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Background. Adjuvant endocrine therapy in breast cancer has increased survival rates; however, it is not without musculoskeletal side effects. Purpose. The purpose of this review was to systematically and critically appraise the available scientific evidence concerning the effect of adjuvant endocrine treatment on grip strength in women being treated for breast cancer. Data sources and study selection. The National Library of Medicine (MEDLINE-PubMed), Cochrane Central Register of Controlled Trials (CENTRAL), Excerpta Medical Database by Elsevier (EMBASE), Cumulative Index to Nursing and Allied Health Literature (CINAHL), and Physiotherapy Evidence Database (PEDro) were searched from inception to February 2017 for appropriate papers that could answer the focused question. The searches were independently screened by 2 reviewers. The data from 7 papers that met the eligibility criteria were processed for further analysis. Data extraction and synthesis. The collective data and the statistical analysis of all included studies were summarized and presented in a descriptive manner. If not provided, based on data from the individual included studies, a mean percent change in grip strength was calculated. The included studies evaluating aromatase inhibitors had inconclusive outcomes, and studies with a follow-up of 6 or 12 months showed a percent reduction in grip strength varying from 0.1% to 9.7%. None of the included studies showed a significant decrease in grip strength in tamoxifen users, with a percent reduction in grip strength varying from 1.4% to 2.2%. Limitations. The 7 studies included cohort studies lacking a control group. Conclusions. There is inconclusive evidence for a small decrease in grip strength in women treated for breast cancer who are also receiving aromatase inhibitors. In those that use tamoxifen, grip strength did not change significantly. [ABSTRACT FROM AUTHOR]

Background. Little is known about the attitudes of children living in Central America toward people with disabilities or the effectiveness of a disability awareness program in influencing their knowledge and attitudes. Objective. The study objectives were to evaluate the effectiveness of a disability awareness program in influencing Belizean children's knowledge of and attitudes toward people with disabilities in the immediate short term and to describe the development of a university-community partnership that resulted in the development of a culturally appropriate disability awareness program. Design. This was a single-group pretest-posttest quasi-experimental study with cluster sampling. Methods. Study participants included 247 children (11-14 years old) from 8 primary schools in Toledo District, Belize. A paper-based disability awareness survey measuring knowledge of and attitudes toward people with disabilities was administered before and after an intervention. The intervention was a 90-minute multimodal disability awareness program. Hierarchical linear modeling was used to model the influence of the intervention on knowledge of and attitudes toward people with disabilities. Results. Significant improvements in knowledge of and attitudes toward people with disabilities were evident immediately after the intervention. Limitations. Children were not randomized to a control group. Although this feature was a limitation in terms of study design, the researchers believed that respecting the wishes of the school principals by providing the disability awareness intervention to all students was important. Conclusions. This study provided an example of how a university-community partnership can positively influence community outcomes. Further research is needed to assess long-term changes in Belizean children's knowledge of, attitudes toward, and behaviors toward people with disabilities, as well as the social inclusion and participation of children with disabilities. [ABSTRACT FROM AUTHOR]

Background. Lymphedema is a common complication of cancer treatment, resulting in swelling and subjective symptoms. Reliable and valid measurement of this side effect of medical treatment is important. Purpose. The purpose of this study was to provide best evidence regarding which measurement instruments are most appropriate in measuring lymphedema in its different stages. Data Sources. The PubMed and Web of Science databases were used, and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed. Study Selection. Clinical studies on measurement instruments assessing lymphedema were reviewed using the Quality Assessment of Diagnostic Accuracy Studies-2 (QUADAS-2) scoring instrument for quality assessment. Data Extraction. Data on reliability', concurrent validity, convergent validity, sensitivity, specificity, applicability', and costs were extracted. Data Synthesis. Pooled data showed good intrarater intraclass correlation coefficients (ICCs) (.89) for bioimpedance spectroscopy (BIS) in the lower extremities and high intrarater and interrater ICCs for water volumetry, tape measurement, and perometry (.98-.99) in the upper extremities. In the upper extremities, the standard error of measurement was 3.6% (a=0.7%) for water volumetry, 5.6% (cr=2.1%) for perometry', and 6.6% (cr=2.6%) for tape measurement. Sensitivity of tape measurement in the upper extremities, using different cutoff points, varied from 0.73 to 0.90, and specificity values varied from 0.72 to 0.78. Limitations. No uniform definition of lymphedema was available, and a gold standard as a reference test was lacking. Items concerning risk of bias were study design, patient selection, description of lymphedema, blinding of test outcomes, and number of included participants. Conclusions. Measurement instruments with evidence for good reliability and validity were BIS, water volumetry, tape measurement, and perometry, where BIS can detect alterations in extracellular fluid in stage 1 lymphedema and the other measurement instruments can detect alterations in volume starting from stage 2. In research, water volumetry is indicated as a reference test for measuring lymphedema in the upper extremities. [ABSTRACT FROM AUTHOR]

Background. In the McKenzie system of mechanical diagnosis and therapy (MDT), a reliable system for the management of spinal problems, classifications are used to guide management strategies. For the classification of extremity disorders, interexaminer agreement has not been investigated with patients. Objective. The study objective was to investigate interexaminer agreement for provisional MDT extremity classification with patients. Design. This was a reliability study with examiner masking. Methods. A therapist with an MDT credential observed the assessments made by 2 therapists with MDT diplomas, who successively performed MDT assessments for 33 patients with extremity pain on the same day. Immediately after each evaluation, all 3 therapists assigned the most appropriate MDT classification from 15 categories; they were unaware of each other's selection. The observed agreement and the Cohen kappa were calculated for the MDT classifications. Results. The observed agreement for the 15 MDT categories of classification between the therapist with an MDT credential and the first therapist with an MDT diploma was 78.8%. The Cohen kappa was .72 (95% confidence interval=.54, .89), indicating good agreement. However, the observed agreement between the 2 therapists with MDT diplomas when the patient was assessed separately was 42.4%. The Cohen kappa was .21 (95% confidence interval=.01, .41), indicating poor agreement. Limitations. Study limitations included convenience sampling of patients, the small number of examiners, and the limited extremity experience of the therapists with MDT diplomas. Conclusions. Interexaminer agreement for provisional MDT extremity classification was good when the examiners were seeing the same patient concurrently but poor when the patient was seen successively. Further studies are needed to establish which factors, including study method, are responsible for the divergent results of the MDT assessments of extremity disorders. [ABSTRACT FROM AUTHOR]

Background. Adequate and user-friendly instruments for assessing physical function and disability in older adults are vital for estimating and predicting health care needs in clinical practice. The Late-Life Function and Disability Instrument Computer Adaptive Test (LLFDI-CAT) is a promising instrument for assessing physical function and disability in gerontology research and clinical practice. Objective. The aims of this study were: (1) to translate the LLFDI-CAT to the Dutch language and (2) to investigate its validity and reliability in a sample of older adults who spoke Dutch and dwelled in the community. Design. For the assessment of validity of the LLFDI-CAT, a cross-sectional design was used. To assess reliability, measurement of the LLFDI-CAT was repeated in the same sample. Methods. The item bank of the LLFDI-CAT was translated with a forward-backward procedure. A sample of 54 older adults completed the LLFDI-CAT, World Health Organization Disability Assessment Schedule 2.0, RAND 36-Item Short-Form Health Survey physical functioning scale (10 items), and 10-Meter Walk Test. The LLFDI-CAT was repeated in 2 to 8 days (mean=4.5 days). Pearson's r and the intraclass correlation coefficient (ICC) (2,1) were calculated to assess validity, group-level reliability, and participant-level reliability. Results. A correlation of .74 for the LLFDI-CAT function scale and the RAND 36-Item Short-Form Health Survey physical functioning scale (10 items) was found. The correlations of the LLFDI-CAT disability scale with the World Health Organization Disability Assessment Schedule 2.0 and the 10-Meter Walk Test were -.57 and -.53, respectively. The ICC (2,1) of the LLFDI-CAT function scale was .84, with a group-level reliability score of .85. The ICC (2,1) of the LLFDI-CAT disability scale was .76, with a group-level reliability score of .81. Limitations. The high percentage of women in the study and the exclusion of older adults with recent joint replacement or hospitalization limit the generalizability of the results. Conclusions. The Dutch LLFDI-CAT showed strong validity and high reliability when used to assess physical function and disability in older adults dwelling in the community. [ABSTRACT FROM AUTHOR]

Background. Accurate measurement of physical activity and sedentary behavior is an important consideration for health care professionals. The activPAL activity monitor has not been validated against a criterion measure for people with rheumatoid arthritis (RA). Objective. The objective of this study was to determine the criterion validity of the activPAL activity monitor for measuring step counts, transition counts, and time spent in sedentary, standing, and walking behaviors in people with RA. Design. A laboratory-based criterion validation study was conducted. Methods. Participants with a confirmed medical diagnosis of RA were recruited from 2 outpatient rheumatology clinics. The testing procedure consisted of standardized testing components and tasks related to activities of daily living. Participants wore an activPAL activity monitor and were video recorded throughout the testing procedure. Direct observation was used as the criterion measure. Data analysis consisted of validation analysis of the activ PAL activity monitor data and the criterion measure data. Results. Twenty-four people participated in the study. Data from 20 participants were included in the final analysis. The activPAL significantly underestimated step counts by 26% and transition counts by 36%. There was no significant difference between the activPAL activity monitor and the criterion measure for time spent in sedentary, standing or light activity, and walking behaviors. Limitations. Validation of activities of daily living in a laboratory environment is a limitation of this study. Conclusions. The activPAL activity monitor underestimated step and transition counts and, therefore, is not valid for measuring these outcomes in people with RA. Relative to direct observation, the activPAL activity monitor is valid for measuring time spent in sedentary, standing, and walking behaviors in people with RA. [ABSTRACT FROM AUTHOR]

