Showing papers in "Physical Therapy in 2016"

Consensus on Exercise Reporting Template (CERT): Modified Delphi Study

Abstract: BACKGROUND: Exercise interventions are often incompletely described in reports of clinical trials, hampering evaluation of results and replication and implementation into practice. OBJECTIVE: The aim of this study was to develop a standardized method for reporting exercise programs in clinical trials: the Consensus on Exercise Reporting Template (CERT). DESIGN AND METHODS: Using the EQUATOR Network's methodological framework, 137 exercise experts were invited to participate in a Delphi consensus study. A list of 41 items was identified from a meta-epidemiologic study of 73 systematic reviews of exercise. For each item, participants indicated agreement on an 11-point rating scale. Consensus for item inclusion was defined a priori as greater than 70% agreement of respondents rating an item 7 or above. Three sequential rounds of anonymous online questionnaires and a Delphi workshop were used. RESULTS: There were 57 (response rate=42%), 54 (response rate=95%), and 49 (response rate=91%) respondents to rounds 1 through 3, respectively, from 11 countries and a range of disciplines. In round 1, 2 items were excluded; 24 items reached consensus for inclusion (8 items accepted in original format), and 16 items were revised in response to participant suggestions. Of 14 items in round 2, 3 were excluded, 11 reached consensus for inclusion (4 items accepted in original format), and 7 were reworded. Sixteen items were included in round 3, and all items reached greater than 70% consensus for inclusion. LIMITATIONS: The views of included Delphi panelists may differ from those of experts who declined participation and may not fully represent the views of all exercise experts. CONCLUSIONS: The CERT, a 16-item checklist developed by an international panel of exercise experts, is designed to improve the reporting of exercise programs in all evaluative study designs and contains 7 categories: materials, provider, delivery, location, dosage, tailoring, and compliance. The CERT will encourage transparency, improve trial interpretation and replication, and facilitate implementation of effective exercise interventions into practice.

Effectiveness of Manual Therapy and Therapeutic Exercise for Temporomandibular Disorders: Systematic Review and Meta-Analysis

Abstract: Background Manual therapy (MT) and exercise have been extensively used to treat people with musculoskeletal conditions such as temporomandibular disorders (TMD). The evidence regarding their effectiveness provided by early systematic reviews is outdated. Purpose The aim of this study was to summarize evidence from and evaluate the methodological quality of randomized controlled trials that examined the effectiveness of MT and therapeutic exercise interventions compared with other active interventions or standard care for treatment of TMD. Data Sources Electronic data searches of 6 databases were performed, in addition to a manual search. Study Selection Randomized controlled trials involving adults with TMD that compared any type of MT intervention (eg, mobilization, manipulation) or exercise therapy with a placebo intervention, controlled comparison intervention, or standard care were included. The main outcomes of this systematic review were pain, range of motion, and oral function. Forty-eight studies met the inclusion criteria and were analyzed. Data Extraction Data were extracted in duplicate on specific study characteristics. Data Synthesis The overall evidence for this systematic review was considered low. The trials included in this review had unclear or high risk of bias. Thus, the evidence was generally downgraded based on assessments of risk of bias. Most of the effect sizes were low to moderate, with no clear indication of superiority of exercises versus other conservative treatments for TMD. However, MT alone or in combination with exercises at the jaw or cervical level showed promising effects. Limitations Quality of the evidence and heterogeneity of the studies were limitations of the study. Conclusions No high-quality evidence was found, indicating that there is great uncertainty about the effectiveness of exercise and MT for treatment of TMD.

Effect of Virtual Reality Training on Balance and Gait Ability in Patients With Stroke: Systematic Review and Meta-Analysis.

Abstract: Background Virtual reality (VR) training is considered to be a promising novel therapy for balance and gait recovery in patients with stroke. Purpose The aim of this study was to conduct a systematic literature review with meta-analysis to investigate whether balance or gait training using VR is more effective than conventional balance or gait training in patients with stroke. Data Sources A literature search was carried out in the databases PubMed, Embase, MEDLINE, and Cochrane Library up to December 1, 2015. Study Selection Randomized controlled trials that compared the effect of balance or gait training with and without VR on balance and gait ability in patients with stroke were included. Data Extraction and Synthesis Twenty-one studies with a median PEDro score of 6.0 were included. The included studies demonstrated a significant greater effect of VR training on balance and gait recovery after stroke compared with conventional therapy as indicated with the most frequently used measures: gait speed, Berg Balance Scale, and Timed “Up & Go” Test. Virtual reality was more effective to train gait and balance than conventional training when VR interventions were added to conventional therapy and when time dose was matched. Limitations The presence of publication bias and diversity in included studies were limitations of the study. Conclusions The results suggest that VR training is more effective than balance or gait training without VR for improving balance or gait ability in patients with stroke. Future studies are recommended to investigate the effect of VR on participation level with an adequate follow-up period. Overall, a positive and promising effect of VR training on balance and gait ability is expected.

What Influences Patient-Therapist Interactions in Musculoskeletal Physical Therapy? Qualitative Systematic Review and Meta-Synthesis

Abstract: Background Musculoskeletal physical therapy involves both specific and nonspecific effects. Nonspecific variables associated with the patient, therapist, and setting may influence clinical outcomes. Recent quantitative research has shown that nonspecific factors, including patient-therapist interactions, can influence treatment outcomes. It remains unclear, however, what factors influence patient-therapist interaction. Purpose This qualitative systematic review and meta-synthesis investigated patients' and physical therapists' perceptions of factors that influence patient-therapist interactions. Data Sources Eleven databases were searched independently. Study Selection Qualitative studies examining physical therapists' and patients' perceptions of factors that influence patient-therapist interactions in musculoskeletal settings were included. Data Extraction Two reviewers independently selected articles, assessed methodological quality using the Critical Appraisal Skills Programme (CASP), and performed the 3 stages of analysis: extraction of findings, grouping of findings (codes), and abstraction of findings. Data Synthesis Thirteen studies were included. Four themes were perceived to influence patient-therapist interactions: (1) physical therapist interpersonal and communication skills (ie, presence of skills such as listening, encouragement, confidence, being empathetic and friendly, and nonverbal communication), (2) physical therapist practical skills (ie, physical therapist expertise and level of training, although the ability to provide good education was considered as important only by patients), (3) individualized patient-centered care (ie, individualizing the treatment to the patient and taking patient's opinions into account), and (4) organizational and environmental factors (ie, time and flexibility with care and appointments). Limitations Only studies published in English were included. Conclusions A mix of interpersonal, clinical, and organizational factors are perceived to influence patient-therapist interactions, although research is needed to identify which of these factors actually influence patient-therapist interactions. Physical therapists' awareness of these factors could enhance patient interactions and treatment outcomes. Mechanisms to best enhance these factors in clinical practice warrant further study.

