Physical Therapy Evaluation and Treatment After Concussion/Mild Traumatic Brain Injury.

Over the last decade, numerous concussion evidence-based clinical practice guidelines (CPGs), consensus statements, and clinical guidance documents have been published. These documents have typically focused on the diagnosis of concussion and medical management of individuals post concussion, but provide little specific guidance for physical therapy management of concussion and its associated impairments. Further, many of these guidance documents have targeted specific populations in specific care contexts. The primary purpose of this CPG is to provide a set of evidence-based recommendations for physical therapist management of the wide spectrum of patients who have experienced a concussive event. J Orthop Sports Phys Ther 2020;50(4):CPG1-CPG73. doi:10.2519/jospt.2020.0301.

Measuring Community Mobility in Survivors of Stroke Using Global Positioning System Technology: A Prospective Observational Study.

BACKGROUND AND PURPOSE: Returning to community mobility is important for people recovering from a stroke, yet few studies have directly measured this construct following inpatient rehabilitation. Using global positioning system (GPS) technology, we examined community mobility of survivors of stroke (SS) over the first year after discharge and compared them to an age-matched comparison group without neurological impairment. METHODS: We conducted a prospective observational study that included SS (n = 14) and age- and location-matched comparison subjects (CS; n = 6). All participants identified target locations important to their community mobility goals and wore a GPS unit during the first, fifth and ninth weeks after discharge, or from baseline for CS, and at 26 and 52 weeks' follow up. The 6-minute walk test (SMWT), Berg balance test (BBT), Reintegration to Normal Living (RNLI), and Short Form-36 Quality of Life Survey Physical Functioning domain (SF-36-PF) were collected. Number of trips and percentage of targets visited were extracted from GPS data. RESULTS: Twelve of 14 SS completed 9 weeks, 7 completed the full year, and no CS withdrew. The SS took fewer trips and attained fewer targets compared with CS at weeks 1 and 9, but not at weeks 5, 26, and 52. All 4 clinical outcome measures were significantly correlated to trips (Spearman r for SMWT = 0.5067, BBT = 0.3841, RNLI = 0.4119, and SF-36-PF = 0.4192). DISCUSSION AND CONCLUSIONS: Directly measured community mobility in SS was decreased through 9 weeks following discharge from inpatient rehabilitation. The limited strength of bivariate correlations between clinical measures and number of trips supported the uniqueness of the community mobility construct.Video Abstract available for more insights from the authors (see Supplemental Digital Content 1, available at: http://links.lww.com/JNPT/A277).

Age-Related Differences in Postural and Goal-Directed Movements During Medial-Lateral Rhythmic Stepping.

Lateral stability and weight transfer are important for successful stepping and are associated with falls in older adults (OAs). This study assessed the influence of step pacing frequency during medial-lateral stepping in place on body center of mass and lower limb movement in young adults, middle-aged adults, and OAs. Medial-lateral center of mass and stepping limb motion and lower limb loading data were collected. Center of mass motion decreased with increasing pacing frequency and increased to a lesser extent with decreasing pacing frequency. Step length was relatively resistant to changes in pacing frequency. OAs exhibited reductions in whole body and stepping motion compared with younger adults. OAs exhibited greater support limb loading. OAs adapt both postural and stepping strategies to successfully step under time-critical conditions.

Readiness for Clinical Practice Promoting Safe Student Performance in Physical Therapy Education.

BACKGROUND: Physical therapy educators have a responsibility to graduate entry-level PTs who can provide safe high-quality care. The main purpose of this retrospective study was to determine if students who were not safe on campus have different midterm Clinical Performance Instrument (CPI) safety scores on clinical education experiences (CEEs) than students who were safe on campus. METHODS: Forty-six DPT students were categorized into two safety groups: (1) students who were not safe on campus and had successful safety remediation (n=17) and (2) students who were safe on campus (n=29). Student self-assessment (SSA) and clinical instructor (CI) midterm CPI safety scores were analyzed from 10-week CEEs (Practicum 2, 3, and 4). RESULTS: CPI data show that neither SSA nor CI midterm CPI safety scores were significantly different between safety groups for Practicum 2, 3, and 4 (p>0.05). Students who were not safe on campus had significantly higher Practicum 2 SSA midterm CPI safety scores in the majority outpatient setting (median 12.0) compared to the majority inpatient setting (median 8.5) (p=0.015). CONCLUSION: Early identification and formal remediation of safety concerns on campus can lead to suc¬cessful safety performance during CEEs.

Community mobility after stroke: a systematic review.

Background Stroke is the leading cause of severe disability and many survivors report long-term physical or cognitive impairments that may impact their ability to achieve community mobility (CM). PURPOSE: To determine the extent to which people with chronic stroke achieve CM compared to age-matched norms or non-neurologically impaired controls. Methods The StrokEDGE outcome measures were searched to identify validated tools that included >25% of items addressing CM. MEDLINE, CINAHL, Google Scholar, PubMed, PEDro and the Cochrane databases were searched from 2001 to 2015 with the identified outcome measures cross-referenced against search terms related to stroke and CM. INCLUSION CRITERIA: utilized a validated CM outcome measure, chronic (>3 months post) stroke survivors, and randomized controlled trial, observational or cohort study design. One reviewer screened the studies and performed data extraction and three performed quality appraisal. Fourteen studies met all inclusion criteria. Results Stroke survivors have impaired CM as demonstrated by 30-83% of normative or non-stroke subject CM scores. As time post-stroke increased, CM improved only slightly. Factors found to correlate with the CM were age, education, general well-being, emotional state, motor function and coordination, independence in activities of daily living, balance, endurance and driving status. Limitations of this review include a relatively high functioning cohort, no meta-analysis and reliance on outcome measures not specifically designed to measure CM. Conclusion Survivors of stroke may experience a significant decrease in CM compared to people without neurological injury. Rehabilitation addressing motor function, coordination, independence in activities of daily living, balance and endurance may be important for achieving higher levels of CM. Outcome measures directly addressing CM are needed.

