High intensity functional training for people with spinal cord injury & their care partners.

STUDY DESIGN: Non-randomized clinical trial. OBJECTIVES: Examine the feasibility, physical and psychosocial effects of a high intensity functional training (HIFT) exercise program for people with spinal cord injury (pSCI) and their care partners (CPs). SETTING: Community fitness center in a Medically Underserved Area (Fort Smith, USA.) METHODS: A single-group design with three assessment points (before the program, at midpoint (13 weeks), and post-program (25 weeks) was used to examine the effects of up to 49 HIFT sessions over 25-weeks. Sessions were 60 to 75 min in duration and adapted to the abilities of participants. Feasibility measures included recruitment, retention, attendance, safety and fidelity (exercise intensity rated via session-Rating of Perceived Exertion (RPE). Physical measures included cardiovascular endurance, anaerobic power, and muscular strength. Psychosocial measures included perceived social support for exercise, exercise self-efficacy and health-related quality of life. RESULTS: Fourteen pSCI (7 with paraplegia and 7 with tetraplegia, 2 females) and 6 CPs (4 females) were included (median age = 60) (IQR = 15.8). Recruitment rates were 40% for pSCI and 32% for CPs. On average, participants attended 73% (22%) of exercise sessions with a median session-RPE of 5 (IQR = 1). Retention rates were 83% and 67% for pSCI and CPs, respectively. For pSCI and their CPs, large effect sizes were observed for cardiovascular endurance, anaerobic power, muscular strength, and social support for exercise. CONCLUSIONS: For pSCI and their CPs, HIFT appears feasible and potentially leads to improvements in physical and psychosocial health for both groups.

Factors Contributing to Physical Therapist Attrition: A Qualitative Study.

BACKGROUND: Physical therapists (PTs) report job satisfaction when delivering autonomous, high-quality care, but they also experience work-related stress, burnout, and emotional exhaustion. Retaining experienced and skilled clinicians is important. However, a subset of PTs are choosing to voluntarily leave clinical practice (i.e., experience attrition). PT attrition may negatively impact patient care, increase organizational costs, and negatively impact the profession. PURPOSE: This study examined the nature of the experiences of PTs voluntarily leaving clinical practice in order to understand factors contributing to PT attrition. METHOD: A pragmatic qualitative approach with individual, semi-structured interviews conducted with PTs who left clinical practice was used. Interviews were transcribed verbatim and analyzed using deductive thematic analyses. DISCUSSION: Nineteen US-based PTs who left clinical practice were interviewed. Participants were predominately female (n=15), Doctors of Physical Therapy (n=10), with a median of 6 years working in clinical practice as a PT. Analyses revealed five key themes contributing to leaving clinical practice subdivided into Herzberg's Theory: 1) lack of career advancement opportunities; 2) rising productivity requirements reducing the quality of patient care; 3) financial concerns due to imbalance between cost of PT education and compensation; 4) physical demands either contributing to attrition or seen as a benefit of the profession; and 5) emotional burden contributing to attrition or emotional connection seen as professional value. CONCLUSIONS: Understanding the factors contributing to PT attrition is important to guide future strategies to address these factors. Further research may identify opportunities to address these concerns in entry-level education, workplace environments, and professional continuing education.

High Intensity Functional Training for People with Parkinson's & Their Care Partners: A Feasibility Study.

