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  • CoHSTAR Seeks Postdoctoral Fellow

    The Center on Health Services Training and Research (CoHSTAR) has opened its latest call for a full-time postdoctoral fellow—this time for a project related to postacute stroke services.

    The 2-year position, to be located at the University of Pittsburgh, will begin in January 2019. Qualifications for consideration include being a physical therapist with an advanced degree (PhD, ScD, DrPH) completed in the last 5 years and status as a US citizen or noncitizen national. Individuals with strong analytic and writing skills and experience with the analysis of claims data, electronic health record data, and other large data are preferred.

    The successful candidate will work with the Comprehensive Post-Acute Stroke Services (COMPASS) trial, a clinician-led quality improvement model providing early supported discharge and transitional care for individuals who have had a stroke and have been discharged home. The study is entering its fourth year and has produced a wealth of data that provides opportunities for secondary analyses. This fellowship will focus on data related to uptake of rehabilitation care and associated outcomes.

    APTA was a major financial contributor to CoHSTAR, having donated $1 million toward the center's startup in 2015. In addition to APTA’s contribution, funding for CoHSTAR came from gifts from 50 APTA components, as well as foundations, corporations, and individual physical therapists. The Foundation for Physical Therapy also awarded the center a $2.5 grant.

    Study: Estimated 1 in 3 Medicare Beneficiaries Receiving Inpatient/SNF Rehab Report No Improvement in Function

    Authors of a new study on inpatient and skilled nursing facility (SNF) rehabilitation say that when it comes to patients' own opinions of their progress, an estimated 1 in 3 Medicare beneficiaries are likely to report experiencing no improvement in functioning while they were receiving rehabilitation in those settings. And those rates can trend higher depending on certain demographic and health-related variables.

    The study, published in the Journal of the American Medical Directors Association (abstract only available for free), analyzes survey responses from 479 Medicare beneficiaries who received inpatient or SNF rehabilitation between 2015 and 2016. Data were drawn from the National Health and Aging Trends Study (NHATS), with respondents comprising a nationally representative sample of the Medicare population.

    Participants were asked, "While you were receiving rehab services in the last year, did your functioning and ability to do activities improve, get worse, or stay about the same?" Responses were compared with various demographic, socioeconomic, health, and rehabilitation variables to investigate possible correlations. Here's what researchers found:

    • Overall, 33.4% of respondents said that they did not improve in functioning during treatment.
    • Respondents who reported no improvement were more likely to have less formal education, more anxiety, and 1 or more impairments in their ability to perform instrumental activities of daily living (IADL)—preparing meals, doing the laundry, doing light housework, shopping for groceries, managing money, taking medicine, or making phone calls. These respondents also were more likely to require a proxy respondent to answer survey questions due to physiological or cognitive disability.
    • Respondents who reported no improvement were less likely to have received rehabilitation services for surgical reasons.
    • Impairment related to activities of daily living (ADL)—eating, transferring out of bed, transferring out of chairs, walking inside, going outside, dressing, bathing, or toileting—was not associated with lower patient-reported outcomes. The same was true for specific medical conditions and clinically significant depression.
    • Respondents with IADL impairments whose primary condition was "other musculoskeletal condition" or a cardiovascular condition, and who received less than 1 month of rehabilitation services with no outpatient services also were more likely to report no improvement in functioning.

    Authors write that the correlation between lack of improvement and a patient's education level is a "somewhat concerning" finding in the study.

    "Health literacy can be a substantial barrier to effective medical care," authors write, "and perhaps those with less education had a lower level of health literacy, which may have affected their expectations for rehabilitation outcomes and/or negatively impacted their ability to participate in and receive the full benefits of rehabilitation services."

    As for the reasons why impairment in IADLs would be more strongly associated with reports of no improvement than would impairment in ADLs, authors speculate that "perhaps ADL limitations are more amenable to rehabilitation than are IADL impairments, especially because IADL involve more complex tasks that may be particularly sensitive to cognitive status."

