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Video Abstract availablefor more insights from the authors (see the Video, Supplemental Digital Content 1 available at: http://links.lww.com/JNPT/A462).

In health care, “person centeredness” is a valued (though nebulous) concept. In physical therapy, clinical interactions often strive to be person-centered, for example, by focusing on participation and valuing patient empowerment. However, the available evidence has mostly been constructed around populations (or study samples) rather than individuals. In this perspective, an alternative evidence framework is described, constructed around measurements in routine practice. Specifically, the authors propose developing “people-like-me” reference charts, generated with historical outcomes data, to provide real-time information on an individual’s status relative to similar people. The authors present an example of how this could work using their experience with people rehabilitating after total knee arthroplasty. They also describe several challenges that must be addressed to bring this innovation into practice. First, the most important outcome measures for stakeholders (eg, patients, clinicians) need to be identified and monitored longitudinally to ensure that “people-like-me” estimates are useful and support the goals of person-centered care. Statistical methods for selecting “people-like-me” need to be examined and refined. Finally, the “people-like-me” information needs to be packaged in such a way that it is accessible, intuitive, and helpful at the point of care. Ideally, the entire process should recognize from the outset that practice patterns evolve, so databases, statistical models, and decision tools should be dynamic by design. Ultimately, the authors propose this framework as a practical mechanism to advance person-centered decisions in physical therapy according to the ideals of evidence-based practice.

This study aims to determine feasibility of strengthening muscles that are important contributors to gait for people with multiple sclerosis, yet are not routinely targeted in the literature. An 8-week strengthening intervention targeted ankle plantarflexion, hip abduction, and trunk muscles using a repeated-measures design. Outcomes included satisfaction, adherence, muscle strength, gait speed (timed 25-foot walk), gait endurance (6-min walk test), and self-reported gait-related participation (Multiple Sclerosis Walking Scale-12). Ten participants (Expanded Disability Status Scale: 3.5–5.5) completed the intervention. All participants were at least ‘satisfied’; adherence was 87% (supervised sessions) and 75% (home sessions). All quantitative measures improved: muscle strength (23.1–47.6%, P<0.001–0.039), timed 25-foot walk (−13.4%, P<0.001), 6-min walk test (41.56 m, P=0.019), and Multiple Sclerosis Walking Scale-12 (−10.5, P=0.007). Strengthening of ankle plantarflexion, hip abduction, and trunk muscles was feasible and associated with improvements in gait performance.

IMPORTANCE: Parkinson disease is a progressive neurologic disorder. Limited evidence suggests endurance exercise modifies disease severity, particularly high-intensity exercise. OBJECTIVES: To examine the feasibility and safety of high-intensity treadmill exercise in patients with de novo Parkinson disease who are not taking medication and whether the effect on motor symptoms warrants a phase 3 trial. DESIGN, SETTING, AND PARTICIPANTS: The Study in Parkinson Disease of Exercise (SPARX) was a phase 2, multicenter randomized clinical trial with 3 groups and masked assessors. Individuals from outpatient and community-based clinics were enrolled from May 1, 2012, through November 30, 2015, with the primary end point at 6 months. Individuals with idiopathic Parkinson disease (Hoehn and Yahr stages 1 or 2) aged 40 to 80 years within 5 years of diagnosis who were not exercising at moderate intensity greater than 3 times per week and not expected to need dopaminergic medication within 6 months participated in this study. A total of 384 volunteers were screened by telephone; 128 were randomly assigned to 1 of 3 groups (high-intensity exercise, moderate-intensity exercise, or control). INTERVENTIONS: High-intensity treadmill exercise (4 days per week, 80%-85% maximum heart rate [n = 43]), moderate-intensity treadmill exercise (4 days per week, 60%-65% maximum heart rate [n = 45]), or wait-list control (n = 40) for 6 months. MAIN OUTCOMES AND MEASURES: Feasibility measures were adherence to prescribed heart rate and exercise frequency of 3 days per week and safety. The clinical outcome was 6-month change in Unified Parkinson’s Disease Rating Scale motor score. RESULTS: A total of 128 patients were included in the study (mean [SD] age, 64 [9] years; age range, 40-80 years; 73 [57.0%] male; and 108 [84.4%] non-Hispanic white). Exercise rates were 2.8 (95% CI, 2.4-3.2) days per week at 80.2% (95% CI, 78.8%-81.7%) maximum heart rate in the high-intensity group and 3.2 (95% CI, 2.8-3.6; P = .13) days per week at 65.9% (95% CI, 64.2%-67.7%) maximum heart rate in the moderate-intensity group (P &lt; .001). The mean change in Unified Parkinson’s Disease Rating Scale motor score in the high-intensity group was 0.3 (95% CI, −1.7 to 2.3) compared with 3.2 (95% CI, 1.4 to 5.1) in the usual care group (P = .03). The high-intensity group, but not the moderate-intensity group, reached the predefined nonfutility threshold compared with the control group. Anticipated adverse musculoskeletal events were not severe. CONCLUSIONS AND RELEVANCE: High-intensity treadmill exercise may be feasible and prescribed safely for patients with Parkinson disease. An efficacy trial is warranted to determine whether high-intensity treadmill exercise produces meaningful clinical benefits in de novo Parkinson disease. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT01506479

