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Poor walking endurance in Parkinson disease (PD) may be attributable to both bioenergetic and biomechanical factors, but locomotor training methods addressing both these factors simultaneously are understudied. Our objective was to examine the effects of overground locomotor training (OLT) on walking endurance in individuals with mild-to-moderate PD, and to further explore potential cardiorespiratory contributions.A single-arm, longitudinal design was used to examine the effects of 24 biweekly sessions of OLT in people with mild-to-moderate PD (n = 12). Walking endurance was measured as total distance walked during a 10-minute walk test (10minWT). Oxygen uptake (V˙o2) on-kinetic profiles were determined using a monoexponential function. Perceived fatigability was assessed following the 10minWT using a self-report scale. Magnitude of change in primary outcomes was assessed using Cohen's d and adjusted for sample size (Cohen's d(unbiased)).Participants executed 3036 (297) steps and maintained 65.5% (8%) age-predicted heart rate maximum in a typical session lasting 56.9 (2.5) minutes. Medium effects in total distance walked-885.9 (157.2) versus 969.5 (140.9); Cohen's d(unbiased) = 0.54-and phase II time constant of the V˙o2 on-kinetic profile-33.7 (12.3) versus 25.9 (15.3); Cohen's d(unbiased) = 0.54-were observed alongside trivial effects for perceived fatigability-4.7 (1.4) versus 4.8 (1.5); Cohen's d(unbiased) = 0.11-following OLT.These preliminary findings may demonstrate the potential for moderate-intensity OLT to improve walking endurance and enhance cardiorespiratory adjustments to walking activity in adults with mild-to-moderate PD.Video Abstract available for more insights from the authors (see the Video, Supplemental Digital Content 1, available at: http://links.lww.com/JNPT/A407).

Objective: The purpose of this study was to examine the effects of overground locomotor training (OLT) on walking endurance and gastrocnemius oxygen extraction in people with chronic cervical motor-incomplete spinal cord injury (SCI). Design: Prospective single-arm pre–post pilot study. Setting: Human Performance Research Laboratory. Participants: Adult men with traumatic chronic cervical SCI (n = 6; age = 30.8 ± 12.5). Intervention: Twenty-four sessions of structured OLT. Outcome measures: Walking endurance was determined during a constant work-rate time-to-exhaustion treadmill test. Normalized perceived fatigability was calculated by dividing subjective ratings of tiredness by walking time. Cardiorespiratory outcomes and muscle oxygen extraction were analyzed using breath-by-breath gas-exchange and near-infrared spectroscopy. Results: OLT resulted in large effects on walking endurance (1232 ± 446 s vs 1645 ± 255 s; d = 1.1; P = 0.045) and normalized perceived fatigability (5.3 ± 1.5 a.u. vs 3.6 ± 0.9 a.u.; d = 1.3; P = 0.033). Small-to-medium effects on absolute (2.8 ± 2.5 a.u. vs 4.2 ± 3.5 a.u.; d = 0.42; P = 0.035) and isotime (2.8 ± 2.5 a.u. vs 3.8 ± 3.0 a.u.; d = 0.33; P = 0.023) muscle oxygen extraction were also observed after OLT. Conclusion: These findings provide preliminary data supporting the potential for improved walking endurance, enhanced muscle O(2) extraction, and reduced perceived fatigability in people with chronic cervical motor-incomplete SCI following the OLT program described in this study.

To examine the effect of muscle fiber recruitment patterns on muscle oxygen utilization during treadmill walking in a group of individuals who have incomplete spinal cord injury.5 participants with motor incomplete spinal cord injury (Age; 42.2 ± 18.8 years, Male;A significant increase in median power of the power spectrum of the electromyography signal was observed during both bouts of treadmill walking, 6-minute walking bout and longer fatiguing bout (49%The main finding of the current study was that median power of the power spectrum significantly increased following 12 weeks of over ground locomotor training, with no significant change in deoxygenation hemoglobin/myoglobin. The recruitment of more and/or larger motor units was seen in conjunction with no changes in muscle oxygen utilization for the same walking task.Implications for RehabilitationThe reduction of skeletal muscle innervation in Spinal Cord Injury may adversely affect the orderly recruitment of motor units, which could in turn blunt the oxidative metabolic response during physical activity.Over-ground locomotor could be a useful tool in the rehabilitative process following an incomplete spinal cord injury.

IntroductionThere is weak relationship between the presence of lumbar spondylolisthesis [SPL] and low back pain that is not always associated with instability, either at the involved lumbar segment or at different spinal levels. Therefore patients with lumbar symptomatic SPL can be divided into stable and unstable, based on the level of mobility during flexion and extension movements as general classifications for diagnostic and therapeutic purposes. Different opinions persist about best treatment (conservative vs. surgical) and among conservative treatments, on the type, dosage, and progression of physical therapy procedures.Purpose and importance to practiceThe aim of this Masterclass is to provide clinicians evidence-based indications for assessment and conservative treatment of SPL, taking into consideration some subgroups related to specific clinical presentations.Clinical implicationsThis Masterclass addresses the different phases of the assessment of a patient with SPL, including history, imaging, physical exam, and questionnaires on disability and cognitive-behavioral components. Regarding conservative treatment, self- management approaches and graded supervised training, including therapeutic relationships, information and education, are explained. Primary therapeutic procedures for pain control, recovery of the function and the mobility through therapeutic exercise, passive mobilization and antalgic techniques are suggested. Moreover, some guidance is provided on conservative treatment in specific clinical presentations (lumbar SPL with radiating pain and/or lumbar stenosis, SPL complicated by other factors, and SPL in adolescents) and the number/duration of sessions.Future research prioritiesSome steps to improve the diagnostic-therapeutic approach in SPL are to identify the best cluster of clinical tests, define different lumbar SPL subgroups, and investigate the effects of treatments based on that classification, similarly to the approach already proposed for non-specific LBP.

