Clinical Outcomes of an Intensity Program for Children With Movement Challenges.

PURPOSE: Physical therapists at an outpatient pediatric facility developed and implemented an Intensity Program for children with movement challenges. The program was initiated on the basis of best evidence, parent advocacy, and clinician expertise. The purpose of this investigation is to analyze outcome data gathered from the program since 2012 to determine the effect of the program along with any specific child characteristics that were more likely to lead to positive outcomes. METHODS: A variety of outcome data were analyzed to compare preprogram performance with postprogram performance. RESULTS: Program participants made statistically significant and clinically important improvement in most outcome measures. Parents were highly satisfied with the program, including 98% of respondents who indicated that they would like to repeat their participation in the program. CONCLUSIONS: The results of this investigation suggest that many children with movement challenges are likely to benefit from participation in an Intensity Program.

The How and the Why of Including Children: Experiential Learning in Teaching Physical Therapist Students.

PURPOSE: This study describes experiential learning (EL) activities with children and the rationale for using EL. Experiential learning with children in entry-level doctor of physical therapy (DPT) education has not been described. METHODS: Eighteen pediatric educators from accredited DPT programs participated in semistructured, in-depth interviews. Researchers analyzed written interview transcriptions using an iterative, consensus-building, thematic analysis approach. RESULTS: Educators described their EL activities. Educators' rationale for using EL grouped around 4 themes: (1) EL is valued by multiple stakeholders, (2) EL provides an additional learning modality, (3) EL introduces students to pediatric physical therapy, and (4) EL addresses standards and competencies for DPT education. CONCLUSIONS: This research provides a rich description of EL with children and rationale for integrating EL in DPT education. These findings may inform educators and program directors regarding the value of EL and the investment of resources to support EL in DPT education. SUPPLEMENTAL VIDEO ABSTRACT AVAILABLE: at: http://links.lww.com/PPT/A386.

Experiential Learning in Pediatric Physical Therapist Education: Challenges and Facilitators.

PURPOSE: The purpose of this study was to conduct an in-depth investigation of physical therapist educators' challenges to and facilitators of the use of experiential learning (EL) with children. Although EL with children has been called an essential component of doctor of physical therapy (DPT) education, variability in the amount of EL used among DPT programs indicates that educators may experience different challenges and facilitators of the use of EL. METHODS: Eighteen pediatric DPT educators participated in a semistructured interview. Researchers used thematic analysis to qualitatively analyze interview transcripts. RESULTS: Three themes emerged: (1) stakeholder considerations, (2) pedagogical considerations, and (3) logistical considerations. CONCLUSIONS: This research illustrates challenges and facilitators to the use of EL with children. How these challenges and facilitators are perceived by DPT educators has implications for faculty and program directors, particularly as they consider the use of EL with children in DPT programs nationally.

Experiential Learning in Pediatric Physical Therapist Education: Faculty and Student Perceptions.

SUBJECTS: Faculty teaching pediatric content in accredited doctor of physical therapy programs was recruited; 106 responded. Students representing 20 participating programs were also invited to participate; 23 responded. METHODS: Participants received an online questionnaire including closed- and open-ended questions regarding EL with children. Descriptive statistics were used to describe responses. Responses to open-ended questions were compiled and reviewed. RESULTS: Respondents reported an average of 12.4 hours of EL with children in required courses. Satisfaction with quality was stronger than with amount of EL. Several perceived barriers and facilitators were reported. CONCLUSIONS: Use of and satisfaction with EL with children in physical therapists' education vary. Continued research on this variation and potential effects to educational outcomes is needed.

Delays in the Reticulospinal System Are Associated With a Reduced Capacity to Learn a Simulated Feeding Task in Older Adults.

