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  • Study: Knee, Hip OA May Increase Risk of CVD-Related Death, Underscoring Need for Emphasis on Physical Activity in OA Treatment

    In this review: Cause-specific mortality in osteoarthritis of peripheral joints
    (Osteoarthritis and Cartilage, June 2019)
    Abstract

    The message
    Researchers from Sweden found that among individuals studied, those with hip or knee osteoarthritis (OA) died from chronic ischemic heart diseases and heart failure at a greater rate than both the non-OA population and those with OA in other peripheral joints. No other significant correlations were found between the presence of OA and other causes of death, including diabetes, dementia, neoplasms, or diseases of the digestive system.

    The study
    Researchers tracked 469,512 health records from individuals in southern Sweden who were between the ages of 25 and 84 in 2003, including individuals who received an OA diagnosis between 1998 and 2003. Authors of the study then compared causes of death among the OA and non-OA group reported over an 11-year span, from 2004 to 2014. The researchers wanted to find out the degree to which the presence of OA in a peripheral joint (or joints) increased the hazard risk for various individual causes of death.

    Findings

    • Among all individuals studied, the most common causes of death were neoplasms and cardiovascular diseases (CVD), accounting for 66% of all deaths.
    • Compared with the non-hip/knee OA groups, those with hip OA were 1.13 times as likely to die from CVD, while the knee OA group was found to be 1.16 times as likely to die from CVD. Those differences increased as the individuals aged.
    • The CVD-related deaths among the hip and knee OA groups were primarily related to heart failure and ischemic heart disease, and rates didn't differ significantly between men, women, and when adjusted for other demographic variables.
    • Researchers found no correlation between OA and other causes of death studied: diabetes, hypertension, cerebrovascular disease, neoplasm, dementia, and liver disease.
    • Among the knee OA group, 26% underwent knee replacement during the study period. Of the hip OA group, 55% had a joint replacement procedure; however, the mortality results were similar even when both replacement groups were excluded from the hazard ratio analysis.

    Why it matters
    The bulk of research related to OA and causes of death tend to focus on all-cause mortality. This large-scale study took a more granular approach to identify possible relationships between types of OA and specific causes of death. Authors believe the findings further underscore the importance of emphasizing physical activity in the treatment of OA.

    What APTA's doing
    APTA is a strong supporter of the importance of physical activity in the treatment of OA. The association offers resources on encouraging healthy, active lifestyles at APTA's Prevention, Wellness, and Disease Management webpage as well as information on arthritis management through community programs. Members also can dive deeper into the issues by joining APTA's Council on Prevention, Health Promotion, and Wellness in Physical Therapy, and by checking out evidence-based resources such as this clinical practice guidelines on hip pain mobility deficits, available at the association's PTNow website. Patient-focused resources are available through APTA's MoveForwardPT.com website; additionally the Osteoarthritis Action Alliance offers a free booklet to help consumers participate in its "Walk With Ease" program.

    Keep in mind…
    Researchers were unable to adjust for body mass, a factor related to both the presence of OA and higher all-cause mortality. Additionally, the individuals with OA included those at all stages of the disease, and were limited to those who received an OA diagnosis—authors acknowledge it's likely that the non-OA group included individuals with undiagnosed OA.

    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.

    Military System Study: PTs in Primary Care Provide Safe Treatment and Are Less Likely to Order Ancillary Services or Make Referrals

    While civilian health care policymakers and stakeholders in the US continue to debate whether physical therapists (PTs) should be included as primary care providers, the country's military health systems have marched ahead with the concept. A new study adds to the evidence that the idea is working, both in terms of patient safety and reduced health care utilization.

    Authors of the study, published in Military Medicine (abstract only available for free) and first presented as a poster at the 2019 APTA Combined Sections Meeting, frame their research as an exploration of the potential for PTs to address the nationwide physician shortage by lowering costs and increasing access to care. They assert that the potential for more team-based, effective care could be at least partially realized if civilian PTs were treated like their military counterparts and included as primary care providers. It's a position that APTA strongly supports in its strategic goals and is consistent with APTA's own investigations into the PT's role in primary care settings. In addition, in 2018 the association conducted a practice analysis aimed at determining the feasibility of primary care as a specialty area recognized by the American Board of Physical Therapy Specialties and the American Board of Physical Therapy Residency and Fellowship Education.

