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Stabilization exercises have been a focus and mainstay of many therapeutic and performance training programs in the past decade. Whether the focus is core stabilization for the spine or scapular stabilization, clinicians and trainers alike have endorsed these programs, largely on the basis of conceptual theory and anecdotal experience. The notion that an unstable scapula is related to shoulder dysfunction and pathology is well accepted, but is it accurate? The aim of this perspective article is to challenge the concept of scapular stabilization through the application of biomechanical and motor control constructs. The objectives are to critically examine current beliefs about scapular stabilization, to discuss definitions of stabilization and stability in the context of the scapulothoracic region, and to evaluate key evidence regarding scapular stabilization and scapular dyskinesia. Several new approaches that may affect the understanding of normal and atypical scapula motion are explored. Finally, a historical analogy is presented and future research and clinical directions are suggested. The aims are to lead readers to the essential concepts implied on scapular stabilization, to increase the critical thought process in rehabilitation practice, and to suggest some open topics to be explored in future research., The notion that an unstable scapula is related to shoulder dysfunction and pathology is well accepted. (1,2) The prevailing theory asserts that for proper function of the glenohumeral joint, the [...]

Background. Only a small percentage of research is ever successfully translated into practice. The Graded Repetitive Arm Supplementary Program (GRASP) is a stroke rehabilitation intervention that anecdotally has had rapid translation from research to clinical practice. This study was conducted to explore the characteristics of this practice implementation. Objectives. The aims of this study were: (1) to explore the extent of practice implementation of GRASP in the United Kingdom; (2) using an implementation framework, to explore UK therapists' opinions of implementing GRASP; and (3) if GRASP is found to be used in the United Kingdom, to investigate differences in opinions between therapists who are using GRASP in practice and those who are not. Design. A cross-sectional study design was used. Methods. Data were collected via an online questionnaire. Participants in this study were members of the College of Occupational Therapy Specialist Section Neurological Practice and the Association of Chartered Physiotherapists Interested in Neurology. Results. Of the 274 therapists who responded to the survey, 6l (22.3%) had experience of using GRASP, 114 (41.6%) knew of GRASP but had never used it, and 99 (36.1%) had never heard of GRASP. Therapists displayed positive opinions toward the implementation of a manual with graded progressions of structured upper limb exercises for people after stroke. Opinions were different between therapists who had used GRASP and those who had not. Limitations. The findings of this study may be limited by response bias. Conclusions. GRASP is a relatively new stroke rehabilitation intervention that has made impressive translation into the knowledge and practice of UK therapists. Therapists' opinions would suggest that GRASP is both an acceptable and feasible intervention and has the potential to be implemented by a greater number of therapists in a range of settings., It is increasingly recognized that significant gaps exist between what is known to improve health and what is done to improve health. The time it takes for research to become [...]

Background. Repeated heel raises have been proposed as a method of ankle plantar-flexor strength testing that circumvents the limitations of manual muscle testing (MMT). Objective. The study objective was to examine the relationships among ankle plantar-flexion isometric maximum voluntary contraction (MVC), repeated single-limb heel raises (SLHRs), and MMT in people with myositis. Design. This was a cross-sectional study with a between-group design. The ability to complete 1 SLHR determined group assignment (SLHR group, n=24; no-SLHR group, n=19). Methods. Forty-three participants with myositis (13 women; median age=64.9 years) participated. Outcome measures included MVC, predicted MVC, Kendall MMT, and Daniels-Worthingham MMT. Results. The Kendall MMT was unable to detect significant ankle plantar-flexor weakness established by quantitative methods and was unable to discriminate between participants who could and those who could not perform the SLHR task. Ankle plantar-flexion MVC was not associated with the number of heel-raise repetitions in the SLHR group (pseudo [R.sup.2] =.13). No significant relationship was observed between MVC values and MMT grades in the SLHR and no-SLHR groups. However, a moderate relationship between MVC values and MMT grades was evident in a combined-group analysis (ρ=.50-.67). Limitations. The lower half of both MMT grading scales was not represented in the study despite the profound weakness of the participants. Conclusions. Both Kendall MMT and Daniels-Worthingham MMT had limited utility in the assessment of ankle plantar-flexor strength. Repeated SLHRs should not be used as a proxy measure of ankle plantar-flexion MVC in people with myositis., The performance of many fundamental upright activities of daily living, such as walking, running, and rising from a chair, depends on adequate concentric and eccentric functioning of the ankle plantar-flexor [...]

Background. The Balance Evaluation Systems Test (BESTest) and Mini-BESTest are clinical examinations of balance impairment, but the tests are lengthy and the Mini-BESTest is theoretically inconsistent with the BESTest. Objective. The purpose of this study was to generate an alternative version of the BESTest that is valid, reliable, time efficient, and founded upon the same theoretical underpinnings as the original test. Design. This was a cross-sectional study. Methods. Three raters evaluated 20 people with and without a neurological diagnosis. Test items with the highest item-section correlations defined the new Brief-BESTest. The validity of the BESTest, the Mini-BESTest, and the new BriefBESTest to identify people with or without a neurological diagnosis was compared. Interrater reliability of the test versions was evaluated by intraclass correlation coefficients. Validity was further investigated by determining the ability of each version of the examination to identify the fall status of a second cohort of 26 people with and without multiple sclerosis. Results. Items of hip abductor strength, functional reach, one-leg stance, lateral push-and-release, standing on foam with eyes closed, and the Timed 'Up & Go' Test defined the Brief-BESTest. Intraclass correlation coefficients for all examination versions were greater than .98. The accuracy of identifying people from the first cohort with or without a neurological diagnosis was 78% for the BESTest versus 72% for the Mini-BESTest or Brief-BESTest. The sensitivity to fallers from the second cohort was 100% for the Brief-BESTest, 71% for the Mini-BESTest, and 86% for the BESTest, and all versions exhibited specificity of 95% to 100% to identify nonfallers. Limitations. Further testing is needed to improve the generalizability of findings. Conclusions. Although preliminary, the Brief-BESTest demonstrated reliability comparable to that of the Mini-BESTest and potentially superior sensitivity while requiring half the items of the Mini-BESTest and representing all theoretically based sections of the original BESTest., Injuries resulting from falls contribute to decreased health status and increased mortality, particularly for individuals of advanced age or with chronic disease. (1) In addition, falls are linked to a [...]

