Integrating Motor Variability Evaluation Into Movement System Assessment.

Common assessment tools for determining therapeutic success in rehabilitation typically focus on task-based outcomes. Task-based outcomes provide some understanding of the individual's functional ability and motor recovery; however, these clinical outcomes may have limited translation to a patient's functional ability in the real world. Limitations arise because (1) the focus on task-based outcome assessment often disregards the complexity of motor behavior, including motor variability, and (2) mobility in highly variable real-world environments requires movement adaptability that is made possible by motor variability. This Perspective argues that incorporating motor variability measures that reflect movement adaptability into routine clinical assessment would enable therapists to better evaluate progress toward optimal and safe real-world mobility. The challenges and opportunities associated with incorporating variability-based assessment of pathological movements are also discussed. This Perspective also indicates that the field of rehabilitation needs to leverage technology to advance the understanding of motor variability and its impact on an individual's ability to optimize movement. IMPACT: This Perspective contends that traditional therapeutic assessments do not adequately evaluate the ability of individuals to adapt their movements to the challenges faced when negotiating the dynamic environments encountered during daily life. Assessment of motor variability derived during movement execution can address this issue and provide better insight into a patient's movement stability and maneuverability in the real world. Creating such a shift in motor system assessment would advance understanding of rehabilitative approaches to motor system recovery and intervention.

Excellence in Academic Physical Therapy: Promoting a Culture of Data Sharing.

BACKGROUND AND PURPOSE: Data analytics are increasingly important in health professions education to identify trends and inform organizational change in rapidly evolving environments. Unfortunately, limitations exist in data currently available to determine physical therapy (PT) academic excellence. It is imperative that the American Council of Academic Physical Therapy (ACAPT) be able to demonstrate data-informed progress in addressing the common challenges faced by Doctor of Physical Therapy programs. POSITION AND RATIONALE: The Task Force to Explore Data and Technology to Evaluate Program Outcomes was convened by ACAPT to explore current and desired data and the needs, technology, and costs that would be required for ACAPT to assess program outcomes relative to excellence criteria. The Task Force performed a gap analysis of measures of excellence, provided evidence-based recommendations for advancing the use of data and technology systems in academic PT, and generated a comprehensive Assessment Excellence Map that subsequently led to a new streamlined Excellence Framework in the launch of the ACAPT Center for Excellence. DISCUSSION AND CONCLUSION: The vision of universal excellence in PT education necessitates clear alignment and centralization of common data to support efficient processes to assess excellence. The transformative nature of data is untapped in PT academic endeavors, and nascent work to establish and sustain a culture of centralized data sharing and assessment will help to drive program-level and profession-level excellence in PT education.

Crises as the Crucible for Change in Physical Therapist Education.

This Perspective issues a challenge to physical therapists to reorient physical therapist education in ways that directly address the crises of COVID-19 and systemic racism. We advocate that professional education obligates us to embrace the role of trusteeship that demands working to meet society's needs by producing graduates who accept their social and moral responsibilities as agents and advocates who act to improve health and health care. To achieve this, we must adopt a curriculum philosophy of social reconstruction and think more deeply about the why and how of learning. Currently, health professions education places strong emphasis on habits of head (cognitive knowledge) and hand (clinical skills) and less focus on habits of heart (professional formation). We believe that habits of heart are the essential foundations of the humanistic practice needed to address health inequities, find the moral courage to change the status quo, and address imbalances of power, privilege, and access. A social reconstruction orientation in physical therapist education not only places habits of heart at the center of curricula, but it also requires intentional planning to create pathways into the profession for individuals from underrepresented groups. Adopting social reconstructionism begins with a faculty paradigm shift emphasizing the learning sciences, facilitating learning, metacognition, and development of a lifelong master adaptive learner. Achieving this vision depends not only on our ability to meet the physical therapy needs of persons with COVID-19 and its sequalae but also on our collective courage to address injustice and systemic racism. It is imperative that the physical therapy community find the moral courage to act quickly and boldly to transform DPT education in ways that enable graduates to address the social determinants of health and their systemic and structural causes that result in health disparities. To succeed in this transformation, we are inspired and strengthened by the example set by Geneva R. Johnson, who has never wavered in recognizing the power of physical therapy to meet the needs of society.

Change in Depression, Confidence, and Physical Function Among Older Adults With Mild Cognitive Impairment.