    The relationship between rehabilitation of less than 1 month and the absence of outpatient rehabilitation services also was singled out for additional comment by the study's authors, who believe that "effective rehabilitation for some…may be a longer-term process that extends months and spans nursing home, inpatient, outpatient, and/or in-home settings."

    Authors point to a move toward more integrated, multisetting care as a positive step, writing that "As about 1 in 5 community-dwelling Medicare beneficiaries report receiving any rehabilitation services in the prior year, more closely integrating rehabilitation services across service settings (and with other health and social services) offers promise in improving outcomes in Medicare beneficiaries who desire to maintain their independence."

    The study, according to authors, contains its share of limitations, including a relatively small sample size, no differentiation between inpatient facility settings, the use of self-reported data, and lack of information on whether the patients actually met their rehabilitation goals.

    Despite those issues, authors of the study think their analysis opens up areas for future research. They write: "Our findings lead to more questions: does health literacy play a role in patient-reported outcomes? Are those with IADL impairments less able to engage in and thereby benefit from rehabilitation services? How do contextual factors and the dose of rehabilitation services affect patient-reported outcomes? Would patient-reported outcomes among this population be improved if: (1) more of these patients received rehabilitation services longer and/or in outpatient or home settings or (2) if patient-centered rehabilitation targets were more incorporated into treatment planning?"

    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.

    From PTJ: Common Activity Trackers May Be Inaccurate for Patients With PD

    It's important for physical therapists (PTs) to encourage patients with Parkinson Disease (PD) to stay physically active, and it would seem as though commercially available fitness trackers would be a good way to do that, by allowing the PT and patient to set home goals and track progress through step counts. But new research suggests that PTs may want to think twice about the data they get from the devices.

    In an article published in the August issue of PTJ(Physical Therapy), researchers in Boston analyzed data from 4 fitness trackers—2 worn on the wrist and 2 that attach at the waist—to see how the tracker step reports stacked up against videos that allowed PTs to visually observe and count steps taken. The trackers in question were the wrist-worn Fitbit Surge and the Jawbone Up 2 and the waist-worn Fitbit Zip and Jawbone Up Move.

    A total of 33 patients with mild to moderate PD were recruited for the study, which involved tests of both continuous and discontinuous walking while wearing all 4 activity trackers, with the wrist trackers worn on the less-affected arm. The continuous walking tests involved 2 bouts of 2-minute walks around a 92-meter rectangular track, the first lap at a comfortable speed, and second at a fast speed; the discontinuous walking tests consisted of an "obstacle navigation course" and a "household" course, where patients were required walk to different areas to perform typical household tasks such as taking off and hanging up a coat, washing and drying hands, throwing away trash, and picking up and setting down a glass. In addition to recording tracker data, the tests also were video-recorded so that a pair of PTs could count steps taken. Researchers then compared tracker data with the results of the video monitoring. Here's what they found:

    • Overall, the trackers were reasonably accurate at recording steps taken during continuous walking, with the waist-worn Fitbit Zip showing the highest accuracy, followed by the wrist-worn Jawbone Surge, and wrist-worn Fitbit Surge, and the waist-worn Jawbone Up 2.
    • Tracking discontinuous walking proved to be more problematic, with authors of the study describing all 4 trackers as "generally inaccurate" in both courses. The Jawbone Up Move proved to be the least reliable device, with a mean absolute percent error rate approaching 60% in the household course. The Fitbit Zip was the most reliable, but that's not saying much: its error rate in the household course was close to 30%. The devices fared somewhat better in the obstacle negotiation course but still produced error rates ranging from about 10% to 20%. All devices underreported steps taken.