Background. Pelvic-floor dysfunction (PFD) affects a substantial proportion of individuals, especially women. Objective. The purposes of this study were: (1) to describe the characteristics of individuals with disorders associated with PFD who were seeking outpatient physical therapy services and (2) to identify the prevalence of specific pelvic-floor disorders in the group. Design. This was a prospective, longitudinal, cohort study of 2,452 patients (mean age=50 years, SD=16, range=18-91) being treated in 109 outpatient physical therapy clinics in 26 states (United States) for their PFD. Methods. This study examined patient demographic variables and summarized patient serf-reported responses to questions related to urinary and bowel functioning at admission prior to receiving the therapy for their PFD disorders. Results. Patients primarily were female (92%), were under 65 years of age (39%: 18 to Limitations. Because this study was a secondary analysis of data collected prospectively, the researchers were not in control of the data collection procedure. Missing data were common. Conclusions. Data suggested most patients with PFD receiving outpatient physical therapy services were female, younger than 65 years, and had disorders lasting for more than 90 days. Combinations of urinary, bowel, or pelvic-floor pain disorders were not uncommon., Pelvic-floor dysfunction (PFD) (1) may result in a group of clinical disorders that includes urinary incontinence, (2) anal incontinence, (3) pelvic organ prolapse, (4) sensory and emptying abnormalities of the [...]

Background. Many apparently independent older adults modify daily tasks. Task modifications strongly predict future mobility disability. Clinically intuitive, easily measured 'biomarkers' associated with task modifications would offer quantifiable treatment targets for prevention of age-related functional limitations. Objective. The objective of the study was to examine lower-extremity muscle strength deficits and functionally relevant cutoff points associated with daily task modifications in community dwelling older adults living independently. Design. This was a cross-sectional observational study. Methods. Fifty-three participants (mean age=76.4 years, SD=5.2)were tested for task modifications and leg strength. Task modifications were assessed using a previously described tool (summary task modification score). Twenty-six of the participants were classified as task modifiers (TM group), and 27 participants were classified as non-task modifiers (NTM group). A net antigravity leg force in the sagittal plane (NETforce) was calculated by summing the normalized isometric and isokinetic torques from the hip extensors, knee extensors, and ankle plantar flexors. Results. Compared with the NTM group, the TM group exhibited 30.0% and 33.5% reduction in lower-extremity isometric and isokinetic NETforces, respectively. Isometric and isokinetic NETforce cutoff points for task modifications were≤ 4.24 and 2.77 N.m/kg body weight, respectively. The isometric and isokinetic models both yielded sensitivity and specificity values of 74.1% and 80.8%, respectively (positive likelihood ratio=3.852, 95% confidence interval=1.699-8.735; negative likelihood ratio=0.321, 95% confidence interval=0.167-0.618). Isometric and isokinetic NET-forces were significantly associated with task modifications (odds ratio=2.50 and 2.42, respectively). Limitations. The cross-sectional design of this study does not allow for a test of causal relationships. This study used a modest yet adequate sample size that may limit generalization of the results. Conclusions. Isometric and isokinetic NETforce cutoff points provide quantifiable biomarkers that discriminate community-dwelling older adults who modify daily tasks from those who do not., Mobility disability is a common medical condition (1) among older adults. Mobility disability is the end result of a gap between an individual's personal abilities (eg, muscle strength) and the [...]

Background and Purpose. Persistent deficits in gait speed and spatiotemporal symmetry are prevalent following stroke and can limit the achievement of community mobility goals. Rehabilitation can improve gait speed, but has shown limited ability to improve spatiotemporal symmetry. The incorporation of combined visual and proprioceptive feedback regarding spatiotemporal symmetry has the potential to be effective at improving gait. Case Description. A 60-year-old man (18 months poststroke) and a 53-year-old woman (21 months poststroke) each participated in gait training to improve gait speed and spatiotemporal symmetry. Each patient performed 18 sessions (6 weeks) of combined treadmill-based gait training followed by overground practice. To assist with relearning spatiotemporal symmetry, treadmill-based training for both patients was augmented with continuous, real-time visual and proprioceptive feedback from an immersive virtual environment and a dual belt treadmill, respectively. Outcomes. Both patients improved gait speed (patient 1:0.35 m/s improvement; patient 2:0.26 m/s improvement) and spatiotemporal symmetry. Patient 1, who trained with step-length symmetry feedback, improved his step-length symmetry ratio, but not his stance-time symmetry ratio. Patient 2, who trained with stance-time symmetry feedback, improved her stance-time symmetry ratio. She had no steplength asymmetry before training. Discussion. Both patients made improvements in gait speed and spatiotemporal symmetry that exceeded those reported in the literature. Further work is needed to ascertain the role of combined visual and proprioceptive feedback for improving gait speed and spatiotemporal symmetry after chronic stroke., Following stroke, intensive rehabilitation is used to reduce deficits in gait speed, efficiency, and symmetry. Restoring symmetric gait is important to improve gait efficiency and gait speed (1,2) and to [...]

