2011 Annual Conference

Tapley, Howell

The purpose of this study was to examine relationships between physical, mental and spiritual health. An additional purpose was to determine if the practice of aikido was associated with measurable levels of somatic symptoms, perceived stress, anxiety and spirituality.

A total of 278 subjects participated in the study. The subjects came from 26 separate aikido schools in a total of 13 states across the continental United States. Age ranged from 21 to 73 with a mean of 37.

A cross-sectional research design was utilized in this study to test the following hypotheses: 1)  After controlling for demographic variables, daily spiritual experience will explain variability in perceived stress, anxiety and somatic symptoms. Higher levels of daily spiritual experience will be associated with lower levels of perceived stress, anxiety and somatic symptoms, and 2)  After controlling for demographic variables, aikido experience level as measured by belt rank will explain variability in perceived stress, anxiety, somatic symptoms and daily spiritual experiences. Higher levels of aikido experience will be associated with lower levels of perceived stress, anxiety, and somatic symptoms and higher levels of daily spiritual experience. Paper surveys were mailed, completed by subjects, then returned via US mail in sealed envelopes. Measurement instruments included Cohen’s 10-item Perceived Stress Scale (PSS), Spielberger’s 20-item Trait Anxiety Inventory (TAI), the Patient Health Questionnaire-15 (PHQ-15), and the 16-item Daily Spiritual Experiences Scale (DSES).

Data was entered into SPSS version 15. Relationships between variables were explored.

Hierarchical (sequential) regression was performed using SPSS version 15.0. The results did not support either hypothesis. Additional analysis, however, indicated that daily spiritual experience was associated with trait anxiety. More daily spiritual experience was associated with less trait anxiety (r = .131, p = .035). Specifically, more daily spiritual experience was associated with feeling pleasant, having less nervousness and restlessness, more satisfaction with self, fewer wishes to be as happy as others, more happiness, less discontentment and more steadiness (r = .124 to .205, p<.05). More daily spiritual experience also was associated with less trouble sleeping (r = .126, p<.05) as measured using the PHQ-15.

      Belt rank in aikido was associated with 2 individual items on the PHQ-15. More experience in aikido was associated with more pain in the back (r = .191, p<.05), and more pain in the arms, legs and joints (r = .224, p<.05). Belt rank in aikido also was associated with 1 item on the TAI. More experience in aikido was associated with more feelings of steadiness (r = -.199, p<.05). When compared with normative data, female aikido students presented with lower perceived stress (t = 2.02, p<.05) as measured using the PSS. A surprising finding of this study was that aikido students presented with less daily spiritual experience (t = 4.83, p<.05) when compared with normative data for the DSES.

Experience level in martial arts (aikido), had weak associations with some holistic health variables. Weak associations also exist between mental, physical and spiritual health in this population. More experience in martial arts was related to more musculoskeletal symptoms.

Martial artists experience significant musculoskeletal pain and dysfunction, often due to injuries. Nonetheless, students persevere through aches and pains in search of mental and spiritual health. This study does not support the idea that experience in the martial arts leads to significantly less stress, anxiety and higher levels of spirituality. Healthcare providers should use caution when counseling adults in the health-related benefits of martial arts practice, specifically taking into account the high injury rates in some forms such as aikido.

Guild, Jeffrey

Canes are often used by older adults to increase stability and mobility during ambulation. Due to the different number of tips at the cane’s bottom, the single tip cane (STC), tri-tip cane (TTC, also called Flex Stick), and small quad cane (SQC) may theoretically provide differences in gait stability and mobility during ambulation. The purpose of this study was to compare the gait parameters on normal subjects ambulating with these three types of canes.

Twenty healthy physical therapy students, aged 21-31 years old, were recruited from a local university.

Gait data, including force and impulse, were collected using a Tekscan Gait Walkway during ambulation. Force is how much pressure a foot applies on the ground during ambulation and impulse is the amount of force with respect to time. All subjects held their canes with the right hand during ambulation.

One way ANOVA with post hoc tests were used for comparison of different cane conditions and paired t-tests with Bonferroni adjustment were used for comparison between left and right foot under each cane condition.

No significant differences were identified in forces of either left or right foot, in stance time and swing time of left foot, and in impulse of left foot when compared different cane conditions. However, significant differences were identified in cadence, velocity, stance time of right foot, swing time of right foot, and impulse on right foot (p < .05) with one-way ANOVA. In the order from STC, TTC, to SQC, subjects showed decreased cadence, decreased velocity, decreased swing time and increased stance time and increased impulse on right foot. Further, the Post Hoc tests demonstrated there were no statistical differences (p > .05) on cadence (between STC and TTC), on velocity and impulse on right foot (between TTC and SQC).  When comparing these variables between the left and right foot, the right foot showed significantly higher forces (under all three cane conditions) and higher impulse (only under  TTC and SQC conditions) than the left foot (all p < .01) during ambulation, although there was no difference of impulse between the TTC and SQC. 

By using a cane in the order from single tip cane, tri-tip cane, to quad cane, subjects ambulated in decreasing gait speed, steps per minute, and swing time of right foot, but increasing stance time and increasing pressure applied to ground per minute from right foot.  Also, the right foot demonstrated more pressure applied to ground than the left foot at any cane conditions, and such applied pressure to the ground per minute was more obvious when using the tri-tip (flexStick) cane or the quad cane. These results may indicate that a cane with more tip at its bottom may increase the subject’s gait stability (stance time), but it can also decrease the mobility (speed, cadence, swing time). In this study, everyone used the right hand for holding the cane to purposely reduce load on the left lower extremity, so, it makes sense why the right foot applied more forces to the ground than the left one during ambulation.

Clinically, when one is selecting a cane, consideration of preference to either mobility or stability may decide what type cane will be chosen. The tri-tip FlexStick cane may be the useful transitional one from quad cane to single tip cane during progress of rehabilitation.

Lin, Suh-Jen

The six-minute walk test is a field exercise test which measures how far a person can walk in 6 minutes. During the walk test, a person can speed up or slow down as needed which provides us an opportunity to look into gait patterns in naturally varying speeds of walking over ground. However, gait patterns during the walk test have not been reported before. The purpose of this study was to explore gait characteristics during the walk test, specifically the relationship between step length and velocity, in individuals with amputation. We hypothesized that with increasing speed of walking, (1) the step length of both legs would increase, and (2) the step length of the prosthetic leg would be greater than that of the sound leg.

Fourteen individuals (5 women, 9 men) with unilateral lower-limb amputation participated in the study (age: 53±8.3 yrs, length of prosthesis experience ≥ 6 months). Seven healthy age-matched individuals served as the control group. Informed consent was obtained.

For the walk test, participants were instructed to walk as far as possible in 6 minutes on a hallway to cover the maximal distance. The temporal-spatial gait data were captured by an instrumented walkway (GaitRite) during each lap of walking.

The gait data were then exported for further analysis. Step length and velocity were charted with trends analyzed for each participant and grouped together if they had similar trends. Linear regression analysis was conducted for the step length and velocity for each group.

Gait patterns during the six-minute walk test appeared to fall into three categories. Category 1 (n=7): data were typical for people with amputation and supported both hypotheses. Category 2 (n=5): data were only consistent with hypothesis (1), showing a symmetrical gait pattern similar to that in the control group. Category 3 (n=2): data were only consistent with hypothesis (2). Possible factors such as a longer experience in prosthesis use and a better fitness level might contribute to the more symmetrical gait patterns observed for the Category 2 data. Further studies with a larger sample size are needed to confirm our observations.

During the six-minute walk test, changes in step length at naturally varying velocities were not typically observed in individuals with lower-limb amputation.

In addition to the distance of walking, it is important to document the gait patterns when applying the six-minute walk test as an outcome measure for individuals with lower-limb amputation.

Daniel Perry Wingard

Stroke is the leading cause of adult disability. Of the 730,000 survivors of stroke (SSs) each year, 73% will have residual disability. Of the SSs who achieve independent ambulation, 60-80% walk at speeds less than 0.8 m/s, placing them below an effective community ambulation speed. The purpose of this project was to assess the effects of locomotor robotic-assisted body weight supported (BWS) treadmill, Lokomat®, training (LT) and conventional gait training (CGT) on gait speed, endurance, and function in SSs.

20 subjects (11 LT & 9 CGT)

SSs were randomly assigned into either the LT or CGT group. Both groups participated in five one-hour sessions per week for a total of 40 sessions. If randomized to the LT group 40% of BWS was provided initially and gait speed was progressed to 2 mph. Initially time duration and guidance force were progressed, then BWS was decreased as tolerated. If randomized to the CGT group, SSs worked on gait training on level and unlevel surfaces, and exercises to develop strength, balance, endurance, flexibility, and motor control needed for gait activities. The primary outcome measures used were the 10 meter walk test (10mWT), 6 minute walk test (6MWT), and the Functional Independence Measure (FIM). Outcome measures were assessed at baseline, post intervention, and at three month follow up by assessors blinded to group assignment.