Roland-Morris Disability Questionnaire. and Oswestry Disability Index: Which Has Better Measurement Properties for Measuring Physical Functioning in Nonspecific Low Back Pain? Systematic Review and Meta-Analysis

Abstract: Background Physical functioning is a core outcome domain to be measured in nonspecific low back pain (NSLBP). A panel of experts recommended the Roland-Morris Disability Questionnaire (RMDQ) and Oswestry Disability Index (ODI) to measure this domain. The original 24-item RMDQ and ODI 2.1a are recommended by their developers. Purpose The purpose of this study was to evaluate whether the 24-item RMDQ or the ODI 2.1a has better measurement properties than the other to measure physical functioning in adult patients with NSLBP. Data Sources Bibliographic databases (MEDLINE, Embase, CINAHL, SportDiscus, PsycINFO, and Google Scholar), references of existing reviews, and citation tracking were the data sources. Study Selection Two reviewers selected studies performing a head-to-head comparison of measurement properties (reliability, validity, and responsiveness) of the 2 questionnaires. The COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) checklist was used to assess the methodological quality of these studies. Data Extraction The studies' characteristics and results were extracted by 2 reviewers. A meta-analysis was conducted when there was sufficient clinical and methodological homogeneity among studies. Data Synthesis Nine articles were included, for a total of 11 studies assessing 5 measurement properties. All studies were classified as having poor or fair methodological quality. The ODI displayed better test-retest reliability and smaller measurement error, whereas the RMDQ presented better construct validity as a measure of physical functioning. There was conflicting evidence for both instruments regarding responsiveness and inconclusive evidence for internal consistency. Limitations The results of this review are not generalizable to all available versions of these questionnaires or to patients with specific causes for their LBP. Conclusions Based on existing head-to-head comparison studies, there are no strong reasons to prefer 1 of these 2 instruments to measure physical functioning in patients with NSLBP, but studies of higher quality are needed to confirm this conclusion. Foremost, content, structural, and cross-cultural validity of these questionnaires in patients with NSLBP should be assessed and compared.

Evidence of Impaired Proprioception in Chronic, Idiopathic Neck Pain: Systematic Review and Meta-Analysis.

Abstract: Background Despite common use of proprioceptive retraining interventions in people with chronic, idiopathic neck pain, evidence that proprioceptive dysfunction exists in this population is lacking. Determining whether proprioceptive dysfunction exists in people with chronic neck pain has clear implications for treatment prescription. Purpose The aim of this study was to synthesize and critically appraise all evidence evaluating proprioceptive dysfunction in people with chronic, idiopathic neck pain by completing a systematic review and meta-analysis. Data Sources MEDLINE, CINAHL, PubMed, Allied and Complementary Medicine, EMBASE, Academic Search Premier, Scopus, Physiotherapy Evidence Database (PEDro), and Cochrane Collaboration databases were searched. Study Selection All published studies that compared neck proprioception (joint position sense) between a chronic, idiopathic neck pain sample and asymptomatic controls were included. Data Extraction Two independent reviewers extracted relevant population and proprioception data and assessed methodological quality using a modified Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement. Data Synthesis Thirteen studies were included in the present review. Meta-analysis on 10 studies demonstrated that people with chronic neck pain perform significantly worse on head-to-neutral repositioning tests, with a moderate standardized mean difference of 0.44 (95% confidence interval=0.25, 0.63). Two studies evaluated head repositioning using trunk movement (no active head movement thus hypothesized to remove vestibular input) and showed conflicting results. Three studies evaluated complex or postural repositioning tests; postural repositioning was no different between groups, and complex movement tests were impaired only in participants with chronic neck pain if error was continuously evaluated throughout the movement. Limitations A paucity of studies evaluating complex or postural repositioning tests does not permit any solid conclusions about them. Conclusions People with chronic, idiopathic neck pain are worse than asymptomatic controls at head-to-neutral repositioning tests.

Effectiveness of Rehabilitation Interventions to Improve Gait Speed in Children With Cerebral Palsy: Systematic Review and Meta-analysis

Abstract: Background Children with cerebral palsy (CP) have decreased gait speeds, which can negatively affect their community participation and quality of life. However, evidence for effective rehabilitation interventions to improve gait speed remains unclear. Purpose The purpose of this study was to determine the effectiveness of interventions for improving gait speed in ambulatory children with CP. Data Sources MEDLINE/PubMed, CINAHL, ERIC, and PEDro were searched from inception through April 2014. Study Selection The selected studies were randomized controlled trials or had experimental designs with a comparison group, included a physical therapy or rehabilitation intervention for children with CP, and reported gait speed as an outcome measure. Data Extraction Methodological quality was assessed by PEDro scores. Means, standard deviations, and change scores for gait speed were extracted. General study information and dosing parameters (frequency, duration, intensity, and volume) of the intervention were recorded. Data Synthesis Twenty-four studies were included. Three categories of interventions were identified: gait training (n=8), resistance training (n=9), and miscellaneous (n=7). Meta-analysis showed that gait training was effective in increasing gait speed, with a standardized effect size of 0.92 (95% confidence interval=0.19, 1.66; P =.01), whereas resistance training was shown to have a negligible effect (effect size=0.06; 95% confidence interval=−0.12, 0.25; P =.51). Effect sizes from negative to large were reported for studies in the miscellaneous category. Limitations Gait speed was the only outcome measure analyzed. Conclusions Gait training was the most effective intervention in improving gait speed for ambulatory children with CP. Strength training, even if properly dosed, was not shown to be effective in improving gait speed. Velocity training, electromyographic biofeedback training, and whole-body vibration were effective in improving gait speed in individual studies and warrant further investigation.