Objective To determine changes in balance and gait following a task-specific, performance-based training protocol for overground locomotor training (OLT) in individuals with motor-incomplete spinal cord injury (iSCI). Design Convenience sample, prepilot and postpilot study. Setting Human performance research laboratory. Participants Adults (N=15; 12 men and 3 women; mean age [y] ± SD, 41.5±16.9), American Spinal Injury Association Impairment Scale C or D, >6 months post-spinal cord injury. Interventions Two 90-minute OLT sessions per week over 12 to 15 weeks. OLT sessions were built on 3 principles of motor learning: practice variability, task specificity, and progressive overload (movement complexity, resistance, velocity, volume). Training used only voluntary movements without body-weight support, robotics, electrical stimulation, or bracing. Subjects used ambulatory assistive devices as necessary. Main Outcome Measures Berg Balance Scale (BBS), Spinal Cord Injury Functional Ambulation Inventory (SCI-FAI) gait parameters, spatiotemporal measures of gait (step length, step width, percent stance, stance:swing ratio) from 7 participants who walked across a pressure-sensitive walkway. Results Fourteen participants completed the OLT protocol and 1 participant completed 15 sessions due to scheduled surgery. The BBS scores showed a mean improvement of 4.53±4.09 (P Conclusion This pilot demonstrated improvements in balance and selected gait characteristics using a task-specific, performance-based OLT for chronic iSCI.

Background Only low-quality evidence is currently available to support the effectiveness of different traction modalities in the treatment of lumbar radiculopathy (LR). Yet, traction is still very commonly used in clinical practice. Some authors have suggested that the subgroup of patients presenting signs and symptoms of nerve root compression and unresponsive to movements centralizing symptoms may benefit from lumbar traction. The aim of this study is to conduct a systematic review of randomized controlled trials (RCTs) on the effects of vertical traction (VT) on pain and activity limitation in patients affected by LR. Methods We searched the Cochrane Controlled Trials Register, PubMed, CINAHL, Scopus, ISI Web of Science and PEDro from their inception to March 31, 2019 to retrieve RCTs on adults with LR using VT to reduce pain and activity limitation. We considered only trials reporting complete data on outcomes. Two reviewers selected the studies, extracted the results, and performed the quality assessment using the Risk of Bias and GRADE tools. Results Three studies met the inclusion criteria. Meta-analysis was not possible due to the heterogeneity of the included studies. We found very low quality evidence for a large effect of VT added to bed rest when compared to bed rest alone (g = − 1.01; 95% CI = -2.00 to − 0.02). Similarly, VT added to medication may have a large effect on pain relief when compared to medication alone (g = − 1.13; 95% CI = -1.72 to − 0.54, low quality evidence). Effects of VT added to physical therapy on pain relief were very small when compared to physical therapy without VT (g = − 0.14; 95% CI = -1.03 to 0.76, low quality evidence). All reported effects concerned short-term effect up to 3 months post-intervention. Conclusions With respect to short-term effects, VT may have a positive effect on pain relief if added to medication or bed rest. Long-term effects of VT are currently unknown. Future higher quality research is very likely to have an important impact on our confidence in the estimate of effect and may change these conclusions.

Purpose To determine the impact of smartphone use on neck impairment and functional limitation in university students. Methods A cross-sectional correlational study was conducted in a sample of students selected through convenience sampling between September 2016 and March 2017. The inclusion criteria were university students at the School of Medicine and Surgery, routine/daily use of mobile devices with advanced computing and connectivity capability built on an operating system, and aged 18–30 years. Participants completed questionnaires that measured general characteristics of smartphone use and demographic characteristics. Neck pain was assessed using a visual analogue pain score (VAS) and a pain drawing (PD); disability status was measured using the Neck Disability Index (NDI-I); and cervical postures while using the phone were captured using the Deluxe Cervical Range of Motion (CROM) device. Results A total of 238 volunteers were recruited (22.4 ± 2.2 years of age, 53.4% males), 35.9% of whom were overweight (>25 BMI). Regarding neck pain, 42.4% reported mild pain, 8.4% had moderate pain, and the remaining 49.2% had no pain. NDI-I and VAS were 3.8 ± 3.8 and 13.6 ± 18.4 mm, respectively. The pain categories did not influence the variables. No significant correlations were observed between the number of hours spent and posture (CROM) while using a smartphone and neck pain and NDI-I. Conclusion While half of young medical students reported neck pain, the use of smartphones was not correlated with neck pain and disability. While we wait for future prospective studies, there is no reason to recommend a change in smartphone use habits among young adults in the meantime.

Background: Despite increasing interest throughout sports rehabilitation in psychological factors that affect outcome such as the impact of self-efficacy on readiness to return to play, few clinical tools are available to assess a patient’s self-confidence in performing sports-specific movement patterns in the pediatric/adolescent population prior to return to sport. Hypothesis/Purpose: The purpose of this study was to develop and validate sports-specific modules to supplement a general measure of movement self-efficacy, the Adolescent Measure of Confidence and Movement Performance (AMCaMP) and provide clinicians with reliable and valid tools to assess adolescent self-confidence in performing sports-specific movements. Methods: After preliminary testing for readability and ease of administration, we administered one of 12 sport-specific modules pertinent to the individual’s sport (baseball, softball, basketball, football, gymnastics, cheerleading, soccer, ballet, swimming, lacrosse, tennis, and cross country), to a total of 14,744 patients, 11-18 years of age, who were drawn from 12 pediatric sports physical therapy facilities in a single health care system. Respondents completed the assigned sport-specific self-report questionnaire both at their initial visits and upon conclusion of their episodes of care. Results were analyzed using classical test theory measures including but not limited to factor analysis suitability, exploratory factor analysis, and confirmatory factor analysis. Results: Based on sample sizes, Bartlett’s Test of Sphericity, and Kaiser-Myer-Olkin measures, nine of the 12 candidate modules (baseball, softball, basketball, football, gymnastics, cheerleading, soccer, ballet, and swimming) were deemed suitable for factor analysis. The sample for each module was then divided into a test sample and a validation sample to avoid model overfitting and to check for generalizability. Exploratory factor analysis revealed an underlying structure ranging from one to three factors depending upon the particular module. Subsequent confirmatory factor analyses fully supported the hypothesized factor structures for each module except swimming. Additional analyses to determine coefficient alpha (range=0.8-0.976), Standard Error of Measurement (range=1.12-2.33), and Minimum Detectable Change (range=3.1-6.47) confirmed the reliability of each of these modules. Conclusion: The AMCAMP sport-specific modules are reliable and valid self-report tools to capture self-confidence in performing essential movements specific to a sport and supplement the AMCAMP’s evaluation of self-efficacy in performing the general movements of everyday life. The results of this study support the use of the AMCAMP sport-specific modules as a reliable and valid self-report instruments as part of the overall clinical evaluation of psychological readiness to return to sport.

