 (2.0–6.5)

11.92 (P⬍.001)

⬁

12.5

10.55 (P⬍.001)

7.67 (P⬍.01)

0.2 (0–1.4)

13.1 6.43 (P⬍.03)

Confidence intervals shown in parentheses. NaN⫽not a number.

0.91 for the DGI, and 0.89 for the TUG. The metrics for various values of the FGA, DGI, and TUG to predict prospective falls are listed in Table 4. The optimum cutoff score for the FGA to identify falls was ⱕ20/30. The optimum cutoff score for the DGI to identify prospective falls was ⱕ20/24. The optimum cutoff score for the TUG was ⱖ12.3 seconds. Metrics for the FGA to predict future falls with cutoff scores of 20 and 22 and for previously established cutoff scores for the DGI and TUG are listed in Table 3B.

May 2010

Discussion Although an FGA cutoff score of ⱕ22/30 provided the optimum metrics to classify fall risk in older adults as identified by scores on the TUG and DGI, an FGA score of ⱕ20/30 provided the optimum metrics in identifying older adults who sustained unexplained falls in the following 6 months. However, when classifying fall risk in older adults, it is more important to have more false positives than false negatives. The consequences of falsely classifying someone at risk for falling are greater than providing intervention to someone with a lower risk for falls. Al-

though someone may not be at increased risk for falling in the following 6 months, lower scores on the FGA are correlated with slower gait speeds and other measures of imbalance and frailty that may influence a person’s mobility and ultimately increase the risk of falling or other consequences of decreased mobility.8 Providing intervention early may deter some of these complications. Therefore, we propose that clinicians use the more conservative criterion score of ⱕ22/30 to classify increased risk for falls in older adults.

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Functional Gait Assessment in Community-Dwelling Older Adults Table 4. Metrics of Individual Scores on the Functional Gait Assessment (FGA), Dynamic Gait Index (DGI), and Timed “Up & Go” Test (TUG) for Identifying Prospective Falls in Community-Dwelling Older Adultsa A. Metrics of Individual Scores on the FGA for Identifying Prospective Falls in Community-Dwelling Older Adults FGA (Abnormal < Score)

Sensitivity

30

100.0%

0.0%

29

100.0%

13.8%

28

100.0%

26

100.0%

25 24

LRⴚ

True Positive

1.00

NaN

6

1.16

0.000

6

27.6%

1.38

0.000

6

8

21

0

34.5%

1.53

0.000

6

10

19

0

100.0%

51.7%

2.07

0.000

6

15

14

0

100.0%

58.6%

2.42

0.000

6

17

12

0

23

100.0%

62.1%

2.64

0.000

6

18

11

0

22*

100.0%

72.4%

3.63

0.000

6

21

8

0

Specificity

LRⴙ

True Negative

False Positive

False Negative

0

29

0

4

25

0

21

100.0%

75.9%

4.14

0.000

6

22

7

0

20

100.0%

82.8%

5.80

0.000

6

24

5

0

19

66.7%

82.8%

3.87

0.403

4

24

5

2

18

50.0%

93.1%

7.25

0.537

3

27

2

3

16

50.0%

96.6%

14.50

0.518

3

28

1

3

14

33.3%

100.0%

NaN

0.667

2

29

0

4

11

16.7%

100.0%

NaN

0.833

1

29

0

5

8

0.0%

100.0%

NaN

1.000

0

29

0

6

False Positive

False Negative

B. Metrics of Individual Scores on the DGI for Identifying Prospective Falls in Community-Dwelling Older Adults DGI (Abnormal < Score)

Sensitivity

24

100.0%

0.0%

23

100.0%

27.6%

22

100.0%

21

100.0%

20 19*

LRⴚ

True Positive

1.00

NaN

6

0

29

0

1.38

0.000

6

8

21

0

44.8%

1.81

0.000

6

13

16

0

58.6%

2.42

0.000

6

17

12

0

100.0%

75.9%

4.14

0.000

6

22

7

0

66.7%

86.2%

4.83

0.387

4

25

4

2

18

50.0%

89.7%

4.83

0.558

3

26

3

3

17

50.0%

93.1%

7.25

0.537

3

27

2

3

16

50.0%

96.6%

14.50

0.518

3

28

1

3

15

16.7%

96.6%

4.83

0.863

1

28

1

5

11

16.7%

100.0%

NaN

0.833

1

29

0

5

100.0%

NaN

1.000

0

29

0

6

7

Specificity

0.00%

LRⴙ

True Negative

(Continued)

The prospective falls in this study were divided into explained and unexplained falls. We felt this distinction was necessary, as the follow-up period was only 6 months and environmental conditions would be different for different seasons of the year. Previous 770

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studies have considered all participants who fell, participants with injurious falls, or participants with multiple falls. Only one of the older adults in the current study had multiple falls, and no one had injurious falls. Classification of the older

Number 5

adults’ falls into explained and unexplained falls seemed reasonable, as many of the circumstances of the participants’ explained falls were similar to those that occur in young adults.42 Other studies that have monitored falls weekly or monthly using a fall calMay 2010

Functional Gait Assessment in Community-Dwelling Older Adults Table 4. Continued C. Metrics of Individual Scores on the TUG for Identifying Prospective Falls in Community-Dwelling Older Adults

a

TUG (Abnormal > Cutoff)

Sensitivity

6.16

100.0%

7.24 7.53

LRⴙ

LRⴚ

True Positive

False Positive

False Negative

0.0%

1.00

NaN

6

0

29

0

100.0%

3.4%

1.04

0.000

100.0%

6.9%

1.07

0.000

6

1

28

0

6

2

27

0

7.82

100.0%

10.3%

1.12

8.01

100.0%

13.8%

1.16

0.000

6

3

26

0

0.000

6

4

25

0

8.18

100.0%

17.2%

8.27

100.0%

20.7%

1.21

0.000

6

5

24

0

1.26

0.000

6

6

23

0

8.33

100.0%

8.41

100.0%

24.1%

1.32

0.000

6

7

22

0

27.6%

1.38

0.000

6

8

21

0

8.53 8.80

100.0%

31.0%

1.45

0.000

6

9

20

0

100.0%

34.5%

1.53

0.000

6

10

19

0

9.23

100.0%

37.9%

1.61

0.000

6

11

18

0

9.65

83.3%

37.9%

1.34

0.439

5

11

18

1

Specificity

True Negative

9.87

83.3%

41.4%

1.42

0.403

5

12

17

1

10.08

83.3%

44.8%

1.51

0.372

5

13

16

1

10.24

83.3%

48.3%

1.61

0.345

5

14

15

1

10.28

83.3%

51.7%

1.73

0.322

5

15

14

1

10.34

83.3%

55.2%

1.86

0.302

5

16

13

1

10.37

83.3%

58.6%

2.01

0.284

5

17

12

1

10.51

83.3%

62.1%

2.20

0.269

5

18

11

1

10.76

83.3%

65.5%

2.42

0.254

5

19

10

1

10.90

83.3%

69.0%

2.69

0.242

5

20

9

1

11.07*

83.3%

72.4%

3.02

0.230

5

21

8

1

11.23

83.3%

75.9%

3.45

0.220

5

22

7

1

11.24

83.3%

79.3%

4.03

0.210

5

23

6

1

11.47

83.3%

82.8%

4.83

0.201

5

24

5

1

11.70

83.3%

86.2%

6.04

0.193

5

25

4

1

11.87

83.3%

89.7%

8.06

0.186

5

26

3

1

12.09

83.3%

93.1%

12.08

0.179

5

27

2

1

12.34

83.3%

96.6%

24.17

0.173

5

28

1

1

12.62

66.7%

96.6%

19.33

0.345

4

28

1

2

12.84

50.0%

96.6%

14.50

0.518

3

28

1

3

13.22

50.0%

100.0%

NaN

0.500

3

29

0

3

13.97

33.3%

100.0%

NaN

0.667

2

29

0

4

23.35

16.7%

100.0%

NaN

0.833

1

29

0

5

33.23

0.0%

100.0%

NaN

1.000

0

29

0

6

Optimum cutoff scores are in bold type. Current cut scores are indicated with asterisks. NaN⫽not a number.

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Functional Gait Assessment in Community-Dwelling Older Adults endar have shown fall rates similar to those of our study (49% with 1 or more fall),43,44 which are higher than the fall rates found in other studies.1–3 The criterion score recommended for the FGA in classifying fall risk is higher than the mean FGA score found by Walker et al29 for older adults over 80 years of age. Seven adults over the age of 80 years participated in that study. Their mean FGA score (SD) was 20.7 (5.1). Two of the 7 participants over 80 years of age reported unexplained falls. Their scores were significantly lower than those of the other participants over 80 years of age (scores of 14 and 15). Two of the participants over 80 years of age had FGA scores of ⬍22/30 but did not fall in the ensuing 6 months. However, their FGA scores were within the normative ranges found by Walker et al29 (95% confidence interval⫽19.2–22.6). It may be that adults over the age of 80 years have a different criterion score than adults under the age of 80 years. However, Walker et al29 did not ensure that their participants had clinical balance scores within normal limits, and it is unknown how many of the older adults they tested fell following their testing. Until true normative scores are established, it is safer to use the same criterion score so that all who are at risk for falling are identified. The FGA identified more of the people who fell in the 6 months after testing than the TUG or DGI. The FGA had a slightly larger AUC than either the DGI or TUG, indicating that the FGA is better at predicting prospective falls. The Sn of the FGA was higher than that of either the DGI or the TUG, although the Sp was lower than that of the TUG, resulting in slightly poorer LR⫹ and LR⫺ values. The American Geriatrics Society8 recommendation for the use of the TUG as a screening tool to classify older adults at increased risk for falls 772

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based on the metrics of the test and the ease of performance is supported by our research. However, a TUG score of ⱖ12.3 seconds is the optimum cutoff score for predicting falls in the ensuing 6 months, in agreement with previous research.18,37 The FGA provides excellent metrics for classify fall risk and predicting future falls. Clinical tools such as the TUG and BBS have performed inconsistently in classifying older adults at risk for falls.22,24,26,39,40,45– 47 The identification of those at risk for falls appears to be highly dependent on the population of interest, the definition of a fall, and how the prediction is made. Clinicians often emphasize the ability of clinical balance tools to predict future falls or classify people at increased risk of falls. However, these tools also are important in identifying balance impairment and directing treatment. The FGA incorporates timed walking at speeds required to cross a street safely, the ability to walk with head movements, the ability to turn safely, the ability to walk backward, the ability to walk with vision decreased, and the ability to walk with a narrow base of support. All are necessary for daily functional mobility. These tasks may direct specific interventions directed at improving functional gait, such as walking with head turns on various surfaces or providing education on compensation techniques. The moderate-to-strong correlations between the FGA and the ABC, BBS, and TUG indicate that the FGA provides different information than the other clinical tests and may encompass a more comprehensive measure of balance and the ability to perform various gait tasks. The FGA also has eliminated the ceiling effect demonstrated by the DGI, allowing it to be more sensitive to change. There were several limitations in the current study. Although an adequate

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level of power was achieved, a relatively small sample was enrolled. The small sample size did not allow for the discriminative and predictive validity to be evaluated by decade. The study should be repeated with a larger sample size and with people of various impairments and pathologies across the life span. The older adults were followed for only 6 months to determine prospective falls. Collecting data for a longer period of time likely would have increased the number of falls reported and possibly led to a different optimum cutoff score. Further research is needed to determine other psychometric properties of the FGA, such as true normative scores, minimum detectable difference, and minimum clinically important difference.

Conclusion A cutoff score of 22/30 on the FGA provides optimum validity for classifying fall risk in older adults at risk for falling and in predicting unexplained falls in community-dwelling older adults. The FGA appears to predict falls in community-dwelling older adults better than the currently recommended clinical tools. Dr Wrisley provided concept/idea/research design, writing, and data analysis. Both authors provided data collection, project management, fund procurement, facilities/ equipment, and consultation (including review of manuscript before submission). This study was approved by the Health Science Institutional Review Board of the University at Buffalo. This work was supported by New York Physical Therapy Association Research Designated Funds and University at Buffalo’s Mark Diamond Research Fund. This article was received February 26, 2009, and was accepted September 6, 2009. DOI: 10.2522/ptj.20090069

References 1 Campbell AJ, Borrie MJ, Spears GF, et al. Circumstances and consequences of falls experienced by a community population 70 years and over during a prospective study. Age Ageing. 1990;19:136 –141.

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Functional Gait Assessment in Community-Dwelling Older Adults 2 Campbell AJ, Spears GF, Borrie MJ. Examination by logistic regression modelling of the variables which increase the relative risk of elderly women falling compared to elderly men. J Clin Epidemiol. 1990;43: 1415–1420. 3 Rubenstein LZ, Josephson KR. The epidemiology of falls and syncope. Clin Geriatr Med. 2002;18:141–158. 4 Brown AP. Reducing falls in elderly people: a review of exercise interventions. Physiother Theory Pract. 1999;15:59 – 68. 5 Robbins AS, Rubenstein LZ, Josephson KR, et al. Predictors of falls among elderly people: results of two population-based studies. Arch Intern Med. 1989;149: 1628 –1633. 6 Rubenstein LZ, Josephson KR, Robbins AS. Falls in the nursing home. Ann Intern Med. 1994;121:442– 451. 7 Tinetti ME, Williams TF, Mayewski R. Fall risk index for elderly patients based on number of chronic disabilities. Am J Med. 1986;80:429 – 434. 8 American Geriatrics Society, British Geriatrics Society, and American Academy of Orthopedic Surgeons Panel on Falls Prevention. Guideline for the prevention of falls in older persons. J Am Geriatr Soc. 2001;49:664 – 672. 9 Jarrett PG, Rockwood K, Carver D, et al. Illness presentation in elderly patients. Arch Intern Med. 1995;155:1060 –1064. 10 Cumming RG, Kelsey JL, Nevitt MC. Methodologic issues in the study of frequent and recurrent health problems: falls in the elderly. Ann Epidemiol. 1990;1:49 –56. 11 Cummings SR, Nevitt MC, Kidd S. Forgetting falls: the limited accuracy of recall of falls in the elderly. J Am Geriatr Soc. 1988; 36:613– 616. 12 Gillespie LD, Gillespie WJ, Robertson MC, et al. Interventions for preventing falls in elderly people. Cochrane Database Syst Rev. 2003;(4):CD000340. 13 Zijlstra GA, van Haastregt JC, van Rossum E, et al. Interventions to reduce fear of falling in community-living older people: a systematic review. J Am Geriatr Soc. 2007;55:603– 615. 14 Gillespie LD, Robertson MC, Gillespie WJ, et al. Interventions for preventing falls in older people living in the community. Cochrane Database Syst Rev. 2009;(2): CD007146. 15 Howe TE, Rochester L, Jackson A, et al. Exercise for improving balance in older people. Cochrane Database Syst Rev. 2007;(4):CD004963. 16 Berg K, Wood-Dauphine´e S, Williams JI. The Balance Scale: reliability assessment with elderly residents and patients with an acute stroke. Scand J Rehabil Med. 1995; 27:27–36. 17 Berg KO, Wood-Dauphine´e SL, Williams JI, Maki B. Measuring balance in the elderly: validation of an instrument. Can J Public Health. 1992;83(suppl 2):S7–S11. 18 Podsiadlo D, Richardson S. The timed “Up & Go”: a test of basic functional mobility for frail elderly persons. J Am Geriatr Soc. 1991;39:142–148.

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19 Shumway-Cook A, Woollacott M. Motor Control: Theory and Practical Applications Baltimore, MD: Williams & Wilkins; 2001. 20 Tinetti ME. Performance-oriented assessment of mobility problems in elderly patients. J Am Geriatr Soc. 1986;34:119 –126. 21 Berg KO, Maki BE, Williams JI, et al. Clinical and laboratory measures of postural balance in an elderly population. Arch Phys Med Rehabil. 1992;73:1073–1080. 22 Shumway-Cook A, Brauer S, Woollacott M. Predicting the probability for falls in community-dwelling older adults using the Timed Up & Go Test. Phys Ther. 2000; 80:896 –903. 23 Whitney SL, Marchetti GF, Schade A, Wrisley DM. The sensitivity and specificity of the Timed “Up & Go” and the Dynamic Gait Index for self-reported falls in persons with vestibular disorders. J Vestib Res. 2004;14:397– 409. 24 Shumway-Cook A, Baldwin M, Polissar NL, Gruber W. Predicting the probability for falls in community-dwelling older adults. Phys Ther. 1997;77:812– 819. 25 Bogle Thorbahn LD, Newton RA. Use of the Berg Balance Test to predict falls in elderly persons. Phys Ther. 1996;76:576 – 583; discussion 584 –575. 26 Riddle DL, Stratford PW. Interpreting validity indexes for diagnostic tests: an illustration using the Berg Balance Test. Phys Ther. 1999;79:939 –948. 27 Wrisley DM, Walker ML, Echternach JL, Strasnick B. Reliability of the dynamic gait index in people with vestibular disorders. Arch Phys Med Rehabil. 2003;84:1528 – 1533. 28 Wrisley DM, Marchetti GF, Kuharsky DK, Whitney SL. Reliability, internal consistency, and validity of data obtained with the functional gait assessment. Phys Ther. 2004;84:906 –918. 29 Walker ML, Austin AG, Banke GM, et al. Reference group data for the functional gait assessment. Phys Ther. 2007;87: 1468 –1477. 30 Myers AM, Powell LE, Maki BE, et al. Psychological indicators of balance confidence: relationship to actual and perceived abilities. J Gerontol A Biol Sci Med Sci. 1996;51:M37–M43. 31 Powell LE, Myers AM. The Activitiesspecific Balance Confidence (ABC) Scale. J Gerontol A Biol Sci Med Sci. 1995;50: M28 –M34. 32 Myers AM, Fletcher PC, Myers AH, Sherk W. Discriminative and evaluative properties of the activities-specific balance confidence (ABC) Scale. J Gerontol A Biol Sci Med Sci. 1998;53:M287–M294. 33 Lajoie Y, Gallagher SP. Predicting falls within the elderly community: comparison of postural sway, reaction time, the Berg Balance Scale and the Activitiesspecific Balance Confidence (ABC) Scale for comparing fallers and non-fallers. Arch Gerontol Geriatr. 2004;38:11–26. 34 McConvey J, Bennett SE. Reliability of the Dynamic Gait Index in individuals with multiple sclerosis. Arch Phys Med Rehabil. 2005;86:130 –133.

35 Whitney SL, Hudak MT, Marchetti GF. The dynamic gait index relates to self-reported fall history in individuals with vestibular dysfunction. J Vestib Res. 2000;10:99 –105. 36 Rose DJ, Jones CJ. Predicting the probability of falls in community-residing older adults using the 8-foot Up-and-Go: a new measure of functional mobility. J Aging Phys Act. 2002;10:466 – 475. 37 Trueblood PR, Hodson-Chennault N, McCubbin A, Youngclarke D. Performance and impairment-based assessments among community dwelling elderly: sensitivity and specificity. Issues on Aging. 2001;24:2– 6. 38 Lyons SS. Evidence-based protocol: fall prevention for older adults. J Gerontol Nurs. 2005;31:9 –14. 39 Dibble LE, Lange M. Predicting falls in individuals with Parkinson disease: a reconsideration of clinical balance measures. J Neurol Phys Ther. 2006;30:60 – 67. 40 Nordin E, Lindelof N, Rosendahl E, et al. Prognostic validity of the Timed Up-and-Go test, a modified Get-Up-and-Go test, staff’s global judgement and fall history in evaluating fall risk in residential care facilities. Age Ageing. 2008;37:442– 448. 41 Ganz DA, Higashi T, Rubenstein LZ. Monitoring falls in cohort studies of community-dwelling older people: effect of the recall interval. J Am Geriatr Soc. 2005;53:2190 –2194. 42 Talbot LA, Musiol RJ, Witham EK, Metter EJ. Falls in young, middle-aged and older community dwelling adults: perceived cause, environmental factors and injury. BMC Public Health. 2005;5:86. 43 Russell MA, Hill KD, Blackberry I, et al. The reliability and predictive accuracy of the falls risk for older people in the community assessment (FROP-Com) tool. Age Ageing. 2008;37:634 – 639. 44 Shumway-Cook A, Silver IF, LeMier M, et al. Effectiveness of a community-based multifactorial intervention on falls and fall risk factors in community-living older adults: a randomized, controlled trial. J Gerontol A Biol Sci Med Sci. 2007;62: 1420 –1427. 45 Botolfsen P, Helbostad JL, Moe-Nilssen R, Wall JC. Reliability and concurrent validity of the Expanded Timed Up-and-Go test in older people with impaired mobility. Physiother Res Int. 2008;13:94 –106. 46 Muir SW, Berg K, Chesworth B, Speechley M. Use of the Berg Balance Scale for predicting multiple falls in communitydwelling elderly people: a prospective study. Phys Ther. 2008;88:449 – 459. 47 van Iersel MB, Munneke M, Esselink RA, et al. Gait velocity and the Timed-Upand-Go test were sensitive to changes in mobility in frail elderly patients. J Clin Epidemiol. 2008;61:186 –191.

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Functional Gait Assessment in Community-Dwelling Older Adults

Invited Commentary

Jennifer S. Brach

Falling is a major issue in older adults, with 30% to 50% of older adults reporting a fall each year.1 Thus, recognizing which older adults are at risk for falling is important. Several measures of mobility and balance have been examined in relation to falls; however, most have been related to past fall history, with little work being conducted on the measures’ ability to predict future falls.2– 4 Wrisley and Kumar5 are to be recognized for conducting a study to fill in this gap in knowledge by examining the concurrent, discriminative, and predictive validity of the Functional Gait Assessment (FGA) for fall risk and future falls in community-dwelling older adults. They are to be commended for conducting a prospective study and gathering information on falls over a 6-month period using monthly fall calendars. However, their findings need to be interpreted with caution, given the specificity of the sample and the restricted definition of the outcome or condition, which greatly limit the generalizability of the results. Wrisley and Kumar demonstrated that an FGA score of ⱕ22/30 provides both discriminate validity for fall risk and predictive validity for unexplained falls, with 100% sensitivity, 72% specificity, a positive likelihood ratio of 3.6, and a negative likelihood ratio of 0. A score of ⱕ22 on the FGA correctly identified all of the older adults who experienced an unexplained fall and falsely identified only 28% of those who did not have an unexplained fall. The high sensitivity of the FGA means that when a negative test result is obtained (ie, a score of ⬎22 on the FGA), the clinician can, with confidence, rule out the potential of a future unexplained fall in the older

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adult.6 Although the findings are impressive, I question the usefulness of this information in clinical practice. When evaluating the usefulness of a diagnostic test, a person must consider whether the test had demonstrated performance on patients who resemble the individual with whom the physical therapist is working.7 Wrisley and Kumar examined community-dwelling older adults who were 60 to 90 years of age and excluded anyone who had fallen in the past 6 months or had more than 1 fall in the past year, thus selecting a sample with a relatively low fall risk.8 –10 Given that the prevalence of falls in older adults ranges from 30% to 50%, the authors are excluding a large portion of older adults who would routinely be referred for physical therapy. Another way to examine Wrisley and Kumar’s sample would be to compare their reported fall rate with that in the literature. However, because Wrisley and Kumar collected fall data only over a 6-month period, it is difficult to compare their fall rate with those in the literature, which usually are reported over a 12-month period. With that being said, Wrisley and Kumar’s fall rate over 6 months were 49%, which is quite high. This high fall rate is even more surprising given that their participants could not have fallen in the past 6 months or had more than 1 fall in the past year, which makes them at low risk for falls.8 –10 When interpreting Wrisley and Kumar’s findings, it is important to note that the cutoff points were not determined for all falls but were determined specifically for unexplained falls, a much more restrictive definition of the outcome or condition. Traditionally, a fall has been defined

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as unintentionally coming to rest on the ground or at some other lower level, not as a result of a major intrinsic event (eg, stroke, syncope) or overwhelming hazard.8,9,11 Wrisley and Kumar used a similar definition to define a fall in their study (ie, unintentionally coming in contact with any surface lower than the individual’s height); however, they further classified their falls as either explained or unexplained. If there was a medical, environmental, or taskrelated explanation for a fall that was unavoidable, the fall was classified as explained. All other falls were unexplained. The investigators were required to use their judgment in order to classify the falls as explained or unexplained. I am concerned that by just examining unexplained falls the authors are underestimating the magnitude of the problem. Their unexplained fall rate was 17% compared with the overall fall rate of 49%. Most falls result from several different factors. These factors generally can be lumped into 3 categories: (1) the type of activity in which the person is participating when he or she falls, (2) intrinsic characteristics of the person, and (3) hazards and demands of the environment. Environmental factors contribute in some way to most falls, with the most common environmental factors being objects to trip over, poor lighting, slippery surfaces, and inappropriate furniture.8,11 I believe these so-called explained falls account for a large percentage of falls in communitydwelling older adults. By excluding explained falls from the analyses, we are potentially overlooking older adults who might benefit from an intervention to improve mobility and prevent further falls. By examining only unexplained falls, Wrisley and

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Functional Gait Assessment in Community-Dwelling Older Adults Kumar excluded a large proportion (11/18 or 61%) of the falls in their study. In addition to examining the FGA with respect to future unexplained falls, I encourage Wrisley and Kumar to report the diagnostic criteria of the FGA for identifying all future falls. By examining all falls as the outcome, and not just unexplained falls, the following would be accomplished: (1) the clinical usefulness of the information would be improved, (2) the magnitude of the problem would be less likely to be underestimated, and (3) the definition of their outcome or condition would be consistent with the fall literature.

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J.S. Brach, PT, PhD, GCS, is Assistant Professor, Department of Physical Therapy, University of Pittsburgh, Pittsburgh, PA 15260. Address all correspondence to Dr Brach at: [email protected]. DOI: 10.2522/ptj.20090069.ic

References 1 Rubenstein LZ, Josephson KR. The epidemiology of falls and syncope. Clin Geriatr Med. 2002;18:141–158. 2 Tinetti ME. Performance-oriented assessment of mobility problems in elderly patients. J Am Geriatr Soc. 1986;34: 119 –126. 3 Shumway-Cook A, Brauer S, Woollacott MH. Predicting the probability for falls in community-dwelling older adults using the Timed Up & Go Test. Phys Ther. 2000;80:896 –903. 4 Berg KO, Wood-Dauphine´e SL, Williams JI, Maki BE. Measuring balance in the elderly: validation of an instrument. Can J Public Health. 1992;83:7–11.

5 Wrisley DM, Kumar NA. Functional Gait Assessment: concurrent, discriminative, and predictive validity in communitydwelling older adults. Phys Ther. 2010;90:761–773. 6 Sackett DL, Haynes RB, Guyatt GH, Tugwell P. Clinical Epidemiology: A Basic Science for Clinical Medicine. Boston, MA: Little, Brown & Co; 1991. 7 Jewell DV. Guide to Evidence-Based Physical Therapy Practice. Sudbury, MA: Jones and Bartlett; 2008:235–260. 8 Tinetti ME, Speechley M, Ginter SF. Risk factors for falls among elderly persons living in the community. N Engl J Med. 1988;319:1701–1707. 9 Nevitt MC, Cummings SR, Kidd S, et al. Risk factors for recurrent nonsyncopal falls: a prospective study. JAMA. 1989;261: 2663–2668. 10 Nevitt MC, Cummings SR, Hudes ES. Risk factors for injurious falls: a prospective study. J Gerontol. 1991;46:M164 –M170. 11 Tinetti ME, Speechley M. Prevention of falls among the elderly. N Engl J Med. 1989;320:1055–1059.