PURPOSE: Various forms of exercise have proven health benefits for people with Parkinson's (pwPD) yet high intensity functional training (HIFT) has yet to be studied. The purpose of this study was to examine the feasibility, physical and psychosocial impacts of a HIFT program for pwPD and their care partners (CPs). DESIGN: A single group, pre-post design with assessments before, in the middle (13 weeks), and after the 25-week intervention. SETTING: Community fitness facility. PARTICIPANTS: Fourteen pwPD (10 at Hoehn Yahr Stage ≤2, 4 females) and 10 CPs (5 females) were included (mean age = 71.5 (6.1)). INTERVENTION: A 25-week HIFT program (≤49 exercise sessions, ≤75 min long). MEASURES: Recruitment, retention, attendance, safety and exercise intensity (measured via session-Rating of Perceived Exertion (RPE)) was assessed in addition to cardiovascular endurance, lower extremity strength, walking speed, balance, exercise self-efficacy, balance confidence, social support for exercise and health-related quality of life. ANALYSIS: Descriptive data was used to describe feasibility measures. Wilcoxon signed-rank test was used to compare pre- and post-program data. Effect size, r, was calculated. RESULTS: Recruitment rates were ≥40% for pwPD and CPs and retention rates were 80% for pwPD and 62.5% for CPs. Average session attendance was 71.2% with 15 adverse events reported, including 7 non-injurious falls. Median session-RPE was 5 (IQR = 1) out of 10. PwPD demonstrated significant improvements in cardiovascular endurance, self-selected and fast walking speeds, balance and social support for exercise. CPs demonstrated significant improvements in cardiovascular endurance and lower extremity strength. Exercise self-efficacy, balance confidence and health-related quality of life did not significantly change for pwPD or CPs. CONCLUSION: High intensity functional training appears feasible for pwPD and their CPs and may lead to health benefits. Healthcare providers should consider HIFT as another option to engage pwPD in community-based exercise.

Active Participation of Care Partners in a Physical Activity Intervention Alongside People with Stroke: A Feasibility Study.

Purpose: This study investigated the feasibility of a physical activity intervention for people with stroke and their care partners and the role social support plays in physical activity adherence. Method: The study used a single-group, pretest-posttest design with follow-up. Participants were adults with chronic stroke and their care partners. The intervention consisted of 8 weeks of structured, group-based physical activity classes, followed by 19 weeks of self-directed physical activity. Recruitment, adherence, safety, and retention were assessed. Familial social support was assessed before and after the 8-week structured portion and again 19 weeks later. Results: A total of 21 participants (15 people with stroke, 6 care partners), mean age 67.6 (SD 11.6) years, were recruited; 19 (90.5%) completed the 19-week assessment. No adverse events were experienced during the programme. Attendance during the 8-week portion was better than during the 19-week portion (mean difference 0.95; p < 0.001; 95% CI: 0.71, 1.19 visits/wk). No relationship was found between social support and physical activity adherence (p > 0.05). Conclusions: Involvement of care partners in a physical activity intervention is feasible and safe. Both people with stroke and their care partners may require ongoing support to participate in long-term physical activity. The relationship between social support and physical activity adherence requires further study.

Objectif : explorer la faisabilité d'une intervention d'activité physique pour les personnes ayant subi un accident vasculaire cérébral (AVC) et leurs partenaires de soins, de même que le rôle du soutien social dans l'adhésion à l'activité physique. Méthodologie : test avant-après à groupe unique comportant un suivi auprès d'adultes ayant un AVC chronique et de leurs partenaires de soins. L'intervention se composait d'un cours d'activité physique de groupe structuré sur huit semaines, suivi d'activité physique autonome sur 19 semaines. Les chercheurs ont évalué le recrutement, l'adhésion, la sécurité et la rétention, de même que le soutien social familial avant et après la partie structurée de huit semaines, puis de 19 semaines. Résultats : au total, 21 participants (15 personnes ayant un AVC, six partenaires de soins) d'un âge moyen (ÉT) de 67,6 ans (11,6) ont été recrutés, et 19 (90,5 %) ont terminé l'évaluation de 19 semaines. Aucun événement indésirable n'a été ressenti pendant le programme. La participation a été plus élevée pendant le volet de huit semaines que pendant celui de 19 semaines (différence moyenne = 0,95; p < 0,001; IC à 95 % : 0,71, 1,19 visite par semaine). Il n'y avait pas relation entre le soutien social et l'adhésion à l'activité physique (p > 0,05). Conclusion : la participation des partenaires de soins à une intervention d'activité physique est faisable et sécuritaire. Les personnes ayant un AVC et leurs partenaires de soins peuvent avoir besoin d'un soutien continu pour faire de l'activité physique à long terme. La relation entre le soutien social et l'adhésion à l'activité physique devra faire l'objet d'études plus approfondies.

We Don't Know Our Own Strength: A Survey of Strength Training Attitudes, Behaviors, and Knowledge in Physical Therapists and Physical Therapist Students.

