Evidence suggests that there are several fall predictors in the elderly population, including previous fall history and balance impairment. To date, however, the role of psychological factors has not ...yet been thoroughly vetted in conjunction with physical factors as predictors of future falls.
The purpose of this study was to determine which measures, physical and psychological, are most predictive of falling in older adults.
This was a prospective cohort study.
Sixty-four participants (mean age=72.2 years, SD=7.2; 40 women, 24 men) with and without pathology (25 healthy, 17 with Parkinson disease, 11 with cerebrovascular accident, 6 with diabetes, and 5 with a cardiovascular diagnosis) participated. Participants reported fall history and completed physical-based measures (ie, Berg Balance Scale, Dynamic Gait Index, self-selected gait speed, Timed "Up & Go" Test, Sensory Organization Test) and psychological-based measures (ie, Fear of Falling Avoidance Behavior Questionnaire, Falls Efficacy Scale, Activities-specific Balance Confidence Scale). Contact was made 1 year later to determine falls during the subsequent year (8 participants lost at follow-up).
Using multiple regression, fall history, pathology, and all measures were entered as predictor candidates. Three variables were included in the final model, explaining 49.2% of the variance: Activities-specific Balance Confidence Scale (38.7% of the variance), Fear of Falling Avoidance Behavior Questionnaire (5.6% additional variance), and Timed "Up & Go" Test (4.9% additional variance).
Falls were based on participant recall rather than a diary.
Balance confidence was the best predictor of falling, followed by fear of falling avoidance behavior, and the Timed "Up & Go" Test. Fall history, presence of pathology, and physical tests did not predict falling. These findings suggest that participants may have had a better sense of their fall risk than with a test that provides a snapshot of their balance.
The aim of this prospective single group, time-series study was to determine the feasibility, adherence, and effectiveness of an individualized physical therapist (PT)-driven hybrid model of the ...exercise component of cardiac rehabilitation (CR) that uses a novel intensity-recovery progression protocol (IRPP) and cardiac testing template (CTT) to assess achieved heart rate (HR) intensity, HR recovery, and intensity-recovery total to guide treatment.PURPOSEThe aim of this prospective single group, time-series study was to determine the feasibility, adherence, and effectiveness of an individualized physical therapist (PT)-driven hybrid model of the exercise component of cardiac rehabilitation (CR) that uses a novel intensity-recovery progression protocol (IRPP) and cardiac testing template (CTT) to assess achieved heart rate (HR) intensity, HR recovery, and intensity-recovery total to guide treatment.Assessment of a questionnaire, treadmill 6-min walk (6MW), 1-min sit-to-stand (1STS), 1-min step, and 1-min agility square tests were assessed on 100 participants. Compared to traditional CR the 36-visit 1:1 hybrid model was individualized using the IRPP program and CTT.METHODSAssessment of a questionnaire, treadmill 6-min walk (6MW), 1-min sit-to-stand (1STS), 1-min step, and 1-min agility square tests were assessed on 100 participants. Compared to traditional CR the 36-visit 1:1 hybrid model was individualized using the IRPP program and CTT.Adherence was 35% (timely) and 44% (overall) completion. The per-protocol analysis (PPA) and intent-to-treat (ITT) analysis suggest significant improvement in objective assessments baseline to visit 15 (PPA = 11 of 14) (ITT = 13 of 14), baseline to visit 30 (PPA = 12 of 14) (ITT = 12 of 14) and visit 15 to visit 30 (PPA = 9 of 14) (ITT = 10 of 14). Improvement beyond the minimal clinically important difference (MCID) was 94.3% in the 6MW and 91.4% in the 1STS.RESULTSAdherence was 35% (timely) and 44% (overall) completion. The per-protocol analysis (PPA) and intent-to-treat (ITT) analysis suggest significant improvement in objective assessments baseline to visit 15 (PPA = 11 of 14) (ITT = 13 of 14), baseline to visit 30 (PPA = 12 of 14) (ITT = 12 of 14) and visit 15 to visit 30 (PPA = 9 of 14) (ITT = 10 of 14). Improvement beyond the minimal clinically important difference (MCID) was 94.3% in the 6MW and 91.4% in the 1STS.The PT-driven IRPP program was feasible in terms of adherence and safety, showing significant improvement in a majority of assessments. Analysis of HR using the CTT may help clinical decision making for progression in CR.Implications for rehabilitationCardiac rehabilitation (CR) is an underutilized means of improving health for people recovering from cardiac surgery.People recovering from cardiac surgery have complex reasons for why they choose to enroll in, drop out from, or complete a CR program.Reporting of outcomes in CR and progression in intensity is not often individualized.An individualized physical therapist driven CR program using both subjective and objective assessments may be successful at improving adherence and effectiveness in this cohort.CONCLUSIONSThe PT-driven IRPP program was feasible in terms of adherence and safety, showing significant improvement in a majority of assessments. Analysis of HR using the CTT may help clinical decision making for progression in CR.Implications for rehabilitationCardiac rehabilitation (CR) is an underutilized means of improving health for people recovering from cardiac surgery.People recovering from cardiac surgery have complex reasons for why they choose to enroll in, drop out from, or complete a CR program.Reporting of outcomes in CR and progression in intensity is not often individualized.An individualized physical therapist driven CR program using both subjective and objective assessments may be successful at improving adherence and effectiveness in this cohort.