Sitting and Activity Time in People With Stroke

Abstract: Background Excessive sitting time is linked to cardiovascular disease morbidity. To date, no studies have accurately measured sitting time patterns in people with stroke. Objective The purpose of this study was to investigate the amount and pattern of accumulation of sitting time, physical activity, and use of time in people with stroke compared with age-matched healthy peers. Design This study used an observational design. Methods Sitting time (total and time accumulated in prolonged, unbroken bouts of ≥30 minutes) was measured with an activity monitor. Physical activity and daily energy expenditure were measured using an accelerometer and a multisensory array armband, respectively. All monitors had a 7-day wear protocol. Participants recalled 1 day of activity (during monitor wear time) using the Multimedia Activity Recall for Children and Adults. Results Sixty-three adults (40 with stroke and 23 age-matched healthy controls) participated. The participants (35% female, 65% male) had a mean age of 68.4 years (SD=10.0). Participants with stroke spent significantly more time sitting (X=10.9 h/d, SD=2.0) compared with controls (X=8.2 h/d, SD=2.0), with much of this sitting time prolonged (stroke group: X=7.4 h/d, SD=2.8; control group: X=3.7 h/d, SD=1.7). Participants with stroke accumulated most of their sitting time while watching television and in general quiet time, whereas control participants spent more time reading and on the computer. Physical activity and daily energy expenditure were lower in the stroke group compared with the control group. Limitations A sample of convenience was used to select participants for the stroke and control groups, which may reduce the generalizability of results. Conclusions Participants with stroke spent more time sitting and less time in activity than their age-matched peers. Further work is needed to determine whether reducing sitting time is feasible and leads to clinically important reductions in cardiovascular risk in this population.

Measurement Properties of Instruments for Measuring of Lymphedema: Systematic Review

Abstract: Background Lymphedema is a common complication of cancer treatment, resulting in swelling and subjective symptoms. Reliable and valid measurement of this side effect of medical treatment is important. Purpose The purpose of this study was to provide best evidence regarding which measurement instruments are most appropriate in measuring lymphedema in its different stages. Data Sources The PubMed and Web of Science databases were used, and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed. Study Selection Clinical studies on measurement instruments assessing lymphedema were reviewed using the Quality Assessment of Diagnostic Accuracy Studies-2 (QUADAS-2) scoring instrument for quality assessment. Data Extraction Data on reliability, concurrent validity, convergent validity, sensitivity, specificity, applicability, and costs were extracted. Data Synthesis Pooled data showed good intrarater intraclass correlation coefficients (ICCs) (.89) for bioimpedance spectroscopy (BIS) in the lower extremities and high intrarater and interrater ICCs for water volumetry, tape measurement, and perometry (.98–.99) in the upper extremities. In the upper extremities, the standard error of measurement was 3.6% (σ=0.7%) for water volumetry, 5.6% (σ=2.1%) for perometry, and 6.6% (σ=2.6%) for tape measurement. Sensitivity of tape measurement in the upper extremities, using different cutoff points, varied from 0.73 to 0.90, and specificity values varied from 0.72 to 0.78. Limitations No uniform definition of lymphedema was available, and a gold standard as a reference test was lacking. Items concerning risk of bias were study design, patient selection, description of lymphedema, blinding of test outcomes, and number of included participants. Conclusions Measurement instruments with evidence for good reliability and validity were BIS, water volumetry, tape measurement, and perometry, where BIS can detect alterations in extracellular fluid in stage 1 lymphedema and the other measurement instruments can detect alterations in volume starting from stage 2. In research, water volumetry is indicated as a reference test for measuring lymphedema in the upper extremities.

Balance Confidence and Fear of Falling Avoidance Behavior Are Most Predictive of Falling in Older Adults: Prospective Analysis

Abstract: Background Evidence suggests that there are several fall predictors in the elderly population, including previous fall history and balance impairment. To date, however, the role of psychological factors has not yet been thoroughly vetted in conjunction with physical factors as predictors of future falls. Objective The purpose of this study was to determine which measures, physical and psychological, are most predictive of falling in older adults. Design This was a prospective cohort study. Methods Sixty-four participants (mean age=72.2 years, SD=7.2; 40 women, 24 men) with and without pathology (25 healthy, 17 with Parkinson disease, 11 with cerebrovascular accident, 6 with diabetes, and 5 with a cardiovascular diagnosis) participated. Participants reported fall history and completed physical-based measures (ie, Berg Balance Scale, Dynamic Gait Index, self-selected gait speed, Timed “Up & Go” Test, Sensory Organization Test) and psychological-based measures (ie, Fear of Falling Avoidance Behavior Questionnaire, Falls Efficacy Scale, Activities-specific Balance Confidence Scale). Contact was made 1 year later to determine falls during the subsequent year (8 participants lost at follow-up). Results Using multiple regression, fall history, pathology, and all measures were entered as predictor candidates. Three variables were included in the final model, explaining 49.2% of the variance: Activities-specific Balance Confidence Scale (38.7% of the variance), Fear of Falling Avoidance Behavior Questionnaire (5.6% additional variance), and Timed “Up & Go” Test (4.9% additional variance). Limitations Falls were based on participant recall rather than a diary. Conclusions Balance confidence was the best predictor of falling, followed by fear of falling avoidance behavior, and the Timed “Up & Go” Test. Fall history, presence of pathology, and physical tests did not predict falling. These findings suggest that participants may have had a better sense of their fall risk than with a test that provides a snapshot of their balance.

Expanded Distribution of Pain as a Sign of Central Sensitization in Individuals With Symptomatic Knee Osteoarthritis.

