Assessment of Fall-Related Emergency Medical Service Calls and Transports after a Community-Level Fall-Prevention Initiative.

Background: Getting effective fall prevention into the homes of medically and physically vulnerable individuals is a critical public health challenge. Community paramedicine is emerging globally as a new model of care that allows emergency medical service units to evaluate and treat patients in non-emergency contexts for prevention efforts and chronic care management. The promise of community paramedicine as a delivery system for fall prevention that scales to community-level improvements in outcomes is compelling but untested.Objective: To study the impact of a community paramedic program's optimization of a fall prevention system entailing a clinical pathway and learning health system (called Community-FIT) on community-level fall-related emergency medical service utilization rates.Methods: We used an implementation science framework and quality improvement methods to design and optimize a fall prevention model of care that can be embedded within community paramedic operations. The model was implemented and optimized in an emergency medical service agency servicing a Midwestern city in the United States (∼35,000 residents). Primary outcome measures included relative risk reduction in the number of community-level fall-related 9-1-1 calls and fall-related hospital transports. Interrupted time series analysis was used to evaluate relative risk reduction from a 12-month baseline period (September 2016 - August 2017) to a 12-month post-implementation period (September 2018-August 2019).Results: Community paramedic home visits increased from 25 in 2017, to 236 in 2018, to 517 in 2019, indicating a large increase in the number of households that benefited from the efforts. A relative risk reduction of 0.66 (95% [CI] 0.53, 0.76) in the number of fall calls and 0.63 (95% [CI] 0.46, 0.75) in the number of fall-related calls resulting in transports to the hospital were observed.Conclusions: Community-FIT may offer a powerful mechanism for community paramedics to reduce fall-related 9-1-1 calls and transports to hospitals that can be implemented in emergency medical agencies across the country.

Adolescent and Parent Perceptions of the Impact of Concussion/mTBI on Family Functioning and Activity Levels in Recovery.

OBJECTIVE: To explore adolescent and parent perceptions of the impact of a concussion/mild traumatic brain injury (mTBI) on family functioning and activity levels in the first 4 weeks of recovery. SETTING: Outpatient research setting. PARTICIPANTS: Twenty-seven adolescents (aged of 13-17 years) within 1 week of a concussion/mTBI and a parent/guardian were enrolled in the study. DESIGN: Prospective ecological study with qualitative, semistructured interviews. MAIN MEASURES: Adolescents reported symptoms electronically every 2 days for 28 days via the Post-Concussion Symptom Inventory. Semistructured interviews were completed with each adolescent-parent dyad at the end of the 28-day period. Interview questions focused on perceptions of recovery progress and study procedures. RESULTS: Symptom trajectories were variable across participants. Three main themes emerged from thematic analysis, including: (1) disruption of routines and activities, (2) injury management considerations, and (3) positive and negative influential factors (eg, school and coach support, timing of injury, and recovery expectations). Results highlighted nuances of recovery challenges that families specifically face and help emphasize the potential benefits of shared decision-making and where more guidance would be appreciated such as more specific self-management of symptoms and physical activity reintegration strategies. CONCLUSIONS: Study findings support a shared decision-making approach with the identified themes as potential topics to help consider social and environmental influences on recovery. The themes presented in the results could be topics emphasized during intake and follow-up visit processes to help guide plans of care and return-to-activity decisions.

Parent Perspectives Regarding Care Delivery for Children With Idiopathic Toe Walking to Inform an American Physical Therapy Association Clinical Practice Guideline.

PURPOSE: This study summarizes experiences and perceptions of parents whose children received physical therapy for idiopathic toe walking (ITW) to inform clinical practice guideline development and identify perceived strengths and gaps in care. METHODS: A US-based survey was distributed to parents of children with ITW. Data from 98 respondents were compiled through descriptive statistics of item responses and review of comments. RESULTS: Parents reported variability in timing of diagnosis and intervention, ITW care, and extent they felt educated and involved in decision making. Rates of confidence, satisfaction, and effectiveness of physical therapy care varied. CONCLUSIONS: A parent-informed clinical practice guideline for physical therapy management of ITW and family-friendly supplemental knowledge translation tools could reduce care variability, optimize shared decision making, and increase satisfaction of outcomes. RECOMMENDATIONS FOR CLINICAL PRACTICE: Clinicians should be knowledgeable about ITW diagnosis, prognosis, and treatment options, educating families and engaging them in shared decision making around ITW care.