There were no significant differences in the 10mWT, 6MWT, and FIM scores over time or between groups across time points using the repeated measures analysis of variance (ANOVA) Greenhouse-Geisser F test (p > 0.0167). The minimally clinically important difference (MCID) and minimal detectable change (MDC) for the 10mWT and 6MWT was significant in one subject in CGT group from baseline to post intervention.

This study recruited low functioning assisted ambulating chronic SSs, as this population of SSs has not been studied much. For this population, the outcome measures selected may not have been sensitive enough to detect subtle changes that may have occurred. A strength of this study included that each SS participated in a fairly standardized treatment protocol, modified to address individual needs dependent on the group assignment. The limitations of this study include the small sample size with a diverse amount of functional and cognitive ability to participate.

Although no differences were detectable in the current study, further study is warranted in combining LT with CGT for people with chronic stroke. One hour sessions were selected due to typical sessions provided in an out-patient environment. Due to the low ambulation status required for inclusion in this study, these deconditioned SSs may have needed more time per session to get enough practice in order to show significant improvement.

Geelhoed, Michael

The purpose of this cross sectional study was to determine the correlation between body mass index (BMI) and three different performance-based tests.

Twenty-six students were randomly selected from a group of young athletes that participated in Vacation Plyo School, a three day plyometrics camp held in San Antonio, Texas. Subjects in the study consisted of 13 girls and 13 boys ranging from 12-18 years of age. The camp is an annual free event provided by local PT clinicians and DPT students to prepare athletes for the upcoming fall sports season. Ideally, camp organizers hope participation in camp will enhance athletic performance and prevent injuries commonly sustained in fall sports.

Students participating in the study were asked to perform three different performance-based tests which included: 1) 40 yard dash, 2) Standing broad jump, and 3) Vertical leap. Each test was measured accordingly in seconds or inches. These performance-based tests were chosen because of their recognition in the literature to be relevant to the fall sports that most of these subjects compete in. Anthropometric measures were also taken to compute their BMI. 

A Pearson coefficient of correlation was used to evaluate the relationship between the subjects’ BMI and their respective performance-based tests results.

The correlation coefficient for the BMI versus the 40 yard dash was 0.39, with a standard deviation of ±0.54. The correlation coefficient for BMI versus the broad jump was -0.13 with a standard deviation of ±10.53. The correlation coefficient for BMI versus vertical leap was -0.27 with a standard deviation of ±4.00. The standard deviation of BMI alone was ±4.27.

BMI can be indicative of how an athlete will perform on performance based-tests. With a higher BMI, the athlete’s performance decreased. Underweight individuals also demonstrated a slight decrease in performance, especially female athletes. When data was separated between males and females, male data showed a linear positive correlation for BMI versus the 40 yard dash. This concluded that the leaner the male, the faster he ran. The female data revealed decreased performance for exceedingly high or low BMI. However, there was an optimal range at which female performance was best. For the broad jump, there was a slight negative correlation for both males and females. This revealed that as BMI increased, the athlete’s performance decreased. This negative inverse relationship was also observed on the vertical leap test. Performance decreased as BMI increased for males and females alike. For all tests, we found a small correlation between the variables.

Maintaining an ideal body mass index for an athlete can enhance athletic performance. Education on BMI should be provided to young athletes, along with nutrition and exercise counseling in order to achieve ideal BMI, and therefore maximize athletic performance.

Kelli Brizzolara, PT, OCS

The purposes of this study were to: 1) compare how compression of the sacroiliac joint (SIJ) affects the thickness of the deep abdominal muscles during an active straight leg raise (ASLR) in healthy subjects and in those with pelvic girdle pain, and 2) determine the between-day intratester reliability of ultrasound imaging for assessing percent change of muscle thickness for the deep abdominals.

Fifteen subjects with unilateral symptoms near the SIJ and 15 age-matched and sex-matched control subjects (28 women, 2 men) were recruited for the study via flyers and word-of-mouth marketing.

An ultrasound machine was used to determine muscle thickness of the transverse abdominus (TrA) and internal oblique (IO).  The muscle thickness of each subject was measured at rest and during the ASLR with and without pelvic compression. The percent change of muscle thickness between rest and during an ASLR was used for data analysis.  To complete the reliability portion of the study, the participants returned 2-4 days later to repeat the procedure.

Two separate two-way (group x pelvic compression) ANOVAs with repeated measures were used to analyze the muscle thickness for the TrA and IO.  The between-day intratester reliability was determined using the Intraclass Correlation Coefficient (ICC_3,3) to assess the consistency in measuring the percent change of the deep abdominal muscle thickness.

The results of the ANOVAs were not significant for either the TrA (p = 0.16) or the IO (p =  0.10).  ICC_3,3 was calculated for each group with and without pelvic compression, respectively.  For those with SIJ pain, intratester reliability for measuring percent change without pelvic compression was fair for the IO (ICC_3,3 = 0.70-0.76) and good to excellent for the TrA (ICC_3,3 = 0.63-0.88).  The reliability for the controls without pelvic compression was excellent for the IO (ICC_3,3 = 0.85-0.89) and fair to good for the TrA (ICC_3,3 = 0.52-0.71).  With pelvic compression, the reliability for those with SIJ pain was good for the IO (ICC_3,3 = 0.61-0.74) and good to excellent for the TrA (ICC_3,3 = 0.77-0.94).  The reliability for the controls during pelvic compression was excellent for the IO (ICC_3,3 = 0.82-0.98) and good to excellent for the TrA (ICC_3,3 = 0.71-0.93).

Pelvic compression did not seem to immediately alter the behavior of the deep abdominal muscles during the ASLR in those with SIJ pain or their age- and sex-matched controls.

This study illuminates the immediate effect of pelvic compression on the behavior of the deep abdominal muscles during an ASLR with compression.  Patients with SIJ pain are commonly given pelvic compression belts and instructed to wear these belts for extended periods of time.  Further research is needed to determine any long-term effect of pelvic compression on the behavior of the deep abdominal muscles, as this will guide physical therapists in prescribing effective therapeutic interventions for a subgroup of patients with low back pain.

BARNETT, JULIE

The purpose of this pilot study is to describe the incidence of different running styles (forefoot, midfoot, rearfoot landing) among a group of recreational runners training for a marathon. In an extensive review of literature performed, no investigations with normative values were found related to this topic.  This preliminary investigation was undertaken to add to the body of knowledge related to running styles, shoe characteristics (shoe age and shoe changes) during training and existence of injury.  It is anticipated that results from this investigation will allow for further research lines related to biomechanical assessment of running styles and identification of relevant variables that can contribute to the incidence of injury and injury prevention.

439 runners ranging in age from 18-65 were filmed within this investigation however, not all runners completed all questionnaires.  A smaller cohort comprised the second sample of runners (73% female, 27% male) who completed the questionnaires (n=56). Recruitment was done during the initial meetings for marathon training sessions sponsored by a local running store. 

There were two aspects of data collection during this investigation. The initial segment occurred during the first 3 training sessions where filming of runners was done as well as the  initial questionnaire regarding age, gender, current injuries and shoe age were distributed for completion.  Initial analysis will provide proportion values for running style.  Participants were given an identifying number and this number was written with a grease pencil on the lower extremities in accordance standard triathlon racing procedures. Instructions were reviewed with all participants about running along cones demarcating the filming zone in order to obtain video of their running style.  A 200 meter length after the first mile of the training route was marked with red cones and served as the filming area. Runners ran along this area and had a posterior and lateral video view taken of their lower extremities with three video cameras placed along the lateral border and 1 along the posterior border of the path. 

PROCEDURES ORDER: 1) Flyers announcing the investigation were placed at a local running store that for a third year sponsored the USA Fit training regimen.  2) Investigators presented the project at the Introductory Training Session consent forms were distributed to interested participants with questions answered. 3) The  “running shute” with cameras for filming was set prior to the start of the second training session. Filming and questionnaire completion were done on the initial training session with similar opportunities at the third and fourth training sessions. 4) Participants were reminded to complete subsequent surveys every 2 months for a total of 4 surveys completed.

Video footage was assessed by two physical therapists experienced in biomechanical analysis of the lower extremity for elite and recreational runners.  The zoom and frame capture features of the video footage were used to identify the running style with agreement needed by two investigators.  A descriptive analysis was done to begin establishment of normative data from a large cohort or recreational runners.  Data that was recorded and summarized to describe this sample included:  Running style, age, gender, shoe age, shoe brand and existence of injury.   Further assessment regarding existence of injuries during the duration of training to marathon date are pending at this time.

Initial Results:  Out of 439 recreational runners, video footage demonstrates that 95% were rearfoot strikers (n=417), 2.5% were midfoot strikers (n=11) and 2.5% were midfoot strikers (n=11).  Assessment of questionnaires reveals that of the 52 rearfoot strikers upon initial investigation 32 of 52 runners presented with lower extremity pain while of the remaining runners in this group, 3 forefoot strikers and 2 midfoot stikers had no lower extremity pain. The majority of runners 62.5% upon inception of training had shoes that were less than 6 months old (n=35).  The most commonly used shoes were Asics and Brooks brands followed by New Balance and Reebok shoes.