Abstract: Background Expanded distribution of pain is considered a sign of central sensitization (CS). The relationship between recording of symptoms and CS in people with knee osteoarthritis (OA) has been poorly investigated. Objective The aim of this study was to examine whether the area of pain assessed using pain drawings relates to CS and clinical symptoms in people with knee OA. Design This was a cross-sectional study. Methods Fifty-three people with knee OA scheduled to undergo primary total knee arthroplasty were studied. All participants completed pain drawings using a novel digital device, completed self-administration questionnaires, and were assessed by quantitative sensory testing. Pain frequency maps were generated separately for women and men. Spearman correlation coefficients were computed to reveal possible correlations between the area of pain and quantitative sensory testing and clinical symptoms. Results Pain frequency maps revealed enlarged areas of pain, especially in women. Enlarged areas of pain were associated with higher knee pain severity (rs=.325, P Limitations Firm conclusions about the predictive role of pain drawings cannot be drawn. Further evaluation of the reliability and validity of pain area extracted from pain drawings in people with knee OA is needed. Conclusion Expanded distribution of pain was correlated with some measures of CS in individuals with knee OA. Pain drawings may constitute an easy way for the early identification of CS in people with knee OA, but further research is needed.

Prevalence of Wheelchair and Scooter Use Among Community-Dwelling Canadians.

Abstract: Background Mobility impairments are the third leading cause of disability for community-dwelling Canadians. Wheelchairs and scooters help compensate for these challenges. There are limited data within the last decade estimating the prevalence of wheelchair and scooter use in Canada. Objective The aims of this study were: (1) to estimate the prevalence of wheelchair and scooter use in Canada and (2) to explore relevant demographic characteristics of wheelchair and scooter users. Design This study was a secondary analysis of a cross-sectional national survey. Methods The Canadian Survey on Disability (2012) collected data on wheelchair and scooter use from community-dwelling individuals aged 15 years and over with a self-identified activity limitation on the National Household Survey. Prevalence estimates were calculated as weighted frequencies, with cross-tabulations to determine the number of wheelchair and scooter users in Canada, by province, and demographic characteristics (ie, age, sex) and bootstrapping to estimate the variance of all point estimates. Results There were approximately 288,800 community-dwelling wheelchair and scooter users aged 15 years and over, representing 1.0% of the Canadian population. The sample included 197,560 manual wheelchair users, 42,360 powered wheelchair users, and 108,550 scooter users. Wheelchair and scooter users were predominantly women, with a mean age of 65 years. Approximately 50,620 individuals used a combination of 2 different types of devices. Limitations The results are representative of individuals living in the community in Canada and exclude individuals in residential or group-based settings; estimates do not represent the true population prevalence. Conclusion This analysis is the first in more than 10 years to provide a prevalence estimate and description of wheelchair and scooter users in Canada. Since 2004, there has been an increase in the proportion of the population who use wheelchairs and scooters, likely related to an aging Canadian population. These new prevalence data have potential to inform policy, research, and clinical practice.

Cognitive Contributions to Freezing of Gait in Parkinson Disease: Implications for Physical Rehabilitation

Abstract: People with Parkinson disease (PD) who show freezing of gait also have dysfunction in cognitive domains that interact with mobility. Specifically, freezing of gait is associated with executive dysfunction involving response inhibition, divided attention or switching attention, and visuospatial function. The neural control impairments leading to freezing of gait have recently been attributed to higher-level, executive and attentional cortical processes involved in coordinating posture and gait rather than to lower-level, sensorimotor impairments. To date, rehabilitation for freezing of gait primarily has focused on compensatory mobility training to overcome freezing events, such as sensory cueing and voluntary step planning. Recently, a few interventions have focused on restitutive, rather than compensatory, therapy. Given the documented impairments in executive function specific to patients with PD who freeze and increasing evidence of overlap between cognitive and motor function, incorporating cognitive challenges with mobility training may have important benefits for patients with freezing of gait. Thus, a novel theoretical framework is proposed for exercise interventions that jointly address both the specific cognitive and mobility challenges of people with PD who freeze.

High-Intensity Interval Training and Moderate-Intensity Continuous Training in Ambulatory Chronic Stroke: Feasibility Study.

Abstract: Background Poststroke guidelines recommend moderate-intensity, continuous aerobic training (MCT) to improve aerobic capacity and mobility after stroke. High-intensity interval training (HIT) has been shown to be more effective than MCT among healthy adults and people with heart disease. However, HIT and MCT have not been compared previously among people with stroke. Objective The purpose of this study was to assess the feasibility and justification for a definitive randomized controlled trial (RCT) comparing HIT and MCT in people with chronic stroke. Design A preliminary RCT was conducted. Setting The study was conducted in a cardiovascular stress laboratory and a rehabilitation research laboratory. Patients Ambulatory people at least 6 months poststroke participated. Intervention Both groups trained 25 minutes, 3 times per week, for 4 weeks. The HIT strategy involved 30-second bursts at maximum-tolerated treadmill speed alternated with 30- to 60-second rest periods. The MCT strategy involved continuous treadmill walking at 45% to 50% of heart rate reserve. Measurements Measurements included recruitment and attendance statistics, qualitative HIT acceptability, adverse events, and the following blinded outcome variables: peak oxygen uptake, ventilatory threshold, metabolic cost of gait, fractional utilization, fastest treadmill speed, 10-Meter Walk Test, and Six-Minute Walk Test. Results During the 8-month recruitment period, 26 participants consented to participate. Eighteen participants were enrolled and randomly assigned to either the HIT group (n=13) or the MCT group (n=5). Eleven out of the 13 HIT group participants attended all sessions. Participants reported that HIT was acceptable and no serious adverse events occurred. Standardized effect size estimates between groups were moderate to very large for most outcome measures. Only 30% of treadmill speed gains in the HIT group translated into overground gait speed improvement. Limitations The study was not designed to definitively test safety or efficacy. Conclusions Although further protocol optimization is needed to improve overground translation of treadmill gains, a definitive RCT comparing HIT and MCT appears to be feasible and warranted.

Simulated Patients in Physical Therapy Education: Systematic Review and Meta-Analysis.

