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The updated Integrated Framework for Clinical Decision Making responds to changes in evidence, policy, and practice since the publication of the first version in 2008. The original framework was proposed for persons with neurological health conditions, whereas the revised framework applies to persons with any health condition across the lifespan. In addition, the revised framework (1) updates patient-centered concepts with shared clinical decision-making; (2) frames the episode of care around the patient's goals for participation; (3) explicitly describes the role of movement science; (4) reconciles movement science and International Classification of Function language, illustrating the importance of each perspective to patient care; (5) provides a process for movement analysis of tasks; and (6) integrates the movement system into patient management. Two cases are used to illustrate the application of the framework: (1) a 45-year-old male bus driver with low back pain whose goals for the episode of care are to return to work and recreational basketball; and (2) a 65-year-old female librarian with a fall history whose goals for the episode of care are to return to work and reduce future falls. The framework is proposed as a tool for physical therapist education and to guide clinical practice for all health conditions across the lifespan. Keywords: Decision-Making: Clinical, Movement Analysis of Tasks, Movement System, Shared Decision-Making, Introduction The Integrated Framework for Clinical Decision Making, published in 2006, (1) innovated clinical reasoning in neurological physical therapy by being explicitly patient centered and combining both enablement (2) and [...]

Objective. The purpose of the study was to determine the impact of novel coronavirus 2019 (COVID-19) restrictions on community-based exercise classes for people with Parkinson disease (PD) and their instructors. Methods. Data were collected via custom-designed electronic surveys for people with PD and class instructors who reported attending or teaching PD-specific exercise class >1 time/week for >3 months prior to pandemic restrictions (March 2020). The PD group also completed the Godin Leisure-Time Questionnaire, Self-Efficacy for Exercise scale, Schwab-England scale, and Parkinson's Disease Questionnaire 8. Results. Eighty-seven people with PD (mean = 70 [7.3] years old) and 43 instructors (51 [12.1] years old) from the United States completed surveys (October 2020 to February 2021). Mean Schwab-England (84 [16]) and Parkinson's Disease Questionnaire 8 (21 [15]) scores indicated low-to-moderate disability in the PD group. Ninety-five percent of the PD group had COVID-19 exposure concerns, and 54% reported leaving home 50% reported decreased exercise quantity/intensity compared with pre-COVID. There was decreased in-person and increased virtual class participation for both groups. The top in-person class barrier for the PD (63%) and instructor (51%) groups was fear of participant COVID-19 exposure. The top virtual class barriers were lack of socialization (20% of PD group) and technology problems (74% of instructor group). Conclusion. During COVID-19, there has been less in-person and more virtual exercise class participation in people with PD and decreased exercise quantity and intensity. Virtual classes may not fully meet the needs of people with PD, and primary barriers include technology and lack of socialization. Impact. As COVID-19 restrictions wane, it is imperative to help people with PD increase exercise and activity. The barriers, needs, and facilitators identified in this study might help inform approaches to increase participation in exercise and activity for people with PD. Lay Summary. During COVID-19, there has been less in-person and more virtual exercise class participation in people with PD and a decrease in exercise quantity and intensity. If you have PD, virtual classes might not fully meet your needs. Primary barriers may include technology problems and lack of social interaction. Keywords: Exercise, Health Care Surveys, Movement Disorders, Neurology, Parkinson Disease, Introduction Parkinson disease (PD) is a neurodegenerative movement disorder characterized by rigidity, bradykinesia, tremor, and postural instability. (1) Physical activity and exercise are essential complements alongside pharmacological treatment in the [...]

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., According to the Sicily Statement on Evidence-Based Practice (EBP), 'healthcare decisions should be made by those receiving care, informed by the tacit and explicit knowledge of those providing care, within [...]

Background. The relative importance of lower extremity and trunk muscle function to gait in people with multiple sclerosis (MS) is unknown. Objective. This study aimed to investigate the association of lower extremity and trunk muscle function with gait performance in people who have MS and mild-to-moderate disability. Design. This was a cross-sectional, observational study. Methods. Participants were people who had an Expanded Disability Status Scale score of Results. Seventy-two participants with MS and a mean Expanded Disability Status Scale score of 3.5 (SD = 1.14) were enrolled. Adjusted for age and sex, the multivariate model including hip abduction, ankle plantar flexion, trunk flexion, and knee flexion explained 57% of the adjusted variance in the T25FW; hip abduction, ankle plantar flexion, and trunk flexion explained 61% of the adjusted variance in the 6MWT. The strongest predictors were ankle plantar flexion endurance for the T25FW and hip abduction strength for the 6MWT: a 1-SD increase in ankle plantar flexion (15.2 heel-raise repetitions) was associated with a 0.33-second reduction in the T25WT (95% CI = -0.71 to -0.14 seconds); a 1-SD increase in normalized hip abduction strength (0.14 kg/body mass index) was associated with a 54.4-m increase in the 6MWT (28.99 to 79.81 m). Limitations. Different measurement scales for independent variables were included because the muscle function assessment used either force or endurance. Conclusions. For the major muscles in the lower extremity and trunk, hip abduction, ankle plantar flexion, trunk flexion, and knee flexion were the strongest predictors of gait performance., Difficulty walking is one of the most commonly reported problems in people with multiple sclerosis (MS). (12) A complex interplay of primary body structure impairments can contribute to difficulty walking, [...]