BACKGROUND AND PURPOSE: Nearly a quarter of those in the United States older than 71 years experience mild cognitive impairment. Persons with mild cognitive impairment battle depression and progressive disengagement from daily activities, which contribute to participation restriction and activity limitation. Daily engagement in meaningful activity (DEMA) is a tailored intervention designed to benefit persons with mild cognitive impairment and their caregivers through preserved engagement and supported adjustment to cognitive changes. This secondary analysis was guided by the International Classification of Functioning, Disability and Health (ICF) model. Aims were to (i) explore the extent to which change in self-rated activity performance and physical function can predict change in depressive symptoms, (ii) evaluate for difference in confidence and depressive symptoms at ICF levels of activity and participation, and (iii) quantify the impact of daily engagement at the ICF level of participation on physical function. METHODS: A secondary analysis was conducted using data from the parent study, which was a 2-group randomized trial involving persons with mild cognitive impairment and their informal caregivers participating in the Indiana Alzheimer Disease Center DEMA program. Quantitative analysis (dyads: DEMA N = 20, Information Support N = 20) examined outcomes at posttest and follow-up. Analysis employed linear regression to model the relationship between explanatory and dependent variables and independent t test to examine for difference in confidence, depression, and physical function. RESULTS AND DISCUSSION: At posttest, change in self-rated performance predicted change in depressive symptoms. Those in the DEMA group who engaged in activity at the ICF level of participation demonstrated a significant increase in confidence and physical function. Although not significant, the control group posttest results showed a mean decrease in confidence. CONCLUSIONS: Results demonstrate a positive impact of DEMA on depressive symptoms, confidence, and physical function. Change in occupational performance predicted change in depressive symptoms. Confidence significantly improved among those who engaged at the ICF participation level. A larger, randomized controlled longitudinal trial is needed to better assess the impact of DEMA on physical function, activity, participation restriction, and quality of life.

A Volunteer Basketball Clinic for Children with Disabilities: Professional Development Impact on Student-Athletes and Physical Therapy Students.

The purpose of this study was to assess the change in perceptions of student-athletes, physical therapy students, and parents of children who helped to facilitate an athletic skills camp for children with disabilities. Participants experienced 3 hours of basketball activity yearly. Data were collected for 3 consecutive years from a total of 51 parents, 15 student-athletes, and 22 physical therapy students. Pre- and post-survey data were evaluated by two independent researchers. Common themes were developed for all participant groups and cross-group comparisons were evaluated. Findings indicated a synergistic benefit for student-athletes and physical therapy students derived from their impact and children with disabilities. Perceptual changes in students included a decrease in fear in working with disabled children, an appreciation for the value of having fun, and increased growth in civic identity and desire to volunteer.

The effect of random or sequential presentation of targets during robot-assisted therapy on children.

BACKGROUND: Robot assisted upper extremity therapy has been shown to be effective in adult stroke patients and in children with cerebral palsy (CP) and other acquired brain injuries (ABI). The patient's active involvement is a factor in its efficacy. However, this demands focused attention during training sessions, which can be a challenge for children. OBJECTIVE: To compare results of training requiring two different levels of focused attention. Differences in short term performance and retention of gains as a function of training protocol as measured by the Fugl-Meyer (FM) were predicted. METHODS: Thirty-one children with CP or ABI were randomly divided into two groups. All received 16 one hour sessions of robot-assisted therapy (twice a week for 8 weeks) where they moved a robot handle to direct a cursor on the screen toward designated targets. One group had targets presented sequentially in clockwise fashion, the other presented in random order. Thus, one group could anticipate the position of each target, the other could not. RESULTS: Both groups showed significant functional improvement after therapy, but no significant difference between groups was observed. CONCLUSIONS: Assist-as-needed robotic training is effective in children with CP or ABI with small non-significant differences attributed to attentional demand.

Examination of sustained gait speed during extended walking in individuals with chronic stroke.

