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Background and purpose: This study examined the association of a commonly used gait assessment, the Dynamic Gait Index, with falls and lower extremity and trunk muscle function in people with multiple sclerosis. Materials and methods: Cross-sectional data from 72 people with multiple sclerosis (Expanded Disability Status Scale 3.5 ± 1.14) were used. The ability of the Dynamic Gait Index to identify fallers was evaluated using the receiver operating characteristic curve. Multiple linear regression determined contributions of muscle function variables to Dynamic Gait Index scores. Results: Thirty-seven participants reported at least one fall in the previous 3 months (51%). The area under the curve for the Dynamic Gait Index was 0.80 (95% CI: 0.69–0.90), indicating a good ability to identify fallers with a cutoff of ≤19/24. After adjusting for age, sex, and disability level, a one standard deviation increase in ankle plantarflexion (15.2 repetitions) and trunk flexion (15.1 repetitions) endurance were associated with an increase in Dynamic Gait Index score of 0.73 (95% CI: 0.07–1.39) and 0.62 (95% CI: 0.002–1.25), respectively. Conclusions: The Dynamic Gait Index may be a useful tool to identify fallers, and was associated with ankle plantarflexion and trunk flexion endurance. The Dynamic Gait Index appears to be a useful tool to identify people with multiple sclerosis at increased risk for falls using a cutoff score of ≤19/24. The ability to do fewer than 13 single leg heel raises had a moderate ability to identify fallers in this study. Out of 11 lower extremity and trunk muscles, only ankle plantarflexion and trunk flexion muscle endurance were significant predictors of Dynamic Gait Index scores. Clinicians may consider targeting ankle plantarflexion and trunk muscle endurance to improve dynamic gait and fall risk in patients with multiple sclerosis. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Background: There are mixed reports on the effectiveness of strength training to improve gait performance in people with multiple sclerosis (MS), yet the reasons for these inconsistent results are not clear. Therefore, a critical review was conducted to explore dosage, frequency, mode, position, and muscle targets of studies that have included strength training in people with MS. Methods: An electronic search was conducted through July 2017. Randomized controlled trials involving people with MS were included that implemented strength training with or without other interventions and assessed 1) strength in the lower extremities and/or trunk and 2) gait speed and/or endurance. Strength and gait results were extracted, along with exercise frequency, intensity, duration, mode, position, and muscle targets. Results: Thirteen trials met the inclusion criteria; nine used dosing consistent with recommended guidelines. Overall, six studies reported significant between-group strength improvements, and four reported within-group changes. Four studies reported significant between-group gait improvements for gait speed and/or endurance, and two reported within-group changes. Most exercises were performed on exercise machines while sitting, supine, or prone. The most common intervention target was knee extension. Conclusions: Studies generally improved strength, yet only two studies reported potentially meaningful between-group changes in gait. Future strength intervention studies designed to improve gait might consider dosing beyond that of the minimum intensity to improve strength and explore muscles targets, positions, and modes that are task-specific to walking. [ABSTRACT FROM AUTHOR]

Rationale: Early physical therapy (PT) interventions may benefit patients with acute respiratory failure by preventing or attenuating neuromuscular weakness. However, the optimal dosage of these interventions is currently unknown.Objectives: To determine whether an intensive PT program significantly improves long-term physical functional performance compared with a standard-of-care PT program.Methods: Patients who required mechanical ventilation for at least 4 days were eligible. Enrolled patients were randomized to receive PT for up to 4 weeks delivered in an intensive or standard-of-care manner. Physical functional performance was assessed at 1, 3, and 6 months in survivors who were not currently in an acute or long-term care facility. The primary outcome was the Continuous Scale Physical Functional Performance Test short form (CS-PFP-10) score at 1 month.Measurements and Main Results: A total of 120 patients were enrolled from five hospitals. Patients in the intensive PT group received 12.4 ± 6.5 sessions for a total of 408 ± 261 minutes compared with only 6.1 ± 3.8 sessions for 86 ± 63 minutes in the standard-of-care group (P < 0.001 for both analyses). Physical function assessments were available for 86% of patients at 1 month, for 76% at 3 months, and for 60% at 6 months. In both groups, physical function was reduced yet significantly improved over time between 1, 3, and 6 months. When we compared the two interventions, we found no differences in the total CS-PFP-10 scores at all three time points (P = 0.73, 0.29, and 0.43, respectively) or in the total CS-PFP-10 score trajectory (P = 0.71).Conclusions: An intensive PT program did not improve long-term physical functional performance compared with a standard-of-care program. Clinical trial registered with www.clinicaltrials.gov (NCT01058421). [ABSTRACT FROM AUTHOR]

