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Showing papers in "Physical Therapy in 2001"


Journal ArticleDOI
TL;DR: The validity of a global rating of change as a reflection of meaningful change in patient status was supported by the stability of the Physical Impairment Index across the study period in patients defined as stable by the global rating and by the decrease in physical impairment across thestudy period.
Abstract: Background and Purpose. The quality of a disability scale should dictate when it is used. The purposes of this study were to examine the validity of a global rating of change as a reflection of meaningful change in patient status and to compare the measurement properties of a modified Oswestry Low Back Pain Disability Questionnaire (OSW) and the Quebec Back Pain Disability Scale (QUE). Subjects. Sixty-seven patients with acute, work-related low back pain referred for physical therapy participated in the study. Methods. The 2 scales were administered initially and after 4 weeks of physical therapy. The Physical Impairment Index, a measure of physical impairment due to low back pain, was measured initially and after 2 and 4 weeks. A global rating of change survey instrument was completed by each subject after 4 weeks. Results. An interaction existed between patients defined as improved or stable based on the global rating using a 2-way analysis of variance for repeated measures on the impairment index. The modified OSW showed higher levels of test-retest reliability and responsiveness compared with the QUE. The minimum clinically important difference, defined as the amount of change that best distinguishes between patients who have improved and those remaining stable, was approximately 6 points for the modified OSW and approximately 15 points for the QUE. Conclusion and Discussion. The construct validity of the global rating of change was supported by the stability of the Physical Impairment Index across the study period in patients defined as stable by the global rating and by the decrease in physical impairment across the study period in patients defined as improved by the global rating. The modified OSW demonstrated superior measurement properties compared with the QUE.

911 citations


Journal ArticleDOI
TL;DR: Retest reliability and interrater reliability of the TUG measurements were high, and the measurements reflected changes in performance according to levodopa use.
Abstract: Background and Purpose. The Timed “Up & Go” Test (TUG) is used to measure the ability of patients to perform sequential locomotor tasks that incorporate walking and turning. This study investigated the retest reliability, interrater reliability, and sensitivity of TUG scores in detecting changes in mobility in subjects with idiopathic Parkinson disease (PD). Subjects. The performance of 12 people with PD was compared with that of 12 age-matched comparison subjects without PD. Methods. The subjects with PD completed 5 trials of the TUG after withdrawal of levodopa for 12 hours (“off” phase of the medication cycle) as well as an additional 5 trials 1 hour after levodopa was administered (“on” phase of the medication cycle). They were scored on the Modified Webster Scale at both sessions. The comparison subjects also performed 5 TUG trials. All trials were videotaped and timed by 2 experienced raters. The videotape was later rated by 3 experienced clinicians and 3 inexperienced clinicians. Results. For the subjects with PD, within-session performance was highly consistent, with correlations ( r ) ranging from .80 to .98 for the “off” phase and from .73 to .99 for the “on” phase. The performance of the comparison subjects across the 5 trials was also highly consistent ( r =.90–.97). Comparisons showed differences between trials 1 and 2 on the TUG for both groups. Removal of data for trial 1 (the practice trial) further enhanced retest reliability. There was close agreement in TUG scores among raters despite different levels of experience (intraclass correlation coefficient [3,1]=.87–.99). Mean TUG scores were different between the “on” and “off” phases of the levodopa cycle and between subjects with PD and comparison subjects during the “on” phase. Conclusion and Discussion. Retest reliability and interrater reliability of the TUG measurements were high, and the measurements reflected changes in performance according to levodopa use. The TUG can also be used to detect differences in performance between people with PD and elderly people without PD.

603 citations



Journal ArticleDOI
TL;DR: It is revealed that there is currently insufficient biophysical evidence to provide a scientific foundation for the clinical use of therapeutic ultrasound for the treatment of people with pain and soft tissue injury.
Abstract: Almost 2 decades ago, it was pointed out that physical therapists tended to overlook the tenuous nature of the scientific basis for the use of therapeutic ultrasound. The purpose of this review is to examine the literature regarding the biophysical effects of therapeutic ultrasound to determine whether these effects may be considered sufficient to provide a reason (biological rationale) for the use of insonation for the treatment of people with pain and soft tissue injury. This review does not discuss articles that examined the clinical usefulness of ultrasound (see article by Robertson and Baker titled “A Review of Therapeutic Ultrasound: Effectiveness Studies” in this issue). The frequently described biophysical effects of ultrasound either do not occur in vivo under therapeutic conditions or have not been proven to have a clinical effect under these conditions. This review reveals that there is currently insufficient biophysical evidence to provide a scientific foundation for the clinical use of therapeutic ultrasound for the treatment of people with pain and soft tissue injury.

540 citations


Journal ArticleDOI
TL;DR: This methodology of developing EBCPGs provides a structured approach to assessing the literature and developing guidelines that incorporates clinicians' feedback and is widely acceptable to practicing clinicians.
Abstract: Introduction. A structured and rigorous methodology was developed for the formulation of evidence-based clinical practice guidelines (EBCPGs), then was used to develop EBCPGs for selected rehabilitation interventions for the management of low back pain. Methods. Evidence from randomized controlled trials (RCTs) and observational studies was identified and synthesized using methods defined by the Cochrane Collaboration that minimize bias by using a systematic approach to literature search, study selection, data extraction, and data synthesis. Meta-analysis was conducted where possible. The strength of evidence was graded as level I for RCTs or level II for nonrandomized studies. Developing Recommendations. An expert panel was formed by inviting stakeholder professional organizations to nominate a representative. This panel developed a set of criteria for grading the strength of both the evidence and the recommendation. The panel decided that evidence of clinically important benefit (defined as 15% greater relative to a control based on panel expertise and empiric results) in patient-important outcomes was required for a recommendation. Statistical significance was also required, but was insufficient alone. Patient-important outcomes were decided by consensus as being pain, function, patient global assessment, quality of life, and return to work, providing that these outcomes were assessed with a scale for which measurement reliability and validity have been established. Validating the Recommendations. A feedback survey questionnaire was sent to 324 practitioners from 6 professional organizations. The response rate was 51%. Results. Four positive recommendations of clinical benefit were developed. Therapeutic exercises were found to be beneficial for chronic, subacute, and postsurgery low back pain. Continuation of normal activities was the only intervention with beneficial effects for acute low back pain. These recommendations were mainly in agreement with previous EBCPGs, although some were not covered by other EBCPGs. There was wide agreement with these recommendations from practitioners (greater than 85%). For several interventions and indications (eg, thermotherapy, therapeutic ultrasound, massage, electrical stimulation), there was a lack of evidence regarding efficacy. Conclusions. This methodology of developing EBCPGs provides a structured approach to assessing the literature and developing guidelines that incorporates clinicians' feedback and is widely acceptable to practicing clinicians. Further well-designed RCTs are warranted regarding the use of several interventions for patients with low back pain where evidence was insufficient to make recommendations.

