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  • Researchers: A City's 'Stress Level' Could Affect Local Hospital Ratings

    Could it be that when it comes to the Centers for Medicare and Medicaid's (CMS) star rating system, no hospital is an island? Some researchers are wondering just that, after finding a high correlation between a city's level of "stress" among residents and lower overall ratings for local hospitals.

    The report, published as a research letter in the November 28 edition of JAMA Internal Medicine (abstract only available for free), compares CMS hospital ratings with the results of a recent study that compiled demographic, health, and financial data on residents of 150 cities across the US. The CMS star system, posted at its Hospital Compare website, bases its ratings on factors such as readmission rates, surgical mortality, and hospital-acquired infection. The stress study, sponsored by WalletHub, looked at 5 categories of stress: work, money, family, health/safety, and coping mechanisms. Using data that touched on a range of issues including, among others, poverty levels, divorce rates, suicide rates, average hours of sleep per night, binge drinking, and number of psychologists per capita, WalletHub researchers assigned an overall "stress level" score to each city.

    Authors of the JAMA letter compared the star ratings of 657 hospitals with the stress ratings of the 150 cities in which they were located. They found that the less stressed a city is, the more likely it would be to contain hospitals with higher overall star ratings. For example, 2 of the most highly stressed cities in the US—Detroit, Michigan, and Newark, New Jersey—also contained hospitals with relatively lower star ratings. The same was true at the other end of the spectrum: low-stress cities such as Madison, Wisconsin, and Sioux Falls, South Dakota, tended to have hospitals with higher star ratings.

    Researchers for the JAMA article estimate that "around 20% of the variance in the star ratings can be explained by community characteristics such as poverty or unemployment rate."

    The correlation may cast the CMS rating system in a somewhat different light, say researchers—one that isn't entirely related to factors within the hospital's control.

    "On one hand, hospitals in stressed cities might provide care of lower quality on average, perhaps because of inability to invest in needed clinical or technological infrastructure or staff shortage," authors write. "On the other hand, the star rating component measures may be affected by community factors such as poor public transportation or limited social support services through causal pathways other than hospital quality."

    Research-related stories featured in PT in Motion News are intended to highlight a topic of interest only and do not constitute an endorsement by APTA. For synthesized research and evidence-based practice information, visit the association's PTNow website.

    USBJI Young Investigators Program Accepting Applications for 2017 Program

    Physical therapist investigators have an opportunity to receive guidance in getting their research funded and "other survival skills required for pursuing an academic career" through a program that connects them with experienced researcher-mentors.

    The United States Bone and Joint Initiative (USBJI) and Bone and Joint Canada are now accepting applications for the Young Investigator Initiative, a career development and grant mentoring program. Investigators chosen for the program will attend 2 workshops 12-18 months apart and work with faculty between workshops to develop grant applications.

    This grant mentoring workshop series is open to promising junior faculty, senior fellows, or postdoctoral researchers nominated by their department or division chairs. It also is open to senior fellows or residents who are doing research and have a faculty appointment in place or confirmed and have a commitment to protected time for research. Basic and clinical investigators, with or without training awards (including K awards), are invited to apply.

    Application requirements and more details can be found at the USBJI website. Deadline is January 15, 2017, to participate in the next workshop, April 7-9, 2017, in Rosemont, Illinois.

    APTA is a founding member of USBJI.

    'Proof of Concept' Study Points to Possible Link Between Aerobic Exercise and Improvement in Cognitive Function in Patients With Vascular-Based Impairment

    Although results are far from conclusive, a recently published "proof of concept" study points to the possibility that aerobic exercise could improve cognitive performance among older adults with a type of impairment caused by problems with blood supply to the brain.