Background. During gait, the hip flexors generate 40% of the total power. Nevertheless, no device has been tested extensively for clinical purposes to cope with weakness in the hip flexors in patients with stroke. Objective. The purpose of this study was to assess the efficacy and safety of a newly developed hip flexion assist orthosis in adult patients with hemiparesis after stroke. Design. The study used a prospective, randomized, before-after trial design. The inclusion criteria were hemiparesis resulting from stroke (onset [greater than or equal to]8 weeks); ability to walk, even ff with assistance; and hip flexion weakness (Medical Research Council Scale score [less than or equal to]4). Methods. The main outcome measures were the 10-Meter Walk Test and the Six-Minute Walk Test. Patients also were evaluated with the Trunk Control Test, the Functional Ambulation Categories, the Motricity Index, and hip flexor strength on the Medical Research Council Scale. Sixty-two survivors of stroke were tested in random order with and without the orthosis. Any adverse event associated with its use was recorded. Results. Both the Six-Minute Walk Test and the 10-Meter Walk Test scores improved with the use of the orthosis. A significant negative correlation was found for improvement between scores on the 2 main outcome measures with the orthosis and the Functional Ambulation Categories scores. The improvement in Six-Minute Walk Test scores with the orthosis was related inversely to hip flexor strength. Conclusions. The data showed that the use of a hip flexion assist orthosis can improve gait in patients with poststroke hemiparesis, particularly those with more severe walking impairment., Stroke, the primary cause of adult disability, leads to impairments in mobility and walking. Even though about a third of patients with stroke survive 5 years after the event, mobility [...]

Background. A simple test of aerobic fitness for patients with traumatic brain injury (TBI) that is valid, reliable, and responsive to change is needed to provide clinicians a functional measure of cardiorespiratory capacity. Objective. The purpose of this study was to examine the validity and responsiveness to change of the Six-Minute Walk Test (6MWT) in individuals with TBI. Design. A cohort, pretest-posttest, comparison study was conducted. Methods. Twenty-one patients performed the 6MWT upon admission to and prior to discharge from a postacute rehabilitation facility. Heart rate and distance traveled were recorded. A physiologic cost index (PCI) (beats per meter) was calculated based on steady-state heart rate. At discharge, all participants were able to perform a graded treadmill exercise test to exhaustion during which peak oxygen consumption ([??][o.sub.2]) was measured. Results. Between admission and discharge, mean total distance increased from 342.6 m (SD = 127.0) to 408.9 m (SD = 124.2), and work increased from 27,185 kg x m (SD = 10,528) to 34,114 kg x m (SD = 12,057). The effect size indexes were 1.10 and 1.12 for distance and work, respectively. Correlations (r) between the discharge peak [??][o.sub.2] and the discharge 6MWT distance, PCI, and work were .58, -.61, and .47, respectively. Limitations. Stratification by gait speed may have improved responsiveness, especially for the slow ambulators. Conclusions. All measures correlated well with peak [??][o.sub.2], establishing an acceptable level of criterion-related (concurrent) validity. The addition of heart rate and calculating the PCI was only slightly better at predicting peak [??][o.sub.2], albeit non-significant, than a simple measure of total distance. The 6MWT provides a good estimate of peak aerobic capacity, and some measures are more responsive to change than others in patients recovering from TBI., The Centers for Disease Control and Prevention estimates that at least 5.4 million Americans currently have long-term or lifelong need for help in performing activities of daily living as a [...]

Background. Clinical observations have suggested that hippotherapy may be an effective strategy for habilitating balance deficits in children with movement disorders. However, there is limited research to support this notion. Objective. The purposes of this study were to assess the effectiveness of hippotherapy for the management of postural instability in children with mild to moderate balance problems and to determine whether there is a correlation between balance and function. Design. A repeated-measures design for a cohort of children with documented balance deficits was used. Methods. Sixteen children (9 boys and 7 girls) who were 5 to 16 years of age and had documented balance problems participated in this study. Intervention consisted of 45-minute hippotherapy sessions twice per week for 6 weeks. Two baseline assessments and 1 postintervention assessment of balance, as measured with the Pediatric Balance Scale (PBS), and of function, as measured with the Activities Scale for Kids--Performance (ASKp), were performed. Results. With the Friedman analysis of variance, the PBS and the ASKp were found to be statistically significant across all measurements (P.05). Limitations. Lack of a control group and the short duration between baseline assessments are study limitations. Conclusions. The findings suggest that hippotherapy may be a viable strategy for reducing balance deficits and improving the performance of daily life skills in children with mild to moderate balance problems., Postural control is considered to be an integral part of a person's ability to interact with the environment and engage in coordinated movement. (1) For children with movement disorders, the [...]

Background. Providing specific treatment based on symptom response for people with low back pain (LBP) and a directional preference (DP) is a widely used treatment approach. The efficacy of treatment using the principles of directional preference management (DPM) for LBP is unclear. Objective. The purpose of this study was to determine the efficacy of treatment using the principles of DPM for people with LBP and a DP. Methods. Computer databases were searched for randomized controlled trials (RCTs) published in English up to January 2010. Only RCTs investigating DPM for people with LBP and a DP were included. Outcomes for pain, back specific function, and work participation were extracted. Results. six RCTs were included in this review. Five were considered high quality. Clinical heterogeneity of the included trials prevented meta-analysis. GRADE quality assessment revealed mixed results; however, moderate evidence was identified that DPM was significantly more effective than a number of comparison treatments for pain, function, and work participation at short-term, intermediate-term, and long-term follow-ups. No trials found that DPM was significantly less effective than comparison treatments. Conclusions. Although this systematic review showed mixed results, some evidence was found supporting the effectiveness of DPM when applied to participants with a DP, particularly at short-term and intermediate-term follow-ups. Further high-quality RCTs are warranted to evaluate the effect of DPM applied to people with LBP and a DP., Low back pain (LBP) is a common problem that has reached epidemic levels. (1,2) Contrary to previous reports of a favorable prognosis, (3) it has been reported that an average [...]