Learning declines with age. Recent evidence indicates that the brainstem may play an important role in learning and motor skill acquisition. Our objective was to determine if delays in the reticular formation, measured via the startle reflex, correspond to age-related deficits in learning and retention. We hypothesized that delays in the startle reflex would be linearly correlated to learning and retention deficits in older adults. To determine if associations were unique to the reticulospinal system, we also evaluated corticospinal contributions with transcranial magnetic stimulation. Our results showed a linear relationship between startle onset latency and percent learning and retention but no relationship between active or passive motor-evoked potential onsets or peak-to-peak amplitude. These results lay the foundation for further study to evaluate if (1) the reticular formation is a subcortical facilitator of skill acquisition and (2) processing delays in the reticular formation contribute to age-related learning deficits.

Development of a Grading Rubric to Assess Learning in Pediatric Physical Therapy Education.

The purpose of this perspective article is to describe the development and potential use of a grading rubric to assess pediatric psychomotor and clinical reasoning skills in professional pediatric physical therapist students. Feedback from focus groups made up of pediatric physical therapy educators informed development of the rubric. In addition, preliminary reliability and feasibility of the rubric were evaluated using videotaped student performance on a related pediatric case. Pilot data suggest a range of reliability between slight and moderate across the components of the rubric. Both the case and the rubric are included as appendices, and recommendations are provided for implementation and for future research.

Pediatric Physical Therapists' Use of the Congenital Muscular Torticollis Clinical Practice Guidelines: A Qualitative Implementation Study.

PURPOSE: This study is a follow-up to the quantitative survey to examine the perceptions of pediatric physical therapists (PTs) on the application of the 2013 Congenital Muscular Torticollis Clinical Practice Guideline (CMT CPG). METHOD: Qualitative semi-structured telephone interviews were completed. Interview questions focused on how the guidelines influenced practice, facilitators and barriers to implementation, and knowledge translation activities. RESULTS: Thirteen pediatric PTs from a variety of practice settings participated. Positive perceptions about the CMT CPG included the use of flow charts, synthesized literature in one place, and validation of examination and intervention approaches. Negative perceptions included its length and that approaches without published evidence were not addressed. Three major themes were identified: knowledge and evidence for practice, education of clinicians, and the CPG structure and components that influenced practice. CONCLUSIONS: The CMT CPG provided a number of benefits. Recommendations for future enhancement and development are provided.

Micro Screw Fixation for Small Proximal Pole Scaphoid Fractures with Distal Radius Bone Graft.

Background Achieving adequate fixation and healing of small proximal pole acute scaphoid fractures can be surgically challenging due to both fragment size and tenuous vascularity. Purpose The purpose of this study was to demonstrate that this injury can be managed successfully with osteosynthesis using a "micro" small diameter compression screw with distal radius bone graft with leading and trailing screw threads less than 2.8 mm. Patients and Methods Patients with proximal pole scaphoid fragments comprising less than 20% of the entire scaphoid were included. Fixation was accomplished from a dorsal approach with a micro headless compression screw and distal radius bone graft. Six patients were included. Average follow-up was 44 months (range, 11-92). Results Mean proximal pole fragment size was 14% (range, 9-18%) of the entire scaphoid. The mean immobilization time was 6 weeks, time-to-union of 6 weeks, and final flexion/extension arc of 88°/87°. All patients had a successful union, and no patient had deterioration in range of motion, avascular necrosis, or fragmentation of the proximal pole. Conclusion Small diameter screws with a maximal thread diameter of ≤ 2.8 mm can be used to fix the union of proximal pole acute scaphoid fractures comprising less than 20% of the total area with good success. Level of Evidence Therapeutic case series, Level IV.

Comparative Evaluation of Surgical Procedures with Clinical Equipoise: the Unique Perspective of Our Hand Therapy Colleagues.

