Development of an exercise therapy referral clinical support tool for patients with osteoporosis at risk for falls.

BACKGROUND: The purpose of this study was to develop a clinical support tool for osteoporosis clinic providers to support risk assessment and referrals for evidence-based exercise therapy programs. METHODS: A sequential Delphi method was used with a multidisciplinary group of national falls experts, to provide consensus on referral to exercise therapy for patients at risk for falls. The Delphi study included a primary research team, expert panel, and clinical partners to answer the questions: (1) "What patient characteristics are needed to develop a clinical support tool?"; (2) "What are the recommended exercise referrals for patients with osteoporosis at risk for falls?" The consensus process consisted of two rounds with 8 weeks between meetings. Two qualitative researchers analyzed the data using a modified version of a matrix analysis approach. RESULTS: The following were the most important variables to include when determining exercise therapy referrals for patients with osteoporosis: Patient history and demographics, falls history over the last year, current physical function and balance, caregiver and transportation status, socioeconomic and insurance status, and patient preference. Potential exercise therapy referrals included one-on-one physical therapy, group physical therapy, home health, community-based exercise programs, and not acceptable for exercise therapy. CONCLUSIONS: Patient characteristics including patient history, physical function and balance performance, socioeconomic and insurance status, and patient preference for exercise therapy are important to inform both the medical provider and patient with osteoporosis to choose the most appropriate exercise therapy referral. Adoption of the algorithmic suggestions may have a significant impact on uptake and adherence to exercise therapy, ultimately improving patient physical function and reducing falls risk.

A Cluster Analysis of Initial Primary Care Orders for Patients with Acute Low Back Pain.

PURPOSE: Primary care physicians (PCPs) often face a complex intersection of patient expectations, evidence, and policy that influences their care recommendations for acute low back pain (aLBP). The purpose of this study was to elucidate patterns of PCP orders for patients with aLBP, identify the most common patterns, and describe patient clinical and demographic characteristics associated with patterns of aLBP care. METHODS: This prospective cohort study included 9574 aLBP patients presenting to 1 of 77 primary care practices in 4 geographic locations in the United States. We performed a cluster analysis of PCP orders extracted from electronic health records within the first 21 days of an initial visit for aLBP. RESULTS: 1401 (15%) patients did not receive a PCP order related to back pain within the first 21 days of their initial visit. These patients predominantly had aLBP without leg pain, less back-related disability, and were at low-risk for persistent disability. Of the remaining 8146 patients, we found 4 distinct order patterns: combined nonpharmacologic and first-line medication (44%); second-line medication (39%); imaging (10%); and specialty referral (7%). Among all patients, 29% received solely 1 order from their PCP. PCPs more often combined different guideline concordant and discordant orders. Patients with higher self-reported disability and psychological distress were more likely to receive guideline discordant care. CONCLUSION: Guideline discordant orders such as steroids and NSAIDS are often combined with guideline recommended orders such as physical therapy. Further defining patient, clinician, and health care setting characteristics associated with discordant care would inform targeted efforts for deimplementation initiatives.

Feasibility of Implementing Patient-Reported and Physical Performance Measures to Identify and Manage Fall Risk in Older Adults Within a Secondary Fracture Clinic.

The purpose of this study was to assess the feasibility of implementing both electronic and in-person assessments to assess falls risk in an older adult secondary fracture clinic. Electronic data capture feasibility was defined as the proportion of patients that completed the electronic questionnaires prior to their clinic visit. In-clinic feasibility was defined in two ways: (1) the proportion of patients that consented to participate at their clinic visit; (2) time to complete testing. Patients were contacted electronically through their health system portal for electronic consent. Patients were invited to complete consent, the STopping Elderly Accidents, Deaths, and Injuries (STEADI) falls risk assessment tool, and the visual analog scale (VAS) for pain. The Short Physical Performance Battery (SPPB) was performed at the clinic visit. A total of 310 patients were contacted electronically. No patients (0%) provided consent through their health portal. Of the 310 patients, 200 (65%) consented in person (Ineligible: 67 [21%]; Declined: 43 [14%]), resulting in an 82% response rate. In-person data collection took a median of 38.48 (Range: 12.34-54.30) minutes to complete. It was not feasible to contact and collect older adult patient data electronically prior to clinic; but, was feasible to obtain these patient-reported outcomes and physical performance data in person.