    Authors speculate that the inaccuracies may have something to do with a lack of tracker sensitivity to steps taken "in environments with greater discontinuity, where starting, stopping, and turning occur frequently." The longer, more symmetrical step lengths associated with continuous walking are better suited to the device's abilities, whereas the "smaller, slower, shuffling steps" taken by participants during the discontinuous walking tests tend to be missed by the devices, they write.

    As for waist-worn versus wrist-worn devices, authors think that the higher accuracy of the waist-worn devices may be due to the fact that the device is closer to an individual's center of mass, which allows for more accurate measurement. Wrist devices worn by patients with PD may be less accurate due to the effects of tremor, dyskinesia, extraneous upper extremity movement, and reduced arm swing often associated with individuals with PD, they believe.

    Another common feature of PD—freezing of gait—may also come into play as a factor affecting device accuracy, according to authors. Although only 1 participant in the study experienced freezing during the tests, that individual's devices produced an aggregate 60% error rate in the household course and 20% error rate in the obstacle negotiation course. "In general, the magnitude of this error exceeded that observed among nonfreezers," they write.

    The overarching problem, according to authors, is that none of the devices studied performed reliably in the setting that arguably would be the most important one for PTs treating patients with PD—the patient's home. "Other mechanisms of monitoring discontinuous walking, such as time spent walking, may be better options when the goal of intervention is focused on increasing physical activity in the home environment," they write.

    APTA members Nicholas Wendel, PT, DPT; Chelsea Macpherson, PT, DPT; Tamara DeAngelis, PT, DPT; and Cristina Colon-Semenza, PT, MPT, were among the coauthors 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.

    Study: Popular Shoulder Procedure Provides No Relevant Clinical Benefit Over 'Placebo Surgery'

    Researchers in Finland have once again conducted a study that used "placebo surgery" to conclude that another frequently used arthroscopic procedure likely has little to no benefit: this time around, it was subacromial decompression surgery for shoulder impingement that was found to be no better than diagnostic arthroscopy alone. The procedure was also compared with physical therapy alone, but researchers are uncertain about the reliability of the results.

    The study, published in BMJ, compared shoulder pain at rest and with arm activity among 122 participants, aged 35 to 65, who presented with shoulder impingement occurring for at least 3 months and unresponsive to "conventional treatment." Participants agreed to undergo arthroscopic surgery and understood that they may be receiving either simple diagnostic arthroscopy with no other surgical procedure, or arthroscopic subacromial decompression surgery (ASD), a procedure that involves smoothing the undersurface of the acromion in hopes of easing the passage of the rotator cuff tendon through the subacromial space. Authors characterize ASD as "one of the most frequently performed orthopaedic procedures in the world."

    Researchers were careful to avoid introducing any hints as to who received which procedure, even going so far as seeing to it that the surgeons themselves didn't know which procedure they were doing until after the initial diagnostic arthroscopy and a nurse opened a sealed envelope telling the surgeon whether to proceed with ASD or end the procedure. Additionally, patients who did not receive ASD were kept in the surgical room for the time it would've taken to conduct the procedure, and no other facility staff were told which patients received which kind of surgery.

    Both groups received the same postoperative care—a single visit to a physical therapist (PT) "for guidance and instructions for home exercises." The PT was also in the dark about whether the participant had received ASD or placebo surgery.

    After 24 months, the researchers measured participants' shoulder pain at rest and during arm activity by use of a 0-100 visual analogue pain scale. Secondary outcomes were related to shoulder function, assessed through a Constant-Murley score and the 15D, a health-related quality of life measure. All 24-month assessments were compared with those captured at baseline and 3-months, 6-months, and 12-months postsurgery.

    Researchers noted "marked improvement" among all the participants, but that's what was so revealing: it didn't seem to matter whether the patient had received ASD or the placebo. The results were true for both pain and function assessments.

    Authors of the study believe the findings are made stronger by what they describe as the "stringent eligibility criteria" they used to select only participants "most likely to benefit from ASD."