BACKGROUND: There are several accepted surgical treatment options available for carpal tunnel syndrome, thumb carpometacarpal joint (CMC), osteoarthritis (OA), and wrist degenerative joint disease. QUESTIONS/PURPOSES: We sought to obtain the views and preferences from a cohort of certified hand therapists (CHT) and hypothesized that this source may identify differences in procedures that are otherwise widely believed to have clinical equipoise. METHODS: Five hundred twelve CHTs were surveyed regarding their experience, volume, and referral base along with their subjective assessments and preferences regarding open versus endoscopic carpal tunnel release (CTR), various surgical procedures for CMC OA, and proximal row carpectomy (PRC) versus 4-corner fusion (4-CF). RESULTS: The average CHT surveyed had 15.2 years experience and had a referral base of 7.7 different hand surgeons. Twenty-seven percent of respondents perceived superior pain control and incisional tenderness following open CTR compared to that of endoscopic CTR. However, 68% of CHTs would elect to undergo an open CTR themselves. There was no clear consensus for the optimal reconstructive technique for thumb CMC OA. As compared to that of 4-CF, PRC was thought to result in superior pain control (34 versus 22%), motion (43 versus 18%), and earlier discharge from therapy (32 versus 19%); however, 53% of respondents would prefer a 4-CF for themselves. CONCLUSIONS: Hand therapists are intimately involved in the care of surgical patients and provide an educated and unique source for evaluating postoperative outcomes.

Changes in Local Bone Density in Early Thumb Carpometacarpal Joint Osteoarthritis.

PURPOSE: Thumb carpometacarpal (CMC) osteoarthritis (OA) represents a major source of functional morbidity. The effects of early CMC OA on loading and use patterns potentially lead to changes in local bone density and microarchitecture. Hounsfield units (HU), a quantitative attenuation coefficient obtained from computed tomography (CT) scans, have been shown to be a reliable marker of bone density. We hypothesized that early CMC OA is associated with lower local bone density about the CMC joint as assessed by HU. METHODS: We examined HU units from CT scans in 23 asymptomatic subjects and 91 patients with early CMC OA. The HU measurements were obtained within cancellous portions of the trapezium, capitate, first and third metacarpal bases, and distal radius. Linear regression models, with age and sex included as covariates, were used to assess the relationship between CMC OA and HU values at each anatomical site. RESULTS: Early OA patients had significantly lower HU than asymptomatic subjects within the trapezium (mean, 377 HU vs 436 HU) and first metacarpal bases (265 HU vs 324 HU). No significant group differences were noted at the capitate, third metacarpal, or distal radius. Male sex and younger age were associated with significantly higher HU at all the anatomical sites, except the first metacarpal base, where age had no significant effect. CONCLUSIONS: Subjects presenting with early CMC OA had significantly lower bone density as assessed with HU at the thumb CMC joint (trapezium and first metacarpal base). Early thumb CMC OA and discomfort may lead to diminished loading across the basal joint, producing focal disuse osteopenia. These findings in symptomatic early arthritis suggest a relationship between symptoms, functional use of the CMC joint, and local bone density. TYPE OF STUDY/LEVEL OF EVIDENCE: Diagnostic II.

Opportunistic Use of CT Imaging for Osteoporosis Screening and Bone Density Assessment: A Qualitative Systematic Review.

BACKGROUND: The purpose of this study was to determine the clinical opportunities for the use of computed tomography (CT) imaging for inferring bone quality and to critically analyze the correlation between dual x-ray absorptiometry (DXA) and diagnostic CT as reported in the literature. METHODS: A systematic review of the MEDLINE database was performed in February 2016 using the PubMed interface. The inclusion criteria were English language, studies performed using living human subjects, studies pertaining to orthopaedics, use of conventional diagnostic CT scans, studies that measured cancellous bone, and studies that reported Hounsfield unit (HU) measurements directly rather than a computed bone mineral density. RESULTS: Thirty-seven studies that reported on a total of 9,109 patients were included. Of these, 10 studies correlated HU measurements of trabecular bone with DXA-based bone assessment. Reported correlation coefficients ranged between 0.399 and 0.891, and 5 of the studies reported appropriate threshold HU levels for diagnosing osteoporosis or osteopenia. CONCLUSIONS: Direct HU measurement from diagnostic CT scans has the potential to be used opportunistically for osteoporosis screening, but in its current state it is not ready for clinical implementation. There is a lack of exchangeability among different machines that limits its broad applicability. Future research efforts should focus on identifying thresholds at specific anatomic regions in high-risk patients in order to have the greatest impact on patients. However, using diagnostic CT to infer region-specific osteoporosis could be extraordinarily valuable to orthopaedic surgeons and primary care physicians, and merits further research.