    The study, conducted in Canada between 2009 and 2014, focused on 70 adults (with an average age of 74) diagnosed with mild subcortical ischemic vascular cognitive impairment (SIVCI). Participants were placed into 2 groups: the first group received usual care and monthly educational materials on maintaining a healthy diet; the second group received usual care but also took part in a 6-month walking program with progressive aerobic intensity. Researchers used 3 tests to measure cognitive function at baseline, at 6 months after the start of the program, and again after 1 year: the Alzheimer's Disease Assessment Scale-Cognitive subscale (ADAS-Cog), the Executive Interview (EXIT-25), and the Alzheimer's Disease Cooperative Study – Activities of Daily Living (ADCS-ADL) scale.

    Authors of the study, which appears in Neurology (abstract only available for free), found that after 6 months, the aerobic group had improved scores on the ADAS-Cog, with an average decrease of 1.71 on the 70-point scale (a higher ADAS-Cog number indicates greater impairment). There were no significant differences in scores on the other 2 tests, and the ADAS-Cog differences seemed to disappear at the 1-year mark, or 6 months after the exercise program had ended. While authors acknowledge that a drop of 4 points on the ADAS-Cog is considered clinically meaningful, they describe the 1.71 decline as "significant."

    The exercise program consisted of 60-minute walking sessions held 3 times a week. All walking took place outdoors, and providers monitored each participant's heart rate reserve (HRR), gradually increasing the intensity of the exercise from an initial 40% of HRR to 65% of HRR, and keeping it there for the rest of the program. Participants in the aerobic group were also given pedometers and encouraged to track the number of steps they took every day.

    Authors believe that the slight improvement is likely related to a drop in the aerobic participants' diastolic blood pressure, "a key and modifiable risk factor for SIVCI," and a possible protection against future stroke.

    An editorial accompanying the study characterizes it as one of the first to point to a possible connection between physical activity and improvement in cognition among patients with SIVCI, and asserts that the findings should "encourage further studies on larger groups of people with [vascular cognitive impairment]." Authors of the editorial write that while it was "surprising" that the program didn't improve executive functions as measured by the EXIT-25, "physical activity may require a longer period to improve executive function, as it may exert its effect by lowering the diastolic blood pressure, as demonstrated in this study."

    As for the lack of difference in the 2 groups at the 1-year mark, authors of the study believe the effect could be countered by better "sustainability" strategies.

    "This might entail a longer intervention period (eg, 12 months) or the inclusion of behavioral components (eg, self-monitoring or incentive schemes) to facilitate maintenance of this frequency and intensity of walking upon intervention cessation," authors write.

    Research-related stories featured in PT in Motion News are intended to highlight a topic of interest only and do not constitute an endorsement by APTA. For synthesized research and evidence-based practice information, visit the association's PTNow website.

    Study: EHR Interoperability Necessary for Evaluating Quality Improvement

    Electronic health records (EHRs) are effective for improving patient care and clinical decision making, and the transition to value-based care and the increasing focus on population health also makes them a promising tool for comparing quality data across the board. But with so many different EHR vendors out there, increased standardization is essential, according to a new study from the Netherlands published inBMC Medical Informatics and Decision Making.

    In the study, authors examined whether data extracted from EHRs was as complete and correct as data from 5,960 physical therapist (PT) surveys describing patient cases for calculating quality indicators. There were 160,000 patient cases in the survey and 90,000 from EHRs.

    After identifying 8 quality indicators based on current practice guidelines, authors found that 3 could not be extracted from the EHRs at all, and another could not be compared with the survey data due to errors in the extraction software. Of the remaining 4, EHR data turned out to be both more complete for 3, and more correct for all 4, than survey data.

    “Data extraction from EHRs based on routine data collection of clinicians and patients provides the best opportunity for providing real-time feedback on process and outcomes of care,” according to co-author Philip van der Wees, PT, PhD, who is also a member of the Scientific Advisory Panel (SAP) for APTA’s Physical Therapy Outcomes Registry (Registry).