524 citations


Journal ArticleDOI
TL;DR: Children in the functional physical therapy group improved more than children in a reference group whose physical therapy was based on the principle of normalization of the quality of movement when examining functional skills in daily situations.
Abstract: Background and Purpose. The purpose of this study was to determine whether the motor abilities of children with spastic cerebral palsy who were receiving functional physical therapy (physical therapy with an emphasis on practicing functional activities) improved more than the motor abilities of children in a reference group whose physical therapy was based on the principle of normalization of the quality of movement. Subjects. The subjects were 55 children with mild or moderate cerebral palsy aged 2 to 7 years (median=55 months). Methods. A randomized block design was used to assign the children to the 2 groups. After a pretest, the physical therapists for the functional physical therapy group received training in the systematic application of functional physical therapy. There were 3 follow-up assessments: 6, 12, and 18 months after the pretest. Both basic gross motor abilities and motor abilities in daily situations were studied, using the Gross Motor Function Measure (GMFM) and the self-care and mobility domains of the Pediatric Evaluation of Disability Inventory (PEDI), respectively. Results. Both groups had improved GMFM and PEDI scores after treatment. No time × group interactions were found on the GMFM. For the PEDI, time × group interactions were found for the functional skills and caregiver assistance scales in both the self-care and mobility domains. Discussion and Conclusion. The groups' improvements in basic gross motor abilities, as measured by the GMFM in a standardized environment, did not differ. When examining functional skills in daily situations, as measured by the PEDI, children in the functional physical therapy group improved more than children in the reference group.

442 citations


Journal ArticleDOI
TL;DR: There was little evidence that active therapeutic ultrasound is more effective than placebo ultrasound for treating people with pain or a range of musculoskeletal injuries or for promoting soft tissue healing.
Abstract: Background and Purpose. Therapeutic ultrasound is one of the most widely and frequently used electrophysical agents. Despite over 60 years of clinical use, the effectiveness of ultrasound for treating people with pain, musculoskeletal injuries, and soft tissue lesions remains questionable. This article presents a systematic review of randomized controlled trials (RCTs) in which ultrasound was used to treat people with those conditions. Each trial was designed to investigate the contributions of active and placebo ultrasound to the patient outcomes measured. Depending on the condition, ultrasound (active and placebo) was used alone or in conjunction with other interventions in a manner designed to identify its contribution and distinguish it from those of other interventions. Methods. Thirty-five English-language RCTs were published between 1975 and 1999. Each RCT identified was scrutinized for patient outcomes and methodological adequacy. Results. Ten of the 35 RCTs were judged to have acceptable methods using criteria based on those developed by Sackett et al. Of these RCTs, the results of 2 trials suggest that therapeutic ultrasound is more effective in treating some clinical problems (carpal tunnel syndrome and calcific tendinitis of the shoulder) than placebo ultrasound, and the results of 8 trials suggest that it is not. Discussion and Conclusion. There was little evidence that active therapeutic ultrasound is more effective than placebo ultrasound for treating people with pain or a range of musculoskeletal injuries or for promoting soft tissue healing. The few studies deemed to have adequate methods examined a wide range of patient problems. The dosages used in these studies varied considerably, often for no discernable reason.

403 citations


Journal ArticleDOI
TL;DR: The objective of this update is to provide the basic knowledge necessary to read and interpret research on human skeletal muscle to understand the muscle fiber classification techniques.
Abstract: Human skeletal muscle is composed of a heterogenous collection of muscle fiber types.1–3 This range of muscle fiber types allows for the wide variety of capabilities that human muscles display. In addition, muscle fibers can adapt to changing demands by changing size or fiber type composition. This plasticity serves as the physiologic basis for numerous physical therapy interventions designed to increase a patient's force development or endurance. Changes in fiber type composition also may be partially responsible for some of the impairments and disabilities seen in patients who are deconditioned because of prolonged inactivity, limb immobilization, or muscle denervation.2 Over the past several decades, the number of techniques available for classifying muscle fibers has increased, resulting in several classification systems. The objective of this update is to provide the basic knowledge necessary to read and interpret research on human skeletal muscle. Muscle fiber types can be described using histochemical, biochemical, morphological, or physiologic characteristics; however, classifications of muscle fibers by different techniques do not always agree.1 Therefore, muscle fibers that may be grouped together by one classification technique may be placed in different categories using a different classification technique. A basic understanding of muscle structure and physiology is necessary to understand the muscle fiber classification techniques. Muscle fibers are composed of functional units called sarcomeres.3 Within each sarcomere are the myofibrillar proteins myosin (the thick filament) and actin (the thin filament). The interaction of these 2 myofibrillar proteins allows muscles to contract (Fig. 1).4 Several classification techniques differentiate fibers based on different myosin structures (isoforms) or physiologic capabilities.1,2,5 The myosin molecule is composed of 6 polypeptides: 2 heavy chains and 4 light chains (2 regulatory and 2 alkali). A regulatory and an alkali light chain are associated …

