Validity and reliability of the 20-m run, horizontal leap, and four-bound tests measuring high-level mobility in neurologically impaired patients.

BACKGROUND: High-level mobility (HLM) training including running forms an integral part of physical rehabilitation for neurologically impaired patients. OBJECTIVE: This study examines the validity and reliability of three quickly administrable measures of HLM, namely, the 20-m run, horizontal leap, and four-bound tests in patients with neurological disorders. METHODS: This is a retrospective data audit of 62 patients (23 women, 37.1%; 39 men, 62.9%) participating in the HLM (running retraining) task. All participants were recovering from neurological conditions such as stroke, brain injury, brain/spinal tumour, Guillain-Barré syndrome, and cerebral palsy complications. RESULTS: High levels of test-retest reliability of the investigated tests (interclass correlation coefficient > 0.95) were obtained. The 95% minimum detectable changes were as follows: 20-m run, 1.9 seconds; horizontal leap, 0.20 m; four-bound test, 0.57 m. The area under the receiver-operated characteristic curve was 0.96 for the 20-m run, 0.90 for the horizontal leap, and 0.91 for the four-bound test, which suggests high validity of the tests to discriminate between participants who were classified as "running" and those as "not running". Participants performing at < 7.2 seconds for the 20-m run test or ≥ 0.75 m for the horizontal leap test or 4.0 m for the four-bound test were most likely classified as running. CONCLUSION: The 20-m run, horizontal leap, and four-bound tests are valid and reliable objective measures of HLM when administered in people with neurological conditions.

Gait classification in a population of adults with hereditary spastic paresis.

BACKGROUND: Classification of gait in adults with hereditary spastic paresis is limited. Our aim was to use a previously established system to classify gait. METHODS: Forty-nine participants were retrospectively recruited and grouped into existing classifications based on sagittal plane knee joint kinematic data extracted from a 3D analysis. Waveform analysis was used to compare the grouped data to determine if and where differences in the subjective classifications appeared. FINDINGS: Classification of gait patterns in adults with hereditary spastic paresis is successful. Differences between groups in line with the classification system were confirmed by statistical analysis. Crouch gait is illustrated by a flexed knee throughout stance phase. Recurvatum gait is dominated by knee hyperextension in mid-late stance. Stiff-knee gait demonstrates limited knee range of motion in stance and jump-knee gait is characterised by less knee flexion in early and mid-stance phase than all groups. Sagittal plane hip and ankle kinematics compliment group differences at the knee joint. The jump-knee group is more flexed at the hip than all groups during loading response phase and mid-stance; and the recurvatum group is more extended at the hip than the crouch, jump-knee, and stiff-knee groups during mid and late-stance phase. There is less ankle dorsiflexion throughout stance phase in the recurvatum group than in all other groups. INTERPRETATION: Sagittal plane knee joint kinematic data can be subjectively used to classify gait features in adults with hereditary spastic paresis. Novel analysis show hip and ankle sagittal plane kinematics can be used to further assist classification.

Three short sessions of physiotherapy during rehabilitation after hip fracture were no more effective in improving mobility than a single longer session: a randomised controlled trial.