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Research Report

Validation of a New Device to Measure Postsurgical Scar Adherence Giorgio Ferriero, Stefano Vercelli, Ludovit Salgovic, Valeria Stissi, Francesco Sartorio G. Ferriero, MD, is Physiatrist, Fondazione Salvatore Maugeri, Istituto Scientifico di Veruno, Servizio di Fisiatria Occupazionale ed Ergonomia, Via per Revislate 13, I-28010, Veruno (NO), Italy. Address all correspondence to Dr Ferriero at: [email protected]. S. Vercelli, PT, is Physical Therapist, Unit of Occupational Rehabilitation and Ergonomics, Instituto Scientifico di Veruno, Fondazione Salvatore Maugeri, Clinica del Lavoro e della Riabilitazione. L. Salgovic, MD, CSc, is Lecturer in Surgery, Univerzita sv Cyrila a Metoda, Trnava, Slovak Republic. V. Stissi, PT, is Physical Therapist, Unit of Occupational Rehabilitation and Ergonomics, Instituto Scientifico di Veruno, Fondazione Salvatore Maugeri, Clinica del Lavoro e della Riabilitazione. F. Sartorio, PT, is Physical Therapist, Unit of Occupational Rehabilitation and Ergonomics, Instituto Scientifico di Veruno, Fondazione Salvatore Maugeri, Clinica del Lavoro e della Riabilitazione. [Ferriero G, Vercelli S, Salgovic L, et al. Validation of a new device to measure postsurgical scar adherence. Phys Ther. 2010;90: 776 –783.] © 2010 American Physical Therapy Association

Background and Purpose. Scarring after surgery can lead to a wide range of disorders. At present, the degree of scar adhesion is assessed manually and by ordinal scales. This article describes a new device (the Adheremeter) to measure scar adhesion and assesses its validity, reliability, and sensitivity to change. Design. This was a reliability and validity study. Setting. The study was conducted at the Scientific Institute of Veruno. Participants and Methods. Two independent raters, a physical therapist and a physical therapist student, used the Adheremeter to measure scar mobility and contralateral normal skin in a sample of 25 patients with adherent postsurgical scars before (T1) and after (T2) physical therapy. Two indexes of scar mobility, the adherence’s surface mobility index (SMA) and the adherence severity index (AS), were calculated. Their correlation with the Vancouver Scar Scale (VSS) and its pliability subscale (PL-VSS) was assessed for the validity analysis. Results. Both the SMA and the AS showed good-to-excellent intrarater reliability (intraclass correlation coefficient [ICC]⫽.96) and interrater reliability (SMA: ICC⫽.97 and .99; AS: ICC⫽.87 and .87, respectively, at T1 and T2), correlated moderately with the VSS and PL-VSS only at T1 (rs⫽⫺.58 to ⫺.66), and were able to detect changes (physical therapist/physical therapist student): z score⫽⫺4.09/⫺3.88 for the SMA and ⫺4.32/⫺4.24 for the AS; effect size⫽0.6/0.4 for the SMA and 1.4/1.2 for the AS; standard error of measurement⫽4.59/4.79 mm2 for the SMA and 0.05/0.06 for the AS; and minimum detectable change⫽12.68/13.23 mm2 for the SMA and 0.14/0.17 for the AS. Limitations. The measurement is based on the rater’s evaluation of force to stretch the skin and on the patient’s judgment of comfort. Discussion and Conclusions. The Adheremeter showed a good level of reliability, validity, and sensitivity to change. Further studies are needed to confirm these results in larger cohorts and to assess the device’s validity for other types of scars.

Post a Rapid Response to this article at: ptjournal.apta.org 776

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carring after surgery can lead to a wide range of disorders such as pain, movement limitation, functional impairment, and aesthetic or psychological disturbance.1,2 The assessment of pathological postsurgical scars is crucial for planning their treatment.3– 6 It usually includes evaluation of physical characteristics (eg, height, pliability, relief, adhesion), cosmetic appearance (color, cosmetic defects), and the patient’s symptoms (pain, itching). In particular, scar adherence (defined as the failure of the tissues to successfully establish independent layering)7 may produce several clinical problems, limiting range of motion and muscle strength (forcegenerating capacity) and altering the local proprioceptive input.6,7

To date, most clinicians assess adherent scars only by simple manual evaluation.8 None of the available scar rating scales9,10 have been proved valid for measuring scar adherence.6 Moreover, there are many devices for measuring different aspects of scars,11,12 but none for scar adherence. Due to the lack of assessment tools for scar adherence and the clinical impact of this disturbance for physical therapist practice, we focused our attention on developing a simple new device for scar adhesion assessment: the Adheremeter. The aim of this study was to validate the Adheremeter in assessment of postsurgical scars by analyzing its reliability, concurrent validity with the Vancouver Scar Scale (VSS), and sensitivity to change.

Materials and Method Examiners After a pilot study, 2 raters—a physical therapist and a physical therapist student—were selected as representatives of 2 hypothetical categories of interest among raters: expert and inexpert, respectively. The physical therapist was an employee of the Scientific Institute of Veruno, who was May 2010

Figure 1. The Adheremeter. The diameter of the largest concentric ring is 28 mm, and the external edge of the device is 17.5 mm from the center.

experienced in treating patients with postsurgical scars. The student was in the third year of study for a physical therapy degree and had no specific experience in assessing postsurgical scars. Both raters were briefly taught how to use the device. Neither rater was involved in the patients’ treatment. Adheremeter The Adheremeter is a new device designed to measure adherence of postsurgical scar, which is defined as the restriction of scar mobility with respect to underlying tissue of the worst adherent point when stretched in 4 orthogonal directions. It is an inexpensive and easy-to-use instrument with an ergonomic shape, consisting of 9 concentric rings with radii of 1, 2, 4, 6, 8, 10, 12, 14, and 15 mm, respectively (Fig. 1), printed on flexible transparency film for copiers (product no. PP2500)* to ensure maximum adaptability to different anatomical surfaces.

* 3M, Corporate Headquarters, 3M Center, St Paul, MN 55144-1000.

Vancouver Scar Scale The VSS is the most widely used outcome scale for scars. Four physical characteristics are rated: vascularity, pigmentation, height, and pliability. In the original version, each variable includes ordinal subscales that are summed to obtain a total score ranging from 0 to 13, with 0 representing normal skin. A different weight is given to each item (eg, the pliability subscale [PL-VSS] ranges from 0 to 5 points). Scar characteristics are defined not only by a numerical score, but also by descriptors to increase the potential for objective rating and facilitate the training process for observers.6 Although the literature on the VSS focuses predominantly on Available With This Article at ptjournal.apta.org • The Bottom Line Podcast • Audio Abstracts Podcast This article was published ahead of print on March 11, 2010, at ptjournal.apta.org.

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Validation of a New Device to Measure Postsurgical Scar Adherence Table 1. Main Characteristics of the Study Participants and of the Scars Patient or Scar Characteristic

Data

Sex, male/female

8/17

Age (y), X (SD)

38.3 (14.3)

Scars, linear/arthroscopic

21/4

Body region, upper arm/leg

8/17

Location, over a joint/not over a joint

13/12

Linear scar length (mm), X (SD)

5 (3.3)

Suture material, needles/staples/adhesive skin closure strips

11/11/3

Time from surgical treatment (d), X (SD)

72 (49.2)

burn scars, the scale also has been validated for rating postsurgical scars.13,14 In this study, we used the modified version proposed by Nedelec et al,9 which takes into account the concept of scar adherence defined as firmness.11 Global adherence in local structures surrounding the scar is assessed with the PL-VSS, in which Nedelec et al changed the term “banding” to “adherent” and eliminated the term “contracture,” reducing the score for this item to a maximum of 4 points. They also slightly adjusted some other subscales, increasing the possible total score to a maximum of 14 points. This version has been proposed to

increase the reliability and the validity of the scale, but, to our knowledge, its psychometrical properties have never been analyzed. Participants The participants in this study represented a convenience sample of patients who were recruited with a consecutive sampling method over a period of 10 months. All participants were patients referred to the Scientific Institute of Veruno, Salvatore Maugeri Foundation, for rehabilitation assessment and treatment. They were assessed by a physiatrist and recruited if they had an adherent scar on one limb as a consequence of orthopedic sur-

The Bottom Line What do we already know about this topic? Assessment of skin adherence postsurgical scaring is crucial prior to planning treatment. Clinicians need tools to reliably measure scar adhesion rather than estimating it or using less reliable methods.

What new information does this study offer? This study reports on the Adheremeter: a new and easy-to-use device for measuring scar adhesion in clinical practice.

If you’re a patient, what might these findings mean for you? Quantification of the extent of scar adhesion with the Adheremeter makes it possible to reliably assess changes at follow-up, and, secondarily, to make better judgments of the effects of your treatment.

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gery. The exclusion criteria were: scars on the face, head, or trunk; previous surgery in the same area; other local problems reducing skin elasticity (eg, hyperkeratosis) in the affected or contralateral limb at the corresponding site of the adherence, considered a reference measure of normal skin mobility. Twenty-five patients between the ages of 21 and 79 years were enrolled in the study. Causes for surgical interventions were: fractures (n⫽10), ligament (n⫽4) and tendon (n⫽4) repairs, entrapment syndromes at the wrist (n⫽3), joint prosthesis (n⫽1), arthrodesis (n⫽1), Dupuytren disease (n⫽1), and traumatic injury of the hand (n⫽1). Table 1 shows the main characteristics of the study sample and of the scars. The mean (SD) duration of treatment was 10 (2) sessions, with a frequency of 2 to 3 sessions per week. During each session, patients underwent a physical therapy program including scar manual therapy plus stretching, joint mobilization, muscle strengthening, and functional exercises, depending on the goal of rehabilitation and their injury. The study was approved by the local institutional review board, and written informed consent was obtained from all participants in accordance with institutional review board guidelines. Procedure The Adheremeter and the VSS were administered simultaneously before (T1) and at the end (T2) of the physical therapy intervention. Only the physical therapist administered the VSS. The 2 raters performed the measurement on the same day (in the morning), one 10 minutes after the other, in random order. During testing, each examiner was alone with the patient in the room. Each rater was blinded to the other’s assessment and their own previous results (at T2). Each rater identified as landmarks the worst adherent point and the skin on May 2010

Validation of a New Device to Measure Postsurgical Scar Adherence

Figure 2. Scar adherence (marked with a black fine-point pen) in original position (O) at rest (left) and at maximal caudal excursion (C) (right) when stretched with maximal force within a comfort range for the patient. Red arrow shows stretching direction. In this example, maximal caudal excursion of the adherence (from O to C) is 3 mm.

the contralateral anatomic position of the adherence and marked them with a fine-line pen. Both surfaces were cleaned. In linear scars, the rater reported on the patient record the position of the worst adherent point by measuring its distance from the 2 extremities of the scar. The Adheremeter was positioned so that the rings were centered on the landmark. Skin was relaxed, and nearby joints were in a loose-packed position. The rater held the device in the hand, supporting the hand on the patient’s body in such a way that there was no contact between the Adheremeter and the patient’s skin. The other thumb was positioned close to the external edge of the device (17.5 mm from the center) (Fig. 2). Before stretching the skin with the thumb with maximal force within a comfortable range for the patient, the rater said to the patient, “Now, I’m beginning to stretch the skin; if you feel any discomfort, tell me immediately.” Traction was applied centrifugally in 4 directions: caudal, rostral, right side, and left side. For every traction, the rater read on the Adheremeter the position of the landmark at the maximal excursion. Once the tension was released, the rater verified that the May 2010

landmark returned to the Adheremeter’s center and, if not, repeated the measurement. Markers on the skin were cleaned at the end of each measurement. The whole procedure generally took a few minutes per landmark. Data Analysis The 4 measurements (ie, caudal, rostral, and the 2 side maximal landmark excursions from the rest position), taken both for the scar and for the normal contralateral skin, were used to obtain a couple of indexes of surface mobility: the adherence’s surface mobility index for the scar (SMA) and the surface mobility index for the normal contralateral skin (SMN). The score of each index of surface mobility was obtained by calculating the area of the quadrilateral whose diagonals, which are orthogonal to each other, are the side-toside and rostro-caudal landmark maximal excursions (Fig. 3). Then, the SMA was compared with the SMN, thus giving an index of adherence severity (AS). The AS estimates the ratio between the SMA and the SMN: AS⫽SMA/SMN (Fig. 4). Its values thus calculated range from 0 to 1, where 0 represents scar immobility in at least one diagonal (side-to-side or

rostro-caudal) and 1 represents completely normal scar mobility. In both indexes, an increase of values means a better scar condition (ie, a higher surface mobility for the SMA and a scar surface mobility approaching that of normal skin for the AS).

Figure 3. Graphic representation of the surface mobility index. O is the original position of the evaluation point, S1 and S2 represent the 2 maximal lateral excursions, and C and R represent the maximal caudal and rostral excursions. Because the diagonals, S1S2 (side-to-side, red) and RC (rostrocaudal, blue), intersect at right angles, the area of the quadrilateral (yellow) is computed as: (S1S2 ⫻ RC)/2. In this example, S1S2⫽7⫹5⫽12 mm, RC⫽8⫹2⫽10 mm, and, consequently, the surface mobility index is scored as 12 ⫻ 10/2⫽60 mm2.

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Validation of a New Device to Measure Postsurgical Scar Adherence mined on the basis of the pilot study expecting to obtain ICC values of about .90, with a 95% confidence interval (CI) close to .2.16 The intrarater reliability of the SMN (T1 versus T2) was calculated for both raters. Interrater reliability was analyzed by comparing the SMA, SMN, and AS at both T1 and T2 for both raters.

Figure 4. Graphic representation of the surface mobility index (patient 7) showing differences between the adherence’s surface mobility index for the scar (SMA) (pathological condition, red quadrilateral) and the surface mobility index for the normal contralateral skin (SMN) (normal skin condition, black quadrilateral) at the initial examination (T1) and the SMA at the end of treatment (T2) (outcome, blue quadrilateral). The figure clearly shows, in this patient, an improvement in scar mobility after the treatment (the blue quadrilateral is larger than the red quadrilateral), but also that maximal rostral excursion did not change. In this example: at T1, SMA⫽10 mm2, SMN⫽60 mm2, and, consequently, AS is scored as 10/60⫽0.17; at T2, SMA⫽12 mm2, SMN⫽60 mm2, and, consequently, AS is scored as 12/ 60⫽0.20.

Intrarater and interrater reliability were calculated by computing the intraclass correlation coefficient (ICC [2,1]) at T1 and T2. Intraclass correlation coefficient values higher than .75 were considered good, and those above .90 were considered excellent.15 The sample size of 25 patients assessed by 2 raters was deter-

Given the sample size of 25 patients15 and the link between scar adherence, pliability, and general scar healing,5 to provide evidence of concurrent validity, we tested our a priori hypothesis, which was to find at least a moderate correlation (r ⬎.50) between the SMA and the AS and both VSS and PL-VSS. Correlation coefficients (rs) were calculated using the Spearman rank method, corrected for ties. Data were analyzed using SPSS statistical software.† The sensitivity to change (ie, the ability to detect change in general, regardless of whether the change was clinically relevant) of the SMA and the AS was determined by: 1. Wilcoxon signed rank tests; 2. The effect size, defined as mean change score (T2⫺T1) divided by the standard deviation of the T1 (admission) scores (values around 0.2, 0.5, and 0.8 are considered, respectively, small, moderate, and good)17;

†

3. The standard error of measurement (SEM) at T1, reflecting the extent of expected errors in different raters’ scores, computed as follows: SEM⫽SD ⫻ 公1 ⫺ R, where SD is the standard deviation of test scores and R is the test-retest reliability coefficient, which in this study was the ICC18; and 4. The minimum detectable change in single subjects (MDC), computed from the SEM, to indicate the amount of change required to be adequately confident that the change that has occurred is not attributable to measurement error or chance variation. The MDC was estimated using a previously described method (1.96 ⫻ SEM ⫻ 公2, where 1.96 is the 2-sided tabled z value for a 95% CI).18

Results The mean duration of the rehabilitation intervention was 17 days (interquartile range⫽12–30 days). No patient reported discomfort during measurement with the Adheremeter. Table 2 shows the mean values for the SMA and the AS at T1 and T2. Both scores increased significantly during the testing period (for all, P⬍.001). Figure 5 shows the correlation between the AS values at T1 and changes that occurred after the treatment period, calculated for each patient with the following formula: [(AS score at T2)⫺(AS score at T1)]. Table 3 shows the mean values for the VSS and the PL-VSS at T1 and T2.

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

Table 2. Mean (SD) Values for the Adherence’s Surface Mobility Index for the Scar (SMA) and the Index of Adherence Severity (AS) at the Initial Examination (T1) and at the End of Treatment (T2) Physical Therapist Index SMA AS a

Physical Therapist Student

T1

T2

T1

T2

20.82 (26.51)

37.96 (47.96)

22.64 (32.31)

37.18 (47.96)

0.22 (0.15)

0.44 (0.25)

0.25 (0.18)

0.44 (0.25)

SMA⫽the adherence’s surface mobility index for the scar, AS⫽index of adherence severity.

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Validation of a New Device to Measure Postsurgical Scar Adherence In normal skin, measurement of intrarater reliability showed excellent and reliable values in both raters (ICC⫽.96; 95% CI⫽.91, .98). Interrater reliability values for the SMN, SMA, and AS are shown in Table 4. Correlations between both the Adheremeter’s indexes (SMA and AS) and the VSS and PL-VSS are shown in Table 5. The z values were ⫺4.09 and ⫺3.88 for the SMA and ⫺4.32 and ⫺4.24 for the AS, for the physical therapist and the physical therapist student, respectively (P⬍.001). The effect size was 0.6 and 0.4 for the SMA index and 1.4 and 1.2 for the AS. The SEM was 4.59 and 4.79 mm2 for the SMA and .05 and .06 for the AS. The MDC was 12.68 and 13.23 mm2 for the SMA and 0.14 and 0.17 for the AS. The MDC for the AS was met or exceeded by more than 50% (13/25) of this cohort.

Discussion Assessment of skin adherence is crucial to obtain outcome measurements regarding treatment of pathological scars and to quantify compensation in medico-legal settings. To our knowledge, the only scale developed for adherent scars is the Skin Glide Grade scale, a nonvalidated 5-point Likert scale for grading the amount of scar restriction.10 In addition, a complex technological device has been proposed, but its validity has not been demonstrated.19

Figure 5. Correlation between the index of adherence severity (AS) at the initial examination (T1) and the AS change after treatment (T2⫺T1), based on the physical therapist’s measurements.

VSS. We chose the version proposed by Nedelec et al9 because this is the only one that considers scar adherence. The 2 Adheremeter indexes (SMA and AS) showed a better correlation with the VSS and the PL-VSS at the initial examination than after rehabilitation. These results could be explained by the fact that scar moTable 3.

Mean (SD) Values of the Vancouver Scar Scale (VSS, Range⫽0 –14) and Its Pliability Subscale (PL-VSS, Range⫽0 – 4) at the Initial Examination (T1) and at the End of Treatment (T2) Index

The Adheremeter showed excellent intrarater reliability, both with the expert and the inexpert examiner, and good-to-excellent interrater reliability for both normal skin and postsurgical scar. Confidence intervals for the AS were larger than for the SMA because the AS is the ratio of 2 random variables and thus has more variability. In fact, the greater the variability, the larger the CI. To verify the validity of the Adheremeter, we compared it with the May 2010

bility is more closely related to contraction and pliability when scar condition is worse, and they suggest a possible use of the Adheremeter to measure not only adherent scars but also scar pliability in general. Unfortunately, the PL-VSS assesses general scar adhesion and is not focused on the worst adherent point.

T1

T2

VSS

5.04 (1.77)

4.44 (1.58)

PL-VSS

2.08 (.81)

1.52 (.77)

Table 4. Interrater Reliabilitya for the Surface Mobility Index for the Normal Contralateral Skin (SMN), the Adherence’s Surface Mobility Index for the Scar (SMA), and the Index of Adherence Severity (AS) at the Initial Examination (T1) and at the End of Treatment (T2) ICC (95% CI) at T1

ICC (95% CI) at T2

SMN

.98 (.96, .99)

.98 (.95, .99)

SMA

.97 (.93, .99)

.99 (.98, .99)

AS

.88 (.75, .94)

.87 (.72, .94)

Index

a

ICC⫽intraclass correlation coefficient, 95% CI⫽95% confidence interval.

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Validation of a New Device to Measure Postsurgical Scar Adherence Table 5. Correlations Among Variablesa at the Initial Examination (T1) and at the End of Treatment (T2) SMA Index

AS

T1

T2

VSS

ⴚ.58

b

PL-VSS

ⴚ.58

b

T1

⫺.50 ⫺.39

b

T2

ⴚ.59

b

⫺.41c

ⴚ.66

b

⫺.32

SMA⫽the adherence’s surface mobility index for the scar, AS⫽index of adherence severity, VSS⫽Vancouver Scar Scale, PL-VSS⫽Pliability Subscale of the Vancouver Scar Scale. Bold values indicate moderate correlation. b P⬍.01. c P⬍.05. a

Figure 5 shows that AS scores changed during the testing period and that there was a greater improvement in scar mobility in participants with the highest initial scores. Both of the Adheremeter’s indexes were able to detect these changes after rehabilitation. The SEM and the MDC were calculated to enhance the measure’s interpretation. The results of this study demonstrate that a clinician should be confident (95%) that an AS change score greater than 0.17 in individuals is not likely to be attributable to measurement error or chance variation, whereas for a large sample, a change greater than 0.06 could be sufficient. Considering that the MDC values obtained from each rater were different, we suggest taking into account a prudent value for MDC equal to 0.20 as a change value not likely to be attributable to measurement error or chance variation. In our sample, more than 50% of the patients had an AS score increase greater than 0.20 (the MDC value suggested). Moreover, most of these individuals had at admission the highest AS scores of the overall sample. These results might suggest that the AS score could represent a possible prognostic indicator of the final outcome after rehabilitation aimed also at treating scar adhesions. In fact, patients affected by a less severe adherent postsurgical scar had a better improvement in scar mobility than the others.

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The results showed that both indexes have adequate psychometric characteristics, but the AS seems the more interesting index due to the fact that differences between scar and normal skin, or different anatomical sites, are normalized. In this study, we assessed the reliability, validity, and sensitivity to change of the Adheremeter in a sample of patients affected by orthopedic postsurgical pathological scars. Further studies are needed to assess its validity for other types of scars, such as traumatic and burn scars, or after surgery in specific clinical fields, such as plastic and reconstructive surgery. Limitations Intrarater reliability was assessed only on normal skin (SMN) because different measuring sessions of scar adherence on different days might have been less valid due to a possible maturation effect, and 2 or more measuring sessions of scar adherence, conducted on the same day, could have been biased by the fact that the rater could have been influenced by the memory of the first scores (rater bias). Nevertheless, there is a chance that such a systematic error could have been present in the intrarater reliability of the SMA and AS scores, even if nearly 3 weeks, on average,

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passed between the original examination and the end of treatment. The Adheremeter showed an adequate sensitivity to change, but in future studies it would be interesting to evaluate the Adheremeter’s ability to detect minimal clinical important changes using anchor-based methods (eg, patients’ or clinicians’ judgments about the changes that occurred). In this study, we did not calculate the measure of a minimal clinically important difference because it is said to be sample specific20 and a larger sample would have been necessary to obtain a universal cut-point measure useful for clinical decision making. Finally, the measurement is based on the rater’s evaluation of force to stretch the skin and on the patient’s judgment of comfort. The experimental protocol required a brief training of the raters in the assessment method, allowing landmark determination and end-range stretching force to vary among raters.21 The results of this study demonstrate that the method is valid, so that minimal differences in the intensity of force (not measured in the study and thus a potential source of error) probably are not relevant. Complex and expensive electronic equipment that would be necessary for a more precise measurement of the intensity of stretching strength is not required with this method, making the Adheremeter feasible for use in any rehabilitation setting or consulting room. Finally, examiners were not completely masked, in that they were aware of the Adheremeter reading during the stretching (as is the case with other common clinical measures, such as a universal goniometer). These limitations are due to the nature of the study and to the partially standardized approach used, chosen precisely to reflect the realities of the clinic.

May 2010

Validation of a New Device to Measure Postsurgical Scar Adherence The Adheremeter might not be reliable for measuring scars situated in highly concave or convex anatomical zones. In the absence of a contralateral landmark (eg, amputation or scar on the midsagittal axis), we suggest comparing the adherence with the nearest healthy skin.

Conclusions In our sample, this new method to measure adherent scars showed an adequate level of reliability, validity, and sensitivity to change. The Adheremeter could be considered a useful device for clinicians working with patients with scars. Caution should be applied in generalizing the results of this study because further studies are needed to confirm our results in larger cohorts and for other types of scars. Dr Ferriero and Dr Vercelli provided concept/ idea/project design. All authors provided writing. Dr Vercelli, Dr Stissi, and Dr Sartorio provided data collection. Dr Ferriero, Dr Vercelli, and Dr Salgovic provided data analysis. Dr Ferriero provided project management and institutional liaisons. Dr Salgovic provided consultation (including review of manuscript before submission). The authors thank Dr Franco Franchignoni for his continuing guidance and advice. The research reported in this article was undertaken in compliance with the Helsinki Declaration and the international principles governing research on animals.

May 2010

This article was received February 18, 2009, and was accepted December 20, 2010. DOI: 10.2522/ptj.20090048

References 1 van de Kar AL, Corion LU, Smeulders MJ, et al. Reliable and feasible evaluation of linear scars by the Patient and Observer Scar Assessment Scale. Plast Reconstr Surg. 2005;116:514 –522. 2 Moran M, Khan A, Sochart DH, Andrew G. Evaluation of patient concerns before total knee and hip arthroplasty. J Arthroplasty. 2003;18:442– 445. 3 Roques C. Massage applied to scars. Wound Repair Regen. 2002;10:126 –128. 4 Roques C, Te´ot L. A critical analysis of measurements used to assess and manage scars. Lower Extremity Wounds. 2007;6: 249 –253. 5 Idriss N, Maibach HI. Scar assessment scales: a dermatologic overview. Skin Res Technol. 2009;15:1–5. 6 Vercelli S, Ferriero G, Sartorio F, et al. How to assess postsurgical scars? A review of outcome measures. Disabil Rehabil. 2009;31:2055–2063. 7 Kobesova A, Morris CE, Lewit K, Safarova M. Twenty-year-old pathogenic “active” postsurgical scar: a case study of a patient with persistent right lower quadrant pain. J Manipulative Phys Ther. 2007;30:234 – 238. 8 Sutton GS, Bartel MR. Soft-tissue mobilization techniques for the hand therapist. J Hand Ther. 1994;7:185–192. 9 Nedelec B, Shankowsky HA, Tredget EE. Rating the resolving hypertrophic scar: comparison of the Vancouver Scar Scale and scar volume. J Burn Care Rehabil. 2000;21:205–212. 10 Silverberg R, Johnson J, Moffat M. The effects of soft tissue mobilization on the immature burn scar: results of a pilot study. J Burn Care Rehabil. 1996;17:252–259.