376 citations


Journal ArticleDOI
TL;DR: Although both groups demonstrated improvement following 4 weeks of physical therapy interventions, no additional effects were found in the group that received visual biofeedback/forceplate training combined with other physical therapy.
Abstract: Background and Purpose. Visual biofeedback/forceplate systems are often used for treatment of balance disorders. In this study, the researchers investigated whether the addition of visual biofeedback/forceplate training could enhance the effects of other physical therapy interventions on balance and mobility following stroke. Subjects. The study included a sample of convenience of 13 outpatients with hemiplegia who ranged in age from 30 to 77 years (X=60.4, SD=15.4) and were 15 to 538 days poststroke. Methods. Subjects were assigned randomly to either an experimental group or a control group when the study began, and their cognitive and visual-perceptual skills were tested by a psychologist. Subjects were also assessed using the Berg Balance Scale and the Timed “Up & Go” Test before and after 4 weeks of physical therapy. Both groups received physical therapy interventions designed to improve balance and mobility 2 to 3 times per week. The experimental group trained on the NeuroCom Balance Master for 15 minutes of each 50-minute treatment session. The control group received other physical therapy for 50 minutes. Results. Following intervention, both groups scored higher on the Berg Balance Scale and required less time to perform the Timed “Up & Go” Test. These improvements corresponded to increased independence of balance and mobility in the study population. However, a comparison of mean changes revealed no differences between groups. Discussion and Conclusion. Although both groups demonstrated improvement following 4 weeks of physical therapy interventions, no additional effects were found in the group that received visual biofeedback/forceplate training combined with other physical therapy.

331 citations


Journal ArticleDOI
TL;DR: Longer hold times during stretching of the hamstring muscles resulted in a greater rate of gains in ROM and a more sustained increase in ROM in elderly subjects, and may differ from those of studies performed with younger populations because of age-related physiologic changes.
Abstract: Background and Purpose. Stretching protocols for elderly people (≥65 years of age) have not been studied to determine the effectiveness of increasing range of motion (ROM). The purpose of this study was to determine which of 3 durations of stretches would produce and maintain the greatest gains in knee extension ROM with the femur held at 90 degrees of hip flexion in a group of elderly individuals. Subjects. Sixty-two subjects (mean age=84.7 years, SD=5.6, range= 65–97) with tight hamstring muscles (defined as the inability to extend the knee to less than 20° of knee flexion) participated. Subjects were recruited from a retirement housing complex and were independent in activities of daily living. Methods. Subjects were randomly assigned to 1 of 4 groups and completed a physical activity questionnaire. The subjects in group 1 (n=13, mean age=85.1 years, SD=6.4, range=70–97), a control group, performed no stretching. The randomly selected right or left limb of subjects in group 2 (n=17, mean age=85.5 years, SD=4.5, range=80–93), group 3 (n=15, mean age=85.2 years, SD=6.5, range=65–92), and group 4 (n=17, mean age=83.2 years, SD=4.6, range=68–90) was stretched 5 times per week for 6 weeks for 15, 30, and 60 seconds, respectively. Range of motion was measured once a week for 10 weeks to determine the treatment and residual effects. Data were analyzed using a growth curve model. Results. A 60-second stretch produced a greater rate of gains in ROM (60-second stretch=2.4° per week, 30-second stretch=1.3° per week, 15-second stretch=0.6° per week), which persisted longer than the gains in any other group (group 4 still had 5.4° more ROM 4 weeks after treatment than at pretest as compared with 0.7° and 0.8° for groups 2 and 3, respectively). Discussion and Conclusion. Longer hold times during stretching of the hamstring muscles resulted in a greater rate of gains in ROM and a more sustained increase in ROM in elderly subjects. These results may differ from those of studies performed with younger populations because of age-related physiologic changes.

299 citations


Journal ArticleDOI
TL;DR: Addition of a talocrural mobilization to the RICE protocol in the management of ankle inversion injuries necessitated fewer treatments to achieve pain-free dorsiflexion and to improve stride speed more than RICE alone.
Abstract: Background and Purpose. Passive joint mobilization is commonly used by physical therapists as an intervention for acute ankle inversion sprains. A randomized controlled trial with blinded assessors was conducted to investigate the effect of a specific joint mobilization, the anteroposterior glide on the talus, on increasing pain-free dorsiflexion and 3 gait variables: stride speed (gait speed), step length, and single support time. Subjects. Forty-one subjects with acute ankle inversion sprains (<72 hours) and no other injury to the lower limb entered the trial. Methods. Subjects were randomly assigned to 1 of 2 treatment groups. The control group received a protocol of rest, ice, compression, and elevation (RICE). The experimental group received the anteroposterior mobilization, using a force that avoided incurring any increase in pain, in addition to the RICE protocol. Subjects in both groups were treated every second day for a maximum of 2 weeks or until the discharge criteria were met, and all subjects were given a home program of continued RICE application. Outcomes were measured before and after each treatment. Results. The results showed that the experimental group required fewer treatment sessions than the control group to achieve full pain-free dorsiflexion. The experimental group had greater improvement in range of movement before and after each of the first 3 treatment sessions. The experimental group also had greater increases in stride speed during the first and third treatment sessions. Discussion and Conclusion. Addition of a talocrural mobilization to the RICE protocol in the management of ankle inversion injuries necessitated fewer treatments to achieve pain-free dorsiflexion and to improve stride speed more than RICE alone. Improvement in step length symmetry and single support time was similar in both groups.