    The study tracked 3 years' worth of patient data from the Malcom Grow Medical Clinic and Surgery Center (MGMC), a facility at Maryland’s Andrews Air Force Base that treats active-duty personnel and their families. MGMC patients with musculoskeletal complaints can choose their care pathway, receiving care through either a family health clinic (FHC) or the facility's physical therapy clinic (PTC). Authors describe the PTC as engaging in "advance practice" physical therapy that, in addition to its direct access status, allows PTs to order diagnostic imaging and lab studies, make referrals, and prescribe a limited range of medications.

    Researchers were interested in answering what they say is 1 of the main reservations about the PT as primary care provider—that patients would face increased risk of harm—and along the way wanted to find out what they could about the PT's use of ancillary services such as imaging and referrals. They analyzed data from nearly 250,000 provider encounters (207,241 from the FHC and 41,656 from the PTC), including information from an internal patient safety reporting database (PSR) that tracks "safety events" in which patients were exposed to or experienced various degrees of harm. Here's what they found:

    • Over the 2015-2017 study period, the FHC recorded 56 documented safety events, compared with 16 reported in the PTC. Adjusting for overall caseload, patients in the FHC were determined to be 1.9 times as likely to experience an actual or "near-miss" safety event (a potential safety event that never reaches a patient) as were the PTC patients.
    • While both clinics reported the majority of their safety events as near-miss, the PTC's near-miss events made up 75% of its total safety events during the study period, compared with a 50% rate at the FHC. A 72% near-miss rate is the MGMC’s benchmark.
    • Imaging was the most frequently used ancillary service in the PTC, but use rates were still significantly lower than the FHC rate, with 1 study per every 37.13 encounters in the PTC and 1 per 4.99 encounters in the FHC. Because of the frequency of imaging use in the PTC, authors believe that "pursuing diagnostic imaging authority may be of utmost importance if pursuing advanced practice physical therapy within a practice act or within a health care organization."
    • No adverse events were associated with the 1,817 thrust manipulations (197 in FCH, 1,621 in PTC) or the 2,910 dry needling procedures (PTC only) provided to patients during the study period.
    • Referrals to other providers were lower among PTs, with a rate of 1 per every 51.88 encounters, compared with 1 per every 3.06 encounters at the FHC.
    • Both the rate of prescriptions and orders for lab studies were dramatically lower among PTs, who wrote prescriptions at a rate of 1 per every 1,487 encounters and ordered lab studies at a 1 per 1,301 rate. Providers in the FHC had rates of 1 per 0.99 for prescriptions and 1 per 2.91 for lab work.

    Authors warn against interpreting the lower PT rates of additional service use as an endorsement of PTC superiority; instead, they are an indication of differences in necessary care pathways in the 2 clinics. Providers in the FHC, they write, must order lab tests "for other functions such as tracking disease progression or identifying proper [pharmaceutical] dosages," something that's not done as frequently in the PTC. Similarly, they write, "the number of images ordered by the PTC may be deflated if the patient had already received the imaging at the FHC."

    Setting aside those factors, they argue, the data show what they hypothesized—"that [physical therapy] has a similar safety profile to primary care within the specified domains of advanced practice [physical therapy]." Additionally, they write, their study supports findings from earlier research that found "significant reductions in health care utilization including pharmaceuticals and imaging services when patients accessed physical therapy first."

    APTA members Lt Col. Lance M. Mabry, BSC, USAF (Ret.), PT, DPT; Jeffrey Notestine, PT, DPT, ATC; Col. Josef Moore, MSC USA, PT, PhD; and Jeffrey Taylor, PT, DPT, PhD, were among the authors 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.

    #Fail? Study Says Physical Therapy's Reach on Social Media Comes up Short

    When it comes to using social media to promote the profession, physical therapy may be missing out: that's the conclusion of a recent study that analyzed physical therapy-related tweets and found that, for the most part, Twitter discussions about the profession are occurring in an "echo chamber"—if they even rise to the level of a discussion in the first place.