OBJECTIVE: Strength training is frequently utilized by physical therapists; however, there has been discussion about whether physical therapists utilize strength training adequately. The purpose of this study was to describe and compare the strength training attitudes, behaviors, and knowledge of physical therapists and physical therapy students and to determine how participant characteristics influenced knowledge scores. METHODS: An anonymous survey was created in 3 rounds. For round 1, researchers used textbooks to create items assessing demographics, attitudes, behaviors, and knowledge regarding strength training. Rounds 2 and 3 consisted of feedback from 7 content experts until 80% consensus was reached; items were added, removed, or edited based on feedback. The final survey was distributed through social media, list servs, and email targeting physical therapists and students based in the United States. Response frequencies for all items were reported. Overall knowledge scores were calculated by summing correct responses for each item, with a maximum score of 13; scores <70% were considered low. Binomial logistic regression determined which characteristics (demographics, attitudes, or behaviors) influenced whether participants adequately utilized strength training principles (scored ≥70% on knowledge items). RESULTS: There were 777 physical therapist and 648 student participants. Nearly 90% of therapists and students reported frequently prescribing strength training. Over 48% of therapists felt their professional education did not prepare them to apply strength training (compared with 24% of students), and 68% believed that strength training is inadequately applied in physical therapy (compared with 40% of students). Sixty-two percent of therapists and 55% of students scored ≥70% for knowledge items. Additional strength training education and regular participation in strength training increased the odds of scoring ≥70% on knowledge items. CONCLUSION: Physical therapists and physical therapy students frequently prescribe strength training despite similarly low knowledge scores. To increase knowledge, greater emphasis on strength training in professional education, continuing education, participation in strength training, or all 3 is warranted. IMPACT: Strength training is an important intervention used in physical therapy and must be used appropriately to improve the health of patients. According to these findings, strength training education may not currently be optimal, as demonstrated by low knowledge scores by both therapists and students. Further work is needed to determine how knowledge of strength training relates to patient outcomes and also how best to implement strength training in physical therapy education and practice.

Physical Activity in De Novo Parkinson Disease: Daily Step Recommendation and Effects of Treadmill Exercise on Physical Activity.

OBJECTIVE: People with Parkinson disease (PD) have low physical activity (PA) levels and are at risk for cardiovascular events. The 3 purposes of this study were to determine a step threshold that corresponds to meeting aerobic PA guidelines, determine effects of treadmill exercise on PA, and quantify the relationship between changes in daily steps and fitness. METHODS: This was a secondary analysis of the Study in Parkinson's Disease of Exercise trial, which randomized participants to high-intensity treadmill exercise, moderate-intensity treadmill exercise, or usual care for 6 months. Daily steps and moderate- to vigorous-intensity PA (MVPA) were assessed at baseline and once each month using an activity monitor. Fitness was assessed via graded exercise test at baseline and at 6 months. A step threshold that corresponds to meeting PA guidelines was determined by receiver operating characteristic curves. The effect of treadmill exercise on PA was examined in those below the step threshold (ie, the least active participants). Pearson r correlations determined the relationship between daily steps and fitness. RESULTS: Individuals with de novo PD (n = 110) were included. Those with ≥4200 steps were 23 times more likely (95% CI = 7.72 to 68) to meet PA guidelines than those with <4200 steps. For those with <4200 steps at baseline (n = 33), only those in the high-intensity exercise group increased daily steps (median of differences = 1250 steps, z = -2.35) and MVPA (median of differences = 12.5 minutes, z = -2.67) at 6 months. For those with <4200 steps, changes in daily steps were not associated with changes in fitness (r = .183). CONCLUSION: In people with PD and <4200 daily steps at baseline, high-intensity treadmill exercise increased daily steps and MVPA, but these changes were not associated with changes in fitness. IMPACT: People with PD should be encouraged to take ≥4200 daily steps to meet PA guidelines through walking.

Predictors of Daily Steps at 1-Year Poststroke: A Secondary Analysis of a Randomized Controlled Trial.