    "Classically, stringent eligibility criteria are considered to decrease the validity of a study," authors write. "Although our patient population was indeed highly selected…we think that the use of stringent eligibility criteria paradoxically increases the generalizability of our findings. When ASD was proven futile under this best case scenario, there is no reason to assume that it would work better under less optimal circumstances or in a more heterogeneous population."

    Researchers also compared the surgery groups with a third group of participants who participated in 15 sessions of physical therapy. While they found no significant differences in outcomes at 24 months, authors caution against reading too much into those results, primarily because participants in the exercise group weren't weeded out as thoroughly as those in the surgery group beforehand. "Thus the ASD versus exercise therapy comparison is likely to be biased in favor of ASD owing to systematic removal of patients with likely poorer prognosis [in the ASD group]," authors write.

    The study's approach is similar to a 2014 research project, also from Finland, that looked into arthroscopic surgery for meniscal tears. Like the shoulder study, the meniscal study involved the use of placebo surgery and found a similar lack of difference in outcomes between those who received the sham meniscal surgery and those who received the real thing. Four of the authors of the shoulder study are listed as coauthors of the meniscus research paper.

    As for the shoulder study, authors were nothing if not direct in their assessment of the results.

    "The results of this study…show that [ASD] provides no clinically relevant benefit over diagnostic arthroscopy in patients with shoulder impingement syndrome," authors write. "The findings do not support the current practice of performing subacromial decompression in patients with shoulder impingement syndrome."

    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.

    From PTJ: Are Pain Measures Asking the Right Questions?

    In terms of measuring how a patient is impacted by chronic pain, there is a gap between what commonly used questionnaires ask and what patients care about most, say authors of a study in the July issue of PTJ(Physical Therapy). It's time, they write, to "embed patients' values and preferences" into the instruments providers use to evaluate the effects of chronic pain.

    In the first phase of an effort to develop a "patient-driven" instrument, researchers in the Netherlands conducted focus groups and developed an online survey to identify the attributes of pain that have the most impact on participants' daily lives. Survey respondents were asked to provide information about their diagnosis and level of pain, complete the Pain Disability Index, and select the 8 (from a total of 84) most important attributes of pain.

    Authors say that while many instruments measure areas such as pain sensation, psychological impact, functional disability, related symptoms, activities of daily living, social functioning, coping strategies, environmental factors, and financial burden, those aren't necessarily the factors that are most important to patients. In the end, the 8 most frequently chosen attributes of pain identified by the 949 survey respondents were fatigue, social life, cramped muscles, sleeping, housekeeping, concentration/focus, feelings of not being understood, and control over pain.

    Authors also broke down the results by gender, age group, diagnosis, and pain intensity. The only significant difference between men and women was the rating for "housekeeping" – ranked at 5 for women and 29 for men. Individuals with back pain rated "concentration" and "not being understood" much lower than did other diagnostic groups.

    Comparing the results against attributes measured in several widely used instruments and item banks, there was some overlap; however, many standard test items were not deemed important by survey respondents. Similarly, some items rated important to patients are absent from these instruments—for example, researchers note that fatigue was consistently identified as an important attribute in their survey, but it is not included in many instruments used for patients with chronic pain.

    Authors say that the results of the study are being used to develop a prototype pain survey, based on the 8 areas identified through the survey and focus groups, that will measure the impact of chronic pain on health-related quality of life (HRQoL). "A preference-based measuring method allows attributes to be weighted so that HRQoL can be calculated," they write, adding that "a substantial amount of information can be ascertained from these 8 attributes."

    "These attributes in [themselves] are not in fact new, but discovering which attributes are most important to people with chronic pain leads to new insights, which should be used to guide further development of a truly patient-centered, preference-based instrument," 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.