Background. An effective compensatory stepping response is the first line of defense for preventing a fall during sudden large external perturbations. The biomechanical factors that contribute to heightened fall risk in survivors of stroke, however, are not clearly understood. It is known that impending sensorimotor and balance deficits poststroke predispose these individuals to a risk of fall during sudden external perturbations. Objective. The purpose of this study was to examine the mechanism of fall risk in survivors of chronic stroke when exposed to sudden, slip-like forward perturbations in stance. Design. This was a cross-sectional study. Methods. Fourteen individuals with stroke, 14 age-matched controls (AC group), and 14 young controls (YC group) were exposed to large-magnitude forward stance perturbations. Postural stability was computed as center of mass (COM) position (...COM/BOS) and velocity (XCOM/BOS) relative to the base of support (BOS) at first step lift-off (LO) and touch-down (TD) and at second step TD. Limb support was quantified as vertical hip descent (Zhip) from baseline after perturbation onset. Results. All participants showed a backward balance loss, with 71% of the stroke group experiencing a fall compared with no falls in the control groups (AC and YC groups). At first step LO, no between-group differences in XCOM/BOS and ... COM/BOS were noted. At first step TD, however, the stroke group had a significantly posterior XCOM/BOS and backward ... COM/BOS compared with the control groups. At second step TD, individuals with stroke were still more unstable (more posterior XCOM/BOS and backward ... COM/BOS) compared with the AC group. Individuals with stroke also showed greater peak Zhip compared with the control groups. Furthermore, the stroke group took a larger number of steps with shorter step length and delayed step initiation compared with the control groups. Limitations. Although the study highlights the reactive balance deficits increasing fall risk in survivors of stroke compared with healthy adults, the study was restricted to individuals with chronic stroke only. It is likely that comparing compensatory stepping responses across different stages of recovery would enable clinicians to identify reactive balance deficits related to a specific stage of recovery. Conclusions. These findings suggest the inability of the survivors of stroke to regain postural stability with one or more compensatory steps, unlike their healthy counterparts. Such a response may expose them to a greater fall risk resulting from inefficient compensatory stepping and reduced vertical limb support. Therapeutic interventions for fall prevention, therefore, should focus on improving both reactive stepping and limb support. [ABSTRACT FROM AUTHOR]

Background. The attainment of walking is a focus of physical therapy intervention in children with cerebral palsy (CP) and may affect their independence in mobility and participation in daily activities. However, knowledge of determinants of independent walking to guide physical therapists' decision making is lacking. Objective. The aim of this study was to identify child factors (postural control, reciprocal lower limb movement, functional strength, and motivation) and family factors (family support to child and support to family) that predict independent walking 1 year later in young children with CP at Gross Motor Function Classification System (GMFCS) levels II and III. Design. A secondary data analysis of an observational cohort study was performed. Methods. Participants were 80 children with CP, 2 through 6 years of age. Child factors were measured 1 year prior to the walking outcome. Parent-reported items representing family factors were collected 7 months after study onset. The predictive model was analyzed using backward stepwise logistic regression. Results. A measure of functional strength and dynamic postural control in a sit-to-stand activity was the only significant predictor of taking ≥3 steps independently. The positive likelihood ratio for predicting a "walker " was 3.26, and the negative likelihood ratio was 0.74. The model correctly identified a walker or "nonwalker " 75% of the time. Limitations. Prediction of walking ability was limited by the lack of specificity of child and family characteristics not prospectively selected and measurement of postural control, reciprocal lower limb movement, and functional strength 1 year prior to the walking outcome. Conclusions. The ability to transfer from sitting to standing and from standing to sitting predicted independent walking in young children with CP. Prospective longitudinal studies are recommended to determine indicators of readiness for independent walking. [ABSTRACT FROM AUTHOR]

Background. Physical therapy for youth with cerebral palsy (CP) who are ambulatory includes interventions to increase functional mobility and participation in physical activity (PA). Thus, reliable and valid measures are needed to document PA in youth with CP. Objective. the purpose of this study was to evaluate the inter-instrument reliability and concurrent validity of 3 accelerometer-based motion sensors with indirect calorimetry as the criterion for measuring PA intensity in youth with CP. Methods. Fifty-seven youth with CP (mean age=12.5 years, SD=3.3; 51% female; 49.1% with spastic hemiplegia) participated. Inclusion criteria were: aged 6 to 20 years, ambulatory, Gross Motor Function Classification System (GMFCS) levels I through III, able to follow directions, and able to complete the full PA protocol. Protocol activities included standardized activity trials with increasing PA intensity (resting, writing, household chores, active video games, and walking at 3 self-selected speeds), as measured by weight-relative oxygen uptake (in mL/kg/min). During each trial, participants wore bilateral accelerometers on the upper arms, waist/hip, and ankle and a portable indirect calorimeter. Intraclass coefficient correlations (ICCs) were calculated to evaluate inter-instrument reliability (left-to-right accelerometer placement). Spearman correlations were used to examine concurrent validity between accelerometer output (activity and step counts) and indirect calorimetry. Friedman analyses of variance with post hoc pair-wise analyses were conducted to examine the validity of accelerometers to discriminate PA intensity across activity trials. Results. All accelerometers exhibited excellent inter-instrument reliability (ICC = .94-.99) and good concurrent validity (rho=.70-.85). All accelerometers discriminated PA intensity across most activity trials. Limitations. This PA protocol consisted of controlled activity trials. Conclusions. Accelerometers provide valid and reliable measures of PA intensity among youth with CP. [ABSTRACT FROM AUTHOR]

Background. Manual therapy (MT) and exercise have been extensively used to treat people with musculoskeletal conditions such as temporomandibular disorders (TMD). The evidence regarding their effectiveness provided by early systematic reviews is outdated. Purpose. The aim of this study was to summarize evidence from and evaluate the methodological quality of randomized controlled trials that examined the effectiveness of MT and therapeutic exercise interventions compared with other active interventions or standard care for treatment of TMD. Data Sources. Electronic data searches of 6 databases were performed, in addition to a manual search. Study Selection. Randomized controlled trials involving adults with TMD that compared any type of MT intervention (eg, mobilization, manipulation) or exercise therapy with a placebo intervention, controlled comparison intervention, or standard care were included. The main outcomes of this systematic review were pain, range of motion, and oral function. Forty-eight studies met the inclusion criteria and were analyzed. Data Extraction. Data were extracted in duplicate on specific study characteristics. Data Synthesis. The overall evidence for this systematic review was considered low. The trials included in this review had unclear or high risk of bias. Thus, the evidence was generally downgraded based on assessments of risk of bias. Most of the effect sizes were low to moderate, with no clear indication of superiority of exercises versus other conservative treatments for TMD. However, MT alone or in combination with exercises at the jaw or cervical level showed promising effects. Limitations. Quality of the evidence and heterogeneity of the studies were limitations of the study. Conclusions. No high-quality evidence was found, indicating that there is great uncertainty about the effectiveness of exercise and MT for treatment of TMD. [ABSTRACT FROM AUTHOR]

Background. The Centers for Medicare & Medicaid Services has mandated rehabilitation professionals to document patients' impairment levels. There is no evidence of responsiveness to change of functional limitation severity modifier codes. Objective. The purpose of this study was to assess the validity of G-code functional limitation severity modifier codes in determining change in function. Design. This was a retrospective observational study. Methods. Patients completed the Activity Measure for Post-Acute Care (AM-PAC) and were assigned G-codes, with severity modifiers based on AM-PAC scores at initial and follow-up visits. Patients were classified as having AM-PAC scores in the upper or lower range for each severity modifier, and sensitivity, specificity, and positive and negative predictive values for change in severity modifier level and odds of changing by one severity modifier level using a change in AM-PAC score of at least 1 minimal detectable change at the 95% confidence interval (MDC95) as the standard were determined. Results. Sensitivity and specificity of change in severity modifier in determining change in function were dependent on patients' initial AM-PAC scores. Improvement in severity modifier level was 2.2 to 4.5 times more likely with scores at the higher end of the range within a severity modifier level than with scores in the lower end of the range. Decline in severity modifier level was 2.7 to 4.8 times more likely with scores at the lower end of the range within a severity modifier than with scores in the higher end of the range. Limitations. Data were from one health care system, and most patients had orthopedic conditions. The MDC95 for AM-PAC tool may not be the best standard for defining functional change. Conclusions. The G-code functional limitation severity modifier system may not be valid for determining change in function and is not recommended for determining if patients have changed over the course of outpatient therapy. [ABSTRACT FROM AUTHOR]

Background. Although preliminary studies have established a good psychometric foundation for the Pediatric Evaluation of Disability Inventory Computer Adaptive Test (PEDI-CAT) for a broad population of youth with disabilities, additional validation is warranted for young children. Objective. The study objective was to (1) examine concurrent validity, (2) evaluate the ability to identify motor delay, and (3) assess responsiveness of the PEDI-CAT Mobility domain and the Alberta Infant Motor Scale (AIMS). Methods. Fifty-three infants and young children (<18 months of age) admitted to a pediatric postacute care hospital and referred for a physical therapist examination were included. The PEDI-CAT Mobility domain and the AIMS were completed during the initial physical therapist examination, at 3-month intervals, and at discharge. A Spearman rank correlation coefficient was used to examine concurrent validity. A chi-square analysis of age percentile scores was used to examine the identification of motor delay. Mean score differences from initial assessment to final assessment were analyzed to evaluate responsiveness. Results. A statistically significant, fair association (rs=.313) was found for the 2 assessments. There was no significant difference in motor delay identification between tests; however, the AIMS had a higher percentage of infants with scores at or below the fifth percentile. Participants showed significant changes from initial testing to final testing on the PEDI-CAT Mobility domain and the AIMS. Limitations. This study included only young patients (<18 months of age) in a pediatric postacute hospital; therefore, the generalizability is limited to this population. Conclusions. The PEDI-CAT Mobility domain is a valid measure for young children admitted to postacute care and is responsive to changes in motor skills. However, further item and standardization development is needed before the PEDI-CAT is used confidently to identify motor delay in children <18 months of age. [ABSTRACT FROM AUTHOR]