    The study, published in APTA's journal PTJ (Physical Therapy), looked at a random sample of 1,000 tweets from a collection of 30,000 tweets gathered over a 12-week period. Researchers sorted out each message according to its author, intended audience, tone, and theme, and—when it occurred—the "pattern" of the twitter conversation, which includes shares as well as actual online exchanges. The collection was based on 9 search terms: physical therapy, physiotherapy, physical therapist, physiotherapist, #physicaltherapy, #physiotherapy, #physical therapist, #physiotherapist, and #physio. Hashtags associated with "known physical therapy campaigns," such as APTA's #ChoosePT, were not included in the searches. [Editor's note: the article appears in the August edition of PTJ, which is the journal's 1,000th issue—help celebrate by checking out the PTJ website for original research, perspectives, podcasts, and more.]

    Here's what they found:

    • Of the tweets that generated shares and discussions, most were what the Pew Research Foundation calls "tight crowd" and "brand cluster"—discussions that "tended to cluster on the periphery, dominated by a small group of highly connected people with few isolated participants," according to authors.
    • A substantial number of tweets, authors write, were from "disconnected participants" whose messages "resulted in no interaction with anyone other than the tweet's original author." The exceptions tended to be when APTA, other national organizations, and celebrities tweeted about physical therapy. As an example, authors offered up a 2016 physical therapy-related tweet by wrestler and actor John Cena, which at the time of the study had 1,550 retweets and 4,403 likes.
    • Almost half the tweets (48.5%) were characterized as "marketing" in nature. Employment-related tweets were a distant second at 17.7% of the total, followed by patient experience (15.7%), education (15.7%), advocacy (14.6%), conversation (14.3%), opinion/editorial (13.8%), physical therapist (PT) education (11.3%), research (7.7%), and continuing education (3.2%).
    • Recruiters and corporations were responsible for 86% of all employment-related tweets. PTs, physical therapist assistants (PTAs), and clinics were the authors of the majority of messages related to patient education, continuing education, and marketing.

    The big takeaway, according to authors, is that if PTs and PTAs want to heighten the profession's profile on social media, they need to do more than just show up.

    "The results of the present study reveal that simply being present on social media may not be enough," authors write. "The power of social media is in the conversation, and information becomes influential through 'likes,' 'retweets,' 'shares,' and 'mentions.' Physical therapy professionals and the hospitals and clinics that employ them need to understand the function and structure of online health conversations so they may influence and effectively engage in these conversations."

    Moving physical therapy discussions beyond what the researchers describe as a social media "echo chamber" will require a more savvy approach, according to the authors. They suggest "leverage[ing] the power and reach of broadcast networks and popular events" such as the Olympic Games, and using more generic hashtags (#rehabilitation, for example), as well as hashtags that "infiltrate another distinct mode of professionals" (#sportsmedicine, for instance) as ways to increase the reach of their messages.

    Authors acknowledge that the samples they studied provide a "limited" and "superficial" view of the entirety of physical therapy-related social media activity, and further admit that the average of 300 physical therapy-related tweets per day is a drop in the bucket compared with Twitterverse activity as a whole. Still, they argue, the profession needs to understand—and leverage—the power of social media as a provider of health information.

    "Online health information seekers have a high level of trust [in information accessed online] and often use it to make health decisions," authors write. "Rehabilitation-related information is not immune to this influence."

    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.

    APTA, Alliance for Physical Therapy Quality and Innovation Report Explores Relationship of 'Baseline' Patient Factors and Patient-Reported Outcomes

    Many patients who see a physical therapist (PT) bring more than just a movement system issue to the clinic: they bring a host of "baseline" factors that can impact patient-reported outcomes (PROs). That reality raises a big question: given a patient's individual mix of comorbidities, socioeconomic status, payer type, and other elements at the onset of treatment, how can PTs, payers, and patients know what constitutes a "typical" amount of improvement—and can currently available data provide any insight?