Implementing Patient-Reported Outcome Measures in Outpatient Rehabilitation Settings: A Systematic Review of Facilitators and Barriers Using the Consolidated Framework for Implementation Research.

OBJECTIVE: This systematic review examines the facilitators and barriers to the use of patient-reported outcome measures (PROMs) in outpatient rehabilitation settings and provides strategies to improve care to maximize patient outcomes. DATA SOURCES: Eleven databases were systematically searched from November 2018 to May 2019. STUDY SELECTION: Two reviewers independently assessed articles based on the following inclusion criteria: English text, evaluate barriers and facilitators, include PROMs, and occur in an outpatient rehabilitation setting (physical therapy, occupational therapy, speech language pathology, or athletic training). Of the 10,164 articles initially screened, 15 articles were included in this study. DATA EXTRACTION: Data were extracted from the selected articles by 2 independent reviewers and put into an extraction template and into the Consolidated Framework for Implementation Research (CFIR) model. The Appraisal Tool for Cross-Sectional Studies (AXIS) was conducted on each study to assess study design, risk of bias, and reporting quality of the eligible studies. DATA SYNTHESIS: Ten studies were identified as high quality, according to the AXIS. Based on the CFIR model, the top barriers identified focused on clinician training and time in the implementation process, lack of recognized value and knowledge at the individual level, lack of access and support in the inner setting, and inability of patients to complete PROMs in the intervention process. Facilitators were identified as education in the implementation process, support and availability of PROMs in the inner setting, and recognized value at the individual level. CONCLUSIONS: More barriers than facilitators have been identified, which is consistent with PROM underuse. Clinicians and administrators should find opportunities to overcome the barriers identified and leverage the facilitators to improve routine PROM use and maximize patient outcomes.

Progression of Ankle Plantarflexion Contractures and Functional Decline in Duchenne Muscular Dystrophy: Implications for Physical Therapy Management.

PURPOSE: This study characterizes the progressive loss of ankle dorsiflexion range of motion in boys with Duchenne muscular dystrophy (DMD), the relationship to functional decline, and the implications for physical therapy management. METHODS: Longitudinal data for 332 boys with DMD were extracted from medical records and analyzed. Summary statistics for age, number of visits, ankle dorsiflexion measures, and North Star Ambulatory Assessment (NSAA) scores were computed. RESULTS: Ankle dorsiflexion motion ranged from -32.5 to 25 degrees. Progression of ankle contractures is demonstrated by a trend line: slope -1.43 per year. NSAA score was estimated to decline approximately 0.23 points per 1 degree of ankle dorsiflexion lost. CONCLUSIONS: The results of this study describe the progression of ankle contractures and functional decline in DMD. The findings may help inform decisions regarding interventions to support participants with DMD and their families.

Documenting Physical Therapy Dose for Individuals With Cerebral Palsy: A Quality Improvement Initiative.

PURPOSE: To describe the quality improvement (QI) activities used to improve treatment dose documentation for individuals with cerebral palsy (CP) and to discuss insights gained from this project. METHODS: Global and smart aims were established and interventions were tested from January 2017 through February 2018 using Plan-Do-Study-Act cycles. Performance was tracked overtime using run and control charts. RESULTS: The QI initiative resulted in a sustainable increase in percentage of dose elements present in the electronic medical record from 78% to 94%. Key drivers of improvement included (1) knowledge and awareness of dose, (2) clinician buy-in, (3) effective engagement of child and parent, (4) therapist knowledge of evidence-based treatments, (5) transparent and reliable documentation system, and (6) audit and clinician feedback. CONCLUSIONS: QI methods provided the tools to improve workflow and increase dose documentation for individuals with CP.

An Exploration of the Impact of Initial Timing of Physical Therapy on Safety and Outcomes After Concussion in Adolescents.