Journal ArticleDOI
TL;DR: An evidence-based perspective on the diagnostic process in physical therapy is presented and issues relevant to the appraisal of evidence regarding diagnostic tests and integration of the evidence into patient management are presented.
Abstract: Diagnosis is an important aspect of physical therapist practice. Selecting tests that will provide the most accurate information and evaluating the results appropriately are important clinical skills. Most of the discussion in physical therapy to date has centered on defining diagnosis, with considerably less attention paid to elucidating the diagnostic process. Determining the best diagnostic tests for use in clinical situations requires an ability to appraise evidence in the literature that describes the accuracy and interpretation of the results of testing. Important issues for judging studies of diagnostic tests are not widely disseminated or adhered to in the literature. Lack of awareness of these issues may lead to misinterpretation of the results. The application of evidence to clinical practice also requires an understanding of evidence and its use in decision making. The purpose of this article is to present an evidence-based perspective on the diagnostic process in physical therapy. Issues relevant to the appraisal of evidence regarding diagnostic tests and integration of the evidence into patient management are presented.

Journal ArticleDOI
TL;DR: Mental practice may complement physical therapy to improve motor function after stroke and reduction in impairment (Fugl-Meyer Scale) and improvement in arm function, as measured by the ARA and STREAM.
Abstract: Background and Purpose . This case report describes a patient with upper-limb hemiparesis (ULH) who received a program combining physical therapy for the affected side with mental practice. Case Description . The patient was a 56-year-old man with stable motor deficits, including ULH, on his dominant side resulting from a right parietal infarct that occurred 5 months previously. He received physical therapy for an hour 3 times a week for 6 weeks. In addition, 2 times a week the patient listened to an audiotape instructing him to imagine himself functionally using the affected limb. The patient also listened to the audiotape at home 2 times a week. Pretreatment and posttreatment measures were the upper-extremity scale of the Fugl-Meyer Assessment of Sensorimotor Impairment (Fugl-Meyer Scale), the Action Research Arm Test (ARA), and the Stroke Rehabilitation Assessment of Movement (STREAM). Outcomes . The patient exhibited reduction in impairment (Fugl-Meyer Scale) and improvement in arm function, as measured by the ARA and STREAM. Discussion . Mental practice may complement physical therapy to improve motor function after stroke.

Journal ArticleDOI
TL;DR: Among the modalities tested, the use of ultrasound for 7 minutes prior to stretching may be the most effective for increasing ankle dorsiflexion ROM.
Abstract: Background and Purpose. Warm-up prior to static stretching enhances muscle extensibility. The relative effectiveness of different modes of warm-up, however, is unknown. The purpose of this study was to evaluate the effectiveness of superficial heat, deep heat, and active exercise warm-up prior to stretching compared with stretching alone on the extensibility of the plantar-flexor muscles. Subjects. Ninety-seven subjects (59 women, 38 men) with limited dorsiflexion range of motion (ROM) were randomly assigned to 1 of 5 groups. Female subjects had a mean age of 27.6 years (SD=7.68, range=17–50), and male subjects had a mean age of 26.8 years (SD=6.87, range=18–48). Methods. The first group (group 1) was a control group and did not perform the stretching protocol. The 4 experimental groups (groups 2–5) performed a stretching protocol 3 days per week for 6 weeks. Group 2 performed the static stretching protocol only; group 3 performed active heel raises before stretching; group 4 received 15 minutes of superficial, moist heat to the plantar-flexor muscles before stretching; and group 5 received continuous ultrasound for 7 minutes before stretching. Dorsiflexion ROM measurements were taken initially and after 2, 4, and 6 weeks. Results. All experimental groups increased active and passive range of motion (AROM and PROM). The mean AROM/PROM differences at 6 weeks were 1.11/1.39 degrees for group 1, 4.10/6.11 degrees for group 2, 4.16/4.21 degrees for group 3, 4.38/4.90 degrees for group 4, and 6.20/7.35 degrees for group 5. The group receiving ultrasound before performing the stretching protocol (group 5) displayed the greatest increase in both AROM (6.20°) and PROM (7.35°). Discussion and Conclusion. Among the modalities tested, the use of ultrasound for 7 minutes prior to stretching may be the most effective for increasing ankle dorsiflexion ROM.

Journal ArticleDOI
TL;DR: Central activation of the quadriceps femoris muscle in elderly subjects was reduced in both the fatigued and nonfatigued states when compared with young subjects, suggesting that some part of age-related weakness may be attributed to failure of central activation inboth the fatiguing and nonFatiguedStates.
Abstract: APTA is a sponsor of the Decade, an international, multidisciplinary initiative to improve health-related quality of life for people with musculoskeletal disorders. Background and Purpose. Researchers studying central activation of muscles in elderly subjects ($65 years of age) have investigated activation in only the nonfatigued state. This study examined the ability of young and elderly people to activate their quadriceps femoris muscles voluntarily under both fatigued and nonfatigued conditions to determine the effect of central activation failure on age-related loss of force. Subjects and Methods. Twenty young subjects (11 men, 9 women; mean age522.67 years, SD54.14, range518 ‐32 years) and 17 elderly subjects (8 men, 9 women; mean age571.5 years, SD55.85, range565‐ 84 years) participated in this study. Subjects were seated on a dynamometer and stabilized. Central activation was quantified, based on the change in force produced by a 100-Hz, 12-pulse electrical train that was delivered during a 3- to 5-second isometric maximum voluntary contraction (MVC) of the quadriceps femoris muscle. Next, subjects performed 25 MVCs (a 5-second contraction with 2 seconds of rest) to fatigue the muscle. During the last MVC, central activation was measured again. Results. In the nonfatigued state, elderly subjects had lower central activation than younger subjects. In the fatigued state, this difference became larger. Discussion and Conclusion. Central activation of the quadriceps femoris muscle in elderly subjects was reduced in both the fatigued and nonfatigued states when compared with young subjects. Some part of age-related weakness, therefore, may be attributed to failure of central activation in both the fatigued and nonfatigued states. [Stackhouse SK, Stevens JE, Lee SCK, et al. Maximum voluntary activation in nonfatigued and fatigued muscle of young and elderly individuals. Phys Ther. 2001;81:1102‐1109.]