    APTA and the Alliance for Physical Therapy Quality and Innovation (Alliance) are aiming to get a handle on those questions and already have taken a significant step forward in the release of a report that explores benchmarks of quality care. In a joint news release, the 2 organizations describe the document as "the largest multipractice analysis of open-source, risk-adjusted clinical outcomes in the outpatient physical therapy industry."

    To tackle this project, APTA and the Alliance contracted with the Center for Effectiveness Research in Orthopaedics to take a close look at baseline and PRO data from 375,000 patient episodes in 50 states, all related to outpatient orthopedic physical therapy involving spine, shoulder, and knee care. The data were supplied by WebPT, Intermountain, ATI, and PTNorthwest. Those 4 companies, along with APTA, the Alliance, Select Medical, BMS Practice Solutions, ATI Physical Therapy, and US Physical Therapy compose the Physical Therapy Industry Outcome Workgroup responsible for developing the final report

    Among the workgroup's findings:

    Baseline patient data currently available through typical electronic medical records (EMRs) can explain a lot.
    "Payer type, patient socio demographic factors, and comorbidities at baseline all had strong effects on PRO changes over episodes of care," the report states. "Differences in these baseline patient factors must be accounted for to ensure fair performance comparisons of physical therapists."

    Despite baseline patient factors, physical therapists are making an overall difference in patients' lives.
    Researchers found that clinically important improvements in PROs were achieved in all 3 body regions over 12-14 visits.

    When it comes to risk adjustment, the data are there...
    The project also explored just how much patient baseline data are needed to establish risk-adjustment algorithms, labeled "minimal," "practical," and "optimal." In the end, researchers found that the "practical" dataset—commonly available EMR data that include payer source, weight, BMI, sex, patient zip code, and the presence of comorbidities and history of smoking—were sufficient to provide insight on variation in PROs.

    …The data can be put to use right now…
    The report includes risk-adjusted regression models for neck, shoulder, and spine patients that estimate levels of PRO change for every baseline variable in all 3 dataset models: "minimal," "practical," and "optimal."

    …And more is always better.
    "The completeness of data necessary for risk adjustment was a limitation of this project with only 8.8% of the patient episodes received [having] appropriate baseline and discharge PROs and only 6.3% [having] measures of the appropriate set of risk-adjustment factors," the report states. "Physical therapy organizations must be committed to institutional strategies that promote the collection of PROs at baseline and baseline patient factors into existing EMRs."

    Heather Smith, PT, MPH, APTA's director of quality, believes the report sheds light on 2 important issues: the value of physical therapy no matter the patient baseline characteristics, and the crucial need for consistent and thorough data that can help drive that point home.

    "The findings in this report add more depth to what we already know—that physical therapy improves patients' lives in ways patients can see and feel, even when other factors affect outcomes," Smith said. "But just as important, it points to the absolute necessity of widespread, standardized data collection and outcomes reporting throughout the profession. The more data we compile, the more we can help our patients and make the case for the effectiveness of our interventions."

    [Editor's note: APTA's Physical Therapy Outcomes Registry is a key player in the collection of data to improve patient care and strengthen the profession, and actively collects PROs as well as risk variables. Find out how you can participate in the Registry.]

    Survey of PTs Reveals 'Significantly Inadequate' Rates of BP and HR Measurement

    Despite the frequency with which physical therapists (PTs) in outpatient settings encounter patients who have or are at risk for cardiovascular disease (CVD), rates of blood pressure (BP) and heart rate (HR) screening remain "significantly inadequate," say authors of a new study based on a nationwide survey of PTs. The survey reveals that only 14.8% of respondents reported measuring BP and HR on initial examination of new patients, and sheds some light on factors that influence the tendency to perform the screens—or forgo them.

    The analysis, published in the July issue of PTJ (Physical Therapy), is based on survey responses from 1,812 PTs who worked in outpatient settings and were members of the APTA Academy of Orthopaedic Physical Therapy at the time of the survey. The survey was administered online and consisted of 30 multiple-choice questions that delved into CVD-risk screening behaviors and related rationales as well as demographics and education background of the respondents, and patient characteristics.

