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Interpreting change is a requisite component of clinical decision making for physical therapists. Physical therapists often interpret change using minimal detectable change (MDC) values. Current MDC formulas are informed by classical test theory and calculated with group-level error data. This approach assumes that measurement error is the same across a measure's scale and confines the MDC value to the sample characteristics of the study. Alternatively, an item response theory (IRT) approach calculates separate estimates of measurement error for different locations on a measure's scale. This generates a conditional measurement error for someone with a low, middle, or high score. Error estimates at the measure-level can then be used to determine a conditional MDC (cMDC) value for individual patients based on their unique pre- and post-score combination. cMDC values can supply clinicians with a means for using individual score data to interpret change scores while providing a personalized approach that should lower the threshold for change compared with the MDC and enhance the precision of care decisions by preventing misclassification of patients. The purpose of this Perspective is to present how IRT can address the limitations of MDCs for informing clinical practice. This Perspective demonstrates how cMDC values can be generated from item-level psychometrics derived from an IRT model using the patient-reported Activities-specific Balance Scale (ABC) commonly used in stroke rehabilitation and also illustrates how the cMDC compares to the MDC when accounting for changes in measurement error across a scale. Theoretical patient examples highlight how reliance on the MDC value can result in misclassification of patient change and how cMDC values can help prevent this from occurring. This personalized approach for interpreting change can be used by physical therapists to enhance the precision of care decisions. Keywords: Balance, Measurement: Applied, Stroke, Introduction Precision rehabilitation requires that physical therapists accurately interpret a patient's change over time to make appropriate clinical decisions such as whether an intervention is efficacious. Standardized measurement tools can [...]

Objective. The purpose of this study was to describe the process and cost of delivering a physical therapist--guided synchronous telehealth exercise program appropriate for older adults with functional limitations. Such programs may help alleviate some of the detrimental impacts of social distancing and quarantine on older adults at-risk of decline. Methods. Data were derived from the feasibility arm of a parent study, which piloted the telehealth program for 36 sessions with 1 participant. The steps involved in each phase (ie, development, delivery) were documented, along with participant and program provider considerations for each step. Time-driven activity-based costing was used to track all costs over the course of the study. Costs were categorized as program development or delivery and estimated per session and per participant. Results. A list of the steps and the participant and provider considerations involved in developing and delivering a synchronous telehealth exercise program for older adults with functional impairments was developed. Resources used, fixed and variable costs, persession cost estimates, and total cost per person were reported. Two potential measures of the 'value proposition' of this type of intervention were also reported. Per-session cost of $158 appeared to be a feasible business case, especially if the physical therapist to trained assistant personnel mix could be improved. Conclusions. The findings provide insight into the process and costs of developing and delivering telehealth exercise programs for older adults with functional impairments. The information presented may provide a 'blue print' for developing and implementing new telehealth programs or for transitioning in-person services to telehealth delivery during periods of social distancing and quarantine. Impact. As movement experts, physical therapists are uniquely positioned to play an important role in the current COVID-19 pandemic and to help individuals who are at risk of functional decline during periods of social distancing and quarantine. Lessons learned from this study's experience can provide guidance on the process and cost of developing and delivering a telehealth exercise program for older adults with functional impairments. The findings also can inform new telehealth programs, as well as assist in transitioning in-person care to a telehealth format in response to the COVID-19 pandemic., The current coronavirus disease (COVID-19) pandemic highlights areas in health care where we could be better prepared for disruptive events. In rehabilitation, a clear need for more telehealth-delivered options has [...]

Background and Purpose. Locomotor training (LT) enhances walking in adult experimental animals and humans with mild-to-moderate spinal cord injuries (SCIs). The animal literature suggests that the effects of LT may be greater on an immature nervous system than on a mature nervous system. The purpose of this study was to evaluate the effects of LT in a child with chronic, incomplete SCI. Subject. The subject was a nonambulatory 4 1/2-year-old boy with an American Spinal Injury Association Impairment Scale (AIS) C Lower Extremity Motor Score (LEMS) of 4/50 who was deemed permanently wheelchair-dependent and was enrolled in an LT program 16 months after a severe cervical SCI. Methods. A pretest-posttest design was used in the study. Over 16 weeks, the child received 76 LT sessions using both treadmill and over-ground settings in which graded sensory cues were provided. The outcome measures were ASIA Impairment Scale score, gait speed, walking independence, and number of steps. Results. One month into LT, voluntary stepping began, and the child progressed from having no ability to use his legs to community ambulation with a rolling walker. By the end of LT, his walking independence score had increased from 0 to 13/20, despite no change in LEMS. The child's final self-selected gait speed was 0.29 m/s, with an average of 2,488 community-based steps per day and a maximum speed of 0.48 m/s. He then attended kindergarten using a walker full-time. Discussion and Conclusion. A simple, context-dependent stepping pattern sufficient for community ambulation was recovered in the absence of substantial voluntary isolated lower-extremity movement in a child with chronic, severe SCI. These novel data suggest that some children with severe, incomplete SCI may recover community ambulation after undergoing LT and that the LEMS cannot identify this subpopulation., Locomotor training (LT) is a promising experimental approach that has been translated to humans to promote the recovery of walking after incomplete spinal cord injury (SCI). (1,2) By using a [...]