Initial findings demonstrate that 95%, a large majority of shod runners are rearfoot stikers.  Recreational runners who have sought to participate in an organized marathon training program utilize relatively new shoes with combination last options. Future investigations should continue to focus upon large cohort comparisons of recreational runners because these are the populations typcially seen by health care practitioners.  Additional factors for investigation should include ground reaction forces of differing runing styles and correlation of potential predisposing injury factors such as running style and shoe brand components.  Greater incentives in future investigations are needed to facilitate questionnaire completion

There is a great deal of interest and discussion in the current popular culture regarding barefoot running and changing running styles. Current research is scant with quantification of foot strike patterns done with only with elite runners.  As most clinicians work with the scores of recreational runners who look to emulate the styles of elite successful runners, there is a dearth of information available regarding running style norms for runners.  The exploration of norms for running style is imperative due to the potential for injuries that can be associated with running style but also for identification of related contributory factors to injury such as training errors, prior injury history and shoe age. Though it is possible that attempts to change natural running styles could be contributing to training errors, it is difficult to assess this question without the preliminary normative data and specific variable identification for specific investigation. Successful completion of this preliminary descriptive and future correlational investigation will lead to future randomized controlled trials regarding cause and effect of running styles and potential injury factors.

Szot, Lauren and Tseng, Eileen

Utilizing standardized outcome measures (OMs) is essential in assessing the effectiveness of physical therapy (PT) interventions. Despite the need for quantifying patient outcomes, use of OMs in PT practice continues to be limited.  The purpose of this project was to develop decision-making algorithms to guide physical therapists (PTs) across all settings in OM selection for balance and gait.

The target population for this project were physical therapists from acute care, inpatient rehabilitation, and outpatient rehabilitation who identified neurology as their primary area of clinical practice.

A questionnaire was developed and administered to determine factors that impact use and selection of OMs.  The questionnaire (n=28) revealed that 64% of PTs reported difficulty selecting an appropriate OM for a patient’s functional status, with time and ease of use identified as major influences on OM selection. The majority of PTs surveyed identified balance and gait (86% and 67%, respectively) as high priorities in the patient’s plan of care. A literature review of balance and gait outcome measures was performed. Once measures were identified, they were ranked based on psychometric properties and clinical utility using the StrokEDGE Taskforce rating scale.  A balance algorithm and a gait algorithm were constructed with these selected OMs based on the patient’s current functional status. To assess practical utility of the algorithms, PTs from each clinical setting (n=10) were chosen to participate in a one-month trial. 

Qualitative data was collected during the algorithm trials with tracking forms and a final survey was distibuted to the physical therapists involved in the trial.  Clinicians completed a tracking form everytime they utilized either of the algorithms, documenting which algorithm was utilized, at what point in the patient's admission was the algorithm used, what barriers to use occurred, and any suggestions for revision.  The survey assessed how the algorithms may have influenced the physical therapists in their clinical practice and their perception of the clinical utility of the algorithms.

During the trial the balance algorithm and the gait algorithm were utilized 55 times and 41 times, respectively.  Time to complete the algorithms ranged from 5 seconds to 10 minutes (mean=113 seconds). Impaired cognition, medical instability, and functional inappropriateness were reported as barriers to use.  All participants agreed that both algorithms were effective in guiding their decision making in OM selection, and 94% reported increased confidence in their choices of outcome measures. Participants agreed that the balance algorithm (100%) and the gait algorithm (78%) were useful for the majority of their patients. Those who were neutral (11%) or disagreed (11%) reported limited ability to use the gait algorithm due to their patients being non-ambulatory. However, it was reported that with improvements in medical stability and function, the ability to use the gait algorithm increased.  Eighty-nine percent agreed that both algorithms prompted them to select OMs not used previously.

This preliminary trial suggests that the balance and gait outcome measure algorithms developed in this study are appropriate for patients with neurologic disorders and can guide physical therapists in their decision-making process and increase their confidence for outcome measure selection.       

Literature indicates that PTs believe OMs assist in developing the plan of care and monitoring effectiveness of treatment; however, time constraints, lack of familiarity of measures, and difficulty with OM selection result in inconsistent use.  Decision making frameworks have been used in neurologic PT practice to guide clinical judgment. Therefore, an evidence-based, decision making algorithm will aid PTs in selection of OMs with sound psychometric properties and clinical utility. 

Brewer, Jacob F.

Leaders in the physical therapy (PT) profession face the challenge of consistently displaying optimism and resiliency when facing daily adversities while at the same time meeting the expectations of constituents with self-confidence and hope. Therefore the purpose of this study was to examine the relationships and differences among leadership characteristics between several demographic areas including professional association membership, entry-level PT degree, PT experience, gender, age, and primary workplace role or job position.

The survey was accessed by 173 PT leaders; 117 met the inclusion criteria. The sample included PTs within the Midwest District of the Texas Physical Therapy Association (TPTA) as well as alumni from one of the PT programs in Texas. A snowball sampling technique was utilized whereby PT leaders were identified and received the electronic survey with the request to complete and forward it on to other PT leaders whom they deemed might be interested in the topic of leadership.

An 88 item questionnaire, comprised of leadership characteristics and goal achievements identified in the literature, and the Psychological Capital Questionnaire (PCQ) which assessed levels of hope, optimism, resiliency, and self-efficacy was utilized.  Each item was assessed on a 5 or 6 point Likert scale. The questionnaire was distributed as a URL online email link through SurveyMonkey™.  Members of the APTA Health Policy Administration or Education section were excluded because of plans to distribute a similar questionnaire to that population in the future.

Correlations compared the strengths of the relationships between the leader's personal activities, psychological capital, and character qualities. An analysis of variance compared the overall scores of leadership qualities, goal achievements, and psychological capital to assess differences based on demographics. All statistical analyses were computed using SPSS™ 18.0 with the alpha level set at 0.05.

Demographics results included: Males=40, Females=77; TPTA members=65, nonmembers=52; Staff PT or Clinical Instructor=70, Supervisor or Manager= 32, Director or Vice President= 7, Senior Executive/CEO or Owner=8.  A positive moderate correlation (r=.555) was found between PT leader character qualities and psychological capital. A significant difference was found between members and non-members of the TPTA in goal achievement (F=7.828, p= 0.006) with members having higher mean scores on goal achievement.  Additionally, PTs with lower entry-level degrees, yet more experience in the field, also scored significantly higher on goal achievement (F=3.712 , p= 0.01) as well as on total PCQ (F=13.370, p=0.001). Male PTs scored significantly higher than female PTs (F=4.76, p=0.031) on the “hope” subscale of the PCQ. When self-efficacy was compared by generational cohorts and PT experience, PTs who were older and PTs who had more experience scored higher  (F=2.671, p= 0.036 and F=2.587, p=0.041 respectively).  PTs who spent more time volunteering also scored significantly higher on both optimism (F=3.879, p=0.01) and goal achievement (F= 6.753, p=0.001).  No differences were found in PCQ based on primary workplace or position held as a PT.

Psychological capital comprised of resiliency, hope, optimism, and self-efficacy, is now a widely recognized form of human and social capital important in healthcare leadership. This study demonstrated that members of the TPTA had significantly higher scores on leadership goal achievement. Likewise, goal achievement and self-efficacy increased with age and PT experience. Volunteerism was also significantly related to higher optimism and goal achievement. These differences in leadership qualities suggest the PT profession should continue to promote early participation in leadership roles while emphasizing self-efficacy awareness among younger, less experienced PTs.

The goal of every PT should be to improve not only clinically, but also professionally as a leader in the neuromusculoskeletal arena of movement. Effective PT leaders are needed amidst healthcare. More experienced and aged PTs rated higher in certain essential leadership qualities such as self-efficacy and goal achievement, and are needed now to mentor strong leadership examples of clinical and professional excellence. In addition, leadership which can instill hope is also required during the current tumultuous changes in healthcare. As such, the significantly higher scores of psychological hope among male PT leaders warrants further investigation as there were fewer male participants in this study and males are known to be substantially less in number amidst the PT profession. Finally, encouraging active PT professional association membership as well as volunteering in religious or charity activities may also assist in the development of future PT leaders.

Barr, Kelly

Phrenic nerve damage can occur concurrently with brachial plexus injury during traumatic deliveries.  In this case the male infant had mild symptoms of respiratory, sleep and feeding problems that progressed over 8 months after a traumatic birth resulting in a clavicular fracture and Erb’s palsy.  Physical therapy was ordered to manage the secondary impairments during the awaited recovery of innervation.  During this period, respiratory sequellae developed which the therapist communicated to the primary care physician resulting in radiographs and a diagnosis of phrenic nerve damage with right hemidiaphragm paresis and mediastinal shift. The child was treated with plication of the diaphragm due to the severity of the elevation of the diaphragm and respiratory sequellae resolved.  It is important to include respiratory examination in the evaluation for Erb’s palsy and to continuously reassess respiratory function during the first few months of life after traumatic birth.

This is a case study and therefore includes only one client with a brachial plexus injury at birth which included damage to the phrenic nerve and hemidiaphragmatic paresis.  The case study describes the physical therapist screen and referral back to the medical team for further diagnostic work.