11 Cleary C, Sanders AK, Nick TG. Reliability of the skin compliance device in the assessment of scar pliability. J Hand Ther. 2007;20:232–237. 12 Draaijers LJ, Botman YA, Tempelman FR, et al. Skin elasticity meter or subjective evaluation in scars: a reliability assessment. Burns. 2004;30:109 –114. 13 Truong PT, Lee JC, Soer B, et al. Reliability and validity testing of the Patient and Observer Scar Assessment Scale in evaluating linear scars after breast cancer surgery. Plast Reconstr Surg. 2007;119:487– 494. 14 Truong PT, Abnousi F, Yong CM, et al. Standardized assessment of breast cancer surgical scars integrating the Vancouver Scar Scale, Short Form McGill Pain Questionnaire, and patients’ perspective. Plast Reconstr Surg. 2005;116:1291–1299. 15 Portney LG, Watkins MP. Foundations of Clinical Research: Applications to Practice. Upper Saddle River, NJ: Prentice Hall Health; 2000. 16 Bonett DG. Sample size requirements for estimating intraclass correlations with desired precision. Stat Med. 2002;21:1331– 1335. 17 Kazis LE, Anderson JJ, Meenan RF. Effect sizes for interpreting changes in health status. Med Care. 1989;27(suppl 3):S178 – S189. 18 Taylor R, Jayasinghe UW, Koelmeyer L, et al. Reliability and validity of arm volume measurements for assessment of lymphedema. Phys Ther. 2006;86:205–214. 19 Zhang Y, Goldgof DB, Sarkar S, Tsap LV. A modeling approach for burn scar assessment using natural features and elastic property. IEEE Trans Med Imaging. 2004; 23:1325–1329. 20 Copay A, Subach B, Glassman S, et al. Understanding the minimum clinically important difference: a review of concepts and methods. Spine J. 2007;7:541–546. 21 Domholdt E. Rehabilitation Research: Principles and Applications. 3rd ed. Philadelphia, PA: Elsevier Saunders; 2005.

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Case Report

Spondyloarthritis in a Patient With Unilateral Buttock Pain and History of Crohn Disease Rogelio A. Coronado, Charles Z. Sheets, Chad E. Cook, William G. Boissonnault R.A. Coronado, PT, CSCS, FAAOMPT, is a doctoral student in the Department of Physical Therapy, College of Public Health and Health Professions, University of Florida, PO Box 100154, Gainesville, FL 32610-0154 (USA). Address all correspondence to Mr Coronado at: rcoronado@phhp. ufl.edu. At the time of this case, Mr Coronado was enrolled in the Manual Therapy Fellowship Program at Duke University. C.Z. Sheets, PT, OCS, Dip MDT, is Staff Physical Therapist, Duke University Medical Center, Durham, North Carolina.

Background and Purpose. Patients with inflammatory spinal conditions related to spondyloarthritis are rarely seen by primary care practitioners. However, patients with a history of inflammatory bowel disease and chronic low back or buttock pain should be examined carefully for the presence of spondyloarthritis, as proper management may include referral to a rheumatologist and appropriate medical intervention. Case Description. A 27-year-old woman with a 6-month history of posterior buttock pain was referred for physical therapy with a diagnosis of piriformis syndrome. During the second physical therapy visit, a nonmechanical source of lumbopelvic pain was suspected, and the patient was referred for medical consultation. The patient underwent evaluation by a rheumatologist and was eventually diagnosed with spondyloarthritis associated with inflammatory bowel disease.

C.E. Cook, PT, PhD, MBA, OCS, FAAOMPT, is Associate Professor, Division of Physical Therapy, Department of Community and Family Medicine, Duke University.

Outcomes. The patient initiated treatment with anti-tumor necrosis factor med-

W.G. Boissonnault, PT, DHSc, FAAOMPT, is Associate Professor, Division of Physical Therapy, Department of Orthopedics and Rehabilitation, University of Wisconsin– Madison, Madison, Wisconsin.

torical, examination, and imaging findings are present. The posttest probability of spondyloarthritis is increased with the presence of inflammatory back pain and specific spondyloarthritic features, such as a positive history of inflammatory bowel disease, radiographic evidence of sacroiliitis, and improvement with antiinflammatory medication. Referral of patients with these findings for a rheumatological evaluation is warranted, as these diseases are managed effectively with specific treatment.

[Coronado RA, Sheets CZ, Cook CE, Boissonnault WG. Spondyloarthritis in a patient with unilateral buttock pain and history of Crohn disease. Phys Ther. 2010;90: 784 –792.]

ication to address the spondyloarthritis. Medical management resulted in significant improvement in all outcome measures.

Discussion. Clinical suspicion of spondyloarthritis is raised when specific his-

© 2010 American Physical Therapy Association

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Spondyloarthritis in a Patient With Unilateral Buttock Pain and Crohn Disease

P

atients with low back pain (LBP), buttock pain, or hip pain are commonly seen by physical therapists with signs and symptoms that may or may not require referral for further medical evaluation. Although some clinical conditions, such as a large central herniated disk,1 exhibit unique historical features or movement characteristics specific to the disorder, a majority of clinical conditions do not.2 Given the frequent inability to determine specific tissue pathology in the diagnosis of patients with lumbopelvic pain,2 multiple authors3– 6 have advocated moving away from the identification of a specific pain generator. Instead, medical screening, triage, and classification of patients into treatment-based categories have been emphasized during the clinical examination.7–10 Related to medical screening and triage is the importance of differentiating between a mechanical disorder and a nonmechanical pathology.

The differential assessment process is used by physical therapists and can assist in clinical decision making and directing evidence-based management.11 Early emphasis is placed on detecting “red flags” during the patient history and the physical examination to rule out nonmechanical pathology.9 –11 Of particular relevance to the lumbopelvic region is spondyloarthritis (also known as “spondyloarthropathy”), which is a group of progressive, inflammatory diseases that commonly affect the sacroiliac joint.10,12–14 The prevalence of this disease is low, ranging from less than 1% to approximately 5% of patients with chronic LBP.14,15 The key clinical feature of spondyloarthritis is the presence of inflammatory back pain in which early identification is essential to significantly improve prognosis.15–17 Nonetheless, diagnosing spondyloarthritis early is difficult, and radiographic changes in the sacroiliac joint, conMay 2010

sistent with sacroiliitis, may not be evident until years after onset of symptoms. If left untreated, inflammatory back pain related to spondyloarthritis ultimately may progress to ankylosing spondylitis.15,17 This case report describes the management of a patient with a diagnosis of piriformis syndrome who was referred for physical therapy by a physician and who eventually was found to have symptoms that originated from spondyloarthritis. The case report will describe the patient’s history, examination, evaluation, referral for additional testing, subsequent treatment, and prognosis.

Case Description Patient History Prior to the initial evaluation, the 27-year-old female graduate student began physical therapy via direct access at a different clinic approximately 1 month after the onset of her symptoms. Basic hip stretching and strengthening exercises were given at this time. Due to the lack of progress over the next 4 months, the patient scheduled an appointment with a university student health physician. After receiving a medical diagnosis of piriformis syndrome, she was encouraged to attend physical therapy at Duke University with the primary author (R.A.C.) for further evaluation and consultation. In the interim, she was instructed to apply cold packs for pain reduction and take Advil* as needed. The patient was seen for physical therapy 6 months after the onset of her symptoms. She reported an insidious onset of pain, but was unsure whether her previous participation in kickboxing or yoga had contributed to the complaints. She described the primary symptoms as both a sharp pain and ache in her left * Wyeth Pharmaceuticals, Division of Wyeth, PO Box 8299, Philadelphia, PA 19101.

buttock, just superior and lateral to her ischial tuberosity. She reported secondary symptoms of episodic pain down the left posterior thigh to the knee. The patient reported having no pain distal to the left knee. In addition, she reported having no weakness, numbness, or tingling (paresthesia) in the bilateral lower extremities. The primary symptoms were aggravated most with transitioning from a sitting position to a standing position, immediately upon standing, ascending stairs while leading with the left leg, pivoting over the left leg, and rolling in bed. The symptoms improved after standing for a short time, performing exercise, walking, and Advil use. No diagnostic imaging was performed for the current condition, and she reported having no prior history of similar symptoms. She also reported having no symptoms in the low back during this current episode. Past medical history was significant for diagnosis of Crohn disease in 2004 (4 years prior to this encounter) and a laparoscopic total abdominal colectomy with end ileostomy for management of her gastrointestinal complaints in 2005. The surgery was a success in addressing her complaints related to Crohn disease. Aside from the above, the review of systems was noncontributory for the cardiovascular, pulmonary, gastrointestinal, genitourinary, and endocrine systems. The patient completed several outcome measures to assess her pain and level of function. She rated her

Available With This Article at ptjournal.apta.org • Audio Abstracts Podcast This article was published ahead of print on March 18, 2010, at ptjournal.apta.org.

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Spondyloarthritis in a Patient With Unilateral Buttock Pain and Crohn Disease current symptoms as a 3/10 on an 11-point numeric pain rating scale (NPRS), with 0 meaning “no pain” and 10 meaning “worst pain imaginable.” The NPRS has been shown to be accurate in detecting clinically meaningful changes in pain.18 The patient also identified a global function rating of 70%, with 0% representing “unable to perform any activity” and 100% representing “able to perform all prior activity without limitation.” This measure is used to record the patient’s self-reported function and has been shown to correlate well with established outcome measures in the knee19 and shoulder.20 Although the global function rating scale is commonly used in the clinical setting, it has not been specifically validated in patients with lumbopelvic pain. Disability related to her current condition was measured using the Lower Extremity Functional Scale (LEFS) and the Oswestry Disability Index (ODI), as symptoms were present in the lumbopelvic region and the lower extremity. Her score on the LEFS was 49/80, with a best possible score of 80. Test-retest reliability of the LEFS scores is excellent (r⫽.94 [lower limit of the 95% confidence interval (CI)⫽.89]), and LEFS scores have demonstrated high correlation to scores on the Medical Outcomes Study 36-Item Short-Form Health Survey questionnaire (SF36).21 The potential error associated with a score on the LEFS is ⫾5.3 scale points (90% CI), the minimal detectable change is 9 scale points (90% CI), and the minimal clinically important difference (MCID) is 9 scale points (90% CI).22 The ODI is a self-report questionnaire designed to assess an individual’s perceived disability related to LBP and consists of physical and social components. The questionnaire consists of 10 specific functional dimensions: pain intensity, pain variability, personal hygiene, lifting, walking, sitting, 786

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standing, sleeping, social activity, and travel. Higher percentage scores indicate greater perceived disability with normal everyday functions. The ODI has an established reliability (intraclass correlation coefficient [ICC]) of .90 (95% CI⫽.78 –.96) and an area under the curve (AUC) of .94 (95% CI⫽.88 –.98).23 The MCID has been established between 6% and 9%.21,23 The patient’s score of 24% indicated a relatively low level of disability. Overall, her scores on all outcome measures represented a minimal to moderate level of pain and disability. Physical Examination On gait assessment, the patient demonstrated decreased weight shift on the left, decreased hip extension on the left, and a wide base of support. Minimal lateral trunk lean toward the left (compensated Trendelenburg position) was noted as well. She reported difficulty with putting weight on her left leg during a single-leg stance and a feeling of “instability.” Static postural assessment in standing was unremarkable, with no apparent frontal-plane shift. On observation, the cervical and thoracic spines appeared normal, but a more thorough examination of these regions was not performed. Lowerquarter bony landmarks appeared to be symmetrical in a standing position; however, a specific palpatory examination for symmetry was not performed, as it has been shown to have low reliability and does not improve posttest probability.24 No myotome or dermatome neurological deficits were noted with strength or sensation (light touch) testing in the bilateral lower extremities. Neural provocation testing, including the straight leg raise and slump test, was negative. Upper motor neuron testing was negative, including Hoffmann testing, clonus, and Babinski testing. During single and repeated active range of motion

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of the lumbar spine in standing, the patient reported a slight worsening of her buttock pain with repeated trunk flexion, and she returned to her baseline pain level with neutral standing and repeated trunk extension. No change in pain location or intensity consistent with a centralization phenomenon was noted, and there were no changes in movement to indicate a lumbar directional preference.5,6 The patient’s concordant (familiar) left buttock pain was produced with passive left hip flexion and passive left hip lateral (external) rotation. Improvement in concordant pain was reported by the patient during performance of repeated hip extension. Hip provocation special tests were negative, and central and unilateral posterior-to-anterior joint provocation testing of the lumbar spine did not produce concordant pain complaints. A standardized cluster of provocation tests intended to stress the sacroiliac joint and pelvic region, including sacroiliac distraction, thigh thrust, sacroiliac compression, and sacral spring testing, were all positive. These tests have interrater kappa values ranging from .56 to .88, indicating moderate to substantial reliability.25 Two rigorous studies26,27 examined the value of a composite of sacroiliac pain provocation tests. In the absence of centralization, these tests resulted in sensitivity values of .91 (95% CI⫽.62–.98) to .94 (95% CI⫽.72–.99), specificity values of .78 (95% CI⫽.61–.89) to .87 (95% CI⫽.68 –.96), and a positive likelihood ratio of 4.29 (95% CI⫽ 2.34 – 8.58) to 6.97 (95% CI⫽2.7– 20.27) for detecting pain of sacroiliac joint origin when compared with double-block, diagnostic sacroiliac injections.26,27 The active straight leg raise (ASLR) test was positive for left concordant buttock pain, with reported difficulty maintaining the raised straight May 2010

Spondyloarthritis in a Patient With Unilateral Buttock Pain and Crohn Disease leg position.28 This test is performed with the patient positioned supine and involves the patient actively raising one leg at a time approximately 20 cm from the table. During the maneuver, symptoms and perceived difficulty with performing the leg raise are assessed, and a comparison between symptomatic and asymptomatic sides is made. A second phase of the test involves the clinician applying compression to the pelvis and repeating the test to assess whether symptoms or perceived difficulty are decreased with the addition of pelvic compression. In this case, a trial of manual compression and compression with a belt did not elicit a positive reduction in symptoms. This test has shown substantial reliability (ICC⫽.83)29 and has been associated with pelvic girdle and sacroiliac pain.28 –30 Palpation of the superior aspect of the sacroiliac joint and ligaments revealed significant tenderness to palpation, whereas minimal tenderness over the piriformis muscle was present. Pain with palpation over the long dorsal sacroiliac ligament has good to excellent (.76 –.98) sensitivity in patients with peripartum pelvic pain and has a potential role in sacroiliac pain.30 Initial Clinical Impression Given the positive response to the lumbopelvic and hip mobility assessment, coupled with the findings from the tests intended to assess pain provocation and motor control at the pelvis and sacroiliac region, a mechanical lumbopelvic disorder was suspected at the initial visit.11,26 –28,31,32 Although the patient did report a history of Crohn disease and chronic symptoms, she demonstrated a mechanical directional preference that suggests an underlying mechanical disorder.5,6,11 Because several visits often are required for clear assessment of the mechanical behavior of a patient’s symptoms,33 she was enMay 2010

Figure 1. Left lumbopelvic extension home exercise.

couraged to follow up within a short amount of time to determine her response to the specific mobilization and exercise. Initial Physical Therapy Intervention and Follow-up Initial intervention included a passive left-sided lumbopelvic nonthrust mobilization with the patient in a right side-lying position into the movement direction that reduced her symptoms (directional preference).11 The patient reported that this mobilization seemed to decrease her concordant symptoms. She also was instructed on a home exercise that encouraged a similar movement of lumbopelvic and hip extension (Fig. 1) as a follow-up to the mobilization. As mentioned earlier, because the ASLR test was positive, a trial of pelvic stabilization with a belt was performed in the clinic, but was not well tolerated. Thus, the patient was instructed to perform the specific exercise and was asked to return in 2 days to assess her response to the intervention.

The patient returned for physical therapy 2 days later and stated she had reported to the university student health facility in the morning, as her symptoms had worsened. She indicated she awoke that morning with severe, deep, throbbing left buttock pain, and stiffness and was unaware of a potential cause for the aggravation. The physician at the student health facility recommended that she attend the physical therapy appointment for further suggestions. At the initiation of the visit, she rated her current pain as a 6/10. Reexamination revealed a positive Trendelenburg gait pattern on the left. The patient’s left-sided buttock pain was reproduced with left and right passive hip motion testing into flexion and rotations, with no limitation in hip mobility. Sacroiliac provocation testing again was positive for left buttock pain. Difficulty was reported with performance of the ASLR and prone hip extension with the left lower extremity. In an attempt to gain all possible informa-

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Spondyloarthritis in a Patient With Unilateral Buttock Pain and Crohn Disease ated with inflammatory bowel disease, and she initiated treatment with Humira,† an anti-tumor necrosis factor agent.

Figure 2. Left sacroiliac joint widening and cortical indistinctness consistent with sacroiliitis.

tion regarding the change in status, more specific palpation of pelvic girdle musculature was performed, revealing significant left gluteal muscle atrophy. Additional palpation identified continued reports of tenderness over the left sacroiliac joint, sacrotuberous ligament, and long dorsal ligament. Nevertheless, the patient reported that her chief complaint of severe, deep, throbbing pain in the morning or during walking was not reproduced with palpation or mechanical stress testing. Follow-up Clinical Impression Upon returning for her follow-up visit, the patient reported a significant worsening of her current symptoms. However, it was felt that the patient’s symptoms were inconsistent with the prior mechanical presentation. She described her pain as a deep, throbbing pain, whereas initially it was described as “sharp” or an “achy” pain. In addition, she reported she had awakened with this intense pain. Reproduction of this specific pain complaint was not achieved with mechanical stress testing or palpation. Significant left gluteal muscle atrophy also was noted, 788

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which was interpreted as a sign of potential chronicity.34,35 Combined with the patient’s history of inflammatory bowel disease, chronicity of the problem, inconsistent findings on mechanical examination, and failure to reproduce her chief complaint, a nonmechanical pathology was suspected, which required further medical attention.9,10

Intervention and Outcome The physician at the university student health facility was notified for consultation, and the attending physical therapist recommended that evaluation of the pelvic region with diagnostic imaging be undertaken. Although a magnetic resonance image was requested, due to scheduling limitations, a plain film radiograph was scheduled the same day, and the patient was to follow up with her physician later in the afternoon. A plain film radiograph of the pelvis identified findings consistent with left-sided sacroiliitis (Fig. 2). Oral prednisone was prescribed to the patient that day, and a referral to a rheumatologist was placed. She later was diagnosed by a rheumatologist with spondyloarthritis associ-

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Pleased with her improvement, she continued with physical therapy for hip and pelvic strengthening. At the third follow-up physical therapy session, 6 weeks after the initial evaluation, she reported improvement on the ODI to 8% and on the LEFS to 60/80, both surpassing the MCID boundaries of the 2 measures. In addition, she rated global function as 90% of her normal function, reported having no pain on the NPRS, and scored ⫹6 on the Global Rating of Change (GROC) questionnaire. The GROC is a standardized questionnaire using a 15-point Likert scale, ranging from ⫺7 (“a very great deal worse”) to ⫹7 (“a very great deal better”). This scale is commonly used to indicate global change during treatment,36 and the patient’s score represents substantial improvement.

Discussion The incidence of patients seen in a primary care setting with spondyloarthritis is low, yet knowledge of the signs and symptoms associated with this condition is essential for practicing physical therapists.14 “Spondyloarthritis” is a collective term for a group of progressive, inflammatory rheumatic diseases that commonly affect the axial skeleton, sacroiliac joint, and entheses.17 Within this group are diseases such as ankylosing spondylitis, psoriatic arthritis, reactive arthritis, arthritis associated with inflammatory bowel disease, and undifferentiated spondyloarthritis,13,14,17 Palm et al37 reported an overall prevalence of 20% for spondyloarthritis in patients with inflammatory bowel disease, with inflammatory back pain noted in 22% of † Abbott Laboratories, Pharmaceutical Product Division, North Chicago, IL 60064.

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Spondyloarthritis in a Patient With Unilateral Buttock Pain and Crohn Disease patients with Crohn disease. Steer et al38 found that 45% of patients with Crohn disease and LBP had evidence of sacroiliitis on computed tomography. Additional studies have shown the prevalence of sacroiliitis in this population confirmed on either plain film radiograph or computed tomography at 23% to 32%, although not all patients were reported as symptomatic.39 – 41 Although the etiology of the various subgroups of spondyloarthritis differs, there are common clinical manifestations that may allow for early recognition and appropriate medical management to prevent further structural damage.17 Inflammatory back pain associated with sacroiliitis has been shown to be an early clinical symptom and a hallmark of spondyloarthritis.12,17 Characteristics of inflammatory back pain typically include insidious onset, onset before age 40 to 45 years, improvement with exercise, no improvement with rest, morning pain or stiffness, and greater than 3 months’ duration of pain.42– 45 These characteristics of pain were similar to those of the patient presented in this case report, especially after she returned complaining of severe morning pain. In a recent survey of medical and health care practitioners, Walker and Williamson44 found morning pain on waking to have the highest level of agreement as an indicator of inflammatory back pain. Other moderate indicators included constant pain, pain on awakening, and stiffness after resting.44 Despite the lack of consistent signs to direct diagnosis of pain of mechanical origin in patients with pain in the lumbopelvic region, clinical diagnostic information may be gained with the performance of pain provocation tests for detecting pain in the pelvic or sacroiliac region.26,27,31,32,46 When compared with double-block, diagnostic sacroMay 2010

iliac injection, Laslett et al27 found a positive likelihood ratio as high as 6.29 when a composite of 5 pain provocation tests were used to detect sacroiliac pain. A positive likelihood ratio of 4.0 (95% CI⫽2.13– 8.08) was shown when any 2 of 4 sacroiliac provocation tests were positive in the absence of centralization of symptoms.26 The 4 sacroiliac joint tests were sacroiliac distraction, thigh thrust, sacroiliac compression, and sacral thrust. These tests were performed on the patient in our case report to implicate the sacroiliac joint as the pain-generating region, but a differentiation from an inflammatory or mechanical pain source using this cluster was not quantified by Laslett and colleagues. Ozgocmen et al46 attempted to determine the diagnostic accuracy of sacroiliac pain provocation tests to differentiate patients with early sacroiliitis confirmed on magnetic resonance imaging from those with other disorders and found higher likelihood ratios (compared with findings of Laslett et al27) when a cluster of provocation tests were used. Further research into the diagnostic utility of sacroiliac pain provocation tests during discrimination of patients with spondyloarthritis versus mechanical sacroiliac pain is needed. Although it appears that inflammatory back pain exhibits unique characteristics, it is arduous to distinguish from mechanical back pain. No clear agreement among medical and health care practitioners has been reached regarding clinical indicators of back pain of an inflammatory or mechanical origin.44 A common clinical distinction is made with the use of repeated movements. In the presence of inflammation, it is expected that movement will increase symptoms and that no movement will improve symptoms. Symptoms of a mechanical origin, however, often will respond posi-

tively to repeated movements, especially if a directional preference is found.6,11 Although our patient did not have a clear directional preference at initial evaluation, her report of decreased symptoms after repeated exercises and mobilization into hip extension (unilateral lumbopelvic extension) justified attempts to treat what appeared to be improving mechanical symptoms. In light of these findings, we perceived that additional medical follow-up (eg, imaging) was not required, as the signs and symptoms were not suggestive of a sinister pathology.9,14,47 A positive response to conservative care is one criterion used to differentiate patients who require imaging or additional laboratory tests from those who do not.14,48 Crohn disease is judged to be a relative contraindication to manual treatment,11 but given the patient’s immediate positive response to gentle exercise and manual therapy, no initial association was made between this disease and the patient’s current clinical presentation. However, upon re-examination on the return visit, an inflammatory etiology was suspected, and a rapid referral was made for further medical investigation. It is undetermined whether this inflammatory presentation was an exacerbation of her initial symptoms or a recurrence of prior episodic, inflammatory symptoms. One clinical finding noted during the initial visit may have indicated a nonmechanical disorder. The patient demonstrated pain and difficulty with the ASLR, which is consistent with altered mobility of the pelvic joints49 and changes in pelvic-floor musculature.28 The addition of a compressive belt has been shown to be helpful in decreasing pain for 95% of women with postpartum sacroliac joint pain,49 and positioning the belt just caudal to the anterior superior iliac spines, as was performed with this patient, results in the greatest decrease in mobility.50 We are un-

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Spondyloarthritis in a Patient With Unilateral Buttock Pain and Crohn Disease aware of any evidence to explain increased sacroiliac joint symptoms with application of a belt; perhaps in a patient with an inflammatory source of pain, increased compression results in increased symptoms. If this finding is observed in similar patients, it may prove to be another useful clinical indicator of a nonmechanical source of pain. Although radiographic evidence of sacroiliitis is a pathognomic finding in patients with spondyloarthritis, these changes may not be evident until several years after the onset of inflammatory back pain.16,51 Mau et al51 followed 88 patients with clinical features suggestive of spondyloarthritis but with normal sacroiliac joint radiographs and found increased evidence of radiographic sacroiliitis after 5 and 10 years. Radiographic changes have been questioned as an early diagnostic criterion, as these changes represent an inevitable consequence of the disease process and more closely relate to duration of symptoms.16 Magnetic resonance imaging is a more sensitive modality for detection of sacroiliac inflammation,52,53 but costs make this an expensive screening tool. Clinical suspicion of spondyloarthritis based on the presence of inflammatory back pain and, in the absence of radiographic findings, should still prompt further testing. Several classification criteria have been proposed to assist in screening for spondyloarthritis.15,43,54 Hermann et al55 assessed the ability of clinical signs and symptoms to differentiate between patients with LBP due to a noninflammatory disorder and those with early spondyloarthritis. They found spontaneous awakening due to night pain, sacroiliac joint pain on clinical examination, and the presence of Calin’s criteria for inflammatory back pain (persistent back pain for longer than 3 months, age of onset less than 40 years, insid790

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ious onset of back pain, relief with exercise, and morning stiffness) were associated with the presence of spondyloarthritis. Decreased cervical spine sagittal movement and complaints of neck pain were negatively associated with the presence of spondyloarthritis.55 Rudwaleit et al15 proposed an algorithm for detection of early spondyloarthritis. The authors assumed a 5% pretest probability of axial spondyloarthritis in the general population with chronic LBP. Resultant changes in posttest probability were made with the presence or absence of specific historical and clinical examination findings and results from laboratory tests. The presence of inflammatory back pain and at least 3 typical spondyloarthritis features improved the posttest probability to 90% for axial spondyloarthritis. Features implicating the presence of spondyloarthritis included heel pain (enthesitis), family history of spondyloarthritis, Crohn disease, asymmetrical arthritis, positive response to nonsteroidal anti-inflammatory drugs, and others. Using this algorithm, the patient presented in this case report met the diagnostic criteria for spondyloarthritis. Her clinical symptoms were suggestive of inflammatory back pain, and combined with the history of inflammatory bowel disease, chronic symptoms for longer than 6 months, and unilateral nature, a diagnosis of spondyloarthritis was probable. Although diagnosing spondyloarthritis is not the role of physical therapists, key findings consistent with this nonmechanical disorder should result in a quick referral for further medical follow-up.9,10 Finally, the medical intervention provided to this patient proved effective in improving function and reducing pain. Although anti-inflammatory medication and physical therapy have been an accepted strategy for the management of spondyloar-

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thritis, recent evidence has shown clinical efficacy with the administration of specific treatment, such as tumor necrosis factor-alpha blocking agents.56 Specifically, these compounds have been advocated for the management of spondyloarthritis in patients with Crohn disease.57,58 What may be more compelling is the potential benefit these agents may have in younger patients with a shorter disease duration,59 further highlighting the need for early recognition.

Conclusion A source of pain in the lumbopelvic region can be nonmechanical diseases such as spondyloarthritis. Although identification of patients with inflammatory back pain and associated spondyloarthritis in the early stages is difficult, certain historical features may improve the posttest probability of accurate diagnosis. In this case report, the presence of nonmechanical back pain, positive history of Crohn disease, chronic symptoms for longer than 6 months, and severe morning pain led to a referral for radiographic imaging and follow-up evaluation by a rheumatologist. The diagnosis of spondyloarthritis associated with inflammatory bowel disease resulted in initiation of medical treatment with tumor necrosis factor-alpha blocking medication and improvement in all outcome measures. Mr Coronado, Dr Cook, and Dr Boissonnault provided concept/idea/project design. Mr Coronado provided data collection and analysis, project management, and clerical support. All authors provided writing and consultation (including review of manuscript before submission). This case was presented as a poster at the Annual Conference of the American Academy of Orthopaedic Manual Physical Therapists; October 14 –18, 2008; Washington, DC.