    The results showed that although 51% of PTs reported that at least half of their current caseload included patients with or at moderate-to-severe risk of developing CVD—and 28% reported that more than 50% of their patients were in this category—only 14.8% said that BP and HR screenings were a regular part of their initial examination of a new patient. When researchers dug deeper into the results, they uncovered other interesting details, including:

    • Nearly 7 in 10 PTs (68.9%) said they encountered a new patient with or at risk for CVD at least twice a week, and 29% said they encountered this kind of new patient daily.
    • In terms of how frequently BP and HR were measured at the initial visit, 63.74% of the respondents reported doing the measurements less than 50% of the time; 39.8% said they conducted the screenings less than 25% of the time; and 13% responded by saying that they never measured BP or HR.
    • The most commonly reported barriers to BP and HR screening were lack of time (37.44%) and "lack of perceived importance" (35.62%). Most respondents reported that they were adequately equipped to perform routine screening and felt confident in their ability to do so.
    • When it came to factors that were linked to more frequent BP and HR measurements, respondents with higher percentages of patients with or at risk for CVD tended to perform the screenings more often, as did PTs who had completed a residency or fellowship training program, and clinicians with more than 20 years of practice experience. Possessing a board-certified specialization credential of any kind was not linked with increased likelihood of conducting the screenings.

    Authors of the PTJ article describe the results as "surprising," particularly given the typical respondent caseload and the PTs' apparent confidence in their ability to perform BP and HR screenings. They write that current rates, while better than in the past, are still "significantly inadequate in relation to the high rates of CVD risk factors present in the patient population."

    As for what might be done to improve the rates, the researchers point to the link between postprofessional education (specifically, residencies and fellowships) and increased screening as one promising possibility, but they also stress other avenues for increasing clinician knowledge, such as wider use of social media to "improve clinician knowledge and practice patterns." Clinics could make a difference as well, they add, by changing policy to emphasize the importance of initial BP and HR measurements.

    APTA members Richard Severin, PT, DPT, PhD(c); Adam Wielechowski, PT, DPT; and Shane Phillips, PT, PhD, were among the authors of the study. Severin is a board-certified cardiopulmonary clinical specialist; Wielechowski is a board-certified specialist in orthopaedic physical therapy.

    [Editor's note: for an exploration of the importance of blood pressure screening and the role of PTs, check out this #PTTransforms blog post that discusses the impact of changes made to blood pressure guidelines in 2018.]

    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.

    JAMA Neurology: Telerehab Program Works as Well as Clinic-Based Program for Improved Arm Function Poststroke

    It's probably not news to physical therapists (PTs) when research backs up the idea that patients who experience arm impairments poststroke will tend to make greater functional improvements with larger and longer doses of rehabilitation. Unfortunately, PTs are also familiar with the fact that what's optimal isn't necessarily what's typical, with challenges such as payment systems, logistics, and clinic access making it difficult to achieve the best possible results. That's where telerehabilitation could make a big difference, say authors of a new study that found an entirely remotely delivered rehab program to be as effective as an equal amount of clinic-based sessions.

    The findings lend further support to the ideas behind APTA's efforts to increase telehealth opportunities for PTs and their patients—a significant component of the association's current public policy priorities. In addition, APTA provides multiple telehealth resources on a webpage devoted to the topic, and has created the Frontiers in Research, Science, and Technology Council that provides interested members and other stakeholders with an online community to discuss technology's role in physical therapy.

    The study, published in JAMA Neurology (abstract only available for free), involved 124 participants who experienced arm motor deficits poststroke. All participants were enrolled in a rehabilitation therapy program that included 36 70-minute treatment sessions, half of which were supervised, over a 6- to 8-week period. The only major difference: one group's supervised sessions were face-to-face with a physical therapist (PT) or occupational therapist (OT), while the other group received telerehab from a PT or OT via a computer with video capabilities, accompanied by the use of a gaming system.

    Researchers were interested in finding out how patients fared in each approach, using scores from the Fugl Meyer (FM) assessment of motor recovery poststroke as their primary measure. Authors of the study also measured patient adherence with therapy as well as levels of patient motivation related to how well they liked the therapy they were receiving and their degree of dedication to treatment goals.