Abstract: Background Traditional models of physical therapy clinical education are experiencing unprecedented pressures. Simulation-based education with simulated (standardized) patients (SPs) is one alternative that has significant potential value, and implementation is increasing globally. However, no review evaluating the effects of SPs on professional (entry-level) physical therapy education is available. Purpose The purpose of this study was to synthesize and critically appraise the findings of empirical studies evaluating the contribution of SPs to entry-level physical therapy education, compared with no SP interaction or an alternative education strategy, on any outcome relevant to learning. Data Sources A systematic search was conducted of Ovid MEDLINE, PubMed, AMED, ERIC, and CINAHL Plus databases and reference lists of included articles, relevant reviews, and gray literature up to May 2015. Study Selection Articles reporting quantitative or qualitative data evaluating the contribution of SPs to entry-level physical therapy education were included. Data Extraction Two reviewers independently extracted study characteristics, intervention details, and quantitative and qualitative evaluation data from the 14 articles that met the eligibility criteria. Data Synthesis Pooled random-effects meta-analysis indicated that replacing up to 25% of authentic patient–based physical therapist practice with SP-based education results in comparable competency (mean difference=1.55/100; 95% confidence interval=−1.08, 4.18; P =.25). Thematic analysis of qualitative data indicated that students value learning with SPs. Limitations Assumptions were made to enable pooling of data, and the search strategy was limited to English. Conclusion Simulated patients appear to have an effect comparable to that of alternative educational strategies on development of physical therapy clinical practice competencies and serve a valuable role in entry-level physical therapy education. However, available research lacks the rigor required for confidence in findings. Given the potential advantages for students, high-quality studies that include an economic analysis should be conducted.

Treatment-Based Classification System for Low Back Pain: Revision and Update.

Abstract: The treatment-based classification (TBC) system for the treatment of patients with low back pain (LBP) has been in use by clinicians since 1995. This perspective article describes how the TBC was updated by maintaining its strengths, addressing its limitations, and incorporating recent research developments. The current update of the TBC has 2 levels of triage: (1) the level of the first-contact health care provider and (2) the level of the rehabilitation provider. At the level of first-contact health care provider, the purpose of the triage is to determine whether the patient is an appropriate candidate for rehabilitation, either by ruling out serious pathologies and serious comorbidities or by determining whether the patient is appropriate for self-care management. At the level of the rehabilitation provider, the purpose of the triage is to determine the most appropriate rehabilitation approach given the patient's clinical presentation. Three rehabilitation approaches are described. A symptom modulation approach is described for patients with a recent-new or recurrent-LBP episode that has caused significant symptomatic features. A movement control approach is described for patients with moderate pain and disability status. A function optimization approach is described for patients with low pain and disability status. This perspective article emphasizes that psychological and comorbid status should be assessed and addressed in each patient. This updated TBC is linked to the American Physical Therapy Association's clinical practice guidelines for low back pain.

Balance and Gait Represent Independent Domains of Mobility in Parkinson Disease

Abstract: Background The Instrumented Stand and Walk (ISAW) test, which includes 30 seconds of stance, step initiation, gait, and turning, results in many objective balance and gait metrics from body-worn inertial sensors. However, it is not clear which metrics provide independent information about mobility. Objective It was hypothesized that balance and gait represent several independent domains of mobility and that not all domains would be abnormal in individuals with Parkinson disease (PD) or would change with levodopa therapy. Design This was a cross-sectional study. Methods A factor analysis approach was used to identify independent measures of mobility extracted from the ISAW in 100 participants with PD and 21 controls participants. First, a covariance analysis showed that postural sway measures were independent of gait measures. Then, the factor analysis revealed 6 independent factors (mobility domains: sway area, sway frequency, arm swing asymmetry, trunk motion during gait, gait speed, and cadence) that accounted for 87% of the variance of performance across participants. Results Sway area, gait speed, and trunk motion differed between the PD group in the off-levodopa state and the control group, but sway frequency (but not sway area) differed between the PD group in the off-levodopa state and the control group. Four of the 6 factors changed significantly with levodopa (off to on): sway area, sway frequency, trunk motion during gait, and cadence. When participants were on levodopa, the sway area increased compared with off levodopa, becoming more abnormal, whereas the other 3 significant metrics moved toward, but did not reach, the healthy control values. Limitations Exploratory factor analysis was limited to the PD population. Conclusions The different sensitivity various balance and gait domains to PD and to levodopa also support neural control of at least 6 independent mobility domains, each of which warrants clinical assessment for impairments in mobility.

“Stepping Up” Activity Poststroke: Ankle-Positioned Accelerometer Can Accurately Record Steps During Slow Walking

Abstract: Background As physical activity in individuals post-stroke is low, devices that monitor and provide feedback of walking activity provide motivation to engage in exercise and may assist rehabilitation professionals in auditing walking activity. However, most feedback devices are not accurate at slow walking speeds. Objective This study assessed the accuracy of one accelerometer, the Fitbit One, to measure walking steps of community-dwelling individuals post-stroke. Design Cross-sectional study Methods Two accelerometers were positioned on the non-paretic waist and ankle of participants (n=43) and walking steps from these devices were recorded from seven speeds (0.3-0.9m/s) and compared to video recordings (gold standard). Results When positioned at the waist, the accelerometer had more than 10% error at all speeds, except 0.8 and 0.9m/s, and numerous participants recorded zero steps at 0.3-0.5m/s. The device had 10% or less error when positioned at the ankle for all speeds between 0.4-0.9m/s. Limitations Some participants were unable to complete the faster walking speeds secondary to their walking impairments and inability to maintain the requested walking speed. Conclusions Although not recommended by the manufacturer, positioning the accelerometer at the ankle (compared to the waist) may fill a long-standing need for a readily available device that provides accurate feedback for the altered and slow walking patterns that occur with stroke.