Background. Early rehabilitation improves outcomes, and increased use of physical therapist services in the intensive care unit (ICU) has been recommended. Little is known about the implementation of early rehabilitation programs or physical therapists' preparation and perceptions of care in the United States. Objective. A national survey was conducted to determine the current status of physical therapist practice in the ICU. Design. This study used a cross-sectional, observational design. Methods. Self-report surveys were mailed to members of the Acute Care Section of the American Physical Therapy Association. Questions addressed staffing, training, barriers, and protocols, and case scenarios were used to determine perceptions about providing rehabilitation. Results. The response rate was 29% (667/2,320). Staffing, denned as the number of physical therapists per 100 ICU beds, was highest in community hospitals (academic: median=5.4 [range=3-6-9.2]; community: median=6.7 [range=4.4-10.0]) and in the western United States (median=7.5 [range=4.2-12.9]). Twelve percent of physical therapists reported no training. Barriers to providing ICU rehabilitation included insufficient staffing and training, departmental prioritization policies, and inadequate consultation criteria. Responses to case scenarios demonstrated differences in the likelihood of consultation and physical therapists' prescribed frequency and intensity of care based on medical interventions rather than characteristics of patients. Physical therapists in academic hospitals were more likely to be involved in the care of patients in each scenario and were more likely to perform higher-intensity mobilization. Limitations. Members of the Acute Care Section of the American Physical Therapy Association may not represent most practicing physical therapists, and the 29% return rate may have contributed to response bias. Conclusions. Although staffing was higher in community hospitals, therapists in academic and community hospitals cited insufficient staffing as the most common barrier to providing rehabilitation in the ICU. Implementing strategies to overcome barriers identified in this study may improve the delivery of ICU rehabilitation services. [ABSTRACT FROM AUTHOR]

Background. Although studies have established the safety and feasibility of physical therapy in the critical care setting, minimal information about physical therapist practice in the neurological intensive care unit (NICU) is available. Objective. This study describes physical therapists' treatment of people admitted to a NICU. Design. People admitted to the NICU with a diagnosis of subarachnoid hemorrhage, subdural hematoma, intracranial hemorrhage, or trauma were retrospectively studied. Methods. Data on patient demographics, use of mechanical ventilation, and intracranial pressure (ICP) monitoring were collected. For each physical therapy session, the length of the session, the location (NICU or post-NICU setting), and the presence of mechanical ventilation or ICP monitoring were recorded. Data on safety parameters, including vital sign response, falls, and dislodgement of lines, were collected. Results. Over 1 year, 180 people were admitted to the NICU; 86 were evaluated by a physical therapist, for a total of 293 physical therapy sessions in the NICU (n=132) or post-NICU setting (n=161). Only one session (0.3%) was stopped, secondary to an increase in ICP. The first physical therapy session occurred on NICU day 3-0 (25%-75% interquartile range=2.0-6.0). Patients received a median of 3.4 sessions per week (25%-75% interquartile range= 1.8-5.9). Patients with mechanical ventilation received less frequent physical therapy sessions than those without mechanical ventilation. Patients with ICP monitoring received less frequent sessions than those without ICP monitoring. However, after multivariate analysis, only the admission Glasgow Coma Score was independently associated with physical therapy frequency in the NICU. Patients were more likely to stand, transfer, and walk in the post-NICU setting than in the NICU. Limitations. The results are limited by the retrospective, single-center nature of the study. There is inherent bias of evaluating only those patients who had physical therapy, and therapists were unable to completely adjust for the severity of illness of a given patient. Conclusions. Physical therapy was performed safely in the NICU. Patients who required invasive support received less frequent physical therapy. [ABSTRACT FROM AUTHOR]

The article discusses a Cochrane review that focuses on an adult patient with early Parkinson Disease (PD). Topics discussed include a comparison between physical therapist interventions with either placebo or no intervention, the case of a 54-year old financial planner diagnosed with Parkinson Disease (PD) and findings that people with PD gain greater short-term improvements in gait and balance with physical therapist intervention than with placebo or no physical therapist intervention.