    He notes, “This interoperability between EHRs and national registries and other such possibilities are moving swiftly, as with APTA's Registry.” The Registry has completed its pilot testing phase, and is set to debut in early 2017.

    Operationalizing data extraction has its challenges. Authors of the study describe how they had to exclude some quality indicators because 2 of the EHR software vendors deviated from the uniform extraction algorithm, causing “errors in data extraction that further limited comparability” and blocking extraction of correct data.

    Authors also noted that differences in data completeness between 2 different vendors may be due to difference in user interface design, such as whether or not the software identifies missing values for the clinician.

    Another significant hurdle: extracting data from text boxes. Problems in this area highlight the need for “effective natural language processing tools” that can mine the text using a “dictionary” of common clinical terms, according to the study's authors (an example of a uniform dataset is the Registry’s lexicon in the Logical Observation Identifiers Names and Codes [LOINC] database). van der Wees explains that natural language processing technology can be valuable “for in-depth analysis of narrative text,” which is critical to understanding clinical reasoning.

    “Manual data entry is not sustainable,” says James J. Irrgang, PT, PhD, ATC, chair of the Registry's SAP. “Computer algorithms to extract and analyze quality improvement data may be a viable alternative to manual documentation and calculation of the quality indicators. This has the potential to broaden the adoption of the use of registries for quality improvement efforts, which in turn could lead to initiatives to improve the quality of care."

    Authors acknowledge that more needs to be done to "bridge the needs" of both clinicians using EHRs and the researchers hoping to analyze EHR data, but they believe standardization is key.

    "Standardization of the format of EHRs, the use of standardized coding and exploring text mining tools require a considerable effort from the physiotherapy community, researchers, and EHR developers," authors admit, but they assert that the payoff is considerable, allowing "continuous measurement of the quality of care, and for providing real-time feedback to all stakeholders."

    Research-related stories featured in PT in Motion News are intended to highlight a topic of interest only and do not constitute an endorsement by APTA. For synthesized research and evidence-based practice information, visit the association's PTNow website.

    ACOs Beginning to Take Creative Steps to Address Nonmedical Needs – But Can Those Steps Be Expanded?

    Some accountable care organizations (ACOs) are well aware of the ways that nonmedical needs in patients—like housing, transportation, and food insecurity—can impact health outcomes, and are attempting to do something about it. But according to results of a new qualitative study, those sometimes-creative efforts to address the needs through ACOs are in their early stages, and are already meeting some significant challenges.

    In a study published in Health Affairs, researchers reported on the results of telephone interviews with 58 leaders from 32 ACOs, as well as the findings from 3-day site visits of 3 ACOs. They found that while 16 of the 32 ACOs surveyed were addressing patients' nonmedical needs, the ways those needs were addressed varied in how the care was integrated and the nature of the care itself.

    Most ACOs interviewed for the study, including those that did not address nonmedical needs, reported a general state of nonintegration, wherein both the services provided to patients (when they were provided) and the organizations providing those services weren't really working in a coordinated way. For the ACOs that were addressing nonmedical needs, most were moving toward greater integration of services, albeit through the use of outside organizations that were "fully independent and distinct."

    Authors found only 2 ACOs that were moving toward what they describe as a "fully integrated" model.

    "In both of these cases, organizational integration did not involve a merger of organizations; instead, it involved representatives of nonmedical providers or agencies joining representatives of medical providers as voting members of the ACO's board of directors," authors write. "In both cases, ACO formation served as a catalyst for the integration between medical and community services."

    The study also looked at how some ACOs were responding to nonmedical needs in the areas of transportation, housing, and food insecurity. Here are some of the findings:

    There was considerable variation among the ACOs that provided some level of transportation service, based in part on setting (urban vs rural) and the transportation infrastructure in place. Examples include the provision of monthly bus passes to all patients who had 4 or more medical visits per month, an investment in a medical transportation company, and payment to a private for-profit transportation company. According to authors, 1 ACO at the time of the study was also considering a mobile device app that would allow patients to request transportation from private drivers.