Uptake of the Congenital Muscular Torticollis Clinical Practice Guideline Into Pediatric Practice.

PURPOSE: This study describes survey responses about implementation of the congenital muscular torticollis clinical practice guideline (CMT-CPG) by pediatric physical therapists (PT) and successes and challenges with knowledge-brokering activities. METHODS: An online survey was distributed to pediatric PTs who self-identified with practice experience with congenital muscular torticollis. Data were analyzed for implementation frequency of guideline recommendations and differences pre and postpublication of the CMT-CPG. RESULTS: After publication, guideline recommendation implementation improved such that no recommendation was being implemented by less than 50% of respondents, and most were implemented by greater than 90%. The majority of respondents participated in knowledge brokering; however, many indicated minimal effectiveness of those activities. CONCLUSIONS: The CMT-CPG has successfully aided in changing practice. Participants identified areas of challenge and success in translating recommendations into practice and in knowledge brokering that may be helpful for the development of future CPGs.

Simple Assessment of Global Bone Density and Osteoporosis Screening Using Standard Radiographs of the Hand.

PURPOSE: Osteoporosis and fragility fractures have consequences both at the individual level and to the overall health care system. Although dual-energy x-ray absorptiometry (DXA) is the reference standard for assessing bone mineral density (BMD), other, simpler tools may be able to screen bone quality provisionally and signal the need for intervention. We hypothesized that the second metacarpal cortical percentage (2MCP) calculated from standard radiographs of the hand or wrist would correlate with hip BMD derived from DXA and could provide a simple screening tool for osteoporosis. METHODS: Two hundred patients who had hand or wrist radiographs and hip DXA scans within 1 year of each other were included in this series. Mid-diaphyseal 2MCP was calculated as the ratio of the cortical diameter to the total diameter. We assessed the correlation between 2MCP and total hip BMD. Subjects were stratified into normal, osteopenic, and osteoporotic cohorts based on hip t scores, and thresholds were identified to optimize screening sensitivity and specificity. RESULTS: Second metacarpal cortical percentage correlated significantly with BMD and t scores from the hip. A 2MCP threshold of less than 60% optimized sensitivity (88%) and specificity (60%) for discerning osteopenic subjects from normal subjects, whereas a threshold of less than 50% optimized sensitivity (100%) and specificity (91%) for differentiating osteoporotic from normal subjects. CONCLUSIONS: By demonstrating that global BMD may be assessed from 2MCP, these data suggest that radiographs of the hand and wrist may have a role in accurately screening for osteopenia and osteoporosis. This simple investigation, which is already used ubiquitously for patients with hand or wrist problems, may identify patients at risk for fragility fractures and allow for appropriate referral or treatment. TYPE OF STUDY/LEVEL OF EVIDENCE: Diagnostic II.

Assessment of Vertebral Curves Using the Manual Post-It Technique.

STUDY DESIGN: A prospective study of a new technique. OBJECTIVE: The aims of this study were to report a manual technique for measuring vertebral curves on digital spine radiographs, and to assess the agreement of this technique with that of digital software for measuring vertebral curves. SUMMARY OF BACKGROUND DATA: Modern picture archiving and communication systems (PACS) typically include software for evaluating radiographic measurements. However, in the outpatient spine setting, patients may present with radiographs stored on a physical disc, which may not include software for measuring vertebral curves. Certain smartphone applications may be used to determine curve magnitude; however, the need exists for an accurate manual technique to measure vertebral curves on digital radiographs in the absence of available analytic software or smartphone technology. METHODS: We prospectively reviewed anteroposterior and lateral spine radiographs of 24 spinal deformity patients. Two independent observers measured Cobb angles for: (1) the major coronal curve; (2) the thoracic kyphosis (T2-T12); and (3) the lumbar lordosis (T12-S1). Measurements were made: (1) digitally using our institution's PACS; and (2) by a manual technique, which involves placement of an adhesive Post-It note directly on the computer screen, transcribing the angle onto the Post-It note with a pencil, and measuring the angle with a handheld goniometer. Intraclass correlation coefficients (ICCs) were calculated to determine the agreement between the 2 methods. RESULTS: For both observers, the agreement between the digital PACS and manual Post-It techniques was graded as excellent for both coronal and sagittal plane curves (all ICCs>0.9). Interobserver reliability between the 2 observers was also graded as excellent for both the PACS and Post-It techniques (all ICCs>0.9). CONCLUSIONS: The Post-It technique for measuring Cobb angles demonstrated excellent agreement with the PACS system in our series of spinal deformity patients. Curves on digital radiographs can be accurately measured using a convenient manual technique.