Background. Children with developmental coordination disorder (DCD) face evident motor difficulties in daily functioning. Little is known, however, about their difficulties in specific activities of daily living (ADL). Objective. The purposes of this study were: (1) to investigate differences between children with DCD and their peers with typical development for ADL performance, learning, and participation, and (2) to explore the predictive values of these aspects. Design. This was a cross-sectional study. Methods. In both a clinical sample of children diagnosed with DCD (n=25 [21 male, 4 female], age range=5-8 years) and a group of peers with typical development (25 matched controls), the children's parents completed the DCDDaily-Q. Differences in scores between the groups were investigated using t tests for performance and participation and Pearson chi-square analysis for learning. Multiple regression analyses were performed to explore the predictive values of performance, learning, and participation. Results. Compared with their peers, children with DCD showed poor performance of ADL and less frequent participation in some ADL. Children with DCD demonstrated heterogeneous patterns of performance (poor in 10%- 80% of the items) and learning (delayed in 0%-100% of the items). In the DCD group, delays in learning of ADL were a predictor for poor performance of ADL, and poor performance of ADL was a predictor for less frequent participation in ADL compared with the control group. Limitations. A limited number of children with DCD were addressed in this study. Conclusions. This study highlights the impact of DCD on children's daily lives and the need for tailored intervention. [ABSTRACT FROM AUTHOR]

Background. Onset of disability, risk for future falls, frailty, functional decline, and mortality are strongly associated with a walking speed of less than 1.0 m/s. Objective. The study objective was to determine whether there were differences in slow walking speed (< 1.0 m/s) between community-dwelling African American and white American adult women with osteoarthritis symptoms. An additional aim was to examine whether racial differences in walking speed can be attributed to age, obesity, socioeconomic factors, disease severity, or comorbidities. Design. A cross-sectional design was used. Methods. Community-dwelling adults were recruited from Baltimore, Maryland; Columbus, Ohio; Pittsburgh, Pennsylvania; and Pawtucket, Rhode Island. Participants were 2,648 women (23% African American) who were 45 to 79 years of age and had a self-selected baseline walking speed of 20 m/s in the Osteoarthritis Initiative Study. Mixed-effects logistic regression models were used to examine racial differences in walking speed (<1.0 m/s versus ≥1.0 m/s), with adjustments for demographic factors, socioeconomic factors, disease severity, and comorbidities. Results. Walking speed was significantly slower for African American women than for white American women (mean walking speed=1.19 and 1.33 m/s, respectively). The prevalence of a walking speed of less than 1.0 m/s in this cohort of middle-aged women was 9%; about 50% of the women with a walking speed of less than 1.0 m/s were younger than 65 years. Women with a walking speed of less than 1.0 m/s had lower values for socioeconomic factors, higher values for disease severity, and higher prevalences of obesity and comorbidities than those with a walking speed of ≥ 1.0 m/s. After controlling for these covariates, it was found that African American women were 3 times (odds ratio=2.9; 95% confidence interval=2.0, 4.1) more likely to have a walking speed of less than 1.0 m/s than white American women. Limitations. The study design made it impossible to know whether a walking speed of less than 1.0 m/s in women who were 45 years of age or older was a predictor of future poor health outcomes. Conclusions. In this study, race was independently associated with a walking speed of less than 1.0 m/s in community-dwelling women who had or were at risk for osteoarthritis, with African American women having 3 times the risk for slow walking as white American women. This finding suggests that middle-aged African American women have an increased risk for poor health outcomes. Further longitudinal evaluations are needed to confirm the long-term health outcomes in a middle-aged population and to establish walking speed as a useful tool for identifying middle-aged women at high risk for poor health outcomes. [ABSTRACT FROM AUTHOR]

Background. Intermanual transfer implies that motor skills learned on one side of the body transfer to the untrained side. This effect was previously noted in adults practicing with a prosthesis simulator. Objective. The study objective was to determine whether intermanual transfer is present in children practicing prosthetic handling. Design. A mechanistic, pseudorandomized, pretest-posttest design was used. Setting. The study was conducted in a primary school in the Netherlands. Participants. The participants were children who were able-bodied (N=48; 25 boys, 23 girls; mean age=5.1 years) and randomly assigned to an experimental group or a control group. Intervention. The experimental group performed 5 training sessions using a prosthesis simulator on the training arm. Before (pretest), immediately after (post-test), and 6 days after (retention test) the training program, their ability to handle the prosthesis with the contralateral (test) arm was measured. The control group only performed the tests. Half of the children performed the tests with the dominant hand, and the other half performed the tests with the nondominant hand. Measurements. During the tests, movement time and control of force were measured. Results. An interaction effect of group by test was found for movement time. Post hoc tests revealed significant improvement in the experimental group between the posttest and the retention test. No force control effect was found. Limitations. Only children who were able-bodied were included. Measurements should have been masked and obtained without tester interference. The fact that 4 children whose results were slower than the mean result discontinued training may have biased the findings. Conclusions. The intermanual transfer effect was present in 5-year-old children undergoing training in prosthetic handling. After training of one hand, children's movement times for the other, untrained hand improved. This finding may be helpful for training children who are novice users of a prosthesis. [ABSTRACT FROM AUTHOR]

Background. Older adults and individuals with neurological conditions are at an increased risk for falls. Although physical exercise can prevent falls, certain types of exercise may be more effective. Perturbation-based balance training is a novel intervention involving repeated postural perturbations aiming to improve control of rapid balance reactions. Purpose. The purpose of this study was to estimate the effect of perturbation-based balance training on falls in daily life. Data Sources. MEDLINE (1946-July 2014), EMBASE (1974-July 2014), PEDro (all dates), CENTRAL (1991-July 2014), and Google Scholar (all dates) were the data sources used in this study. Study Selection. Randomized controlled trials written in English were included if they focused on perturbation-based balance training among older adults or individuals with neurological conditions and collected falls data posttraining. Data Extraction. Two investigators extracted data independently. Study authors were contacted to obtain missing information. A PEDro score was obtained for each study. Primary outcomes were proportion of participants who reported one or more falls (ie, number of "fallers") and the total number of falls. The risk ratio (proportion of fallers) and rate ratio (number of falls) were entered into the analysis. Data Synthesis. Eight studies involving 404 participants were included. Participants who completed perturbation-based balance training were less likely to report a fall (overall risk ratio=0.71; 95% confidence interval=0.52, 0.96; P=.02) and reported fewer falls than those in the control groups (overall rate ratio=0.54; 95% confidence interval=0.34, 0.85; P=.007). Limitations. Study authors do not always identify that they have included perturbation training in their intervention; therefore, it is possible that some appropriate studies were not included. Study designs were heterogeneous, preventing subanalyses. Conclusions. Perturbation-based balance training appears to reduce fall risk among older adults and individuals with Parkinson disease. [ABSTRACT FROM AUTHOR]

Background. Children report low back pain (LBP) as young as 8 years. Preventing LBP in children may prevent or delay adult incidence. Objectives. The purpose of this study was to determine whether education and daily exercise affect LBP episodes in children compared with education alone. Design. This was a prospective, multicenter cluster randomized controlled trial. Setting. The study was conducted at 7 New Zealand primary schools. Participants. Children (n=708), aged 8 to 11 years, from 7 schools stratified by sample size (36, 114, 151, 168, 113, 45, 83) were randomized and allocated to 2 masked groups: intervention (4 schools, n=469) or control (3 schools, n=239). Interventions. Participants in the intervention group were taught 4 spinal movements for daily practice. Both groups participated in education that emphasized “back awareness.” Measurements. Low back pain history at baseline was assessed. Children reported episodes of LBP during the previous week on trial days 7, 21, 49, 105, 161, and 270. Analysis was at the individual participant level, with adjustment for school clusters. There were no significant differences between groups in the odds of reporting no LBP in the previous week during the study period (odds ratio [OR] =0.72; 95% confidence interval [95% CI]=0.46, 1.14; P=.l6). The intervention group reported significantly fewer episodes of LBP (OR=0.54; 95% CI=0.39, 0.74; /p<.001) and significantly fewer lifetime first episodes of LBP (n=86 [34%]) compared with the control group (n=58 [47%]) (OR=0.60; 95% CI=0.39, 0.91; P=.02). The odds of an episode of LBP were greater in participants with a history of LBP (OR=4.21; 95% 0=3.07, 5.78; P<.001). Low back pain episodes decreased across the trial period for both groups (OR=0.89; 95% CI=0.84, 0.95; 7J<.001). Adherence to exercise was poor. Limitations. Replication in other settings is needed. Conclusions. Regular exercise and education appear to reduce LBP episodes in children aged 8 to 11 years compared with education alone. [ABSTRACT FROM AUTHOR]

Objectives. This study aimed to determine the effect of perceived exercise benefits and barriers on exercise levels among women who have been treated for breast cancer and have not participated in a formal exercise intervention. Design. This was an anonymous, national, online cross-sectional survey study. Methods. Four hundred thirty-two women treated for breast cancer completed an online survey covering their treatment and demographic background, current exercise levels, and perceived exercise benefits and barriers. Each perceived benefit and barrier was considered in a binary logistic regression against reported exercise levels to ascertain significant relationships and associative values (odds ratio [OR]). Results. Agreement with 16 out of 19 exercise barriers was significantly related to being more likely to report insufficient exercise levels, whereas agreement with 6 out of 15 exercise benefits was significantly related to being less likely to report insufficient levels of exercise. Feeling too weak, lacking self-discipline, and not making exercise a priority were the barriers with the largest association to insufficient exercise levels (OR=10.97, 95% confidence interval [CI] =3.90, 30.86; OR=8.12, 95% CI=4.73, 13.93; and OR=7.43, 95% CI=3.72, 14.83, respectively). Conversely, exercise enjoyment, improved feelings of well-being, and decreased feelings of stress and tension were the top 3 benefits associated with being less likely to have insufficient exercise levels (OR=0.21, 95% CI=0.11, 0.39; OR=0.21, 95% CI=0.07, 0.63; and OR=0.31, 95% CI=0.15, 0.63, respectively). Limitations. Self-reported data measures were used to collect exercise data. Conclusions. Targeting exercise barriers specific to women treated for breast cancer may improve exercise participation levels in this cohort. Awareness of the impact of exercise barriers identified in the present study will enable physical therapists to better plan exercise interventions that support all women treated for breast cancer. [ABSTRACT FROM AUTHOR]