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Spondyloarthritis in a Patient With Unilateral Buttock Pain and Crohn Disease This article was received May 26, 2009, and was accepted December 21, 2009. DOI: 10.2522/ptj.20090172

References 1 Deyo RA, Rainville J, Kent DL. What can the history and physical examination tell us about low back pain? JAMA. 1992;268: 760 –765. 2 van Tulder MW, Assendelft WJ, Koes BW, Bouter LM. Spinal radiographic findings and nonspecific low back pain. A systematic review of observational studies. Spine (Phila Pa 1976). 1997;22:427– 434. 3 Delitto A, Erhard RE, Bowling RW. A treatment-based classification approach to low back syndrome: identifying and staging patients for conservative treatment. Phys Ther. 1995;75:470 – 485; discussion 485– 479. 4 Fritz JM, George S. The use of a classification approach to identify subgroups of patients with acute low back pain: interrater reliability and short-term treatment outcomes. Spine (Phila Pa 1976). 2000;25: 106 –114. 5 Long A, Donelson R, Fung T. Does it matter which exercise? A randomized control trial of exercise for low back pain. Spine (Phila Pa 1976). 2004;29:2593–2602. 6 McKenzie R. The Lumbar Spine: Mechanical Diagnosis and Therapy. Waikanae, New Zealand: Spinal Publications; 2003. 7 Boissonnault WG, Goodman C. Physical therapists as diagnosticians: drawing the line on diagnosing pathology. J Orthop Sports Phys Ther. 2006;36:351–353. 8 Fritz JM, Cleland JA, Childs JD. Subgrouping patients with low back pain: evolution of a classification approach to physical therapy. J Orthop Sports Phys Ther. 2007; 37:290 –302. 9 Boissonnault WG. Primary Care for the Physical Therapist: Examination and Triage. St Louis, MO: Elsevier Saunders; 2005. 10 Sizer PS Jr, Brismee JM, Cook C. Medical screening for red flags in the diagnosis and management of musculoskeletal spine pain. Pain Pract. 2007;7:53–71. 11 Cook C. Orthopedic Manual Therapy: An Evidence-Based Approach. Upper Saddle River, NJ: Pearson/Prentice Hall; 2007. 12 Braun J, Sieper J. The sacroiliac joint in the spondyloarthropathies. Curr Opin Rheumatol. 1996;8:275–287. 13 Goodman CC, Snyder TEK. Differential Diagnosis in Physical Therapy. 3rd ed. Philadelphia: Saunders; 2000. 14 Jarvik JG, Deyo RA. Diagnostic evaluation of low back pain with emphasis on imaging. Ann Intern Med. 2002;137:586 –597. 15 Rudwaleit M, van der Heijde D, Khan MA, et al. How to diagnose axial spondyloarthritis early. Ann Rheum Dis. 2004;63: 535–543.

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16 Rudwaleit M, Khan MA, Sieper J. The challenge of diagnosis and classification in early ankylosing spondylitis: Do we need new criteria? Arthritis Rheum. 2005;52: 1000 –1008. 17 Khan MA. Update on spondyloarthropathies. Ann Intern Med. 2002;136:896 –907. 18 Jensen MP, Turner JA, Romano JM. What is the maximum number of levels needed in pain intensity measurement? Pain. 1994; 58:387–392. 19 Williams GN, Taylor DC, Gangel TJ, et al. Comparison of the single assessment numeric evaluation method and the Lysholm score. Clin Orthop Relat Res. 2000:184 – 192. 20 Williams GN, Gangel TJ, Arciero RA, et al. Comparison of the Single Assessment Numeric Evaluation method and two shoulder rating scales: outcome measures after shoulder surgery. Am J Sports Med. 1999; 27:214 –221. 21 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. 22 Binkley JM, Stratford PW, Lott SA, Riddle DL; North American Orthopaedic Rehabilitation Research Network. The Lower Extremity Functional Scale (LEFS): scale development, measurement properties, and clinical application. Phys Ther. 1999;79: 371–383. 23 Childs JD, Piva SR. Psychometric properties of the functional rating index in patients with low back pain. Eur Spine J. 2005;14:1008 –1012. 24 Laslett M. Evidence-based diagnosis and treatment of the painful sacroiliac joint. J Man Manip Ther. 2008;16:142–152. 25 Laslett M, Williams M. The reliability of selected pain provocation tests for sacroiliac joint pathology. Spine (Phila Pa 1976). 1994;19:1243–1249. 26 Laslett M, Aprill CN, McDonald B, Young SB. Diagnosis of sacroiliac joint pain: validity of individual provocation tests and composites of tests. Man Ther. 2005;10: 207–218. 27 Laslett M, Young SB, Aprill CN, McDonald B. Diagnosing painful sacroiliac joints: a validity study of a McKenzie evaluation and sacroiliac provocation tests. Aust J Physiother. 2003;49:89 –97. 28 O’Sullivan PB, Beales DJ, Beetham JA, et al. Altered motor control strategies in subjects with sacroiliac joint pain during the active straight-leg-raise test. Spine. 2002; 27(1):E1–E8. 29 Mens JM, Vleeming A, Snijders CJ, et al. Reliability and validity of the active straight leg raise test in posterior pelvic pain since pregnancy. Spine (Phila Pa 1976). 2001;26:1167–1171. 30 Vleeming A, de Vries HJ, Mens JM, van Wingerden JP. Possible role of the long dorsal sacroiliac ligament in women with peripartum pelvic pain. Acta Obstet Gynecol Scand. 2002;81:430 – 436.

31 van der Wurff P, Buijs EJ, Groen GJ. A multitest regimen of pain provocation tests as an aid to reduce unnecessary minimally invasive sacroiliac joint procedures. Arch Phys Med Rehabil. 2006;87:10 –14. 32 Young S, Aprill C, Laslett M. Correlation of clinical examination characteristics with three sources of chronic low back pain. Spine J. 2003;3:460 – 465. 33 Werneke M, Hart DL. Discriminant validity and relative precision for classifying patients with nonspecific neck and back pain by anatomic pain patterns. Spine (Phila Pa 1976). 2003;28:161–166. 34 Kamaz M, Kiresi D, Oguz H, et al. CT measurement of trunk muscle areas in patients with chronic low back pain. Diagn Interv Radiol. 2007;13:144 –148. 35 Saini A, Faulkner S, Al-Shanti N, Stewart C. Powerful signals for weak muscles. Ageing Res Rev. 2009;8:251–267. 36 Mintken PE, Glynn P, Cleland JA. Psychometric properties of the shortened disabilities of the Arm, Shoulder, and Hand Questionnaire (QuickDASH) and Numeric Pain Rating Scale in patients with shoulder pain. J Shoulder Elbow Surg. 2009;18: 920 –926. 37 Palm O, Moum B, Ongre A, Gran JT. Prevalence of ankylosing spondylitis and other spondyloarthropathies among patients with inflammatory bowel disease: a population study (the IBSEN study). J Rheumatol. 2002;29:511–515. 38 Steer S, Jones H, Hibbert J, et al. Low back pain, sacroiliitis, and the relationship with HLA-B27 in Crohn’s disease. J Rheumatol. 2003;30:518 –522. 39 Queiro R, Maiz O, Intxausti J, et al. Subclinical sacroiliitis in inflammatory bowel disease: a clinical and follow-up study. Clin Rheumatol. 2000;19:445– 449. 40 McEniff N, Eustace S, McCarthy C, et al. Asymptomatic sacroiliitis in inflammatory bowel disease: assessment by computed tomography. Clin Imaging. 1995;19:258 – 262. 41 Scott WW Jr, Fishman EK, Kuhlman JE, et al. Computed tomography evaluation of the sacroiliac joints in Crohn disease: radiologic/clinical correlation. Skeletal Radiol. 1990;19:207–210. 42 Sieper J, van der Heijde D, Landewe R, et al. New criteria for inflammatory back pain in patients with chronic back pain: a real patient exercise by experts from the Assessment of SpondyloArthritis international Society (ASAS). Ann Rheum Dis. 2009;68:784 –788. 43 Dougados M, van der Linden S, Juhlin R, et al. The European Spondylarthropathy Study Group preliminary criteria for the classification of spondylarthropathy. Arthritis Rheum. 1991;34:1218 –1227. 44 Walker BF, Williamson OD. Mechanical or inflammatory low back pain: What are the potential signs and symptoms? Man Ther. 2009;14:314 –320. 45 Calin A, Porta J, Fries JF, Schurman DJ. Clinical history as a screening test for ankylosing spondylitis. JAMA. 1977;237: 2613–2614.

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Spondyloarthritis in a Patient With Unilateral Buttock Pain and Crohn Disease 46 Ozgocmen S, Bozgeyik Z, Kalcik M, Yildirim A. The value of sacroiliac pain provocation tests in early active sacroiliitis. Clin Rheumatol. 2008;27:1275–1282. 47 Chou R, Fu R, Carrino JA, Deyo RA. Imaging strategies for low-back pain: systematic review and meta-analysis. Lancet. 2009;373:463– 472. 48 Chou R, Qaseem A, Snow V, et al. Diagnosis and treatment of low back pain: a joint clinical practice guideline from the American College of Physicians and the American Pain Society. Ann Intern Med. 2007; 147:478 – 491. 49 Mens JM, Vleeming A, Snijders CJ, et al. The active straight leg raising test and mobility of the pelvic joints. Eur Spine J. 1999;8:468 – 473. 50 Mens JM, Damen L, Snijders CJ, Stam HJ. The mechanical effect of a pelvic belt in patients with pregnancy-related pelvic pain. Clin Biomech (Bristol, Avon). 2006; 21:122–127.

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51 Mau W, Zeidler H, Mau R, et al. Clinical features and prognosis of patients with possible ankylosing spondylitis: results of a 10-year followup. J Rheumatol. 1988;15: 1109 –1114. 52 Bollow M, Enzweiler C, Taupitz M, et al. Use of contrast enhanced magnetic resonance imaging to detect spinal inflammation in patients with spondyloarthritides. Clin Exp Rheumatol. 2002;20:S167–174. 53 Oostveen J, Prevo R, den Boer J, van de Laar M. Early detection of sacroiliitis on magnetic resonance imaging and subsequent development of sacroiliitis on plain radiography: a prospective, longitudinal study. J Rheumatol. 1999;26:1953–1958. 54 van der Linden S, Valkenburg HA, Cats A. Evaluation of diagnostic criteria for ankylosing spondylitis: a proposal for modification of the New York criteria. Arthritis Rheum. 1984;27:361–368.

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55 Hermann J, Giessauf H, Schaffler G, et al. Early spondyloarthritis: usefulness of clinical screening. Rheumatology (Oxford). 2009;48:812– 816. 56 Braun J, Sieper J. Biological therapies in the spondyloarthritides: the current state. Rheumatology (Oxford). 2004;43: 1072–1084. 57 Rispo A, Scarpa R, Di Girolamo E, et al. Infliximab in the treatment of extraintestinal manifestations of Crohn’s disease. Scand J Rheumatol. 2005;34:387–391. 58 Chang J, Girgis L. Clinical use of anti-TNFalpha biological agents: a guide for GPs. Aust Fam Physician. 2007;36:1035–1038. 59 Sieper J. Developments in the scientific and clinical understanding of the spondyloarthritides. Arthritis Res Ther. 2009;11:208.

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Case Report E.J. Fox, PT, MHS, DPT, NCS, is a doctoral candidate in the Rehabilitation Sciences Doctoral Program (PhD), Department of Physical Therapy, College of Public Health and Health Professions, University of Florida, Gainesville, Florida.

Ongoing Walking Recovery 2 Years After Locomotor Training in a Child With Severe Incomplete Spinal Cord Injury Emily J. Fox, Nicole J. Tester, Chetan P. Phadke, Preeti M. Nair, Claudia R. Senesac, Dena R. Howland, Andrea L. Behrman

Background and Purpose. The authors previously reported on walking recovery in a nonambulatory child with chronic, severe, incomplete cervical spinal cord injury (SCI) after 76 sessions of locomotor training (LT). Although clinical measures did not predict his recovery, reciprocal patterned leg movements developed, affording recovery of independent walking with a reverse rolling walker. The long-term functional limitations and secondary complications often associated with pediatric-onset SCI necessitate continued follow-up of children with SCI. Therefore, the purpose of this case report is to describe this child’s walking function and musculoskeletal growth and development during the 2 years since his participation in an LT program and subsequent walking recovery. Case Description. Following LT, the child attended elementary school as a full-time ambulator. He was evaluated 1 month (baseline), 1 year, and 2 years after LT. Examination of walking function included measures of walking independence, gait speed and spatiotemporal parameters, gait kinematics, and daily step activity. Growth and development were assessed by tracking his height, weight, incidence of musculoskeletal complications, and gross motor task performance.

Outcomes. Over the 2 years, the child continued to ambulate independently with a reverse rolling walker, increasing his fastest gait speed. Spatiotemporal and kinematic features of his walking improved, and daily step activity increased. Height and weight remained on their preinjury trajectory and within age-appropriate norms. The child experienced only minor musculoskeletal complications. Additionally, he gained the ability to use reciprocal patterned leg movements during locomotor tasks such as assisted stair climbing and independent tricycle pedaling.

Conclusions. Two years after recovery of walking, this child with incomplete SCI had maintained and improved his walking function and experienced age-appropriate growth and development.

N.J. Tester, PhD, is Research Health Scientist, Brain Rehabilitation Research Center, Malcom Randall VA Medical Center, Gainesville, Florida, and Postdoctoral Fellow, Department of Physical Therapy, University of Florida. C.P. Phadke, PT, PhD, is Postdoctoral Fellow, Motor Performance Lab, School of Rehabilitation Therapy, Queen’s University, Kingston, Ontario, Canada. P.M. Nair, PT, PhD, is a faculty member at the School of Health and Medical Sciences, Seton Hall University, South Orange, New Jersey. C.R. Senesac, PT, PhD, PCS, is Clinical Assistant Professor, Department of Physical Therapy, University of Florida. D.R. Howland, OT, PhD, is Associate Professor, Department of Neuroscience, College of Medicine and the McKnight Brain Institute, University of Florida, and Research Neurobiologist, Brain Rehabilitation Research Center, Malcom Randall VA Medical Center. A.L. Behrman, PT, PhD, FAPTA, is Associate Professor, Department of Physical Therapy, College of Public Health and Health Professions, PO Box 100154, University of Florida, Gainesville, FL 32610-0154 (USA), and Research Scientist, Brain Rehabilitation Research Center, Malcom Randall VA Medical Center. Address correspondence to Dr Behrman at [email protected]. [Fox EJ, Tester NJ, Phadke CP, et al. Ongoing walking recovery 2 years after locomotor training in a child with severe incomplete spinal cord injury. Phys Ther. 2010; 90:793– 802.] © 2010 American Physical Therapy Association Post a Rapid Response to this article at: ptjournal.apta.org

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Walking Recovery After Locomotor Training in a Child With Incomplete SCI ediatric spinal cord injury (SCI) represents 3% to 5% of all SCI cases, resulting in nearly 2 cases per 100,000 children in the United States.1 Children with SCI experience motor and sensory impairments,2 resulting in long-term functional limitations endured across their life spans.3 Furthermore, as these children grow and develop, they experience additional complications such as bone and joint deformities resulting from reduced weight bearing after injury.4 Although increasing functional mobility is a primary goal of rehabilitation, it traditionally has been accomplished using compensatory movement strategies, as well as wheelchairs, assistive devices, and braces to compensate for residual motor deficits.2,5 In contrast, rehabilitation to promote walking recovery (ie, relative to preinjury walking patterns) relies on the intrinsic neurobiology of walking control and experience-dependent neuroplasticity.6,7

P

this intervention have been reported in adults with SCI10 and described recently in 2 reports of children with severe, incomplete SCI.11,12 Both reports described significant walking recovery in children less than 6 years old with severe, incomplete, cervical SCI. Prosser11 reported the feasibility of carrying out an LT program as part of inpatient rehabilitation and initiated LT with a 5-year-old 1 month after injury. This child with acute SCI made rapid gains in walking function and a concomitant improvement in leg strength (force-generating capacity). The second case report, published by our research group,12 described LT with a child with chronic injury (16 months after injury) who had no prognosis for walking recovery. This child recovered a reciprocal stepping pattern that enabled him to attend elementary school as a full-time ambulator, but he achieved no parallel improvements in clinical measures of strength or volitional, fractionated movement.

Locomotor training (LT) is a rehabilitation intervention that aims to restore walking after incomplete SCI.7 The principles of LT are based on basic and translational investigations of spinal pattern generators and walking recovery.8 Afferent sensory information critical for producing a basic stepping pattern is optimized in a permissive environment that uses a treadmill and partial bodyweight support to enable repetitive walking practice.9 The benefits of

Although the children described in these reports made significant gains, both were injured at a young age, which is associated with a greater incidence and severity of secondary complications13 such as scoliosis, hip dysplasia, and lower-extremity bone deformities. In particular, scoliosis and hip dislocation occur in nearly all children who are injured before adolescence.14 Secondary complications are a critical issue in the rehabilitation of children with SCI, especially as medical complications and reduced functional independence are associated with increased depression, lower levels of community participation,15 and difficulty transitioning into adulthood.3 The secondary complications commonly experienced by children with SCI,2 combined with the long-term consequences of pediatric SCI,3 necessitate ongoing assessment of these children.16

Available With This Article at ptjournal.apta.org • Video: “Ongoing Walking Recovery” • Audio Abstracts Podcast This article was published ahead of print on March 18, 2010, at ptjournal.apta.org.

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This case report is a follow-up to our previous report of a child who recovered reciprocal stepping and independent ambulation 16 months after incomplete cervical SCI.12 The purposes of this case report are to describe this child’s walking function and to report on his growth and development during the 2 years since his participation in an LT program and recovery of full-time ambulatory status. Because this child reached a critical threshold of walking independence with a reverse rolling walker, he was able to regularly practice walking and thus “self-train” under varying conditions.17 Therefore, we hypothesized that over this 2-year period, he would maintain his ability to ambulate independently with an assistive device and improve his walking function, as evidenced by increased gait speed, improved spatiotemporal features of his gait pattern, improved gait kinematics, and an increased number of daily steps taken in his home and community. We also hypothesized that his growth and development would be characterized by: (1) age-appropriate increases in height and weight and only minor musculoskeletal complications secondary to his incomplete SCI and (2) ongoing gross motor development, as evidenced by improved scores on standardized assessments of gross motor function and clinical assessments of other locomotor tasks.

Case Description and Rehabilitation History A 3.5-year-old boy sustained an accidental, self-inflicted gunshot wound, resulting in a cervical (C6 –7) SCI. Prior to the accident, the child’s motor development was normal, based on his ability to walk, run, jump, bike, and swim. Sixteen months postinjury, he was nonambulatory; his injury was classified using the American Spinal Injury Association (ASIA) Impairment Scale (AIS) as motor-incomplete AIS C, C8 bilaterMay 2010

Walking Recovery After Locomotor Training in a Child With Incomplete SCI ally, with a Lower Extremity Motor Score (LEMS)18,19 of 4/50. He enrolled in an ongoing study of walking recovery after incomplete SCI and participated in 76 sessions of LT using both the treadmill and overground environments.12 During the course of LT, patterned, voluntary stepping emerged that enabled him to achieve over-ground walking with an assistive device. Following completion of LT, he returned to his home community where he attended kindergarten, walking independently with a reverse rolling walker. The complete details of the child’s medical history, his progression throughout and immediately following LT, and LT methods were described by Behrman et al.12 Throughout the 2 years following LT, the child attended outpatient physical therapy and occupational therapy sessions 2 to 3 times per week. Therapy did not include LT, but instead targeted skills necessary to function at home and school, such as standing balance, tall kneeling, transfers from sitting to standing and into and out of a vehicle, and upperbody strength. Interventions that focused on walking were directed at using less restrictive assistive devices, such as forearm crutches. Otherwise, there was little focus on locomotor skills or training of reciprocal lower-extremity tasks. Over the 2 years, the child also received standard medical care from his pediatrician and medical specialists following him for his SCI.

Examination Tests and measures were conducted by a licensed physical therapist at 1 month (baseline), 1 year, and 2 years after LT. Examinations at 1 year and 2 years included about 10 sessions of daily LT to reassess the child’s stepping and make recommendations to his parents. The child’s mother provided informed consent for participation and use of medical records in May 2010

compliance with the US Health Information Portability and Accountability Act (HIPAA). Medical records were obtained in order to track the child’s musculoskeletal development and to review the amount and type of outpatient therapy received.

Tests and Measures Neurologic Status The AIS is a standard assessment of neurologic function for individuals with SCI. Its validity has been established for adults with SCI,18,19 but is questionable when used with young children.20 An alternative assessment for children with SCI has not been established. Therefore, annual assessments included the AIS to classify this child’s spinal cord lesion and level of sensory and motor impairment.18,19 Walking Function Walking independence. Walking independence was categorized using the Walking Index for Spinal Cord Injury–Version II (WISCI-II).21,22 This 21-item scale (0 –20) categorizes walking function based on level of physical assistance required and use of braces and assistive devices required to walk 10 m on a level surface.23 Gait speed and spatiotemporal parameters. Gait speed and spatiotemporal parameters of the child’s walking pattern were examined using computerized, pressure-sensitive mats that record footfalls (GaitMat II* and GAITRite†).23,24 The child walked across the 3.6-m walkway using a reverse rolling walker for a minimum of 2 trials at his fastest comfortable walking speed. Gait speed, cadence, step length, and stride length were calculated using the associated software.

* EQ Inc, 3469 Limekiln Pike, Chalfont, PA 18914. † CIR Systems Inc, 60 Garlor Dr, Havertown, PA 19083.

Observational gait analysis. Walking trials were video recorded from a lateral view and reviewed separately by 2 licensed physical therapists. Qualitative analyses of the child’s gait pattern and use of compensatory strategies were performed independently by each therapist and then reviewed for comparison.25 Daily step activity in the home and community. The number of daily steps taken by the child in his home and community were monitored using the Step Activity Monitor.‡ The Step Activity Monitor is a small accelerometer worn around the ankle that can accurately and reliably count steps in adults with SCI26 and children who are healthy.27 During each assessment, the child wore the device during waking hours for a minimum of 2 days. The total number of steps and activity bouts (number of times the child switched from inactivity to activity) was averaged for the 2 days with the greatest number of steps.28 The total number of steps practiced during LT also was counted from a video recording of session 73 of LT for comparison with the number of steps practiced outside of training. This 1-hour session was representative of the amount of stepping practice the child performed daily in the LT environment. Growth and Development Musculoskeletal growth and development. The child’s medical records were reviewed to track his height, weight, and incidence of musculoskeletal impairment over time. Height and weight were compared with national averages for children of the same age.29 Radiographic reports and medical assessments were reviewed for incidence of spine and bone deformity.

‡ Cyma Corp, 6405 218th St SW, Suite 100, Mountlake Terrace, WA 98043.

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Walking Recovery After Locomotor Training in a Child With Incomplete SCI Table 1. Lower Extremity Motor Scores (LEMS) for Left and Right L2–S1 Myotomes and Light Touch and Pinprick Scores for L1–S3 Dermatomes at Baseline and 1 Year and 2 Years After Locomotor Training (LT)a Lower Extremity Motor Score L2

L3

L4

L5

S1

Left

Right

Left

Right

Left

Right

Left

Right

Left

Right

LEMS

1

0

NT

NT

0

0

0

0

2

1

4/50

1 year after LT

NT

NT

NT

NT

NT

NT

NT

NT

2

2

4/50

2 years after LT

NT

NT

NT

1

NT

NT

NT

NT

NT

NT

1/50

Baseline

Light Touch and Pinprick Light Touch L1–S3

Baseline

Pinprick L1–S3

Left

Right

Total

Left

Right

Total

4

0

4/16

1

8

9/16

1 year after LT

6

2

8/16

8

8

16/16

2 years after LT

4

0

4/16

7

1

8/16

a

Lower Extremity Motor Score scale: 0⫽total paralysis; 1⫽palpable or visible contraction; 2⫽active movement, gravity eliminated; NT⫽not testable due to whole limb synergistic movement, prohibiting standardized muscle testing and grading.18,19 L2⫽hip flexors, L3⫽knee extensors, L4⫽ankle dorsiflexors, L5⫽long toe extensors, S1⫽ankle plantar flexors. Maximum score for both lower extremities⫽50 (25/extremity). Light touch and pinprick scale: A modified score was used for light touch: 1 indicated a correct response regarding occurrence and location, and 0 indicated the response was incorrect or that light touch was not perceived. For pinprick, 1 indicated correct differentiation between dull and sharp stimuli, and 0 indicated an incorrect response or the inability to distinguish between dull and sharp stimuli. The child’s ability to understand the test procedures and the reliability of his responses were first confirmed on his face. Maximum score for light touch or pinprick on each side⫽8, for a total score of 16.

Gross motor skill development. Gross motor skill development was assessed in 2 ways. First, the Gross Motor Function Measure (66-item version) (GMFM-66)30 was administered to quantify changes in motor skills across 5 dimensions: lying and rolling; sitting; crawling and kneeling; standing; and walking, running, and jumping. Although the psychometric properties of this measure have not been reported for use in children with SCI, this measure is a standardized assessment of children with cerebral palsy and is valid and reliable for this population,31 as well as children with traumatic brain injury.32 Second, clinical examination of the child’s ability to perform reciprocal lower-extremity tasks also was conducted. When the child initially completed LT, a gross assessment of his ability to negotiate steps was performed. Based on his unexpected ability to negotiate 3 to 4 steps, performance of reciprocal leg movements during stair climbing was re796

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assessed 1 month after LT (baseline). Examinations at 1 year and 2 years after LT expanded to assess reciprocal leg movements in a supine position and while pedaling an adapted tricycle, crawling, stair climbing, and swimming.