Journal ArticleDOI
TL;DR: Examination of physical therapists' reported management of acute and subacute lumbar impairment found patient education, exercise, and electrotherapeutic and thermal modalities were the preferred interventions, whereas exercise and work modification were preferred for subacuteness.
Abstract: Background and Purpose. Since the release of acute low back pain management guidelines in 1994, little was known about the effect of these guidelines on clinical practice. The purpose of this study was to examine physical therapists' reported management of acute and subacute lumbar impairment. Subjects. One in 10 registered physical therapists who were randomly selected from southern Ontario, Canada, (n=454) and all registered physical therapists from northern Ontario (n=331) were surveyed. Methods. In the questionnaire, case scenarios covered 3 areas related to the management of lumbar impairment: (1) physical examination, (2) treatment and recommendations, and (3) therapists' beliefs regarding its management. Results. Five hundred sixty-nine questionnaires were returned (response rate=72.5%). Only data obtained for therapists (n=274) whose weekly workload included more than 10% of people with lumbar impairment were used in the analysis. Overall, patient education, exercise, and electrotherapeutic and thermal modalities were the preferred interventions for acute lumbar impairment (symptom onset of less than 5 weeks) with or without sciatica, whereas exercise and work modification were preferred for subacute lumbar impairment (symptom onset of 5 weeks or longer). There was a trend of using electrotherapeutic and thermal modalities of uncertain effectiveness. Only 46.3% of the therapists agreed or strongly agreed that practice guidelines were useful for managing lumbar impairment. Discussion and Conclusion. Although the physical therapists surveyed, in general, followed the guidelines in managing acute lumbar impairment, they felt uncertain regarding the value of practice guidelines. Future research should focus on identifying effective treatment approaches and exploring the effectiveness of practice guidelines.

Journal ArticleDOI
TL;DR: Although they did better in the active learning environment, physical therapist students in a basic sciences course (physiology) in the first year of their professional program perceived that they had learned less in active learning courses.
Abstract: Background and Purpose. Self-directed learning is believed to be an important aspect of the reflective clinical practitioner. This study was a comparison of student learning and student perceptions of course and instructor effectiveness, course difficulty, and amount learned between the active learning and lecture sections of a course. Subjects. Participants in this study were 170 physical therapist students in 3 sections of a physiology course in the first year of their professional program. Methods. Course grades and the results of teacher-course evaluations were compared between a lecture section and an active learning section. The students in the original active learning section were reassessed 1 year later to determine their perceptions of the course. The differences were analyzed using Kruskal-Wallis and Mann-Whitney U tests. Results. Course grades were higher in both active learning sections than in the lecture section. However, the students in both active learning sections perceived that they had learned less than students in the lecture section. Students' perceptions of course and instructor effectiveness were lower in the active learning sections than in the lecture section. There were no differences between the lecture and active learning sections on the students' perceptions of course difficulty. Conclusion and Discussion. Although they did better in the active learning environment, physical therapist students in a basic sciences course (physiology) in the first year of their professional program perceived that they had learned less in active learning courses. They also had lower perceptions of course and instructor quality.

Journal ArticleDOI
TL;DR: Whether therapists seek to involve patients in goal setting and, if so, what methods they use is examined and patient and therapist education is needed regarding methods for patient participation during initial goal-setting activities.
Abstract: Background and Purpose. An important part of treatment planning in physical therapy is effective goal setting. The Guide to Physical Therapist Practice recommends that therapists should identify the patient's goals and objectives during the initial examination in order to maximize outcomes. The purpose of this study was to examine whether therapists seek to involve patients in goal setting and, if so, what methods they use. Therapists' attitudes toward participation and patient satisfaction with the examination were also examined. Subjects and Methods. Twenty-two physical therapists audiotaped the initial examination of 73 elderly patients (X=76.4 years of age, SD=7.1, range=65–94). The audiotaped examinations were then scored using the Participation Method Assessment Instrument (PMAI) to determine the frequency of attempts made by therapists to involve patients in goal setting. Therapists and patients completed surveys following the examinations. Results. Therapists' use of participation methods during examinations ranged from a minimum of 1 to a maximum of 19 out of 21 possible items on the PMAI. The therapists stated that they believed that it is important to include patients in goal-setting activities and that outcomes will be improved if patients participate. Patients also indicated that participation is important to them. Discussion and Conclusion. In most cases, the therapists did not fully take advantage of the potential for patient participation in goal setting. Patient and therapist education is needed regarding methods for patient participation during initial goal-setting activities.

Journal ArticleDOI
TL;DR: Issues to consider when selecting measures of physical function for use with community-dwelling older adults over the age of 65 years are described.
Abstract: Often the goal of physical therapy is to reduce morbidity and prevent or delay loss of independence. The purpose of this article is to describe issues to consider when selecting measures of physical function for use with community-dwelling older adults over the age of 65 years. We chose 16 measures of physical function for review because they have been used in studies of community-dwelling older adults and some psychometric properties of reliability and validity have been described in the literature. Three major issues are discussed: (1) appropriateness of the measure for community-dwelling adults, (2) practical aspects of test administration, and (3) psychometric properties. These issues are illustrated using examples from the 16 measures. Two scenarios, applying the measures to the assessment of community-dwelling well older people and to the assessment of community-dwelling frail older people, are used to illustrate how this information can be used.