BACKGROUND AND PURPOSE: Physical therapy (PT) is a management strategy increasingly recognized to facilitate recovery after concussion. The purpose of this study was to investigate the safety and outcomes of multimodal impairment-based PT at varying time points after injury in youth diagnosed with concussion. METHODS: Data were extracted retrospectively from medical records for patients who received PT for concussion-related impairments. Patient records were categorized into 3 cohorts on the basis of the timing of PT implementation: 0-20 days following injury (early intervention), 21 to 41 days following injury (middle intervention), and 42 or more days following injury (late intervention). The primary outcome measure was Post-Concussion Symptom Inventory score from the beginning to the end of the PT episode of care. Additional outcome measures included number of PT sessions, duration of PT episode of care (days), and occurrence of unplanned visits to a health care provider. RESULTS: A total of 120 patient records (mean age of 14.77 years) were analyzed. Thirty-three, 39, and 48 individuals were categorized into the early, middle, and late intervention cohorts, respectively. There were no significant differences between intervention cohorts with regard to symptom change on the Post-Concussion Symptom Inventory from the beginning to the end of the PT episode of care, unplanned health care visits, number of PT sessions, or duration of PT episode of care. DISCUSSION AND CONCLUSIONS: Early initiation of PT may be safe and tolerable. Future prospective studies are needed to explore the efficacy of PT services administered early following injury to help characterize an optimal care plan for youth following concussion.Video Abstract available for more insights from the authors (see Supplemental Digital Content 1, available at: http://links.lww.com/JNPT/A210).

Exertional Tolerance Assessments After Mild Traumatic Brain Injury: A Systematic Review.

OBJECTIVE: To review the literature to identify and summarize strategies for evaluating responses to physical exertion after mild traumatic brain injury (mTBI) for clinical and research purposes. DATA SOURCES: PubMed and EBSCOhost through December 31, 2016. STUDY SELECTION: Two independent reviewers selected studies based on the following criteria: (1) inclusion of participants with mTBI/concussion, (2) use of a measurement of physiological or psychosomatic response to exertion, (3) a repeatable description of the exertion protocol was provided, (4) a sample of at least 10 participants with a mean age between 8 and 65 years, and (5) the article was in English. The search process yielded 2685 articles, of which 14 studies met the eligibility requirements. DATA EXTRACTION: A quality assessment using a checklist was conducted for each study by 2 independent study team members and verified by a third team member. Data were extracted by one team member and verified by a second team member. DATA SYNTHESIS: A qualitative synthesis of the studies revealed that most protocols used a treadmill or cycle ergometer as the exercise modality. Protocol methods varied across studies including differences in initial intensity determination, progression parameters, and exertion duration. Common outcome measures were self-reported symptoms, heart rate, and blood pressure. CONCLUSIONS: The strongest evidence indicates that exertional assessments can provide important insight about mTBI recovery and should be administered using symptoms as a guide. Additional studies are needed to verify optimal modes and protocols for post-mTBI exertional assessments.

A Longitudinal Examination of Postural Impairments in Children With Mild Traumatic Brain Injury: Implications for Acute Testing.

OBJECTIVE: To examine how postural control changes following pediatric mild traumatic brain injury. SETTING: Urban pediatric emergency department. PARTICIPANTS: Children 11 to 16 years old who presented within 6 hours of sustaining mild traumatic brain injury. DESIGN: Prospective observational cohort followed for 1 month. MAIN MEASURES: Total center of pressure path velocity and path velocity within distinct frequency bands, ranging from moderate to ultralow, were recorded by the Nintendo Wii Balance Board during a 2-legged stance. Measurements were recorded in 2 separate tests with eyes open and closed. The scores of the 2 tests were compared, and a Romberg quotient was computed. RESULTS: Eleven children were followed for 1 month postinjury. The ultralow frequency, which reflects slow postural movements associated with exploring stability boundaries, was lower (p = .02) during the eyes closed stance acutely following injury. The Romberg quotient for this frequency was also significantly lower acutely following injury (p = .007) than at 1 month. CONCLUSION: Following mild traumatic brain injury, children acutely demonstrate significantly more rigid sway patterns with eyes closed than with eyes open, which were highlighted by the Romberg quotient. The Romberg quotient could allow for accurate identification and tracking of postural instability without requiring knowledge of preinjury balance ability.