Background. People with spinal cord injury (SCI) may benefit from resistive inspiratory muscle training (RIMT). Current evidence is weak, and little is known about the effect on functional outcomes and long-term effects. Objective. The purpose of this study was to assess immediate and long-term effects of RIMT in people with SCI. Design. This was a single-blinded randomized controlled trial. Setting. The study was conducted at 4 specialized SCI units in the Netherlands. Patients. The study participants were 40 people with SCI (15 with motor complete tetraplegia, 16 with incomplete tetraplegia, 8 with motor complete paraplegia, and 1 with incomplete paraplegia) who had impaired pulmonary function and were admitted for initial inpatient rehabilitation. Intervention. Study participants were randomized to an RIMT group or a control group. All participants received usual rehabilitation care. In addition, participants in the intervention group performed RIMT with a threshold trainer. Measurements. Measurements were performed at baseline, after 8 weeks of intervention, 8 weeks later, and 1 year after discharge from inpatient rehabilitation. Primary outcome measures were: respiratory muscle function, lung volumes and flows, and perceived respiratory function. Secondary outcome measures concerned patient functioning, which included health-related quality of life, limitations in daily life due to respiratory problems, and respiratory complications. Results. During the intervention period, maximum inspiratory pressure (MIP) improved more in the RIMT group than in the control group (11.7 cm H2O, 95% confidence interval=4.3 to 19.0). At follow-up, this effect was no longer significant. No effect on other primary or secondary outcome measures was found except for an immediate effect on mental health. Limitations. The sample size was insufficient to study effects on respiratory complications. [ABSTRACT FROM AUTHOR]

BACKGROUND: Current treatments for low back pain have small effects. A research priority is to identify patient characteristics associated with larger effects for specific interventions. OBJECTIVE: The aim of this study was to identify simple clinical characteristics of patients with chronic low back pain who would benefit more from either motor control exercises or graded activity. DESIGN: This study was a secondary analysis of the results of a randomized controlled trial. METHODS: One hundred seventy-two patients with chronic low back pain were enrolled in the trial, which was conducted in Australian physical therapy clinics. The treatment consisted of 12 initial exercise sessions over an 8-week period and booster sessions at 4 and 10 months following randomization. The putative effect modifiers (psychosocial features, physical activity level, walking tolerance, and self-reported signs of clinical instability) were measured at baseline. Measures of pain and function (both measured on a 0-10 scale) were taken at baseline and at 2, 6, and 12 months by a blinded assessor. RESULTS: Self-reported clinical instability was a statistically significant and clinically important modifier of treatment response for 12-month function (interaction: 2.72; 95% confidence interval=1.39 to 4.06). Participants with high scores on the clinical instability questionnaire (≥9) did 0.76 points better with motor control exercises, whereas those who had low scores (<9) did 1.93 points better with graded activity. Most other effect modifiers investigated did not appear to be useful in identifying preferential response to exercise type. LIMITATIONS: The psychometric properties of the instability questionnaire have not been fully tested. CONCLUSIONS: A simple 15-item questionnaire of features considered indicative of clinical instability can identify patients who respond best to either motor control exercises or graded activity. [ABSTRACT FROM AUTHOR]

Background. Current literature views safe gait as a complex task, relying on motor and cognitive resources. The use of virtual reality (VR) in gait training offers a multifactorial approach, showing positive effects on mobility, balance, and fall risk in elderly people and individuals with neurological disorders. This form of training has been described as a viable research tool; however, it has not been applied routinely in clinical practice. Recently, VR was used to develop an adjunct training method for use by physical therapists in an ambulatory clinical setting. Objective. The aim of this article is to describe the initial clinical experience of applying a 5-week VR clinical service to improve gait and mobility in people with a history of falls, poor mobility, or postural instability. Design. A retrospective data analysis was conducted. Methods. The clinical records of the first 60 patients who completed the VR gait training program were examined. Training was provided 3 times per week for 5 weeks, with each session lasting approximately 1 hour and consisting of walking on a treadmill while negotiating virtual obstacles. Main outcome measures were compared across time and included the Timed “Up & Go” Test (TUG), the Two-Minute Walk Test (2MWT), and the Four Square Step Test (FSST). Results. After 5 weeks of training, time to complete the TUG decreased by 10.3%, the distance walked during the 2MWT increased by 9.5%, and performance on the FSST improved by 13%. Limitations. Limitations of the study include the use of a retrospective analysis with no control group and the lack of objective cognitive assessment. Conclusions. Treadmill training with VR appears to be an effective and practical tool that can be applied in an outpatient physical therapy clinic. This training apparently leads to improvements in gait, mobility, and postural control. It, perhaps, also may augment cognitive and functional aspects. [ABSTRACT FROM AUTHOR]

Background. Adjustment to civilian life in Canadian veterans after release from military service has not been well studied. Objectives. The objectives of this study were: (1) to explore dimensions of postmilitary adjustment to civilian life and (2) to identify demographic and military service characteristics associated with difficult adjustment. Design. Data were analyzed from a national sample of 3,154 veterans released from the regular Canadian Forces during 1998 to 2007 in a cross-sectional survey conducted in 2010 called the Survey on Transition to Civilian Life. Methods. The prevalence of difficult adjustment to civilian life for selected characteristics was analyzed descriptively, and confidence intervals were calculated at the 95% level. Multivariable logistic regression analysis was used to identify characteristics available at the time of release that were associated with difficult adjustment. Results. The prevalence of difficult adjustment to civilian life was 25%. Statistically significant differences were found across indicators of health, disability, and determinants of health. In multivariable regression, lower rank and medical, involuntary, mid-career, and Army release were associated with difficult adjustment, whereas sex, marital status, and number of deployments were not. Limitations. Findings cannot be generalized to all veterans because many characteristics were self-reported, important characteristics may have been omitted, and causality and association among health, disability, and determinants of health characteristics could not be determined. Conclusions. Postmilitary adjustment to civilian life appears to be multidimensional, suggesting the need for multidisciplinary collaboration between physical therapists and other service providers to mitigate difficult transition. Potential risk and protective factors were identified that can inform interventions, outreach strategies, and screening activities, as well as further research. [ABSTRACT FROM AUTHOR]

Background. Plantar heel pain can be managed with dry needling of myofascial trigger points; however, there is only poor-quality evidence supporting its use. Objective. The purpose of this study was to evaluate the effectiveness of dry needling for plantar heel pain. Design. The study was a parallel-group, participant-blinded, randomized controlled trial. Setting. The study was conducted in a university health sciences clinic. Patients. Study participants were 84 patients with plantar heel pain of at least 1 month’s duration. Intervention. Participants were randomly assigned to receive real or sham trigger point dry needling. The intervention consisted of 1 treatment per week for 6 weeks. Participants were followed for 12 weeks. Measurements . Primary outcome measures included first-step pain, as measured with a visual analog scale (VAS), and foot pain, as measured with the pain subscale of the Foot Health Status Questionnaire (FHSQ). The primary end point for predicting the effectiveness of dry needling for plantar heel pain was 6 weeks. Results. At the primary end point, significant effects favored real dry needling over sham dry needling for pain (adjusted mean difference: VAS first-step pain= -14.4 mm, 95% confidence interval [95% CI] = -23.5 to -5.2; FHSQ foot pain= 10.0 points, 95% CI=1.0 to 19-1), although the between-group difference was lower than the minimal important difference. The number needed to treat at 6 weeks was 4 (95% CI=2 to 12). The frequency of minor transitory adverse events was significantly greater in the real dry needling group (70 real dry needling appointments [32%] compared with only 1 sham dry needling appointment [<1%]). Limitations. It was not possible to blind the therapist. Conclusion. Dry needling provided statistically significant reductions in plantar heel pain, but the magnitude of this effect should be considered against the frequency of minor transitory adverse events. [ABSTRACT FROM AUTHOR]

Background. Numerous clinical practice guidelines (CPGs) have been developed to assist clinicians in care options for low back pain (LBP). Knowledge of CPGs has been marginal across health-related professions. Objective. The aims of this study were: (1) to measure US-based physical therapists’ knowledge of care recommendations associated with multidisciplinary LBP CPGs and (2) to determine which characteristics were associated with more correct responses. Design. A cross-sectional survey was conducted. Methods. Consenting participants attending manual therapy education seminars read a clinical vignette describing a patient with LBP and were asked clinical decision-making questions regarding care, education, and potential referral. Descriptive statistics illustrating response accuracy and binary logistic regression determined adjusted associations between predictor variables and appropriate decisions. Results. A total of 1,144 of 3,932 surveys were eligible for analysis. Correct responses were 55.9% for imaging, 54.7% for appropriate medication, 62.0% for advice to stay active, 92.7% for appropriate referral with failed care, and 16.6% for correctly answering all 4 questions. After adjustment, practicing in an outpatient facility was significantly associated with a correct decision on imaging. Female participants were more likely than male participants to correctly select proper medications, refer the patient to another health care professional when appropriate, and answer all 4 questions correctly. Participants reporting caseloads of greater than 50% of patients with LBP were more likely to select proper medications, give advice to stay active, and answer all 4 questions correctly. Participants attending more continuing education were more likely to give advice to stay active and older, and more experienced participants were more likely to appropriately refer after failed care. Limitations. There was potential selection bias, which limits generalizability. Conclusions. The survey identified varied understanding of CPGs when making decisions that were similar in recommendation to the CPGs. No single predictor for correct responses for LBP CPGs was found. [ABSTRACT FROM AUTHOR]