Journal ArticleDOI
TL;DR: The goal of this article is to review the potential cellular events that may occur when muscle fibers are stretched passively and the mechanisms that may result in myofibrillogenesis.
Abstract: To increase range of motion, physical therapists frequently use passive stretch as a means of gaining increased excursion around a joint. In addition to clinical studies showing effectiveness, thereby supporting evidence-based practice, the basic sciences can provide an explanation how a technique might work once a technique is known to be effective. The goal of this article is to review the potential cellular events that may occur when muscle fibers are stretched passively. A biomechanical example of passive stretch applied to the ankle is used to provide a means to discuss passive stretch at the cellular and molecular levels. The implications of passive stretch on muscle fibers and the related connective tissue are discussed with respect to tissue biomechanics. Emphasis is placed on structures that are potentially involved in the sensing and signal transduction of stretch, and the mechanisms that may result in myofibrillogenesis are explored.

Journal ArticleDOI
TL;DR: In this paper it is considered how the practice of significance testing emerged; an arbitrary division of results as “ significant” or “non-significant” (according to the commonly used threshold of P = 0.05) was not the intention of the founders of statistical inference.
Abstract: The findings of medical research are often met with considerable scepticism, even when they have apparently come from studies with sound methodologies that have been subjected to appropriate statistical analysis. This is perhaps particularly the case with respect to epidemiological findings that suggest that some aspect of everyday life is bad for people. Indeed, one recent popular history, the medical journalist James Le Fanu's The Rise and Fall of Modern Medicine , went so far as to suggest that the solution to medicine's ills would be the closure of all departments of epidemiology.1 One contributory factor is that the medical literature shows a strong tendency to accentuate the positive; positive outcomes are more likely to be reported than null results.2–4 By this means alone a host of purely chance findings will be published, as by conventional reasoning examining 20 associations will produce one result that is “significant at P = 0.05” by chance alone. If only positive findings are published then they may be mistakenly considered to be of importance rather than being the necessary chance results produced by the application of criteria for meaningfulness based on statistical significance. As many studies contain long questionnaires collecting information on hundreds of variables, and measure a wide range of potential outcomes, several false positive findings are virtually guaranteed. The high volume and often contradictory nature5 of medical research findings, however, is not only because of publication bias. A more fundamental problem is the widespread misunderstanding of the nature of statistical significance. In this paper we consider how the practice of significance testing emerged; an arbitrary division of results as “significant” or “non-significant” (according to the commonly used threshold of P = 0.05) was not the intention of the founders of statistical inference. P values need to be …

Journal ArticleDOI
TL;DR: These results do not support the premise that exercises with maximum efforts increase spasticity in people with cerebral palsy.
Abstract: Background and Purpose. The Bobath neurodevelopmental treatment approach advised against the use of resistive exercise, as proponents felt that increased effort would increase spasticity. The purpose of this study was to test the premise that the performance of exercises with maximum efforts will increase spasticity in people with cerebral palsy (CP). Spasticity, in the present study, was defined as a velocity-dependent hyperexcitability of the muscle stretch reflex. Subjects. Twenty-four subjects with the spastic diplegic form of CP (mean age=11.4 years, SD=3.0, range=7–17) and 12 subjects without known neurological impairments (mean age=11.6 years, SD=3.5, range= 7–17) were assessed. Methods. Knee muscle spasticity was assessed bilaterally using the pendulum test to elicit a stretch reflex immediately before and after 3 different forms of right quadriceps femoris muscle exercise (isometric, isotonic, and isokinetic) during a single bout of exercise training. Pendulum test outcome measures were: (1) first swing excursion, (2) number of lower leg oscillations, and (3) duration of the oscillations. Results. There were no changes in spasticity following exercise between the 2 groups of subjects. Discussion and Conclusion. These results do not support the premise that exercises with maximum efforts increase spasticity in people with CP.

Journal ArticleDOI
TL;DR: The results suggest that measurements ofScapular positioning based on the difference in side-to-side scapular distance measures are not reliable and that the LSST should not be used to identify people with and without shoulder dysfunction.
Abstract: Background and Purpose. The Lateral Scapular Slide Test (LSST) is used to determine scapular position with the arm abducted 0, 45, and 90 degrees in the coronal plane. Assessment of scapular position is based on the derived difference measurement of bilateral scapular distances. The purpose of this study was to assess the reliability of measurements obtained using the LSST and whether they could be used to identify people with and without shoulder impairments. Subjects. Forty-six subjects ranging in age from 18 to 65 years (X=30.0, SD=11.1) participated in this study. One group consisted of 20 subjects being treated for shoulder impairments, and one group consisted of 26 subjects without shoulder impairments. Methods. Two measurements in each test position were obtained bilaterally. From the bilateral measurements, we derived the difference measurement. Intraclass correlation coefficients (ICC [1,1]) and the standard error of measurement (SEM) were calculated for intrarater and interrater reliability of the difference in side-to-side measures of scapular distance. Sensitivity and specificity of the LSST for classifying subjects with and without shoulder impairments were also determined. Results. The ICCs for intrarater reliability were .75, .77, and .80 and .52, .66, and .62, respectively, for subjects without and with shoulder impairments in 0, 45, and 90 degrees of abduction. The ICCs for interrater reliability were .67, .43, and .74 and .79, .45, and .57, respectively, for subjects without and with shoulder impairments in 0, 45 and 90 degrees of abduction. The SEMs ranged from 0.57 to 0.86 cm for intrarater reliability and from 0.79 to 1.20 cm for interrater reliability. Using the criterion of greater than 1.0 cm difference, sensitivity and specificity were 35% and 48%, 41% and 54%, and 43% and 56%, respectively, for 0, 45, and 90 degrees of abduction. Sensitivity and specificity based on the criterion of greater than 1.5 cm difference were 28% and 53%, 50% and 58%, and 34% and 52%, respectively, for the 3 scapular positions. Conclusion and Discussion. Our results suggest that measurements of scapular positioning based on the difference in side-to-side scapular distance measures are not reliable. Furthermore, the results suggest that sensitivity and specificity of the LSST measurements are poor and that the LSST should not be used to identify people with and without shoulder dysfunction.