OBJECTIVES: To determine if individuals with chronic stroke were able to sustain their peak gait speed during the 6-minute walk test (6MWT), and to explore this sustainability across community ambulation potential subgroups. DESIGN: Prospective cross-sectional study. SETTING: University-based research laboratory, hospitals, and stroke support groups. PARTICIPANTS: A sample of individuals with chronic stroke (N=48) completed a series of questionnaires and physical outcome measures, including gait mat assessment, during a single visit. INTERVENTIONS: Not applicable; 1-time cross-sectional data collection. MAIN OUTCOME MEASURES: During the 6MWT, we measured peak gait speed and end gait speed to assess sustainability, along with beginning gait speed, total distance walked, and rating of perceived exertion. We also assessed maximum gait speed during the 10-meter walk test (10MWT). Finally, we examined these gait outcomes across the subgroups. RESULTS: During the 6MWT, peak gait speed declined from .89m/s (SD=.38) to an end speed of .82m/s (SD=.36), whereas perceived exertion increased from 7.7 (SD=2.6) to 11.8 (SD=3.6). This peak gait speed was slower than the 10MWT maximum speed of 1.06m/s (SD=.51), but faster than the 6MWT beginning speed of .81m/s (SD=.34). The unlimited community ambulator subgroup was the primary contributor to sustainability differences. CONCLUSIONS: Predicting community ambulation potential based on the discrete gait speed from the 10MWT and endurance based on the average from the 6MWT might be incomplete if gait speed sustainability is not also assessed.

Balance is associated with quality of life in chronic stroke.

OBJECTIVE: To investigate the association between balance and quality of life (QOL) in chronic stroke survivors by (1) examining the associations between balance and QOL scores; (2) identifying the frequency of balance impairment and poststroke falls; and (3) determining the differences in QOL scores between persons with and those without balance impairment. METHODS: This is a secondary analysis of a cross-sectional study. People who had a stroke more than 6 months earlier from 3 Midwest states were included in the study if they met the following criteria: were referred to occupational or physical therapy for poststroke physical deficits; had self-reported stroke-related physical deficits; completed all stroke-related rehabilitation; had residual functional disability; had a score of ≥4 out of 6 on the short 6-item Mini-Mental State Examination; and were between 50 and 85 years old (n = 59). The main outcome measures included the Berg Balance Scale (BBS) to assess balance and the Stroke Specific Quality of Life Scale (SS-QOL) to assess QOL. Number of falls since stroke was self-reported. RESULTS: Mean BBS score was 44 ± 8 and mean SS-QOL score was 46 ± 8; these scores were significantly correlated (r = .394, P = .002). Seventy-six percent of the sample reported a fall since stroke. Persons with balance impairment (BBS score ≤46; n = 29; 49%) had an average BBS score of 39 ± 7 and significantly worse SS-QOL scores than those without balance impairment (42 ± 8 vs 49 ± 7; P = .001). CONCLUSION: In the chronic stroke population, balance impairment and fall risk are associated with lower QOL scores. If balance can be improved and maintained into the chronic phases of stroke, it is likely that individuals will benefit with improved QOL.

Fatigue and pain: relationships with physical performance and patient beliefs after stroke.

BACKGROUND: Fatigue and pain are common after stroke, potentially impacting stroke recovery. OBJECTIVE: This study examines the frequency and impact of fatigue and pain in people with chronic stroke. METHOD: Seventy-seven people with chronic stroke completed a one-time assessment consisting of a battery of self-report and performance tools to describe and quantify mobility issues post stroke. We assessed the proportion of individuals with fatigue and pain and the relationship between fatigue and pain and other variables including gait (10-meter walk and 6-minute walk test), balance (Berg Balance Scale), activity and participation (ICF Measure of Participation and Activities), chronic disease self-efficacy (Chronic Disease Self-Efficacy Scale), and balance self-efficacy (Activity-Specific Balance Confidence Scale). Additionally, subgroup comparisons were made between participants with and without coexisting fatigue and pain. RESULTS: Fatigue and pain were reported by 66% and 45% of study participants, respectively. Thirty-four percent of the sample reported co-existing fatigue and pain. Participants with coexisting fatigue and pain demonstrated significantly lower chronic disease and balance self-efficacy and decreased activity than participants without coexisting fatigue and pain. Individually, fatigue correlated with balance, chronic disease self-efficacy, balance self-efficacy, activity, and participation, whereas pain correlated with chronic disease self-efficacy, balance self-efficacy, and activity. CONCLUSION: Fatigue and pain are common after stroke and are negatively correlated with outcomes important to rehabilitation. Efforts focused on examining the impact of interventions on fatigue and pain are warranted. It is possible that changes to these body structure limitations could positively impact functional recovery and community re-entry after stroke.

Is walking faster or walking farther more important to persons with chronic stroke?