Impact of Diabetic Complications on Balance and Falls: Contribution of the Vestibular System

Abstract: Diabetes causes many complications, including retinopathy and peripheral neuropathy, which are well understood as contributing to gait instability and falls. A less understood complication of diabetes is the effect on the vestibular system. The vestibular system contributes significantly to balance in static and dynamic conditions by providing spatially orienting information. It is noteworthy that diabetes has been reported to affect vestibular function in both animal and clinical studies. Pathophysiological changes in peripheral and central vestibular structures due to diabetes have been noted. Vestibular dysfunction is associated with impaired balance and a higher risk of falls. As the prevalence of diabetes increases, so does the potential for falls due to diabetic complications. The purpose of this perspective article is to present evidence on the pathophysiology of diabetes-related complications and their influence on balance and falls, with specific attention to emerging evidence of vestibular dysfunction due to diabetes. Understanding this relationship may be useful for screening (by physical therapists) for possible vestibular dysfunction in people with diabetes and for further developing and testing the efficacy of interventions to reduce falls in this population.

Validity, reliability, and ability to identify fall status of the Berg Balance Scale, BESTest, Mini-BESTest, and Brief-BESTest in patients with COPD

Abstract: Background The Berg Balance Scale (BBS), Balance Evaluation Systems Test (BESTest), Mini-BESTest, and Brief-BESTest are useful in the assessment of balance. Their psychometric properties, however, have not been tested in patients with chronic obstructive pulmonary disease (COPD). Objective This study aimed to compare the validity, reliability, and ability to identify fall status of the BBS, BESTest, Mini-BESTest, and the Brief-BESTest in patients with COPD. Design A cross-sectional study was conducted. Methods Forty-six patients (24 men, 22 women; mean age=75.9 years, SD=7.1) were included. Participants were asked to report their falls during the previous 12 months and to fill in the Activity-specific Balance Confidence (ABC) Scale. The BBS and the BESTest were administered. Mini-BESTest and Brief-BESTest scores were computed based on the participants' BESTest performance. Validity was assessed by correlating balance tests with each other and with the ABC Scale. Interrater reliability (2 raters), intrarater reliability (48–72 hours), and minimal detectable changes (MDCs) were established. Receiver operating characteristics assessed the ability of each balance test to differentiate between participants with and without a history of falls. Results Balance test scores were significantly correlated with each other (Spearman correlation rho=.73–.90) and with the ABC Scale (rho =.53–.75). Balance tests presented high interrater reliability (intraclass correlation coefficient [ICC]=.85–.97) and intrarater reliability (ICC=.52–.88) and acceptable MDCs (MDC=3.3–6.3 points). Although all balance tests were able to identify fall status (area under the curve=0.74–0.84), the BBS (sensitivity=73%, specificity=77%) and the Brief-BESTest (sensitivity=81%, specificity=73%) had the higher ability to identify fall status. Limitations Findings are generalizable mainly to older patients with moderate COPD. Conclusions The 4 balance tests are valid, reliable, and valuable in identifying fall status in patients with COPD. The Brief-BESTest presented slightly higher interrater reliability and ability to differentiate participants' fall status.

The Single-Case Reporting Guideline In BEhavioural Interventions (SCRIBE) 2016 Statement.

Abstract: We developed a reporting guideline to provide authors with guidance about what should be reported when writing a paper for publication in a scientific journal using a particular type of research design: the single-case experimental design. This report describes the methods used to develop the Single-Case Reporting guideline In BEhavioural interventions (SCRIBE) 2016. As a result of 2 online surveys and a 2-day meeting of experts, the SCRIBE 2016 checklist was developed, which is a set of 26 items that authors need to address when writing about single-case research. This article complements the more detailed SCRIBE 2016 Explanation and Elaboration article ([Tate et al., 2016][1]) that provides a rationale for each of the items and examples of adequate reporting from the literature. Both these resources will assist authors to prepare reports of single-case research with clarity, completeness, accuracy, and transparency. They will also provide journal reviewers and editors with a practical checklist against which such reports may be critically evaluated. We recommend that the SCRIBE 2016 is used by authors preparing manuscripts describing single-case research for publication, as well as journal reviewers and editors who are evaluating such manuscripts. Scientific Reporting guidelines, such as the Consolidated Standards of Reporting Trials (CONSORT) Statement, improve the reporting of research in the medical literature ([Turner et al., 2012][2]). Many such guidelines exist and the CONSORT Extension to Nonpharmacological Trials ([Boutron et al., 2008][3]) provides suitable guidance for reporting between-groups intervention studies in the behavioral sciences. The CONSORT Extension for N -of-1 Trials (CENT 2015) was developed for multiple crossover trials with single individuals in the medical sciences ([Shamseer et al., 2015][4]; [Vohra et al., 2015][5]), but there is no reporting guideline in the CONSORT tradition for single-case research used in the behavioral sciences. We developed the Single-Case Reporting guideline In BEhavioural interventions (SCRIBE) 2016 to meet this need. This Statement article describes the methodology of the development of the SCRIBE 2016, along with the outcome of 2 Delphi surveys and a consensus meeting of experts. We present the resulting 26-item SCRIBE 2016 checklist. The article complements the more detailed SCRIBE 2016 Explanation and Elaboration article ([Tate et al., 2016][1]) that provides a rationale for each of the items and examples of adequate reporting from the literature. Both these resources will assist authors to prepare reports of single-case research with clarity, completeness, accuracy, and transparency. They will also provide journal reviewers and editors with a practical checklist against which such reports may be critically evaluated. Keywords: single-case design, methodology, reporting guidelines, publication standards Supplemental materials: [1]: #ref-30 [2]: #ref-34 [3]: #ref-5 [4]: #ref-26 [5]: #ref-36

Exercise for Osteoarthritis of the Hip.

Abstract: highlights the findings and application of Cochrane reviews and other evidence pertinent to the practice of physical therapy. The Cochrane Library is a respected source of reliable evidence related to health care. Cochrane systematic reviews explore the evidence for and against the effectiveness of appropriate interventions—medications, surgery, education, nutrition, exercise— and the evidence for and against the use of diagnostic tests for specific conditions. Cochrane reviews are designed to facilitate the decisions of clinicians, patients, and others in health care by providing a careful review and interpretation of research studies published in the scientific literature.1 Each article in this PTJ series summarizes a Cochrane review or other scientific evidence on a single topic and presents clinical scenarios based on real patients or programs to illustrate how the results of the review can be used to directly inform clinical decisions. This article focuses on an adult patient with osteoarthritis of the hip. Can exercise help this patient? Osteoarthritis (OA) is the most common form of arthritis and is characterized by a progressive degeneration of the joint, affecting most frequently the hands, knees, and hips. Radiographic signs of OA include joint space narrowing, subchondral bone sclerosis, and osteophyte formation. The loss of cartilage is often associated with synovium inflammation,2 thickening of the capsule, and muscle weakness.3,4 Osteoarthritis is a leading cause of disability, especially in the elderly population, with pain and functional limitation being the main associated symptoms.5

Critical and Theoretical Perspective on Scapular Stabilization: What Does It Really Mean, and Are We on the Right Track?