Background. Quantitative sensory testing, including pressure pain threshold (PPT), is seeing increased use in clinical practice. In order to facilitate clinical utility, knowledge of the properties of the tool and interpretation of results are required. Objectives. This observational study used a clinical sample of people with mechanical neck pain to determine: (1) the influence of number of testing repetitions on measurement properties, (2) reliability and minimum clinically important difference, and (3) associations between PPT and key psychological constructs. Design. This study was observational with both cross-sectional and prospective elements. Methods. Experienced clinicians measured PPT in patients with mechanical neck pain following a standardized protocol. Subcohorts also provided repeated measures and completed scales of key psychological constructs. Results. The total sample was 206 participants, but not all participants provided data for all analyses. Interrater and 1-week test-retest reliability were excellent (intraclass correlation coefficients [2,1].75–.95). Potentially important differences in reliability and PPT scores were found when using only 1 or 2 repeated measures compared with all 3. The PPT over a distal location (tibialis anterior muscle) was not adequately responsive in this sample, but the local site (upper trapezius muscle) was responsive and may be useful as part of a protocol to evaluate clinical change. Sensitivity values (range 0.08–0.50) and specificity values (range 0.82– 0.97) for a range of change scores are presented. Depression, catastrophizing, and kinesiophobia were able to explain small but statistically significant variance in local PPT (3.9%–5.9%), but only catastrophizing and kinesiophobia explained significant variance in the distal PPT (3.6% and 2.9%, respectively). Limitations. Limitations of the study include multiple raters, unknown recruitment rates, and unknown measurement properties at sites other than those tested here. Conclusions. The results suggest that PPT is adequately reliable and that 3 measurements should be taken to maximize measurement properties. The variance explained by the psychological variables was small but significant for 3 constructs related to catastrophizing, depression, and fear of movement. Clinical implications for application and interpretation of PPT are discussed. [ABSTRACT FROM AUTHOR]

Background. Global ratings of change (GROCs) are commonly used in research and clinical practice to determine which patients respond to therapy, but their validity as a criterion for change has not been firmly established. One factor related to their validity is the length of the recall period. Objective. The study objective was to examine the influence of the length of the recall period on the validity of a GROC for determining true change over time in the clinical setting. Design. This was a longitudinal, single-cohort observational study. Methods. Data from the Focus on Therapeutic Outcomes clinical database were collected for 8,955 patients reporting for physical therapy treatment of a knee disorder. Computerized adaptive testing was used to assess knee functional status (FS) at the initial and final (discharge) physical therapy visits. Each patient's GROC was obtained at discharge. Correlation and linear regression analyses of knee FS and GROC, stratified by length of time between intake and discharge, were conducted. Results. Correlations of GROC with knee FS change scores were modest even for the shortest period of recall (0-30 days) and were slightly lower for longer recall periods. Regression analyses using knee FS to predict GROC scores revealed similar findings. Correlations of GROC with intake and discharge scores indicated a strong bias toward discharge status, with little or no influence of baseline status. Standardized regression coefficients fitted the pattern expected for a valid measure of change but confirmed the strong bias toward discharge status. Limitations. One version of the GROC administered serially in a cohort of patients seen in clinical practice was examined. Conclusions. These results call into question the validity of GROCs for measuring change over time in routine clinical practice. [ABSTRACT FROM AUTHOR]

Background. There is short-term evidence for treatment of cervicogenic dizziness with Mulligan sustained natural apophyseal glides (SNAGs) but no evidence for treatment with Maitland mobilizations. Objective. The purpose of this study was to compare the effectiveness of SNAGs and Maitland mobilizations for cervicogenic dizziness. Design. A double-blind, parallel-arm randomized controlled trial was conducted. Setting. The study was conducted at a university in Newcastle, Australia. Participants. Eighty-six people with cervicogenic dizziness were the study participants. Interventions. Included participants were randomly allocated to receive 1 of 3 interventions: Mulligan SNAGs (including self-administered SNAGs), Maitland mobilizations plus range-of-motion exercises, or placebo. Measurements. The primary outcome measure was intensity of dizziness. Other outcome measures were: frequency of dizziness, the Dizziness Handicap Inventory (DHI), intensity of pain, and global perceived effect (GPE). Results. Both manual therapy groups had reduced dizziness intensity and frequency posttreatment and at 12 weeks compared with baseline. There was no change in the placebo group. Both manual therapy groups had less dizziness intensity posttreatment (SNAGs: mean difference=-20.7, 95% confidence interval [95% CI]=-33.6, -7.7; mobilizations: mean difference=-15.2, 95% CI=-27.9, -2.4) and at 12 weeks (SNAGs: mean difference=-18.4, 95% CI=-31.3, -5.4; mobilizations: mean difference=-14.4, 95% CI=-27.4, -1.5) compared with the placebo group. Compared with the placebo group, both the SNAG and Maitland mobilization groups had less frequency of dizziness at 12 weeks. There were no differences between the 2 manual therapy interventions for these dizziness measures. For DHI and pain, all 3 groups improved posttreatment and at 12 weeks. Both manual therapy groups reported a higher GPE compared with the placebo group. There were no treatment-related adverse effects lasting longer than 24 hours. Limitations. The therapist performing the interventions was not blind to group allocation. Conclusions. Both SNAGs and Maitland mobilizations provide comparable immediate and sustained (12 weeks) reductions in intensity and frequency of chronic cervicogenic dizziness. INSET: The Bottom Line. [ABSTRACT FROM AUTHOR]

Background. Standardized assessment of patients' activity limitations in acute care settings can provide valuable information. Existing measures have not been widely implemented. Objectives. The aim of this study was to provide evidence for validity of scores on Activity Measure for Post-Acute Care (AM-PAC) "6-Clicks" measures of basic mobility and daily activity in acute care. Design. A retrospective measurement study was conducted. Methods. The study used a database from one health system containing "6-Clicks" scores from first and last physical therapist and occupational therapist visits for 84,446 patients. Validity was analyzed by examining differences in "6-Clicks" scores across categories of patient characteristics; the ability of "6-Clicks" scores to predict patients' having more than one therapy visit; correlation of "6-Clicks" scores with Functional Independence Measure (FIM) scores; and internal responsiveness over the episode of care. Internal consistency reliability also was determined. Results. The "6-Clicks" scores differed across patients' age, preadmission living situation, and number of therapy visits. The areas under receiver operating characteristic curves derived using "6-Clicks" scores at the first visit to predict patients receiving more than one visit were 0.703 and 0.652 using basic mobility and daily activity scores, respectively. The "6-Clicks" scores at the final visit were correlated with scores on subscales of the FIM completed on admission to inpatient rehabilitation facilities (r=.65 and .69). Standardized response means were 1.06 and 0.95 and minimal detectable changes with 90% confidence level (MDC90) were 4.72 and 5.49 for basic mobility and daily activity scores, respectively. Internal consistency reliability of basic mobility and daily activity scores was .96 and .91, respectively. Limitations. Using clinical databases for research purposes has limitations, including missing data, misclassifications, and selection bias. Rater reliability is not known. Conclusions. This study provides evidence for the validity of "6-Clicks" scores for assessing patients' activity limitations in acute care settings. [ABSTRACT FROM AUTHOR]

The article discusses a study which examined the responsiveness of the Spinal Cord Injury Functional Ambulation Profile (SCI-FAP) after spinal cord injury (SCI). The study compared the responsiveness of the SCI-FAP with that of the 10-Meter Walk Test (10MWT) and the Six-Minute Walk Test (6MWT). It also calculated the minimal detectable change. Results showed improvement in SCI-FAP scores with both interventions.

Background. Self-efficacy appears to be an important predictor of functional recovery for women with urinary incontinence, but no specific Spanish-language questionnaires for measuring pelvic-floor exercise self-efficacy exist. Objective. The aim of this study was to design a valid and reliable Spanish version of the Broome Pelvic Muscle Self-Efficacy Scale to measure self-efficacy, as perceived by women with urinary incontinence, in performing pelvic-floor exercises. Design. This was an observational validation study. Methods. Translation-back translation was used to design the survey, and then the survey was validated with a sample of 119 women who were incontinent and had undergone a pelvic-floor exercise training program. The reliability and construct validity of the questionnaire were assessed. Descriptive statistics were used to score the questionnaire. Internal consistency was evaluated with the Cronbach alpha coefficient and the Pearson correlation coefficient. Exploratory factor analysis with both the principal components extraction method and the varimax rotation method was used to assess construct validity. Results. The reliability coefficient (Cronbach alpha=.91) and the correlations among items were high. The factor analysis revealed that 6 main factors accounted for 75.8% of the variance. Limitations. Conclusions regarding the validity of the questionnaire should be drawn with caution because of the inability to assess criterion-related validity. Conclusions. The Spanish version of the Broome questionnaire for self-efficacy appears to be useful as a measuring tool for a psychometrically accurate, clinically relevant estimation of women's self-efficacy in performing pelvic-floor exercises. [ABSTRACT FROM AUTHOR]

Background. Although not well understood, foot kinematics are changed with hallux valgus. Objective. The purpose of this study was to examine tarsal kinematics in women with hallux valgus deformity. Design. A prospective, cross-sectional design was used. Methods. Twenty women with (n=10) and without (n=10) deformity participated. Data were acquired with the use of a magnetic resonance scanner. Participants were posed standing to simulate gait, with images reconstructed into virtual bone datasets. Measures taken described foot posture (hallux angle, intermetatarsal angle, arch angle). With the use of additional computer processes, the image sequence was then registered across gait conditions to compute relative tarsal position angles, first-ray angles, and helical axis parameters decomposed into X, Y, and Z components. An analysis of variance model compared kinematics between groups and across conditions. Multiple regression analysis assessed the relationship of arch angle, navicular position, and inclination of the first-ray axis. Results. Both the hallux and intermetatarsal angles were larger with deformity; arch angle was not different between groups. The calcaneus was everted by ≥6.6 degrees, and the first ray adducted (F=44.17) by ≥9.3 degrees across conditions with deformity. There was an interaction (F=5.06) for the first-ray axis. Follow-up comparisons detected increased inclination of the first-ray axis over middle stance compared with late stance in the group with deformity. Limitations. Gait was simulated, kinetics were not measured, and sample size was small. Conclusions. There were group differences. Eversion of the calcaneus and adduction of the first ray were increased, and the first-ray axis was inclined 24 degrees over middle stance in women with deformity compared with 6 degrees in control participants. Results may identify risk factors of hallux valgus and inform nonoperative treatment (orthoses, exercise) strategies. [ABSTRACT FROM AUTHOR]

