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PROBLEM A simple inexpensive method was needed to record foot placement of the gait pattern of severely to profoundly retarded clients. The methods previously reported in the literature were impractical for a variety of reasons. Some were too expensive and too sophisticated for the basic information we needed to collect.1–3 Others required the use of indelible substances applied to the feet or footwear,3–5 and our subjects could not be depended upon to confine their walking to the prepared walkway. Our entire facility is carpeted, so this was a major concern. Furthermore, our subjects would not readily tolerate the application of pads or other material to their feet or shoes, nor could they understand the necessity for leaving these in place until gait recording was completed. Their interest in the materials on their feet precluded conducting natural walking trials. METHOD To circumvent these difficulties, a method was devised using absorbent paper overlaying water-soaked material placed on top of a protective floor covering.…

[ Editor's note: Both the letter to the editor by Bjordal and colleagues and the response by White and colleagues are commenting on the author manuscript version of the article that was published ahead of print September 15, 2014. ] We have read “The American Physical Therapy Association's Top Five Choosing Wisely Recommendations”1 (CWR) with interest. The article will probably have great impact as an official white paper originating from APTA, and it joins a national initiative aimed at reducing health care costs across professions. This is an important and timely initiative, and it is welcomed. The first of the 5 specific recommendations is to limit the use of “passive” physical agents (PAs) because: “A carefully designed active treatment plan has a greater impact on pain, mobility, function, and quality of life.” Within our profession, other interventions such as massage, manipulation, and mobilization also are “passive” modalities (cf, exercise), but they are very seldom labeled as such. Similarly, analgesic medications, injections, and surgery also are “passive” treatments. All of these non–physical therapy-related interventions come with higher risk than physical agents or even manual therapies. Physical agents can provide safe, low-cost management as an alternative to analgesic medications or more invasive procedures, such as injections or surgery. Some physical agents also can be provided to the patient for home use as part of a self-management plan. Additionally, this recommendation is not based on the best available evidence. It is important to remember that the framework for CWR demands identification of certain tests or treatments commonly used “in the absence of evidence demonstrating benefit.” The ABIM Foundation even strengthens the evidence criterion to say that: “there is strong evidence that demonstrates that the service offers no benefit to most patients.”1 The first CWR states, “Don't use passive physical agents except …

According to Couldrick, “Sexuality is an integral part of being human.”1(p493) Sexual well-being of clients is regarded as a health care concern, which is highlighted in the International Classification of Functioning, Disability and Health 2 (ICF) and is referred to in the United Kingdom Department of Health publication Choosing Health: A White Paper .3 Because the issue is increasingly being considered as an integral component of the total well-being of an individual, it is important that health care professionals address it.4–7 Addressing clients’ sexuality requires a multidisciplinary approach and is not the responsibility of a single professional.4 However, clients’ sexuality sometimes is not addressed in clinical settings. One probable, yet understandable, reason for this is that health care professionals, including physical therapists, feel …

BackgroundOptimal physical activity levels have health benefits for patients with acute coronary syndrome (ACS) and are an important goal of cardiac rehabilitation (CR).PurposeThe purpose of this study was to systematically review literature regarding short-term effects (Data SourcesPubMed, EMBASE, CINAHL, and PEDro were systematically searched for relevant randomized clinical trials (RCTs) published from 1990 until 2012.Study SelectionRandomized clinical trials investigating CR for patients with ACS reporting physical activity level were reviewed.Data ExtractionTwo reviewers independently selected articles, extracted data, and assessed methodological quality. Results were summarized with a best evidence synthesis. Results were categorized as: (1) center-based/home-based CR versus no intervention, (2) comparison of different durations of CR, and (3) comparison of 2 types of CR.Data SynthesisA total of 26 RCTs were included. Compared with no intervention, there was, at most, conflicting evidence for center-based CR and moderate evidence for home-based CR for short-term effectiveness. Limited evidence and no evidence were found for long-term maintenance for center-based and home-based CR, respectively. When directly compared with center-based CR, moderate evidence showed that home-based CR has better long-term effects. There was no clear evidence that increasing training volume, extending duration of CR, or adding an extra intervention to CR is more effective.LimitationsBecause of the variety of CR interventions in the included RCTs and the variety of outcome measures in the included RCTs, pooling of data was not possible. Therefore, a best evidence synthesis was used.ConclusionsIt would appear that center-based CR is not sufficient to improve and maintain physical activity habits. Home-based programs might be more successful, but the literature on these programs is limited. More research on finding successful interventions to improve activity habits is needed.

The purpose of this study was to establish intratester and intertester reliability of four methods of measuring wound surface area from transparency film tracings. Wound area measurements were obtained in 31 subjects with venous stasis ulcers. After tracing each wound on transparency film, wound area was calculated by (1) multiplying length and width measurements with a ruler, (2) placing the transparency film over graph paper and counting the squares, (3) using a planimeter, and (4) using a digitizer. Intraclass correlation coefficients (ICCs) for intratester measurements were .99 for each method. The ICC values for intertester measurements ranged from .97 to .99. The results of this study indicate that intratester and intertester wound measurements can be taken reliably with the graph paper, planimeter, and digitizer methods. The graph paper technique may be preferable in most clinical settings, because it is low in cost and easy to use.