Patient and family member perceptions of physical therapy (PT) in the intensive care unit and the factors that influence their degree of satisfaction have not been described.

highlights the findings and application of Cochrane reviews and other evidence pertinent to the practice of physical therapy. The Cochrane Library is a respected source of reliable evidence related to health care. Cochrane systematic reviews explore the evidence for and against the effectiveness of appropriate interventions—medications, surgery, education, nutrition, exercise—and the evidence for and against the use of diagnostic tests for specific conditions. Cochrane reviews are designed to facilitate the decisions of clinicians, patients, and others in health care by providing a careful review and interpretation of research studies published in the scientific literature.1Each article in thisPTJseries summarizes a Cochrane review or other scientific evidence on a single topic and presents clinical scenarios based on real patients or programs to illustrate how the results of the review can be used to directly inform clinical decisions. This article focuses on an adult patient with relatively early Parkinson disease.Can physical therapist intervention strategies improve his physical functioning and help him reach his goal of engaging in an exercise program to prevent decline related to progressive Parkinson disease?

Patients admitted to the intensive care unit (ICU) can develop a condition referred to as “ICU-acquired weakness.” This condition is characterized by profound weakness that is greater than might be expected to result from prolonged bed rest. Intensive care unit–acquired weakness often is accompanied by dysfunction of multiple organ systems. Individuals with ICU-acquired weakness typically have significant activity limitations, often requiring physical assistance for even the most basic activities associated with bed mobility. Many of these individuals have activity limitations months to years after hospitalization. The purpose of this article is to review evidence that guides physical rehabilitation of people with ICU-acquired weakness. Included are diagnostic criteria, medical management, and prognostic indicators, as well as criteria for beginning physical rehabilitation, with an emphasis on patient safety. Data are presented indicating that rehabilitation can be implemented with very few adverse effects. Evidence is provided for appropriate measurement approaches and for physical intervention strategies. Finally, some of the key issues are summarized that should be investigated to determine the best intervention guidelines for individuals with ICU-acquired weakness.

Although Parkinson disease (PD) is common throughout the world, the evidence for physical therapy interventions that enable long-term improvement in walking is still emerging. This article critiques the major physical therapy approaches related to gait rehabilitation in people with PD: compensatory strategies, motor skill learning, management of secondary sequelae, and education to optimize physical activity and reduce falls. The emphasis of this review is on gait specifically, although balance and falls are of direct importance to gait and are addressed in that context. Although the researchers who have provided the evidence for these approaches grounded their studies on different theoretical paradigms, each approach is argued to have a valid place in the comprehensive management of PD generally and of gait in particular. The optimal mix of interventions for each individual varies according to the stage of disease progression and the patient's preferred form of exercise, capacity for learning, and age.

The updated Integrated Framework for Clinical Decision Making responds to changes in evidence, policy, and practice since the publication of the first version in 2008. The original framework was proposed for persons with neurological health conditions, whereas the revised framework applies to persons with any health condition across the lifespan. In addition, the revised framework (1) updates patient-centered concepts with shared clinical decision-making; (2) frames the episode of care around the patient’s goals for participation; (3) explicitly describes the role of movement science; (4) reconciles movement science and International Classification of Function language, illustrating the importance of each perspective to patient care; (5) provides a process for movement analysis of tasks; and (6) integrates the movement system into patient management. Two cases are used to illustrate the application of the framework: (1) a 45-year-old male bus driver with low back pain whose goals for the episode of care are to return to work and recreational basketball; and (2) a 65-year-old female librarian with a fall history whose goals for the episode of care are to return to work and reduce future falls. The framework is proposed as a tool for physical therapist education and to guide clinical practice for all health conditions across the lifespan.