The Appendix A evaluation was used for Brachial plexus injury which revealed a Erb-Duchenne⁸ palsy presentation during the evaluation.  Assessment was done of the respiratory status. At this time his breathing was tachypneic and effortful or labored.  His abdomen and ribcage were observed for symmetry during respiration.  The right side had decreased excursion and decreased volume of the abdomen during inspiration compared to the left due to the paradoxical motion of the diaphragm during inspiration.  His respirations were shorter and shallower in appearance. Lung sounds were deficient over the right lower lung with auscultation.  He did not demonstrate any coughing during the examination over the entire hour of time.  Position changes did improve the symmetry of the abdominal excursions in supported upright positions.  The baby tended to move less vigorously than a typically developing 6 month old even in the 3 uninvolved extremities and seemed to be content with just quiet visual exploration. Fatigue is difficult to assess in infancy, however, with an absence of muscle tone abnormality combined with paucity of vigorous motion in a 6 month old, fatigue or lethargy were suspected.  The infant had no fever and his coloring was pale.  His regulatory state was good throughout the examination with no crying.

With the suspicion of respiratory problems, a call was made to his physician who promptly referred him directly from the clinic to radiology for chest images.   He followed the next day with examination in his clinic where he revealed the radiological results. These results included right hemidiaphragmatic paresis with mediastinal shift to the left affecting the space of the left lung in addition to the right involved side.  On return to our facility for physical therapy he was given a reflux wedge to help with upright positioning during sleep which helped to increase his sleep to several hours at a time. His respiratory status was constantly monitored during sessions until he saw a specialist and received plication of the diaphragm which took about 6 weeks to get started. By this time he was almost 8 months old and spontaneous return of the diaphragm was not expected.  The mediastinal shift was one of the great concerns because the right diaphragm insufficiency was not able to preserve the heart and left lung spatial orientation. 

 

The infant returned to physical therapy about a week after the plication of the diaphragm and resumed treatment for BPI.  He was able to sleep through the night by this time and had resumed typical respiratory patterns of a 6 month old infant.  He was followed by the specialist for several months and referred to a BPI specialist in Houston for surgical intervention.  This infant had no complications with 2 separate brachial plexus surgeries after his plication surgery.  He was able to develop normal running and cardiovascular skills through age 5 when he moved out of the area.  His right upper extremity still had some motor impairment but, throughout the 4 and half years of care, never had further respiratory symptoms. 

Literature review reveals that brachial plexus surgery is best performed after the diaphragm is repaired or after spontaneous recovery of the phrenic nerve palsy⁶ because there is significant morbidity associated with surgical recovery including difficulty weaning from ventilation after surgery⁴ and infection or even death (10-14%)⁶.  This infant did not have a respiratory infection but often cases of PNI will have repeated respiratory infections⁴. It is important that PNI be identified early for the purpose of providing mechanical support when necessary or support such as wedges and positioning advice. Once the PNI is identified it should be carefully monitored for complications until it resolves spontaneously or surgically. While the literature reveals this to be a rare manifestation of birth trauma (1/15,000 births)⁶, PNI affects a critical respiratory muscle.  As physical therapists the respiratory examination should be included in evaluation of BPI. The presence of dyspnea, tachypnea, sleep disorders, or failure to thrive⁶ combined with the birth trauma should prompt respiratory assessment to include auscultation of each lung, visual inspection of the respiratory muscles at the ribcage and abdomen for symmetry and pace, questions about sleep patterns, feeding patterns, coughing, stridor, and grunting. Radiological images (AP chest) often diagnose the elevated diaphragm and orientation of the mediastinum but sometimes ultrasound may be required and can use height as well as thinning to identify paresis⁹.  Ultrasound is preferred over fluoroscopy^{6, 9} because of radiation exposure and has high specificity for diagnosis of elevated diaphragm prior to scheduling of plication.

This case study describes the importance of vital signs and respiratory evaluation of newborns with brachial plexus injury and birth trauma.

Ernst, Greg

The purpose of this study was to determine if a week long summer program focused on providing an opportunity for participants to learn about and interact with a variety of healthcare professionals could influence the participants’ perceived self efficacy and knowledge of healthcare careers related to sports medicine. Additionally, the purpose of this study was to investigate if there was a relationship between parent education and the participants self efficacy scores before and after the camp.

We recruited 13 male and 13 female (N=26) high school students from five area high schools with an average age of 15.8 and age range from 15 to 17. Of the participants, twenty were of Hispanic origin, 1 Caucasian, 2 Asian and 3 of other origin.

A pre and post survey instrument was used to assess students’ perceived self efficacy towards the healthcare professions related to sports medicine, their knowledge of different healthcare careers and to gather participants’ demographic data.

A statistical analysis using a paired, two tailed t-test was used to evaluate the difference in pre-survey and post-survey self efficacy scores. A linear regression analysis was run to determine if parental education was a predictor for a pre-survey and post-survey self-efficacy score difference.

We found a statistically significant difference between perceived self efficacy scores before the camp compared to perceived self efficacy scores after the camp. Parental education was not found to be a significant predictor for the difference in self efficacy scores on the participants’ pre and post surveys.

There is evidence to suggest that attendance at a summer program that allows high school students to learn about and interact with healthcare professionals will significantly improve perceived self efficacy towards pursuing a healthcare career related to sports medicine. Parental education may not be a predicting factor for the change in perceived self efficacy after attendance to such educational camps. Further research should be conducted to determine the significance of other factors such as ethnicity, gender, socioeconomic status, parent education and academic achievement on an individual’s perceived self efficacy. Additionally, further testing regarding the influence of educational programs on adolescents’ career choices may benefit recruitment in healthcare professions.

Attendance at a summer camp that teaches high school students about various healthcare professions can increase participants’ self efficacy and improve knowledge about the specific professions discussed. Healthcare career educational programs should consider implementing such programs to improve recruitment among potential students.

Newstead, Ann H.

The purpose of this study was to determine the effects of an 8-week intervention program, either cycling or walking, on measures of function and maximal power in sedentary older adults.

A sample of sedentary older adults ages 65-74 (n=6; 3 per group) were recruited from the community. The inclusion criteria were: 1) ability to walk 1-mile by self-report, 2) physician clearance, 3) ability to provide informed consent, and 4) meet the definition of sedentary. In this study “sedentary” was defined as someone who spent more than 60% of their day in less energy consuming activities as measured by the Actical ®.

The intervention study was a repeated-measures within-subjects design with a between-group comparison. There was a baseline pre-test (-3 to 0 weeks), intervention (8 weeks), and post-test phase (week 9). Sedentary older adults were randomly assigned into two different groups: a “cycling” intervention group or a “walking” intervention group. The “cyclists” focused on intermittent fast and moderate, low intensity power training whereas the “walkers” focused on intermittent fast and moderate walking on a treadmill. Both exercise groups met 3 times a week for 30 minutes of exercise for a total of 8 weeks. Outcome measures included power and functional measures (Five time Sit to stand [5STS], Timed Up and Go [TUG], Timed Stair Climb [TSC]). Maximal power (P_max) was measured using specialized cycle ergometer. Heart rate, blood pressure, and perceived exertion were monitored for safety.

Mean and standard deviation (SD) were computed for each group. The Coefficient of Variation ([CV = (T₂ – T₁)/T₁]) was used to determine percent change. The Coefficients of Determination (R²) between power and timed tests were also calculated to show the relationship between the outcome measures.

The cycling group improved Pmax over 8 weeks by 7.1% from pre test (mean + SD; 5.99 + 2.20 w/kg) to post test  (6.42 + 1.27 w/kg). In comparison, the walking group improved Pmax by 0.6% (pre test  6.91 + 1.88 w/kg; post test  7.03 + 1.27 w/kg). For 5STS, the cycling group improved 7.1% (pre-test  8.25 + 2.20 s; post test  7.94 + 2.63 s), whereas the walking group decreased performance by 15% (pre test  6.69 + 0.91 s;  post test 7.15 + 1.87s). For the TUG, the cycling group improved 6% (pre-test 7.16 + 1.09 s; post test 6.94 + 1.98 s), and the walking group improved by 3% (pre test  6.65 + 1.09; post test 6.98 + 1.52 s). Both groups improved the TSC - the cycling group improved by 11% (pre-test  0.9 + 3.19 s/step; post test 0 0.83 + 0.15), and the walking group improved by 16% (pre test 0.78 + .20; post test 0.66 + 0.10). Moderate to high correlations were found between power and 5STS (R2 = .615 for pre test, and R2 = .762 for post test), between power and TUG (R2 = .533 for pre test, and R2 = .750 for post test) and between power and TSC (R2 = .785 for pre test, and R2 = .820 for post test) for the groups combined.

Cycling improved performance on power tasks more so than walking, as the cycling group improved on all timed functional tests as well as power. A comparison of pre and post testing showed that there were more meaningful changes (>5%) in the cycling group for 1) 5STS, 2) TUG, whereas TSC improvements were greatest for the walking group. All functional tests were found to have a positive correlation with power. The largest positive correlation was between power and Timed Stair Climb. Our preliminary results need further study, a larger participant pool and comparison with a control group is in progress.