Physical rehabilitation after spinal cord injury has been based on the premise that the nervous system is hard-wired and irreparable. Upon this assumption, clinicians have compensated for irremediable sensorimotor deficits using braces, assistive devices, and wheelchairs to achieve upright and seated mobility. Evidence from basic science, however, demonstrates that the central nervous system after injury is malleable and can learn, and this evidence has challenged our current assumptions. The evidence is especially compelling concerning locomotion. The purpose of this perspective article is to summarize the evidence supporting an impending paradigm shift from compensation for deficits to rehabilitation as an agent for walking recovery. A physiologically based approach for the rehabilitation of walking has developed, translating evidence for activity-dependent neuroplasticity after spinal cord injury and the neurobiological control of walking. Advanced by partnerships among neuroscientists, clinicians, and researchers, critical rehabilitation concepts are emerging for activity-based therapy to improve walking recovery, with promising clinical findings. Key Words: Locomotion, Recovery of function, Spinal cord injuries., The purpose of this perspective is to summarize the evidence supporting an emerging paradigm shift (1) for the rehabilitation of walking after incomplete spinal cord injury (SCI) from compensation for [...]

Background and Purpose. The use of locomotor training with a body-weight-support system and treadmill (BWST) and manual assistance has increased in rehabilitation. The purpose of this case report is to describe the process for retraining walking in a person with an incomplete spinal cord injury (SCI) using the BWST and transferring skills from the BWST to overground assessment and community ambulation. Case Description. Following discharge from rehabilitation, a man with an incomplete SCI at C5-6 and an American Spinal Injury Association (ASIA) Impairment Scale classification of D participated in 45 sessions of locomotor training. Outcomes. Walking speed and independence improved from 0.19 m/s as a home ambulator using a rolling walker and a right ankle-foot orthosis to 1.01 m/s as a full-time ambulator using a cane only for community mobility. Walking activity ([bar.X]±SD) per 24 hours increased from 1,054 ± 543 steps to 3,924 ± 1,629 steps. Discussion. In a person with an incomplete SCI, walking ability improved after locomotor training that used a decision-making algorithm and progression across training environments. Key Words: Gait, Locomotor training, Recovery, Spinal cord injury., Since Barbeau and colleagues (1,2) first reported suspending a human over a treadmill to assess feasibility for walking retraining, clinicians have increasingly adopted the use of a body-weight-support (BWS) system [...]

Background and Purpose. Motion of the neck and back accompany many daily functional activities. Available range of motion is usually measured regionally and within single planes of motion. This report describes a device and measurement technique that can be used to quantify axial motion in a functionally relevant context. Functional axial rotation (FAR) refers to the available motion that persons use to turn toward the posterior, without regard to the plane of motion; FAR-p refers to the physical motion available, and FAR-v refers to the ability to identify objects. Subjects. Nine men and eight women, aged 20 to 74 years, participated. Methods. Functional axial rotation was determined for each subject. The seated subjects were measured on 2 different days to determine test-retest reliability. Fifteen subjects were measured by two different examiners on the same day to determine interrater reliability. Intraclass correlation coefficients (ICCs) were computed to determine reliability. Results. 7be FAR-p ranged from 78 to 190 degrees; FAR-v ranged from 135 to 250 degrees. Test-retest reliability of FAR-p and FAR-v was excellent (ICC[1,1] values of .95 and .90 respectively, to the right and equivalent to the left). Interrater reliability likewise was excellent, with ICC(2,1) values of .97 to the light and equivalent to the left. Conclusions and Discussion. Functional axial rotation provides one means of quantifying a patient's axial motion as it would be used in functional context. 7be FAR device is easy to construct and portable. Measurement of FAR provides the clinician with reliable information regarding the patient's functional use of available spinal motion, combined with visual ability., Neck and back motion is used during many daily activities. The trunk and neck rotate relative to the pelvis when people look over their shoulders while driving or when they [...]