Decision-making frameworks are used by clinicians to guide patient management, communicate with other health care providers, and educate patients and their families. A number of frameworks have been applied to guide clinical practice, but none are comprehensive in terms of patient management. This article proposes a unifying framework for application to decision making in the management of individuals who have neurologic dysfunction. The framework integrates both enablement and disablement perspectives. The framework has the following attributes: (1) it is patient-centered, (2) it is anchored by the patient/client management model from the Guide for Physical Therapist Practice, (3) it incorporates the Hypothesis-Oriented Algorithm for Clinicians (HOAC) at every step, and (4) it proposes a systematic approach to task analysis for interpretation of movement dysfunction. This framework provides a mechanism for making clinical decisions, developing clinical hypotheses, and formulating a plan of care. Application of the framework is illustrated with a case example of an individual with neurologic dysfunction.

Background and Purpose.The Continuous-Scale Physical Functional Performance Test (CS-PFP) can be used to obtain valid, reliable, and sensitive measurements of physical functional capacity. This test requires a fixed laboratory space and approximately 1 hour to administer. This study was carried out in 4 steps, or substudies, to develop and validate a short, community-based version (PFP-10) that requires less space and equipment than the CS-PFP. Subjects and Methods.Retrospective data (n=228) and prospective data (n=91) on men and women performing the CS-PFP or the PFP-10 are reported. A 12-week exercise program was used to examine sensitivity to change. Data analyses were done using paired t-test, Pearson correlation, intraclass correlation coefficient (ICC), and delta index (DI) procedures. Results.The PFP-10 total score and 4 of the 5 domain scores were statistically similar (within 3%) to those of the CS-PFP. The PFP-10 upper-body strength domain score was 17% lower, but was highly correlated (ICC=.97). Community and established laboratory PFP-10 scores were similar (ICC=.85–.97). The PFP-10 also is sensitive to change (DI=.21–.54). Discussion and Conclusion.The PFP-10 yields valid, reliable, and sensitive measurements and can be confidently substituted for the CS-PFP.

Background and Purpose.Initiation of gait requires transitions from relatively stationary positions to stability with movement and from double- to single-limb stances. These are deliberately destabilizing activities that may be difficult for people with early Parkinson disease (PD), even when they have no problems with level walking. We studied differences in postural stability during gait initiation between participants with early and middle stages of PD (characterized by Hoehn and Yahr as stages 1–3) and 2 other groups of participants without PD—older and younger adults. Subjects.The mean ages of the 3 groups of participants were as follows: subjects with PD, 69.3 years (SD=5.7, range=59–78); older subjects without PD, 69.0 years (SD=3.9, range=65–79); and younger subjects without PD, 27.5 (SD=3.9, range=22–35). Methods.A 3-dimensional motion analysis system was used with 2 force platforms to obtain data for center of mass (COM) and center of pressure (COP). The distance between the vertical projections of the COM and the COP (COM–COP distance) was used to reflect postural control during 5 events in gait initiation. Results.By use of multivariate analysis of variance, differences in COM–COP distance were found among the 3 groups. An analysis of variance indicated differences for 4 of the 5 events in gait initiation. A Scheffe post hocanalysis demonstrated differences in gait initiation between the subjects with PD and both groups of subjects without PD (2 events) and between the subjects with PD and the younger subjects without PD (2 events). Discussion and Conclusion.The COM–COP distance relationship was used to measure postural control during the transition from quiet standing to steady-state gait. Differences between groups indicated that individuals with impaired postural control allow less COM–COP distance than do individuals with no known neurologic problems. The method used could prove useful in the development and assessment of interventions to improve ambulation safety and enhance the independence of people with impaired postural control.