Structural Connectivity Related to Persistent Symptoms After Mild TBI in Adolescents and Response to Aerobic Training: Preliminary Investigation.

OBJECTIVE: To quantify structural connectivity abnormalities in adolescents with mild traumatic brain injury (mTBI) and to investigate connectivity changes following aerobic training using graph theory and diffusion tensor imaging tractography. SETTING: Outpatient research setting. PARTICIPANTS: Twenty-two children (age: 15.83 ± 1.77 years, 10 females) with 4 to 16 weeks of persistent symptoms after mTBI and a matched healthy comparison group. DESIGN: Randomized clinical trial of aerobic training and stretching comparison combined with case-control comparison. MAIN MEASURES: (1) Five global network measures: global efficiency (Eglob), mean local efficiency, modularity, normalized clustering coefficient (γ), normalized characteristic path length (λ), and small-worldness (σ). (2) The self-reported Post-Concussion Symptom Inventory score. RESULTS: At initial enrollment, adolescents with mTBI had significantly lower Eglob and higher γ, λ, and σ (all P < .05) than healthy peers. After the intervention, significantly increased Eglob and decreased λ (both P < .05) were found in the aerobic training group. Improvement in Post-Concussion Symptom Inventory scores was significantly correlated with the Eglob increase and λ decrease in the aerobic training and λ decrease in the stretching comparison group (all P < .05). CONCLUSION: This pilot study showed initial evidence that structural connectivity analysis was sensitive to brain network abnormalities and may serve as an imaging biomarker in children with persistent symptoms after mTBI.

Aerobic Exercise for Adolescents With Prolonged Symptoms After Mild Traumatic Brain Injury: An Exploratory Randomized Clinical Trial.

OBJECTIVE: To describe the methodology and report primary outcomes of an exploratory randomized clinical trial (RCT) of aerobic training for management of prolonged symptoms after a mild traumatic brain injury (mTBI) in adolescents. SETTING: Outpatient research setting. PARTICIPANTS: Thirty adolescents between the ages of 12 and 17 years who sustained a mTBI and had between 4 and 16 weeks of persistent symptoms. DESIGN: Partially blinded, pilot RCT of subsymptom exacerbation aerobic training compared with a full-body stretching program. MAIN MEASURES: The primary outcome was postinjury symptom improvement assessed by the adolescent's self-reported Post-Concussion Symptom Inventory (PCSI) repeated for at least 6 weeks of the intervention. Parent-reported PCSI and adherence are also described. RESULTS: Twenty-two percent of eligible participants enrolled in the trial. Repeated-measures analysis of variance via mixed-models analysis demonstrated a significant group × time interaction with self-reported PCSI ratings, indicating a greater rate of improvement in the subsymptom exacerbation aerobic training group than in the full-body stretching group (F = 4.11, P = .044). Adherence to the home exercise programs was lower in the subsymptom exacerbation aerobic training group compared with the full-body stretching group (mean [SD] times per week = 4.42 [1.95] vs 5.85 [1.37], P < .0001) over the duration of the study. CONCLUSION: Findings from this exploratory RCT suggest subsymptom exacerbation aerobic training is potentially beneficial for adolescents with persistent symptoms after an mTBI. These findings and other recent research support the potential benefit of active rehabilitation programs for adolescents with persistent symptoms after an mTBI. Larger replication studies are needed to verify findings and improve generalizability. Future work should focus on determining the optimal type, timing, and intensity of active rehabilitation programs and characteristics of individuals most likely to benefit.

Influence of Age on Postconcussive Postural Control Measures and Future Implications for Assessment.