Axon Counts Yield Multiple Options for Triceps Fascicular Nerve to Axillary Nerve Transfer.

PURPOSE: To evaluate the relative axonal match between potential donor and recipient nerves, so that maximal reinnervation potential may be reached with the least chance of donor site morbidity. METHODS: In 10 fresh-frozen cadaveric specimens, the main trunk and anterior, posterior, sensory and teres minor branches of the axillary nerve were identified, as were the radial nerve branches to the long, medial, and lateral heads of the triceps. The swing distances of the triceps fascicular nerve branches and the axillary nerve branches relative to the inferior border of the teres major muscle were recorded. Histomorphological analysis and axon counts were performed on sections of each branch. RESULTS: The median number of axons in the main axillary trunk was 7,887, with 4,052, 1,242, and 1,161 axons in the anterior, posterior, and teres minor branches, respectively. All specimens had a single long head triceps branch (median, 2,302 axons), a range of 1 to 3 branches to the medial head of the triceps (composite axon count, 2,198 axons), and 1 to 3 branches to the lateral head of the triceps (composite average, 1,462 axons). The medial and lateral head branches had sufficient swing distance to reach the anterior branch of the axillary nerve in all 10 specimens, with only 4 specimens having adequate long head branch swing distances. CONCLUSIONS: It is anatomically feasible to transfer multiple branches of the radial nerve supplying the medial, lateral, and sometimes, long head of the triceps to all branches of the axillary nerve in an attempt to reinnervate the deltoid and teres minor muscles. CLINICAL RELEVANCE: Understanding the axon counts of the different possible transfer combinations will improve operative flexibility and enable peripheral nerve surgeons to reinnervate for both abduction and external rotation with the highest donor/recipient axon count ratios.

Blunt Force May be an Effective Treatment for Ganglion Cysts.

BACKGROUND: Ganglion cysts are the most common soft tissue tumors of the hand and wrist. There is currently no data available for the recurrence or complication rate of patients that self treat ganglion cysts by using an extrinsic force. Despite this absence of evidence, patients are still using this mode of treatment. QUESTIONS/PURPOSES: The purpose of the study is to evaluate the efficacy of blunt force as a treatment modality for disrupting ganglion cysts. METHODS: We analyzed videos of patients attempting to disrupt their ganglion cysts of the wrist by blunt force on Youtube.com and surveyed them anonymously. Candidates were contacted through YouTube's email server and given a link to an online questionnaire. RESULTS: Two hundred fourteen individuals were reviewed with a total of 1,008,913 views. Eighty three percent of videos were effective in treating the cyst. All 38 individuals that responded to the survey reported that the blunt force was effective in immediate elimination of the cyst in an average of 1.6 attempts (range 1-5). A majority (N = 21, 55%) reported no recurrence since the initial disruption of the cyst at a follow-up of 24 months. CONCLUSIONS: YouTube.com was found to be an effective outlet to study a treatment modality that would otherwise be limited by practical considerations. The study showed that a subset of patients is utilizing blunt force trauma to successfully treat wrist ganglion cysts.