Outcomes Over the 2-year period, the child’s AIS scores remained relatively stable, with no notable changes in segmental sensory or motor impairment. Lower-extremity motor control remained characterized by mass synergistic movements and little to no isolated joint control. Despite this persistent lack of isolated lowerextremity joint control, follow-up evaluations at 1 and 2 years after LT supported our hypotheses. The child’s recovered walking pattern was maintained and improved and his height and weight advanced normally compared with age-matched norms for children who are healthy, with only minor musculoskeletal complications. He continued to develop gross motor skills and demon-

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strated reciprocal patterned leg movements in the context of other locomotor tasks. Neurologic Status The child’s SCI neurological level remained unchanged from baseline (AIS C, C8).12 Lack of isolated lowerextremity movements (noted as “not testable”18,19 in Tab. 1) persisted 1 and 2 years later (Tab. 1). The AIS Motor Examination uses standardized manual muscle testing and grading of key muscles to assess segmental myotome function during voluntary, single-joint movements, such as knee extension. When standardized muscle testing cannot be performed, the muscle is graded as not testable.18,19 Therefore, during instances when the child was unable to perform isolated lower-extremity joint motions and could perform only multijoint, synergistic movements (eg, hip flexion accompanied by knee flexion and ankle dorsiflexion), the myotome was scored as not testable. Variations in sensory scores for light touch and pinprick were May 2010

Walking Recovery After Locomotor Training in a Child With Incomplete SCI

Figure 1. Walking function. Walking independence was achieved with the use of a reverse rolling walker at baseline (A, top panel). Walking independence remained relatively unchanged at 1 year after locomotor training (LT) (A, bottom panel) and 2 years after LT (Walking Index for Spinal Cord Injury–Version II [WISCI-II] scores; B). Fastest gait speed (dashed line) continued to increase over time, despite no changes in the WISCI-II score (B). The number of steps taken across the 24-hour period increased substantially from baseline to 1 year after LT and was sustained at 2 years after LT (C). This trend also was evident in the number of steps averaged from 2 days (D, black bar graphs) and the corresponding average number of total stepping bouts (D, dashed line). Error bars denote standard deviation.

observed (Tab. 1) and attributed to the use of this measure in a young child.20 Walking Function Walking independence. One and 2 years after LT, the child’s walking independence remained unchanged (see video, available at www. ptjournal.apta.org). He still required May 2010

the use of a reverse rolling walker to independently ambulate; therefore, his WISCI-II score remained 13/20 (Fig. 1). Gait speed and spatiotemporal parameters. The child’s fastest gait speed increased from 0.45 m/s at baseline to 0.67 m/s 2 years after LT (Tab. 2, Fig. 1). Concurrent with his

advancing height and leg length, step and stride length increased.33 Although step length became more asymmetrical over the 2 years, stride length remained symmetrical and cadence increased (Tab. 2). Observational gait analysis. Qualitative analysis of the child’s gait pattern during over-ground walking

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Walking Recovery After Locomotor Training in a Child With Incomplete SCI Table 2. Gait Speed and Spatiotemporal Gait Parameters at Baseline and 1 Year and 2 Years After Locomotor Traininga

a

Step Length (cm)

Stride Length (cm)

FC Gait Speed (m/s)

Cadence (Steps/min)

Left Leg

Right Leg

Left Leg

Right Leg

Baseline

0.45

63.35

42.25

44.07

85.95

87.19

1 year after LT

0.50

65.60

44.01

46.72

90.63

91.19

2 years after LT

0.67

70.75

51.31

63.55

114.79

114.47

Data are averaged from 2 trials of walking over-ground with a reverse rolling walker at the child’s fastest comfortable (FC) speed.

using a reverse rolling walker at baseline (Fig. 1 and video) revealed his ability to walk with upright trunk posture, with minimal weight bearing through his arms while stepping reciprocally. Gait deviations were evident throughout the gait cycle as he used his arms and trunk to shift his weight and exaggerate his stepping to clear his toes during swing. Most notable was the use of his upper extremities to reciprocally push into his walker, moving his shoulder and upper trunk anteriorly to exaggerate his weight shift to the contralateral side and facilitating ipsilateral swing. These compensatory movements were more evident on his left side. During swing, his foot occasionally crossed midline, catching behind the contralateral lower leg. This movement also was more pronounced for the left leg. The child’s stepping pattern is shown in Figure 1 and is reviewed in the video. Two years after LT, the child’s gait pattern was improved (Fig. 1 and video). He was able to generate reciprocal stepping with a noticeable absence of shoulder and trunk compensations that were used at baseline. This improvement was particularly evident on his left side, where compensations previously dominated. Although he was able to step reciprocally and perform basic gait adaptations for stopping and turning, he was unable to walk backward, side step, or maintain upright balance without upper-extremity support. 798

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Daily step activity in the home and community. Over the 2 years, the average number of daily steps this child took at home and in the community increased from about 1,600 steps at baseline to more than 3,000 steps at 1 year and 2 years after LT (Fig. 1). In comparison, the number of steps practiced during a 1-hour LT session on the treadmill with manual assistance and bodyweight support totaled 2,732 steps. The average number of stepping bouts steadily increased from 31 at baseline to 88 per day at 2 years after LT (Fig. 1). Growth and Development Musculoskeletal growth and development. Prior to injury, the child ranked in the 90th to 95th percentiles in both weight and height. Following injury, his height remained in the 90th to 95th percentiles, and his weight was in the 80th percentile (Fig. 2). Medical records of the child’s radiology reports indicated minimal changes in his spine curvature and hip joint alignment. Over the 2-year period, he was not diagnosed with scoliosis, but mild coxa valga was noted at both hip joints; radiology reports indicated that all findings were stable. One year after LT, the child returned for his annual evaluation wearing bilateral ankle-foot orthoses. The child’s mother explained that the orthoses were prescribed by the child’s physician because of concern for the child’s “flat feet.” She reported that he wore the orthoses during waking

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hours to improve foot and ankle alignment, but that he had difficulty walking initially while wearing the orthoses and had to adapt his stepping pattern. All assessments in this report were conducted without the use of orthoses. Gross motor skill development. The results from the GMFM-66 suggest this child’s total gross motor function remained stable during the 2 years following LT. The total percentage score, reflecting performance across the 5 dimensions, was 65% across all time points (Tab. 3). However, within each dimension of gross motor function, there were variations in the child’s performance. The child’s fatigue level and lower-extremity muscle tone (resistance to passive stretch) were noted to affect performance on specific test items. For instance, compared with baseline, the child’s score in the standing dimension at 1 year after LT decreased 10%, likely due to increased lower-extremity extensor tone that prohibited him from flexing one leg while standing. Although the child continued to require upper-extremity support for balance (eg, a reverse rolling walker) during upright tasks, it was notable that at 1 year after LT, his score increased 11% in the walk, run, jump dimension. Higher scores in this dimension were achieved on tasks requiring greater gait adaptability, such as stopping and turning and kicking a ball.

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Walking Recovery After Locomotor Training in a Child With Incomplete SCI Clinical examination of reciprocal lower-extremity tasks conducted at baseline demonstrated the child’s ability to negotiate 3 to 4 steps with maximal assistance for balance and perform reciprocal 4-point crawling (examined on the GMFM-66). At 1 year and 2 years after LT, he was able to generate reciprocal leg movements in a supine position and in the context of tricycle pedaling, negotiation of stairs, crawling, and swimming (Fig. 3 and video). Alternating flexion and extension synergistic leg movements were used to perform these tasks. For instance, in a supine position, leg flexion movements incorporated hip flexion with lateral (external) rotation, knee flexion, and ankle dorsiflexion. During extension, the hip and knee extended as the ankle moved into plantar flexion (Fig. 3A and video).

Discussion Reciprocal patterned leg movement enabling independent ambulation with a rolling walker was maintained 2 years after LT in a 6.5-year-old child with severe, incomplete cervical SCI. Although clinical assessments did not predict this child would recover walking,34 16 months after severe SCI, a stepping pattern developed that afforded independent community ambulation with a reverse rolling walker. Two years after this initial recovery, he continued to ambulate full-time, and his fastest walking speed and the number of steps taken daily progressively increased. Because repetition and practice are critical factors in skill acquisition and motor learning, achievement of independent community ambulation was likely a critical threshold that enabled ongoing stepping practice in varying environments to reinforce his stepping pattern.17 Furthermore, during the time since his recovery, he took nearly 3,000 steps per day, which exceeds the more than 2,500 May 2010

Figure 2. Growth percentiles maintained after spinal cord injury. Measurements for height and weight were plotted against the national standards from the Centers for Disease Control and Prevention29 for children of the same age and sex. The red line at 3.5 years denotes the time at which injury occurred.

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Walking Recovery After Locomotor Training in a Child With Incomplete SCI Table 3. Gross Motor Function Measure (GMFM-66) Scores at Baseline and 1 Year and 2 Years After Locomotor Training (LT)a Dimension (Possible Score)

Lying/Rolling (51)

Sitting (60)

Crawling (42)

Standing (39)

Walk/Run/Jump (72)

Total % Score

Baseline

49 (96%)

56 (93%)

32 (76%)

15 (38%)

17 (24%)

327 (65%)

1 year after LT

49 (96%)

57 (95%)

30 (71%)

11 (28%)

25 (35%)

325 (65%)

2 years after LT

47 (92%)

58 (97%)

29 (69%)

12 (31%)

26 (36%)

325 (65%)

a

Composite scores were calculated for each dimension of the GMFM-66. Dimension percentage scores were determined by dividing the dimension score by the total possible in each dimension. Dimension percentage scores were summed and divided by the number of dimensions (5) to calculate the total percentage score.

steps he practiced during a 1-hour session of LT. Although 3,000 daily steps is considerably less than the 8,000 daily steps taken by uninjured children,35 this level of daily walking practice and upright activity is a notable contrast to children who use a wheelchair full-time. Moreover, it is likely that upright physical activity, including load-bearing steps, contributed to his healthy physical development. Nearly 4 years after injury, he had not been diagnosed with scoliosis, a pervasive condition occurring in 97% of children injured before age 10 years.14

Although the child continued to require a reverse rolling walker, this device was specifically selected and used in a manner to minimize compensatory gait strategies and promote ongoing stepping recovery. Compared with a forward walker, the reverse rolling walker places the support base behind the body, which minimizes load bearing on the arms and encourages an upright trunk posture and appropriate limb kinematics. This task-specific sensorimotor experience enhances reciprocal leg muscle activation to generate a rhythmic stepping pattern for

walking and was emphasized during his initial LT program on the treadmill as well as over-ground walking practice.12 As the child matured and became more socially active over the 2 years, his desire to keep up with his peers motivated the development of alternative strategies for using his walker. The child adapted his gait pattern and compensated with his arms to “skate” or “ride” on his rolling walker to gain increased speed. As the child becomes more engaged with his peers, especially as he ap-

Figure 3. Reciprocal lower-extremity tasks. One and 2 years following locomotor training, the child was able to perform rhythmic, reciprocal lower-extremity movements in the context of other locomotor tasks. Lower-extremity activities in addition to walking included reciprocal lower-extremity flexion and extension in a supine position (A), tricycle pedaling (B), crawling (C), stair climbing (D), and swimming (E, F).

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Walking Recovery After Locomotor Training in a Child With Incomplete SCI proaches adolescence, the social demands of keeping up with his peers may further influence his stepping pattern and ultimately his physical development. These complex interactions will continue to be studied as this child enters adolescence and young adulthood. An unexpected outcome of this 2-year follow-up was the child’s ability to produce reciprocal patterned leg movements in the context of other tasks such as tricycle pedaling, crawling, stair climbing, and swimming. When he initially enrolled in the LT program 16 months after injury, he could only initiate mass extension leg movements and could not reciprocally flex and extend his legs. Reciprocal leg movements developed through the course of LT (after 20 sessions) and were dependent on task-specific cues such as upright posture and hip joint kinematics.12 Thus, the ability to perform reciprocating leg movements during other tasks suggests that he was no longer dependent on the afferent information associated with walking. Interestingly, recent investigations suggest that there may be similar control mechanisms for varied rhythmic, reciprocal lower extremity tasks.36 Evidence of potential neural mechanisms contributing to this child’s ongoing recovery, however, is not provided in this report. Furthermore, outcomes in this case report have been limited to clinical assessments without detailed biomechanical analyses of the child’s locomotor pattern over time. These methods are currently in development as we follow this child’s progression into adolescence and adulthood. It is critical to further investigate the efficacy of LT in promoting walking recovery in children with incomplete SCI, and conducting comprehensive, quantitative assessments over time provides a longitudinal May 2010

view of the maintenance and progression of recovery. Rehabilitation interventions that target recovery of function and activation of the neuromuscular system after SCI may be beneficial in reducing the incidence and severity of secondary complications. However, long-term investigations of the complex interactions among injury, recovery, and musculoskeletal development are necessary to better understand the current and potential trajectory of this population.

Conclusions After being severely injured at 3.5 years, at 16 months postinjury, this child was predicted (by a LEMS of 4/50) to remain nonambulatory and require full-time use of a wheelchair. His initial recovery following 76 sessions of LT suggests that voluntary, isolated limb movements are not a prerequisite for walking recovery.12,37 This follow-up report describes the child’s ongoing recovery 2 years following LT and suggests that children with SCI have the potential to sustain the skills recovered following LT. These outcomes are particularly important in a pediatric case given the detrimental impact of long-term, full-time wheelchair use and lack of load bearing on growth and development. Dr Fox, Dr Howland, and Dr Behrman provided concept/idea/project design. Dr Fox, Dr Tester, Dr Howland, and Dr Behrman provided writing. All authors provided data collection and analysis. Dr Fox and Dr Behrman provided project management. Dr Behrman provided fund procurement. Dr Phadke, Dr Nair, and Dr Senesac provided consultation (including review of manuscript before submission). The authors extend their sincere appreciation to the University of Florida undergraduate student volunteers, Doctor of Physical Therapy students, and Rehabilitation Science Doctoral (PhD) students who assisted in this study and to the child and his family for their ongoing support of rehabilitation and recovery research.

The University of Florida Health Science Center Institutional Review Board approved this study. This work, in part, was presented at the Howard H. Steel Conference: Pediatric Spinal Cord Injuries and Dysfunction; December 3–5, 2009; Lake Buena Vista, Florida; the Combined Sections Meeting of the American Physical Therapy Association; February 14 –18, 2007; Boston, Massachusetts; the III STEP Conference, sponsored by the Neurology and Pediatrics sections of the American Physical Therapy Association; July 19, 2005, Salt Lake City, Utah; and the Pediatric Spinal Cord Injury Conference, sponsored by Tingley Children’s Hospital and the Department of Pediatrics, College of Medicine, University of New Mexico; July 10, 2005; Albuquerque, New Mexico. This work was supported by the Craig H. Neilsen Foundation, the University of Florida Brooks Center for Rehabilitation Studies, the Florida Department of Health Brain and Spinal Cord Injury Program, NICHD-NCMRR grant K01 HD 0134801, and NIH (OD) NCRR grant TL1RR029889. This article was received May 26, 2009, and was accepted January 17, 2010. DOI: 10.2522/ptj.20090171

References 1 Vitale MG, Goss JM, Matsumoto H, Roye DP Jr. Epidemiology of pediatric spinal cord injury in the United States: years 1997 and 2000. J Pediatr Orthop. 2006; 26:745–749. 2 Vogel LC, Hickey KJ, Klaas SJ, Anderson CJ. Unique issues in pediatric spinal cord injury. Orthop Nurs. 2004;23:300 –308; quiz 309 –310. 3 Anderson CJ, Vogel LC, Betz RR, Willis KM. Overview of adult outcomes in pediatric-onset spinal cord injuries: implications for transition to adulthood. J Spinal Cord Med. 2004;27(suppl 1):S98 – S106. 4 Bergstrom EM, Short DJ, Frankel HL, et al. The effect of childhood spinal cord injury on skeletal development: a retrospective study. Spinal Cord. 1999;37:838 – 846. 5 Vogel LC, Mendoza MM, Schottler JC, et al. Ambulation in children and youth with spinal cord injuries. J Spinal Cord Med. 2007;30(suppl 1):S158 –S164. 6 Behrman AL, Harkema SJ. Physical rehabilitation as an agent for recovery after spinal cord injury. Phys Med Rehabil Clin N Am. 2007;18:183–202. 7 Behrman AL, Bowden MG, Nair PM. Neuroplasticity after spinal cord injury and training: an emerging paradigm shift in rehabilitation and walking recovery. Phys Ther. 2006;86:1406 –1425.

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Walking Recovery After Locomotor Training in a Child With Incomplete SCI 8 Edgerton VR, Tillakaratne NJ, Bigbee AJ, et al. Plasticity of the spinal neural circuitry after injury. Annu Rev Neurosci. 2004;27:145–167. 9 Barbeau H. Locomotor training in neurorehabilitation: emerging rehabilitation concepts. Neurorehabil Neural Repair. 2003;17:3–11. 10 Behrman AL, Harkema SJ. Locomotor training after human spinal cord injury: a series of case studies. Phys Ther. 2000;80: 688 –700. 11 Prosser LA. Locomotor training within an inpatient rehabilitation program after pediatric incomplete spinal cord injury. Phys Ther. 2007;87:1224 –1232. 12 Behrman AL, Nair PM, Bowden MG, et al. Locomotor training restores walking in a nonambulatory child with chronic, severe, incomplete cervical spinal cord injury. Phys Ther. 2008;88:580 –590. 13 Vogel LC, Krajci KA, Anderson CJ. Adults with pediatric-onset spinal cord injury, part 1: prevalence of medical complications. J Spinal Cord Med. 2002;25: 106 –116. 14 Betz RR, Mulcahey MJ. Spinal cord injury rehabilitation. In: Weinstein SL, ed. The Pediatric Spine: Principles and Practice. 2nd ed. New York, NY: Raven Inc; 2001: 601– 618. 15 Anderson CJ, Kelly EH, Klaas SJ, et al. Anxiety and depression in children and adolescents with spinal cord injuries. Dev Med Child Neurol. 2009;51:826 – 832. 16 Edgerton VR. Invited commentary on “Locomotor training restores walking in a nonambulatory child with chronic, severe, incomplete cervical spinal cord injury.” Phys Ther. 2008;88:590 –591. 17 Wernig A, Nanassy A, Muller S. Maintenance of locomotor abilities following Laufband (treadmill) therapy in para- and tetraplegic persons: follow-up studies. Spinal Cord. 1998;36:744 –749. 18 Marino RJ, Barros T, Biering-Sorensen F, et al. International standards for neurological classification of spinal cord injury. J Spinal Cord Med. 2003;26(suppl 1): S50 –S56.

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19 Maynard FM Jr, Bracken MB, Creasey G, et al. International standards for neurological and functional classification of spinal cord injury: American Spinal Injury Association. Spinal Cord. 1997;35:266 –274. 20 Mulcahey MJ, Gaughan J, Betz RR, Johansen KJ. The International Standards for Neurological Classification of Spinal Cord Injury: reliability of data when applied to children and youths. Spinal Cord. 2007; 45:452– 459. 21 Ditunno JF Jr, Ditunno PL, Graziani V, et al. Walking Index for Spinal Cord Injury (WISCI): an international multicenter validity and reliability study. Spinal Cord. 2000;38:234 –243. 22 Dittuno PL, Dittuno JF Jr. Walking Index for Spinal Cord Injury (WISCI II): scale revision. Spinal Cord. 2001;39:654 – 656. 23 Jackson AB, Carnel CT, Ditunno JF Jr, et al. Outcome measures for gait and ambulation in the spinal cord injury population. J Spinal Cord Med. 2008;31:487– 499. 24 Thorpe DE, Dusing SC, Moore CG. Repeatability of temporospatial gait measures in children using the GAITRite electronic walkway. Arch Phys Med Rehabil. 2005; 86:2342–2346. 25 Observational Gait Analysis Handbook. Downey, CA: Professional Staff Association of Rancho Los Amigos Medical Center; 1989. 26 Bowden MG, Behrman AL. Step Activity Monitor: accuracy and test-retest reliability in persons with incomplete spinal cord injury. J Rehabil Res Dev. 2007;44:355–362. 27 McDonald CM, Widman L, Abresch RT, et al. Utility of a step activity monitor for the measurement of daily ambulatory activity in children. Arch Phys Med Rehabil. 2005;86:793– 801. 28 Cavanaugh JT, Coleman KL, Gaines JM, et al. Using step activity monitoring to characterize ambulatory activity in community-dwelling older adults. J Am Geriatr Soc. 2007;55:120 –124.

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29 National Center for Health Statistics (developed with the National Center for Chronic Disease Prevention and Health Promotion). Available at: http://www.cdc. gov/growthcharts. Published 2000. Accessed May 3, 2009. 30 Russell D, Rosenbaum P, Avery L, Lane M. The Gross Motor Function Measure (GMFM-66 & GMFM-88) User’s Manual. London, United Kingdom: Mac Keith Press; 2002. 31 Russell DJ, Avery LM, Rosenbaum PL, et al. Improved scaling of the Gross Motor Function Measure for children with cerebral palsy: evidence of reliability and validity. Phys Ther. 2000;80:873– 885. 32 Linder-Lucht M, Othmer V, Walther M, et al. Validation of the Gross Motor Function Measure for use in children and adolescents with traumatic brain injuries. Pediatrics. 2007;120:e880 – e886. 33 Sutherland D, Olshen R, Cooper L, Woo S. The development of mature gait. J. Bone Joint Surg Am. 1980;62:336 –353. 34 Burns AS, Ditunno JF. Establishing prognosis and maximizing functional outcomes after spinal cord injury: a review of current and future directions in rehabilitation management. Spine. 2001;26(24 suppl): S137–S145. 35 Song KM, Bjornson KF, Cappello T, Coleman K. Use of the StepWatch activity monitor for characterization of normal activity levels of children. J Pediatr Orthop. 2006;26:245–249. 36 Zehr EP. Neural control of rhythmic human movement: the common core hypothesis. Exerc Sport Sci Rev. 2005;33: 54 – 60. 37 Maegele M, Muller S, Wernig A, et al. Recruitment of spinal motor pools during voluntary movements versus stepping after human spinal cord injury. J Neurotrauma. 2002;19:1217–1229.

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Perspective The Revised APTA Code of Ethics for the Physical Therapist and Standards of Ethical Conduct for the Physical Therapist Assistant: Theory, Purpose, Process, and Significance Laura Lee Swisher, Peggy Hiller; the APTA Task Force to Revise the Core Ethics Documents

Introduction. In June 2009, the House of Delegates (HOD) of the American Physical Therapy Association (APTA) passed a major revision of the APTA Code of Ethics for physical therapists and the Standards of Ethical Conduct for the Physical Therapist Assistant. The revised documents will be effective July 1, 2010. Purpose. The purposes of this article are: (1) to provide a historical, professional, and theoretical context for this important revision; (2) to describe the 4-year revision process; (3) to examine major features of the documents; and (4) to discuss the significance of the revisions from the perspective of the maturation of physical therapy as a doctoring profession.

Process of Revision. The process for revision is delineated within the context of history and the Bylaws of APTA. Format, Structure, and Content of Revised Core Ethics Documents. The revised documents represent a significant change in format, level of detail, and scope of application. Previous APTA Codes of Ethics and Standards of Ethical Conduct for the Physical Therapist Assistant have delineated very broad general principles, with specific obligations spelled out in the Ethics and Judicial Committee’s Guide for Professional Conduct and Guide for Conduct of the Physical Therapist Assistant. In contrast to the current documents, the revised documents address all 5 roles of the physical therapist, delineate ethical obligations in organizational and business contexts, and align with the tenets of Vision 2020.

Significance. The significance of this revision is discussed within historical parameters, the implications for physical therapists and physical therapist assistants, the maturation of the profession, societal accountability and moral community, potential regulatory implications, and the inclusive and deliberative process of moral dialogue by which changes were developed, revised, and approved.

L.L. Swisher, PT, MDiv, PhD, was Co-Chair of the APTA Task Force to Revise the Core Ethics Documents. She is Associate Professor and Coordinator of Professional Education, School of Physical Therapy and Rehabilitation Sciences, and Assistant Dean for Interprofessional Education, College of Medicine, University of South Florida, 12901 Bruce B. Downs Blvd, MDC 77, Tampa, FL 33612-4766 (USA). Address all correspondence to Dr Swisher at: [email protected]. P. Hiller, PT, was Co-Chair of the APTA Task Force to Revise the Core Ethics Documents, Phoenix, Arizona. Ms Hiller is a former member and past chair of the APTA Ethics and Judicial Committee and a former member and past chair of the Ethics and Legislation Committee of the Federation of State Boards of Physical Therapy. Address all correspondence to Ms Hiller at: philler@ cox.net. APTA Task Force to Revise the Core Ethics Documents (see list of task force members on page 817). [Swisher LL, Hiller P; the APTA Task Force to Revise the Core Ethics Documents. The revised APTA Code of Ethics for the physical therapist and Standards of Ethical Conduct for the Physical Therapist Assistant: theory, purpose, process, and significance. Phys Ther. 2010; 90:803– 824.] © 2010 American Physical Therapy Association Post a Rapid Response to this article at: ptjournal.apta.org

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n June of 2009, the House of Delegates (HOD) of the American Physical Therapy Association (APTA) took a decisive and historic action when it passed a major revision of the Code of Ethics1 and Standards of Ethical Conduct for the Physical Therapist Assistant.2 In passing the revised documents, the HOD included a proviso that the new documents would not take effect until July 1, 2010, in order to provide time to educate members about the new ethical standards. This action was historic because of the substantive change in format of the documents and the inclusive and deliberative process of moral dialogue by which the changes were developed, revised, and approved. The purposes of this article are: (1) to provide a historical, professional, and theoretical context for the revision; (2) to describe the 4-year process involved in the development of the revised Code of Ethics and Standards of Ethical Conduct for the Physical Therapist Assistant; (3) to examine major features of the revised documents; and (4) to discuss the significance of the revisions from the perspective of the maturation of physical therapy as a doctoring profession. It is generally recognized that codes of ethics are important to professions, professionals, and the public. Indeed, most physical therapist students learn that the development of a code of ethics represents one of the characteristics necessary for an occupation to be considered a pro-

Available With This Article at ptjournal.apta.org • Audio Abstracts Podcast This article was published ahead of print on March 11, 2010, at ptjournal.apta.org.