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 and appropriateness of 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. (1) Each article in this PTJ series 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 a 32-year-old woman with chronic neck pain with headaches. Could an exercise program help reduce her neck pain and headaches?, It has been reported that 1 in 5 people are currently experiencing neck pain, greater than 50% of the population has had neck pain in the last 6 months, and [...]

Background and Purpose. People with severe, long-standing anorexia nervosa (AN) often develop physical manifestations of medical starvation. Functional deficits are not well described, and little information is available to guide physical intervention. This case report describes the physical therapy clinical decision-making process and intervention provided to a patient with severe AN. Case Description. The patient was a 48-year-old woman admitted to an acute care hospital with medical complications associated with AN and requiring medical stabilization. On admission, she was unable to complete basic functional activities (eg, bed mobility, transfers, ambulation). She was considered at risk for falls, with a score of 17 on the Performance-Oriented Motor Assessment (POMA) and a score of 19.27 seconds on the Timed 'Up & Go' Test (TUG). Physical therapist examination and intervention focused on functional testing and training, strengthening, and postural stability training for return to independence. Outcomes. In 9 weeks, the patient returned to independence in basic activities of daily living, as measured by 3 items from the motor domain (bed mobility, transfers, and ambulation) of the Functional Independence Measure, with improvements from 1 ('total assistance') to 6 ('modified independence') on each item. Postural stability improved to 'low risk' for falls (POMA score of 24). Her TUG score improved to 11.00 seconds. Walking speed improved from 0.35 to 0.81 m/s. Once she attained medical stability, she was discharged home with her parents with outpatient services. Discussion. Physical therapist management of this severely deconditioned patient hospitalized with severe AN focused on the restoration of functional activities, with intervention intensity being guided by physiologic responses. Traditional aerobic and endurance training were de-emphasized to minimize kilocalorie expenditure and tendencies toward exercise compulsion in this patient population., Anorexia nervosa (AN) is a psychiatric disorder that affects pproximately 1% of females (2-3 females for every male diagnosed with AN). (1) It is characterized by a preoccupation with thinness [...]

Background and Purpose. Disability in patients with facial paralysis is the result of impairment or loss of complex and multidimensional functions of the face, including expression of emotions, facial identity, and communication. However, the majority of interventions for facial paralysis are unidimensional and impairment oriented. Thus, a functional training program intended to address various dimensions of disability caused by facial paralysis was devised. This patient-centered, multidimensional approach to the rehabilitation of people with facial paralysis consists of patient education, functional training, and complementary exercises. This approach is focused on various dimensions of disability, including the physical, emotional, and social dimensions, by encouraging context-specific facial functions, positive coping strategies, and social interaction skills. Case Description. The patient was a 25-year-old woman with chronic complete right facial paralysis caused by a postoperative complication of ear surgery. The patient's problems were evaluated with the Facial Disability Index (physical function subscale score=45/100, social/well-being function subscale score=28/100) and an informal interview exploring her experiences and priorities. Outcomes. After 8 weeks of functional training, the patient showed considerable improvement in facial functions (physical function subscale score=95/100, social/ well-being function subscale score= 100/100) and reported positive changes in social interactions and interpersonal relationships. Discussion. The use of a functional training program was associated with positive changes in emotional expression, psychosocial function, and social integration, thus contributing to reduced disability of a person with chronic facial paralysis., Facial functions are multidimensional, serving emotional, social, and physical aspects of a person's health. The primary functions of the face include displaying affective emotions and identifying and communicating with other [...]

Background. Altered neuromuscular control due to compromised joint position sense may contribute to recurrent shoulder instability. Objective. The purpose of the present study was to examine whether individuals with anterior shoulder instability exhibit larger shoulder position sense errors than those with healthy shoulders in both passive matching and active positioning. Design. This was a between-groups study with repeated measures. Methods. Ten people with anterior shoulder instability and 15 people with healthy shoulders participated in the study. Shoulder position sense was examined with 3 different protocols (passive motion to remembered shoulder rotation angles and active shoulder abduction and rotation to verbally specified positions) in positions of both mid-range and end-range of motion. Results. Participants with unstable shoulders exhibited significantly larger errors (by 1.8° on average) in perception of shoulder position compared with those with healthy shoulders during passive matching. During active positioning, participants with unstable shoulders were able to voluntarily move the shoulder to verbally specified angles as accurately as those with healthy shoulders in both abduction (0.85° difference) and rotation (0.99° difference) tasks. Conclusions. Results of this study indicate that people with unstable shoulders can perceive shoulder angles as accurately as people with healthy shoulders in activities with voluntary arm movements. Compared with passive matching, better information from muscle spindles and other sources during voluntary arm movements may compensate for the potential joint position sense deficits after the injury. Therefore, individuals with an unstable shoulder may have adequate neuromuscular control to engage proper protective mechanisms to stabilize the shoulder joint during functional activities., A decrease in shoulder stability due to compromised soft tissues is commonly seen in athletes whose sport, such as baseball, demands strong repetitive overhead movements, as well as in individuals [...]