Background. The original 20-item Upper Extremity Functional Index (UEFI) has not undergone Rasch validation. Objective. The purpose of this study was to determine whether Rasch analysis supports the UEFI as a measure of a single construct (ie, upper extremity function) and whether a Rasch-validated UEFI has adequate reproducibility for individual-level patient evaluation. Design. This was a secondary analysis of data from a repeated-measures study designed to evaluate the measurement properties of the UEFI over a 3-week period. Methods. Patients (n=239) with musculoskeletal upper extremity disorders were recruited from 17 physical therapy clinics across 4 Canadian provinces. Rasch analysis of the UEFI measurement properties was performed. If the UEFI did not fit the Rasch model, misfitting patients were deleted, items with poor response structure were corrected, and misfitting items and redundant items were deleted. The impact of differential item functioning on the ability estimate of patients was investigated. Results. A 15-item modified UEFI was derived to achieve fit to the Rasch model where the total score was supported as a measure of upper extremity function only. The resultant UEFI-15 interval-level scale (0 -100, worst to best state) demonstrated excellent internal consistency (person separation index=0.94) and test-retest reliability (intraclass correlation coefficient [2,1]=.95). The minimal detectable change at the 90% confidence interval was 8.1. Limitations. Patients who were ambidextrous or bilaterally affected were excluded to allow for the analysis of differential item functioning due to limb involvement and arm dominance. Conclusion. Rasch analysis did not support the validity of the 20-item UEFI. However, the UEFI-15 was a valid and reliable interval-level measure of a single dimension: upper extremity function. Rasch analysis supports using the UEFI-15 in physical therapist practice to quantify upper extremity function in patients with musculoskeletal disorders of the upper extremity. [ABSTRACT FROM AUTHOR]

Background. Exercise rehabilitation after cardiac surgery has beneficial effects, especially on a long-term basis. Rehabilitative programs with telemedicine plus appropriate technology might satisfy the needs of performing rehabilitation at home. Objective. The purpose of this study was to compare exercise capacity after home-based cardiac rehabilitation (HBCR) or in-hospital rehabilitation in patients at low to medium risk for early mortality (EuroSCORE 0–5) following cardiac surgery. Design. A quasi-experimental study was conducted. Methods. At hospital discharge, patients were given the option to decide whether to enroll in the HBCR program. Clinical examinations (electrocardiography, cardiac echo color Doppler, chest radiography, blood samples) of patients in the HBCR group were collected during 4 weeks of rehabilitation, and exercise capacity (assessed using the Six-Minute Walk Test [6MWT]) was assessed before and after rehabilitation. A group of patients admitted to the in-hospital rehabilitation program was used as a comparison group. Patients in the HBCR group were supervised at home by a medical doctor and telemonitored daily by a nurse and physical therapist by video conference. Periodic home visits by health staff also were performed. Results. One hundred patients were recruited into the HBCR group. An equal number of patients was selected for the comparison group. At the end of the 4-week study, the 2 groups showed improvement from their respective baseline values only in the 6MWT. No difference was found in time group interaction. Limitations. Because patients self-selected to enroll in the HBCR program and because they were enrolled from a single clinical center, the results of the study cannot be generalized. Conclusions. In patients who self-selected HBCR, the program was found to be effective and comparable to the standard in-hospital rehabilitative approach, indicating that rehabilitation following cardiac surgery can be implemented effectively at home when co-administered with an integrated telemedicine service. INSET: The Bottom Line. [ABSTRACT FROM AUTHOR]

Background. The impact of the relationship (therapeutic alliance) between patients and physical therapists on treatment outcome in the rehabilitation of patients with chronic low back pain (LBP) has not been previously investigated. Objective. The purpose of this study was to investigate whether the therapeutic alliance between physical therapists and patients with chronic LBP predicts clinical outcomes. Design. This was a retrospective observational study nested within a randomized controlled trial. Methods. One hundred eighty-two patients with chronic LBP who volunteered for a randomized controlled trial that compared the efficacy of exercises and spinal manipulative therapy rated their alliance with physical therapists by completing the Working Alliance Inventory at the second treatment session. The primary outcomes of function, global perceived effect of treatment, pain, and disability were assessed before and after 8 weeks of treatment. Linear regression models were used to investigate whether the alliance was a predictor of outcome or moderated the effect of treatment. Results. The therapeutic alliance was consistently a predictor of outcome for all the measures of treatment outcome. The therapeutic alliance moderated the effect of treatment on global perceived effect for 2 of 3 treatment contrasts (general exercise versus motor control exercise, spinal manipulative therapy versus motor control exercise). There was no treatment effect modification when outcome was measured with function, pain, and disability measures. Limitations. Therapeutic alliance was measured at the second treatment session, which might have biased the interaction during initial stages of treatment. Data analysis was restricted to primary outcomes at 8 weeks. Conclusions. Positive therapeutic alliance ratings between physical therapists and patients are associated with improvements of outcomes in LBP. Future research should investigate the factors explaining this relationship and the impact of training interventions aimed at optimizing the alliance. [ABSTRACT FROM AUTHOR]

Background. Illness perceptions have been shown to predict patient activities. Therefore, studies of the effectiveness of a targeted illness-perception intervention on chronic nonspecific low back pain (CLBP) are needed. Objective. The purpose of this study was to compare the effectiveness of treatment of illness perceptions against a waiting list for patients with CLBP. Design. This was a prospectively registered randomized controlled trial with an assessor blinded for group allocation. Setting. The study was conducted in an outpatient rehabilitation clinic. Participants. The participants were 156 patients (18-70 years of age) with CLBP (3 months). Intervention. Patients were randomly assigned to either a treatment group or to a waiting list (control) group. Trained physical therapists and occupational therapists delivered 10 to 14 one-hour treatment sessions according to the treatment protocol. Measurements. The primary outcome measure was change in patient-relevant physical activities (Patient-Specific Complaints questionnaire). The secondary outcome measures were changes in illness perceptions (Illness Perceptions Questionnaire) and generic physical activity level (Quebec Back Pain Disability Scale). Measurements were taken at baseline (0 weeks) and after treatment (18 weeks). Results. A baseline-adjusted analysis of covariance showed that there were statistically significant differences between intervention and control groups at 18 weeks for the change in patient-relevant physical activities. This was a clinically relevant change (19.1 mm) for the intervention group. Statistically significant differences were found for the majority of illness perception scales. There were no significant differences in generic physical activity levels. Limitations. Longer-term effectiveness was not studied. Conclusions. This first trial evaluating cognitive treatment of illness perceptions concerning CLBP showed statistically significant and clinically relevant improvements in patient-relevant physical activities at 18 weeks. [ABSTRACT FROM AUTHOR]

Background. Osteoarthritis (OA) is the most common joint disorder in the world and is recognized as a substantial source of disability. For people with OA of the knee, exercise in combination with weight loss is a proven, effective, conservative treatment option, yet evidence is lacking for people with hip OA. Objective. The aim of this study was to obtain preliminary evidence of the effect of a program of exercise in combination with weight loss on physical function in people who have hip OA and are overweight or obese. Design. This investigation was a prospective cohort study. Methods. Thirty-five people who were 25 years or older, had clinical and radiological evidence of hip OA, and were overweight or obese (body mass index of >25 kg/m2) were included. They participated in an 8-month program of exercise in combination with weight loss. A body mass index of 40 kg/m2 "was used as the upper limit. The primary outcome was self-reported physical function, as measured with a subscale of the Western Ontario and McMaster Universities Osteoarthritis Index. Secondary outcome measures included pain and walking tests as quantitative measures of function. Results. Participation in the combination program resulted in a 32.6% improvement in self-reported physical function after 8 months, a finding that could be considered clinically relevant. Significant improvements also were seen in pain and on walking tests. Limitations. The lack of a control group was a limitation of this study. Conclusions. This appears to be the first study investigating the effect of exercise and weight loss as a combination treatment in people with hip OA. The results provide preliminary evidence that this combination treatment is effective in people with hip OA. [ABSTRACT FROM AUTHOR]

Background. Geriatric rehabilitation reimbursement increasingly requires documented deficits on standardized measures. Tandem stance performance can characterize balance, but protocols are not standardized. Objective. The purpose of this study was to explore the impact of: (1) initial support to stabilize in position and (2) maximum hold time on tandem stance tests of balance in older adults. Design. A cross-sectional secondary analysis of observational cohort data was conducted. Methods. One hundred seventeen community-dwelling older adults (71% female, 12% black) were assigned to 1 of 3 groups based on the need for initial support to perform tandem stance: (1) unable even with support, (2) able only with support, and (3) able without support. The able without support group was further stratified on hold tune in seconds: (1) <10 (low), (2) 10 to 29, (medium), and (3) 30 (high). Groups were compared on primary outcomes (gait speed, Timed "Up & Go" Test performance, and balance confidence) using analysis of variance. Results. Twelve participants were unable to perform tandem stance, 14 performed tandem stance only with support, and 91 performed tandem stance without support. Compared with the able without support group, the able with support group had statistically or clinically worse performance and balance confidence. No significant differences were found between the able with support group and the unable even with support group on these same measures. Extending the hold time to 30 seconds in a protocol without initial support eliminated ceiling effects for 16% of the study sample. Limitations. Small comparison groups, use of a secondary analysis, and lack of generalizability of results were limitations of the study. Conclusions. Requiring initial support to stabilize in tandem stance appears to reflect meaningful deficits in balance-related mobility measures, so failing to consider support may inflate balance estimates and confound hold time comparisons. Additionally, 10-second maximum hold times limit discrimination of balance in adults with a higher level of function. For community-dwelling older adults, we recommend timing for at least 30 seconds and documenting initial support for consideration when interpreting performance. [ABSTRACT FROM AUTHOR]