    What's the Best Post-TKA Intervention in the Acute Care Setting? There's No Easy Answer, Say Researchers

    For patients who undergo total knee arthroplasty (TKA), this much is known: physical therapy in the acute care setting is a key component in successful rehabilitation. What's not so easy to pinpoint are the individual interventions associated with the best outcomes, according to authors of a new systematic review. Their investigation into 20 years' worth of clinical trials and other studies revealed no clear standout interventions but did find "very low" evidence for the use of cryotherapy, accelerated rehabilitation, and neurostimulation within the first 7 postoperative days (PODs).

    The study, published in the Journal of Acute Care Physical Therapy, involved extensive reviews of research published between 1996 and 2016 on various physical therapy-related interventions used in the acute care setting post-TKA. Authors were on the lookout for evidence of effectiveness of a particular approach, because, they write, "despite seemingly routine use of physical therapy and its potential importance in reducing complications after [total joint replacement] in the acute hospital setting, no approach to rehabilitation in this setting appears to be standard."

    In the end, through a review process that pared down a list of 686 research titles to 40 studies that met inclusion criteria, authors were able to come up with a definitive conclusion, albeit not the most rewarding one for those looking for guidance: existing evidence isn't strong enough to support any clear winners when it comes to post-TKA physical therapist interventions in the acute care setting.

    The studies that yielded no or weak evidence looked at approaches including additional sessions of rehabilitation, compression and manual lymph drainage, knee range-of-motion (ROM), continuous passive motion, knee ROM manual passive exercise, knee ROM-active assistive exercise, biofeedback, and acupressure, acupuncture, and traditional Chinese medicine. According to authors, evidence either was insufficient or included a significant risk of bias, or both.

    Three other interventions fared somewhat better than the rest, although none were supported by strong evidence. They were:

    Cryotherapy. Reviewers identified 2 systematic reviews supporting the use of cryotherapy to reduce early postoperative pain and improve ROM, though evidence was described as "very low" quality by authors of both reviews.

    "Early" or "enhanced" physical therapy—for example, having patients walk within hours after surgery. Authors identified "very low level" evidence supporting these approaches to improve ROM and walking ability, and to reduce length-of-stay.

    Neurostimluation. "Very low level" evidence suggested that neurostimulation may help to reduce pain—but only when electrodes were placed near the surgical site, according to authors.

    Further clouding the evidence in most (31 of the 40) studies was the fact that some form of "physical therapy" or exercise intervention was used—in both the special intervention group and the comparison group—in addition to the intervention being studied. "Possibly, the lack of evidence for the effectiveness of most of the studied interventions is due to similar management of the intervention and comparison groups, and that changes in the outcomes studied are largely affected by various forms of interventions suggested by the term 'physical therapy' or 'standard care,'" authors write. In addition, they point out, all study participants likely received medical pain management, which makes it even harder to isolate the effects of a particular intervention.

    Authors say there's a clear need for more research on interventions in the acute setting, but acknowledge that such research may be challenging "because of the difficulty controlling for all the variables that may influence outcomes that affect function."

    For now, authors say, don't count on any clear recommendations on the single best intervention to use for patients post-TKA in the acute care setting.

    "Given the state of the evidence, physical therapists will need to rely on empirical evidence and physiologically plausible rationales for selecting type, intensity, frequency, and duration of interventions," authors write. "In addition, given the likely symbiotic relationship between pain management and physical therapy interventions, peri- and postoperative medical management may have important effects on the immediate gains in patients' function after TKA that cannot be separated from the effects of interventions provided by physical therapists."

    APTA members Alisa Curry, PT, DPT; Meri Goehring, PT, PhD; and Diane Jette, PT, DSc, FAPTA, were among the coauthors 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.

    Study: Ignoring Inappropriate Patient Sexual Behavior Doesn’t Work, but Other Strategies Might

    Inappropriate patient sexual behavior (IPSB) is a problem in health care, but researchers have pinpointed some concrete strategies for responding to these incidents, according to a study in PTJ e-published ahead of print. While several of these strategies can be used by the clinician during treatment, authors say less-than-stellar incident reporting outcomes and lack of administrative support “demonstrate a clear opportunity for the profession to improve.”