Background. The Patient Protection and Affordable Care Act and the Health Care and Education Reconciliation Act of 2010 contain provisions specific to health care quality that apply to physical therapists. Published evidence examining gaps in the quality of physical therapy services is limited. Objective. The primary purpose of this study was to determine the use of quality indicators in physical therapist practice. Design. This was an observational study. Methods. All members of the Orthopaedic and Private Practice sections of the American Physical Therapy Association were invited to participate by completing an electronic survey. The survey included 22 brief patient descriptions, each followed by questions regarding the use of examinations and interventions based on the 2009 list of Medicare-approved quality measures. Separate multivariate logistic regression models were used to determine the odds ratios related to the performance of each examination and intervention on more than 90% of patients, given perceptions of its importance to care, the burden of performing it, and the level of evidence supporting its use. Results. Participants (n = 2,544) reported a relatively low frequency of performing examinations and interventions supporting primary and secondary prevention (3.6%51.3%) and use of standardized measures (5.5%-35.8%). Perceptions of high importance and low burden were associated with greater odds of performing an examination or intervention. Importance and burden were more influential factors than the perceived availability of evidence to support use of identified techniques. Limitations. The survey was not assessed for test-retest reliability. A low response rate was a source of potential bias. Conclusion. The study findings suggest that physical therapists may not see themselves as providers of primary or secondary prevention services. Patient management strategies associated with these types of services also may be perceived as relatively unimportant or burdensome., The Patient Protection and Affordable Care Act (PL 111-148) and the Health Care and Education Reconciliation Act of 2010 (PL 111-152) contain provisions specific to health care quality that apply [...]

Background. The generation of research can be likened to the production of consumer goods, with a producer (the study authors and funders), a product (the study and publications arising from it), and consumers (those who read and cite the published study). Objective. The aim of this study was to use bibliometric indexes to track changes in the producers, products, and consumers of the journal Physical Therapy from 1945 through 2010. Design. An analysis of published manuscripts (excluding letters, editorials, corrections, commentaries, and book reviews) in Physical Therapy was performed using a reliable bibliometric audit tool. Articles were sampled every 3 months and at 5-year intervals over a 65-year period. Information relating to authorship, the research methods used, and citation patterns was collected. Data were analyzed descriptively. Results. There have been substantial shifts in the nature of research published over the last 65 years in Physical Therapy. In 1945, the typical paper was anecdotal and authored by 1.4 American authors (working in hospitals), and consisted of 4 pages and 4 references. In 2010, the typical paper used a cross-sectional survey or randomized controlled trial design, with 4.6 multinational authors (working in universities), and consisted of 12 pages and 49 references. Limitations. Findings are specific to the articles published in Physical Therapy that were sampled in this bibliometric analysis. Conclusions. The changes seen in the research published in Physical Therapy mirror the shifts that have occurred in other industries: increasing quantification, standardization, collaboration, and internationalization. These trends are likely to continue in the future., The journal of the American Physical Therapy Association (APTA), Physical Therapy, commenced in 1921 with the objective of promoting contact between physicians and aides. (1) The journal has moved from [...]

Background. Exercise has many benefits for survivors of breast cancer, yet only haft of this population regularly exercise. Fear has been identified as a barrier to exercise for people with neuromusculoskeletal conditions but has been minimally explored in women with breast cancer. Objectives. The purposes of this study were: (1) to investigate factors that affected decisions about physical activity and exercise in survivors of breast cancer and (2) to determine whether fear was a factor. Design. This investigation was a grounded-theory qualitative study. Qualitative data were triangulated with data from 2 quantitative scales that measured participants' beliefs about exercise and their activity levels. Methods. Thirty-four survivors of breast cancer in 8 focus groups participated in semistructured interviews that were recorded, transcribed, and coded. Concept maps created for each group were merged to develop themes. Beliefs about physical activity and exercise were assessed with the Decisional Balance Scale. The Rapid Assessment of Physical Activity was used to assess behaviors regarding physical activity and exercise before and after the breast cancer diagnosis. Results. Participants generally believed that exercise was beneficial (Decisional Balance Scale score: [bar.X]=28.1 [of a maximum score of 44], SD=7.6, range=10-43). Participants decreased the amount of physical activity or exercise during treatment but increased the amount of exercise beyond prediagnosis levels after treatment (Rapid Assessment of Physical Activity score: median=6, range=2-7). Three prominent themes described participants' behaviors regarding physical activity or exercise: values and beliefs about exercise, facilitators and barriers that were both similar to those affecting the general population and cancer specific, and lack of or inaccurate information about safe exercise. Conclusions. Survivors who were active were not afraid to exercise. However, concern about lymphedema and knowledge about safe and effective exercise programs influenced choices regarding physical activity and exercise., Regular exercise and activity in survivors of breast cancer has been linked to reductions in cancer-related fatigue (1) and nausea symptoms, (2) improvements in immune system function, (3) and reduced [...]