    Using a treatment approach "based on an upper-extremity task-specific training manual and Accelerated Skill Acquisition Program," researchers set up matched programs that included at least 15 minutes per session of arm exercises from a common set of 88 possible exercises, at least 15 minutes of functional training, and 5 minutes of stroke education. The clinic-based participants received in-person instruction on the exercises and used "standard exercise hardware"; the telerehab patients received instructions via video link and engaged in functional exercise via a videogame interface. Here's what the researchers found:

    • Both groups improved at about the same rate, with the telerehab participants averaging a 7.86 FM gain, compared with an average gain of 8.36 points for the clinic-based group.
    • Improvements were also about the same for the subgroup of participants who entered rehabilitation more than 90 days poststroke, with these "late" participants averaging a 6.6-point gain for the telerehab group and a 7.4-point increase for the clinic-based group.
    • While both groups reported high levels of dedication to treatment goals, the clinic-based group tended to report better levels of motivation and satisfaction. Adherence was also high for both groups, with a 93.4% adherence rate for the clinic-based group and a rate of 98.3% for the telerehab group.
    • Both groups increased their knowledge of stroke at similar rates.

    As for the technical details of the telerehab sessions, the system included a computer linked to the internet, a table, a chair, and 12 "gaming input devices." Keyboards were not necessary. The supervised sessions began with a 30-minute videoconference between the patient and therapist, and the functional training games used were designed to match the functional task work being done with the clinic-based participants. Unsupervised sessions adhered to the same content but didn't include contact with the therapist.

    "In an era when prescribed doses of poststroke rehabilitation therapy are declining, adversely affecting patient outcomes, these and prior findings suggest that outcomes could be improved for many patients…if larger doses of rehabilitation therapy were prescribed," authors write. "Our study found that a 6-week course of daily home-based [telerehab] is safe, is rated favorably by patients, is associated with excellent treatment adherence, and produces substantial gains in arm function that were not inferior to dose-matched interventions delivered in the clinic."

    Authors acknowledged that patient satisfaction with telerehab might be improved by increasing the amount of time spent with the therapist—providing that therapist is properly trained. "Current results underscore the importance of maintaining a licensed therapist's involvement during [telerehab]," they write.

    Ultimately, it's still too early to determine just how generalizable the findings are to other populations and conditions, the researchers say, but all indicators seem to point to the need for increasing the availability of telerehab and its inclusion in health plans.

    "The US Bipartisan Budget Act of 2018 expanded telehealth benefits," authors write. "Eventually, home-based [telerehab] may plan an ascendant role for improving patient outcomes."

    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.

    Older-Adult Deaths From Falls Have Increased; Intervention May Help Decrease Falls in the Future

    Researchers analyzing health statistics have uncovered some disturbing news: in 2016, adults 75 and older were dying from falls-related injuries at more than double the rate they were in 2000. And while authors of a recent JAMA editorial on the numbers say the reason for the dramatic increase "is not fully understood," a separate study in the same issue of the journal points to a physical therapist (PT)-led falls prevention program as a potentially effective way to counteract the trend.

    Using data from the National Vital Statistics System, authors of "Mortality from falls among US adults aged 75 years or older, 2000-2016" found that, in adults over age 75, the number of deaths from falls increased from 8,613 in the year 2000 to a staggering 25,189 in 2016. The age-adjusted mortality rates in 2016 was 42.1 per 100,000 people for those aged 75–79 and 590.7 for individuals aged 95 or older.

    Mortality rates increased for both men and women. The age-adjusted mortality rate for men rose from 60.7 deaths per 100,000 people in 2000 to 116.4 in 2016. Likewise, among women, rate of death from falls went from 46.3 per 100,000 people to 105.9 in 2016.

    Authors of the editorial say the reason for the increase in deaths resulting from falls "is not fully understood." Still, they write, while older adults clearly have the highest risk for falls, they also have the highest potential for cost-effective interventions that make a difference.

    One such promising intervention for secondary fall prevention in community-dwelling older adults is the Otago home-based exercise program. In a study (abstract only available for free) published in the same issue of JAMA that includes the falls editorial, researchers including APTA member Teresa Liu-Ambrose, PT, PhD, write that the program "may have been effective because it reduced the number of falls among individuals who fell repeatedly."