    ACOs that provided or coordinated housing services were a bit more similar to each other in their approaches—mostly by serving as an administrative resource for patients—but a few added some creative twists. Among them: an ACO that negotiated with a housing program to alter its substance use requirements to allow the ACO's patients to receive housing before they began addiction treatment, and another that worked with a housing agency to establish beds specifically designated for the ACO's patients, which in turn streamlined the ACO's discharge process.

    Food Insecurity
    Again, in addition to providing support in helping patients to determine eligibility for and access to public assistance programs, some ACOs were employing more-unique approaches. Authors of the study describe 1 ACO that partnered with a local food bank and farmers to purchase local produce and hold a market day to patients, offering reduced prices. Another sought to address the tendency of its patients to obtain processed and unhealthy foods from the local food bank by partnering with the food bank to prepare actual meals for patients with a qualifying illness.

    While the work of some ACOs in these areas is encouraging, authors point out that even the most proactive organizations face a major hurdle: scalability.

    "ACO leaders described instances in which they observed a general need but were able to provide only individual solutions, not broader programs," authors write. "Even ACOs with formalized programs to meet patients' nonmedical needs faced significant implementation barriers."

    In addition to the obvious barriers—like lack of money, limited staff, and lack of expertise—the ability of ACOs to address population health by meeting nonmedical needs can often be hampered by the very fact that the ACO's focus is limited to diagnosed patients. "For example, a patient first had to be diagnosed with diabetes to be referred to the nutrition program," authors write. "Thus, ACOs have only limited ability to comprehensively address any given need—medical or nonmedical—across a broad population."

    Still, they argue, the promise is there, writing that "reform initiatives, especially ACOs, hold the potential for expanding the base of responsibility by moving from a reactive approach to a proactive one."

    Research-related stories featured in PT in Motion News are intended to highlight a topic of interest only and do not constitute an endorsement by APTA. For synthesized research and evidence-based practice information, visit the association's PTNow website.

    Interested in learning more about ACOs and the role of the physical therapist (PT) and physical therapist assistant? Check out APTA's ACO webpage. Also available, online learning from the APTA Learning Center on opportunities and challenges for PTs in ACOs, as well as ACOs as an innovative model of PT care delivery.

    From PTJ: Time for a 'Paradigm Shift' in Treatment of Patients With DPN

    While staying off one’s feet may help heal skin ulcers in people with diabetic peripheral neuropathy (DPN), avoiding weight-bearing activities for long periods could decrease tolerance for stress and physical activity, and even increase likelihood of injury. Authors of a new "Perspective" article in Physical Therapy (PTJ) believe that's a harmful tradeoff, and doing something about it will require nothing less than a "paradigm shift" in the way physical therapists (PTs) think about physical training and activity in this population.

    Their opinion is straightforward enough: “People with DPN should be encouraged to maintain and even increase weight-bearing activities, rather than avoid them.” The authors assert that such a shift is supported by the physical stress theory (PST), which is based on the idea that "changes in the relative level of physical stress cause a predictable response in all biological tissues, even those affected by diabetes and peripheral neuropathy."

    In the article, authors feature areas in which new research is shedding more light on the mechanisms of neuropathy and how it can be managed through physical activity. Here are some highlights from the authors’ review:

    Skin breakdown may be less concerning than in the past.
    While traditional precautions against physical activity for people with DPN were concerned with risk of skin breakdown, a number of studies suggest that the skin is able to physically adapt to stress. Others have shown that people with DPN who are less active are more at risk for skin breakdown than those who engage in regular activity.

    Therapeutic interventions that focus on sensory nerve growth are likely to be successful.
    A study of mice with type 1 diabetes that had restored glucose levels showed improved electrophysiologic function, myelin thickness, and reinnervation—but no plasticity of “preserved sensory fibers.”