Multicenter, randomized, controlled trial on preoperative pain neuroscience education (NE) for lumbar radiculopathy.
To determine if the addition of NE to usual preoperative education would result in ...superior outcomes with regard to pain, function, surgical experience, and health care utilization postsurgery.
One in 4 patients after lumbar surgery (LS) for radiculopathy experience persistent pain and disability, which is nonresponsive to perioperative treatments. NE focusing on the neurophysiology of pain has been shown to decrease pain and disability in populations with chronic low back pain.
Eligible patients scheduled for LS for radiculopathy were randomized to receive either preoperative usual care (UC) or a combination of UC plus 1 session of NE delivered by a physical therapist (verbal one-on-one format) and a NE booklet. Sixty-seven patients completed the following outcomes prior to LS (baseline), and 1, 3, 6, and 12 months after LS: low back pain (numeric rating scale), leg pain (numeric rating scale), function (Oswestry Disability Index), various beliefs and experiences related to LS (10-item survey with Likert scale responses), and postoperative utilization of health care (utilization of health care questionnaire).
At 1-year follow-up, there were no statistical differences between the experimental and control groups with regard to primary outcome measure of low back pain (P = 0.183), leg pain (P = 0.075), and function (P = 0.365). In a majority of the categories regarding surgical experience, the NE group scored significantly better: better prepared for LS (P = 0.001); preoperative session preparing them for LS (P < 0.001) and LS meeting their expectations (P = 0.021). Health care utilization post-LS also favored the NE group (P = 0.007) resulting in 45% less health care expenditure compared with the control group in the 1-year follow-up period.
NE resulted in significant behavior change. Despite a similar pain and functional trajectory during the 1-year trial, patients with LS who received NE viewed their surgical experience more favorably and used less health care facility in the form of medical tests and treatments.
2.
Research suggests that attendance by physical therapists at continuing education (CE) targeting the management of low back pain (LBP) and neck pain does not result in positive impacts on clinical ...outcomes. The aim of this study was to determine if therapists attending a self-paced 3-hour online Pain Neuroscience Education (PNE) program was associated with any observed changes to patient outcomes and also clinical practice.
Participants were 25 different physical therapists who treated 3,705 patients with low back pain (LBP) or neck pain before and after they had completed an online PNE CE course. Change in outcomes measures of pain and disability at discharge were compared for the patients treated before and after the therapist training. Clinical practice patterns of the therapists, including total treatment visits, duration of care, total units billed, average units billed per visit, percentage of 'active' billing units and percentage of 'active and manual' billing units, were also compared for the patient care episodes before and after the therapist training.
There was no significant difference for change in pain scores at discharge for patients treated after therapist CE training compared to those treated before regardless of the condition (LBP or neck pain). However, patients with LBP who were treated after therapist CE training did report greater improvement in their disability scores. Also after CE training, for each episode of care, therapists tended to use less total visits, billed fewer units per visit, and billed a greater percentage of more 'active' and 'active and manual' billing units.