OBJECTIVES: To determine if three short daily sessions of physiotherapy for rehabilitation inpatients after hip fracture is more effective than providing one long daily session in improving mobility. DESIGN: A single-blinded randomised controlled trial. SETTING: Two inpatient rehabilitation wards at a hospital in Melbourne, Australia. PARTICIPANTS: Seventy-six rehabilitation inpatients after hip fracture. The key exclusion criterion was not being allowed to weight bear. INTERVENTIONS: All participants received multidisciplinary rehabilitation. Experimental participants received three 15-minute sessions of physiotherapy 5 days per week until discharge. Control participants received one 45-minute session of physiotherapy 5 days per week until discharge. MAIN OUTCOME MEASURES: The primary outcome, mobility, was assessed with the de Morton Mobility Index 2 weeks after admission and at discharge. Secondary outcomes were Functional Independence Measure mobility (transfers, ambulation, steps), physical activity measured with an accelerometer, length of stay, discharge destination, readmissions within 30 days of discharge, and patient and physiotherapist satisfaction. RESULTS: Sixty-seven (88%) participants completed mobility assessment at discharge and 34 (45%) at 2 weeks. There were a greater proportion of missed sessions in the experimental group (84% adherence vs 95%). There was no between-group difference in mobility at discharge (MD -1.9 points, 95%CI-6.9 to 3.2) or at 2 weeks (MD -3.5 points, 95%CI-15.4 to 8.4). There were no between-group differences in any secondary outcomes. CONCLUSIONS: Providing inpatient physiotherapy rehabilitation in three shorter sessions resulted in more missed sessions and likely did not improve mobility outcomes compared with providing one longer session for patients recovering from hip fracture. CLINICAL TRIAL REGISTRATION NUMBER: ACTRN 12617000863336.

Physiotherapists Prefer Clinical Supervision to Focus on Professional Skill Development: A Qualitative Study.

Purpose: We explored physiotherapists' perceptions of clinical supervision. Method: Individual semi-structured interviews were conducted with a purposive sample of 21 physiotherapists from a public hospital. Qualitative analysis was undertaken using an interpretive description approach. The Manchester Clinical Supervision Scale (MCSS-26) was administered to evaluate the participants' perceptions of the effectiveness of the clinical supervision they had received and to establish trustworthiness in the qualitative data by means of triangulation. Results: The major theme was that the content of clinical supervision should focus on professional skill development, both clinical and non-clinical. Four subthemes emerged as having an influence on the effectiveness of supervision: the model of clinical supervision, clinical supervision processes, supervisor factors, and supervisee factors. All sub-themes had the potential to act as either a barrier to or a facilitator of the perception that clinical supervision was effective. Conclusions: Physiotherapists reported that clinical supervision was most effective when it focused on their professional skill development. They preferred a direct model of supervision, whereby their supervisor directly observed and guided their professional skill development. They also described the importance of informal supervision in which guidance is provided as issues arise by supervisors who value the process of supervision. Physiotherapists emphasized that supervision should be driven by their learning needs rather than health organization processes.

Objectif : explorer les perceptions des physiothérapeutes à l'égard de la supervision clinique. Méthodologie : entrevues individuelles semi-structurées réalisées auprès d'un échantillon choisi de 21 physiothérapeutes d'un hôpital public. Les chercheurs ont procédé à une analyse qualitative au moyen d'une description interprétative. Ils ont utilisé l'échelle de supervision clinique de Manchester (MCSS­26) pour évaluer les points de vue des participants à l'égard de l'efficacité de la supervision et pour établir la fiabilité des données qualitatives par triangulation. Résultats : un thème majeur est ressorti : la supervision clinique devrait être axée sur le perfectionnement d'habiletés professionnelles cliniques et non cliniques. Il a été établi que quatre sous-thèmes avaient une influence sur l'efficacité de la supervision : le modèle de supervision clinique, les processus de supervision clinique, les facteurs liés au superviseur et ceux liés au supervisé. Ces sous-thèmes avaient tous le potentiel d'être un obstacle ou un incitatif à la perception d'efficacité de la supervision clinique. Conclusion : selon les physiothérapeutes, la supervision clinique la plus efficace était axée sur le perfectionnement de leurs habiletés professionnelles. Ils préféraient un modèle de supervision directe, selon lequel leur superviseur observait directement et orientait le perfectionnement de leurs habiletés professionnelles. Ils ont également insisté sur l'importance de la supervision informelle, c'est-à-dire que les superviseurs qui adhèrent à l'importance du processus de supervision donnent des conseils à mesure que des problèmes surgissent. Ils ont souligné que la supervision devrait être dictée par leurs besoins d'apprentissage plutôt que par les processus de l'organisation hospitalière.

Direct supervision of physiotherapists improves compliance with clinical practice guidelines for patients with hip fracture: a controlled before-and-after study.