    Researchers for the recently published JAMA study designed a randomized controlled trial to specifically examine whether the Otago exercise program could do so for adults over age 70 who previously had experienced a fall. Upon seeing a physician after a fall, patients were randomly assigned to receive 12 months of "usual care" or usual care plus the home-based strength and balance retraining program. Usual care included fall risk and medical assessment; treatment by a geriatrician, including lifestyle recommendations; and referral to other providers as necessary.

    In the Otago program, a PT delivers balance, strength, and walking exercises that increase in difficulty over time. Participants in the JAMA study were instructed to repeat the exercises 3 times a week and walk for 30 minutes each week. The PT returned every other week to adjust the exercises, and individuals were evaluated by a physician at 6 and 12 months.

    Authors found that falls were significantly reduced among those who completed the Otago program (236 falls) compared with those who only received usual care (366 falls). While a majority of participants experienced additional falls, the rate was 1.4 per person-year for the Otago group compared with 2.1 for the usual care group.

    However, consistent with previous research, there were no significant differences between groups in fall risk, general balance, and mobility. "It is possible to observe a significant reduction in falls without significant improvements in physical performance," authors conclude. APTA provides extensive resources on falls prevention at its Balance and Falls webpage. Offerings include consumer-focused information, online courses, and links to other sources of information, including the CDC and the National Council on Aging. In addition, APTA's PTNow evidence-based practice resource offers a unilateral vestibular hypofunction clinical summary, a summary on falls risk in community-dwelling elders, an osteoporosis clinical summary, and tests and measures such as a fracture risk assessment, a clinical test of sensory interaction and balance, and a self-paced walk test. The association's scientific journal, PTJ (Physical Therapy) has published a clinical guidance statement from the APTA Academy of Geriatric Physical Therapy on management of falls in community-dwelling older adults.

    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.

    PTJ's Research Impact on the Rise

    The influence of PTJ (Physical Therapy), APTA's scientific journal, continues to grow: according to Journal Citation Reports (JCR), the frequency with which PTJ is cited in other journals—its "impact factor"—made PTJ #7 among rehabilitation journals and #16 among orthopedic journals in 2018. A journal's impact factor is used by many researchers to decide where to publish their work.

    The JCR rating isn't the only indicator of PTJ's increasingly high profile. Another rating, called the Eigenfactor score, ranks PTJ fourth among rehabilitation journals even after excluding self-citation (references from one article in a journal to another article in the same journal).

    "The improved impact factor is a direct result of the hard work and commitment of our Editorial Board members, our reviewers, and, most of all, our authors," noted Editor in Chief Alan Jette, PT, PhD.

    To mark the occasion, Jette has posted a special selection of PTJ's top-cited papers on a PTJ "High Impact Research" webpage.

    'Allow Mistakes': Study of Infants With CP Emphasizes Importance of Balanced Approach to Movement Learning

    Infant prone mobility, considered strongly linked to later mobility gains and psychological development, can be difficult for children with cerebral palsy (CP), putting them at a disadvantage later in childhood. Now authors of a new study believe that pairing special assistive technology with a careful combination of movement learning strategies could facilitate important gains in this population. The study was published as part of a special issue of PTJ (Physical Therapy) focused on the intersection of pediatric physical therapy and development science.

    Researchers were particularly interested in impacts of 2 separate learning "mechanisms" that have been shown to have positive effects on skill learning in adults with neurological deficits: reinforcement learning (RL) and error-based learning (EBL). RL is aimed at optimizing the reception of rewards or penalties, focusing on the outcome; in contrast, EBL focuses on the errors made in movement.

    Both EBL and RL can be useful approaches, authors write, but they each have pros and cons: EBL promotes faster learning but is easier to forget; RL tends to be a longer process with more exploration (and variability) involved but is better retained. Authors of the study hypothesized that infants with CP would achieve better prone mobility gains through a combination of the 2 mechanisms than from RL alone.