Background. Recent studies have demonstrated safety, feasibility, and decreased hospital length of stay for patients with weakness acquired in the intensive care unit (ICU) who receive early physical rehabilitation. The scored Physical Function in Intensive Care Test (PFIT-s) was specifically designed for this population and demonstrated excellent psychometrics in an Australian ICU population. Objective. The purpose of this study was to determine the responsiveness and predictive capabilities of the PFIT-s in patients in the United States admitted to the ICU who required mechanical ventilation (MV) for 4 days or longer. Methods. This nested study within a randomized trial administered the PFIT-s, Medical Research Council (MRC) sum score, and grip strength test at ICU recruitment and then weekly until hospital discharge, including at ICU discharge. Spearman rho was used to determine validity. The effect size index was used to calculate measurement responsiveness for the PFIT-s. The receiver operating characteristic curve was used in predicting participants’ ability to perform functional components of the PFIT-s. Results. From August 2009 to July 2012, 51 patients were recruited from 4 ICUs in the Denver, Colorado, metro area. At ICU discharge, PFIT-s scores were highly correlated to MRC sum scores (rho=.923) and grip strength (rho=.763) (P<.0005). Using baseline test with ICU discharge (26 pairs), test responsiveness was large (1.14). At ICU discharge, an MRC sum score cut-point of 41.5 predicted participants’ ability to perform the standing components of the PFIT-s. Limitations. The small sample size was a limitation. However, the findings are consistent with those in a larger sample from Australia. Conclusions. The PFIT-s is a feasible and valid measure of function for individuals who require MV for 4 days or longer and who are alert, able to follow commands, and have sufficient strength to participate. [ABSTRACT FROM AUTHOR]

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 are 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. [ABSTRACT FROM AUTHOR]

The article describes the case of a 48-year-old woman who was admitted to a hospital with several medical complications associated with anorexia nervosa (AN). Information on the patient's medical history is provided. Based on her initial clinical assessment, the patient was unable to complete basic activities of daily living (ADLs) independently. Also included are information on the patient's physical therapy goals, plan of care and intervention.