Purpose: To determine if the addition of direct supervision to usual clinical supervision practice of physiotherapists can improve compliance with clinical practice guidelines and post-surgical outcomes for inpatients with hip fracture.Methods: A controlled before-and-after study was conducted on two acute orthopedic wards. Junior and mid-level physiotherapists on one ward were provided with direct supervision during their post-operative management of patients with hip fracture. Physiotherapists on the comparison ward received usual reflective supervision. The primary outcome was patient compliance with the hip fracture guideline to mobilize on the day following surgery. Secondary patient outcomes included physical function on the fifth post-operative day.Results: Data were collected from 290 patients with acute hip fracture. Patients at the direct supervision site were more likely to mobilize on the day after surgery [OR 3.14, 95% confidence interval (CI) 1.41-7.01; p = 0.005] and by the second post-operative day (OR 4.62, 95% CI 2.31-9.23; p < 0.001) compared to patients at the comparison site. Patients walked further on the fifth post-operative day (p < 0.001) with less assistance from therapists (p = 0.044).Conclusions: The addition of direct supervision improved physiotherapists' compliance with hip fracture guidelines and walking endurance and independence in hospitalized patients with hip fracture.Implications for rehabilitationThe addition of a direct supervision model, where physiotherapists are directly observed in their management of patients with hip fracture, to usual practice supervision improved early mobilization of patients with hip fractureDirect supervision appears to be an effective guideline implementation strategy that can improve care and outcomes for hospitalized patients with hip fracture.

The association between effectiveness of clinical supervision of allied health professionals and improvement in patient function in an inpatient rehabilitation setting.

Purpose: Clinical supervision is widely accepted as an important element of practice for allied health professionals to ensure a high quality of patient care. However, it is unknown whether effective clinical supervision of allied health professionals improves patients' outcomes. This study investigated whether effective clinical supervision of allied health professionals is associated with improved patient functional independence. Methods: A prospective longitudinal study design and multi-level regression analysis were used to explore the association between effective clinical supervision and patient functional independence. The effectiveness of clinical supervision was assessed using the Manchester Clinical Supervision Scale. Functional improvement in patients treated by allied health professionals was measured utilising the mobility and self-care subscales of the functional independence measure.Results: Physiotherapists (n = 27) and occupational therapists (n = 26) in inpatient rehabilitation were recruited and the medical records of their patients (n = 1846) audited. The effectiveness of clinical supervision of physiotherapists was positively associated with improvement in personal care. Therapist variables accounted for less than 2.5% of the variation in patient improvement in functional independence.Conclusions: Effectiveness of a reflective model of clinical supervision of physiotherapists and occupational therapists was not associated with an improvement in their patients' mobility or personal care, respectively.Implications for rehabilitationEffective clinical supervision of physiotherapists and occupational therapists using a reflective model of practice is a poor predictor of improved functional independence in rehabilitation inpatients.Patient variables, such as the intensity of therapy, were more important predictors of patient functional improvement than effective clinical supervision.Initiatives aimed at increasing intensity of therapy will likely have a greater effect on improving patient functional independence compared with initiatives aimed at improving the effectiveness of clinical supervision using a reflective model of practice.Initiatives to improve the effectiveness of clinical supervision in improving quality of care could explore the use of a direct model of practice where supervisors directly observe and support supervisees during patient treatment sessions.

Saturday allied health services for geriatric evaluation and management: A controlled before-and-after trial.

OBJECTIVE: To assess the effect of Saturday allied health services on a geriatric evaluation and management ward. METHODS: A controlled before-and-after trial at two wards. Allied health services were added to usual weekday staffing on Saturdays for 6 months on the experimental ward. Length of stay, functional independence, readmissions, discharge destination and costs were evaluated at pre-intervention (N = 331) and intervention (N = 462). RESULTS: Relative to the comparison ward, the experimental ward had longer length of stay (mean 7.8 days, 95% CI 4.7-10.8), fewer readmissions (mean 3.1 days, 95% CI 0.6-5.7) and no difference in the proportion discharged home. Cost-effectiveness demonstrated no significant difference in cost ($2639, 95% CI $-386 to $5647) and functional independence gain (3.6 units, 95% CI 0.8-6.5) favouring the experimental ward. CONCLUSION: These findings do not support the provision of additional Saturday allied health services in geriatric evaluation and management to reduce length of stay.