    To test their hypothesis, researchers used the Self-Initiated Prone Progression Crawler (SIPPC), a device developed by study coauthor Thubi Kolobe, PT, PhD. The SIPPC resembles a skateboard outfitted with special motors and monitors. Infants are placed on them in a prone position that allows them to move their arms and legs. The SIPPC can then be programmed to sense and respond to movement the child initiates.

    Thanks to the addition of a specially wired onesie, the SIPPC's movement response was able to work as both an RL and EBL mechanism. Calibrated one way, the SIPPC reinforced RL by rewarding a movement that is consistent with achieving a goal—for instance, moving toward a toy. Set another way, the SIPCC could add an EBL element by picking up on movements that are not consistent with the goal achievement and move the infant in unintended directions.

    For the study, researchers divided 30 infants aged 4.5–6.5 months into 3 groups: infants with CP who received SIPPC sessions with the special suit that could combine RL and EBL, infants with CP who received only an RL experience through the SIPPC, and typically developing infants who received the RL experience only through the SIPPC. The sessions involved 3 5-minute trials that included caregiver-led movement of the SIPPC and of the infants' arms and legs as well as periods during which the infant was encouraged to move independently toward either a toy or the caregiver. Sessions were conducted twice a week for up to 12 weeks.

    Researchers found that after 12 weeks, infants in the combined RL and EBL group made improvements over the RL-only group in the areas of rotational amplitude—essentially, the amount of trial-and-error used—and the length of linear paths achieved. Wrist and foot path lengths remained about the same between the groups, but the combined group registered significantly higher scores than the RL-only group in the Movement Observation Coding Scheme (MOCS), a measure of goal-directed movement.

    "Overall the findings support the differential effect of RL and EBL in skill learning in infants with CP," authors write, adding that the greater use of trial-and-error methods among the combined group reflects the ways that infant learning of new motor skills may at times require RL but at the same time involve uncoordinated movements, a cognitively demanding process "that is likely to respond better to EBL." The ultimate result: greater travel distances and more goal-directed movement among the combined group.

    In a video interview at the 2019 APTA NEXT Conference and Exposition, Kolobe boiled down the essential findings of the study. [Scroll down for video]

    "Allow mistakes," Kolobe said, "because that's part of [infants'] repertoire of learning how to do something. Allow them to go after other options, because eventually they get the right one."

    Kolobe also believes the study scratches the surface of another important consideration—the complex nature of cognitive elements during movement learning.

    "A lot of cognition enters into [learning movement]," Kolobe said. "Infants do strategize. There's a lot of executive function required to move."

    Authors believe the executive function demands may be of special note among infants with CP. In their study population, they write, "adapted behaviors were not readily repeated at the next sessions"—a finding that partly may be attributable to the ease with which EBL can be forgotten and partly attributable to the type of brain insult associated with CP. The memory decay "highlights the need to carefully balance RL and EBL approaches," they add.

    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.

     

     

     

    News From NEXT: 2018-2019 Marquette Challenge Raises Over $266,000 for the Foundation

    Students from across the country were recognized June 13 during the Foundation for Physical Therapy Research (Foundation) awards luncheon for their participation in the 31st annual Marquette Challenge—which for 2019-2020 will be called the VCU-Marquette Challenge. Virginia Commonwealth University (VCU) was recognized as the top fundraising school, raising $34,327. The challenge now takes on VCU’s name along with host Marquette University as part of the contest's tradition.

    Earning second place was the University of Pittsburgh ($22,648), and coming in third was the University of Delaware ($18,323). The Foundation also recognized Marquette University students for their financial commitment to the challenge in raising $25,000.

    The annual challenge is a grassroots fundraising effort coordinated and carried out by student physical therapists and physical therapist assistants across the country.

    This year, more than 150 schools nationwide participated in creative efforts to support the Foundation, raising a total of $266,019.

    Funds raised through the challenge go toward physical therapy research grants and scholarships and support the rigorous scientific review process that helps the Foundation identify the most promising new investigators. Since 2002, 27 research grants and scholarships have been awarded in the name of the challenge. Funds from the challenge also supported a recent high-priority research grant to look at physical therapist interventions for older adults who have multiple chronic conditions.

    To view the complete list of participating schools visit the Foundation's webpage.