Using Hounsfield Units to Assess Osteoporotic Status on Wrist Computed Tomography Scans: Comparison With Dual Energy X-Ray Absorptiometry.

PURPOSE: Rates of evaluation and treatment for osteoporosis following distal radius fragility fractures remain low. As a subset of patients with these fractures undergo diagnostic computed tomography (CT) scan of the wrist, utilizing bone mineral density (BMD) measurements available with this imaging can be used to detect osteopenia or osteoporosis. This information may consequently prompt intervention to prevent a subsequent fracture. The purpose of this study was to determine if Hounsfield unit (HU) measurements at the wrist correlate with BMD measurements of the hip, femoral neck, and lumbar spine and to assess the ability of these HU measurements to detect osteoporosis of the hip. METHODS: Forty-five female patients with distal radius fractures who underwent CT scan and dual energy x-ray absorptiometry scan as part of the management of their wrist fracture were identified. Bone mineral density measurements were made using the regional cancellous bone HU value at the capitate and compared with values obtained by a dual energy x-ray absorptiometry scan. RESULTS: Hounsfield unit values at the capitate were significantly correlated with BMD and t scores at the femoral neck, hip, and lumbar spine. An HU threshold of 307 in the capitate optimized sensitivity (86%) and specificity (94%) for detecting osteoporotic patients. CONCLUSIONS: By demonstrating that capitate HU measurements from clinical CT scans are correlated with BMD and t scores at the hip, femoral neck, and lumbar spine, our data suggest that clinical CT scans should have a role in detecting osteopenia and osteoporosis. TYPE OF STUDY/LEVEL OF EVIDENCE: Diagnostic III.

Experiential Learning With Children: An Essential Component of Professional Physical Therapy Education.

PURPOSE: The Section on Pediatrics of the American Physical Therapy Association has developed a number of resources to support and improve the consistency of professional pediatric physical therapy education, including a set of core competencies that all graduates must attain. The purpose of this article is to advocate for the inclusion of experiential learning activities with children, including children with participation restrictions, as a necessary component to achieve the core competencies. KEY POINTS: Experiential learning is a form of practice-based education that provides exposures and opportunities for students to explore the work, roles, and identities they will encounter as future professionals. Experiential learning is learning by doing, and occurs within a relevant setting. Six representative curricular exemplars are presented to provide readers with a variety of suggestions for development and integration of experiential learning. SUMMARY: Recommendations for future research are provided and 4 key recommendations are provided.

Opportunistic Osteoporosis Screening - Gleaning Additional Information from Diagnostic Wrist CT Scans.

BACKGROUND: Although screening for and treating osteoporosis can prevent subsequent fractures, the rates of such interventions are low following a distal radial fracture. One potential method for identifying metabolic bone disease is via Hounsfield unit (HU) measurements from diagnostic computed tomography (CT) scans. We hypothesized that HU values of the distal aspect of the radius could be used to assess local bone quality and would be predictive of distal radial fracture risk, thereby allowing the identification of patients in need of further management. METHODS: Measurements of bone mineral density (BMD) were made for 100 patients on the basis of HU values of cancellous portions of the distal aspect of the radius, the ulnar head, and the capitate. The HU values in twenty-five male and twenty-five female patients with an acute distal radial fracture documented on CT were compared with those of age and sex-matched control patients who had a CT scan obtained for other indications. RESULTS: Among the control patients, HU values decreased as age increased. When assessed on the basis of sex, both male and female patients with a distal radial fracture had significantly lower regional BMD compared with nonfracture control patients. A distal radial HU value of 218 for females and 246 for males optimized sensitivity and specificity; values below this threshold were associated with an increased risk of distal radial fracture. CONCLUSIONS: HU measurements can be obtained from any diagnostic CT scan using modern software programs and can be obtained by physicians in the office setting with minimal effort and at no additional cost or radiation exposure to the patient. Regardless of imaging indications, we suggest that patients with HU values below the identified thresholds be considered for further metabolic bone disease work-up, such as additional imaging, laboratory assessments, the initiation of osteoporosis treatment, or appropriate referral.