The validity, reliability, responsiveness and minimal clinically important difference of the de Morton mobility index in rehabilitation.

PURPOSE: Determine the clinimetric properties of the de Morton Mobility Index (DEMMI) in an adult inpatient rehabilitation population. METHOD: Prospective open cohort case series. DEMMI and functional independence measure assessed within three days of admission and discharge and seven-point Likert assessment of global change in mobility during inpatient rehabilitation reported by the patient, physical therapist and rehabilitation physician. RESULTS: A total of 366 patients had assessments of the DEMMI completed on both admission into and discharge from rehabilitation. There was no floor or ceiling effect observed in the sample, but there was a mild (19%) ceiling effect at discharge in patients with a stroke. Evidence was obtained for the convergent, discriminant and known group validity of the DEMMI. The minimal clinically important difference was obtained using two methods. The DEMMI was highly responsive to change (Cohen's d = 1.3). CONCLUSIONS: The findings give support to the use of the DEMMI in rehabilitation patients and on the basis of previous studies, support the use of the DEMMI across the continuum of hospital settings. Implications for rehabilitation This study provides evidence that the clinimetric properties of the de Morton Mobility Index (DEMMI) are sound. The findings give support to the use of the DEMMI in rehabilitation patients. Our findings, in conjunction with previous research, support the use of the DEMMI across the continuum of hospital settings.

A comparison of two comorbidity indices for predicting inpatient rehabilitation outcomes.

BACKGROUND: Comorbid conditions are important in health care. The best comorbidity index for predicting the impact of comorbidities on rehabilitation outcomes has not been determined. AIM: Compare the associations of comorbidity measured using the Charlson Comorbidity Index (CCI) and the Cumulative Index Rating Scale (CIRS) with key rehabilitation outcomes. Aim was to determine whether either of these comorbidity indices helped explain the variation in key rehabilitation outcomes. DESIGN: Prospective open-cohort study. SETTING: Inpatient rehabilitation ward, Melbourne, Australia. POPULATION: Adults admitted for inpatient rehabilitation (N.=280). METHODS: The main outcomes were demographic (e.g. age, gender, discharge destination) and clinical outcomes (reason for rehabilitation, length of stay, LOS, Functional Independence Measure, CCI and CIRS). A series of regression analyses were performed to determine the influence of comorbidity on three dependent variables: 1) LOS in rehabilitation; 2) the change in Functional Independence Measure-motor score between rehabilitation discharge and admission; 3) the discharge destination (home vs. other). RESULTS: The mean age was 57.7 years, there were slightly more females (51%), most (95%) patients previously lived at home with family or other relatives (63%). The most common reason for rehabilitation was orthopedic or other conditions (52%) and most (80%) people were discharged home. The median LOS was 27 days. There were 100 (35.7%) patients who had no comorbidity recorded using the CCI, 112 (40.0%) had one comorbidity and 26 (9.3%) who had three or more. All patients had at least one comorbidity recorded with the CIRS, and 264 (94.3%) had 3 or more comorbidities. There was little or no difference between the CCI or CIRS in terms of their ability to explain the variance in LOS (adjusted R2=0.38 with and without comorbidities), change in disability during rehabilitation (adjusted R2=0.31-0.33 with and without comorbidities) or the discharge destination (AUC=0.72 without comorbidities; 0.73-0.74 with comorbidities) beyond that accounted for by demographic and clinical information. CONCLUSIONS: Neither the CIRS nor the CCI in our patient sample provide additional information that explains the impact of comorbidities on key rehabilitation outcomes. CLINICAL REHABILITATION IMPACT: Further research is needed to determine the most appropriate measure of comorbidity of relevance to inpatient rehabilitation outcomes.