STUDY DESIGN: Pre-Post, Repeated Measures. OBJECTIVES: To determine if a warm-up bout of exercise could elicit a phasic ventilatory response to constant work rate (CWR) exercise in individuals with incomplete spinal cord injury (iSCI) during unsupported CWR treadmill walking. Describe the changes in ventilatory kinetics, ventilatory variability and ratings of perceived exertion (RPE) before and after 12 and 24 weeks of overground locomotor training (OLT). Investigate the relationship among minute ventilation (V(E)) variability, RPE, and walking endurance. SETTING: Laboratory. METHODS: A 6-min CWR was used as a warm-up preceding a CWR, at the same walking speed, until volitional fatigue or 30 min. Breath-by-breath ventilatory data were examined during the second CWR using a mono-exponential model. V(E) variability was calculated as the difference between the observed and predicted values. Data were time-matched before and after 12 and 24 weeks of OLT. A Pearson’s correlation was used for V(E) variability, RPE, and walking endurance. RESULTS: A warm-up CWR did elicit a phasic ventilatory response. OLT resulted in faster ventilatory kinetics. Ventilatory variability reduced after 12 weeks of OLT but returned to pre-OLT values after 24 weeks of training. The change in V(E) variability was correlated with the change in RPE throughout the study. 12 and 24 weeks of OLT resulted in significant improvements in treadmill walking time. CONCLUSIONS: SCI patients can achieve a phasic ventilatory response to walking if the exercise bout is preceded by a warm-up. OLT normalizes the ventilatory kinetics and improves walking endurance. The change in V(E) variability is correlated to RPE.

Objective Lumbar radiculopathy (LR) is a pain syndrome caused by compression/irritation of the lumbar nerve root(s). Traction is a well-known and commonly used conservative treatment for LR, although its effectiveness is disputed. The purpose of this systematic review and meta-analysis of randomized controlled trials was to evaluate the effects of different types of traction added to or compared with conservative treatments on pain and disability. Methods Data were obtained from CENTRAL, PUBMED, CINAHL, Scopus, ISI Web of Science, and PEDro from their inception to April 2020. All randomized controlled trials on adults with LR, using mechanical traction, and without any restriction regarding publication time or language were considered. Two reviewers selected the studies, evaluated the quality assessment, and extracted the results. Meta-analysis used a random-effects model. Eight studies met the inclusion criteria, and 5 were meta-analyzed. Results Meta-analyses of results from low-quality studies indicated that supine mechanical traction added to physical therapist treatments had significant effects on pain (g = −0.58 [95% confidence interval = −0.87 to −0.29]) and disability (g = −0.78 [95% confidence interval = −1.45 to −0.11]). Analyses of results from high-quality studies of prone mechanical traction added to physical therapist intervention for pain and disability were not significant. These results were also evident at short-term follow-up (up to 3 months after intervention). Conclusion The literature suggests that, for pain and disability in LR, there is short-term effectiveness of supine mechanical traction when added to physical therapist intervention. Impact This systematic review may be relevant for clinical practice due to its external validity because the treatments and the outcome measures are very similar to those commonly used in a clinical context.

Background Cervical radiculopathy (CR) is a common cervical spine disorder. Cervical traction (CT) is a frequently recommended treatment for patients with CR. Purpose The purpose of this study was to conduct a review and meta-analysis of randomized controlled trials (RCTs) on the effect of CT combined with other physical therapy procedures versus physical therapy procedures alone on pain and disability. Data Sources Data were obtained from COCHRANE Controlled Trials Register, PubMed, CINAHL, Scopus, ISI Web of Science, and PEDro, from their inception to July 2016. Study Selection All RCTs on symptomatic adults with CR, without any restriction regarding publication time or language, were considered. Data Extraction Two reviewers selected the studies, conducted the quality assessment, and extracted the results. Meta-analysis employed a random-effects model. The evidence was assessed using GRADE criteria. Data Synthesis Five studies met the inclusion criteria. Mechanical traction had a significant effect on pain at short- and intermediate-terms (g = –0.85 [95% CI = –1.63 to –0.06] and g = –1.17 [95% CI = –2.25 to –0.10], respectively) and significant effects on disability at intermediate term (g = –1.05; 95% CI = –1.81 to –0.28). Manual traction had significant effects on pain at short- term (g = –0.85; 95% CI = –1.39 to –0.30). Limitations The most important limitation of the present work is the lack of homogeneity in CR diagnostic criteria among the included studies. Conclusions In light of these results, the current literature lends some support to the use of the mechanical and manual traction for CR in addition to other physical therapy procedures for pain reduction, but yielding lesser effects on function/disability.

Objective To determine the effects of a novel overground locomotor training program on walking performance in people with chronic cervical motor incomplete spinal cord injury (iSCI). Design Before-after pilot study. Setting Human performance research laboratory. Participants Adults (N=6, age >18y) with chronic cervical iSCI with American Spinal Injury Association Impairment Scale grades C and D. Interventions Overground locomotor training included two 90-minute sessions per week for 12 to 15 weeks. Training sessions alternated between uniplanar and multiplanar stepping patterns. Each session was comprised of 5 segments: joint mobility, volitional muscle activation, task isolation, task integration, and activity rehearsal. Main Outcome Measures Overground walking speed, oxygen consumption ( V ˙ o 2 ), and carbon dioxide production ( V ˙ co 2 ). Results Overground locomotor training increased overground walking speed (.36±.20 vs .51±.24 m/s, P d =.68). Significant decreases in V ˙ o 2 (6.6±1.3 vs 5.7±1.4mL·kg·min, P =.038, d =.67) and V ˙ co 2 (753.1±125.5 vs 670.7±120.3mL/min, P =.036, d =.67) during self-selected constant work rate treadmill walking were also noted after training. Conclusions The overground locomotor training program used in this pilot study is feasible and improved both overground walking speed and walking economy in a small sample of people with chronic cervical iSCI. Future studies are necessary to establish the efficacy of this overground locomotor training program and to differentiate among potential mechanisms contributing to enhanced walking performance in people with iSCI after overground locomotor training.