Heel Pain - Plantar Fasciitis: Revision 2023.

The Orthopaedic Section of the American Physical Therapy Association (APTA) has an ongoing effort to create evidence-based practice guidelines for orthopaedic physical therapy management of patients with musculoskeletal impairments described in the World Health Organization's International Classification of Functioning, Disability, and Health (ICF). The purpose of these revised clinical practice guidelines is to review recent peer-reviewed literature and make recommendations related to nonarthritic heel pain. J Orthop Sports Phys Ther 2023;53(12):CPG1-CPG39. doi:10.2519/jospt.2023.0303.

Proximal humerus fracture management and outcomes are distinctly different for individuals 60 years of age or younger: a systematic review.

Background: Proximal humerus fractures (PHFs) occur most commonly in an elderly and osteoporotic population, but a considerable proportion of these injuries occur in relatively younger individuals. Differences in treatment principles and outcomes in this younger population remain poorly understood. The purpose of this review was to characterize the treatment algorithms and outcomes for patients less than or equal to 60 years of age with PHFs. Methods: A comprehensive search of the Medline, Pubmed, Embase, and Cochrane databases for articles published between January 2005 and December 2020 was performed in January 2021. Levels of evidence I-IV analyzing outcomes (patient reported outcomes and/or complications) following PHFs in adult patients less than or equal to 60 years of age were included. The search was carried out in accordance with the preferred reported items for systematic reviews and meta-analyses guidelines. The risk of bias 2 tool and methodological index for nonrandomized studies score were utilized to evaluate included studies. Results: Fourteen studies met the inclusion criteria (open reduction internal fixation: 5, intramedullary nail: 4, hemiarthroplasty: 2, nonoperative: 1, and reverse total shoulder arthroplasty (RTSA): 1). Seven studies reported differences in outcomes between younger and older patient populations, with three studies noting separate management algorithms for those 60 years of age or younger. There were no studies comparing different treatments modalities in those less than 60 years of age, and the lone study on RTSA did not include patient-reported outcomes. Conclusion: Treatment algorithms and outcomes following PHFs in patients less than or equal to 60 years of age are distinctly different from that of a more elderly population. However, evidence-based treatment recommendations for this younger population are limited by the lack of studies comparing treatment modalities and the absence of patient-reported outcomes for individuals undergoing RTSA.

Learning Health Systems Research Competencies: A Survey of the Rehabilitation Research Community.

OBJECTIVE: The Learning Health Systems Rehabilitation Research Network (LeaRRn), an NIH-funded rehabilitation research resource center, aims to advance the research capacity of learning health systems (LHSs) within the rehabilitation community. A needs assessment survey was administered to inform development of educational resources. METHODS: The online survey included 55 items addressing interest in and knowledge of 33 LHS research core competencies in 7 domains and additional items on respondent characteristics. Recruitment targeting rehabilitation researchers and health system collaborators was conducted by LeaRRn, LeaRRn health system partners, rehabilitation professional organizations, and research university program directors using email, listservs, and social media announcements. RESULTS: Of the 650 people who initiated the survey, 410 respondents constituted the study sample. Respondents indicated interest in LHS research and responded to at least 1 competency item and/or demographic question. Two-thirds of the study sample had doctoral research degrees, and one-third reported research as their profession. The most common clinical disciplines were physical therapy (38%), communication sciences and disorders (22%), and occupational therapy (10%). Across all 55 competency items, 95% of respondents expressed "a lot" or "some" interest in learning more, but only 19% reported "a lot" of knowledge. Respondents reported "a lot" of interest in a range of topics, including selecting outcome measures that are meaningful to patients (78%) and implementing research evidence in health systems (75%). "None" or "some" knowledge was reported most often in Systems Science areas such as understanding the interrelationships between financing, organization, delivery, and rehabilitation outcomes (93%) and assessing the extent to which research activities will improve the equity of health systems (93%). CONCLUSION: Results from this large survey of the rehabilitation research community indicate strong interest in LHS research competencies and opportunities to advance skills and training. IMPACT: Competencies where respondents indicated high interest and limited knowledge can inform development of LHS educational content that is most needed.