Abstract: Stabilization exercises have been a focus and mainstay of many therapeutic and performance training programs in the past decade. Whether the focus is core stabilization for the spine or scapular stabilization, clinicians and trainers alike have endorsed these programs, largely on the basis of conceptual theory and anecdotal experience. The notion that an unstable scapula is related to shoulder dysfunction and pathology is well accepted, but is it accurate? The aim of this perspective article is to challenge the concept of scapular stabilization through the application of biomechanical and motor control constructs. The objectives are to critically examine current beliefs about scapular stabilization, to discuss definitions of stabilization and stability in the context of the scapulothoracic region, and to evaluate key evidence regarding scapular stabilization and scapular dyskinesia. Several new approaches that may affect the understanding of normal and atypical scapula motion are explored. Finally, a historical analogy is presented and future research and clinical directions are suggested. The aims are to lead readers to the essential concepts implied on scapular stabilization, to increase the critical thought process in rehabilitation practice, and to suggest some open topics to be explored in future research.

Reactive Balance in Individuals With Chronic Stroke: Biomechanical Factors Related to Perturbation-Induced Backward Falling.

Abstract: Background An effective compensatory stepping response is the first line of defense for preventing a fall during sudden large external perturbations. The biomechanical factors that contribute to heightened fall risk in survivors of stroke, however, are not clearly understood. It is known that impending sensorimotor and balance deficits poststroke predispose these individuals to a risk of fall during sudden external perturbations. Objective The purpose of this study was to examine the mechanism of fall risk in survivors of chronic stroke when exposed to sudden, slip-like forward perturbations in stance. Design This was a cross-sectional study. Methods Fourteen individuals with stroke, 14 age-matched controls (AC group), and 14 young controls (YC group) were exposed to large-magnitude forward stance perturbations. Postural stability was computed as center of mass (COM) position (XCOM/BOS) and velocity (ẊCOM/BOS) relative to the base of support (BOS) at first step lift-off (LO) and touch-down (TD) and at second step TD. Limb support was quantified as vertical hip descent (Zhip) from baseline after perturbation onset. Results All participants showed a backward balance loss, with 71% of the stroke group experiencing a fall compared with no falls in the control groups (AC and YC groups). At first step LO, no between-group differences in XCOM/BOS and ẊCOM/BOS were noted. At first step TD, however, the stroke group had a significantly posterior XCOM/BOS and backward ẊCOM/BOS compared with the control groups. At second step TD, individuals with stroke were still more unstable (more posterior XCOM/BOS and backward ẊCOM/BOS) compared with the AC group. Individuals with stroke also showed greater peak Zhip compared with the control groups. Furthermore, the stroke group took a larger number of steps with shorter step length and delayed step initiation compared with the control groups. Limitations Although the study highlights the reactive balance deficits increasing fall risk in survivors of stroke compared with healthy adults, the study was restricted to individuals with chronic stroke only. It is likely that comparing compensatory stepping responses across different stages of recovery would enable clinicians to identify reactive balance deficits related to a specific stage of recovery. Conclusions These findings suggest the inability of the survivors of stroke to regain postural stability with one or more compensatory steps, unlike their healthy counterparts. Such a response may expose them to a greater fall risk resulting from inefficient compensatory stepping and reduced vertical limb support. Therapeutic interventions for fall prevention, therefore, should focus on improving both reactive stepping and limb support.

Comparison of the Fullerton Advanced Balance Scale, Mini-BESTest, and Berg Balance Scale to predict falls in Parkinson disease

Abstract: BACKGROUND: The correct identification of patients with Parkinson's disease (PD) at risk of falling is important to early initiate appropriate treatment. OBJECTIVE: This study compares the Fullerton Advanced Balance (FAB) scale with the Mini Balance Evaluation Systems Test (Mini-BESTest) and Berg Balance Scale (BBS) to identify individuals with PD at risk for falls and to analyze which of the items of the scales best predict future falls. DESIGN: Prospective study to assess predictive criterion-related validity. SETTING: University hospital in an urban community. PATIENTS: 85 patients with idiopathic PD (Hoehn & Yahr stage: 1-4). MEASUREMENTS: Number of falls (assessed prospectively over 6 months), FAB scale, Mini-BESTest, BBS and Unified Parkinson's Disease Rating Scale. RESULTS: The FAB scale, Mini-BESTest and BBS had an accuracy to predict future falls of 0.68, 0.65 and 0.69 of the area under the curve (AUC) of the receiver operating characteristic (ROC) curve, respectively. A model combining the items "tandem stance", "rise to toes", "one leg stance", "compensatory stepping backward", "turning" and "placing alternate foot on stool" had an AUC of 0.84 of the ROC curve. LIMITATIONS: Drop-out rate of 19 subjects. CONCLUSIONS: The FAB scale, Mini-BESTest and BBS provide moderate capacity to predict fallers with one or more falls from non-fallers. Only some items of the three scales contribute to the detection of future falls. Clinicians should particularly focus on the items "tandem stance" in addition with the items "one leg stance", "rise to toes", "compensatory stepping backward", "turning 360°" and "placing foot on stool" when analyzing postural control deficits related to fall risk. Future research should analyze if balance training including the aforementioned items is effective to reduce fall risk. Language: en

Physical Training and Activity in People With Diabetic Peripheral Neuropathy: Paradigm Shift.