STUDY DESIGN: Pre-post, pilot study. OBJECTIVES: To characterize ventilatory (V(E)) responses to exercise following warm-up walking in individuals with chronic incomplete spinal cord injury (iSCI) during constant work rate (CWR) exercise. Secondarily, to investigate V(E) and tidal volume (V(T)) variability, and ratings of perceived exertion (RPE) before and after overground locomotor training (OLT). SETTING: Research laboratory. METHODS: A 6-min CWR walking bout at preferred pace was used as a warm-up followed by 6 min of rest and a second 6-min CWR bout at above preferred walking pace. The second CWR bout was analyzed. Breath-by-breath ventilatory data were examined using a curvilinear least squares fitting procedure with a mono-exponential model. V(E) and V(T) variability was calculated as the difference between the observed and predicted values and RPE was taken every 2 min. RESULTS: Participants (n = 3, C4–C5) achieved a hyperpneic response to exercise in V(E) and V(T). OLT resulted in faster ventilatory kinetics and reductions of 24 and 29% for V(E) and V(T) variability, respectively. A 30% reduction in RPE was concurrent with the reductions in ventilatory variability. CONCLUSIONS: OLT may improve ventilatory control during CWR in patients with cervical motor-iSCI. These data suggest that in some participants with iSCI, ventilation may influence RPE during walking. Future research should investigate mechanisms of ventilatory variability and its implications in walking performance in patients with iSCI.

To characterize left ventricular diastolic function during an exertional challenge in adults with incomplete cervical spinal cord Injury (icSCI). In this cross-sectional study, a two-group convenience sample was used to compare left ventricular LV diastolic performance during a 5–10 W·min−1 incremental arm ergometer exercise protocol, using bioimpedance cardiography. Subjects were eight males with cervical incomplete spinal cord injury (icSCI; C5-C7: age 39 ± 14 years) versus eight able-bodied males (CON: age 38 ± 13 years). Left ventricular (LV) diastolic indices included end-diastolic volume (EDV) and early diastolic filling ratio (EDFR). LV ejection time (LVET), inotropic index (dZ/dT2) and stroke volume (SV) were compared between the groups at peak exercise, and maximum workload for the icSCI group (isomax). EDV (at peak exercise:131.4 ± 7.3 vs 188.78 ± 9.4, p

Pulmonary arterial hypertension (PAH) is a chronic debilitating illness. The effects of vigorous aerobic exercise training (AET) on heart function in PAH are poorly understood.Eighteen women with PAH (aged 56.2 ± 8.8 yr, body mass index: 28.8 ± 7.3 kg/m) underwent 10 wk of vigorous AET. Cardiac function was observed at rest and peak exercise using bioelectrical impedance cardiography before and after the AET. Cardiac function was observed in a small PAH subset (n = 7) for 10 wk before beginning the AET. A cohort of sedentary women (n = 19) served as healthy controls.Left ventricular ejection fraction (48 ± 9.2 vs 61.5 ± 13.3%, P = .034) and the systemic vascular resistance index (2258 ± 419.1 vs 2939 ± 962.4 dyn·sec/cm·m, P = .008) were lower at supine rest in the baseline PAH group versus the healthy group, as were peak exercise heart rate (140 ± 13.3 vs 170 ± 13.8 beats/min, P.001) and systemic vascular resistance index (828 ± 141.1 vs 824 ± 300.9 dyn·sec/cm·m, P = .050) after controlling for age and heart rate. Systemic vascular resistance index measured at peak exercise decreased in the PAH group after AET (828 ± 141.1 vs 766 ± 139.6 dyn·sec/cm·m, P = .020). Left ventricular early diastolic filling ratio worsened in the PAH subset prior to AET (95.9 ± 19.4 vs 76.2 ± 18.9%, P = .043) and remained unchanged after AET.Vigorous AET was not associated with significant declines in left ventricular systolic or diastolic function in women with PAH. Aerobic exercise training may be beneficial for reducing afterload and may preserve left ventricular diastolic function.

Reply to the letter to the Editor “Complete transparency of a systematic review for readers”. First of all, we thank for the contribution aimed to improve a complete transparency of our systematic review for readers. It allows us to clarify some aspects that we did not specify in the published manuscript. We agree with you on the importance of the PRISMA statement that guided our systematic review, because the first author of its original paper, Prof. Liberati Alessandro, who disappeared prematurely, was our mentor. This can be an opportunity to remember him and his great commitment to the scientific community. Therefore, we confirm that we followed the PRISMA statement suggestions concerning the methods used for the systematic review. More specifically, despite we did not register the study protocol, we did not amend in any case our research design after the initiation of our study. A protocol exists but it was not made public and it is a “data not shown”. In the protocol we established a priori the objectives and methods of our review, the outcomes, the methods of data extraction and those for qualitative and quantitative synthesis. The protocol was not modified during the editing of the systematic review. Moreover, we extracted data in an agreed beforehand report, an excel cartel with color codes. We verified the report on some randomly selected studies and then it was improved accordingly. Subsequently two authors extracted all the data independently. The disagreements were solved by discussion among all the authors and if consent was not reached the decision was made by the most expert author. It was not necessary contacting other authors for more information. We searched data about the characteristics of participants (e.g. age, diagnosis, symptoms, red flags, inclusion and exclusion criteria), the characteristics of interventions (e.g. type, dosage, position, and time of traction, and type of physical therapy interventions), the characteristics of outcome measures for pain and disability. The data we extracted from included studies were about authors (names of Authors, countries, and publication years), characteristics of participants (number of participants for each group, mean age, and gender), outcome measures employed for pain and disability (e.g. VAS, NRS, Neck Pain and Disability Scale, etc.), follow-up timing (e.g. immediately post-treatment and/or at different post-treatment intervals), results (means and standard deviations at pre- and post-treatment for each outcome measure and for each follow-up time), and adverse events. We hope that these clarifications will improve the readability of the systematic review on the effectiveness of traction added to physical therapy interventions in cervical radiculopathy.