Cycling may be a more effective than walking as a mode of exercise to improve leg power production. Both modes of exercise, cycling and walking, improved overall power and functional task performance. Older adults who are sedentary will benefit from regular exercise. Health professionals are encouraged to provide exercise prescriptions for their patients.

Seale, Jill

To investigate the relationships between gait symmetry (temporal and spatial) and overall walking function (Classification of Walking Handicap), voluntary movement and basic mobility (STREAM), and gait velocity.

Thirty participants at least 1 year post stroke, ranging in age from 29-80 were recruited from the community. Participants were all community dwellers, although many relied on a caregiver for some amount of assistance in mobility and/or activities of daily living. All were able to ambulate at least 10 meters without assistance.

Following informed consent, the participant completed the Stroke Rehabilitation Assessment of Movement (STREAM). Participants then completed 3 walks on the GAITRite^®, walking at their comfortable pace. Based on average velocity, participants' overall walking function was classified using the Classification of Walking Handicap (CWH).

Descriptive statistics and distributions of data for all variables were examined. The data from trials two and three were averaged (trial one was considered a practice trial) to obtain average velocity, as well as average step length, stance time, and swing time for each limb. Spearman’s correlation coefficients were used to determine the level of association for all comparisons. Correlational analysis of gait symmetry (step length, stance time, and swing time ratios) and the STREAM scores, walking classification, and gait velocity were performed. Participants were categorized according to level of asymmetry (normal, mild, and severe), and secondary analyses were conducted to determine any differences in STREAM scores between groups (specifically the LE voluntary movement subscale of the STREAM) using Kruskal-Wallis followed by Mann-Whitney tests with Bonferroni adjustments.

Swing time asymmetry was the most prevalent asymmetry, found in 73.33% of the sample. Stance time had the smallest degree of asymmetry (53.33% of sample had normal stance time asymmetry) while swing time had the greatest (only 26.67% of sample had normal swing time asymmetry). Step length asymmetry significantly, inversely correlated with the CHW, all STREAM measures, and velocity (r_s=0.456-0.708). Likewise, swing time symmetry significantly, inversely correlated with all measures except STREAM basic mobility (r_s=0.427-0.474).Stance time symmetry demonstrated the least association with the dependent variables, correlating significantly with the STREAM lower extremity subscale only (r_s=0.440).Secondary analyses were completed to determine if there were significant differences in STREAM LE scores between the categories of asymmetry. For stance asymmetry, all subjects were either normal or mildly asymmetric. Therefore, a Mann-Whitney Test was performed and revealed significant differences between STREAM LE scores of the two categories (p=0.039). In the case of swing time and stance time asymmetry, subjects were normal, mildly asymmetric, or severely asymmetric. Kruskal-Wallis tests were performed to determine significant difference, followed by post-hoc analyses of Mann-Whitney tests with Bonferroni adjustments of alpha to p=0.017. For swing time asymmetry, the Krusal-Wallis revealed a significant difference (p=0.018). Post-hoc analysis indicated no significant differences between normal and mild swing asymmetry or normal and severe swing asymmetry. The only significant difference in STREAM LE scores were found between the mild and severely asymmetric samples. With step length asymmetry, a significant difference was found between groups (p=0.022), with post-hoc comparisons revealing similar results as found in swing asymmetry significant difference. The only significant difference was between the mild and severe categories of step length asymmetry (p=0.003).

The results of this study indicate that gait asymmetry is common in persons with chronic stroke. This study included only those who could walk without assistance; therefore, independence with gait does not seem to preclude substantial gait asymmetries. Several gait parameters correlated inversely with the chosen measures of asymmetry. The strongest correlation was between CWH and step length asymmetry, indicating that the higher overall walking function is associated with more symmetrical step lengths. Moderate correlations were also demonstrated between step length symmetry and the STREAM Total and STREAM Basic Mobility subscale, but only a fair association was found between step length symmetry and STREAM LE subscale. The current study, and those previously done indicate that motor impairment/recovery is related to gait asymmetry, but the lack of consistent strong correlations signify that other factors are involved in asymmetry. In fact, there were significant differences in the STREAM LE subscale scores in all three of the symmetry measures. However, post-hoc analysis revealed significant differences between the mild and severely asymmetric categories only. These results are surprising, as one would assume there would be significant differences between the normal and severely asymmetric. Although this study found that velocity and symmetries are related, assessment and understanding of gait asymmetry should be considered an important facet of gait evaluation. This work suggests that understanding the presence, type, and degree of gait asymmetry can guide therapists in developing appropriate treatment plans to address all gait deficits.

Gait symmetry including swing time, stance time, and step length is only moderately related to return of lower extremity voluntary motor movement. Results suggest that other factors contribute to gait symmetry, in addition to motor recovery; potential factors include abnormal tone, loss of flexibility, impairments in sensation. Interventions which promote recovery of voluntary lower extremity movement may positively impact gait asymmetry post stroke.

Ferro Emerenciana

Using a hand-held dynamometer (HHD) provides a way to quantify muscle strength but reliability of measurements has been problematic when testing large muscle groups. Stabilization straps to secure the HHD have been used to remove tester strength as a source of error when measuring large muscle groups but a comparison of muscle strength values obtained using a HHD with and without a stabilization strap has not been studied. The purposes of this study were: 1) to determine the intra-and inter-tester reliability of an electronic HHD (MicroFet) with and without a stabilization strap when measuring quadriceps and hamstring strength, and 2) to compare quadriceps and hamstring strength values obtained using a HHD with and without a stabilization strap. We hypothesized that intra- and inter-tester reliability would be improved with a strap, and that muscle strength values measured with a strap would be greater than when measured without a strap.

30 men and women (Mean age: 37.57±16.15 years).

2 trained entry-level students of physical therapy measured participants’ quadriceps and hamstring strength in the seated position using the same test procedures. Each of the testers performed the tests under 2 conditions: 1) securing the HHD to the lower leg just proximal to the medial and lateral malleoli on the anterior aspect for knee extensors, and posterior aspect for knee flexors, using a strap affixed to an immoveable object, and 2) stabilizing the HHD manually in the same locations as for condition 1. Two trials were performed for each test condition and the order of testing under the 2 conditions randomized. One tester repeated the tests under both conditions after a 20 min rest to assess intra-tester reliability.

Data was analyzed using the 15.0 version of SPSS for Windows (SPSS Inc., Chicago, IL).  Descriptive statistics was calculated for the subject’s age, height, weight, and lower muscle strength values. An analysis of variance (ANOVA) was conducted using repeated measures of lower extremity values in order to calculate an intraclass correlation coefficient (ICC). ICC(3,2), ICC (2,2) values for Q-angle measurements was calculated to asses intra-tester and inter-tester reliability, respectively. A dependent t-test was used to compare differences between lower extremity muscle values using an electronic dynamometer with and without a stabilization strap.  An alpha level of .05 was used for this test in the analysis of each research.

Intra-tester reliability for measuring knee flexion and extension using a HHD with strap stabilization was excellent (ICC_3,2 =.98 and .98, respectively). Intra-tester reliability of measurements taken without strap stabilization for knee flexion and extension was also excellent (ICC_3,2 = .97 and .98, respectively). Inter-tester reliability for measuring knee flexion and extension using the HHD with a strap was good (ICC_2,2 =.90  and .93), while inter-tester reliability without a stabilization strap was also excellent  for knee flexion (ICC_2,2 = .93) but considerably lower  for knee extension  (ICC_2,2 =.76).  A dependent t-test showed a significant difference between hamstring strength values when taken with and without a strap (t= 2.16, p =0.039). It also showed a significant difference between quadriceps strength values obtained with and without a stabilization strap (t= 5.11, p<.001).

An electronic HHD (MicroFet) can be used effectively by a single tester to measure quadriceps and hamstring strength with or without a stabilization strap. When different testers are used however, a strap is needed to get consistent measures.

Use of stabilization straps effectively removes variability of measures due to tester strength and improved stabilization of the testing device results in higher strength values when large muscles are tested.

Boucher, Brenda

Evidence exists to support an impairment-based physical therapy examination to guide treatment for knee pain.  In addition, evidence supports use of manual techniques directed at the lumbar spine to positively affect pain and function at distant segments, including the knee.  Finally, evidence exists to support the use of manual techniques to address positive neurodynamic examination findings to reduce pain and increase function of distal joints. The purpose of this case report is to describe an examination process, inclusive of spine and neurodynamic impairments, and intervention approach to treat a patient with primary complaint of anterior knee pain.

50 y/o female with a 3 week history of left knee pain following an incident in which she missed a step while descending stairs, resulting in twisting of the left knee.  She reported no immediate pain; however, the following day she experienced swelling and pain in the knee.  Within one week, she experienced two episodes of sharp, posterior to anterior, knee pain while walking.  She presented to therapy with report of anterior knee pain, knee joint swelling, inability to fully straighten the knee or bear weight through the left leg.  She was referred to physical therapy with a medical diagnosis of patellofemoral arthritis and hamstring contracture.