Abstract: Diabetic peripheral neuropathy (DPN) occurs in more than 50% of people with diabetes and is an important risk factor for skin breakdown, amputation, and reduced physical mobility (ie, walking and stair climbing). Although many beneficial effects of exercise for people with diabetes have been well established, few studies have examined whether exercise provides comparable benefits to people with DPN. Until recently, DPN was considered to be a contraindication for walking or any weight-bearing exercise because of concerns about injuring a person's insensitive feet. These guidelines were recently adjusted, however, after research demonstrated that weight-bearing activities do not increase the risk of foot ulcers in people who have DPN but do not have severe foot deformity. Emerging research has revealed positive adaptations in response to overload stress in these people, including evidence for peripheral neuroplasticity in animal models and early clinical trials. This perspective article reviews the evidence for peripheral neuroplasticity in animal models and early clinical trials, as well as adaptations of the integumentary system and the musculoskeletal system in response to overload stress. These positive adaptations are proposed to promote improved function in people with DPN and to foster the paradigm shift to including weight-bearing exercise for people with DPN. This perspective article also provides specific assessment and treatment recommendations for this important, high-risk group.

Objectively Measured Physical Activity and Health-Related Physical Fitness in Secondary School-Aged Male Students With Autism Spectrum Disorders

Abstract: Background Recent evidence suggests that childhood obesity is increasing in children with typical development (TD) and in children with autism spectrum disorders (ASD). The associations between physical activity (PA) levels and physical fitness components have not yet been objectively examined in this population but may have clinical implications for the development of secondary health complications. Objective The aims of this study were: (1) to compare PA and physical fitness between secondary school-aged male students with ASD and their peers with TD and (2) to assess possible interrelationships between PA and physical fitness levels in each group. Design This was a cross-sectional study. Methods Physical activity was recorded every 10 seconds by using accelerometry in 70 male students with (n=35) and without (n=35) ASD for up to 5 weekdays and 2 weekend days. The Brockport Physical Fitness Test was used to assess physical fitness. Results The primary findings were: (1) participants with ASD were less physically active overall and engaged in moderate-to-vigorous PA for a lower percentage of time compared with participants with TD during weekdays; (2) participants with ASD had significantly lower scores on all physical fitness measures, except body composition; and (3) group-dependent relationships existed between physical fitness profiles and PA levels. Limitations The study design limits causal inference from the results. Conclusion Specific interventions for maximizing PA and physical fitness levels in secondary school-aged male students with ASD are urgently needed.

Workforce Projections 2010–2020: Annual Supply and Demand Forecasting Models for Physical Therapists Across the United States

Abstract: Background Health human resources continue to emerge as a critical health policy issue across the United States. Objective The purpose of this study was to develop a strategy for modeling future workforce projections to serve as a basis for analyzing annual supply of and demand for physical therapists across the United States into 2020. Design A traditional stock-and-flow methodology or model was developed and populated with publicly available data to produce estimates of supply and demand for physical therapists by 2020. Methods Supply was determined by adding the estimated number of physical therapists and the approximation of new graduates to the number of physical therapists who immigrated, minus US graduates who never passed the licensure examination, and an estimated attrition rate in any given year. Demand was determined by using projected US population with health care insurance multiplied by a demand ratio in any given year. The difference between projected supply and demand represented a shortage or surplus of physical therapists. Results Three separate projection models were developed based on best available data in the years 2011, 2012, and 2013, respectively. Based on these projections, demand for physical therapists in the United States outstrips supply under most assumptions. Limitations Workforce projection methodology research is based on assumptions using imperfect data; therefore, the results must be interpreted in terms of overall trends rather than as precise actuarial data–generated absolute numbers from specified forecasting. Conclusions Outcomes of this projection study provide a foundation for discussion and debate regarding the most effective and efficient ways to influence supply-side variables so as to position physical therapists to meet current and future population demand. Attrition rates or permanent exits out of the profession can have important supply-side effects and appear to have an effect on predicting future shortage or surplus of physical therapists.

Role of Physical Therapists in Reducing Hospital Readmissions: Optimizing Outcomes for Older Adults During Care Transitions From Hospital to Community

Abstract: Hospital readmissions in older adult populations are an emerging quality indicator for acute care hospitals. Recent evidence has linked functional decline during and after hospitalization with an elevated risk of hospital readmission. However, models of care that have been developed to reduce hospital readmission rates do not adequately address functional deficits. Physical therapists, as experts in optimizing physical function, have a strong opportunity to contribute meaningfully to care transition models and demonstrate the value of physical therapy interventions in reducing readmissions. Thus, the purposes of this perspective article are: (1) to describe the need for physical therapist input during care transitions for older adults and (2) to outline strategies for expanding physical therapy participation in care transitions for older adults, with an overall goal of reducing avoidable 30-day hospital readmissions.

Neck Posture Clusters and Their Association With Biopsychosocial Factors and Neck Pain in Australian Adolescents.

Abstract: Background There is conflicting evidence on the association between sagittal neck posture and neck pain Objective The purposes of this study were: (1) to determine the existence of clusters of neck posture in a cohort of 17-year-olds and (2) to establish whether identified subgroups were associated with biopsychosocial factors and neck pain Design This was a cross-sectional study Methods The adolescents (N=1,108) underwent 2-dimensional photographic postural assessment in a sitting position One distance and 4 angular measurements of the head, neck, and thorax were calculated from photo-reflective markers placed on bony landmarks Subgroups of sagittal sitting neck posture were determined by cluster analysis Height and weight were measured, and lifestyle and psychological factors, neck pain, and headache were assessed by questionnaire The associations among posture subgroups, neck pain, and other factors were evaluated using logistic regression Results Four distinct clusters of sitting neck posture were identified: upright, intermediate, slumped thorax/forward head, and erect thorax/forward head Significant associations between cluster and sex, weight, and height were found Participants classified as having slumped thorax/forward head posture were at higher odds of mild, moderate, or severe depression Participants classified as having upright posture exercised more frequently There was no significant difference in the odds of neck pain or headache across the clusters Limitations The results are specific to 17-year-olds and may not be applicable to adults Conclusion Meaningful sagittal sitting neck posture clusters were identified in 17-year-olds who demonstrated some differences with biopsychosocial profiling The finding of no association between cluster membership and neck pain and headaches challenges widely held beliefs about the role of posture in adolescent neck pain