Background. Disability in adults with low back pain (LBP) is associated with negative back pain beliefs (BPBs). Adult BPBs can be positively influenced with education, resulting in reduced LBP disability. By late adolescence, the prevalence of LBP reaches adult levels. The relationship among LBP experience, LBP impact, and BPBs has not been investigated in late adolescence. Objective. The aim of this study was to document unknown relationships among LBP experience, LBP impact, and BPBs in 17-year-olds. Design. A cross-sectional study design was used. Methods. Adolescents (n= 1,126) in the Raine Study provided full information on LBP, LBP impact (sought professional advice or treatment, taken medication, missed school or work, interfered with normal activities, interfered with physical activities), BPBs, and a number of covariates. Results. Back pain beliefs were more positive in participants with experience of LBP (X=30.2, SD=5.6) than in those without experience of LBP (X=28.5, SD=5.1). Individuals with LBP without activity modification impacts had more positive BPBs than those with activity modification impacts, even after adjustment for mental well-being and sex. The adjusted difference in BPBs between participants with experience of LBP but no activity modification impacts and those reporting all 3 activity modification impacts was 2.9 points (95% confidence interval=1.7 to 4.2). Participants with no activity modification impacts had more positive BPBs than those with no experience of LBP (adjusted difference=2.2 points, 95% confidence interval 1.4 to 2.9). More positive BPBs also were associated with female sex, lower body mass index, higher family income, better 36-Item Short-Form Health Survey (SF-36) Mental Health scale scores, and more positive primary caregiver beliefs. Limitations. Cause and effect cannot be ascertained with the cross-sectional design. Conclusion. Differences in BPBs are associated with different levels of LBP impact at 17 years of age. This finding provides a potential target for intervention early during the life course. [ABSTRACT FROM AUTHOR]

Background. The construct validity and reliability of the short form of the Wolf Motor Function Test (S-WMFT) in people with subacute stroke and chronic stroke (S-WMFT subacute stroke and chronic stroke versions) have not been investigated. Objective. The purpose of this study was to investigate the dimensionality, item difficulty hierarchy, differential item functioning (DIF), and reliability of the S-WMFT subacute stroke and chronic stroke versions in people with mild to moderate upper-extremity (UE) dysfunction. Design. This was a secondary study in which data collected from randomized controlled trials were used. Methods. Data were collected at baseline from 97 people with chronic stroke (>12 months after stroke) and 75 people "with subacute stroke (3-9 months after stroke) at 3 medical centers in Taiwan. Test structure, hierarchical properties, DIF, and reliability were assessed with Rasch analysis. Results. The test structure for both versions was unidimensional. No DIF relevant to sex, age, or stroke location (hemispheric laterality) was detected. The tasks of moving a hand to a box and moving a hand to a table in the S-WMFT for subacute stroke showed a significantly high correlation. The reliability coefficients for both versions were approximately .90. Limitations. The findings were limited to people with stroke and mild to moderate impairment of UE function. Conclusions. The S-WMFT subacute stroke and chronic stroke versions are useful tools for assessing UE function in different subgroups of people with stroke and show evidence of construct validity and reliability. A high correlation between the tasks of moving a hand to a box and moving a hand to a table in the S-WMFT for subacute stroke suggests that the removal of 1 of these 2 items is warranted. [ABSTRACT FROM AUTHOR]

Background. The influence of elevated fear-avoidance beliefs on change in functional status is unclear. Objective. The purpose of this study was to determine the influence of fear- avoidance on recovery of functional status during rehabilitation for people with shoulder impairments. Design. A retrospective longitudinal cohort study was conducted. Methods. Data were collected from 3,362 people with musculoskeletal conditions of the shoulder receiving rehabilitation. At intake and discharge, upper- extremity function was measured using the shoulder Computerized Adaptive Test. Pain intensity was measured using an 11-point numerical rating scale. Completion rate at discharge was 57% for function and 47% for pain intensity. A single-item screen was used to classify patients into groups with low versus elevated fear-avoidance beliefs at intake. A general linear model (GLM) was used to describe how change in function is affected by fear avoidance in 8 disease categories. This study also accounted for within-clinic correlation and controlled for other important predictors of functional change in functional status, including various demographic and health- related variables. The parameters of the GLM and their standard errors were estimated with the weighted generalized estimating equations method. Results. Functional change was predicted by the interaction between fear and disease categories. On further examination of 8 disease categories using GLM adjusted for other confounders, improvement in function was greater for the low fear group than for the elevated fear group among people with muscle, tendon, and soft tissue disorders (A = 1.37, P<.01) and those with osteopathies, chondropathies, and acquired musculoskeletal deformities (A = 5.52, P<.02). These differences 'were below the minimal detectable change. Limitations. Information was not available on whether therapists used information on level of fear to implement treatment plans. Conclusions. The influence of fear-avoidance beliefs on change in functional status varies among specific shoulder impairments. [ABSTRACT FROM AUTHOR]

Background. Clinical observations have suggested that hippotherapy may be an effective strategy for habilitating balance deficits in children with movement disorders. However, there is limited research to support this notion. Objective. The purposes of this study were to assess the effectiveness of hippotherapy for the management of postural instability in children with mild to moderate balance problems and to determine whether there is a correlation between balance and function. Design. A repeated measures design for a cohort of children with documented balance deficits was used. Methods. Sixteen children (9 boys and 7 girls) who were 5 to 16 years of age and had documented balance problems participated in this study. Intervention consisted of 45-minute hippotherapy sessions twice per week for 6 weeks. Two baseline assessments and 1 postintervention assessment of balance, as measured with the Pediatric Balance Scale (PBS), and of function, as measured with the Activities Scale for Kids-Performance (ASKp), were performed. Results. With the Friedman analysis of variance, the PBS and the ASKp were found to be statistically significant across all measurements (P<.0001 for both measures). Post hoc analysis revealed a statistical difference between baseline and postintervention measures (P<.017). This degree of difference resulted in large effect sizes for PBS(d=1.59) and ASKp (d=1.51) scores after hippotherapy. A Spearman rho correlation of .700 indicated a statistical association between PBS and ASKp postintervention scores (P=.003). There was no correlation between the change in PBS scores and the change in ASKp scores (rx.13, P>.05).Limitations. Lack of a control group and the short duration between baseline assessments are study limitations. Conclusions. The findings suggest that hippotherapy may be a viable strategy for reducing balance deficits and improving the performance of daily life skills in children with mild to moderate balance problems. [ABSTRACT FROM AUTHOR]

Background. Pressure ulcer development is a common, serious complication after spinal cord injury (SCI). Although many biophysical agents are available for treatment, few randomized controlled trials of their efficacy have been done. Objective. The study objective was to examine the efficacy of low-pressure pulsatile lavage treatment for stage III and IV pressure ulcers in people with SCI. Design. This study was a randomized controlled trial. Participants and assessors were unaware of intervention assignments. Setting. This study was conducted in an SCI tertiary care center inpatient unit. Participants. Participants were 28 people with SCI and stage III and IV pelvic pressure ulcers; 14 participants each were randomly assigned to treatment and control (sham treatment) groups. Intervention. Daily low-pressure pulsatile lavage treatment with 1 L of normal saline at 11 psi of pressure was applied to the treatment group along with standard dressing changes. The control group received only sham treatment and standard dressing changes. Measurements. Linear and volume measurements of pressure ulcer dimensions were obtained weekly for 3 weeks. Results. Statistical analysis with the t test revealed no statistically significant difference in demographics between groups. Random-coefficient models for analysis of linear and volume measurements revealed improvements over time for both groups. Time trend analysis revealed greater measurement decreases for the treatment group. Differences in rates of change (with 95% confidence intervals) for treatment and control groups, respectively, were: depth, -0.24 (0.09 to -0.58) cm/wk; width, -0.16 (0.06 to -0.39) cm/wk; length, -0.47 (0.18 to -1.12) cm/wk; and volume, -0.33 (0.13 to -0.80) cm3/wk. Limitations. Study limitations were small sample size and inclusion of only one site. Additionally, participants were not queried about their group assignments. Conclusions. Pulsatile lavage enhanced stage III and IV pelvic pressure ulcer healing rates in people with SCI relative to standard pressure ulcer treatment alone. INSET: The Bottom Line. [ABSTRACT FROM AUTHOR]

Background. The incidence of obesity is increasing in older adults, with associated worsening in the burden of disability. Little is known about the impact of body mass index (BMI) on self-report and performance-based balance and mobility measures in older adults. Objective. The purposes of this study were (1) to examine the association of BMI with measures of balance and mobility and (2) to explore potential explanatory factors. Design. This was a cross-sectional, observational study. Methods. Older adults (mean age=77.6 years) who participated in an ongoing observational study (N120) were classified as normal weight (BMI=18.5-24.9 kg/m2), overweight (BMI=25.0 -29.9 kg/m2), moderately obese (BMI=30.0 -34.9 kg/m2), or severely obese (BMI≥35 kg/m2). Body mass index data were missing for one individual; thus, data for 119 participants were included in the analysis. Mobility and balance were assessed using self-report and performance-based measures and were compared among weight groups using analysis of variance and chi-square analysis for categorical data. Multiple linear regression analysis was used to examine the association among BMI, mobility, and balance after controlling for potential confounding variables. Results. Compared with participants who were of normal weight or overweight, those with moderate or severe obesity were less likely to report their mobility as very good or excellent (52%, 55%, 39%, and 6%, respectively); however, there was no difference in self-report of balance among weight groups. Participants with severe obesity (n=17) had the lowest levels of mobility on the performance-based measures, followed by those who were moderately obese (n=31), overweight (n=42), and of normal weight (n=29). There were no differences on performance-based balance measures among weight groups. After controlling for age, sex, minority status, physical activity level, education level, and comorbid conditions, BMI still significantly contributed to mobility (β=-.02, adjusted R2=.41). Conclusions. Although older adults with severe obesity were most impaired, those with less severe obesity also demonstrated significant decrements in mobility. [ABSTRACT FROM AUTHOR]