[Purpose] Oswestry Disability Index includes an item (Oswestry Disability Index-8) aiming to assess sexual disability associated to low back pain. The aim of this study is to investigate the percentage of participants who answered the Oswestry Disability Index-8, and the relevance and characteristics of sexual disability due to low back pain in Italian patients. [Participants and Methods] Design: multicenter retrospective analysis. Population: six hundred and ninety-seven outpatients with non-specific low back pain. Variables: pain characteristics (amount, localization, and duration of perceived pain), disability, and psychological variables (anxiety, depression, catastrophizing, kinesiophobia, pain acceptance, and pain vigilance and awareness). [Results] Seventy-seven participants (11.05%) did not answer the Oswestry Disability Index-8. The odds of being not responding to the Oswestry Disability Index-8 item appeared related to age (odds=7.50 for over 60), gender (odds=2.65 for females), and marital status (odds=2.33 for not married). Concerning the psychological variables, Activity Avoidance (coefficient=0.071), Depression (coefficient=0.068), and Rumination (coefficient=0.031) showed a positive impact on sexual disability. [Conclusion] In Italian patients, the percentage of not-responding to Oswestry Disability Index-8 was relatively low. In addition, sexual disability was related to depression, activity avoidance, and rumination.

Aim: Chronic low back pain represents a major problem throughout the world which is increasing largely because of the aging world population. Clinical practice Guidelines can be powerful tools for promoting evidence-based practice, as they integrate research findings in order to support decision making. This study aimed to review recommendations for the management of Chronic low Back Pain in primary care based on high-quality recent and recently updated Clinical practice Guidelines. Methods: CINHAL, PubMed, EMBASE, PEDro, Google Scholar, Government websites, Scientific Association websites were searched until April 2019. The retrieved documents underwent several consecutive selection steps: semi-automated duplicate screening, documents selection based on title and abstract screening. Finally, three independent investigators screened the documents for the selected inclusion criteria and reviewed the retrieved documents by means of the AGREE II instrument. Results: A total of 3055 records were retrieved, of which 10 Clinical practice Guidelines met the inclusion criteria. The overall quality of these Clinical practice Guidelines was moderately variable. The recommendations of four Clinical practice Guidelines deemed as "excellent" were extracted and summarized. Although we tried to implement the most comprehensive research strategies, some Clinical practice Guidelines may be missing due to publication bias or incomplete indexing. Conclusions: This study showed a partial progress in respect of the methodological quality of the Clinical practice Guidelines. Several AGREE II domains demonstrated low scores, particularly the "applicability" and "monitoring and auditing criteria" are the domains most susceptible to amendments in future. Implications for rehabilitation Clinicians should be aware that among recently published/updated clinical practice guidelines for the management of chronic low back pain in primary care only few were deemed to have high quality. Increasing evidence suggests the efficacy for self-management to improve low back pain outcome. Physical treatments are recommended in order to improve low back pain outcome while many physical modalities such as TENS, ultrasound, laser therapy are not. Psychological treatments are recommended and should be included as part of a broader treatment plan. Aim: Chronic low back pain represents a major problem throughout the world which is increasing largely because of the aging world population. Clinical practice Guidelines can be powerful tools for promoting evidence-based practice, as they integrate research findings in order to support decision making. This study aimed to review recommendations for the management of Chronic low Back Pain in primary care based on high-quality recent and recently updated Clinical practice Guidelines. Methods: CINHAL, PubMed, EMBASE, PEDro, Google Scholar, Government websites, Scientific Association websites were searched until April 2019. The retrieved documents underwent several consecutive selection steps: semi-automated duplicate screening, documents selection based on title and abstract screening. Finally, three independent investigators screened the documents for the selected inclusion criteria and reviewed the retrieved documents by means of the AGREE II instrument. Results: A total of 3055 records were retrieved, of which 10 Clinical practice Guidelines met the inclusion criteria. The overall quality of these Clinical practice Guidelines was moderately variable. The recommendations of four Clinical practice Guidelines deemed as “excellent” were extracted and summarized. Although we tried to implement the most comprehensive research strategies, some Clinical practice Guidelines may be missing due to publication bias or incomplete indexing. Conclusions: This study showed a partial progress in respect of the methodological quality of the Clinical practice Guidelines. Several AGREE II domains demonstrated low scores, particularly the “applicability” and “monitoring and auditing criteria” are the domains most susceptible to amendments in future.Implications for rehabilitation Clinicians should be aware that among recently published/updated clinical practice guidelines for the management of chronic low back pain in primary care only few were deemed to have high quality. Increasing evidence suggests the efficacy for self-management to improve low back pain outcome. Physical treatments are recommended in order to improve low back pain outcome while many physical modalities such as TENS, ultrasound, laser therapy are not. Psychological treatments are recommended and should be included as part of a broader treatment plan.

Walking is commonly recommended to relieve pain and improve function in chronic low back pain. The purpose of this study was to conduct a systematic review and meta-analysis of randomized controlled trials concerning the effectiveness of walking interventions compared to other physical exercise on pain, disability, quality of life and fear-avoidance, in chronic low back pain.Randomized controlled trials investigating the effects of walking alone compared to exercise and to exercise with added walking on adults with chronic low back pain were identified using the MEDLINE, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Physiotherapy Evidence Database (PEDro), Cochrane Central Register of Controlled Trials (CENTRAL), PsychINFO, and SPORT DiscusMeta-analysis of five randomized controlled trials meeting inclusion criteria was performed. The effectiveness of walking and exercise at short-, mid-, and long-term follow-ups appeared statistically similar. Adding walking to exercise did not induce any further statistical improvement, at short-term.Pain, disability, quality of life and fear-avoidance similarly improve by walking or exercise in chronic low back pain. Walking may be considered as an alternative to other physical activity. Further studies with larger samples, different walking dosages, and different walking types should be conducted. Implications for Rehabilitation Walking is commonly recommended as an activity in chronic low back pain. Pain, disability, and fear-avoidance similarly improve by walking or exercise. Adding walking to exercise does not induce greater improvement in the short-term. Walking may be a less-expensive alternative to physical exercise in chronic low back pain.