OBJECTIVE: To examine the influence of age, sex, attention-deficit hyperactivity disorder (ADHD) status, previous history of concussion, and days since injury on postconcussion postural control assessment in adolescents who have suffered a concussion. DESIGN: Prospective cohort study. SETTING: Hospital-based outpatient clinic. PARTICIPANTS: Seventy-one participants (42 males; 29 females) with mean age 14.14 ± 2.44. INDEPENDENT VARIABLES: Age, sex, previous concussion history, ADHD status, total and severity of postconcussion symptoms, and days since injury. MAIN OUTCOME MEASURES: Total Balance Error Scoring System score, path length, center-of-pressure (COP) area, sample entropy, and Romberg quotient. RESULTS: Pearson product-moment correlation coefficients were calculated to test for potential associations between the continuous participant characteristics and the postural control variables. Spearman correlation was used to test the association between symptom severity and the postural control variables. Standard multiple regression was used to model the extent to which participant characteristics accounted for the variance in the postural sway variables. Age was significantly associated with all of the postural sway variables except COP area for the eyes open condition and sample entropy in the anterior-posterior direction for the eyes closed condition. Sex, ADHD status, and previous concussion history did not significantly predict postural control scores. CONCLUSIONS: Age significantly influences scores on common postconcussion postural control assessments. CLINICAL RELEVANCE: This study demonstrates that age is a critical factor that needs to be accounted for to improve the clinical appropriateness and utility of current postconcussion postural control assessments.

Young Athletes' Concerns About Sport-Related Concussion: The Patient's Perspective.

OBJECTIVE: Few studies have examined the experience and concerns of the concussed athlete. The purpose of this study was to identify the most pressing concerns of athletes with concussion. DESIGN: Cross-sectional survey of athletes who presented for evaluation of a new sport-related concussion during an 8-month period. SETTING: Tertiary-level sports medicine division of a large academic pediatric medical center. PARTICIPANTS: One hundred twenty one patients (67 male, 54 female) aged 8 to 18 years who had sustained a sport-related concussion participated in the study by responding to "What is the worst thing for you about having a concussion?" on the study questionnaire. Questionnaires were completed in the clinic waiting room before the visit with a provider. INTERVENTION: Inductive content analysis was used to identify themes in the responses to the study question. MAIN OUTCOME MEASURES: Age, sex, sport played at the time of the current injury, history of previous concussion, known contacts with concussion, and subjective report of worst aspect of concussion. RESULTS: Seventy respondents (57.9%) cited symptoms, and 68 (56.2%) reported loss of activity as the worst part of concussion, including 17 (14.0%) who listed both symptoms and loss of activity. CONCLUSIONS: Over half of concussed athletes indicate that the most distressing part of the injury is loss of activities, which may result from symptoms of the injury itself and/or the prescribed treatment. CLINICAL RELEVANCE: Health care providers should not underestimate the degree to which symptoms and loss of activities affect young athletes' general well-being. In addition to the negative impact of concussion symptoms, there is an obvious cost of physical, cognitive, and social activity restrictions for patients recovering from sport-related concussions that should be explicitly addressed.

Postconcussion Postural Sway Variability Changes in Youth: The Benefit of Structural Variability Analyses.

PURPOSE: The purpose of this study was to evaluate the utility of postural sway variability as a potential assessment to detect altered postural sway in youth with symptoms related to a concussion. METHODS: Forty participants (20 who were healthy and 20 who were injured) aged 10 to 16 years were assessed using the Balance Error Scoring System (BESS) and postural sway variability analyses applied to center-of-pressure data captured using a force plate. RESULTS: Significant differences were observed between the 2 groups for postural sway variability metrics but not for the BESS. Specifically, path length was shorter and Sample and Renyi Entropies were more regular for the participants who were injured compared with the participants who were healthy (P < .05). CONCLUSION: The results of this study indicate that postural sway variability may be a more valid measure than the BESS to detect postconcussion alterations in postural control in young athletes.

The utility of the balance error scoring system for mild brain injury assessments in children and adolescents.

The Balance Error Scoring System (BESS) is widely recognized as an acceptable assessment of postural control for adult patients following a mild traumatic brain injury (mTBI) or concussion. However, the measurement properties of the BESS as a post-mTBI assessment test for younger patients are not well understood. The purpose of this study was to evaluate the utility of the BESS as a post-mTBI assessment test for children and adolescents aged 8 to 18 years through 2 investigations: (1) a retrospective medical records review of the relationship among age, BESS scores, and other common post-mTBI assessment tests; and (2) a prospective study comparing BESS scores for a cohort of children with a recent mTBI and BESS scores for a cohort of matched healthy peers. Age was found to be significantly correlated with several of the BESS measures and the total BESS score (P < 0.05). Significant differences were observed between the injured and healthy cohorts for 3 of the BESS measures and the total BESS score. However, the observed differences were not likely to be clinically meaningful. Cumulatively, evidence from the literature and the results of these studies indicate that the BESS may be limited for producing accurate assessments of younger athletes' post-mTBI postural control abilities. Future research recommendations include testing of modified versions of the BESS or other alternatives for post-mTBI postural control assessments with younger individuals.