Linking job duties, functioning, and employment status using the Work-Disability Functional Assessment Battery (WD-FAB): An expert coding and quantitative analysis.

BACKGROUND: An understanding of the link between specific occupational demands and individual worker functioning is limited, although such information could permit an assessment of the fit between the two in a manner that would inform national and state disability programs such as vocational rehabilitation and Social Security disability programs. OBJECTIVE: Our goal was to examine the utility of assessing physical and mental functioning relative to self-reported job duties to identify the domains of worker functioning most likely to create barriers to fulfilling an occupation's specific requirements. METHODS: Through primary survey data collection, 1770 participants completed the Work-Disability Functional Assessment Battery (WD-FAB) instrument after reporting details on their occupations (or most recent occupation if not working). Expert coders evaluated the level of function expected to successfully carry out each self-reported job duty with respect to six scales of physical and mental function. Quantitative analysis is used to examine the relationship between functioning and job duties. RESULTS: Those not working due to disability were more likely to fall short of the threshold of the physical and mental functioning requirements of their last job's three main job duties compared to those currently employed. Mental function scales were most likely to be the area experiencing a shortfall. CONCLUSIONS: Functional difficulties impede the ability to continue working in particular jobs that require that ability. This points to a need for specific accommodations to be implemented to bridge the gap between job requirements and functional capacity so that workers may remain engaged in their current work.

A multi-center trial of exercise and testosterone therapy in women after hip fracture: Design, methods and impact of the COVID-19 pandemic.

BACKGROUND: Up to 75% of hip fracture patients never recover to their pre-fracture functional status. Supervised exercise that includes strength training can improve functional recovery after hip fracture. The role of testosterone replacement for augmenting the effects of exercise in older women after hip fracture is unknown. METHODS: The Starting Testosterone and Exercise after Hip Injury (STEP-HI) Study is a 6-month Phase 3 multicenter randomized placebo-controlled trial designed to compare supervised exercise (EX) plus 1% testosterone topical gel, with EX plus placebo gel, and with enhanced usual care (EUC). Female hip fracture patients age ≥ 65 years are being recruited from clinical centers across the United States. Participants are community dwelling and enrolled within 24 weeks after surgical repair of the fracture. The EX intervention is a center-based program of progressive resistance training. The EUC group receives a home exercise program and health education. Participants receive dietary counseling, calcium and vitamin D. The primary outcome is the Six Minute Walk Distance. Secondary outcomes include physical performance measures, self-reported function and quality of life, and dual energy x-ray absorptiometry measures of body composition and bone mineral density. RESULTS: Enrollment, interventions, and follow-up are ongoing. We describe the impact of the coronavirus disease 2019 pandemic on the trial, including modifications made to allow continuation of the interventions and outcome data collection using remote video and audio technology. CONCLUSIONS: Results from the STEP-HI study are expected to have important clinical and public health implications for management of the growing population of hip fracture patients.

Physical Therapy Management of Older Adults With Hip Fracture.