Background. Studies have suggested that constraint-induced therapy combined with trunk restraint (CIT-TR) improves arm movement and reduces trunk compensation. Whether participants who receive CIT-TR can translate the benefits to real-life circumstances awaits further investigation. Objective. The effects of distributed CIT-TR (dCIT-TR) on motor function, daily function, quality of life (QOL), and arm-trunk control were investigated. Design. The study was a single-blind, randomized controlled trial. Setting. The study took place at 4 hospitals. Participants. Participants were 57 people who had had a stroke 6 to 55 months earlier. Intervention. Participants received a dose-matched intervention (2 hours per day, 5 days per week, for 3 weeks) of dCIT-TR, distributed constraint-induced therapy (dCIT), or control therapy. Measurements. The Action Research Arm Test (ARAT), Motor Activity Log, Frenchay Activities Index (FAI), and Stroke Impact Scale (SIS) were used to evaluate motor function, daily function, and QOL. Data for reaching kinematics were recorded. Results. Participants receiving dCIT-TR and dCIT exhibited higher overall scores on the ARAT, FAI, and hand function domain of the SIS and better quality of movement and larger amount of use (of the affected arm) on the Motor Activity Log than participants in the control group. Participants receiving dCIT-TR further demonstrated greater improvements on the ARAT grip subscale and FAI outdoor activities scale than participants receiving dCIT or participants in the control group. However, participants receiving dCIT showed greater improvements on the strength domain of the SIS after training than participants receiving dCIT-TR or participants in the control group. Limitations. Research with a larger sample size is needed. Conclusions. Participants who received dCIT-TR were able to translate gains in arm-trunk control into functional performance and QOL, specifically in grip function and outdoor activities. A long-term study to examine the recovery course for force output may be needed to evaluate people's perception of less improvement in strength after dCIT-TR., Constraint-induced therapy (CIT) (1-3) and its modified (4) and distributed (5,6) derivatives reduce movement deficits, improve movement performance, and improve real-world functional use of the hemiparetic upper extremity (UE) by [...]

Background: Acupuncture is frequently advocated as an adjunct treatment during stroke rehabilitation. The aim of this review was to assess its effectiveness in this setting. Methods: We searched 25 databases and 12 major Korean traditional medicine journals from their inception to October 2009. We included randomized controlled trials, with no language restrictions, that compared the effects of acupuncture (with or without electrical stimulation) with sham acupuncture. We assessed the methodologic quality of the trials using the Cochrane risk-of-bias criteria and the PEDro (Physiotherapy Evidence Database) scale. Results: Ten of 664 potentially relevant studies met our inclusion criteria. For acute and subacute stages after stroke, we included seven trials. A meta-analysis of the five studies that assessed functionality did not show a significant difference in favour of acupuncture, with high heterogeneity. A post-hoc sensitivity analysis of three trials with low risk of bias did not show beneficial effects of acupuncture on activities of daily living at the end of the intervention period (n = 244; standard mean difference 0.07, 95% confidence interval [CI] -0.18 to 0.32; [I.sup.2] = 0%) or after follow-up (n = 244; standard mean difference 0.10, 95% CI -0.15 to 0.35; [I.sup.2] = 0%). For the chronic stage after stroke, three trials tested effects of acupuncture on function according to the Modified Ashworth Scale; all failed to show favourable effects. Interpretation: Our meta-analyses of data from rigorous randomized sham-controlled trials did not show a positive effect of acupuncture as a treatment for functional recovery after stroke., Acupuncture is often used as an adjunct to mainstream rehabilitation after stroke. It involves the insertion of an acupuncture needle into the skin at certain points of the body. Acupuncture [...]

Background. Muscle architecture is known to be predictive of muscle function. However, it is unknown whether this relationship is similar in children and adolescents with and without cerebral palsy (CP). Objective. The objective of this study was to determine whether the architecture of the rectus femoris (RF) and vastus lateralis (VL) muscles was predictive of maximum voluntary knee extensor torque in children and adolescents with and without CP and whether these measures were related to activity and participation levels. Design. A case-control design was used. Methods. Eighteen participants with CP (mean age = 12.0 years, SD = 3.2) at Gross Motor Function Classification System (GMFCS) levels I through IV and 12 age-matched peers with typical development (mean age = 12.3 years, SD = 3.9) were evaluated. Muscle thickness, fascicle length, and fascicle angle of the RF and VL muscles were measured with 2-dimensional, B-mode ultrasound imaging. The activity and participation measures used for participants with CP were the Pediatric Outcomes Data Collection Instrument (PODCD and the Activities Scale for Kids, Performance Version (ASKp). Results. When age and GMFCS level were controlled for, VL muscle thickness was the best predictor of knee extensor isometric torque in the group with CP ([R.sup.2] = .85). This prediction was similar to the prediction from VL muscle thickness and age in participants with typical development ([R.sup.2] = .91). Rectus femoris muscle fascicle length was significantly correlated with the Sports and Physical Functioning Scale of the PODCI (ρ = .49), and VL muscle fascicle angle was correlated with the Transfers and Basic Mobility Scale of the PODCI (r = .47) and with ASKp Locomotion subdomain (r =.50). Limitations. A limitation of this study was the small sample size. Conclusions. Ultrasound measures of VL muscle thickness, adjusted for age and GMFCS level, were highly predictive of maximum torque and have the potential to serve as surrogate measures of voluntary strength (force-generating capacity) in children and adolescents with and without CP., Cerebral palsy (CP) is a group of disorders of movement and posture, often characterized by impairments such as muscle weakness, spasticity (hypertonicity), stiffness, and excessive co-contraction. (1) In children and [...]