Impact of vision impairment on discharge destination for patients with hip fracture.

Introduction: Vision impairment (VI) due to low vision or blindness is a major sensory health problem affecting quality of life and contributing to increased risk of falls and hip fractures (HF). Up to 60% of patients with hip fracture have VI, and VI increases further susceptibility to falls due to mobility challenges after HF. We sought to determine if VI affects discharge destination for patients with HF. Materials and methods: Cross-sectional analysis of 2015 Inpatient Medicare claims was performed and VI, blindness/low vision), HF and HF surgery were identified using ICD-9, and ICD-10 codes. Patients who sustained a HF with a diagnosis of VI were categorized as HF + VI. The outcome measure was discharge destination of home, skilled nursing facility (SNF), long-term care facility (LTCF) or other. Results: During the one-year ascertainment of inpatient claims, there were 10,336 total HF patients, 66.82% female, 91.21% non-Hispanic white with mean (standard deviation) age 82.3 (8.2) years. There was an age-related increase in diagnosis of VI with 1.49% (29/1941) of patients aged 65-74, 1.76% (63/3574) of patients aged 75-84, and 2.07% (100/4821) of patients aged 85 and older. The prevalence of VI increased with age, representing 1.5% (29/1941) of adults aged 65-74, 1.8% (63/3574) of adults aged 75-84, and 2.1% (100/4821) of adults aged 85 and older. The age-related increase in VI was not significant (P = 0.235). Patients with HF were most commonly discharged to a SNF (64.46%), followed by 'Other' (25.70%), home (7.15%), and LTCF (2.67%). VI was not associated with discharge destination. Male gender, Black race, systemic complications, and late postoperative discharge significantly predicted discharge to LTCF with odds ratios (95%CI) 1.42 (1.07-1.89), 1.90 (1.13-3.18), 2.27 (1.66-3.10), and 1.73 (1.25-2.39) respectively. Conclusions: The co-morbid presence of VI was not associated with altered discharge destinations to home, skilled nursing facility, LTCF or other setting.

The role of community paramedicine in fall prevention: A SWOT analysis.

BACKGROUND: Millions of older US adults fall annually, leading to catastrophic injuries, over 32,000 deaths and healthcare costs of over $55 billion. This study evaluated perceived benefits and limitations of using community paramedicine for fall prevention strategies from the lens of older adults, caregivers, and healthcare providers. METHODS: Semi-structured focus groups were held with individuals from three stakeholder groups: (1) community-dwelling older adults (age ≥60), (2) caregivers, and (3) healthcare providers. The Strengths-Weaknesses-Opportunities-Threats (SWOT) framework was used to quantitatively analyze stakeholder perceptions of using community paramedicine for fall prevention strategies. RESULTS: A total of 10 focus groups were held with 56 participants representing older adults (n = 15), caregivers (n = 16), and healthcare providers (n = 25). Community paramedicine was supported as a model of fall prevention by older adults, caregivers, and healthcare providers. Participants identified strengths such as visibility to the home environment, ability to implement home modifications, implicit trust in emergency medical services (EMS), and capacity to redirect resources toward prevention. Additionally, participants acknowledged opportunities such as providing continuity of care across the healthcare spectrum, improving quality and safety of care and potentially reducing unnecessary emergency department use. Participants endorsed weaknesses and threats such as funding, concerns of patients about stigma, and struggles with medical data integration. CONCLUSIONS: The results of this study illuminate the opportunity to leverage community paramedicine to address a variety of perceived barriers in order to design and implement better solutions for fall prevention efforts.

Understanding social determinants of health and physical therapy outcomes in patients with low back pain: A scoping review.