    Exercise “mediates” peripheral nerve growth.
    In studies of diabetic and prediabetic animals, exercise led to decreased pain, “normalized epidermal innervation,” increased nerve regeneration, and “restored electrophysiological function.”

    Exercise influences “multiple pathways” to restore peripheral nerve function and encourage nerve cell growth.
    Exercise can restore neurotrophin levels, reduce oxidative stress and inflammation, prevent myelin damage, and improve electrophysiologic function.

    Exercise may help prevent neuropathy.
    People with diabetes who participated in supervised brisk walking for 4 hours a week were less likely to develop motor or sensory neuropathy.

    Unfortunately, authors write, there is limited high-quality evidence for type, intensity, and duration of certain types of exercise, and there is no consensus on what outcomes measures are most appropriate. However, authors do offer some detailed recommendations for exercise and assessment in the article, and argue that application of PST in this patient population shows promise—providing the level of stress is right.

    "Contrary to traditional clinical approaches and even to most current clinical approaches, the PST hypothesizes that people with DPN may benefit from overload stress to become more tolerant of subsequent stress," authors write. "Although no one would argue against a clear 'injury' window that occurs because of excessive stress, the PST postulates that there is a window of 'increased tolerance' that is just below the injury threshold but above a 'maintenance' level of stress."

    The article’s authors are Patricia Kluding, PT, PhD; Sonja Bareiss, PT, PhD; Mary Hastings, PT, DPT; Robin Marcus, PT, PhD; David Sinacore, PT, PhD, FAPTA; and Michael Mueller, PT, PhD, FAPTA.

    Research-related stories featured in PT in Motion News are intended to highlight a topic of interest only and do not constitute an endorsement by APTA. For synthesized research and evidence-based practice information, visit the association's PTNow website.

    Survey Results Reveal Traction Popular Among PTs Treating Neck Pain

    Authors of a new study write that although systematic reviews provide "limited support" for the use of cervical traction to manage neck pain, a recent survey of APTA Orthopaedic Section (OS) members revealed that most physical therapists (PTs) in the section use it, even when it's a less strongly indicated intervention. They believe that the high rate of use—and the variety of traction methods employed—point to the tendency of PTs to pursue "comprehensive plans of care."

    The study, e-published ahead of print in The Journal of Orthopaedic and Sports Physical Therapy (abstract only available for free), is based on responses to a survey sent to 4,000 OS members nationwide. A total of 1,001 members responded to the questionnaire, which included 28 open- and closed-ended questions on demographics, adherence to classification criteria for traction, delivery methods used, and additional interventions, as well as 2 clinical scenarios.

    The scenarios focused on situations in which the respondent might use traction. The first described a case that pointed to the possibility of nerve root compression "and matched the characteristics of patients preliminarily identified as those who may benefit from traction”; the second involved a patient whose signs and symptoms were consistent with joint disease without neck-related arm pain. In the second scenario, the patient was described as having a positive response to a manual distraction technique "but did not necessarily fit the classification system for the use of traction."

    When they looked at the results of the survey, researchers found a combination of the expected and the surprising. In the first scenario—in which patients were more likely to benefit from traction—93.1% of respondents said that they'd incorporate traction into a plan of care. But unexpectedly, a sizable majority of respondents—78.7%—also said they'd use traction in the second scenario, wherein the patient's symptoms seemed to make them less likely to benefit from the intervention. "We were surprised by the response rate to the second scenario as clinical studies reveal conflicting results on the use of traction for patients with neck pain without neck-related arm pain," authors write.