Background Global postural re-education (GPR) has shown positive results for patients with musculoskeletal disorders, but no previous randomized controlled trial (RCT) has investigated its effectiveness as the sole procedure for adult patients with chronic nonspecific neck pain (NP). Objective The purpose of this study was to evaluate the effectiveness of applying GPR compared with a manual therapy (MT) intervention to patients with chronic nonspecific NP. Design An RCT was conducted. Patients Ninety-four patients with chronic nonspecific NP (72 women and 22 men; average age=47.5 years, SD=11.3) were randomly assigned to receive either a GPR intervention or an MT intervention. Outcome Measures Pain intensity (visual analog scale), disability (Neck Disability Index), cervical range of motion, and kinesiophobia (Tampa Scale of Kinesiophobia) were assessed. Methods The experimental group received GPR, and the reference group received MT. Both groups received nine 60-minute-long sessions with one-to-one supervision from physical therapists as the care providers. All participants were asked to follow ergonomic advice and to perform home exercises. Measures were assessed before treatment, following treatment, and at a 6-month follow-up. Results No important baseline differences were found between groups. The experimental group exhibited a statistically significant reduction in pain following treatment and in disability 6 months after the intervention compared with the reference group. Limitations Randomization did not lead to completely homogeneous groups. It also was noted that the time spent integrating the movements practiced during the session into daily routines at the end of each session was requested only of participants in the GPR group and may have had an impact on patient adherence that contributed to a better outcome. Conclusions The results suggest that GPR was more effective than MT for reducing pain after treatment and for reducing disability at 6-month follow-up in patients with chronic nonspecific NP.

The Outpatient Physical Therapy Improvement in Movement Assessment Log (OPTIMAL) is a self-report instrument developed to measure the ability to perform mobility actions.To validate a Spanish version of the OPTIMAL instrument.Cross-cultural adaptation and validation study.Primary and specialized outpatient care settings.Three hundred seven patients beginning physical therapy treatment and 30 subjects from the general population.A 2-part study was designed based on guidelines for cultural adaptation of patient-reported outcome measures.Reliability was estimated by internal consistency (Cronbach α), SE of measurement, and test-retest reliability (intraclass correlation coefficient) at 2 weeks. Confirmatory factor analysis was performed to examine structural validity. The association with the Physical Functioning Subscale was assessed with Spearman correlation coefficients. OPTIMAL scores across different groups were compared with Mann-Whitney U and Kruskal-Wallis tests. Effect size, standardized response mean, and minimal detectable change were determined for responsiveness.The Spanish version of the OPTIMAL instrument showed a similar structure to the original English questionnaire. Cronbach α was 0.95 for the difficulty and confidence scales. Intraclass correlation coefficient was 0.91 (95% CI 0.87-0.94) for the difficulty scale and 0.90 (95% CI 0.85-0.93) for the confidence scale. The SE of measurement was 5.11 for the difficulty scale and 6.54 for the confidence scale. The association with the Physical Functioning Subscale was strong and significant (P .001). The 2 scales showed significantly different scores for each of the established patient groups. The effect size was 0.61 (95% CI 0.48-0.74) for the difficulty scale and 0.53 (95% CI 0.38-0.69) for the confidence scale. The standardized response mean was 0.97 (95% CI 0.78-1.13) for the difficulty scale and 0.76 (95% CI 0.48-1.01) for the confidence scale. The minimal detectable change, of a possible score of 100, was 14.2 for the difficulty scale and 18.1 for the confidence scale.The Spanish version of the OPTIMAL has appropriate reliability, validity, and responsiveness and it is an adequate self-report instrument for the assessment of mobility actions.III.

Background Different types of pillows have been proposed for neck pain, but no previous randomized controlled trial has investigated the effectiveness of a “spring pillow” for adults with chronic nonspecific neck pain. Objective We evaluated the effectiveness of using a pillow made from viscoelastic polyurethane and 60 independent springs compared with an educational intervention in individuals with chronic nonspecific neck pain. Design This was a randomized controlled trial with crossover study design. Setting The setting was the Occupational Medicine Unit, University Hospital, Bologna (Italy). Participants We recruited 70 adults with chronic nonspecific neck pain, of whom 64 completed the trial. Intervention Participants were randomly assigned to 2 groups. One group used the spring pillow for 4 weeks, and the other group followed educational advice for 4 weeks while continuing to use their own pillows. After 4 weeks of treatment and 4 weeks of washout, groups were crossed over. Pain perceived in the neck, thoracic, and shoulder areas and headache were the primary outcome measures. In addition, disability, sleep quality, subjective improvement, and pillow comfort were assessed. Measures were captured at pretreatment, after 4 weeks, after the 4-week washout period, and 4 weeks after crossover. The mean differences (MD) in outcomes between groups were assessed. Results Treatment with the spring pillow appeared to reduce neck pain (MD = −8.7; 95% confidence interval [CI] = −14.7 to −2.6), thoracic pain (MD = −8.4; 95% CI = −15.2 to −1.5), and headache (MD = −16.0; 95% CI = −23.2 to −8.7). Reductions in shoulder pain were not statistically significant between groups (MD = −6.9; 95% CI = −14.1–0.3). Neither the crossover sequence nor the period (first vs second intervention administration) significantly affected the results. Limitations Education may not have been the best comparator for the spring pillow; drug consumption, actual pillow use, and the implementation of the educational suggestions as prescribed were not controlled. Conclusions Use of the spring pillow in this study was more effective than an educational intervention for improving cervical, thoracic, and head pain. Whether a spring pillow is more effective than other ergonomic pillows remains to be tested.