Background. Fatigue and impaired upright postural control (balance) are the 2 most common findings in people with multiple sclerosis (MS), with treatment approaches varying greatly in effectiveness. Objectives. The aim of this study was to investigate the benefits of implementing a vestibular rehabilitation program for the purpose of decreasing fatigue and improving balance in patients with MS. Design. The study was a 14-week, single-blinded, stratified blocked randomized controlled trial. Setting. Measurements were conducted in an outpatient clinical setting, and interventions were performed in a human performance laboratory. Patients. Thirty-eight patients with MS were randomly assigned to an experimental group, an exercise control group, or a wait-listed control group. Intervention. The experimental group underwent vestibular rehabilitation, the exercise control group underwent bicycle endurance and stretching exercises, and the wait-listed control group received usual medical care. Measurements. Primary measures were a measure of fatigue (Modified Fatigue Impact Scale), a measure of balance (posturography), and a measure of walking (Six-Minute Walk Test). Secondary measures were a measure of disability due to dizziness or disequilibrium (Dizziness Handicap Inventory) and a measure of depression (Beck Depression Inventory-II). Results. Following intervention, the experimental group had greater improvements in fatigue, balance, and disability due to dizziness or disequilibrium compared with the exercise control group and the wait-listed control group. These results changed minimally at the 4-week follow-up. Limitations. The study was limited by the small sample size. Further investigations are needed to determine the underlying mechanisms associated with the changes in the outcome measures due to the vestibular rehabilitation program. Conclusion. A 6-week vestibular rehabilitation program demonstrated both statistically significant and clinically relevant change in fatigue, impaired balance, and disability due to dizziness or disequilibrium in patients with MS. INSET: The Bottom Line. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Objective: Despite considerable effort to reduce low back pain (LBP), approximately 60% of patients have recurrence after their first episode. The high rate of recurrence suggests that more effective intervention approaches are needed. This randomized, controlled feasibility trial was designed to compare disability, physical functional capacity, and pain outcomes at 2, 6, and 12 months for 2 conventional and 1 novel physical therapy (functional movement training) intervention for recurrent LBP. Design: Randomized, controlled feasibility trial. Setting: University hospital outpatient physical therapy clinic. Participants: Sixty-one participants (60% female) with recurrent LBP. Interventions: Subjects were randomized to 1 of 3 intervention groups: group 1 had a single session consisting of standard back pain education; group 2 had 6 sessions in 8 weeks of conventional physical therapy; and group 3 had 6 sessions in 8 weeks of a novel method of functional movement training. Change from baseline was used to determine within-group changes and between-group differences for participants who finished each time point (2, 6, and 12 months). Changes were evaluated using analysis of variance and Newman-Keuls post hoc analysis. Main Outcome Measures: The primary outcome measure was the novel Continuous Scale Physical Functional Performance test (CS-PFP), a measure of actual physical functional capacity. Secondary measures included the revised Oswestry Disability Index, a measure of pain-related disability, the Roland Morris Disability Questionnaire, and a standard visual analogue pain scale. Results: Of the participants, 67% provided data at 2 months and 44% provided information at 12 months. Raw change scores were evaluated at 2, 6, and 12 months. While no statistical significance was reached with any outcome measure, the trends suggested little change for group 1 (education) and suggested that greatest improvement in function may occur in group 3 (functional movement training). In particular, at 2 months, the CS-PFP change scores revealed a trend (P=.072) toward greater improvement in groups 2 (conventional physical therapy) and 3 (functional movement training) compared with group 1. At 12 months, Oswestry Disability Index and CS-PFP scores also trended toward significance for groups 2 and 3 (P=.7 and .9, respectively). Mean change scores were also calculated and revealed groups 2 and 3 had improved by 2 months and this improvement remained stable at the 1-year mark. Trends in the direction of best improvement occurred for those in the functional movement training group. Conclusion: A large-scale randomized, controlled trial is warranted to determine whether an intervention based on functional movement training is superior to conventional, impairment-based intervention for individuals with recurrent LBP. [Copyright &y& Elsevier]

Background and Purpose Even early in Parkinson disease (PD), individuals have reduced economy of movement. In this case report, the effects of endurance exercise training are examined on walking economy and other measures for 3 individuals in early and middle stages of PD. Patients The patients were 1 woman and 2 men with PD, aged 52 to 72 years, classified at Hoehn and Yahr stages 2 to 2.5. Intervention Each patient completed 4 months of supervised endurance exercise training and 12 months of home exercise, with monthly clinic follow-up sessions. Strategies were included to enhance adherence to exercise. Outcomes The main outcome measure was economy of movement (rate of oxygen consumption during gait) measured at 4 treadmill speeds. Secondary outcome measures included the Unified Parkinson's Disease Rating Scale (UPDRS), Continuous-Scale Physical Functional Performance Test (CS-PFP), Functional Reach Test (FRT), and Functional Axial Rotation Test (FAR). Economy of movement improved for all 3 patients after 4 months of supervised exercise and remained above baseline at 16 months. Two patients also had scores that were above baseline for UPDRS total score, CS-PFP, FRT, and FAR, even at 16 months. Discussion and Conclusions Evidence from these 3 individuals suggests that gains may occur with a treadmill training program that is coupled with specific strategies to enhance adherence to exercise. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Presents a case study of a patient who developed right shoulder pain following upper-extremity exercise. Referral to physical therapy for evaluation and treatment; Diagnosis of patient's condition as isolated paralysis of the serratus anterior muscle; Symptoms of condition; Clinical implications of thoracic neuropathy and shoulder pathokinesiology.

The article focuses on the effectiveness of physical therapy (PT) program to low back pain treatment. Topics mentioned include the exercise for spinal manipulation, the clinical prediction rule (CPR) in low back pain treatment, and the measurement of the quality of life of low back pain patients. Also mentioned are the challenges by primary care providers in giving treatment to patients and the medical care for low back pain patients.