This case report describes physical therapy management using an impairment-based examination and movement dysfunction approach to treat a patient with anterior knee pain.  Outcome measures included the Knee Outcome Survey for ADL's (KOS), the Lower Extremity Functional Scale (LEFS), Numeric Pain Rating Scale (NPRS) and Global Rating of Change (GROC).

Examination of the patient's left lower extremity revealed primary findings of decreased ROM of the hip (IR & flex) and knee (flex & ext), decreased passive accessory ROM (tibiofemoral joint ER), hypomobility of joint accessory motion (tibiofemoral and patellofemoral), pain with muscle resistance testing (quadriceps) and knee joint swelling. 

Treatment was initiated with grade III-IV knee and hip joint mobilizations in the direction of restriction and grade V long-axis thrust manipulation to the hip followed by exercise to facilitate motion, strength and neuromuscular movement training for visits 1-6.  By visit 6, the following gains were measured:  increased knee AROM (Flex=125°, up from 100°; Ext=-1, up from -10°), decreased pain (1/10 down from 4/10) and overall perceived improvement of +4 on the GROC, indicating a moderate change for improvement.  At this time the patient's primary complaint was a "dull" ache on the medial aspect of the knee at rest, sharp 3/10 medial knee pain with 2 inch step-up and pain (6/10) with full knee extension when walking.

Further examination found hypomobility of L5/S1 and left SIJ, positive Slump with posterior knee pain and reproduction of the patient’s knee pain with neurodynamic testing with bias to the left Saphenous nerve.  Treatment was progressed to include thrust manipulation to L5/S1 and left SIJ, nerve gliding with Saphaneous nerve bias, followed by neuromuscular movement training to facilitate optimal movement patterns.  At the conclusion of visit 9, the patient demonstrated no knee joint swelling, full knee extension and reported ability to bear full weight during gait and 100% functional return at work.  GROC= +7; KOS = 98%; LEFS=93%; NPRS=0/10.

Initial examination identified subjective and objective findings consistent with anterior knee pain similar to PF jt pain syndrome.  Knee symptoms began to diminish with intervention directed at the hip and knee; however, lingering symptoms persisted.  Further examination identified impairments of the lumbo-pelvic region and nervous system that reproduced the patient’s lingering symptoms.  Manual techniques directed at the lumbar spine and nervous system, followed by neuromuscular training, resulted in immediate reduction of the patient’s symptoms.  At visit 9 (three additional visits), the patient reported abolishment of all symptoms.

This case report describes an impairment-based and movement dysfunction examination and intervention approach to treat a patient with anterior knee pain that presented with symptoms similar to PF joint pain syndrome.  Varying impairments have the potential to contribute to knee pain, and findings of this case report suggest contribution from the spine and neural tissues.   Although no cause-and-effect relationship can be established, this case report suggests that use of an impairment-based and movement dysfunction approach, including examination of and intervention of the spine and neural tissues, may be an effective strategy for patients with knee pain.

Baker, Christine

The purpose of this study was to assess physical therapists’ and their employers’ perceptions of the therapists’ skills and knowledge as they enter a transitional post-professional (DPT) program.

Forty-four students, all licensed physical therapists, were enrolled in the online program at the time of data collection. Returned surveys reflected the skills of 41 (93%) scholars.  Thirty-nine (89%) of students/therapists returned surveys; while 34 (77%) of employers returned surveys. The range of experience of therapists was 5 to 36 years, with mean of 17 years of experience. Therapists/students represent 10 states: AZ, CA, GA, MD, ND, NJ, OH, OK, TX, and WI. 

Pre-program surveys were given to each online student at entry into program. Each student rated herself on 20 skills that measured perceived ability to perform key concepts necessary in pediatric settings as well as newer ‘core’ areas of differential diagnosis, imaging, pharmacology, evidence based practice, management, and medical Spanish. Each student asked her immediate supervisor to complete similar survey and rate the therapist on the same skills/ content areas. Completed surveys were sent to the investigator; surveys were coded and names removed. Ratings ranged from 1 (poor), 2 (fair), 3 (good), to 4 (excellent).

Descriptive statistics were calculated: mean, range, percentages. Fisher’s exact test was calculated to determine if significant differences existed between means of students’ and employers’ ratings for individual items as well as total average rating. Significance level was p

Twenty-nine percent (10 of 34) of employers did not address all the ‘core’ skill areas of imaging, pharmacology, etc. Looking at individually rated items, the highest mean rating from students was in ‘Communication with children’ with rating of 3.57; the highest rating from employers was in ‘Communication with parents’ with a mean rating of 3.79. Conversely, the lowest mean rating from students was found in ‘Imaging’ (mean rating 1.6), while employers rated ‘Medical Spanish’ with the lowest mean rating (2.3). Significant differences were found between the ratings given by employers and scholars in the areas of ‘Communications with parents’, ‘Embracing individual and cultural differences in interactions’, and ‘Time management’. Significant differences also were found between ratings in the ‘core’ areas of management, pharmacology, imaging, and medical Spanish.

A review of scores shows that employers consistently rated scholars higher than the scholars rated themselves; this may be because employers are better able to compare scholars’ skills to other employees in the facility, or perceived the purpose of the survey differently, or that scholars are more ‘critical’ of their own skills as enter the program and recognize the scope of what they need to know.

Educational Relevance: By comparing student perception of skills and knowledge on pre-tests with those of their employers as they enter our online t-DPT program, we are able to detect perceived knowledge and perceptions of skill in specific areas of foundational knowledge and pediatrics among these experienced therapists and provide a baseline for post-program surveys.

Johnson, Merri Leigh, PT, NCS

Background and Purpose: Acquired weakness syndromes are a cause of high mortality and long term morbidity in critically ill intensive care unit (ICU) patients with septic shock and multi-organ failure who have been on mechanical ventilation. There are a number of names in the literature for these critical illness neuromuscular syndromes: ICU-acquired weakness, Critical Illness Myopathy, Critical Illness Polyneuropathy, Critical Illness Neuromyopathy, and Critical Illness Polyneuropathy. These disorders are characterized by severe, generally symmetrical weakness, reduced or absent limb reflexes, muscle wasting, and difficulty weaning from mechanical ventilation. Descriptions of presentation and treatment in the ICU, possible risk factors and causes, and the tendency for long term residual disability have been reported in the literature. No reports have addressed the clinical progression of patients from the acute care setting back to the community. The purpose of this case study will be to describe the physical and functional recovery of a single middle aged female with severe ICU-acquired weakness during her acute rehabilitation hospital stay from her post-acute care discharge to her return home.

Case Description: The patient was a 50 year old female who developed severe quadriparesis after prolonged critical illness with respiratory failure leading to ventilator support for > 3 weeks, septic shock, and multi-organ failure. Upon admission to the acute rehabilitation hospital, the patient demonstrated profound upper and lower extremity weakness with little to no anti-gravity movement. Her Barthel Index was 30/100. She was functionally dependent to maximal assist for bed mobility and level transfers using a sliding board. She was unable to stand or ambulate but she could push a manual wheelchair 25 feet over smooth, level surfaces with minimal assist. Treatment consisted of a minimum of 3 hours of therapy a day 5-7 days a week for 5 1/2 weeks. Interventions included general strengthening exercises/activities, functional mobility practice, gait training, developmental activities, proprioceptive neuromuscular facilitation and aquatics.

Outcomes: Upon discharge the patient's Barthel Index was 90/100. She was modified independent with ambulation within the hospital using a rolling walker and supervision for short community distances. Her gait speed over 10 meters was 0.74 meters/second and her gait capacity was 1,041 feet with a rolling walker and no rest breaks during a 6 Minute Walk Test. The patient was able to climb 5 steps with bilateral rails and minimal assistance and scored a 46/56 on the Berg Balance Scale.

Discussion/Conclusions: The patient demonstrated dramatic improvement in her functional mobility and Barthel Index which allowed her to discharge home. However, she continued to have significant weakness of her bilateral upper and lower extremities with manual muscle testing. She also complained of poor endurance and stamina for community outings. Her 6 Minute Walk test, though over the 1,000 feet considered by many to be community distance, falls in the 57th percentile for height, weight, and age matched healthy females. In spite of the patient's considerable functional improvement and discharge to her home setting, the patient complained of frustration with her significant residual weakness, decreased endurance/stamina, her reliance on a rolling walker for gait, a manual wheelchair for longer distances or when too fatigued to walk safely, and a tub bench for bathing safety. These results are consistent with those found in the literature for the long term outcomes in patients with ICU-acquired weakness. The residual weakness can remain for weeks, months or years post ICU stay with a notable deleterious impact on health related quality of life.

Jason Zafereo, PT

Shoulder pain and disability ipsilateral to the implant site is a common complication of cardiac rhythm device implantation, yet very little has been published about this morbidity. We designed a study to assess the potential benefit of a simple exercise protocol in preventing shoulder pain postoperatively.