    Other results from the survey:

    • Overall, 76.6% of respondents reported that they use traction to treat neck pain—a much higher proportion than rates reported in an international study of health professionals who treat neck pain, in which only 28% indicated that they use traction.
    • A higher proportion of PTs with American Board of Physical Therapy Specialties orthopaedic clinical certification used traction (88.6%) than those without the certification (73%).
    • Of the 93.1% of respondents who said they'd use traction to treat the patient with the stronger clinical indication (the first scenario), the most common approach cited (41.6%) was intermittent mechanical traction while the patient was supine, and with 20 degrees of neck flexion.
    • In the second scenario, where traction was not as strongly indicated, the 78.7% of respondents who said that they would use traction leaned toward manual traction (42.4%). A smaller percentage (22.4%) reported that they would use intermittent mechanical traction in the same supine/20-degree approach cited by respondents in the first scenario.
    • Respondents indicated that traction is just 1 of several approaches they use to treat neck pain, citing stabilization exercises (90.5%), posture and body mechanics education (86.3%), mobilization techniques (85%), general exercise and fitness programs (70%), and massage or soft tissue mobilization (65.2%) as the most common additional interventions.

    Authors believe the survey points to a high degree of consistency among PTs when it comes to the use of traction for patients whose presentation and symptoms seem to indicate that traction would be helpful, but they were less certain about why the rates would be so high in cases that weren't as strongly correlated to efficacy.

    They have a theory, though.

    "During the clinical examination of a patient complaining of neck pain, [PTs] normally perform some version of manual distraction to assess whether it relieves the patient's pain and/or neck related arm symptoms," authors write. "If a patient reports a change in their neck and/or arm-related pain during a manual traction technique, it may seem intuitive to the clinician to consider this an appropriate intervention."

    Given that tendency, they write, the use of traction in these cases may have more to do with building a strong therapeutic alliance than employing a strongly clinically indicated intervention.

    "Studies reveal that a positive within-session change in a patient's symptoms and response to a particular intervention may be associated with a good outcome," authors write. "The patient's ability to notice immediate changes in [her or his] condition during an evaluation provides support for … [a] 'therapeutic alliance' between the health care provider and patient. Such alliances have been associated with better outcomes."

    Authors point out that traction is just 1 in a "vast array" of approaches used by PTs to treat neck pain as part of a "comprehensive plan of care." The study's authors were Timothy Madson, PT, MS, and John Hollman, PT, PhD. Madson is a certified clinical specialist in orthopaedic physical therapy.

    Research-related stories featured in PT in Motion News are intended to highlight a topic of interest only and do not constitute an endorsement by APTA. For synthesized research and evidence-based practice information, visit the association's PTNow website.

    Study: Low-Intensity Pulsed Ultrasound Ineffective in Speeding Recovery From Tibial Fractures

    Authors of a new study say that when it comes to healing and functional recovery after a tibial fracture, the home use of low-intensity pulsed ultrasound (LIPUS) devices doesn’t help speed things along. Researchers believe that in addition to altering some orthopedic surgeons' treatment approaches, their findings may also underscore a flawed US Food and Drug Administration (FDA) device approval process.

    The study, published in BMJ, monitored the progress of 481 adult patients who had experienced a tibial fracture that required intramedullary nail fixation. All patients received a LIPUS device, with education on proper use, and instructions to administer the ultrasound once a day for 20 minutes. However, only half of the devices actually transmitted ultrasound—the others were sham devices that looked and behaved exactly like their operational counterparts.

    Patients used the devices at the prescribed rate until either their surgeons found radiographic evidence of radiographic healing (all 4 cortices), or until 1 year had elapsed, whichever came first. Researchers assessed imaging and patient responses to a return-to-function physical component survey, the SF-36, at 6, 12, 18, 26, 38, and 52 weeks postoperatively. The return-to-function assessment included questions about return to work, return to household activities, return to at least 80% of preinjury function, return to leisure activities, and weight-bearing, among other areas.

    After a study period that lasted from October, 2008, to September, 2012, researchers found no difference in recovery between patients using the functional LIPUS and the sham device. Radiographic images reflected nearly identical rates of repair, and functional measures didn't vary in any meaningful way. Additionally, authors of the study found no differences in treatment effect for patients who experienced open versus closed tibial fractures.