    The release of this study happens to coincide with action last week by APTA’s House of Delegates to strengthen the association’s position on sexual harassment in all forms, including encouraging incidents of harassment to be reported, with permission of the affected individual, to ensure that others are not similarly harmed.

    Funded by the APTA Section on Women’s Health, the study follows up a 2017 survey of PTs, PTAs, and students that found 84% experienced IPSB—47% in the previous year. In the prior study, authors defined IPSB as a range of behaviors, "from leering and sexual remarks to deliberate touch, indecent exposure, and sexual assault." Physical therapy clinicians were more likely to experience IPSB if they were female, treating mostly male patients, or newer to the profession.

    Researchers surveyed 1,027 members of APTA specialty sections and students in PT and PTA education programs to learn how individuals who experienced IPSB responded to it, and if those responses were effective at mitigating the problem.

    Similar to the previous survey, 38% had experienced IPSB. The participants described a variety of responses, from simply ignoring the patient’s behavior to documenting and reporting it to management. Respondents who are younger (under age 40) and less experienced (students or clinicians with less than 10 years of experience) were more likely to ignore IPSB. The less experienced group also were more likely to respond by joking with patients. Respondents younger than 40 were more likely to ignore IPBS, while students and newer Not surprisingly, ignoring inappropriate sexual behavior—a strategy used by more than 70% of respondents—was not found to be a successful response.

    Respondents also identified strategies that, according to them, significantly improved the situation more than half the time. They include:

    • Distraction
    • Choosing a more public place for treatment or a different treatment method
    • Direct confrontation
    • Establishing a behavioral contract with the patient
    • Transferring care to a different clinician
    • Using a chaperone

    Authors suggest that clinicians be educated on “assertive communication and redirection strategies” but add that the changes shouldn't stop there.

    There is a “need for clear workplace policies coupled with training for managers and supervisors to support clinicians in resolving IPSB,” authors write. They encourage practices to establish policies on using behavioral contracts and warning letters, chaperones, and transfer of care in response to IPSB.

    (Editor's Note: Articles e-published ahead of print are not the final version. The final version of this article will be published in the September issue of PTJ.)

    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.

    CDC: Concussion Rates Among High Schoolers May be Undercounted

    A new report from the US Centers for Disease Control and Prevention (CDC) says that in 2017, an estimated 15% of high school students experienced 1 or more concussions, and 6% experienced 2 or more. Authors of the study say that's a number higher than some previous estimates, probably because the CDC study includes anonymous self-reports from the students themselves, many of whom may try to hide the injury from coaches and parents.

    The data were drawn from the most recent Youth Risk Behavior Study (YRBS), which, in addition to gathering demographic variables, asked students “During the past 12 months, how many times did you have a concussion from playing a sport or being physically active?” Students were also asked to respond to the question, “During the past 12 months, on how many sports teams did you play? (Count any teams run by your school or community groups.)”

    Here's what researchers found:

    • Overall, 9.1% of high school students reported 1 concussion, 3.0% reported 2, 1.0% reported 3, and 2.0% reported 4 or more concussions related to sports or physical activity during the 12 months before the survey.
    • Male students were more likely to report 1, 2, and 4 or more concussions than were female students.
    • Students in grades 9, 10, and 11 were more likely to report a single concussion than were students in grade 12, and students in grade 9 were more likely to report a single concussion than were students in grade 10.
    • Black and Hispanic students were more likely to report 4 or more concussions than were white students.
    • Among students who played on 1, 2, and 3 or more sports teams, the prevalence of reporting having had at least 1 concussion was 16.7%, 22.9%, and 30.3%, respectively.