Background and Purpose: Walking has the potential to improve endurance and community participation after stroke. Obtaining ≥6000 daily steps can decrease subsequent stroke risk. Early identification of those prone to low daily steps could facilitate interventions that lead to increased walking and improved health. The purpose of this study was to (1) determine which factors at 2 months poststroke can predict daily step counts at 1 year and (2) determine what step count at 2 months corresponds to obtaining ≥6000 daily steps at 1-year poststroke. Methods: This was a secondary analysis of data from the Locomotor Experience Applied Post Stroke trial, which enrolled participants with walking speeds <0.80 m/second at 2 months poststroke. Daily steps were assessed at 2 months and 1-year poststroke. Linear regression was used to predict daily step counts at 1 year based on factors including age, sex, race and/or ethnicity, stroke severity, walking speed, endurance, fitness, motor function, balance, and balance confidence. A receiver operating characteristic curve determined which step count corresponded to reaching ≥6000 steps at 1 year. Results: Data from 206 participants, mean age=63 (13) years, 43% female, mean baseline daily step count=2922 (2749) steps, were analyzed. The final model to predict daily steps at 1 year poststroke contained daily steps at 2 months and balance (Berg Balance Scale score); these factors explained 38% of the variability in daily steps at 1 year (P≤0.001). Participants obtaining ≥1632 daily steps at 2 months were 1.86 (95% CI, 1.52­2.27) times more likely to reach ≥6000 daily steps at 1-year poststroke. Conclusions: Daily steps and balance at 2 months poststroke were the strongest predictors of future daily steps. Improving daily physical activity and targeting balance early after stroke may be necessary to increase physical activity at 1-year poststroke.

Targeted Engagement of the Action Selection Network during Task-Oriented Arm Training after Stroke.

Action selection (AS), or selection of an action from a set of alternatives, is an important movement preparation process that engages a frontal-parietal network. The addition of AS demands to arm training after stroke could be used to engage this motor planning process and the neural network that supports it. The purpose of this case series is to describe the feasibility and outcomes associated with task-oriented arm training aimed at engaging the AS behavioral process and the related neural network in three individuals with chronic stroke. Three participants with mild to moderate motor deficits completed 13 to 15 sessions of task-oriented arm training that included AS cues for each movement repetition; cues dictated movement direction, height, or distance. Before and after training, individuals completed an AS brain-behavior probe during functional MRI. AS behavioral performance improved after training (increased accuracy, decreased reaction time) in all participants while brain activation in the AS network (dorsal premotor, parietal, dorsolateral prefrontal cortices) decreased in two participants. Gains in motor function were also found in all three participants, especially on patient-reported measures of perceived difficulty and confidence to complete upper extremity functional tasks. It was feasible to target the AS behavioral process and the related neural network through the addition of AS demands to functional, task-oriented arm training in three individuals with mild to moderate motor dysfunction poststroke.

Skilled Reach Performance Correlates With Corpus Callosum Structural Integrity in Individuals With Mild Motor Impairment After Stroke: A Preliminary Investigation.

BACKGROUND: Recovery of arm function after stroke is often incomplete. An improved understanding of brain structure-motor behavior relationships is needed for the development of novel and targeted rehabilitation interventions. OBJECTIVE: To examine the relationship between skilled reach performance and the integrity of two putative white matter motor pathways, corticospinal tract and corpus callosum, after stroke. METHODS: Eleven individuals with chronic stroke (poststroke duration, mean 62.5 ± 42.4 months) and mild motor impairment (upper extremity Fugl-Meyer score, mean 54.2 ± 7.6) reached to six targets presented at three distances and two directions. Fractional anisotropy (FA) obtained from diffusion tensor imaging was used to determine the structural integrity of the corticospinal tract and the corpus callosum. RESULTS: Overall reach performance was decreased in the paretic arm compared with the nonparetic arm. While FA was decreased in the ipsilesional corticospinal tract, FA in the corticospinal tract did not correlate with variability in reach performance between individuals. Instead, FA in the premotor section of the corpus callosum correlated with reach performance; individuals with higher FA in premotor corpus callosum tended to reach faster with both the paretic and nonparetic arms. CONCLUSIONS: The structural connections between the two premotor and supplemental cortices that traverse the premotor corpus callosum may play an important role in supporting motor control and could become a target for interventions aimed at improved arm function in this population.