Background: Locomotor training (LT) is the most commonly used treatment to improve walking performance following spinal cord injury (SCI). The advancement of LT treatments requires the addition of integrative models accounting for the numerous systems responsible for the recovery of walking function following SCI. Objective: This perspective monograph aims to (a) describe a performance-based framework for overground LT (OLT), (b) describe principles of adaptation and motor learning used to inform OLT program design, and (c) present an example OLT program based on the proposed framework. Methods: Individuals with chronic motor-incomplete SCI (7 male, 1 female) classified according to the American Spinal Injury Association Impairment Scale (AIS) as C and D were included. OLT included two 90-minute sessions performed over 12 weeks for a total of 24 sessions. Outcomes measures included overground walking speed, walking economy, pulmonary oxygen uptake, and muscle oxygen extraction measured via near-infrared spectroscopy. Results: Preliminary findings demonstrate the potential of OLT, as describe here, to increase overground walking speed, improve walking economy, accelerate processes associated with oxygen delivery and utilization at the rest-to-work transition, and lower oxygen extraction requirements of skeletal muscle during walking in individuals with chronic motor-incomplete SCI. Conclusion: The proposed framework offers a valuable template for LT program design in both clinical and research settings. Further research is necessary to better understand the effects of OLT and how principles of specificity, progressive overload, and variation within the performance-based framework can be manipulated to maximize function, health, and quality of life in SCI.

Introduction Although there has been substantial emphasis on the neuromuscular and cardiovascular adaptations following rehabilitation, pulmonary adaptations in individuals with incomplete SCI (iSCI) in response to locomotor training have been less frequently studied. In healthy individuals, effective transition from rest to work is accomplished by a hyperpneic response, which exhibits an exponential curve with three phases. However, the degree to which our current understanding of exercise hyperpnea can be applied to individuals with iSCI is unknown. The purpose of this case series was to characterize exercise hyperpnea during a rest to constant work rate (CWR) transition before and after 12-15 weeks of overground locomotor training (OLT). Case presentation Six subjects with cervical motor incomplete spinal cord injury participated in 12-15 weeks of OLT. Subjects were trained in 90-min sessions twice a week. All training activities were weight-bearing and under volitional control without the assistance of body-weight support harnesses, robotic devices or electrical stimulation. Six minutes of CWR treadmill walking was performed at self-selected pace with cardiorespiratory analysis throughout the tests before and after OLT. Averaged group data for tidal volume, breathing frequency or VE showed no difference before and after training. VE variability was decreased by 46.7% after OLT. Discussion CWR VE from rest to work was linear throughout the transition. Following OLT, there was a substantial reduction in VE variability. Future research should investigate the lack of a phasic ventilatory response to exercise, as well as potential mechanisms of ventilatory variability and its implications for functional performance.

The purpose of the present study was to characterize hypothesized relationships among fatigability and cardiorespiratory fitness in individuals with chronic motor-incomplete SCI (iSCI) during treadmill walking. The theoretical framework was that exacerbated fatigability would occur concomitantly with diminished cardiorespiratory fitness in people with iSCI. Subjects with iSCI (n = 8) and an able-bodied reference group (REF) (n = 8) completed a 6-min walking bout followed by a walking bout of 30-min or until volitional exhaustion, both at a self-selected walking speed. Fatigability was assessed using both perceived fatigability and performance fatigability measures. Pulmonary oxygen uptake kinetics (VO2 on-kinetics) was measured breath-by-breath and changes in deoxygenated hemoglobin/myoglobin concentration (∆[HHb]) of the lateral gastrocnemius was measured by near-infrared spectroscopy. Adjustment of VO2 and ∆[HHb] on-kinetics were modeled using a mono-exponential equation. Perceived fatigability and performance fatigability were 52% and 44% greater in the iSCI group compared to the REF group (p = 0.003 and p = 0.004). Phase II time constant (τp) of VO2 on-kinetics and ∆[HHb] ½ time during resting arterial occlusion were 55.4% and 16.3% slower in iSCI vs REF (p

Objectives: To evaluate patients’ participation during physical therapy sessions as assessed with the Pittsburgh rehabilitation participation scale (PRPS) as a possible predictor of functional gain after rehabilitation training. Methods: All patients aged 65 years or older consecutively admitted to a Department of Rehabilitation and Aged Care (DRAC) were evaluated on admission regarding their health, nutritional, functional and cognitive status. Functional status was assessed with the functional independence measure (FIM) on admission and at discharge. Participation during rehabilitation sessions was measured with the PRPS. Functional gain was evaluated using the Montebello rehabilitation factor score (MRFS efficacy), and patients stratified in two groups according to their level of functional gain and their sociodemographic, clinical and functional characteristics were compared. Predictors of poor functional gain were evaluated using a multivariable logistic regression model adjusted for confounding factors. Result: A total of 556 subjects were included in this study. Patients with poor functional gain at discharge demonstrated lower participation during physical therapy sessions were significantly older, more cognitively and functionally impaired on admission, more depressed, more comorbid, and more frequently admitted for cardiac disease or immobility syndrome than their counterparts. There was a significant linear association between PRPS scores and MRFS efficacy. In a multivariable logistic regression model, participation was independently associated with functional gain at discharge (odds ratio 1.51, 95 % confidence interval 1.19–1.91). Conclusion: This study showed that participation during physical therapy affects the extent of functional gain at discharge in a large population of older patients with multiple diseases receiving in-hospital rehabilitation