Attending an online 3-hour CE course on PNE resulted in improved disability scores for patients with LBP, but not for those with neck pain. Changes in clinical behavior by the therapists included using less visits, billing fewer total units, and shifting to more active and manual therapy interventions. Further prospective studies with control groups should investigate the effect of therapist CE on patient outcomes and clinical practice.
Abstract
Producing science that supports the physical therapist profession in all its endeavors is critical to ensure that the best evidence is used in practice and education. In this Perspective, ...numerous conundrums are discussed that can constrain efforts to be productive in research in the academic institutions that serve as the intellectual centers of the discipline. Taken together, these conundrums and the conditions that create them collectively contribute to the wicked problem of how to generate sufficient evidence to support the practice of physical therapy. In response, this Perspective recommends changes in the Standards and Elements of the Commission on Accreditation in Physical Therapy Education to support the importance of faculty research, reconfigure the rules for faculty composition, and introduce a new metric of productivity that reinforces the need of all programs to produce evidence for the profession, while still allowing flexibility and institutional prerogative to govern how this need is expressed.
Alzheimer’s disease (AD) is characterized by a distinct pattern of cortical thinning and resultant changes in cognition and function. These result in prominent deficits in cognitive-motor ...automaticity. The relationship between AD-related cortical thinning and decreased automaticity is not well-understood. We aimed to investigate the relationship between cortical thickness regions-of-interest (ROI) and automaticity and attention allocation in AD using hypothesis-driven and exploratory approaches. We performed an ROI analysis of 46 patients with AD. Data regarding MR images, demographic characteristics, cognitive-motor dual task performance, and cognition were extracted from medical records. Cortical thickness was calculated from MR T1 images using FreeSurfer. Data from the dual task assessment was used to calculate the combined dual task effect (cDTE), a measure of cognitive-motor automaticity, and the modified attention allocation index (mAAI). Four hierarchical multiple linear regression models were conducted regressing cDTE and mAAI separately on (1) hypothesis-generated ROIs and (2) exploratory ROIs. For cDTE, cortical thicknesses explained 20.5% (
p
= 0.014) and 25.9% (
p
= 0.002) variability in automaticity in the hypothesized ROI and exploratory models, respectively. The dorsal lateral prefrontal cortex (DLPFC) (
β
= − 0.479,
p
= 0.018) and superior parietal cortex (SPC) (
β
= 0.467,
p
= 0.003), and were predictors of automaticity. For mAAI, cortical thicknesses explained 20.7% (
p
= 0.025) and 28.3% (
p
= 0.003) variability in attention allocation in the hypothesized ROI and exploratory models, respectively. Thinning of SPC and fusiform gyrus were associated with motor prioritization (
β
= − 0.405,
p
= 0.013 and
β
= − 0.632,
p
= 0.004, respectively), whereas thinning of the DLPFC was associated with cognitive prioritization (
β
= 0.523,
p
= 0.022). Cortical thinning in AD was related to cognitive-motor automaticity and task prioritization, particularly in the DLPFC and SPC. This suggests that these regions may play a primary role in automaticity and attentional strategy during dual-tasking.
Postural instability in Parkinson's disease (PD) is associated with several downstream consequences that ultimately lead to a greater risk of falling. Among the prominent downstream consequences is ...fear of falling (FOF), which is both common and problematic in PD. It can lead to a vicious cycle of FOF avoidance behavior that results in more sedentary behavior, physical deconditioning, and weakening of already impaired balance systems. This, in turn, may make the person with PD more susceptible to a future fall even with benign daily tasks. While FOF activity avoidance can be adaptive (appropriate), it can also be maladaptive (inappropriate or exaggerated). When this adaptive and maladaptive FOF avoidance behavior is contextualized to gait/balance performance, it provides a theoretical framework that can be used by clinicians to match patterns of behavior to a concordant treatment approach. In the theoretical framework proposed in this perspective, four different patterns related to FOF avoidance behavior and gait/balance performance are suggested: appropriate avoiders, appropriate non-avoiders, inappropriate avoiders, and inappropriate non-avoiders. For each of the four FOF avoidance behavior patterns, this paper also provides suggested treatment focuses, approaches and recommendations.
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