    According to the CDC, the study yielded higher prevalence rates than those from earlier studies based on emergency department reports and data from athletic trainers, which yielded rates of 622.5 per 100,000 and 1.8 per 100, respectively. Authors of the CDC report speculate that the numbers from both sources may be artificially low, as emergency department data lack information on concussions treated elsewhere, and athletic trainer data miss concussions sustained outside school sports—and neither include medically untreated concussions.

    The CDC report acknowledges that its higher numbers may reflect a greater awareness of concussion symptoms but says that another factor may be at play.

    "A study of high school athletes found that among athletes with concussions, 40% reported that their coach was unaware of their symptoms," the report states. "Students might not always recognize or remember that they have experienced a concussion, or they might not want to report having experienced a concussion. In this study, the opportunity to anonymously self-report a concussion, without negative consequences, such as a loss of playing time, might have aided in including concussions missed by other data sources."

    The bottom line, according to the report, is that concussions among high school students may be undercounted and that more needs to be done to educate students, parents, coaches, and school personnel to recognize and report the injury.

    "Coaches and parents can encourage athletes to follow the rules of play for their sport with an emphasis on player safety, which might reduce the incidence and severity of concussions," authors write. "It is important that any athlete with a suspected concussion be removed from practice and competition and not return to play without the clearance of a health care provider."

    Physical therapists have a critical role in concussion prevention and management. APTA offers multiple resources on concussion, which include a Traumatic Brain Injury webpage and a clinical summary on concussion available for free to members on PTNow. The association also offers a patient-focused Physical Therapist's Guide to Concussion on APTA's MoveForwardPT.com consumer website. Continuing education offerings from APTA include the prerecorded webinar "Managing Concussions With an Interprofessional Team" available through the APTA Learning Center.

    Study: Progressive Strengthening Program Shows Promise Over 'Standard of Care' Rehab for Patients Post-TKA

    In brief:

    • Reseachers studied 2 groups of adults 50 and over who underwent total knee arthroplasty (TKA): 1 group that engaged in "standard of care" rehabilitation, and 1 group that participated in a clinic's progressive strengthening program. The groups were compared with each other and with a group of adults 50 and older who had no joint pathology.
    • Function was assessed through knee flexion measures, knee extension measures, quadriceps strength measures, the timed up-and-go test (TUG), stair-climbing time (SCT), the 6-minute walk test (6MW), and patient self-reports.
    • Overall, neither the strengthening group nor the standard-of-care group achieved function equivalent to the control group, but the strengthening group more often achieved scores at or better than lower-boundary scores of the control group.
    • Authors believe a progressive strengthening approach can bring TKA patients closer to "normal clinical and functional scores" than can standard-of-care approaches focused on range of motion and exercises without weights.

    Adults 50 and older who undergo TKA may never fully achieve the same function as older adults without knee pain, but a progressive strengthening exercise program may bring them closer to those levels than would the variable approaches considered "standard-of-care," according to authors of a recent study.

    The study compared self-reported function and test performance for 3 groups: 88 adults aged 50 and older without knee or joint pain (and no TKA); 40 adults aged 50 and older who underwent TKA and participated in "standard-of-care" rehabilitation; and 165 adults aged 50 and over who underwent TKA and participated in what authors describe as an outpatient clinic program that "included progressive strengthening exercises that targeted muscle groups in the lower extremity." Results were published in Physiotherapy Theory and Practice (abstract only available for free).

    The strengthening program was conducted at a University of Delaware physical therapy clinic beginning 3 weeks after TKA, and consisted of at least 12 outpatient visits 2–3 times a week. The visits themselves focused on strengthening exercises that were progressively adjusted to maintain maximal effort for 3 sets of 10 repetitions for all exercises. The "standard of care" group participated in outpatient rehabilitation elsewhere for an average of 23 sessions that mostly focused on range of motion (ROM), stationary cycling, and "various straight-leg raising exercises without weights," according to the study's authors.