Background. Exercise benefits patients with chronic nonspecific low back pain; however, the most effective type of exercise remains unknown. Objective. This study compared outcomes after motor control exercises, sling exercises, and general exercises for low back pain. Design. This was a randomized controlled trial with a 1-year follow-up. Setting. The study was conducted in a primary care setting in Norway. Patients. The participants were patients with chronic nonspecific low back pain (n=109). Interventions. The interventions in this study were low-load motor control exercises, high-load sling exercises, or general exercises, all delivered by experienced physical therapists, once a week for 8 weeks. Measurements. The primary outcome measure was pain reported on the Numeric Pain Rating Scale after treatment and at a 1-year follow-up. Secondary outcome measures were self-reported activity limitation (assessed with the Oswestry Disability Index), clinically examined function (assessed with the Fingertip-to-Floor Test), and fear-avoidance beliefs after intervention. Results. The postintervention assessment showed no significant differences among groups with respect to pain (overall group difference) or any of the outcome measures. Mean (95% confidence interval) group differences for pain reduction after treatment and after 1 year were 0.3 (-0.7 to 1.3) and 0.4 (-0.7 to 1.4) for motor control exercises versus sling exercises, 0.7 (-0.6 to 2.0) and 0.3 (-0.8 to 1.4) for sling exercises versus general exercises, and 1.0 (-0.1 to 2.0) and 0.7 (-0.3 to 1.7) for motor control exercises versus general exercises. Limitations. The nature of the interventions made blinding impossible. Conclusions. This study gave no evidence that 8 treatments with individually instructed motor control exercises or sling exercises were superior to general exercises for chronic low back pain., Nonspecific low back pain (LBP) is a major public health problem in industrialized societies, with lifetime prevalence between 60% and 85%. (1) Reviews point to beneficial effects of supervised exercises [...]

Background. Benign paroxysmal positional vertigo (BPPV) is the most common cause of vertigo. Purpose. The purpose of this systematic review was to determine whether patients diagnosed with posterior canal (PC) BPPV, based on positional testing, and treated with a particle repositioning maneuver will show the resolution of benign paroxysmal positional nystagmus (BPPN) on the Dix-Hallpike Test performed 24 hours or more after treatment. Data Sources. Data were obtained from an electronic search of the MEDLINE, EMBASE, and CINAHL databases from 1966 through September 2009. Study Selection. The study topics were randomized controlled trials (RCTs), quasi-RCTs, the diagnosis of PC BPPV, treatment with the particle repositioning maneuver, and outcome measured with a positional test 24 hours or more after treatment. Data Extraction. Data extracted were study descriptors and the information used to code for effect size. Data Synthesis. In 2 double-blind RCTs, the odds in favor of the resolution of BPPN were 22 times (95% confidence interval=3.41-141.73) and 37 times (95% confidence interval=8.75-159.22) higher in people receiving the canalith repositioning procedure (CRP) than in people receiving a sham treatment. This finding was supported by the results reported in 8 nonmasked quasi-RCTs. Studies with limited methodological quality suggested that a liberatory maneuver (LM) was more effective than a control intervention; there was no significant difference in the effectiveness of the LM and the effectiveness of the CRP; the self-administered CRP was more effective than the self-administered LM; and the CRP administered together with the self-administered CRP was more effective than the CRP administered alone. The Brandt-Daroff exercises were the least effective self-administered treatments. Limitations. The limitations included the methodological quality of the studies, the lack of quality-of-life measures, and confounding factors in reporting vertigo. Conclusions. Randomized controlled trials provided strong evidence that the CRP resolves PC BPPN, and quasi-RCTs suggested that the CRP or the LM performed by a clinician or with proper instruction at home by the patient resolves PC BPPN. There were no data on the effects of the maneuvers on outcomes relevant to patients., Benign paroxysmal positional vertigo (BPPV) is characterized by brief periods of vertigo triggered by a change in the position of a person's head relative to gravity. In the general population, [...]

Background. At 6 months poststroke, most patients cannot incorporate their affected hand into daily activities, which in turn is likely to reduce their perceived quality of life. Objective. This preliminary study explored change in patient-reported, health-related quality of life associated with robotic-assisted therapy combined with reduced therapist-supervised training. Design and Setting. A single-blind, multi-site, randomized clinical trial was conducted. Participants. Seventeen individuals who were 3 to 9 months poststroke participated. Intervention. stay hours of therapist-supervised repetitive task practice (RTP) was compared with 30 hours of RTP combined with 30 hours of robotic-assisted therapy. Measurements. Participants completed the Stroke Impact Scale (SIS) at baseline, immediately postintervention, and 2 months postintervention. Change in SIS score domains was assessed in a mixed model analysis. Results. The combined therapy group had a greater increase in rating of mood from preintervention to postintervention, and the RTP-only group had a greater increase in rating of social participation from preintervention to follow-up. Both groups had statistically significant improvement in activities of daily living and instrumental activities of daily living scores from preintervention to postintervention. Both groups reported significant improvement in hand function postintervention and at follow-up, and the magnitude of these changes suggested clinical significance. The combined therapy group had significant improvements in stroke recovery rating postintervention and at follow-up, which appeared clinically significant; this also was true for stroke recovery rating from preintervention to follow-up in the RTP-only group. Limitations. Outcomes of 30 hours of RTP in the absence of robotic-assisted therapy remain unknown. Conclusion. Robotic-assisted therapy may be an effective alternative or adjunct to the delivery of intensive task practice interventions to enhance hand function recovery in patients with stroke., Stroke is the most prevalent cause of adult-onset disability in the United States. An estimated 5.8 million people who have had a stroke have residual neurological deficits. (1,2) At 6 [...]

John Garzione, PT, DPT, DAAPM, cites the case of a patient whose pain was getting steadily worse following extensive shoulder surgery, but whose orthopedist, the patient said, had discharged him [...]