Hip fracture is a leading cause of profound morbidity in individuals aged 65 years and older, ranking in the top 10 causes of loss of disability-adjusted life-years for older adults. Worldwide, the number of people with hip fracture is expected to rise significantly due to the aging population and other factors. Physical therapist management is recommended within medical, surgical, and multidisciplinary clinical practice guideline (CPGs) and is considered to be the standard of care in rehabilitation for people with hip fracture. The goal of this CPG was to review the evidence relevant to physical therapist management and to provide evidence-based recommendations for physical therapy diagnosis, prognosis, intervention, and assessment of outcome in adults with hip fracture. J Orthop Sports Phys Ther 2021;51(2):CPG1-CPG81. doi:10.2519/jospt.2021.0301.

The Development of a Crosswalk for Functional Measures in Postacute Medicare Claims.

OBJECTIVE: Although Medicare assessment files will include Standardized Patient Assessment Data Elements from 2016 forward, lack of uniformity of functional data prior to 2016 impedes longitudinal research. The purpose of this study was to create crosswalks for postacute care assessment measures and the basic mobility and daily activities scales of the Activity Measure for Post-Acute Care (AM-PAC) and to test their accuracy and validity in development and validation datasets. METHODS: This cross-sectional study is a secondary analysis of AM-PAC, the Inpatient Rehabilitation Facility Patient Assessment Instrument, the Minimum Data Set, and the Outcome and Assessment Information Set data from 300 adults receiving rehabilitation recruited from 6 health care networks in 1 metropolitan area. Rasch analysis was used to co-calibrate items from the 3 measures onto the AM-PAC metric and to create look-up tables to create estimated AM-PAC (eAM-PAC) scores. Mean scores and correlation and agreement between actual and estimated scores were examined in the development dataset. Scores were estimated in a cohort of Medicare beneficiaries with hip, humerus and radius fractures. Correlations between eAM-PAC and Functional Independence Measure motor scores were examined. Differences in mean eAM-PAC scores were evaluated across groups of known differences (age, fracture type, dementia). RESULTS: Strong correlations were found between actual and eAM-PAC scores in the development dataset. Moderate to strong correlations were found between the eAM-PAC basic mobility and Functional Independence Measure motor scores in the validation dataset. Differences in basic mobility scores across known groups were statistically significant and appeared to be clinically important. Differences between mean daily activities scores were statistically significant but appeared not to be clinically important. CONCLUSION: Although further testing is warranted, the basic mobility crosswalk appears to provide valid scores for aggregate analysis of Medicare postacute care data. IMPACT: This study reports on a method to take data from different Medicare administrative data sources and estimate scores on 1 scale. This approach was applied separately for data related to basic mobility and to daily activities. This may allow researchers to overcome challenges with using Medicare administrative data from different sources.

Association of Initial Provider Type on Opioid Fills for Individuals With Neck Pain.

OBJECTIVE: To determine whether the initial care provider for neck pain was associated with opioid use for individuals with neck pain. DESIGN: Retrospective cohort study. SETTING: Marketscan research databases. PARTICIPANTS: Patients (N=427,966) with new-onset neck pain from 2010-2014. MAIN OUTCOME MEASURES: Opioid use was defined using retail pharmacy fills. We performed logistic regression analysis to assess the association between initial provider and opioid use. Adjusted odds ratios (ORs) with 95% confidence intervals (CIs) were calculated using bootstrapping logistic models. We performed propensity score matching as a robustness check on our findings. RESULTS: Compared to patients with neck pain who saw a primary health care provider, patients with neck pain who initially saw a conservative therapist were 72%-91% less likely to fill an opioid prescription in the first 30 days, and between 41%-87% less likely to continue filling prescriptions for 1 year. People with neck pain who initially saw emergency medicine physicians had the highest odds of opioid use during the first 30 days (OR, 3.58; 95% CI, 3.47-3.69; P<.001). CONCLUSIONS: A patient's initial clinical contact for neck pain may be an important opportunity to influence subsequent opioid use. Understanding more about the roles that conservative therapists play in the treatment of neck pain may be key in unlocking new ways to lessen the burden of opioid use in the United States.