Background. Recent evidence demonstrates growth in both the quality and quantity of evidence in physical therapy. Much of this work has focused on randomized controlled trials and systematic reviews. Objective. The purpose of this study was to conduct a comprehensive bibliometric assessment of Physical Therapy (PTJ) over the past 30 years to examine trends for all types of studies. Design. This was a bibliometric analysis. Methods. All manuscripts published in PTJ from 1980 to 2009 were reviewed. Research reports, topical reviews (including perspectives and nonsystematic reviews), and case reports were included. Articles were coded based on type, participant characteristics, physical therapy focus, research design, purpose of article, clinical condition, and intervention. Coding was performed by 2 independent reviewers, and author, institution, and citation information was obtained using bibliometric software. Results. Of the 4,385 publications identified, 2,519 were included in this analysis. Of these, 67.1% were research reports, 23.0% were topical reviews, and 9.9% were case reports. Percentage increases over the past 30 years were observed for research reports, inclusion of "symptomatic" participants (defined as humans with a current symptomatic condition), systematic reviews, qualitative studies, prospective studies, and articles focused on prognosis, diagnosis, or metric topics. Percentage decreases were observed for topical reviews, inclusion of only "asymptomatic" participants (defined as humans without a current symptomatic condition), education articles, nonsystematic reviews, and articles focused on anatomy/physiology. Limitations. Quality assessment of articles was not performed. Conclusions. These trends provide an indirect indication of the evolution of the physical therapy profession through the publication record in PTJ. Collectively, the data indicated an increased emphasis on publishing articles consistent with evidence-based practice and clinically based research. Bibliometric analyses indicated the most frequent citations were metric studies and references in PTJ were from journals from a variety of disciplines. [ABSTRACT FROM AUTHOR]

Background. Several studies have investigated criteria for classifying patientswith low back pain (LBP) into treatment-based subgroups. A comprehensive algorithm was created to translate these criteria into a clinical decision-making guide. Objective. This study investigated the translation of the individual subgroup criteria into a comprehensive algorithm by studying the prevalence of patients meeting the criteria for each treatment subgroup and the reliability of the classification. Design. This was a cross-sectional, observational study. Methods. Two hundred fifty patients with acute or subacute LBP were recruited from the United States and Australia to participate in the study. Trained physical therapists performed standardized assessments on all participants. The researchers used these findings to classify participants into subgroups. Thirty-one participants were reassessed to determine interrater reliability of the algorithm decision. Results. Based on individual subgroup criteria, 25.2% (95% confidence interval [CI]19.8%-30.6%) of the participants did not meet the criteria for any subgroup, 49.6% (95% CI43.4%-55.8%) of the participants met the criteria for only one subgroup, and 25.2% (95% CI19.8%-30.6%) of the participants met the criteria for more than one subgroup. The most common combination of subgroups was manipulation specific exercise (68.4% of the participants who met the criteria for 2 subgroups). Reliability of the algorithm decision was moderate (kappa0.52, 95% CI0.27- 0.77, percentage of agreement67%).Limitations. Due to a relatively small patient sample, reliability estimates aresomewhat imprecise. Conclusions. These findings provide important clinical data to guide future research and revisions to the algorithm. The finding that 25% of the participants met the criteria for more than one subgroup has important implications for the sequencing of treatments in the algorithm. Likewise, the finding that 25% of the participants did not meet the criteria for any subgroup provides important information regarding potential revisions to the algorithm's bottom table (which guides unclear classifications). Reliability of the algorithm is sufficient for clinical use. [ABSTRACT FROM AUTHOR]

Background and Objective. Professional meetings, such as the American Physical Therapy Association's (APTA's) Combined Sections Meeting (CSM), provide forums for sharing information relevant to physical therapy. An indicator of whether therapists fully disseminate their work is the number of full-text peer-reviewed publications that result. The purposes of this study were: (1) to determine the full-text publication rate of work presented in abstract form at CSM and (2) to investigate factors influencing this rate. Methods. A systematic search was undertaken to locate full-text publications of work presented in abstract form within the Orthopaedic and Sports Physical Therapy sections at CSM between 2000 and 2004. Eligible publications were published within 5 years following abstract presentation. The influences of APTA section, year of abstract presentation, institution of origin, study design, sample size, study significance, reporting of a funding source, and presentation type on full-text publication rate were assessed. Characteristics of full-text publications were explored. Results. Work presented in 1 out of 4 abstracts (25.4%) progressed to full-text publication. Odds of full-text publication increased if the abstract originated from a doctorate-granting or "other" institution, reported findings of an experimental study, reported a statistically significant finding, included a larger sample size, disclosed a funding source, or was presented as a platform presentation. More than one third (37.8%) of full-text publications were published in the Journal of Orthopaedic and Sports Physical Therapy or Physical Therapy, and 4 out of 10 full-text publications (39.2%) contained at least one major change from information presented in abstract form. Conclusions. The full-text publication rate for information presented in abstract form within the Orthopaedic and Sports Physical Therapy sections at CSM is low relative to comparative disciplines. Caution should be exercised when translating information presented at CSM into practice. [ABSTRACT FROM AUTHOR]

Background. Patient satisfaction is an important patient-centered health outcome. To date, no systematic review of the literature on patient satisfaction with musculoskeletal physical therapy care has been conducted. Purpose. The purpose of this study was to systematically and critically review the literature to determine the degree of patient satisfaction with musculoskeletal physical therapy care and factors associated with satisfaction. Data Sources. The databases CINAHL, MEDLINE, and EBM Reviews were searched from inception to September 2009. Study Selection. Articles were included if the design was a clinical trial, observational study, survey, or qualitative study; patient satisfaction was evaluated; and the study related to the delivery of musculoskeletal physical therapy services conducted in an outpatient setting. The search located 3,790 citations. Fifteen studies met the inclusion criteria. Data Extraction. Two authors extracted patient satisfaction data and details of each study. Data Synthesis. A meta-analysis of patient satisfaction data from 7 studies was conducted. The pooled estimate of patient satisfaction was 4.44 (95% confidence interval=4.41- 4.46) on a scale of 1 to 5, where 5 indicates high satisfaction and 1 indicates high dissatisfaction. Additional data were summarized in tables and critically appraised. Limitations. Nonrespondent bias from individual studies may affect the accuracy and representativeness of these data. Conclusion. Patients are highly satisfied with musculoskeletal physical therapy care delivered across outpatient settings in northern Europe, North America, the United Kingdom, and Ireland. The interpersonal attributes of the therapist and the process of care are key determinants of patient satisfaction. An unexpected finding was that treatment outcome was infrequently and inconsistently associated with patient satisfaction. Physical therapists can enhance the quality of patient-centered care by understanding and optimizing these determinants of patient satisfaction. INSET: The Bottom Line. [ABSTRACT FROM AUTHOR]

Background. Research suggests that cancer rehabilitation reduces fatigue in survivors of cancer. To date, it is unclear what type of rehabilitation is most beneficial. Objective. This randomized controlled trial compared the effect on cancer-related fatigue of physical training combined with cognitive behavioral therapy with physical training alone and with no intervention. Design. In this multicenter randomized controlled trial, 147 survivors of cancer were randomly assigned to a group that received physical training combined with cognitive-behavioral therapy (PT+CBT group, n = 76) or to a group that received physical training alone (PT group, n=71). In addition, a nonintervention control group (WLC group) consisting of 62 survivors of cancer who were on the waiting lists of rehabilitation centers elsewhere was included. Setting. The study was conducted at 4 rehabilitation centers in the Netherlands. Patients. All patients were survivors of cancer. Intervention. Physical training consisting of 2 hours of individual training and group sports took place twice weekly, and cognitive-behavioral therapy took place once weekly for 2 hours. Measurements. Fatigue was assessed with the Multidimensional Fatigue Inventory before and immediately after intervention (12 weeks after enrollment). The WLC group completed questionnaires at the same time points. Results. Baseline fatigue did not differ significantly among the 3 groups. Over time, levels of fatigue significantly decreased in all domains in all groups, except in mental fatigue in the WLC group. Analyses of variance of postintervention fatigue showed statistically significant group effects on general fatigue, on physical and mental fatigue, and on reduced activation but not on reduced motivation. Compared with the WLC group, the PT group reported significantly greater decline in 4 domains of fatigue, whereas the PT+CBT group reported significantly greater decline in physical fatigue only. No significant differences in decline in fatigue were found between the PT+CBT and PT groups. Conclusions. Physical training combined with cognitive-behavioral therapy and physical training alone had significant and beneficial effects on fatigue compared with no intervention. Physical training was equally effective as or more effective than physical training combined with cognitive-behavioral therapy in reducing cancer-related fatigue, suggesting that cognitive-behavioral therapy did not have additional beneficial effects beyond the benefits of physical training. INSET: The Bottom Line. [ABSTRACT FROM AUTHOR]

Background. Neuromuscular electrical stimulation (NMES) has demonstrated efficacy in improving quadriceps muscle strength (force-generating capacity) and activation following knee replacement and ligamentous reconstruction. Yet, data are lacking to establish the efficacy of NMES in people with evidence of early radiographic osteoarthritis. Objective. The purpose of this study was to determine whether NMES is capable of improving quadriceps muscle strength and activation in women with mild and moderate knee osteoarthritis. Design. This study was a randomized controlled trial. Methods. Thirty women with radiographic evidence of mild or moderate knee osteoarthritis were randomly assigned to receive either no treatment (standard of care) or NMES treatments 3 times per week for 4 weeks. The effects of NMES on quadriceps muscle strength and activation were evaluated upon study enrollment, as well as at 5 and 16 weeks after study enrollment, which represent 1 and 12 weeks after cessation of NMES among the treated participants. The Western Ontario and McMaster Universities Osteoarthritis Index and a 40-foot (12.19-m) walk test were used at each testing session. Results. Improvements in quadriceps muscle strength or activation were not realized for the women in the intervention group. Quadriceps muscle strength and activation were similar across testing sessions for both groups. Limitations. Women were enrolled based on radiographic evidence of osteoarthritis, not symptomatic osteoarthritis, which could have contributed to our null finding. A type II statistical error may have been committed despite an a priori power calculation. The assessor and the patients were not blinded to group assignment, which may have introduced bias into the study. Conclusions. Four weeks of NMES delivered to women with mild and moderate osteoarthritis and mild strength deficits was insufficient to induce gains in quadriceps muscle strength or activation. Future research is needed to examine the dose- response relationship for NMES in people with early radiographic evidence of osteoarthritis. INSET: The Bottom Line. [ABSTRACT FROM AUTHOR]