Parkinson disease PD is a chronic progressive neurological disorder, often resulting in substantial limitation of function. A number of selfreport and performancebased measures have been used to quantify change of disease state or function in people who have PD. These measures have limitations when used to quantify function in individuals in the early or midstages of PD, especially in people with preclinical levels of functional difficulty. The purpose of this paper is to 1 review tests and measures currently available to quantify functional limitations of those with PD 2 determine reliability and concurrent validity of a new measure, the Continuous Scale Physical Functional Performance CSPFP test applied to those with PD. Participants were 42 independent, communitydwelling adults with idiopathic PD. Mean SD age was 63.7 11.5 31.7 were women. Participants completed selfreport measures of function, the CSPFP, and 3 other performancebased tests Functional Reach, Timed Up & Go, 360° turn. Ten participants were tested twice on the CSPFP, one week apart. The CSPFP was found to be a reliable measure of physical function in the early and midstages of PD k0.95. The CSPFP correlated moderately strongly with other selfreport measures eg, United Parkinson Disease Rating Scale UPDRS r .62, p.0001 Northwestern University Disability Scale, r .43, p .006 and with performance based measures eg, Functional Reach, r .70, p .0001Timed Up & Go, r .69, p .0001. Multivariate analysis showed the UPDRS to be a predictor of CSPFP score. The regression model including control variables of age, sex, depression, and pain explained over 50 of the variance in CSPFP age and UPDRS scores were the significant predictors. The CSPFP is a reliable and valid measure for determining physical function in individuals who are in the early and midstages of PD. This scale identified substantial functional decline to a greater extent than other scales specific to PD.

Background and Purpose. Evidence suggests that individuals with early and mid-stage Parkinson disease (PD) have diminished range of motion (ROM). Spinal ROM influences the ability to function. In this investigation, the authors examined available spinal ROM, segmental excursions (the ROM used) during reaching, and their relationships in community-dwelling adults with and without PD. Subjects. The subjects were 16 volunteers with PD (modified Hoehn and Yahr stages 1.5–3) and 32 participants without PD who were matched for age, body mass index, and sex. Methods. Range of motion of the extremities was measured using a goniometer, and ROM of the spine was measured using the functional axial rotation (FAR) test, a measure of unrestricted cervico-thoracic-lumbar rotation in the seated position. Motion during reaching was determined using 3-dimensional motion analysis. Group differences were determined using multivariable analysis of variance followed by analysis of variance. Contributions to total reaching distance of segmental excursions (eg, thoracic rotation, thoracic lateral flexion) were determined using forward stepwise regression. Results. Subjects with PD as compared with subjects without PD had less ROM (FAR of 98.2° versus 110.3°, shoulder flexion of 151.9° versus 160.1°) and less forward reaching (29.5 cm versus 34.0 cm). Lateral trunk flexion and total rotation relative to the ground contributed to reaching, with the regression model explaining 36% of the variance. Discussion and Conclusion. These results contribute to the growing body of evidence demonstrating that spinal ROM is impaired early in PD.

Access to financial resources influences the quality of life that individuals are able to lead. An important aspect of quality of life for persons with chronic neurological disorders and their families is the financial burden placed on the family due to the illness. Health care providers may assume that most illness related expenses are covered by insurance. While many studies examine the cost of illnesses to society, research is only beginning to explore the financial burden that such disorders place on the family. This manuscript describes several recent studies that evaluate the financial burden that 2 chronic neurological disorders, Multiple Sclerosis and Parkinson's Disease, place on persons with the disorders and their families. A better understanding of the financial burden of disorders may help health care providers to better meet the need of their patients either through improved counseling or through referral of patients to appropriately trained individuals.

Physical therapists require focused and efficient clinical reasoning skills to determine effective treatment plans, write appropriate goals, and choose intervention strategies that optimize patients' functional abilities. Disablement models applied to clinical practice assist the clinical reasoning process and the resulting patient management. One such model, developed by Schenkman and Butler and published in 1989, has been used in a variety of settings. The original model focused on interrelationships among impairments and disability resulting from a single pathological process. Models also are needed that take into account impairments and disability resulting from multiple underlying disorders. This article presents an updated version of Schenkman and Butler's model, using the pathway to disablement proposed by Nagi and incorporating risk factors and modifiers as elaborated by several other authors. The clinical reasoning process, based on this model, is then illustrated by a patient who was admitted for rehabilitation following shunt revision for normal pressure hydrocephalus. The patient had several other pathologies, including a prior CVA, plantar fasciitis, and blindness in one eye. The influence of his cognitive status, support system, and home environment are discussed.