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, defined 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., Complications of critical illness include intensive care unit (ICU)-acquired weakness, neuropsychiatric abnormalities, impaired functional mobility, decreased quality of life, and high costs of health care use. (1-5) Physical therapist services [...]

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., Growing evidence supports early mobilization and physical therapy to improve both short and long-term physical function in patients who are critically ill. Muscle strength decreases 1% to 2% daily in [...]

highlights the findings and application of Cochrane reviews and other evidence pertinent to the practice of physical therapist. The Cochrane Library is a respected source of reliable evidence related to [...]

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) (PC.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., A growing body of evidence supports the use of early mobilization and physical rehabilitation for patients while in the intensive care unit (ICU). Recent studies have demonstrated safety, feasibility, and [...]

The article discuses challenges in Consciousness research. It is reported that qualitative descriptions from the "Measure of Expanding Consciousness" tap into personal feelings such as intuition, inspiration, humility, and love. It is further reported that quantitative data from the "Measure of Expanding Consciousness" is used to study groups of people or populations but the information is necessarily limited.

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

Exercise benefits people who are in the early and middle stages of Parkinson disease (PD); however, there is insufficient evidence to determine the best approach. This investigation compared short-term and [...]

Background. Neuromuscular electrical stimulation (NMES) can facilitate the recovery of quadriceps muscle strength after total knee arthroplasty (TKA), yet the optimal intensity (dosage) of NMES and its effect on strength after TKA have yet to be determined. Objective. The primary objective of this study was to determine whether the intensity of NMES application was related to the recovery of quadriceps muscle strength early after TKA. A secondary objective was to quantify quadriceps muscle fatigue and activation immediately after NMES to guide decisions about the timing of NMES during rehabilitation sessions. Design. This study was an observational experimental investigation. Methods. Data were collected from 30 people who were 50 to 85 years of age and who received NMES after TKA. These people participated in a randomized controlled trial in which they received either standard rehabilitation or standard rehabilitation plus NMES to the quadriceps muscle to mitigate strength loss. For the NMES intervention group, NMES was applied 2 times per day at the maximal tolerable intensity for 15 contractions beginning 48 hours after surgery over the first 6 weeks after TKA. Neuromuscular electrical stimulation training intensity and quadriceps muscle strength and activation were assessed before surgery and 3.5 and 6.5 weeks after TKA. Results. At 3.5 weeks, there was a significant association between NMES training intensity and a change in quadriceps muscle strength ([R.sup.2]=.68) and activation ([R.sup.2]=.22). At 6.5 weeks, NMES training intensity was related to a change in strength ([R.sup.2]=.25) but not to a change in activation ([R.sup.2]=.00). Furthermore, quadriceps muscle fatigue occurred during NMES sessions at 3.5 and 6.5 weeks, whereas quadriceps muscle activation did not change. Limitations. Some participants reached the maximal stimulator output during at least 1 treatment session and might have tolerated more stimulation. Conclusions, Higher NMES training intensities were associated with greater quadriceps muscle strength and activation after TKA., Total knee arthroplasty (TKA) successfully relieves pain and improves function in patients with knee osteoarthritis, although the recovery of quadriceps muscle force and function is suboptimal compared with that in [...]

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

Background. Overall functional ability declines over time in people with Parkinson disease (PD). Established benchmarks are needed to allow clinicians and researchers to facilitate meaningful interpretation of data. Objective. The purposes of this study were: (1) to report typical values for standard measures of functional ability commonly used in intervention studies and clinical practice with individuals in the early and middle stages of PD and (2) to describe the profile of functional limitations using the Hoehn and Yahr (H&Y) stages of disease and Unified Parkinson's Disease Rating Scale (UPDRS) motor scores. Design. Cross-sectional data were obtained from 5 different studies. Methods. Three hundred thirty-nine patients were evaluated for disease severity (UPDRS motor score); functional capacity (Continuous Scale Physical Functional Performance Test [CS-PFP]); balance and gait (Functional Reach Test [FRT], Timed 'Up & Go' Test [TUG], 360-degree turn, Six-Minute Walk Test [6MWT], and Two-Minute Walk Test); and basic functional activities (supine-to-stand task, stand-to-supine task, and functional axial rotation [FAR]). Results. The mean UPDRS motor score for the sample was 39.2 (SD=12.93). At each stage of PD (from least to most involved), scores on functional measures indicated a significant and progressively reduced functional status. Limitations began early in the disease for the CS-PFP and FAR. Losses in performance were consistent across all stages of disease for the CS-PFP, FRT, 6MWT, and FAR. Several measures demonstrated meaningful losses of function only in later stages of disease. Findings extend current appreciation of functional limitations that begin early in PD and can guide the choice of functional outcome measures at different stages of disease severity. Limitations. Data were obtained only from participants in H&Y stages 1 through 3 and only for some of the performance measures typically used. Conclusions. The findings demonstrate that functional loss occurs at different points in the disease process, depending on the task under consideration. The resulting profile of functional limitations provides benchmarks that clinicians and researchers can use to interpret and monitor status of patients., Several measures of physical function are available to clinicians and researchers to assess walking, balance, and general mobility in people with Parkinson disease. Despite the wide use of these measures, [...]