 

Patients undergoing subcutaneous device implantation were randomized to one of two groups, a control group (n=29) and an exercise group (n=28). Demographic data for control group: Age 58 years, 16males/13 females, 48% black, 31% white, and 21% hispanic. Demographic data for exercise group: Age 60 years, 19males/9 females, 50% black, 39% white, and 11% hispanic. 

The control group received standard instructions, whereas the exercise group was instructed on specific exercises aimed at strengthening or stretching the shoulder girdle, to be completed 3 days per week. Groups were postoperatively monitored for the development of shoulder discomfort and shoulder impingement by using physical examination and disability questionnaires.

 

At 1 month, seven of 21 control patients reported developing shoulder pain or discomfort compared to one of 23 in the exercise group (P = 0.02). At 6 months, four of 23 control patients still reported worsening shoulder symptoms, compared to none in the exercise group (P = 0.11). In the control group, five of 19 patients developed a positive impingement test at 1 month, versus none in the exercise group (P = 0.01). Scores for the questionnaires designed to assess shoulder pain and dysfunction were worse in the control group.

 

 

 

Shoulder pain and disability occurs often following cardiac rhythm management device implantation. A simple exercise program aimed at strengthening the shoulder girdle is effective at preventing this complication.

Okere, Suzanna PT, ATC

The purpose of this study was to document the internal consistency and test re-test reliability of the Inventory for Assessing the Process of Cultural Competence Among Healthcare Professionals – Student Version (IAPCC-SV) for student physical therapists.  In addition, the effect of a cultural competence education module on the cultural competence of student physical therapists as measured by the IAPCC-SV was documented.

Thirty-nine student physical therapists in the first semester of their physical therapist education participated in this study.

The Texas State University-San Marcos and Texas Woman’s University Institutional Review Boards approved this study and all participants gave informed consent prior to participating in the study.  Participants completed the IAPCC-SV, Time 1 (test), and again the following week, Time 2 (re-test/pre-test) prior to any cultural competence education.  Subjects then participated in a cultural competence education module based upon the Campinha-Bacote model of cultural competence.  The module included both lecture instruction and group discussion of patient case studies.  Upon completion of the module, participants completed the IAPCC-SV, Time 3 (post-test).

Internal consistency of the Time 1 scores was calculated using Cronbach’s Alpha. Test re-test reliability was calculated using an ICC (2,1) for the Time 1 (test) and Time 2 (re-test/pre-test) scores.  A two-tailed paired samples t test was used to measure the change in IAPCC-SV scores from Time 2 (re-test/pre-test) to Time 3 (post-test).  The effect size was also calculated.

The IAPCC-SV demonstrated good internal consistency (Cronbach’s Alpha = .75) and good test-re-test reliability (ICC (2,1) = .87).  The IAPCC-SV score increased following participation in the cultural competence learning module (Time 2, 58.44 +/- 6.08 versus Time 3, 64.95 +/- 7.25, t(38)=8.205, (p<.001)). The effect size was .977. 

 

This study provides preliminary support for the use of the IAPCC-SV to measure the cultural competence of student physical therapists.  In addition, this pilot study provides preliminary evidence that a cultural competence education module may assist with improving student physical therapists’ cultural competence. 

The results of this study can be utilized to design future studies that incorporate an experimental research design, to document the effects of a cultural competence education module on the cultural competence of student physical therapists.

Welsh, Rod

The purpose of this study was to identify patient and clinical factors most strongly associated with consultation for physical therapy (PT) services among older patients hospitalized for acute illness.  

233 patients 65 years and older admitted to an Acute Care for Elders (ACE) unit were studied; 102 received a PT consult sometime during their stay.

All patients wore a Step Activity Monitor from admission to discharge.  Logistic Regression was used to examine the association between the dependent physical therapy consult variable (yes vs. no) and the independent clinical and demographic variables. To further examine the association between length of stay and likelihood of receiving a PT consult, the estimated probabilities of PT consultation were calculated from an unadjusted logistic regression model and plotted over the entire distribution of lengths of stay.

Patients who received a PT consult were more likely to be older (p=.002), have mobility impairments prior to admission (p=.001), have a neurologic or orthopedic diagnosis (p<.001), and have longer lengths of stay (p<.001). In the fully adjusted multivariate model, age (OR=1.07; 95% CI=1.02–1.11), length of stay (OR=1.27; 95% CI=1.10–1.46) use of a cane or walker prior to admission (OR=2.12; 95% CI, 1.04–4.33), and an orthopedic (OR=19.38; 95% CI=2.14–175.3) or neurologic diagnosis (OR=3.98; 95% CI=1.01–15.78) remained significantly associated with PT consultation. The longer the length of stay the greater the odds of receiving a PT consult. At length of stay=6 days, the odds of receiving a PT consult were approximately 50:50; at 11 days, the probability increased to over 90%.

Physicians consult PT for the most vulnerable subset of older patients during acute hospitalization but consults may be occurring late during the patient’s stay. Further research is needed into the timing of PT consultations during hospitalization.

Gleeson, Peggy

To gather information on the content and features which are most useful for a fall risk screen, based on the preferences of individual geriatric care workers in different components of a senior care agency in Houston, Texas. This information could guide the development of an integrated fall-risk screening procedure for all geriatric workers.

Thirteen workers were from the agency’s components: Day Center, Case Management, Home Care, and Outreach to Potential Clients.

This was a qualitative study, using a semi-structured interview. Two researchers conducted the interviews; one researcher guided the questions and comments and the other researcher observed and took notes. Each geriatric care worker attended only one interview session. The researcher asked the same open-ended introductory questions and explored different opinions of an ideal fall risk intake form at each of three separate interview sessions. The interviews were tape recorded and then transcribed into a computer verbatim by the primary investigator (PI) to preserve the language of the participants.

Triangulation was used for establishing the reliability of identified emerging themes from the interview. Data coding was performed by the PI and a physical therapist (PT) experienced in qualitative research who did not participate in the interview. The PI and the PT reached consensus on the identified themes through discussion during three scheduled meetings. When no new codes or themes emerged from the interviews, data collection ended. The transcripts were reviewed by two interviewees to assure final agreement on the accuracy. Furthermore, the themes were confirmed by the interviewing researcher who participated in the interview but not in data coding.

Two major themes were identified: (1) factors which are relevant in assessing fall risk and (2) factors which affect the utility of the fall risk screening procedure. Under theme (1) are 6 categories: fall history, physical function, impairments, medications, mental and psychological status, and home environment. Under theme (2) are 3 categories: methods of gathering information for fall risk assessment, features useful to a fall risk assessment form, and actions taken in response to fall risk assessment. The 6 fall risk categories identified in the interviews were combined with 2 other categories identified in the literature review, health status and fear of falling, to produce a universal form for use by different agency components. A 3-step procedure is proposed to improve the effectiveness of fall-risk screening: (1) Initial screening with an outreach worker using a quick question assessment. (2) Follow up with a more comprehensive fall risk assessment. (3) Recommendation of a “what-to-do” action plan is presented for each item based on each question’s response on the comprehensive form.

Integrating all fall-risk categories into a universal form improves the completeness of the form used by different senior care agencies. A 3-step procedure with an integrated follow-up service plan is proposed to improve the utility of the fall risk screening.

The integrated fall-risk screening form and 3-step screening procedure can be easily administered by all geriatric care workers as part of their routine practice for systematically identifying elders at risk of falling. Intervention strategies could then be applied to reduce fall risk.

Kunder, Karina Amani

Rehabilitative ultrasound imaging (RUSI) has been shown to be a reliable and valid method of assessing the morphology of spinal stabilizers, such as the multifidus, in adults without scoliosis. It is hypothesized that spinal stability in adolescent idiopathic scoliosis (AIS), the most common type of scoliosis, may be reduced due to structural changes from spinal deformity. However, RUSI has not been used to examine the multifidus in adolescents with and without scoliosis. The purpose of this cross-sectional study is to determine the reliability of ultrasonographic measurements of the lumbar and thoracic multifidus muscles in both healthy adolescents and adolescents with IS.

Twenty 10-12 years old adolescents, 10 with AIS and 10 age-matched controls, completed the study. The participants with AIS had curves of 15-24° and Risser 0-1.

An ultrasound machine with a curved array transducer with a frequency range of 1 to 4 MHz was used to capture the image of the multifidus muscle. The parasagittal method was used to determine muscle thickness of the multifidus at both sides of T8, L1, and L4 vertebral levels. The transducer was placed centrally and longitudinally over the spinous process and then moved laterally with a 30-45° angle toward the spinous processes to locate the zygapophyseal joints. Images were taken in the relaxed prone and standing positions for two sessions on the same day. Muscle thickness was measured from the zygapophyseal joints to the inner edge of the fascia between the multifidus and superficial tissue.

Intraclass Correlation Coefficients (ICC_3,3) were used to calculate intrarater reliability.

Ultrasonographic measurements of multifidus thickness had good intrarater reliability (ICC = 0.83 - 0.99) at T8, L1, and L4 in the relaxed prone and standing positions for both groups. Reliabilities were similar between the relaxed prone (ICC = 0.83 – 0.99) and standing positions (ICC = 0.88 – 0.99) in both groups. The ICC was higher in the control group (ICC = 0.94 – 0.99) than the scoliosis group (ICC = 0.83 – 0.98) in the relaxed condition.