Surface Perturbation Training to Prevent Falls in Older Adults: A Highly Pragmatic, Randomized Controlled Trial.

BACKGROUND: Falls are the leading cause of injuries among older adults, and trips and slips are major contributors to falls. OBJECTIVE: The authors sought to compare the effectiveness of adding a component of surface perturbation training to usual gait/balance training for reducing falls and fall-related injury in high-risk older adults referred to physical therapy. DESIGN: This was a multi-center, pragmatic, randomized, comparative effectiveness trial. SETTING: Treatment took place within 8 outpatient physical therapy clinics. PATIENTS: This study included 506 patients 65+ years of age at high fall risk referred for gait/balance training. INTERVENTION: This trial evaluated surface perturbation treadmill training integrated into usual multimodal exercise-based balance training at the therapist's discretion versus usual multimodal exercise-based balance training alone. MEASUREMENTS: Falls and injurious falls were assessed with a prospective daily fall diary, which was reviewed via telephone interview every 3 months for 1 year.A total of 211/253 (83%) patients randomized to perturbation training and 210/253 (83%) randomized to usual treatment provided data at 3-month follow-up. At 3 months, the perturbation training group had a significantly reduced chance of fall-related injury (5.7% versus 13.3%; relative risk 0.43) but no significant reduction in the risk of any fall (28% versus 37%, relative risk 0.78) compared with usual treatment. Time to first injurious fall showed reduced hazard in the first 3 months but no significant reduction when viewed over the entire first year. LIMITATIONS: The limitations of this trial included lack of blinding and variable application of interventions across patients based on pragmatic study design. CONCLUSION: The addition of some surface perturbation training to usual physical therapy significantly reduced injurious falls up to 3 months posttreatment. Further study is warranted to determine the optimal frequency, dose, progression, and duration of surface perturbation aimed at training postural responses for this population.

Knee Morphological Risk Factors for Anterior Cruciate Ligament Injury: A Systematic Review.

BACKGROUND: Anterior cruciate ligament (ACL) reconstruction incidence has increased substantially in the past 25 years. Recently, there has been a focus on knee morphology as a contributor to ACL injury risk. The purpose of this study was to systematically review the literature to assess the influence of knee morphology on ACL injury. METHODS: In accordance with PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, PubMed, Embase, and MEDLINE were searched in September 2017 for studies reporting on knee morphology and ACL injury. The search was updated in June 2018. The following inclusion criteria were used: English language; full text available; Level-I, II, or III evidence; human studies; and skeletally mature patients. RESULTS: After systematically screening 6,208 studies, 65 studies met the inclusion/exclusion criteria. Three additional studies were identified in the search update, for a total of 68 studies comprising 5,834 ACL-injured knees. Intercondylar notch stenosis, most commonly defined by an "A-shaped" notch, decreased notch width, or decreased notch width index, was the most commonly reported femoral morphological risk factor for ACL injury. Increased femoral condylar offset ratio (>63%) and decreased condylar radius of curvature also were associated with an increased risk of ACL injury. Increased medial and lateral tibial slopes were the most commonly reported tibial risk factors. A smaller tibial eminence, reduced ACL size, and poor tibiofemoral congruity were also associated with increased injury risk. CONCLUSIONS: Intercondylar notch stenosis, variations in sagittal condylar shape, increased tibial slope, reduced tibial eminence size, poor tibiofemoral congruity, and reduced ACL size are substantial risk factors for ACL injury. In future research, it would be valuable to identify a slope beyond which slope correction should be performed concomitantly with ACL reconstruction, and to determine whether an optimal relationship of notch size to graft size exists. To achieve optimal outcomes, the osseous morphological risk factors should be considered in individualized anatomic ACL reconstructions. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Unrestricted Direct Access to Physical Therapist Services Is Associated With Lower Health Care Utilization and Costs in Patients With New-Onset Low Back Pain.