Management of falls in community-dwelling older adults: clinical guidance statement from the Academy of Geriatric Physical Therapy of the American Physical Therapy Association.

BACKGROUND: Falls in older adults are a major public health concern due to high prevalence, impact on health outcomes and quality of life, and treatment costs. Physical therapists can play a major role in reducing fall risk for older adults; however, existing clinical practice guidelines (CPGs) related to fall prevention and management are not targeted to physical therapists. OBJECTIVE: The purpose of this clinical guidance statement (CGS) is to provide recommendations to physical therapists to help improve outcomes in the identification and management of fall risk in community-dwelling older adults. DESIGN AND METHODS: The Subcommittee on Evidence-Based Documents of the Practice Committee of the Academy of Geriatric Physical Therapy developed this CGS. Existing CPGs were identified by systematic search and critically appraised using the Appraisal of Guidelines, Research, and Evaluation in Europe II (AGREE II) tool. Through this process, 3 CPGs were recommended for inclusion in the CGS and were synthesized and summarized. RESULTS: Screening recommendations include asking all older adults in contact with a health care provider whether they have fallen in the previous year or have concerns about balance or walking. Follow-up should include screening for balance and mobility impairments. Older adults who screen positive should have a targeted multifactorial assessment and targeted intervention. The components of this assessment and intervention are reviewed in this CGS, and barriers and issues related to implementation are discussed. LIMITATIONS: A gap analysis supports the need for the development of a physical therapy-specific CPG to provide more precise recommendations for screening and assessment measures, exercise parameters, and delivery models. CONCLUSION: This CGS provides recommendations to assist physical therapists in the identification and management of fall risk in older community-dwelling adults.

Monitoring community mobility with global positioning system technology after a stroke: a case study.

BACKGROUND: Stroke survivors often experience difficulty returning to activities and places they deem important to their social, leisure, and occupational aspirations. The extent to which stroke survivors return to community mobility and their ability to navigate and access locations they deem meaningful have not been objectively measured. PURPOSE: We used global positioning system technology (GPSt) to measure the community mobility of a person poststroke, and assess the relationship between GPSt measures and clinical measures of mobility. METHODS: : The participant was a 56-year-old man who sustained a right pontine stroke. At discharge from rehabilitation, his Six-Minute Walk Test distance was 73 m. He was fitted with a GPS unit and an accelerometer attached to a single belt and instructed to wear the devices at all times when out of bed. After identifying 10 locations that were important to his goals, he was monitored for 5 separate 1-week periods, on the first, fifth, and ninth weeks and at 6 and 12 months after discharge. RESULTS: During the first 10 weeks, he averaged 7.6 target visits (70%) and 26.7 trips per week. At 1 year, his Six-Minute Walk distance score was 287.5 m. Accelerometry data revealed that he remained primarily sedentary. Target visits and trips per week did not change substantially over the course of 1 year, and compliance wearing the GPS unit was variable. CONCLUSIONS: Given the limited correlation in gait speed and distance with target attainment and trips, these outcomes likely measure different constructs for this subject. GPSt may offer insights into participation for stroke survivors following rehabilitation.

Lateral rhythmic unipedal stepping in younger, middle-aged, and older adults.

PURPOSE: Voluntary and protective stepping performance changes with age. This has implications for the problem of falls in older adults. The purpose of this study was to examine the influence of metronome paced stepping practice on self-selected preferred rhythmic unipedal stepping performance in the medial-lateral direction among younger, middle-aged and older adults. METHODS: Thirty-two healthy adult subjects (0 younger, 0 middle-aged, 2 older) participated. They performed rhythmic lateral stepping with their dominant limb at their preferred pace before and after 6 trials of metronome-paced stepping. RESULTS: Older subjects had longer stride periods than young and middle-aged subjects prior to metronome pacing. Older subjects exhibited a 25% decrease in preferred stride period between pre- and postpacing trials. This is compared to a 5% and 11 % decrease exhibited by middle-aged and younger subjects respectively. Preferred stride period was similar for older subjects as compared to younger and middle-aged subjects after paced practice. Modification of the stride period occurred mainly during the stance phase of rhythmic stepping. CONCLUSIONS: Comparable stride periods across groups after pacing suggest stepping performance is modifiable. Brief intervals of paced stepping may offer older adults a short-term benefit to stepping performance.

Base of support feedback in gait rehabilitation.

The purpose of this study was to investigate the effect of feedback information about base of support in gait rehabilitation. Sixteen individuals with hemiparesis resulting in narrow base of support, were randomly placed into two equal groups, experimental and control. The experimental group was provided with a portable device that provided extrinsic auditory feedback information about base of support incorporated in the functional context of conventional gait therapy, whereas the control group received a conventional gait therapy only. Changes in step width with treatment were assessed with step print technique. The experimental group of subjects improved their step width with treatment from 0.09 +/- 0.003 m to 0.16 +/- 0.006 m while individuals assigned to the control group showed smaller improvement from 0.099 +/- 0.004 m to 0.13 +/- 0.003 m. While both groups demonstrated statistically significant improvement (p < 0.05), the level of recovery of step width seen in the experimental group was greater.