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TL;DR: These results contribute to the growing body of evidence demonstrating that spinal ROM is impaired early in PD.
Abstract: Background and Purpose . Evidence suggests that individuals with early and mid-stage Parkinson disease (PD) have diminished range of motion (ROM). Spinal ROM influences the ability to function. In this investigation, the authors examined available spinal ROM, segmental excursions (the ROM used) during reaching, and their relationships in community-dwelling adults with and without PD. Subjects . The subjects were 16 volunteers with PD (modified Hoehn and Yahr stages 1.5–3) and 32 participants without PD who were matched for age, body mass index, and sex. Methods . Range of motion of the extremities was measured using a goniometer, and ROM of the spine was measured using the functional axial rotation (FAR) test, a measure of unrestricted cervico-thoracic-lumbar rotation in the seated position. Motion during reaching was determined using 3-dimensional motion analysis. Group differences were determined using multivariable analysis of variance followed by analysis of variance. Contributions to total reaching distance of segmental excursions (eg, thoracic rotation, thoracic lateral flexion) were determined using forward stepwise regression. Results . Subjects with PD as compared with subjects without PD had less ROM (FAR of 98.2° versus 110.3°, shoulder flexion of 151.9° versus 160.1°) and less forward reaching (29.5 cm versus 34.0 cm). Lateral trunk flexion and total rotation relative to the ground contributed to reaching, with the regression model explaining 36% of the variance. Discussion and Conclusion . These results contribute to the growing body of evidence demonstrating that spinal ROM is impaired early in PD.

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TL;DR: A number of body systems and functions that may need to be investigated if clinical trials of prolonged standing in people with SCI are undertaken are identified.
Abstract: Background and Purpose . Prolonged standing in people with spinal cord injuries (SCIs) has the potential to affect a number of health-related areas such as reflex activity, joint range of motion, or well-being. The purpose of this study was to document the patterns of use of prolonged standing and their perceived effects in subjects with SCIs. Subjects . The subjects were 152 adults with SCIs (103 male, 49 female; mean age=34 years, SD=8, range=18–55) who returned mailed survey questionnaires. Methods . A 17-item self-report survey questionnaire was sent to the 463 members of a provincial spinal cord support organization. Results . Survey responses for 26 of the 152 respondents were eliminated from the analysis because they had minimal effects from their injuries and did not need prolonged standing as an extra activity. Of the 126 remaining respondents, 38 respondents (30%) reported that they engaged in prolonged standing for an average of 40 minutes per session, 3 to 4 times a week, as a method to improve or maintain their health. The perceived benefits included improvements in several health-related areas such as well-being, circulation, skin integrity, reflex activity, bowel and bladder function, digestion, sleep, pain, and fatigue. The most common reason that prevented the respondents from standing was the cost of equipment to enable standing. Discussion and Conclusion . Considering the many reported benefits of standing, this activity may be useful for people with SCI. This study identified a number of body systems and functions that may need to be investigated if clinical trials of prolonged standing in people with SCI are undertaken.

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TL;DR: This methodology of developing EBCPGs provides a structured approach to assessing the literature and developing E BCPGs that incorporates clinicians' feedback and is widely acceptable to practicing clinicians.
Abstract: Introduction. A structured and rigorous methodology was developed for the formulation of evidence-based clinical practice guidelines (EBCPGs), then was used to develop EBCPGs for selected rehabilitation interventions for the management of low back, neck, knee, and shoulder pain. Methods. Evidence from randomized controlled trials (RCTs) and observational studies was identified and synthesized using methods defined by the Cochrane Collaboration that minimize bias by using a systematic approach to literature search, study selection, data extraction, and data synthesis. Meta-analyses were conducted where possible. The strength of evidence was graded as level I for RCTs or level II for nonrandomized studies. Developing Recommendations. An expert panel was formed by inviting stakeholder professional organizations to nominate a representative. This panel developed a set of criteria for grading the strength of both the evidence and the recommendation. The panel decided that evidence of clinically important benefit (defined as 15% greater relative to a control based on panel expertise and empiric results) in patient-important outcomes was required for a recommendation. Statistical significance was also required but was insufficient alone. Patient-important outcomes were decided by consensus as being pain, function, patient global assessment, quality of life, and return to work, providing that these outcomes were assessed with a scale for which measurement reliability and validity have been established. Validating the Recommendations. A feedback survey questionnaire was sent to 324 practitioners from 6 professional organizations. The response rate was 51%. Results. Eight positive recommendations of clinical benefit were developed. These recommendations were mainly in agreement with previous EBCPGs, although some were not covered by other EBCPGs. There was wide agreement with these recommendations from practitioners (greater than 75% agreement). For several interventions and indications (eg, thermotherapy, therapeutic ultrasound, massage, electrical stimulation, mechanical traction), there was a lack of evidence regarding efficacy. Conclusions. This methodology of developing EBCPGs provides a structured approach to assessing the literature and developing EBCPGs that incorporates clinicians' feedback and is widely acceptable to practicing clinicians. Further well-designed RCTs are warranted regarding the use of several interventions where evidence was insufficient to make recommendations.