BACKGROUND: Low back pain (LBP) is the number one cause of disability worldwide; however, it is not clear how social determinants of health (SDOH) impact care management and outcomes related to physical therapy (PT) services for patients with LBP. OBJECTIVE: The purposes of this scoping review are to examine and assimilate the literature on how SDOH and PT care relate to non-specific LBP outcomes and identify gaps in the literature to target for future research. METHODS: Data were extracted from eight electronic databases from January 2011 to February 2022. Reviewers independently screened all studies using the PRISMA extension for scoping review guidelines. Data related to study design, type of PT, type of non-specific LBP, patient demographics, PT intervention, SDOH, and PT outcomes were extracted from the articles. RESULTS: A total of 30,523 studies were screened, with 1961 articles undergoing full text review. Ultimately, 76 articles were identified for inclusion. Sex and age were the most frequent SDOH examined (88% and 78% respectively) followed by education level (18%). Approximately half of the studies that examined age, sex, and education level identified no effect on outcomes. The number of studies examining other factors was small and the types of outcomes evaluated were variable, which limited the ability to pool results. CONCLUSIONS: Sex and age were the most frequent SDOH examined followed by education level. Other factors were evaluated less frequently, making it difficult to draw conclusions. Study design and heterogeneity of determinants and outcomes were barriers to examining the potential impact on patients with LBP.

The feasibility and acceptability of integrating dogs into inpatient rehabilitation therapy with children with acquired brain injury.

INTRODUCTION: Children with acquired brain injury (ABI) are at risk for poor therapeutic engagement due to cognitive impairment, affect lability, pain, and fatigue. Animal-assisted therapy (AAT) has the potential to improve patient engagement in rehabilitation therapies; however, the feasibility of integrating AAT into the rigorous therapy schedule of inpatient clinical care or its reception by patients, families, and staff is unknown. OBJECTIVE: To examine the feasibility and acceptability of incorporating dogs into physical therapy and occupational therapy sessions with pediatric patients being treated on an inpatient rehabilitation unit for acquired brain injury. DESIGN: A feasibility study of AAT within the context of a within-subjects crossover study. SETTING: Pediatric inpatient rehabilitation unit. PARTICIPANTS: Sixteen patients, aged 7-28 years (mean = 13.6 years, standard deviation [SD] = 5.2 years; 50% male), being treated on the inpatient rehabilitation unit following ABI. INTERVENTION: AAT - the integration of dogs into inpatient physical therapy and occupational therapy sessions. MAIN OUTCOME MEASURES: Feasibility measures: enrollment rate, the proportion of AAT sessions a dog attended, adverse events, instances where therapist or handler ended session early, patient animal closeness, and utilization of dog in session. Satisfaction measures: parent satisfaction questionnaires and therapist feedback. RESULTS: Feasibility was supported by high enrollment rate (88.9%) and dog attendance rate of 93%-95%; 84.3% of sessions used the dog in multiple ways and patients reported a high level of closeness with the dog in session, indicating that the dogs were integrated in meaningful ways. No adverse events were noted, therapists reported that intervention was convenient, and clinical care was not negatively impacted. A high level of satisfaction was reported by families and therapists. CONCLUSIONS: Findings suggest that AAT is feasible and acceptable, and it may be a valuable tool for therapists working with patients with ABI on an inpatient rehabilitation unit.

Internal consistency and validity of the QuickDASH instrument for upper extremity injuries in older children.

BACKGROUND: The short version of the Disabilities of the Arm, Shoulder and Hand instrument (QuickDASH) has been shown to be a valid, reliable, and responsive measure of upper extremity function in adults. However, the psychometric properties of the QuickDASH for younger patients have not been well established. The purpose of this study was to evaluate the internal consistency and validity of the QuickDASH for use with older children and adolescents. METHODS: The QuickDASH and PedsQL instruments were administered to 149 patients grouped into ages 8 to 12 and 13 to 18 years. RESULTS: Item response analysis showed a low SE of measurement (0.06) and a high coefficient α (0.91), suggesting high internal consistency among items. The QuickDASH was found to be a predictor of PedsQL score for both groups (P<0.01). CONCLUSIONS: The results indicate that the QuickDASH is a consistent and valid instrument for older children and adolescents with upper extremity pathology. LEVEL OF EVIDENCE: III, case series.