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fession. However, there is significantly less agreement about the purpose and format of codes of ethics and the roles that they play in promoting ethical conduct. In the following paragraphs, we provide a theoretical and historical background for the discussion of the revised core ethics documents. A significant body of literature has evaluated the societal role played by codes of ethics from the sociological perspective on professions. Paul Starr3 summarized this literature in this way: “A profession, sociologists have suggested, is an occupation that regulates itself through systematic, required training and collegial discipline; that has a base in technical, specialized knowledge; and that has a service rather than a profit orientation, enshrined in its code of ethics.”3(p15) For Starr, these characteristics of professions parallel the 3 different types of professional legitimacy or authority: collegial, cognitive, and moral.3(pp15, 451) Some sociologists would expand upon Starr’s definition of a profession by highlighting the social-political process of attaining the status of being considered a profession (professionalization).4,5 Others might note that the autonomy implied by Starr’s description of self-regulation is a litmus test for “real” professions that is granted in exchange for public accountability as part of the “social contract.”6 –9 On the other hand, Pellegrino10 has argued that it is the vulnerability of those who seek assistance that creates special ethical obligations for the professional: Those who seek out helping professionals share a certain common phenomenological ground. They all deal with a human being in compromised existential states. The persons they see are dependent, anxious, in distress, and lacking something essential to human flourishing. . . . Humans in these compromised existential states are eminently vulnerable and exploit-

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able. Persons in that state are invited to trust the professional. . . .10(p573)

A number of scholars have elaborated upon the purposes of professional codes of ethics. Fullinwider described the role that professional codes play in providing a “vocabulary for intraprofessional argument, self-criticism, and reform,”11(p83) stimulating public discussion of professional obligations,11(p83) fostering a “moral self-understanding,” and creating a professional moral community.11(p83) Similarly, Frankel stated that “a profession’s code of ethics is perhaps its most visible and explicit enunciation of its professional norms. A code embodies the collective conscience of a profession and is testimony to the group’s recognition of its moral dimension.”12(p110) Table 1 summarizes the multiple purposes of codes of ethics discussed in the literature under 3 major categories: articulating a moral vision and self-understanding; educating and providing guidance to members of the profession; and promoting the “social contract,” public accountability, and societal expectations. Although most of the literature about codes of ethics focuses on their positive purposes, it also is widely accepted that codes of ethics may be self-serving or function in negative ways within society. For example, Starr noted that occupational groups may create a code of ethics in order to achieve professional recognition or authority,3(pp15, 451) and, as Table 1 indicates, codes of ethics may contain items with the primary purpose of protecting the profession or working in the self-interest of its members. Beauchamp and Childress16(p7) elaborated on the weaknesses of professional codes of ethics, noting that they may be too vague, simplistic, or rigid to provide appropriate guidance. Likewise, some professional codes might more appropriately be seen as codes of professional “etiquette” rather than “ethics.”16(p7) May 2010

Revised APTA Code of Ethics and Standards of Ethical Conduct for the Physical Therapist Assistant Schwartz17 examined the influence of corporate codes of ethics on behavior. Interviews with employees, managers, and ethics officers revealed 8 primary metaphors for the manner in which a code of ethics may influence behavior: (1) rule book (clarifies expectation for behavior), (2) signpost (alerts one to seek clarification), (3) mirror (feedback for self-critique), (4) magnifying glass (focuses need for caution and reflection), (5) shield (protects those who challenge pressure for unethical conduct), (6) smoke detector (convinces others of unethical practices), (7) fire alarm (contacts appropriate authority), and (8) club (forces compliance).17(p255) These metaphors may provide additional insight into how individuals experience the multiple purposes, strengths, and weaknesses of codes described in the literature. Some professions and scholars distinguish between “codes of ethics” and “codes of conduct.” When this distinction is made, the code of ethics typically outlines the general ethical principles or ideals and the code of conduct provides specific rules for behavior.18(p9) Although this differentiation highlights a distinctive characteristic of a code of ethics (explicit focus on ethics and not merely rules of etiquette), Beauchamp and Childress suggested that a rigid distinction between ethical principles and ethical rules may not be theoretically sound: “We treat principles as the most general and comprehensive norms, but we draw only a loose distinction between rules and principles. Both are general norms of obligation. The difference is that rules are more specific in content and more restricted in scope than principles.”16(p13) Beauchamp and Childress argued that general principles require specification in order to provide helpful and meaningful guidance. Specification is the process of spelling out what actions are reMay 2010

Table 1. Purposes of Professional Codes of Ethics Articulate the moral vision and self-understanding of the profession ● Provide a vocabulary for discussion, self-criticism, and moral community11 ● Articulate the “moral understanding” of the profession13(p11) ● Express the shared ideals of the profession14(p86) ● Represent a consensus about how practitioners can compete and cooperate13(p11) ● Facilitate professional socialization by strengthening professional identity and loyalty12(p111) ● Public statement of the commitment of the profession to promoting the public good13(p11) ● Basis for adjudicating disagreements inside and outside of the profession12(p111) ● Make it more difficult for practitioners to continue behaviors that are explicitly labeled as unethical15(p20) ● Enhance public trust and professional status12(p111) ● Protect the interests of the profession ● Process of development and revision promotes ethical reflection within the profession14(p86) Educate and provide guidance to members of the profession in ethical decision making and conduct ● Enable the professional to make better choices and provide guidance for acting12(p111) ● Deter unethical conduct12(p111) ● Assist professionals in resisting ethical temptations14(p86) ● Support for professionals who may be asked by employers to engage in unethical practices13(p11) ● Provide limits to self-interest13(p11) ● Foster an ethical environment14(p86) ● Make it more difficult for practitioners to continue behaviors that are explicitly labeled as unethical15(p20) ● Serve as a valuable educational tool for professionals, students, organizations, and society14(p86) ● Facilitate professional socialization by strengthening professional identity and loyalty12(p111) ● Enhance public trust and professional status12(p112) ● Preserve professional biases12(p111) Promote the “social contract,” public accountability, and societal expectations ● Function as a social contract between the profession and the public13(p11) ● Public statement of the commitment of the profession to promoting the public good13(p11) ● Basis for public expectation and evaluation12(p111) ● Basis for adjudicating disagreements inside and outside of the profession12(p111) ● Provide limits to self-interest13(p11) ● Protect the interests of the profession ● Foster an ethical environment14(p86) ● Enhance public trust and professional status12(p111)

quired by whom and under what circumstances.16(p17) Given the importance of specification to clarify the meaning of ethical principles, therefore, it is not surprising that many codes combine general and specific principles in a single document.18(p9)

Relatively little has been written in the physical therapy literature about the APTA Code of Ethics.19 In her classic 1977 article, Ruth Purtilo20 outlined the historical foundations for the Code of Ethics of the APTA, noting that the first ethical code was the Code of Hammurabi, a Babylo-

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Revised APTA Code of Ethics and Standards of Ethical Conduct for the Physical Therapist Assistant The American Physiotherapy Association Code of Ethics and Discipline (Adopted at APA Convention, Atlantic City, June 1935) I. Professional Practice

III. Behavior a. Members shall not indulge, before patients, in criticism of doctors, coworkers, or predecessors who have handled the case. b. It is well to bear in mind that our reputation as individuals and a group depends upon professional accomplishments and upon adherence to the standards of our organization.

a. Diagnosing, stating the prognosis of a case, and prescribing treatment shall be entirely the responsibility of the physician. Any assumption of this responsibility by one of our members shall be considered unethical. b. The patient shall be referred back to the physician for periodical examinations. c. A member shall not attempt to criticize the physician or dictate technique or procedure. II. Advertising

IV. Discipline a. Charges and evidence against offenders will be weighed and acted upon by the Executive Committee.

a. Members shall not procure patients by means of solicitors, agents, circulars, displays, or advertisements inserted into commercial periodicals. b. Announcements in medical journals or business cards, not stating fees, are permissible. A statement that the work is medically supervised should appear on the announcement. c. A member may use the term “Physiotherapist” or “Physical Therapist” on an office door.

Figure 1. First Code of Ethics of the American Physical Therapy Association (1935). Reprinted with permission of the American Physical Therapy Association.

nian document written in 2500 BC. In this same article, Purtilo recognized the roots of modern codes of ethics in the Hippocratic Oath and the Oath of Maimonides, both of which provided a foundation for subsequent formal codes of ethics. Purtilo credited Percival’s textbook on medical ethics published in England in 1803 and Florence Nightingale’s nursing text in the same century with developing awareness of ethical issues: “In short, the ethics emphasis in the textbooks of Percival, Nightingale, and others, must be 806

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viewed as exerting an important influence in the development of an ethics awareness among health professionals of the 19th and early 20th centuries.’’20(p1003) Purtilo noted that the American Medical Association’s Code of Ethics published in 1846 became a “prototype” for subsequent professional codes, including the first Code of Ethics of APTA (then the American Physiotherapy Association [APA]) published in 1935 (Fig. 1). 21

Ten years later, Purtilo revisited the concept of the code of ethics in

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an article whose purpose was to examine the usefulness of codes of ethics in reference to professionalism and practical guidance in physical therapist practice. She observed that a code of ethics serves 2 important functions. Because having a code of ethics is considered a hallmark of being a profession, one function is to legitimate the claim that an occupational group has attained the status of being a profession. The second function is to provide guidance for practitioners. Regardless of these functions, Purtilo stated that the test of being a true code of ethics is having a true ethical standard: “Therefore, the more a document actually reflects ethical standards, the closer it comes to being a genuine code of ethics.”21(p31) From this perspective, the first Code of Ethics was, in her estimation, not successful in passing this litmus test: Declaring a document a code of ethics does not in itself assume that one has a code of ethics! Elsewhere I have shown that the early attempts of the American Physical Therapy Association to design a code of ethics was gallant in its intent though unsuccessful in its outcome: one can hardly judge this document’s set of rules designed solely to show devotion and complete deference to the physician as being grounded in any specifically ethical standards, even in the 1930s. While serving as a guide for good etiquette befitting the young ladies of the time, and while serving some other important ends, nonetheless it did not serve as an ethical guide (Purtilo, 197720).21(pp30 –31)

However, Purtilo also observed that a code of ethics may be deficient at the other end of the spectrum by being “vaguely-stated ideals, or are too narrowly conceived to be of much help with everyday problems.”21(p28) Linker’s22 analysis of this first physical therapy code of ethics provides insight into the historical and interMay 2010

Revised APTA Code of Ethics and Standards of Ethical Conduct for the Physical Therapist Assistant professional context that may have contributed to the early leaders of the physical therapy profession producing a code of ethics that was clearly deficient in its concern for patients and the public, even for those early times. Linker observed that “codes of ethics are dynamic documents that provide a unique window into the workings of interprofessional conflicts and negotiations. For the historian, codes of ethics are, above all, statements of distinct fears, concerns, and desires of a professional group of people in a specific time and place.”22(p323) She described in detail the unique interprofessional, economic, and genderrelated pressures that contributed to the wording in the first code, noting that APA was one of the first “ancillary” professions to produce a code of ethics during this period of time:

In effect, the 1935 Code of Ethics sacrificed professional autonomy for stability in relating to the medical profession. Based on her reading of association publications and correspondence, Linker believed that the omission of a service orientation and focus on the patient were most likely strategic rather than merely an “oversight.” As Linker described it: “Although such an agreement required that the therapists subvert their tendencies toward a feminine rhetoric of care and relinquish a considerable degree of autonomy as health care providers, APA therapists willingly paid the price of adhering to the rules of medical professionalism. They wanted to maintain their professional identity and keep their occupation afloat in a tumultuous marketplace, and with their code of ethics, they said as much.”22(p352)

The history of codes of ethics in health care has almost exclusively been told as a story of how medical doctors developed their own professional principles of conduct. Yet telling the history of medical ethics solely from the physicians’ perspective neglects not only the numerous allied health care workers who developed their own codes of ethics in tandem with the medical profession, but also the role that gender played in the writing of such professional creeds. By focusing on the predominantly female organization of the American Physiotherapy Association (APA) and its 1935 “Code of Ethics and Discipline,” I demonstrate how these women used their creed to at once curry favor from and challenge the authority of the medical profession . . . . [C]ontrary to historians and philosophers who contend that professional women have historically operated under a gender-specific ethic of care, the physiotherapists avoided [Victorian] rhetoric construed as feminine and instead created a “businesslike” creed in which they spoke solely about their relationship with physicians and remained silent on the matter of patient care.22(p320)

In the Thirty-First Mary McMillan Lecture delivered in 2000, Purtilo23 described 3 basic periods or “seasons” of ethics in physical therapy. Using agrarian metaphors, Purtilo stated that professional ethics requires sowing 2 primary types of “seeds” amidst shifting societal land-

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scapes: the seeds of care and the seeds of accountability. She identified 3 fundamental periods of ethics in physical therapy: the period of self-identity, patient-focused identity, and an emerging period of societal identity (Fig. 2), with each period focusing on different ethical obligations with regard to care and accountability. Consistent with Linker’s analysis, Purtilo described the 1935 APA Code of Ethics as focusing primarily upon establishing our professional identity: These therapists had read, correctly, a shifting social landscape that was enduring a worldwide depression and would, a few short years later, feel the corrosive effects of a world war and the challenges of social reconstruction following it, as well as face the global ravages of the polio epidemic. Indeed, the entire social terrain of the western world would force physicians down from the mountaintops to labor shoulder to shoulder with nurses and whoever else would share the crushing burden of health care in these extreme circumstances. They found physical therapists ready. Be-

Ethical Self-Identity (1935) Care and accountability to health care providers

Patient-Focused Identity (1950s) Care and accountability to patients Partnership with patient Emphasis on patient rights and teamwork

Societal Identity (Evolving and Future) Partnership with community and institutions Self-identity and patient-focused identity “nested” in societal priorities

Figure 2. Three seasons of physical therapy ethics described by Purtilo.23

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Revised APTA Code of Ethics and Standards of Ethical Conduct for the Physical Therapist Assistant cause physical therapy had planted a professional ethical identity, however new and fragile and however constrained its arena of accountability may seem today, its members were positioned to move from serfdom to strong moral partnership.23(p1115)

Baker24 theorized that professional codes of ethics evolve in 3 distinct stages: traditionalism, formalization, and professionalization. In the traditionalism stage, there is no formal code of ethics, and ethical decisions are based on “traditions of practice.”24(p34) During the formalization stage, there is an attempt to formulate rules and oaths, but adherence is voluntary and there is no mechanism for enforcement or regulation. An example of this stage within physical therapy might be the Loyalty to Country oath taken by students at Reed College described by Linker.22 The professionalization stage is characterized by the formal public promulgation of autonomy and ethical ideals consistent with maturation into a profession. In comparison with medicine,24 law,24 and nursing,25 it is striking how quickly the early physical therapists moved to the stage of professionalization with regard to developing the early code of ethics. Nevertheless, as both Purtilo and Linker pointed out, this early code did not, in fact, fully articulate the ethical ideals of the profession. In this way, there remained unfinished business for physical therapy with regard to full maturation in the professionalization stage. The last 20 years has witnessed a remarkable evolution of the physical therapy profession in the United States. During this period, the profession has defined its scope of practice, secured direct access in most state jurisdictions, and articulated a vision of physical therapists as doctorally educated and evidence-based professionals serving as practitioners, educators, consultants, researchers,

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and administrators. The APTA published the Guide to Physical Therapist Practice26 in 1997, Vision 202027 in 2000, and Professionalism in Physical Therapy: Core Values,28 endorsed by the HOD, in 2007. The core ethics documents that are currently in force were adopted in 1973 and had been revised 5 times (1977, 1978, 1981, 1987, and 1991) before the most recent previous revision in 2000. This section of the article has attempted to delineate the theoretical and historical context for the revision of the core ethics documents. As Linker suggested, a code of ethics provides a “window” into the profession in a historical context. Internal communications within APTA suggest that there was growing concern about the adequacy of the Code of Ethics as early as 1999. A review of the annual reports of the Ethics and Judicial Committee (EJC) for 199929 and 200030 reveals that the EJC, Board of Directors (BOD), and HOD began a dialogue about the core ethics documents in 1999. These reports indicate that each of these bodies had at different times recommended changes to the core ethics documents. These efforts apparently culminated in the revisions completed in 2000. The 2000 Annual Report of the EJC described the resulting documents as “much more patient-centered than their predecessors. They articulate that a basic obligation a physical therapist or physical therapist assistant owes a patient is trustworthiness, a term introduced into the document.”30 Reflecting back on these annual reports, it may be that the 2009 revision of the core ethics documents represents the culmination of an increasing awareness within the profession and the professional organization of the ethical implications of the maturation of the profession. At the same time, the dialogue among the EJC, BOD, and HOD did not nec-

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essarily engender widespread reflection on the core ethics documents. In retrospect and using Purtilo’s language, it may be that the “seeds” of the 2009 revision were sown in the 1999 period following the adoption of the Guide to Physical Therapist Practice and Vision 2020.

Process of Revision Frankel12 and Pritchard14 both noted that the process of development or revision of a code of ethics can be important in the maturation of a profession. As they implied, the process for revision may be as important as the actual product. It would be unfortunate if the emphasis on a code of ethics as a product obscured the value of the process by which a code is developed and subsequently revised. This process is a time of critical self-examination by both individual members and the profession as a whole. The profession must institutionalize a process whereby its moral commitments are regularly discussed and assessed in the light of changing conditions both inside and outside the profession. The widespread participation of members in such an effort helps to reinvigorate and bring into sharp focus the underlying values and moral commitments of their profession . . . . This process of self-criticism, codification, and consciousness-raising reinforces or redefines the profession’s collective responsibility and is an important learning and maturing experience for both individual members and the profession.12(pp112–113)

As the quote by Frankel suggests, the value of revising a code of ethics does not reside merely in the resulting documents but also, just as importantly, in the individual and collective learning, maturation, and professional development that result from engaging in the process of revision. For this reason, it is important to describe the events and processes involved in revising the core ethics documents. We believe that the process of revision of the core ethics May 2010

Revised APTA Code of Ethics and Standards of Ethical Conduct for the Physical Therapist Assistant Table 2. Time Line of Key Events in Adopting Revised Core Ethics Documents (2006 –2010)a Date

Events

Code Critique (EJC) March–November 2006

APTA EJC completes an extensive review of APTA core ethics documents and codes of ethics of other professions. EJC recommends to APTA BOD that a task force of internal and external stakeholders be funded to revise core ethics documents.

Revision Process (Task Force to Revise Core Ethics Documents) March 2007–April 2008

APTA BOD contracts project manager and external ethics consultant and appoints Task Force to Revise the Core Ethics Documents. Task force meets to draft documents. BOD approves draft documents for review and comment by APTA leadership, membership, and communities of interest.

Professional and Stakeholder Comment: Surveys and Feedback June 2008–March 2009

APTA Department of Research develops and posts online surveys. Survey data tabulated and task force co-chairs revise draft documents based on survey feedback. Revised drafts reviewed by task force and submitted to BOD.

BOD Action and HOD Adoption March–June 2009

a

BOD drafts RC 4 and RC 5 for HOD. HOD passes RC 4-09: Amend Code of Ethics and RC 5-09: Amend Standards of Ethical Conduct for the Physical Therapist Assistant with proviso to become effective in July 2010.

EJC⫽Ethics and Judicial Committee, APTA⫽American Physical Therapy Association, BOD⫽Board of Directors, HOD⫽House of Delegates.

documents that culminated in approval by the HOD in June 2009 was indeed a learning and maturing experience for our professional association. It is especially noteworthy that the profession consciously engaged in self-critical moral dialogue based on actual ethical situations encountered by physical therapists in this most recent revision process. This dialogue spanned a 4-year period, and sought the input of members and nonmembers through forums at national and state conferences, Internet feedback surveys, and debate before and during the HOD meeting. In this section of the article, we discuss the process and timeline for the revision process. After delineating specific responsibilities and authority within the association, we describe the process in detail, identifying 4 major phases: code critique, revision process, professional and stakeholder comment, and BOD action and HOD approval (Tab. 2). Code Critique As indicated in Table 3, the Bylaws of APTA31 give the HOD the sole auMay 2010

thority for adopting ethical principles and standards to govern the conduct of members of the Association in their roles as physical therapists and physical therapist assistants.31 The EJC is charged with proposing revisions of the ethical principles and standards of the Association, interpreting the ethical principles and standards, and making revisions, as necessary, to the documents that interpret the ethical principles and standards of the Association.31 The documents that interpret the ethical principles are the Guide for Professional Conduct33 and the Guide for Conduct of the Physical Therapist Assistant.34 Each group (BOD, HOD, and EJC) has authority over specific aspects of the ethics process, and none of the 3 entities enjoy absolute authority over the documents and process (Tab. 3). Beginning in 2005 and concluding in 2006, the EJC conducted a thorough and systematic review of these core ethics documents, as well as the ethical codes of other health care professions, to see how such codes com-

pared with APTA’s Code of Ethics and Standards of Ethical Conduct for the Physical Therapist Assistant in content and arrangement. In summary, the EJC found that the ethics documents: (1) focused primarily on the physical therapists’ and physical therapist assistants’ roles in patient client management, with limited attention to their other roles as educators, researchers, consultants, and administrators, as articulated in the Guide to Physical Therapist Practice; (2) did not provide guidance for the expanded responsibilities of the physical therapist related to autonomous practice as described in Vision 2020; (3) did not address the complexities encountered by physical therapists and physical therapist assistants in the contemporary health care environment that includes individual, organizational, and societal obligations; (4) did not capture a contemporary notion of relationships with other health care providers; and (5) did not articulate the unique moral self-understanding of the physical therapy professional.35 As a result of this critical analysis, in July 2006, the EJC recommended that the

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Revised APTA Code of Ethics and Standards of Ethical Conduct for the Physical Therapist Assistant Table 3. Excerpts From American Physical Therapy Association Bylaws and Standing Rules Delineating Authority for Ethical Matters31,32 Governance Documents, Specific Sections

Topic

Bylaws31

APTA Article VIII HOD Section 1

General powers HOD

Provisions –

–

a

The APTA HOD has all legislative and elective powers and authority to determine policies of the Association, including the power to . . . C. Adopt ethical principles and standards to govern the conduct of members of the Association in their roles as physical therapists or physical therapist assistants

APTA Bylaws31 Article IX BOD Section 5

Duties of BOD

–

APTA Bylaws31 Article X committees and councils Section 1

Committees: B. EJC

This committee shall: (1) Interpret the ethical principles and standards of the Association. (2) Propose revisions of the ethical principles and standards of the Association and the Disciplinary Action Procedural Document. (3) Make revisions, as necessary, to the documents that interpret the ethical principles and standards of the Association. (4) Promote activities for the dissemination of information on ethics. (5) Process reported violations of ethical principles and standards. (6) Make final decisions in disciplinary proceedings against a member, subject only to appeal to the BOD.

Standing Rules32 Section 16 A

Definition of association viewpoints and administrative directives

A. Association viewpoints 1. Standard: a binding statement used to judge quality of action or activity. The use of “ethical standard” refers to right and wrong conduct, as articulated in the Code of Ethics. 2. Position: a firmly held Association stance or point of view. Positions of the Association direct subsequent decisions on similar matters of both the Association and its members. 3. Guideline: a statement of advice. B. Association administrative directives 1. Policy: Association directives defining operational and administrative activities. 2. Procedure: steps required to achieve a result.

The BOD shall, in addition to the duties otherwise imposed by these Bylaws and the Standing Rules: – N. Approve the procedure by which reported violations of the ethical principles and standards of the Association are to be processed.

APTA⫽American Physical Therapy Association, HOD⫽House of Delegates, BOD⫽Board of Directors, EJC⫽Ethics and Judicial Committee.

APTA BOD appoint a task force of internal and external stakeholders to develop new core ethics documents reflective of elements outlined in Vision 202027 and guided by APTA’s Professionalism in Physical Therapy: Core Values28 (Tab. 2). In November 2006, the BOD adopted a 2007 budget that included funding for a task force as envisioned by the EJC (Tab. 2).

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Code Revision Process In March 2007, the BOD appointed an 18-member task force that included physical therapy leaders and emerging leaders, clinicians, educators, regulators, consumers, a project manager, a DPT student representative, and a non–physical therapist ethics consultant. The Task Force for Revision of Core Ethics Documents met in Sep-

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tember 2007, working under the following key assumptions36,37: 1. The drafting should begin with the identification and assessment of frontline ethical factors/issues derived from the “firsthand” experience of physical therapists and physical therapist assistants in a variety of roles and settings. The task force members gener-

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Revised APTA Code of Ethics and Standards of Ethical Conduct for the Physical Therapist Assistant ated more than 350 ethical issues addressing all aspects of physical therapist practice, reimbursement, policy, technology, and professional relationships. 2. The revised documents should set forth principles for the ethical practice of physical therapy that address the multitude of physical therapist and physical therapist assistant practice settings and roles applicable to individual, organizational, and societal realms. 3. The revised documents should be fully congruent with the relevant elements of APTA’s Vision 2020 and a doctoring profession. 4. The documents should include both foundational principles as well as interpretive guidelines as to the intent, meaning, and application of ethical behaviors. 5. APTA’s core values (Professionalism in Physical Therapy: Core Values28) should be embedded in the principles. As indicated in Table 2, the draft documents of the task force were reviewed, refined, and edited by a subgroup of the full task force. The resulting draft documents ultimately were reviewed and edited by all members of the task force and the members of the EJC prior to submission of an Interim Report to the BOD in March 2008. In April 2008, the BOD approved the drafts contained in the Interim Report for review and comment by APTA leadership, membership, and targeted communities of interest (Tab. 2). Professional and Stakeholder Comment: Surveys and Feedback Following approval of the draft documents for distribution and comment, APTA’s Department of Research, working in collaboration with the task force leadership, deMay 2010

veloped surveys for soliciting feedback from professional and targeted public stakeholders. The APTA staff created an online survey using the Vovici38 (formerly WebSurveyor) survey and data management software platform. The surveys were designed around a Likert scale whereby respondents could indicate their level of agreement regarding the clarity and need for inclusion of the preambles, principles and standards, and interpretive guidelines of the proposed revisions. The survey included a total of 128 Likert items for the Code of Ethics and a total of 114 Likert items for the Standards of Ethical Conduct for the Physical Therapist Assistant. In addition, there were areas for open comment in each section that encouraged submission of suggested revisions, additions, or deletions. A final question asked whether the revised Code of Ethics and Standards of Ethical Conduct for the Physical Therapist Assistant represented an improvement in articulating the ethical standards for physical therapists and physical therapist assistants compared with the current versions (Tab. 2). The surveys were posted on APTA’s Web site in 2 phases: a first mailing occurred in early September 2008 (Tab. 2) to a targeted group of approximately 400 physical therapy leaders, inviting them to complete the online surveys by October 1. Included in this first group were APTA component (chapters and sections) presidents and executive personnel; EJC members; chapter ethics committee chairpersons; the Federation of State Boards of Physical Therapy (targeting state physical therapy licensing board members and executive directors); APTA panels, committees, and liaisons to other groups; academic administrators; certified specialists; APTA BOD; and physical therapist staff members. In early October 2008, APTA members were invited to complete the surveys, with

responses requested by October 31. The goal of this survey strategy was to solicit feedback from APTA members, APTA staff, and public stakeholders. Data from the 2 survey phases were aggregated without identification or differentiation of the source of individual responses or comments. As indicated in Table 4, a total of 1,137 responses were received addressing the proposed revisions. Table 4 summarizes the results of the survey for each of the documents. The task force co-chairs, in collaboration with the staff project manager, met on December 12 and 13, 2008, to analyze the aggregated descriptive data and comments from both phases of the survey. Because the data were not identified by source, comments of each group were given equal weight. Each principle and standard was examined to determine whether the preponderance of feedback indicated the need for editing, rewriting, or deletion. Particular attention was given to principles and guidelines that received a favorable rating (Likert scale scores 4 and 5) of less than 70% or a negative rating (Likert scale scores 1 and 2) of more than 10%. Both the Code of Ethics and Standards of Ethical Conduct for the Physical Therapist Assistant changed substantively in light of survey feedback. The goal of the task force co-chairs was to produce a document that was consistent with the general themes of the majority of survey comments. A number of the comments reflected concerns about the overall length of the draft documents, the number of interpretive guidelines, and perceived redundancies within the documents. In response, the editors reduced the number of words in both documents by 33% and reduced the number of interpretive guidelines in the Code of Ethics and the Standards of Ethical Conduct for the Physical Therapist Assistant by 35% and 30%, respectively. Overall, 48% of the state-

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Revised APTA Code of Ethics and Standards of Ethical Conduct for the Physical Therapist Assistant Table 4. Results of American Physical Therapy Association Online Survey

Respondents

Code of Ethics Number (%)

Standards of Ethical Conduct for the Physical Therapist Assistant Number (%)

808 (91.5)

182 (71.7)

12 (1.4)

56 (22.0)

8 (0.9)

1 (0.4)

Physical therapists Physical therapist assistants Non–physical therapists/ non–physical therapist assistants on state regulatory board Other

36 (4.1)

7 (2.8)

Not identified

19 (2.2)

8 (3.1)

883 (100)

254 (100)

Total

Percentage

Percentage

Responses

Agree (4–5)a

Disagree (1–2)b

Agree (4–5)a

Disagree (1–2)b

Revision represents an improvement

77.9

8.4

82.5

7.8

Preamble clearly stated

84.7

9.3

85.6

9.2

Preamble should be included

83.1

Mean of all survey responsesc

85.6

9.4

88.7

8.2

4.1

1.9

3.7

2.0

Standard deviation

c

10

85.9

10

a

Figures represent the percentage of respondents who responded “agree” (4) or “strongly agree” (5). b Figures represent the percentage of respondents who responded “strongly disagree” (1) or “disagree” (2). c Figures represent the mean or standard deviation of responses to all Likert items (clarity and inclusion) for the preamble, principles, standards, interpretive guidelines, and overall reaction to the Code of Ethics (128 Likert items) and Standards of Ethical Conduct for the Physical Therapist Assistant (114 Likert items).

ments, inclusive of both principles and guidelines, were edited, rewritten, or deleted. The edited drafts and a comprehensive summary of actions were distributed to the entire task force in January 2008 for final review and comment. In March 2008, the task force submitted its final report to the BOD with a recommendation that the BOD submit motions to amend by substitution the Code of Ethics and Standards of Ethical Conduct for the Physical Therapist Assistant to the 2009 HOD. BOD Action and HOD Adoption At its March 2008 meeting, the APTA BOD voted to send motions to the 2009 HOD to amend the Code of Ethics and Standards of Ethical Conduct for the Physical Therapist Assistant. Following review by the Reference Committee of the HOD, 2 substantive changes were made to the format of the documents prior to submission to the HOD. The task 812

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force had originally referred to the more specific, lettered principles as “interpretive guidelines” because their purpose was to clarify the meaning of the more general principles. However, the BOD removed all references to “interpretive guidelines” because the term “guideline” is defined in the APTA Standing Rules as “a statement of advice” and distinct from the “binding statements” that articulate “ethical standards”32 (Tab. 3). In addition, the BOD hoped to avoid confusion between the specific lettered principles in the Code of Ethics and Standards of Ethical Conduct for the Physical Therapist Assistant and the “interpretive” documents produced by the EJC (Guide for Professional Conduct and Guide for Conduct of the Physical Therapist Assistant).33,34 The BOD further noted that all of the items (numbered and lettered) were principles with equal weight and obligation. A proviso was

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added to both documents so that the amended Code of Ethics and Standards of Ethical Conduct for the Physical Therapist Assistant, if adopted, would not take effect until July 1, 2010, to allow for education of the profession concerning the significant changes encompassed in the revised ethics documents. The debate and adoption of the revised Code of Ethics and Standards of Ethical Conduct for the Physical Therapist Assistant during the 2009 HOD meeting spanned 2 days, during which the entire representative body engaged in meaningful and substantive analysis of the current and future moral foundations of physical therapists and physical therapist assistants within the context of a changing health care environment. The co-chairs of the task force and the chair of the EJC were present during the HOD meeting to address questions about the revision proMay 2010

Revised APTA Code of Ethics and Standards of Ethical Conduct for the Physical Therapist Assistant cess, clarify content of the documents, and consult with delegates regarding ethical implications. A description of the depth and breadth of debate is beyond the scope of this article, but the debate included discussions about personal biases and discrimination, patient empowerment and collaboration, exploitation of all individuals over whom physical therapists and physical therapist assistants have influence, personal boundaries, impaired colleagues, reimbursement for services, and advocacy for health care services. The HOD had traditionally left the process of specifying ethical principles to the EJC through the interpretations in the Guide for Professional Conduct and the Guide for Conduct of the Physical Therapist Assistant. Delegating the important process of specification of principles to the EJC had the practical effect of confining moral dialogue about the meaning of the principles to a relatively small group of members: the 5 appointed members of the EJC. Despite the clarity of the APTA Bylaws about the responsibility of the HOD for the core ethics documents, a number of delegates had legitimate practical concerns about the ability of such a large group (approximately 400 delegates) to effectively review and edit both documents, especially in light of the expanded content of this revision. These concerns were effectively handled by the HOD leadership through the creative use of parliamentary procedure that permitted discussion of the document as a whole and in seriatim before proceeding to a vote on adoption of each document.