BACKGROUND: Low back pain (LBP) is one of the most prevalent conditions for which patients seek physical therapy in the United States. The American Physical Therapy Association categorizes direct access to physical therapist services into 3 levels: limited, provisional, and unrestricted. OBJECTIVE: The objective of this study was to evaluate the association of level of access to physical therapist services with LBP-related health care utilization and costs. DESIGN: This was a retrospective cohort study of patients with new-onset LBP between 2008 and 2013; data were from OptumLabs Data Warehouse. METHODS: We identified 59,670 individuals who were 18 years old or older, who had new-onset LBP, and who had commercial or Medicare Advantage insurance through a private health plan. We examined 2 samples. The first was health care utilization among individuals who saw a physical therapist first in states with either unrestricted access or provisional access. The second was LBP-related costs among individuals who saw either a physical therapist or a primary care physician first. RESULTS: Individuals who saw a physical therapist first in states with provisional access had significantly higher measures of health care utilization within 30 days, including plain imaging and frequency of physician visits, than individuals who saw a physical therapist first in states with unrestricted access. Compared with individuals who saw a primary care physician first, pooled across provisional-access and unrestricted-access states, those who saw a physical therapist first in provisional-access states had 25% higher relative costs at 30 days and 32% higher relative costs at 90 days, whereas those who saw a physical therapist first in unrestricted-access states had 13% lower costs at 30 days and 32% lower costs at 90 days. LIMITATIONS: This was a claims-based study with limited information on patient characteristics, including severity and duration of pain. CONCLUSIONS: Short-term LBP-related health care utilization and costs were lower for individuals in unrestricted-access states than in provisional-access states.

Patellofemoral Pain.

Patellofemoral pain (PFP) is a common musculoskeletal-related condition that is characterized by insidious onset of poorly defined pain, localized to the anterior retropatellar and/or peripatellar region of the knee. The onset of symptoms can be slow or acutely develop with a worsening of pain accompanying lower-limb loading activities (eg, squatting, prolonged sitting, ascending/descending stairs, jumping, or running). Symptoms can restrict participation in physical activity, sports, and work, as well as recur and persist for years. This clinical practice guideline will allow physical therapists and other rehabilitation specialists to stay up to date with evolving PFP knowledge and practices, and help them to make evidence-based treatment decisions. J Orthop Sports Phys Ther. 2019;49(9):CPG1-CPG95. doi:10.2519/jospt.2019.0302.

Patterns of Opioid Use in the 12 Months Following Geriatric Fragility Fractures: A Population-Based Cohort Study.

OBJECTIVES: Fractures of the hip, distal radius, and proximal humerus are common in the Medicare population. This study's objective was to characterize patterns and duration of opioid use, including regional variations in use, after both surgical and nonoperative management. DESIGN: Population-based cohort study. SETTING AND PARTICIPANTS: A cohort of opioid-naïve community-dwelling US Medicare beneficiaries who survived a hip, distal radius, or proximal humerus fracture between January 1, 2007 and December 31, 2010. Cohort members were required to be opioid-naïve for 4 months prior to fracture. MEASURES: We analyzed the proportion of patients with an active opioid prescription in each month following the index fracture, and report continued fills at 12 months postfracture. We also compared opioid prescription use in fractures treated surgically and nonsurgically and characterized state-level variation in opioid prescription use at 3 months postfracture. RESULTS: There were 91,749 patients included in the cohort. Hip fracture patients had the highest rate of opioid use at 12 months (6.4%), followed by proximal humerus (5.7%), and distal radius (3.7%). Patients who underwent surgical fixation of proximal humerus and wrist fractures had higher rates of opioid use in each of the first 12 postoperative months compared with those managed nonoperatively. There was significant variation of opioid use at the state level, ranging from 7.6% to 18.2% of fracture patients filling opioid prescriptions 3 months after the index fracture. CONCLUSIONS/IMPLICATIONS: Opioid-naïve patients sustaining fragility fractures of the hip, proximal humerus, or distal radius are at risk to remain on opioid medications 12 months after their index injury, and surgical management of proximal humerus and distal radius fractures increases opioid use in the 12 months after the index fracture. There is significant state-level variation in opiate consumption after index fracture in nonvertebral geriatric fragility fractures. Opportunity exists for targeted quality improvement efforts to reduce the variation in opioid use following common geriatric fragility fractures.