PURPOSE: The purposes of this mixed-methods study were to (1) investigate whether walking faster or walking farther was more important for getting "out and about" to persons with chronic stroke and (2) explore explanations for walking preferences. METHOD: A convenience sample of 77 adults with chronic stroke completed questionnaires and walking outcomes in one visit. Participants were asked whether walking faster or farther was more important to them for getting "out and about", and differences between response groups (faster vs. farther) were evaluated. Participants also described their preference for walking faster or farther. Qualitative responses were analyzed using content analysis. RESULTS: The majority of participants (76%; n = 58) reported walking farther was more important, while 18% (n = 14) reported walking faster was more important. Statistically significant differences were not found between response groups for any variable. Primary themes identified from participant preferences for walking faster included: (1) faster speed equals better walking ability and (2) getting places faster/quicker. Primary themes from preferences for walking farther included: (1) engaging in activity and participation within home and community; (2) walking farther at a slower pace; and (3) fatigue with walking. CONCLUSIONS: Individual preferences for walking faster versus walking farther by persons with chronic stroke should be considered by clinicians when making decisions for rehabilitation. IMPLICATIONS FOR REHABILITATION: • Individual preferences for walking faster versus walking farther by patients with chronic stroke should be considered by rehabilitation clinicians when making decisions about examination and intervention. • The majority of participants with chronic stroke in this study indicated the importance of walking farther in order to better engage in activities both at home and away from home. • Interventions that focus on improving endurance and energy conservation may need to be used for persons with chronic stroke who want to walk father in order to maximize their potential for walking longer distances.

Poststroke balance improves with yoga: a pilot study.

BACKGROUND AND PURPOSE: Balance impairment is common after stroke; modified yoga may be able to improve balance and other important poststroke variables. Scientific-evidence is needed to support such treatment interventions. The purpose of this study was to assess the impact of a yoga-based rehabilitation intervention on balance, balance self-efficacy, fear of falling (FoF), and quality of life after stroke. METHODS: This was a prospective, randomized, pilot study of yoga-based rehabilitation for people with chronic stroke. All yoga sessions were taught by a registered yoga therapist, occurred twice per week for 8 weeks and included seated, standing, and floor postures with relaxation and meditation. Balance was assessed with the Berg Balance Scale, balance self-efficacy with the Activities-specific Balance Confidence Scale, FoF with a dichotomous yes/no question, and quality of life with the Stroke Specific Quality of Life scale. RESULTS: There were no significant differences between wait-list control (n=10) and yoga (n=37) groups in baseline or follow-up scores. However, using within-group comparisons, yoga group data demonstrated significant improvement in balance (Berg Balance Scale, 41.3±11.7 vs 46.3±9.1; P<0.001) and FoF (51% vs 46% with FoF; P<0.001). CONCLUSIONS: A group yoga-based rehabilitation intervention for people with chronic stroke has potential in improving multiple poststroke variables. Group yoga may be complementary to rehabilitation, may be possible in medical-based and community-based settings, and may be cost-effective. Further testing of group yoga-based rehabilitation interventions is warranted. Clinical Trial Registration- URL: http://clinicaltrials.gov. Unique Identifier: NCT01109602.

Balance and balance self-efficacy are associated with activity and participation after stroke: a cross-sectional study in people with chronic stroke.

OBJECTIVES: To (1) examine the relationships between multiple poststroke mobility variables (gait speed, walking capacity, balance, balance self-efficacy, and falls self-efficacy) and activity and participation; and (2) determine which poststroke mobility variables are independently associated with activity and participation. DESIGN: This is the primary analysis of a prospective cross-sectional study completed to understand the impact of mobility on activity and participation in people with chronic stroke. SETTING: University-based research laboratory, hospitals, and stroke support groups. PARTICIPANTS: People (N=77) with stroke greater than 6 months ago were included in the study if they were referred to occupational or physical therapy for physical deficits as a result of the stroke, completed all stroke related inpatient rehabilitation, had residual functional disability, scored a ≥4 out of 6 on the short, 6-item Mini-Mental State Examination, and were between the ages of 50 and 85. INTERVENTIONS: Not applicable, this is a cross-sectional data collection of 1 timepoint. MAIN OUTCOME MEASURES: We measured activity and participation with the validated International Classification of Functioning, Disability and Health Measure of Participation and Activities. Other variables included gait speed (10-meter walk), walking capacity (6-minute walk), balance (Berg Balance Scale), balance self-efficacy (Activities Specific Balance Confidence Scale), and falls self-efficacy (Modified Falls Efficacy Scale). RESULTS: Only balance self-efficacy was found to be independently associated with poststroke activity (ß=-.430, P<.022, 95% confidence interval [CI], -.247 to -.021) and participation (ß=-.439, P<.032, 95% CI, -.210 to -.010). CONCLUSIONS: Among people with chronic stroke, balance self-efficacy, not physical aspects of gait, was independently associated with activity and participation. While gait training continues to be important, this study indicates a need to further evaluate and address the psychological factors of balance and falls self-efficacy to obtain the best stroke recovery.