Background and Purpose.Parkinson's disease (PD) is characterized by rigidity, postural instability, bradykinesia, and tremor, as well as other musculoskeletal impairments and functional limitations. The purpose of this investigation was to determine the reliability and stability of measures of impairments and physical performance for people in the early and middle stages of PD. Subjects.Thirteen men and 2 women in Hoehn and Yahr stages 2 and 3 of PD participated. Their mean age was 74.5 years (SD=5.7, range=64–84). Methods.Thirteen impairment-level variables and 8 physical performance variables were measured. Measurements were taken on two consecutive days and again a week later on the corresponding two consecutive days. Reliability and stability were assessed using analysis of variance and intraclass correlation coefficients (ICCs). Results.Test-retest reliability (ICCs) of variables ranged from .69 (hamstring muscle length) to .97 (lumbar flexion). Intraclass correlation coefficients were .85 or greater for 10 of the variables. Conclusions and Discussion.The results suggest that in the early and middle stages of PD, many of the measures of impairment and physical performance are relatively stable.

Background and Purpose.Many day-to-day activities require bending and twisting motions of the spine (axial mobility). Because little is known about the relationship between axial mobility and physical performance, this investigation explored these relationships. Subjects.Thirty-one men and 26 women, aged 20 to 91 years (X=58.4, SD=24.4), participated. Methods.Subjects were assigned to one of three age groups: 20 to 40 years, 60 to 74 years, or 75 years and older. Five sets of variables were identified and measured: cervical, lumbar, sagittal configuration (ie, kyphosis, lordosis), combined spinal motion, and physical performance. Results.A multivariate analysis of variance revealed age effects for all sets of variables; a post hocanalysis of variance revealed age effects for all variables within the sets. Canonical correlations, controlling for age, demonstrated associations between the cervical and combined spinal motion sets of variables and between the combined spinal motion and physical performance sets of variables. Conclusion and Discussion.This investigation demonstrated an age effect for selected measures of axial mobility, sagittal configuration, and physical performance thought to depend on axial motion. Controlling for age, the results also demonstrated associations between measures of axial mobility and physical performance.

Samenvatting: In dit patiëntenverslag wordt een patiënt beschreven die pijn kreeg in zijn rechter schouder na inspannende oefeningen van de bovenste extremiteit. Na ongeveer zes weken was de pijn verdwenen, maar bemerkte hij een aanhoudende zwakte in de rechter bovenste extremiteit. Hij werd naar fysiotherapie verwezen voor onderzoek en behandeling. Uit het fysiotherapeutische onderzoek bleek een geïsoleerde paralyse van de M. serratus anterior. Een neuropathie van de N. thoracicus longus werd vervolgens door elektromyografische tests bevestigd. Er wordt een overzicht gegeven van de etiologie, pathofysiologie en pathokinesiologie van een M. serratus anterior-paralyse. Er wordt een patiëntengeval beschreven, waarin geïllustreerd wordt hoe de klinische besluitvorming gebaseerd is op de pathokinesiologie en pathofysiologie. De patiënt is gedurende 17 maanden onder controle gebleven en heeft de volledige actieve bewegingsuitslag in zijn rechter schouder teruggekregen. De spierkracht van zijn M. serratus anterior is toegenomen tot Goed- minus, en hij vermeldt een beduidend verbeterd functioneel gebruik van de bovenste extremiteit.

Cerebra1 hemispheric asymmetries were assessed in relation to motor and functional recovery in nine patients with stroke. All were globally aphasic, assuring similar location and extent of lesion. Initial motor and functional ability were appraised from medical records and compared with neurologic and functional outcome. Frontal and occipital hemispheric widths and lengths were determined from CT. Patients were classified into three groups on the basis of mean combined asymmetry for width (typical asymmetry, atypical asymmetry, and equal symmetry). Patients with the most atypical cerebral asymmetries showed greater recovery than patients in other groups. Two patients with atypical mean occipital asymmetry (width) fared best functionally, whereas the patient who showed the greatest motor recovery had the most atypical mean occipital asymmetry (width). Cerebral asymmetries may contribute to recovery after stroke.

OBJECTIVES: The effectiveness of an exercise intervention for people in early and midstage Parkinson's disease (stages 2 and 3 of Hoehn and Yahr) in improving spinal flexibility and physical performance in a sample of community‐dwelling older people is described.