Psychometric Evaluation of the Improved Work-Disability Functional Assessment Battery.

OBJECTIVE: To assess psychometric properties of the improved Work Disability Functional Assessment Battery (WD-FAB 2.0). DESIGN: Longitudinal study. SETTING: Community. PARTICIPANTS: Three samples of working-age (21-66) adults (N=1006): (1) unable to work because of a physical condition (n=375); (2) unable to work because of a mental health condition (n=296); (3) general United States working age sample (n=335). INTERVENTION: NA. MAIN OUTCOME MEASURES: All samples completed the WD-FAB 2.0; the second administration came 5 days after the first. Construct validity was examined by convergent and divergent correlational analysis using legacy measures. Test-retest reliability was assessed by intraclass correlation coefficients (ICC3,1). Standard error of the mean (SEM) and minimal detectable change (MDC90) were calculated to measure scale precision and sensitivity. RESULTS: Physical function ICCs ranged from 0.69 to 0.77 in the general sample, and 0.66 to 0.86 in the disability sample. Mental health function scales ICCs ranged from 0.62 to 0.73 in the general sample, and 0.74 to 0.76 in the disability sample. SEMs for all scales indicated good discrimination; those for the physical function scales were generally lower than those for the mental health scales. MDC90 values ranged from 3.41 to 10.55. Correlations between all WD-FAB 2.0 scales and legacy measures were in the expected direction. CONCLUSIONS: The study provides substantial support for the reliability and construct validity of the WD-FAB 2.0 among 3 diverse samples. Although initially developed for use within the Social Security Administration (SSA), these results suggest that the WD-FAB 2.0 could be used for assessment and measurement of work-related physical and mental health function in other contexts as well.

Retraining Reflexes: Clinical Translation of Spinal Reflex Operant Conditioning.

Neurological disorders, such as spinal cord injury, stroke, traumatic brain injury, cerebral palsy, and multiple sclerosis cause motor impairments that are a huge burden at the individual, family, and societal levels. Spinal reflex abnormalities contribute to these impairments. Spinal reflex measurements play important roles in characterizing and monitoring neurological disorders and their associated motor impairments, such as spasticity, which affects nearly half of those with neurological disorders. Spinal reflexes can also serve as therapeutic targets themselves. Operant conditioning protocols can target beneficial plasticity to key reflex pathways; they can thereby trigger wider plasticity that improves impaired motor skills, such as locomotion. These protocols may complement standard therapies such as locomotor training and enhance functional recovery. This paper reviews the value of spinal reflexes and the therapeutic promise of spinal reflex operant conditioning protocols; it also considers the complex process of translating this promise into clinical reality.

Achilles Pain, Stiffness, and Muscle Power Deficits: Midportion Achilles Tendinopathy Revision 2018.

The Orthopaedic Section of the American Physical Therapy Association (APTA) has an ongoing effort to create evidence-based practice guidelines for orthopaedic physical therapy management of patients with musculoskeletal impairments described in the World Health Organization's International Classification of Functioning, Disability, and Health (ICF). The purpose of these revised clinical practice guidelines is to review recent peer-reviewed literature and make recommendations related to midportion Achilles tendinopathy. J Orthop Sports Phys Ther 2018;48(5):A1-A38. doi:10.2519/jospt.2018.0302.