BACKGROUND AND PURPOSEIn 2008, the Institute of Medicines (IOM) Committee on the Future Health Care Workforce for Older Americans released its report "Retooling for an Aging America: Building the Health Care Workforce."1 As a call for fundamental reform in the way that the workforce is both trained and utilized in the care of older adults, this report advocated a 3-pronged approach to an aging America: enhancing the geriatric competence of the entire workforce; increasing recruitment and retention of geriatric specialists and caregivers; and improving the way care is delivered to this population. This paper focuses on the third prong, by discussing how potential changes in the delivery and utilization of care to older adults poses both challenges and opportunities for the physical therapy profession, and describing the demographic sociopolitical backdrop for the companion paper by Wong and associates, "Building the Physical Therapy Workforce for an Aging America,"2 that addresses the first 2 components of the IOM report related to the profession of physical therapy, particularly the education of the workforce.Leaders in physical therapy education are committed to preparing physical therapists and physical therapist assistants to provide services to older adults in the United States, therefore must prepare students entering the workforce with the abilities to negotiate a drastically altered heath care landscape, especially when working with older adults. The purposes of this paper are to: (1) inform the physical therapy education community about important age-related population factors that deserve emphasis in physical therapy education curricula; (2) describe the evolving nature of health care financing and service utilization that will effect changes in health care delivery; and (3) identify the challenges and opportunities in the clinical practice of physical therapy that may arise in the profession's efforts to meet societal needs related to our aging population more effectively and efficiently.POSITION AND RATIONALEIt is our position that the profession of physical therapy in the United States (US) needs to be nimble in an evolving environment that will change health care financing and delivery over the next decade. The profession must also continue to exercise sure-footed steps forward in clinical practice and education that can maximize the contributions that the profession can make to our growing population of older adults.The Changing Landscape of Aging in the United StatesIn the past decade alone, the number of persons whose age is 65 years or older in the US grew faster than the rest of the population.3 In 2010, 40.3 million people counted in the US Census were 65 and older, representing 13% of the entire population.3 By 2030, it is estimated that the number of people 65 and older will reach to 72 million.4 By 2050 the number of individuals who are 65 years of age and older should reach 88.5 million, with about 19 million over the age of 85 who will account for over 4% of the population.4With aging comes increased risk of managing one or more chronic diseases, often associated with disabilities. In the United States, over 45% of adults age 65 or over have 2-3 chronic conditions.5 Arthritis, hypertension, diabetes, coronary heart disease, cancer, and chronic obstructive pulmonary disease appear most frequently as various dyads or triads of multiple chronic conditions among men and women in this age group.5 For noninstitutionalized Americans, ambulatory disability (ie, serious difficulty in walking or climbing stairs) affects the highest proportion of the population. Stratified by age, 16% of 65-74-year-olds and 33% of those 75 years of age and older have an ambulatory disability.6 This segment of the population with multiple chronic conditions that impede daily function offers a critical opportunity for the profession, as many of these individuals are living and still working in the community and are not the typical geriatric patients seen in acute care, home care, or nursing home settings. …

Introduction The ability to express one's sexuality and engage in sexual activity requires multisystemic coordination involving many psychological functions as well as the integrity of the nervous, hormonal, vascular, immune, and neuromuscular body structures and functions. Aim The purpose of this study was to investigate the associations among pelvic floor function, sexual function, and demographic and clinical characteristics in a population of women initiating physical therapy evaluation and treatment for pelvic floor–related dysfunctions (urinary incontinence, pelvic organ prolapse, vulvodynia, vaginismus, and constipation). Methods We consented and collected completed demographic data and data related to symptoms and clinical condition on 85 consecutive patients in an outpatient physical therapy clinic. Clinical and anthropometric characteristics were analyzed descriptively. Analysis of variance and linear regression analyses were used to analyze Female Sexual Function Index (FSFI) scale ratings, whereas zero-inflated beta-binomial regression was applied to the pain subscale. Main Outcome Measures Main outcome measure was FSFI score, whereas the secondary outcome measure was the FSFI subscale score related to pain. Results Women in our sample were 38 years old on average, 33% of whom had given birth and 82% of whom had high tone pelvic floor. Being in the middle-tercile age group and exhibiting low pelvic floor tone (Beta = 6.8; 95% confidence interval [CI] = [1.4; 12.0]) were significantly associated with lower levels of sexual dysfunction. Women with low tone pelvic floor also reported lower pain (odds ratio = 4.0; 95% CI = [1.6; 9.6]), whereas younger aged and physically unsatisfied subjects were more likely not to have sexual activity in the month prior to scale measurement. Conclusion In female patients with pelvic floor muscle dysfunction undergoing physical therapy and rehabilitation, sexual dysfunction appears to be significantly correlated with age and high pelvic floor muscle tone.

BackgroundPatient satisfaction is an important measure for evaluating interventions in health care. No patient satisfaction questionnaire for physical therapy treatment has been validated to date for use in an Italian outpatient population.ObjectiveThe aim of this study was to translate, culturally adapt, and validate the Italian version of the Physical Therapy Patient Satisfaction Questionnaire (PTPSQ-I).DesignA measurement study was conducted.MethodsThe PTPSQ-I was developed through forward-backward translation, final review, and pre-final version. An acceptability analysis was first conducted. Reliability was measured by internal consistency (Cronbach α), and a factor analysis was applied to investigate the internal structure. Divergent validity was measured by comparing the PTPSQ-I with a visual analog scale (VAS) and with a 5-point Likert-type scale evaluating the global perceived effect (GPE) for the physical therapy treatment.ResultsThe process for developing the PTPSQ-I required 3 months using data on 315 outpatients. Based on our initial analyses, 5 items were deleted from the PTPSQ-I, which was renamed the PTPSQ-I(15). The PTPSQ-I(15) showed high internal consistency (α=.905). Divergent validity was moderate for the GPE (r=.33) but not significant for the VAS (r=−.07). A factor analysis revealed evidence for a 2-factor structure related to perceived “Overall Experience” and “Professional Impression” that explained 62% of the total variance. A third factor, “Efficiency and Convenience,” brought explained total variance to near 70%.LimitationsIt may be necessary to add items to the PTPSQ-I(15) to assess other dimensions not currently represented by these 15 items.ConclusionThe PTPSQ-I(15) showed good psychometric properties, and its use can be recommended with Italian-speaking outpatient populations.

Although the relationship of self-efficacy to sports performance is well established, little attention has been paid to self-efficacy in the movements or actions that are required to perform daily activities and prepare the individual to resume sports participation following an injury and associated period of rehabilitation. There are no instruments to measure self-confidence in movement validated in an adolescent population.The purpose of this paper is to report on the development of the AMCaMP, a self-report measure of confidence in movement and provide some initial evidence to support its use as a measure of confidence in movement.The AMCaMP was adapted from OPTIMAL, a self-report instrument that measures confidence in movement, which had been previously designed and validated in an adult population. Data were collected from 1,115 adolescent athletes from 12 outpatient physical therapy clinics in a single healthcare system.Exploratory factor analysis of the 22 items of the AMCaMP using a test sample revealed a three factor structure (trunk, lower body, upper body). Confirmatory factor analysis using a validation sample demonstrated a similar model fit with the data. Reliability of scores on each of three clusters of items identified by factor analysis was assessed with coefficient alpha (range = 0.82 to 0.94), Standard Error of Measurement (1.38 to 2.74), and Minimum Detectable Change (3.83 to 7.6).AMCaMP has acceptable psychometric properties for use in adolescents (ages 11 to 18) as a patient-centric outcome measure of confidence in movement abilities after rehabilitation.IV.