    Both TKA groups were evaluated 12 months after surgery by way of 7 measures: the Knee Outcome Survey-Activities of Daily Living (KOS-ADL) self-assessment, measures of active knee flexion, measures of active knee extension, measures of quadriceps strength, TUG, SCT, and 6MW. Researchers then compared these groups with each other, as well as with results from the 88 older adults who had no history of knee pain (control group). Authors of the study were especially interested in finding out how many participants in each TKA group achieved scores at the lowest bounds of the control group. Here's what they found:

    • The control group consistently reported higher KOS-ADL scores, greater active knee ROM, greater strength, and better performance on TUG, SCT, and 6MW than either TKA group—a result that authors say is consistent with past research showing that function post-TKA hardly ever reaches the levels of age-matched individuals without joint pathology.
    • Compared with the standard-of-care group, a higher percentage of strengthening group participants achieved scores at or above the lower-boundary control group cutoff in knee extension ROM (30% in the strengthening group versus 15% in the standard-of-care group), quadriceps strength (18% vs 5%), and SCT (34% vs 18%). No significant differences were found in KOS-ADL scores, knee flexion ROM, TUG, and 6MW.
    • Compared with the standard-of-care group, participants in the strengthening group were twice as likely to achieve performance above the lower-boundary cutoff for knee extension angle and SCT, and 4 times as likely as the standard-of-care participants to outperform the cutoff for quadriceps strength.
    • Overall, 67% of the strengthening group achieved an above-cutoff score in at least 1 of the 7 variables measured, compared with 47.5% of participants in the standard-of-care group.

    "A greater proportion of patients who participated in the progressive strengthening protocol achieved what could be considered normal clinical and functional scores," authors write. "This suggests that although clinicians cannot expect TKA to restore normative function for all individuals, participating in a progressive strengthening protocol may improve the likelihood of achieving normal age-matched outcomes for a subset of patients."

    Aside from their lack of focus on strengthening, "standard of care" approaches also may be less effective because often they are anything but "standard," according to authors.

    "The lack of consensus between therapists and surgeons on the optimal timing and amount of rehabilitation, and substantial variability in timing, amount, and exercise content of rehabilitation services, may potentially have important negative effects on postsurgical outcomes," they write. "Failure to restore function by 12 months after TKA may be deleterious, as outcome measures plateau around 12 months following TKA, and no meaningful gains have been observed with longer-term follow ups."

    Authors acknowledge several limitations of their study, including a smaller number of participants in the standard-of-care group, and the fact that both TKA groups were heavier than the control group.

    APTA members Federico Pozzi, PT, MA, PhD; Daniel K. White, PT, ScD, MSc; Lynn Snyder-Mackler, PT, ScD FAPTA; and Joseph A. Zeni, PT, PhD, were among the coauthors 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.

    APTA Selects Rapport for Education Research Fellowship

    A physical therapist (PT) educator with more than 2 decades of education experience and more than 40 research publications has been selected as APTA's 2018 Visiting Scholar.

    Mary Jane K. Rapport, PT, DPT, PhD, FAPTA, has been selected as the recipient of the APTA Early-Investigator Research Fellowship. Rapport will spend her sabbatical year focusing on research related to physical therapy education and its impact on professional behaviors, clinical decision making, and/or clinical outcomes. Her responsibilities also will include other activities in support of research-related programs at APTA.

    Rapport is a professor at the University of Colorado School of Medicine, where she also is director of the pediatric physical therapy residency program. With a background that includes extensive publications on topics ranging from pediatric physical therapy to PT education and development of the physical therapy workforce, Rapport brings firsthand knowledge of the research landscape.

    "This is an important time for investigations into clinical education in physical therapy, and Dr Rapport will play a key role in helping APTA contribute to the body of knowledge that will guide the evolution of education programs," said Robyn Watson Ellerbe, PhD, APTA's vice president of research. "We are excited to have an investigator of such a high caliber join the APTA team."