    The reason the research matters, they write, is that LIPUS remains a "commonly used" treatment for tibial fractures among orthopedic surgeons in North America. Authors cite a recent survey of orthopedic trauma surgeons that found nearly 23% of those who use intramedullary nailing for tibial fractures also prescribe LIPUS. Researchers believe that their study overcomes the limitations of earlier work on the effectiveness of LIPUS, partly through the current study's incorporation of functional recovery data, rather than solely relying on imaging.

    Authors of the study also point to an even broader implication of their study—one that has to do with the ways the FDA goes about its device approval process.

    "The FDA approved LIPUS for fracture healing in 1994 on the basis of small trial at high risk of bias," authors write, describing a process consistent with findings of a 2016 study that looked at 99 FDA-approved devices and found that 43 achieved approval before a clinical study was published.

    "Further, as is the case with LIPUS, device inventors or industry employees are often investigators on clinical trials that are used to gain regulatory approval," authors write. "Our experience suggests the high desirability of demanding evidence from randomized trials conducted by investigators other than those who will gain financially from clinical use of the device before approval by regulatory agencies."

    Research-related stories featured in PT in Motion News are intended to highlight a topic of interest only and do not constitute an endorsement by APTA. For synthesized research and evidence-based practice information, visit the association's PTNow website.

    Researchers Say ‘Soft Robots’ Could Play a Role in Rehabilitation

    The idea of “soft robots”—robotic components that don’t comprise rigid parts—has been around for a while, but now researchers in Switzerland believe they may have come up with a combination of components that will allow soft robot technology to be more widely applied to a range of uses, including physical rehabilitation.

    The soft robots developed in the Reconfigurable Robotics Laboratory (RRL) look like a sausage hooked to pressurized air pump, and are basically akin to balloons whose expansion and contraction can be finely controlled—both in terms of direction and force. They’re known as soft pneumatic actuators (SPAs).

    And while that concept may seem simple enough, things quickly get complicated: the materials used for the SPAs have to be rigid enough to withstand significant air pressure without distorting their shape, yet pliant enough to bend and stretch in muscle-like fashion; they need to be light; and they need to be sensitive to both quick blasts of air for strong movement and weaker blasts for more delicate, slower motion. Perhaps most important of all for researchers, the SPAs need to be predictable, so that computer modeling can guide development.

    Writing in the journal Scientific Reports, the RRL researchers believe they may have hit on the right combination of materials, a 2-part arrangement of plastic materials consisting of a pliant actuator body and a rigid shell that guides the type of motion required—think along the lines of a caterpillar wearing a corset. The resulting SPAs are capable of bending up to 200 degrees or stretching to 6 times uninflated length, depending on the model. The materials also allow for reliable computer modeling—so much so that RRL has published open-source online software that allows anyone to investigate various configurations of bodies and shells.

    After developing a workable technology, the RRL team began collaborating with physical therapists in Switzerland to develop a prototype belt that could help individuals poststroke as part of gait rehabilitation. The prototype, included in a video from RRL, uses SPAs that lengthen and contract to help create stability in the lower torso and hips.

    Researchers admit that while their findings are moving soft robot technology forward, the concept has a long way to go—at least when it comes to physical rehabilitation. Right now, the SPAs are controlled by a series of bulky pneumatic pumps, and researchers are looking for ways to create miniaturized, wearable devices to power the SPAs.

    Research-related stories featured in PT in Motion News are intended to highlight a topic of interest only and do not constitute an endorsement by APTA. For synthesized research and evidence-based practice information, visit the association's PTNow website.

    Many IRF Patients Experience Interruptions in Care – About 10% Due to Preventable Conditions

    New research into Medicare data has found that potentially costly interruptions in inpatient rehabilitation for neurological conditions may be occurring for as many as 1 in 3 patients, depending on the condition—and about 10% of all interruptions are related to complications that are considered preventable.