The results demonstrate that RUSI is reliable in measuring the thoracic and lumbar multifidus in adolescents with and without IS. However, RUSI is more reliable in adolescents without IS.

RUSI imaging may provide a reliable and objective method for further understanding of the pathophysiology of AIS. Nonoperative treatments for scoliosis such as bracing and exercise may be improved with a clearer understanding of muscle mass and strength changes in scoliosis, especially in adolescents with a high likelihood of progression.

Laura Goehrs at LHGoers@tmhs.org , Mica Smith at MMSmith@tmhs.org , Christy Parks at CParks@tmhs.org

To review literature and determine best practice for physical and occupational therapy treatments  to guide clinicians on when to follow sternal precautions.

An extensive literature review was conducted regarding surgical risks, surgical wiring techniques, upper extremity involvement and functional transitional movements. We conducted two surveys on sternal precautions: one nationwide of clinicians and the second with cardiothoracic surgeons at The Methodist Hospital and St Lukes Hospital in Houston.

After reviewing the literature, the nationwide survey results, and the surgeon survey we have included a few findings:  1. When a patient coughs, it creates a greater force across the sternum versus lifting greater than 8 pounds. 2.  If a patient has a BMI >30 or a sternal wound infection, they are at greater risk for dehiscence/sternal instability, regardless of the sternal suturing techniques used.  3. Postoperatively, patients are able to perform upper extremity activity without risk of sternal compromise.  4. From the clinicians’ survey responses, 15 out of 31 hospitals allowed patients to use bilateral upper extremities during transfers but varied on length of time to follow precautions. 5.  In the surgeons’ survey, the majority of responses did not express a concern with their patients’ having sternal instability.  

From the literature review and survey results, sternal precautions should be individually applied based on the patients’ co-morbidities.  We developed and implemented an inclusion criteria ie. BMI > 30, osteoporosis, breast cup size >C to effectively treat post sternotomy patients. These, newly developed guidelines will lead to best practice for physical and occupational therapists during activities of daily living, general strengthening and conditioning.

A sternal precaution decision tree, revised sternal precautions, and a modified upper extremity exercise program were created and implemented to guide and educate clinicians, students, and patients  on proper usage of sternal precautions.   The Methodist Hospital Cardiothoracic surgeons approved the revised information.  The teachings have been implemented for over one year without incident.  

Hale, Jennifer

Clinicians and researchers alike recognize the gap in translating scientific evidence to physical therapy (PT) practice, as well as the potential impact of this evidence on clinical outcomes. In recovery following brain injury (BI), current evidence indicates a need for high intensity, task-specific, repetitive practice to maximize motor recovery. These principles are well supported in the literature, but often not applied within the clinical setting. Circuit training (CT) is a novel intervention which utilizes a series of workstations to encourage greater intensity and repetition of motor tasks. CT is a cost effective intervention for promoting motor recovery in acute rehabilitation and outpatient settings. The goals of this research were to: 1.) demonstrate how a body of research can be synthesized and effectively translated to clinical practice 2.) assess the effectiveness of CT in promoting motor recovery in persons with acquired BI participating in an outpatient community re-entry program.

10 individuals with acquired brain injury

Individuals with acquired BI participated in 60 minutes of CT group therapy twice weekly, in addition to standard therapy (those who participated less than twice weekly were excluded). An average of 4 group participants rotated through a series of workstations, including gait, transfers, balance, obstacle negotiation, and lower extremity strengthening (specific to walking function). A PT was present to continually challenge and progress the participants as appropriate. Walking performance and balance were assessed pre and post intervention with the 6 minute walk test (6MWT), 10 meter walk test (10MWT), and Functional Gait Assessment (FGA). The average time duration of CT varied based on individual performance, with a range of 4-10 weeks (mean=6.6 weeks).

The well founded principles from neuroscience research of high intensity, task-specific, repetitive practice were successfully integrated into an outpatient clinical practice. Following group CT, all participants demonstrated improvements in walking performance. The mean change on the 6MWT and 10 MWT from pre to post intervention was 484 feet and 0.5 m/s, respectively. Functional balance was assessed in five participants and all demonstrated improvements, with a mean change of 6.4 points from pre to post intervention.

The implementation of a CT group within an outpatient community re-entry program is feasible and appears to contribute to improved walking performance and balance, with the mean change in walking performance and balance exceeding the minimal detectable change (MDC) across all measures. Further research with a larger sample and control group is essential.

CT is an evidence-based, cost effective intervention that was relatively easy to implement and warrants consideration across a variety of practice settings for persons recovering from BI.

O'Connell, Dennis

To examine if adherence to exercise scores change over the course of a semester in students enrolled in an entry-level doctoral physical therapy program.  Secondly, to examine the correlations between total scores on the surveys when given on three occasions.  Thirdly, to determine if a slight modification in terminology affected scores on the “Self-Motivation and Adherence to Habitual Physical Activity Scale.”

Twenty-five entry-level Physical Therapy doctoral students.

After providing informed consent, twenty-five entry level DPT students were given a 7-question, Likert  scale survey (1-5) on three separate occasions.  The original survey was given during weeks one and 13 and the modified survey was given during week 14 of a 14-week fall semester.  Surveys one and two used the terms “uncharacteristic” and “characteristic” in stems.  These terms were substituted in survey three with “unlike” and “like.”  A score ≤14 (35 total possible points) suggests will drop out of exercise.  Higher scores indicate the likelihood of consistent exercise adherence.

A repeated measures ANOVA (PASW18) was calculated to determine if survey scores changed over time for the seven questions.  A one-way ANOVA was calculated to determine if the total score on the survey questions varied between tests one, two, or three. Correlations between total scores for tests one, two, and three were also calculated using Pearson correlation statistics. Statistical significance was set at p ≤0.05.

Total scores (mean /sd) for tests one, two, and three were 25.28+/-4.02; 26.56 +/-4.36; and 26.92 +/-4.10, respectively.  The RMANOVA revealed no significant differences between tests one, two, or three for questions 1-7 over time (F(2,12) = 0.51, p=.91).  The one-way ANOVA revealed no significant differences between the total survey scores over time (F(2,71 = 1.71, p=.32). The statistically significant correlations between total scores one and two, one, and three, and two and three were r =0.49, 0.68, and 0.90, respectively. 

Based on the mean scores for the Adherence to Habitual Activity Scale," the PT students in this sample were likely to adhere to an independent home exercise program. Additionally, responses were reliable over a 14-233k time period.   Slight modifications in terminology did not negatively affect concurrent validity.

Adherence to home exercise programs is a major concern with physical therapy patients.  The adherence scale tested in this study was found to be reliable and valid.  The modified version of this survey needs to be tested in a patient sample.  Following that, we hope to utilize this survey with our patients to determine who might need additional support in following their home exercise programs.

Boles, A., Hernandez, V., Kollehner, A.L., Miao, M., & Medley, A.

To establish reliability and validity of the Sitting Balance Scale (SBS) in community dwelling adults with functional limitations.

Forty three community dwelling volunteers, mean age 58.6 ± 18.1 years old, who are primarily non-ambulatory or have limitations in ambulation and are currently not receiving physical therapy services.

Volunteers were recruited through word of mouth, local support groups, or organizations serving individuals with neurological disorders. Participants performed the SBS, Berg Balance Scale (BBS), Five Times Sit to Stand test (FTSTS), and Dynamic Gait Index (DGI) in a single session. Two researchers were present during testing, one guarding the participant, one providing instruction and scoring the assessments. Individuals were systematically videotaped for the reliability portion of the study. Videotapes were viewed within 7-10 days to determine intrarater (n=7) and interrater reliability (n=11).

Outcome scores and demographic information from all participants were collected and analyzed using SPSS. Statistical analysis included descriptive statistics, Pearson correlation coefficients, and Intraclass Correlation Coefficients (ICC).

Mean performance for SBS=37.4, BBS=33.4, FTSTS=11.2s, DGI=12.6. The SBS is highly correlated with the BBS (r = .83, p<0.0001) and moderately correlated with the FTSTS (r = .45, p<0.002) and DGI (r = .57, p< 0.0001). Good inter-rater reliability of the SBS was established, ICC=.98 (95% CI=.96-1.0). Excellent intra-rater reliability was also established, ICC=.98 (95% CI=.88-1.0). SBS performance was not related to the number of medications or number of falls in the past year.

Based on BBS and DGI mean performance, participants were at risk for falls from the standing position. Mean performance on the FTSTS suggests that participants also had lower extremity weakness. The SBS was developed to assess sitting balance in individuals who are primarily non-ambulatory. Our results suggest that the SBS is a reliable measure. While the tools used in this study assess different aspects of balance and strength, all generally address functional ability based on the correlation analyses. Therefore, the SBS appears to be a valid measure of functional ability in the seated position. Future studies should assess the responsiveness of the SBS to change over time.

The SBS is a clinically useful tool in that it is an objective measure of functional ability in the seated position. The tool is a reliable and valid assessment that clinicians may use to identify impairments.