Full-text publication of abstract-presented work in physical therapy: do therapists publish what they preach?

BACKGROUND AND OBJECTIVE: Professional meetings, such as the American Physical Therapy Association's (APTA's) Combined Sections Meeting (CSM), provide forums for sharing information relevant to physical therapy. An indicator of whether therapists fully disseminate their work is the number of full-text peer-reviewed publications that result. The purposes of this study were: (1) to determine the full-text publication rate of work presented in abstract form at CSM and (2) to investigate factors influencing this rate. METHODS: A systematic search was undertaken to locate full-text publications of work presented in abstract form within the Orthopaedic and Sports Physical Therapy sections at CSM between 2000 and 2004. Eligible publications were published within 5 years following abstract presentation. The influences of APTA section, year of abstract presentation, institution of origin, study design, sample size, study significance, reporting of a funding source, and presentation type on full-text publication rate were assessed. Characteristics of full-text publications were explored. RESULTS: Work presented in 1 out of 4 abstracts (25.4%) progressed to full-text publication. Odds of full-text publication increased if the abstract originated from a doctorate-granting or "other" institution, reported findings of an experimental study, reported a statistically significant finding, included a larger sample size, disclosed a funding source, or was presented as a platform presentation. More than one third (37.8%) of full-text publications were published in the Journal of Orthopaedic and Sports Physical Therapy or Physical Therapy, and 4 out of 10 full-text publications (39.2%) contained at least one major change from information presented in abstract form. CONCLUSIONS: The full-text publication rate for information presented in abstract form within the Orthopaedic and Sports Physical Therapy sections at CSM is low relative to comparative disciplines. Caution should be exercised when translating information presented at CSM into practice.

Postural instability in idiopathic Parkinson's disease: discriminating fallers from nonfallers based on standardized clinical measures.

BACKGROUND: Parkinson's disease (PD) predisposes one to falls, which in turn may lead to serious injury and decreased quality of life. Therefore, it is critical to accurately identify those at risk of falling so that preventive measures may be properly applied. METHODS: Forty-nine participants (25 retrospectively identified fallers and 24 nonfallers) with a diagnosis of idiopathic PD were included in this study. Each was assessed using three categories of measurement tools: PD-specific scales (modified Hoehn and Yahr [HY] and Unified Parkinson's Disease Rating Scale [UPDRS]), balance-specific scales (Berg Balance Scale [BBS], Sensory Organization Test [SOT], and Activities-Specific Balance Confidence Scale [ABC]), and functional gait scales (Self-Selected Gait Velocity [SSGV], Dynamic Gait Index [DGI]), and a standardized obstacle course. RESULTS: Using discriminant function analysis, the BBS, HY, and UPDRS-Activities of Daily Living subscale (UPDRS-ADL) were found to be the best discriminators of faller or nonfaller group membership. Receiver operating characteristic (ROC) curves were employed to suggest cutoff scores and to determine overall predictability. The area under the ROC curves, and the corresponding cutoff scores were as follows for the highest three clinical tests: UPDRS-ADL (0.888/12.5), UPDRS-Overall (0.879/36.5), and the BBS (0.851/43.5). The odds ratios for the UPDRS-ADL, UPDRS-Overall, and the BBS were 32.8, 26.7, and 48.9, respectively. Using positive likelihood ratios and a pretest probability of 51.0%, the changes in posttest probability were UPDRS-ADL (85.9%), UPDRS-Overall (89.9%), and BBS (94.4%). CONCLUSION: Results from this study suggest that the UPDRS-ADL, UPDRS-Overall, and the BBS are the best clinical tests for discriminating falls in persons with PD.