    In an article e-published ahead of print in The American Journal of Physical Medicine and Rehabilitation, researchers analyzed data from nearly 80,000 Medicare beneficiaries admitted to an inpatient rehabilitation facility (IRF) for services related to stroke (71,769), traumatic brain injury (TBI; 7,109), and spinal cord injury (SCI; 659) between 2012 and 2013. Their analysis was focused on the prevalence and causes of 2 types of interruptions in care: "program interruptions," wherein patients are transferred to another facility and returned to the IRF within 3 days; and "short-stay transfers," in which patients are transferred to a hospital, skilled nursing facility (SNF), or other facility before their expected IRF length-of-stay ends.

    Next, authors of the study looked at the reason for the interruption, paying special attention to interruptions caused by what the Agency for Health Care Research and Quality (AHRQ) defines as "preventable" conditions. Examples include urinary tract infection, dehydration, bacterial pneumonia, and heart failure.

    Here's what they found:

    Program Interruptions

    • About 1 in 100 patients experienced this type of interruption, with relatively minor variation among groups.
    • Virtually all program interruptions (100% for the TBI and SCI groups, 99% for the stroke group) were to acute care hospitals.
    • Just over 10% of all program interruptions were potentially preventable (12.3% in the stroke group, 11.7% in the TBI group, and 11.1% in the SCI group).
    • For individuals with stroke, the most frequent preventable conditions were dehydration (35.9%) and urinary tract infections (28.2%). In the TBI group, urinary tract infections were most frequent (42.9%), followed by heart failure (28.6%). Researchers had insufficient data to report on causes among the SCI group.

    Short-stay transfers

    • Short-stay transfers were more prevalent than program interruptions, with 22.3% of the stroke group, 21.8% of the TBI group, and 31.6% of the SCI group experiencing a transfer sooner than anticipated, given their case-mix and comorbidity tier.
    • Transfers to acute care settings accounted for 7.2% for the stroke group, 10.2% for individuals with TBI, and 12.3% for patients with SCI.
    • For individuals with stroke, 14.7% of the transfers were for preventable causes. That rate was 10.2% for the TBI group, and 3.8% for those with SCI.
    • As for types of preventable conditions, dehydration (30.6%) and heart failure (26.8%) were most common among individuals with stroke. Dehydration and bacterial pneumonia were equally prevalent among the TBI group (26.4% for both). The most prevalent preventable conditions for SCI patients were bacterial pneumonia (66.7%) and urinary tract infections (33.3%).
    • Rates of short-stay transfers to a nonacute care settings were 15.1% for the stroke group, 11.6% for individuals with TBI, and 19.3% for those with SCI.

    While authors of the study recognize that not all short-stay transfers represent an "undesirable" outcome, they assert that when combined with rates of program interruption, rates of short-stay transfers to acute care settings, and the fact that nearly all other nonacute short-stay transfers were to SNFs ("not the ideal or desired discharge setting for patients admitted to an [IRF]," they write), doing something about preventable interruptions could make a difference in patient experience and overall health care costs.

    Authors further point out that those potential cost reductions could in fact be an important element in emerging payment scenarios—particularly in bundled payment systems that are likely to be widely used in the future.

    "As bundled payments become a reality, providers (hospitals) will be incentivized to partner with other providers who deliver efficient quality care; for example, those with low program interruption and transfer rates," authors write. "Our findings indicate that program interruptions and short-stay transfers represent targets for care improvement efforts among Medicare fee-for-service beneficiaries receiving care for stroke, TBI and SCI."

    APTA member Addie Middleton, PT, PhD, was a co-author of the study.

    Research-related stories featured in PT in Motion News are intended to highlight a topic of interest only and do not constitute an endorsement by APTA. For synthesized research and evidence-based practice information, visit the association's PTNow website.