Background. The Facial Grading Scale (FGS) is a quantitative instrument used to evaluate facial function after facial nerve injury. However, quantitative improvements in function after facial rehabilitation in people with chronic facial paralysis have not been shown. Objective. The objectives of this study were to use the FGS in a large series of consecutive subjects with facial paralysis to quantitatively evaluate improvements in facial function after facial nerve rehabilitation and to describe the management of chronic facial paralysis. Design. The study was a retrospective review. Methods. A total of 303 individuals with facial paralysis were evaluated by 1 physical therapist at a tertiary care facial nerve center during a 5-year period. Facial rehabilitation included education, neuromuscular training, massage, meditation-relaxation, and an individualized home program. After 2 months of home exercises, the participants were re-evaluated, and the home program was tailored as necessary. All participants were evaluated with the FGS before the initiation of facial rehabilitation, and 160 participants were re-evaluated after receiving treatment. All participants underwent the initial evaluation at least 4 months after the onset of facial paralysis; for 49 participants, the evaluation took place more than 3 years after onset. Results. Statistically significant increases in FGS scores were seen after treatment (P Limitations. A limitation of this study was that evaluations were performed by only 1 therapist. Conclusions. For 160 patients with facial paralysis, statistically significant improvements after facial rehabilitation were shown; the improvements appeared to be long lasting with continued treatment. The improvements in the FGS scores indicated that patients can successfully manage symptoms with rehabilitation and underscored the importance of specialized therapy in the management of facial paralysis., People with long-standing facial paresis experience facial disfigurement and psychological difficulties and may be unable to convey emotions through facial expressions. (1) These people often have been told by health [...]

Background. Effective interventions to improve and maintain strength (force-generating capacity) and endurance are needed for children with cerebral palsy (CP). Objective. This study was performed to examine the effects of a stationary cycling intervention on muscle strength, locomotor endurance, preferred walking speed, and gross motor function in children with spastic diplegic CP. Design. This was a phase I randomized controlled trial with single blinding. Setting. The interventions were performed in community-based outpatient physical therapy clinics. Outcome assessments were performed in university laboratories. Participants. Sixty-two ambulatory children aged 7 to 18 years with spastic diplegic CP and Gross Motor Function Classification System levels I to III participated in this study. Intervention and Measurements. Participants were randomly assigned to cycling or control (no-intervention) groups. Thirty intervention sessions occurred over 12 weeks. Primary outcomes were peak knee extensor and flexor moments, the 600-Yard Walk-Run Test, the Thirty-Second Walk Test, and the Gross Motor Function Measure sections D and E (GMFM-66). Results. Significant baseline-postintervention improvements were found for the 600-Yard Walk-Run Test, the GMFM-66, peak knee extensor moments at 120[degrees]/s, and peak knee flexor moments at 30[degrees]/s for the cycling group. Improved peak knee flexor moments at 120[degrees]/s were found for the control group only, although not all participants could complete this speed of testing. Significant differences between the cycling and control groups based on change scores were not found for any outcomes. Limitations. Heterogeneity of the patient population and intrasubject variability were limitations of the study. Conclusions. Significant improvements in locomotor endurance, gross motor function, and some measures of strength were found for the cycling group but not the control group, providing preliminary support for this intervention. As statistical differences were not found in baseline-postintervention change scores between the 2 groups; the results did not demonstrate that stationary cycling was more effective than no intervention. The results of this phase I study provide guidance for future research., Children with cerebral palsy (CP) have decreased capacity to participate in play and sports activities at intensities sufficient to develop and maintain adequate levels of muscular strength (force-generating capacity) and [...]

Background. There is a lack of standardized mobility measures specific to the long-term care (LTC) population. Therefore, the Continuing Care Activity Measure (CCAM) was developed. Objective. This study determined levels of reliability, validity for clinical utilization, and sensitivity to change of this measure. Design. This was a prospective longitudinal cohort study among elderly people with primarily physical or medical impairments who were residing in LTC institutions that provide nursing home and more-complex care, with access to physical therapy services. Method. The CCAM, the Clinical Outcome Variables Scale (COVS), the Social Engagement Scale (SES) of the Resident Assessment Instrument--Minimum Data Set (RAI-MDS) 2.0 instrument, and the Resource Utilization Groups, version 3, (RUG-III) were administered by clinical and research physical therapists, with timing dictated by the study purpose. Results. The participants were 136 residents of LTC institutions and 21 physical therapists. The CCAM interrater reliability (intraclass correlation coefficient [ICC]) was .97 (95% confidence interval=.91-1.00), and test-retest reliability (ICC) over a period of 1 week was .99 (95% confidence interval=.93-1.00). Over 6 months, the absolute change in total score was 5.88 for the CCAM and 4.26 for the COVS; the CCAM was 28% more responsive across all participants (n=105) and 68% more responsive for those scoring in the lower half (n=49). The minimal detectable difference of the CCAM was 8.6 across all participants. The CCAM correlated with the COVS, nursing care hours inferred from the RUG-III, and the SES. Limitations. some participants were lost to follow-up. Conclusions. The CCAM is a reliable and valid tool to measure gross motor function and physical mobility for elderly people in LTC institutions. It discriminates among functional levels, measures individual functional change, and can contribute to clinical decision making., Physical functioning is an important component of quality of life for elderly people because it affects their sense of autonomy, social engagement, and overall sense of well-being. (1) This finding [...]

Byline: Photographed by Nick Knight. LOOKING BACK Acupuncture, pills, surgerypeople will try almost anything to alleviate back pain. But, as Robert Sullivan discovers, the solution may be far simpler. Painthat's [...]

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The study investigated the effect of aquatic vertical traction on spinal height, pain intensity, and centralization response compared with a land-based supine flexion position for patients with low back pain [...]