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TL;DR: When postoperative rehabilitation regimens that focus on early mobilization of the patient are used, adjunct ROM therapies that are added to daily SE sessions are not required.
Abstract: Background and Purpose. The primary purpose of this randomized controlled trial was to determine which method of mobilization—(1) standardized exercises (SE) and continuous passive motion (CPM), (2) SE and slider board (SB) therapy, using an inexpensive, nontechnical device that requires minimal knee active range of motion (ROM), or (3) SE alone—achieved the maximum degree of knee ROM in the first 6 months following primary total knee arthroplasty (TKA). The secondary purpose was to compare health-related quality of life among these 3 groups. Subjects. The subjects were 120 patients (n=40/group) who received a TKA at a teaching hospital between June 1997 and July 1998 and who agreed to participate in the study. Methods. Subjects were examined preoperatively, at discharge, and at 3 and 6 months after surgery. The examination consisted of measurement of knee ROM and completion of the Western Ontario and McMaster Universities (WOMAC) Osteoarthritis Index and the Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36). Results. The 3 treatment groups were similar with respect to age, sex, and diagnosis at the start of the study. There were no differences in knee ROM or in WOMAC Osteoarthritis Index or SF-36 scores at any of the measurement intervals. The rate of postoperative complications also was not different among the groups. Discussion and Conclusion. When postoperative rehabilitation regimens that focus on early mobilization of the patient are used, adjunct ROM therapies (CPM and SB) that are added to daily SE sessions are not required. Six months after TKA, patients attain a satisfactory level of knee ROM and function.

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TL;DR: A few straightforward questions exhibited excellent agreement with physical therapists' assessments for identifying at least moderate lymphedema, and the sensitivity of the questionnaire varied from 0.86 to 0.92 and specificity was 0.90; however, sensitivity was higher than specificity for the diagnosis of any lyMPhedema.
Abstract: Background and Purpose. Accurate and economical characterization of lymphedema is needed for population-based studies of incidence and risk. The purpose of this study was to develop and validate a telephone questionnaire for characterizing lymphedema. Subjects. Forty-three women who were treated previously for breast cancer and who were recruited from physical therapy practices and a cancer support organization were studied. Methods. Questionnaire assessment of the presence and degree of lymphedema was compared with physical therapists' diagnoses, based primarily on circumferential measurements. Twenty-five of the 43 subjects were measured independently by 2 physical therapists to assess interobserver agreement. Results. Interobserver agreement on clinical assessments of the presence and degree of lymphedema was high (20/25, weighted kappa=.80); all of the disagreements were between judgments of whether there was no lymphedema or mild lymphedema. For the diagnosis of at least moderate lymphedema (differential in the circumferences of the upper extremities greater than 2 cm), sensitivity of the questionnaire varied from 0.86 to 0.92 and specificity was 0.90. However, sensitivity (varying from 0.93 to 0.96) was higher than specificity (varying from 0.69 to 0.75) for the diagnosis of any lymphedema. Discussion and Conclusion. A few straightforward questions exhibited excellent agreement with physical therapists' assessments for identifying at least moderate lymphedema.

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TL;DR: Muscle torque and fatigue of electrically induced contractions depend on the waveform used to stimulate the contraction, with monophasic and biphasic waveforms having an advantage over the polyphasic waveform.
Abstract: Background and Purpose. Neuromuscular electrical stimulation is used by physical therapists to improve muscle performance. Optimal forms of stimulation settings are yet to be determined, as are possible sex-related differences in responsiveness to electrical stimulation. The objectives of the study were: (1) to compare the ability of 3 different waveforms to generate isometric contractions of the quadriceps femoris muscles of individuals without known impairments, (2) to compare muscle fatigue caused by repeated contractions induced by these same waveforms, and (3) to examine the effect of sex on muscle force production and fatigue induced by electrical stimulation. Subjects. Fifteen women and 15 men (mean age=29.5 years, SD=5.4, range=22–38) participated in the study. Methods. A portable battery-operated stimulator was used to generate either a monophasic or biphasic rectangular waveform. A stimulator that was plugged into an electrical outlet was used to generate a 2,500-Hz alternating current. Phase duration, frequency, and on-off ratios were kept identical for both stimulators. Participants did not know the type of waveform being used. Torque was measured using a computerized dynamometer: a maximal voluntary isometric contraction (MVIC) of the right quadriceps femoris muscle set at 60 degrees of knee flexion was determined during the first session. In each of the 3 testing sessions, torque of contraction and fatigue elicited by one waveform were measured. Order of testing was randomized. Torque elicited by electrical stimulation was expressed as a percentage of average MVIC. A mixed-model analysis of variance was used to determine the effect of stimulation and sex on strength of contraction and fatigue. Bonferroni-corrected post hoc tests were used to further distinguish between the effects of the 3 stimulus waveforms. Results. The results indicated that the monophasic and biphasic waveforms generated contractions with greater torque than the polyphasic waveform. These 2 waveforms also were less fatiguing. The torques from the maximally tolerated electrically elicited contractions were greater for the male subjects than for the female subjects. Discussion and Conclusion. Muscle torque and fatigue of electrically induced contractions depend on the waveform used to stimulate the contraction, with monophasic and biphasic waveforms having an advantage over the polyphasic waveform. All tested waveforms elicited, on average, stronger contractions in male subjects than in female subjects when measured as a percentage of MVIC.

Journal ArticleDOI
TL;DR: From the data obtained in this project, plots that can provide the therapist with information about the forces needed for exercises with Thera-Band Tubing were generated and should allow therapists to make better choices about which size of tubing to use for each patient.
Abstract: Background and Purpose . Thera-Band Tubing has been used in rehabilitation to provide resistance for exercise and splinting. However, the forces required to stretch the tubing have not been thoroughly quantified. Therefore, the therapist cannot assess, with certainty, how much force is applied when using a given length and type of Thera-Band Tubing. The purpose of this study was to quantify the material properties of Thera-Band Tubing. Methods . Force versus percentage of strain for all types of Thera-Band Tubing was measured during elongation in a mechanical testing machine. Results . The material is very compliant and displays nonlinear behavior in the initial stretching phase and linear behavior after 50% elongation. Discussion and Conclusion . From the data obtained in this project, plots that can provide the therapist with information about the forces needed for exercises with Thera-Band Tubing were generated. These data should allow therapists to make better choices about which size of tubing to use for each patient.