Format, Structure, and Content of Revised Core Ethics Documents General Numbered Principles, Core Values, and Specific Lettered Principles Much of the discussion before and during the HOD meeting focused on

May 2010

the expanded format of the proposed revisions. Throughout the history of APTA, the format of the Code of Ethics and Standards of Ethical Conduct for the Physical Therapist Assistant had been limited to a few general principles. The final revised core ethics documents (Appendixes 1 and 2) have the following general structure: preamble followed by 8 general numbered principles, each followed by specific lettered principles. In the Code of Ethics, the numbered principle also is followed by the most relevant core values. As described in the theoretical discussion of codes with regard to specification, the lettered principles specify what is meant by the more general numbered principle. For example, principle 3 states, “Physical therapists shall be accountable for making sound professional judgments.” The lettered principles under principle 3 educate readers that the general numbered principle is related to the core values of excellence and integrity and would entail behaviors enumerated in the lettered principles of “independent and objective judgment” (principle 3A), “judgment informed by professional standards, evidence (including current literature and established best practice), practitioner experience, and patient/client values” (principle 3B), “within their scope of practice and level of expertise” (principle 3C), avoiding “conflicts of interest that interfere with professional judgment” (principle 3D), and providing “appropriate direction of and communication with physical therapist assistants and support personnel” (principle 3E). In essence, the lettered and numbered principles interpret each other, specifying what is meant by “sound professional judgment.” Table 5 summarizes the differences in format and content between the current Code of Ethics and Standards of Ethical Conduct for the Physical Therapist Assistant and the revisions

that will become effective in July 2010. In addition to these differences in format, the revised documents also have distinct topical content. Overall, the 8 numbered principles and their associated lettered principles deal with the following topics: Principle 1: Ethical obligations to all people Principle 2: Duties owed to patients and clients Principle 3: Accountability for making sound professional judgments Principle 4: Integrity in relationships with other people Principle 5: Fulfilling legal and professional obligations Principle 6: Lifelong acquisition of knowledge, skills, and abilities Principle 7: Promoting organizational and business practices to benefit patients/clients and society Principle 8: Meeting the health needs of people locally, nationally, or globally. As described in the example, a full understanding of these general obligations would require reading both numbered (general) and lettered (specific) principles. The revised core ethics documents also attempt to integrate ethical guidance for all of the roles of the physical therapist delineated in the Guide to Physical Therapist Practice: management of patients/clients, consultation, education, research, and administration.

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Revised APTA Code of Ethics and Standards of Ethical Conduct for the Physical Therapist Assistant Table 5. Major Differences Between Current and Revised Ethics Documents Current (Effective Through June 2010)

Revised (Effective July 1, 2010)

No. of principles

11 principles (Code of Ethics) 7 principles (Standards of Ethical Conduct for the Physical Therapist Assistant)

46 principles (Code of Ethics) 42 principles (Standards of Ethical Conduct for the Physical Therapist Assistant)

Nature of principles and standards

General

8 general numbered principles and 38 specific lettered principles (Code of Ethics) 8 general numbered standards and 34 specific lettered principles (Standards of Ethical Conduct for the Physical Therapist Assistant)

Core values

Not linked to core values

Linked to core values (Code of Ethics) Physical therapists to adhere to core values (principle 2A of Code of Ethics)

Roles of the physical therapist

Focus on patient client management role

Addresses all 5 roles: management of patients and clients, consultation, education, research, and administration (Code of Ethics)

Unique moral obligation of physical therapists and physical therapist assistants

Not addressed

Addressed in preamble (Code of Ethics) Addressed in preamble (Standards of Ethical Conduct for the Physical Therapist Assistant)

Vision 2020

Partial inclusion

Full integration

Realms of ethical obligation

Focus on individual realm

Addresses individual, organizational, and societal realms

International Classification of Functioning, Disability and Health (ICF) language

No

Yes

Evidence-based practice

Obligation not stated

Stated in principle 3B of the Code of Ethics Physical therapist assistants to be guided by “best practices” (principle 3B of the Standards of Ethical Conduct for the Physical Therapist Assistant)

Significance The passage of time undoubtedly will provide insight into the impact and enduring contributions of these most recent revisions to the Code of Ethics and Standards of Ethical Conduct for the Physical Therapist Assistant. Likewise, it is premature and perhaps impossible to determine whether the revised documents will facilitate enhanced ethical behavior. It is reasonable, however, to articulate the significance of these revisions within historical parameters, the continued maturation of the physical therapy profession, the significance of revisions for practitioners, the openness of the process for revision, the theoretical basis for the changes, the experiences of individuals and groups involved in the effort, and the potential regulatory implications of the revised Code and Standards.

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In different ways, Linker22 and Purtilo23 described codes of ethics as products of the social landscape of the times. From a historical perspective, they recognized that the early physical therapists first secured the survival of the fledgling profession before attending to ethical matters. Indeed, Linker suggested that the early leaders muted their ethical knowledge and suppressed any hint of an ethic of care. Despite these early ethical omissions, both authors noted that the profession later returned to the pressing ethical issue of patient-focus that was missing from their first attempts. Given this history, it is not surprising that in this most recent period of professional maturation, the physical therapy profession first addressed issues of professional autonomy, direct access, standards of practice, and communicating the contemporary role of the physical therapist before returning

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to ethical concerns. From that perspective, these revisions represent a similar backtracking to attend to ethical issues inherent in the maturation of the profession. In the previous section, we noted that the expanded format of the revisions had engendered a significant amount of debate before and during the HOD meeting. We believe that the deliberate process of discussion, debate, and moral dialogue is a significant indicator of the maturation and professionalization of physical therapy. The primary arguments advanced for the expanded format of the documents were the educational value of more specific guidance for physical therapists and physical therapist assistants, the enhanced public accountability of publishing consistent normative standards of conduct, and the opportunity for the membership and their representatives in the May 2010

Revised APTA Code of Ethics and Standards of Ethical Conduct for the Physical Therapist Assistant HOD to have greater input into ongoing dialogue about ethical matters. Just as the revised ethics documents reflect the maturation of the profession, so too can the revisions serve as scaffolding for the members of the profession to assess and enhance their individual ethical maturation. Many of the features of the revised ethics documents have particular significance for physical therapy practitioners. Practitioners may use the Code of Ethics and Standards of Ethical Conduct for the Physical Therapist Assistant to obtain more specific guidance to inform ethical decision making in their interactions with patients and clients, colleagues, other health care professionals, employers, and organizations. For example, the revised documents spell out more clearly the ethical behaviors that are consistent with being “trustworthy,” “respecting others,” and making “sound professional judgments.” Likewise, the expanded documents may assist practitioners in bringing ethical concerns forward within health care organizations. As indicated in principles 7 and 7A through 7F, a primary goal of both the EJC and the task force was to provide more guidance for ethical situations in business and organizational settings. These principles could provide an opportunity for practitioners to indicate to others within their health care organizations where policies may conflict with the accepted ethical standards of the physical therapy profession. The revised format also may benefit educators and students who have experienced difficulty in distinguishing the relative roles of the Code of Ethics, Standards of Ethical Conduct for the Physical Therapist Assistant, and interpretive guides. The revised documents undoubtedly make clearer to students the specific ethical behaviors that are prohibited or required. Finally, the revised documents are significant for practitioMay 2010

ners and educators because of the clarity with which they articulate the ethical obligations inherent within Vision 2020 with regard to autonomous evidence-based practice. The revised core ethics documents clarify that physical therapists have an ethical obligation to exercise independent, evidence-based, and accountable judgments. We have previously discussed the metaphors for using codes of ethics that Schwartz17 developed based on interviews with employees and managers. These metaphors also may suggest ways that physical therapists and physical therapist assistants might use the revised core ethics documents to clarify expectations for ethical behavior (rule book), to seek clarification in areas that are unclear (signpost), as a basis for selfevaluation (mirror), as a stimulus for reflection or caution (magnifying glass), as protection against organizational pressures for unethical practices (shield), to alert others within organizations about questionable practices (smoke detector), as a stimulus to report unethical conduct (fire alarm), and to leverage organizational support for compliance with professional ethical standards (club).17 Noting that the 4 areas in which health care professionals are most likely to have regulatory infractions (boundary violations, misrepresentations, financial, and other), Bloom39 recommeneds that members of the Health Policy and Administration Section use the revised documents as a basis for self-evaluation. Kirsch also offered suggestions as to how the revised documents might be used by practioners.40 – 42 Despite the strengths and positive qualities that we have identified in the revised core ethics documents, it is undoubtedly true that they also have limitations and weaknesses. One important limitation is that the documents (like other ethical codes)

focus on principles, duties, and rules for behavior, and they constitute only one aspect of professional ethics and virtuous practice. A significant body of ethics scholarship has documented the limitations of “principlism.”43– 45 This literature observes that focusing on principles overemphasizes deductive rational processes and pays too little attention to other important ethical processes such as caring, relationships, intuition, virtue, character, emotions,46 and moral courage. Several other limitations were identified throughout the revision process. Would expanding the documents lead members to bring numerous proposed edits to the core ethics documents before the HOD on an ongoing basis? Although limited revision on an ongoing basis would contribute to maintaining relevancy, constant major revision would perhaps prove to be a distraction to the HOD and would make it difficult for members to know the current ethical obligations. Likewise, does publication of extensive, detailed documents erroneously suggest that the documents capture all that is required from an ethical standpoint? A final consideration is that a definitive format and role for the Guide for Professional Conduct and Guide for Conduct of the Physical Therapist Assistant requires further clarification. Several times in this perspective, we have returned to the point made by both Frankel12 and Pritchard14 that the process of revising a code of ethics is important. We believe that this is especially true of the revisions passed by the HOD in June 2009, with implementation in July 2010. Although there is little written about the process involved in previous APTA revisions, it appears that the process begun in 2006 and completed in 2009 was unique in several ways. First, it was unique in the number of people who were involved in the dialogue about ethical matters

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Revised APTA Code of Ethics and Standards of Ethical Conduct for the Physical Therapist Assistant through presentations and discussions at APTA Combined Sections Meetings and Annual Conferences, chapter delegate discussions, HOD bulletin board discussions, the online surveys, presentations and forums at section meetings, and the HOD meeting. To our knowledge, it is the first time that proposed revisions were placed before the physical therapy communities of interest in this format and with this level of involvement. The process also was unique in that the revisions were based on ethical issues generated by practitioners, educators, administrators, students, and researchers, making it to some extent reflective of real-world situations across the range of physical therapist education and practice settings. Although the online survey was not a scientific sample, it nevertheless constituted another source of data as to whether the revised documents were representative of current practice. In Frankel’s words, it was a “process of self-criticism, codification, and consciousness-raising” and one that did indeed prove to be “an important learning and maturing experience for both individual members and the profession.”12(p113) Although it is impossible to characterize the experience of more than 400 delegates, it did appear that many of the delegates matured in their ethical understanding throughout the debate. Although a good deal of the early concern of the pre-HOD and early HOD discussion focused on format and process, it seemed to us that the delegates increasingly “owned” the responsibility of the HOD to adopt ethical documents that would set a high standard for member conduct. Some scholars of professional ethics have discussed the meaning of community and moral community. Hester47 described community as “intelligent working together and not merely the believing or being together that marks/makes community. Com816

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munity, then, is not shared values but shared valuing and shared evaluation. Though communities do have shared values, those values are the result of processes which are themselves already instances of community(ifying). . . .”47(p432) Engelhardt defined a community as “a body of men and women bound together by common moral traditions and/or practices around a shared vision of the good life, which allows them to collaborate as moral friends.”48(p7) Responding to Englehardt, Laabs49 stated that “moral family” may be a better term. On the other hand, Webster and Baylis defined a moral community as “a community where there is coherence between what healthcare institutions publicly profess to be . . . and what employees, patients, and others both witness and participate in.”50(p228) It is possible that what the delegates were experiencing through debate and adoption of these revisions was a sense of moral community. The revised Code of Ethics and Standards of Ethical Conduct for the Physical Therapist Assistant also may have regulatory significance in states that have provisions requiring adherence to APTA’s ethical documents or the “standards of ethics of the profession” within state practice acts. In light of the fact that most states allow either partial or completely unrestricted direct access to physical therapists, the educational and political evolution of autonomous physical therapist practice supports higher and more specific standards of ethical behavior. Although it is not possible to predict whether this will cause more physical therapists or physical therapist assistants to be cited for violations of their practice act, it is true that the revised documents set an elevated and more detailed standard of ethical conduct and perhaps provide a clearer basis for state regulatory agencies to evaluate whether someone might have engaged in unethical conduct. Simi-

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larly, the higher standard potentially could be used by patients and clients in supporting civil claims. Nevertheless, the discussion of the multiple purposes of codes of ethics illustrates that there are important purposes of ethical codes that may take precedence over the fear of consequences for physical therapists or physical therapist assistants who may be accused of violating the more expanded versions of APTA’s ethics documents. Looking back on our early history and first Code of Ethics, we cannot help but believe that our predecessors would celebrate that the historical and social landscape has changed sufficiently to allow us to speak freely in writing our Code of Ethics and Standards of Ethical Conduct for the Physical Therapist Assistant, without fear that it might jeopardize the future of our profession. Using Starr’s framework, we might say that we have claimed not only our collegial and cognitive legitimacy, but also our moral legitimacy. Invoking Purtilo’s metaphors, there is no way to determine the social “landscape” that the future may hold for our profession, nor how well the “seeds” of care and accountability planted in the revised core ethics documents will take root in serving members of the profession and the public. We do know that the profession has engaged in a robust moral dialogue about its obligations to patients, clients, students, colleagues, organizations, and society as a whole. Although we may not all agree on every point within the documents, as a profession we have done our collective best to capture what we believe to be our professional duties, and perhaps we have come together as a moral community.

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Revised APTA Code of Ethics and Standards of Ethical Conduct for the Physical Therapist Assistant Both authors provided concept/idea/project design, writing, data analysis, project management, and consultation (including review of manuscript before submission). The authors thank the members of the Task Force to Revise the Core Ethics Documents; the members and Chair Nancy R. Kirsch, PT, DPT, PhD, of the Ethics and Judicial Committee during the revision process; staff members Jennifer Baker, MSW, CAE; John J. Bennett, JD; Lauren Dockter, JD; Angela K. Boyd; Mary Jane Harris, PT, MS; BOD liaison Sharon L. Dunn, PT, PhD, OCS; House of Delegates officers Shawne E. Soper, PT, DPT, MBA, Laurita M. Hack, PT, DPT, MBA, PhD, FAPTA, and Babette Sanders, PT, MS; Marc Goldstein, EdD; and Sarah C. Miller from APTA’s Department of Research; respondents to the online survey; and the delegates to the 2009 APTA House of Delegates for their commitment to and efforts in support of the process to revise APTA’s core ethics documents. Special thanks to Project Manager Joseph P.H. Black, MDiv, PhD, whose vision was instrumental to the revision process. The authors also thank Gina Maria Musolino, PT, MSEd, EdD, for her thoughtful review of and suggested edits to the manuscript. Task Force to Revise the Core Ethics Documents: Debora Kay Bornmann, PTA, BAS; Kathryn L. Bossen, PT, DPT; Ann Giffin, PT, MS; Meredith Hinds Harris, PT, DPT, EdD; Peggy L. Hiller, PT; Gail M. Jensen, PT, PhD, FAPTA; Milagros Jorge, PT, EdD; Nancy R. Kirsch, PT, DPT, PhD; Lee Nelson, PT, DPT, MS; Charlene Portee, PT, PhD; Jeffrey M. Rosa, MPP; Babette Sanders, PT, MS; Neil Shiosaki, PT; Susan W. Sisola, PT, PhD; Laura Lee (Dolly) Swisher, PT, MDiv, PhD; Herman Triezenberg, PT, PhD; John J. Bennett, JD (APTA General Counsel); Joseph P.H. Black, MDiv, PhD (Project Manager); and Michael S. Pritchard, PhD (Consultant). Some of the content in this article was presented at APTA Combined Sections Meetings and Annual Conferences during the last several years. This article was received November 12, 2009, and was accepted January 18, 2010. DOI: 10.2522/ptj.20090373

References 1 Code of Ethics. American Physical Therapy Association. Available at http://www.apta. org/AM/Template.cfm?Section⫽Ethics_and_ Legal_Issues1&Template⫽/CM/ContentDisplay.cfm&ContentID⫽63686. Accessed November 2, 2009.

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2 Standards of Ethical Conduct for the Physical Therapist Assistant. American Physical Therapy Association. Available at: http:// www.apta.org/AM/Template.cfm?Section⫽ Ethics_and_Legal_Issues1&Template⫽/CM/ ContentDisplay.cfm&ContentID⫽63688. Accessed November 2, 2009. 3 Starr P. The Social Transformation of American Medicine. New York, NY: Basic Books; 1982. 4 Wilensky HL. The professionalization of everyone? AJS. 1964;70:137–158. 5 Forsyth BF, Danisiewicz TJ. Toward a theory of professionalization. Work Occup. 1985;12:59 –76. 6 Sandstrom RW. The meanings of autonomy for physical therapy. Phys Ther. 2007;87:98 –106; erratum 2007;87:227. 7 Rothstein JM. Autonomy or professionalism [editor’s note]? Phys Ther. 2003;83: 206 –207. 8 Rothstein JM. Autonomy and dependency [editor’s note]. Phys Ther. 2002;82:750 – 751. 9 Swisher LL, Beckstead JW, Bebeau MJ. Factor analysis as a tool for survey analysis using a professional role orientation inventory as an example. Phys Ther. 2004;84: 784 –799. 10 Pellegrino ED. The internal morality of clinical medicine: a paradigm for the ethics of the helping and healing professions. J Med Philos. 2001;26:559 –579. 11 Fullinwider RK. Professional codes and moral understanding. In: Coady M, Block S, eds. Codes of Ethics and the Professions. Victoria, Australia: Melbourne University Press; 1996:72– 87. 12 Frankel MS. Professional codes: why, how, and with what impact? J Bus Ethics. 1989; 8:109 –115. 13 Gabard D, Martin M. Physical Therapy Ethics. Philadelphia, PA: FA Davis Co; 2003. 14 Pritchard MS. Professional Integrity: Thinking Ethically. Lawrence, KS: University Press of Kansas; 2006. 15 Lichentberg J. “What are codes of ethics for?” In: Coady M, Block S, eds. Codes of Ethics and the Professions. Victoria, Australia: Melbourne University Press; 1996: 13–27. 16 Beauchamp TL, Childress JF. Principles of Biomedical Ethics. 6th ed. New York, NY: Oxford University Press; 2009. 17 Schwartz M. The nature of the relationship between corporate codes of ethics and behavior. J Bus Ethics. 2001;32:247–262. 18 Coady M, Block S, eds. Codes of Ethics and the Professions. Victoria, Australia: Melbourne University Press; 1996. 19 Swisher LL. A retrospective analysis of ethics knowledge in physical therapy (1970 – 2000). Phys Ther. 2002;82:692–706. 20 Purtilo RB. The American Physical Therapy Association’s code of ethics: its historical foundations. Phys Ther. 1977; 57:1001–1006. 21 Purtilo RB. Codes of ethics in physiotherapy: a retrospective view and look ahead. Physiotherapy Practice. 1987;3:28 –34.

22 Linker B. The business of ethics: gender, medicine, and the professional codification of the American Physiotherapy Association, 1918 –1935. J Hist Med Allied Sci. 2005;60:320 –354. 23 Purtilo RB. Thirty-First Mary McMillan lecture: A time to harvest, a time to sow: ethics for a shifting landscape. Phys Ther. 2000;80:1112–1119. 24 Baker R. A draft model aggregated code of ethics for bioethicists. Am J Bioeth. 2005; 5:33– 41. 25 Dahnke MD. The role of the American Nurses Association code in ethical decision making. Holist Nurs Pract. 2009;23: 112–119. 26 Guide to Physical Therapist Practice. Phys Ther. 1997;77:1163–1650. 27 Vision 2020. American Physical Therapy Association. Available at: http://www. apta.org/AM/Template.cfm?Section⫽Vision_ 20201&Template⫽/TaggedPage/TaggedPageDisplay.cfm&TPLID⫽285&ContentID⫽ 32061. Accessed October 18, 2009. 28 Professionalism in Physical Therapy: Core Values. Consensus document of the American Physical Therapy Association. 2003. Available at: http://www.apta.org/AM/Template.cfm? Section⫽Vision_20201&CONTENTID⫽ 41460&TEMPLATE⫽/CM/ContentDisplay. cfm. Accessed October 18, 2009. 29 Report of the Ethics and Judicial Committee. 1999. Available at: http://www.apta.org/AM/ Template.cfm?Section⫽Annual_Reports1 &Template⫽/TaggedPage/TaggedPageDisplay.cfm&TPLID⫽149&ContentID⫽ 19089. Accessed October 11, 2009. 30 Report of the Ethics and Judicial Committee. 2000. Available at: http://www.apta.org/AM/ Template.cfm?Section⫽Ethics_and_Legal_ Issues1&TEMPLATE⫽/CM/ContentDisplay.cfm&CONTENTID⫽43131. Accessed October 11, 2009. 31 Bylaws of the American Physical Therapy Association. Available at: http://www.apta.org/ AM/Template.cfm?Section⫽Policies_and_ Bylaws2&Template⫽/TaggedPage/TaggedPageDisplay.cfm&TPLID⫽253&ContentID⫽ 40373. Accessed October 18, 2009. 32 Standing Rules of the American Physical Therapy Association. Available at: http:// www.apta.org/AM/Template.cfm?Section⫽ Home&Template⫽/CM/ContentDisplay. cfm&ContentID⫽67416. Accessed October 18, 2009. 33 Guide for Professional Conduct. American Physical Therapy Association. Available at: http://www.apta.org/AM/Template.cfm? Section⫽Core_Documents1&Template⫽ /CM/HTMLDisplay.cfm&ContentID⫽24781. Accessed November 2, 2009. 34 Guide for Conduct of the Physical Therapist Assistant. American Physical Therapy Association. Available at: http://www. apta.org/AM/Template.cfm?Section⫽Core_ Documents1&Template⫽/CM/HTMLDisplay. cfm&ContentID⫽23731. Accessed November 2, 2009. 35 Report of the Ethics and Judicial Committee to the Board of Directors. August 2006. Available at: http://www.apta.org/AM/ Template.cfm?Section⫽Annual_Reports1 &TEMPLATE⫽/CM/ContentDisplay.cfm& CONTENTID⫽43142.

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Revised APTA Code of Ethics and Standards of Ethical Conduct for the Physical Therapist Assistant 36 Handbook for the Consensus Conference for Revising the Core Ethics Documents. Alexandria, VA: American Physical Therapy Association; 2007. 37 Hiller P, Swisher LL, Black J. Open forum on the revision of the APTA’s core ethics documents. Presented at: Annual Conference and Exposition of the American Physical Therapy Association; June 11–14, 2008; San Antonio, Texas. 38 Vovici. Dulles, VA. Available at: http:// www.vovici.com/index.aspx. Accessed December 31, 2009. 39 Bloom C. Revised core documents present opportunity for self evaluation. HPA Resource. 2009;9(4):15. 40 Kirsch NR. Bringing us up to code. PT in Motion. 2009;1(1):64 – 66.

41 Kirsch NR. New and improved. PT in Motion. 2009;1(2):50 –55. 42 Kirsch NR. Practical matters: applying the new ethics documents to clinical scenarios. PT in Motion. 2009;1(3):48 –50. 43 Clouser KD, Gert B. A critique of principlism. J Med Philos. 1990;15:219 –236. 44 Beauchamp TL. Principlism and its alleged competitors. Kennedy Institute of Ethics Journal. 1995;5:181–198. 45 Campbell AV. The virtues (and vices) of the 4 principles. J Med Ethics. 2003;29: 292–296. 46 Greenfield B. The role of emotions in ethical decision making: implications for physical therapist education. J Phys Ther Educ. 2007;21:14 –21.

47 Hester DM. What must we mean by “community”: a processive account. Theor Med. 2004;25:423– 437. 48 Engelhardt HT. The Foundation of Bioethics. 2nd ed. New York, NY: Oxford University Press; 1996. 49 Laabs CA. The community of nursing: moral friends, moral strangers, moral family. Nurs Philos. 2008;9:225–232. 50 Webster GC, Baylis F. Moral residue. In: Rubin SB, Zoloth L. eds. Margin of Error: The Ethics of Mistakes in the Practice of Medicine. Hagerstown, MD: University Publishing Group; 2000:217–230.

Appendix 1. Code of Ethics

EFFECTIVE JULY 1, 2010. For more information, go to www.apta.org/ethics. CODE OF ETHICS HOD S06-09-07-12 [Amended HOD S06-00-12-23; HOD 06-91-05-05; HOD 06-87-11-17; HOD 06-81-06-18; HOD 06-78-06-08; HOD 06-78-06-07; HOD 06-77-18-30; HOD 06-77-17-27; Initial HOD 06-73-13-24] [Standard] Preamble The Code of Ethics for the Physical Therapist (Code of Ethics) delineates the ethical obligations of all physical therapists as determined by the House of Delegates of the American Physical Therapy Association (APTA). The purposes of this Code of Ethics are to: 1. Define the ethical principles that form the foundation of physical therapist practice in patient/client management, consultation, education, research, and administration. 2. Provide standards of behavior and performance that form the basis of professional accountability to the public. 3. Provide guidance for physical therapists facing ethical challenges, regardless of their professional roles and responsibilities. 4. Educate physical therapists, students, other health care professionals, regulators, and the public regarding the core values, ethical principles, and standards that guide the professional conduct of the physical therapist. 5. Establish the standards by which the American Physical Therapy Association can determine if a physical therapist has engaged in unethical conduct. No code of ethics is exhaustive nor can it address every situation. Physical therapists are encouraged to seek additional advice or consultation in instances where the guidance of the Code of Ethics may not be definitive. This Code of Ethics is built upon the five roles of the physical therapist (management of patients/clients, consultation, education, research, and administration), the core values of the profession, and the multiple realms of ethical action (individual, organizational, and societal). Physical therapist practice is guided by a set of seven core values: accountability, altruism, compassion/caring, excellence, integrity, professional duty, and social responsibility. (Continued)

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Throughout the document the primary core values that support specific principles are indicated in parentheses. Unless a specific role is indicated in the principle, the duties and obligations being delineated pertain to the five roles of the physical therapist. Fundamental to the Code of Ethics is the special obligation of physical therapists to empower, educate, and enable those with impairments, activity limitations, participation restrictions, and disabilities to facilitate greater independence, health, wellness, and enhanced quality of life. Principles: Principle #1: Physical therapists shall respect the inherent dignity and rights of all individuals. (Core Values: Compassion, Integrity) 1A. Physical therapists shall act in a respectful manner toward each person regardless of age, gender, race, nationality, religion, ethnicity, social or economic status, sexual orientation, health condition, or disability. 1B. Physical therapists shall recognize their personal biases and shall not discriminate against others in physical therapist practice, consultation, education, research, and administration. Principle #2: Physical therapists shall be trustworthy and compassionate in addressing the rights and needs of patients/clients. (Core Values: Altruism, Compassion, Professional Duty) 2A. Physical therapists shall adhere to the core values of the profession and shall act in the best interests of patients/clients over the interests of the physical therapist. 2B. Physical therapists shall provide physical therapy services with compassionate and caring behaviors that incorporate the individual and cultural differences of patients/clients. 2C. Physical therapists shall provide the information necessary to allow patients or their surrogates to make informed decisions about physical therapy care or participation in clinical research. 2D. Physical therapists shall collaborate with patients/clients to empower them in decisions about their health care. 2E. Physical therapists shall protect confidential patient/client information and may disclose confidential information to appropriate authorities only when allowed or as required by law. Principle #3: Physical therapists shall be accountable for making sound professional judgments. (Core Values: Excellence, Integrity) 3A. Physical therapists shall demonstrate independent and objective professional judgment in the patient’s/client’s best interest in all practice settings. 3B. Physical therapists shall demonstrate professional judgment informed by professional standards, evidence (including current literature and established best practice), practitioner experience, and patient/client values. 3C. Physical therapists shall make judgments within their scope of practice and level of expertise and shall communicate with, collaborate with, or refer to peers or other health care professionals when necessary. 3D. Physical therapists shall not engage in conflicts of interest that interfere with professional judgment. 3E. Physical therapists shall provide appropriate direction of and communication with physical therapist assistants and support personnel. (Continued)

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Principle #4: Physical therapists shall demonstrate integrity in their relationships with patients/clients, families, colleagues, students, research participants, other health care providers, employers, payers, and the public. (Core Value: Integrity) 4A. Physical therapists shall provide truthful, accurate, and relevant information and shall not make misleading representations. 4B. Physical therapists shall not exploit persons over whom they have supervisory, evaluative or other authority (eg, patients/clients, students, supervisees, research participants, or employees). 4C. Physical therapists shall discourage misconduct by health care professionals and report illegal or unethical acts to the relevant authority, when appropriate. 4D. Physical therapists shall report suspected cases of abuse involving children or vulnerable adults to the appropriate authority, subject to law. 4E. Physical therapists shall not engage in any sexual relationship with any of their patients/clients, supervisees, or students. 4F. Physical therapists shall not harass anyone verbally, physically, emotionally, or sexually. Principle #5: Physical therapists shall fulfill their legal and professional obligations. (Core Values: Professional Duty, Accountability) 5A. Physical therapists shall comply with applicable local, state, and federal laws and regulations. 5B. Physical therapists shall have primary responsibility for supervision of physical therapist assistants and support personnel. 5C. Physical therapists involved in research shall abide by accepted standards governing protection of research participants. 5D. Physical therapists shall encourage colleagues with physical, psychological, or substance related impairments that may adversely impact their professional responsibilities to seek assistance or counsel. 5E. Physical therapists who have knowledge that a colleague is unable to perform their professional responsibilities with reasonable skill and safety shall report this information to the appropriate authority. 5F. Physical therapists shall provide notice and information about alternatives for obtaining care in the event the physical therapist terminates the provider relationship while the patient/client continues to need physical therapy services. Principle #6: Physical therapists shall enhance their expertise through the lifelong acquisition and refinement of knowledge, skills, abilities, and professional behaviors. (Core Value: Excellence) 6A. Physical therapists shall achieve and maintain professional competence. 6B. Physical therapists shall take responsibility for their professional development based on critical self-assessment and reflection on changes in physical therapist practice, education, health care delivery, and technology. (Continued)

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6C. Physical therapists shall evaluate the strength of evidence and applicability of content presented during professional development activities before integrating the content or techniques into practice. 6D. Physical therapists shall cultivate practice environments that support professional development, lifelong learning, and excellence. Principle #7: Physical therapists shall promote organizational behaviors and business practices that benefit patients/clients and society. (Core Values: Integrity, Accountability) 7A. Physical therapists shall promote practice environments that support autonomous and accountable professional judgments. 7B. Physical therapists shall seek remuneration as is deserved and reasonable for physical therapist services. 7C. Physical therapists shall not accept gifts or other considerations that influence or give an appearance of influencing their professional judgment. 7D. Physical therapists shall fully disclose any financial interest they have in products or services that they recommend to patients/clients. 7E. Physical therapists shall be aware of charges and shall ensure that documentation and coding for physical therapy services accurately reflect the nature and extent of the services provided. 7F. Physical therapists shall refrain from employment arrangements, or other arrangements, that prevent physical therapists from fulfilling professional obligations to patients/clients. Principle #8: Physical therapists shall participate in efforts to meet the health needs of people locally, nationally, or globally. (Core Values: Social Responsibility) 8A. Physical therapists shall provide pro bono physical therapy services or support organizations that meet the health needs of people who are economically disadvantaged, uninsured, and underinsured. 8B. Physical therapists shall advocate to reduce health disparities and health care inequities, improve access to health care services, and address the health, wellness, and preventive health care needs of people. 8C. Physical therapists shall be responsible stewards of health care resources and shall avoid over-utilization or under-utilization of physical therapy services. 8D. Physical therapists shall educate members of the public about the benefits of physical therapy and the unique role of the physical therapist. Proviso: The Code of Ethics as substituted will take effect July 1, 2010, to allow for education of APTA members and non-members. (General Counsel, ext.3253)

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EFFECTIVE JULY 1, 2010. For more information, go to www.apta.org/ethics STANDARDS OF ETHICAL CONDUCT FOR THE PHYSICAL THERAPIST ASSISTANT HOD S06-09-20-18 [Amended HOD S06-00-13-24; HOD 06-91-06-07; Initial HOD 06-82-04-08] [Standard] Preamble The Standards of Ethical Conduct for the Physical Therapist Assistant (Standards of Ethical Conduct) delineate the ethical obligations of all physical therapist assistants as determined by the House of Delegates of the American Physical Therapy Association (APTA). The Standards of Ethical Conduct provide a foundation for conduct to which all physical therapist assistants shall adhere. Fundamental to the Standards of Ethical Conduct is the special obligation of physical therapist assistants to enable patients/clients to achieve greater independence, health and wellness, and enhanced quality of life. No document that delineates ethical standards can address every situation. Physical therapist assistants are encouraged to seek additional advice or consultation in instances where the guidance of the Standards of Ethical Conduct may not be definitive. Standards: Standard #1: Physical therapist assistants shall respect the inherent dignity, and rights, of all individuals. 1A. Physical therapist assistants shall act in a respectful manner toward each person regardless of age, gender, race, nationality, religion, ethnicity, social or economic status, sexual orientation, health condition, or disability. 1B. Physical therapist assistants shall recognize their personal biases and shall not discriminate against others in the provision of physical therapy services. Standard #2: Physical therapist assistants shall be trustworthy and compassionate in addressing the rights and needs of patients/clients. 2A. Physical therapist assistants shall act in the best interests of patients/clients over the interests of the physical therapist assistant. 2B. Physical therapist assistants shall provide physical therapy interventions with compassionate and caring behaviors that incorporate the individual and cultural differences of patients/clients. 2C. Physical therapist assistants shall provide patients/clients with information regarding the interventions they provide. 2D. Physical therapist assistants shall protect confidential patient/client information and, in collaboration with the physical therapist, may disclose confidential information to appropriate authorities only when allowed or as required by law. Standard #3: Physical therapist assistants shall make sound decisions in collaboration with the physical therapist and within the boundaries established by laws and regulations. 3A. Physical therapist assistants shall make objective decisions in the patient’s/client’s best interest in all practice settings. 3B. Physical therapist assistants shall be guided by information about best practice regarding physical therapy interventions. (Continued)

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3C. Physical therapist assistants shall make decisions based upon their level of competence and consistent with patient/client values. 3D. Physical therapist assistants shall not engage in conflicts of interest that interfere with making sound decisions. 3E. Physical therapist assistants shall provide physical therapy services under the direction and supervision of a physical therapist and shall communicate with the physical therapist when patient/client status requires modifications to the established plan of care. Standard #4: Physical therapist assistants shall demonstrate integrity in their relationships with patients/clients, families, colleagues, students, other health care providers, employers, payers, and the public. 4A. Physical therapist assistants shall provide truthful, accurate, and relevant information and shall not make misleading representations. 4B. Physical therapist assistants shall not exploit persons over whom they have supervisory, evaluative or other authority (eg, patients/clients, students, supervisees, research participants, or employees). 4C. Physical therapist assistants shall discourage misconduct by health care professionals and report illegal or unethical acts to the relevant authority, when appropriate. 4D. Physical therapist assistants shall report suspected cases of abuse involving children or vulnerable adults to the supervising physical therapist and the appropriate authority, subject to law. 4E. Physical therapist assistants shall not engage in any sexual relationship with any of their patients/clients, supervisees, or students. 4F. Physical therapist assistants shall not harass anyone verbally, physically, emotionally, or sexually. Standard #5: Physical therapist assistants shall fulfill their legal and ethical obligations. 5A. Physical therapist assistants shall comply with applicable local, state, and federal laws and regulations. 5B. Physical therapist assistants shall support the supervisory role of the physical therapist to ensure quality care and promote patient/client safety. 5C. Physical therapist assistants involved in research shall abide by accepted standards governing protection of research participants. 5D. Physical therapist assistants shall encourage colleagues with physical, psychological, or substance related impairments that may adversely impact their professional responsibilities to seek assistance or counsel. 5E. Physical therapist assistants who have knowledge that a colleague is unable to perform their professional responsibilities with reasonable skill and safety shall report this information to the appropriate authority. (Continued)

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Standard #6: Physical therapist assistants shall enhance their competence through the lifelong acquisition and refinement of knowledge, skills, and abilities. 6A. Physical therapist assistants shall achieve and maintain clinical competence. 6B. Physical therapist assistants shall engage in lifelong learning consistent with changes in their roles and responsibilities and advances in the practice of physical therapy. 6C. Physical therapist assistants shall support practice environments that support career development and lifelong learning. Standard #7: Physical therapist assistants shall support organizational behaviors and business practices that benefit patients/clients and society. 7A. Physical therapist assistants shall promote work environments that support ethical and accountable decision-making. 7B. Physical therapist assistants shall not accept gifts or other considerations that influence or give an appearance of influencing their decisions. 7C. Physical therapist assistants shall fully disclose any financial interest they have in products or services that they recommend to patients/clients. 7D. Physical therapist assistants shall ensure that documentation for their interventions accurately reflects the nature and extent of the services provided. 7E. Physical therapist assistants shall refrain from employment arrangements, or other arrangements, that prevent physical therapist assistants from fulfilling ethical obligations to patients/clients. Standard #8: Physical therapist assistants shall participate in efforts to meet the health needs of people locally, nationally, or globally. 8A. Physical therapist assistants shall support organizations that meet the health needs of people who are economically disadvantaged, uninsured, and underinsured. 8B. Physical therapist assistants shall advocate for people with impairments, activity limitations, participation restrictions, and disabilities in order to promote their participation in community and society. 8C. Physical therapist assistants shall be responsible stewards of health care resources by collaborating with physical therapists in order to avoid over-utilization or under-utilization of physical therapy services. 8D. Physical therapist assistants shall educate members of the public about the benefits of physical therapy. Proviso: The Standards of Ethical Conduct for the Physical Therapist Assistant as substituted will take effect July 1, 2010, to allow for education of APTA members and non-members. (General Counsel, ext.3253)

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Letters to the Editor Message From Dr. Jacquelin Perry I appreciate being considered 9 feet tall (“Jacquelin Perry, 9 Feet Tall,” February 2010 issue1), but I can’t imagine it even on a conceptual basis. I am sure you have given me more credit than I deserve. My life course has profited from several timely opportunities, and I grabbed each one: (1) In 1935, University of California at Los Angeles tuition was only $27. Even as a 40 cents/ hour dishwasher in a laboratory, I could earn enough to register (mother provided room and board). Dreams of medical school had to wait. One year of calculus was evidence I should change from mathematics to physical education. This combined science with sports, and I could substitute the pre-med level of basic science. (2) A senior-year health course introduced me to physical therapy. Also, the Army announced that its physical therapy school had become a civil service program. My 1-unit classes on Greek and Latin roots helped me pass the vocabulary entry exam. Thus, my future began. (3) By the end of World War II, the GI Bill was available. It provided 4 years of education in any field. I already had the necessary entry science courses, managed to get into the University of California at San Francisco medical school, and followed with an orthopaedic surgery residency.

May 2010

Letter 5.10.indd 825

(4) A classmate introduced me to his brother, who was the chief of orthopaedic surgery at the Rancho Los Amigos hospital polio program. He needed help, and the program was perfect for me. The big challenge at Rancho was the patients’ severe spinal and respiratory muscle paralysis. Even the private hospitals couldn’t provide the necessary care. The patients’ collapsing spine prevented sitting and aggravated an already limited ability to breathe. Also, these patients couldn’t tolerate the anesthesia needed for surgical stabilization. The addition of an elective tracheotomy allowed the anesthetist to safely control the patients’ breathing. Now, the orthopedists could restore spinal stability by long surgical fusions that included all the paralyzed vertebral segments. Introduction of the Salk vaccine eliminated the need for that program within 4 years. This allowed our trained clinicians to turn to other severely impaired populations in need of a mixture of rehabilitation and reconstructive surgery. We began with spinal cord injury, stroke, and arthritis; as we became aware of new needs, we soon included amputations, traumatic brain injury, and fractures. The basic principles and new horizons were largely unknown. There always is something to learn! This environment has been a continual stimulus for my curiosity. I was eager to share my new knowledge, and you know the rest.

Thank you for supporting Sara’s Festschrift and honoring me with a dedicated issue in PTJ, focused on gait. The oral presentations at the “Stepping Forward With Gait Rehabilitation” PTJ symposium sponsored by APTA’s Neurology Section at the Combined Sections Meeting in San Diego were great. It was a wonderful display of the tremendous progress physical therapists have made, both professionally and personally. I also want to thank Dr Craik for her leadership as editor in chief of PTJ. Jacquelin Perry J. Perry, MD, ScD(Hon), is Professor Emeritus, Department of Orthopaedics, University of Southern California Keck School of Medicine. [DOI: 10.2522/ptj.2010.90.5.825.1]

Correction The Bottom Line for Young IA, Michener LA, Cleland JA, et al. “Manual Therapy, Exercise, and Traction for Patients With Cervical Radiculopathy…” (July 2009;89:628–629.) In the “Who participated in this study” section of the Bottom Line, one of the 4 criteria in the clinical prediction rule for patients with cervical radiculopathy—ipsilateral neck rotation <65°—was incorrect. This should read “ipsilateral neck rotation <60°”. The Journal regrets the error. [DOI: 10.2522/ptj.2010.90.5.825.2]

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Letters to the Editor Message From Dr. Jacquelin Perry I appreciate being considered 9 feet tall (“Jacquelin Perry, 9 Feet Tall,” February 2010 issue1), but I can’t imagine it even on a conceptual basis. I am sure you have given me more credit than I deserve. My life course has profited from several timely opportunities, and I grabbed each one: (1) In 1935, University of California at Los Angeles tuition was only $27. Even as a 40 cents/ hour dishwasher in a laboratory, I could earn enough to register (mother provided room and board). Dreams of medical school had to wait. One year of calculus was evidence I should change from mathematics to physical education. This combined science with sports, and I could substitute the pre-med level of basic science. (2) A senior-year health course introduced me to physical therapy. Also, the Army announced that its physical therapy school had become a civil service program. My 1-unit classes on Greek and Latin roots helped me pass the vocabulary entry exam. Thus, my future began. (3) By the end of World War II, the GI Bill was available. It provided 4 years of education in any field. I already had the necessary entry science courses, managed to get into the University of California at San Francisco medical school, and followed with an orthopaedic surgery residency.

May 2010

Letter 5.10.indd 825

(4) A classmate introduced me to his brother, who was the chief of orthopaedic surgery at the Rancho Los Amigos hospital polio program. He needed help, and the program was perfect for me. The big challenge at Rancho was the patients’ severe spinal and respiratory muscle paralysis. Even the private hospitals couldn’t provide the necessary care. The patients’ collapsing spine prevented sitting and aggravated an already limited ability to breathe. Also, these patients couldn’t tolerate the anesthesia needed for surgical stabilization. The addition of an elective tracheotomy allowed the anesthetist to safely control the patients’ breathing. Now, the orthopedists could restore spinal stability by long surgical fusions that included all the paralyzed vertebral segments. Introduction of the Salk vaccine eliminated the need for that program within 4 years. This allowed our trained clinicians to turn to other severely impaired populations in need of a mixture of rehabilitation and reconstructive surgery. We began with spinal cord injury, stroke, and arthritis; as we became aware of new needs, we soon included amputations, traumatic brain injury, and fractures. The basic principles and new horizons were largely unknown. There always is something to learn! This environment has been a continual stimulus for my curiosity. I was eager to share my new knowledge, and you know the rest.

Thank you for supporting Sara’s Festschrift and honoring me with a dedicated issue in PTJ, focused on gait. The oral presentations at the “Stepping Forward With Gait Rehabilitation” PTJ symposium sponsored by APTA’s Neurology Section at the Combined Sections Meeting in San Diego were great. It was a wonderful display of the tremendous progress physical therapists have made, both professionally and personally. I also want to thank Dr Craik for her leadership as editor in chief of PTJ. Jacquelin Perry J. Perry, MD, ScD(Hon), is Professor Emeritus, Department of Orthopaedics, University of Southern California Keck School of Medicine. [DOI: 10.2522/ptj.2010.90.5.825.1]

Correction The Bottom Line for Young IA, Michener LA, Cleland JA, et al. “Manual Therapy, Exercise, and Traction for Patients With Cervical Radiculopathy…” (July 2009;89:628–629.) In the “Who participated in this study” section of the Bottom Line, one of the 4 criteria in the clinical prediction rule for patients with cervical radiculopathy—ipsilateral neck rotation <65°—was incorrect. This should read “ipsilateral neck rotation <60°”. The Journal regrets the error. [DOI: 10.2522/ptj.2010.90.5.825.2]

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Letters to the Editor

On “Effect of intensive outpatient physical training on gait performance and cardiovascular health...” Jørgensen JR, Bech-Pedersen DT, Zeeman P, et al. Phys Ther. 2010;90:527– 537. The effectiveness of gait training using body-weight support on a treadmill (BWST) compared with conventional gait training for people with subacute stroke who were unable to walk has been demonstrated in many experiments. At the present time, in continental Europe, BWST usually is considered as effective as conventional gait training. The study by Jørgensen et al1 suggested potential benefits of BWST for cardiovascular markers and other gait performance measures such as walking speed. Apart from the small study size, the main confounders that may have biased the study results are: (1) absence of any measure of premorbid disability (eg, Rankin Scale) in the

inclusion criteria; (2) lack of an assessment of poststroke disability (eg, Functional Independence Measure scores), which is a vital parameter in understanding the reproducibility of the experiment; and (3) a stratification for cardiovascular risk factors (CHADS2 scores often are suggested) to adjust the cardiovascular status with baseline cardiac characteristics.

makes the use of robotic-assisted systems more promising.

At the present time, findings from research do not agree on intensity, frequency, and duration of gait training using BWST.2 Because no control group without gait training was used, it is difficult to evaluate the role of spontaneous recovery of the gait. This study supports the hypothesis that gait training using BWST is a feasible and safe treatment for people with chronic stroke. However, this study did not demonstrate any clear superiority of gait training using BWST compared with conventional treatments. Furthermore, the need for a large number of therapists to administer gait training using BWST

M. Zampolini, MD, Brain Injury Unit, St. Giovanni Battista Hospital.

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Francesco Corea, Mauro Zampolini

Federico

Scarponi,

F. Corea, MD, PhD, Brain Injury Unit, St. Giovanni Battista Hospital, Foligno, Italy. Address all correspondence to Dr Corea at: [email protected]. F. Scarponi, MD, Brain Injury Unit, St. Giovanni Battista Hospital.

This letter was posted as a Rapid Response on March 16, 2010, at ptjournal.apta.org.

References 1 Jørgensen JR, Bech-Pedersen DT, Zeeman P, et al. Effect of outpatient intensive physical training on gait performance and cardiovascular health in people with hemiparesis after stroke. Phys Ther. 2010;90:527–537. 2 Franceschini M, Carda S, Agosti M, et al; Gruppo Italiano Studio Allevio Carico Ictus. Walking after stroke: what does treadmill training with body weight support add to overground gait training in patients early after stroke? A single-blind, randomized, controlled trial. Stroke. 2009;40:3079–3085. [DOI: 10.2522/ptj.2010.90.5.826]

May 2010

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Scholarships, Fellowships, and Grants News from the Foundation for Physical Therapy Current Funding Opportunities The Foundation for Physical Therapy is now accepting applications for the Kendall Scholarship and Research Grant programs! Students beginning their doctoral programs are encouraged to apply to win one of the $5,000 Kendall Scholarships. The Foundation also awards $40,000 Research Grants to emerging investigators to help them establish a track record of funding. For details on these 2 exciting opportunities, please visit the Foundation’s Web site at www. FoundationforPhysicalTherapy. org and click on “Grants, Fellowships & Scholarships.”

The Foundation for Physical Therapy Welcomes a New Member to the Scientific Review Committee Rose Marie Rine, PT, PhD (Figure), is 1 of 3 new members who will begin serving on the Scientific Review Committee (SRC) this year. The SRC is a dediFigure. New SRC member Rose Marie cated committee of volunteers Rine, PT, PhD. with extensive research experience that reviews applications for the grants, scholarships, and fellowships awarded by the Foundation each year. A native of Shrewsbury, Massachusetts, Rine is a Research Professor at the University of North Florida in Jacksonville, Florida, and also works as a private consultant for pediatric vestibular rehabilitation.

Rine’s research interests include the effect of vestibular deficits on development (motor development, balance, visual acuity, reading, and cognition) and the efficacy of interventions to address the related impairments. Rine previously received Foundation funding with the 2000 Pediatric Section Research Grant for her research project, “Examination of the Effect of Exercise on Motor Development in Children with Hearing Loss.” Joining the SRC was Rine’s way of giving back to the Foundation for supporting her in the early stages of her research career. “It’s important to give back and help others develop their research interests,” she said. “This is also another way to contribute to the profession that I have thoroughly enjoyed for over 30 years. I want to be of assistance to the Foundation in moving physical therapy research and future researchers forward.” Would you like to make an impact on the future of physical therapy research? Visit the Foundation’s “Grants, Fellowships & Scholarships” page online to view the criteria for SRC membership.

22nd Annual Foundation Split Raffle Did you know that funds raised through the Foundation’s Annual Split Raffle support doctoral scholarships for today’s emerging physical therapist researchers? The purchase of a split raffle ticket serves as an investment in the strength and future of the physical therapy profession with a chance to win 1 of 9 $2,000 prizes or the $10,000 grand prize. Contact Barbara Malm for more information

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on how to participate, or visit the Foundation’s Web site for complete rules.

Recent Publications by Foundation-Funded Researchers “The Architectural Design of the Gluteal Muscle Group: Implications for Movement and Rehabilitation,” by Ward SR, Winters TM, and Blemker SS, was published in the Journal of Orthopaedic & Sports Physical Therapy (2010;40[2]:95– 102). Sam Ward, PT, PhD, received a 1998 Kendall Scholarship, a 2001 Promotion of Doctoral Studies (PODS) I Scholarship, and a 2002 PODS II Scholarship. “Comparative Effectiveness Research: Opportunities and Challenges for Physical Therapy,” by Freburger JK and Carey TS, was published in Physical Therapy (2010;90[3]:327–332). Janet Freburger, PT, PhD, received a 2003 Research Grant. “Sex Differences in Fatigue Resistance Are Muscle Group Dependent,” by Avin KG, Naughton MR, Ford BW, Moore HE, MonittoWebber MN, Stark AM, Gentile AJ, and Frey Law LA, was published online in Medicine & Science in Sports & Exercise on February 26, 2010. Keith Avin, PT, DPT, received a 2006 McMillan Scholarship, 2008 Kendall Scholarship, and a 2009 PODS I. Laura Frey Law, PT, PhD, was awarded a 2000 McMillan Scholarship, a 2001 PODS I Scholarship, and a 2002 PODS II Scholarship.

May 2010

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Scholarships, Fellowships, and Grants “Somatosensory-Evoked Cortical Activity in Spastic Diplegic Cerebral Palsy,” by Wingert JR, Sinclair RJ, Dixit S, Damiano DL, and Burton H, was published online in Human Brain Mapping on March 4, 2010. Jason Wingert, PT, MPT, received a 2003 PODS I Scholarship and PODS II Scholarships in 2005 and 2006. Diane Damiano, PT, PhD, previously served on the Foundation’s Scientific Review Committee.

“Community-Based Disability Prevention Programs for Elders: Predictors of Program Completion,” by Dossa A and Capitman JA, was published in the Journal of Gerontological Social Work (2010;53[3]:235– 250). Almas Dossa was the recipient of a 2000 McMillan Scholarship, a 2001 PODS I Scholarship, and a 2004 PODS II Scholarship.

Do You Have News You Would Like to Share? If you would like to include any announcements in the Foundation’s section, contact our communications assistant at abegailmatienzo@ apta.org. [DOI: 10.2522/ptj.2010.90.5.828]

Don’t Miss These Foundation Events Rock Out PT-Style at Manipalooza! Mark your calendars: support the Foundation by attending the Dick Erhard Tribute on Saturday, May 22, 8:00 am–12:00 pm at the University of Colorado Denver Anschutz Medical Campus, Education 2 South Building off East 19th Avenue. This event is cosponsored by the University of Colorado Denver, Regis University physical therapy students, and Evidence in Motion. See the flyer at www.manipalooza.com for details.

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Save the Date for PT 2010 Break out your zoot suits and flapper dresses! The Foundation is taking you back to the 1920s at their annual gala, “Puttin’ on the Ritz,” on Thursday, June 17, 2010, during APTA’s Annual Conference in Boston. Visit the Foundation’s Web site to purchase your tickets today.

Win a Trip to Hawaii! The Foundation is sponsoring the “Aloha Getaway” Sweepstakes, where you could win a trip for 2 to Hawaii valued at $4,000! Every $10

donation to the Foundation will receive 1 entry into the drawing, and a $40 donation receives 5 entries. Enter online at the Foundation’s Web site. No Purchase Necessary to Enter or Win: The “Aloha Getaway” Sweepstakes is open to all legal residents of the United States, age 18 years or older as of January 22, 2010. Sweepstakes entry ends on June 25, 2010. The staffs of the Foundation and APTA are not eligible to participate. View the complete Official Rules, which govern the Sweepstakes, at the Foundation’s Web site. Void where prohibited.

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