Physical therapists evaluate the shape of the low back area when they gather data to assist in identifying causes of low back pain and dysfunction. The results of patient interviews, palpation, and visual inspections typically are combined to acquire such information. These subjective methods, however, do not provide comparative information. To more objectively document the status of the low back contour in a variety of patients, I developed a clinically useful surface measurement system, which provides quantified, permanent, and comparable records. MATERIALS The system comprises the contour measuring device (Fig. 1); a wooden board, metric graph paper, and tape for recording materials (Fig. 2); and several fine tip pens of various colors. The handle portion of the measurement device is a hollow metal bar from stock typically used for table legs. To construct the system, follow these steps: Drill 19 holes 0.125 in* wide in the handle at 1-cm intervals slightly to one side of the center.…

Abstract The objectives of this Perspective paper are to educate physical therapists on their important role in assessing and treating common pregnancy- and delivery-related health conditions and to advocate for their routine inclusion in postpartum care during the fourth trimester. Pelvic floor dysfunction (PFD) and diastasis recti abdominis (DRA) are 2 examples of musculoskeletal disorders associated with pregnancy and childbirth that can have negative physical, social, and psychological consequences. This paper reviews evidence from 2010 through 2021 to discuss the efficacy of physical therapist intervention in the fourth trimester for PFD and DRA. The role of physical therapy in the United States is compared with its role in other developed nations, with the intent of illustrating the potential importance of physical therapy in postpartum care. Evidence shows physical therapy is an effective, low-risk, therapeutic approach for PFD and DRA; however, physical therapists in the United States currently have a peripheral role in providing postpartum care. Lack of awareness, social stigma, and policy barriers prevent women from receiving physical therapist care. Recommendations are made regarding ways in which physical therapists can increase their involvement in the fourth trimester within their community, stimulate policy change, and promote improved postpartum care practices. Impact This Perspective highlights the valuable role of physical therapist assessment and treatment during the postpartum period for some common musculoskeletal conditions associated with pregnancy and delivery.

The movement system was identified as the focus of our expertise as physical therapists in the revised vision statement for the profession adopted by the American Physical Therapy Association in 2013. Attaining success with the profession’s vision requires the development of movement system diagnoses that will be useful in clinical practice, research, and education. To date, only a few movement system diagnoses have been identified and described, and none of these specifically address balance dysfunction. Over the past 2 years, a Balance Diagnosis Task Force, a subgroup of the Movement System Task Force of the Academy of Neurologic Physical Therapy, focused on developing diagnostic labels (or diagnoses) for individuals with balance problems. This paper presents the work of the task force that followed a systematic process to review available diagnostic frameworks related to balance, identify 10 distinct movement system diagnoses that reflect balance dysfunction, and develop complete descriptions of examination findings associated with each balance diagnosis. A standardized approach to movement analysis of core tasks, the Framework for Movement Analysis developed by the Academy of Neurologic Physical Therapy Movement Analysis Task Force, was integrated into the examination and diagnostic processes. The aims of this perspective paper are to (1) summarize the process followed by the Balance Diagnosis Task Force to develop an initial set of movement system (balance) diagnoses; (2) report the recommended diagnostic labels and associated descriptions; (3) demonstrate the clinical decision-making process used to determine a balance diagnosis and develop a plan of care; and (4) identify next steps to validate and implement the diagnoses into physical therapist practice, education, and research. Impact The development and use of diagnostic labels to classify distinct movement system problems is needed in physical therapy. The 10 balance diagnosis proposed can aid in clinical decision making regarding intervention.

Background The importance of motor learning knowledge for physical therapist practice is well known; however, its application is lacking. Conceptual frameworks that place motor learning knowledge within a clinical context are a potential mediator to overcome this gap. Purpose This study aimed to conduct a scoping review of the literature to identify and describe the content of such conceptual frameworks in physical therapy/rehabilitation, including the approaches taken in their development and the “elements” or building blocks of motor learning–based interventions within each conceptual framework. Data Sources The data sources used were PubMed, CINAHL, and PsychInfo databases. Study Selection Articles that were selected had a primary focus on motor learning and its application in physical therapy/rehabilitation and were published between 2000 and 2017. Data Extraction Twelve of 62 relevant articles met the inclusion criteria. Data Synthesis Papers attempted to translate theoretical knowledge into a coherent, clinically accessible conceptual framework via 3 main approaches: synthesizing selected motor learning elements into original new conceptual frameworks, mapping motor learning elements in current clinical practices, and assembling selected motor learning elements. The elements of motor learning that were common across papers included theoretical concepts (such as “meaningful goal setting” and “active involvement”); practice variables (including the type, frequency, and timing of feedback; the focus of instructions; task breakdown; and the amount, variability, and order of practice); and intervention strategies (task specific and mental practice). Psychological aspects related to self-efficacy and motivation were also considered integral. Limitations Papers published before the year 2000 were excluded. Conclusion The scoping review revealed that the presentation of motor learning elements in a coherent framework encompassed very diverse approaches and used different categorization systems. In addition, to fully grasp the complexity of clinical practice, motor learning should be coupled with other fields of knowledge.

Background Many practitioners experience complex, uncertain, and unique clinical practice situations that can be navigated with reflection. Little is known about the theoretical and pragmatic perspectives of reflection in physical therapy. Purpose The purpose of this paper was to examine the literature on reflection in physical therapy and identify gaps in the literature. Data Source The Cumulative Index to Nursing and Allied Health Literature (CINAHL), PubMed, EMBASE, Scopus, and PsycINFO were used to identify articles. Study Selection Studies were selected to describe: (1) theoretical concepts related to reflection, (2) examples of reflection, and (3) the use of reflection in clinical or educational contexts. Data Extraction Authors, year of publication, country of origin, publication type or source, methodology, conceptual approach (including terminology used, definition of terminology used), and practical approach (including theoretical underpinning, context of reflection/reflective practice, and target group) guided the data extraction. Data Synthesis A total of 46 articles were reviewed spanning from 1992 to 2017, which included research studies, field articles, editorials, and a review article. Theoretical underpinnings of reflection were based on the thoughts of Donald Schön. Written approaches to reflection were most common, and reflection was used to inform education, clinical practice, and professional growth. Limitations As with any review paper, there is a certain level of interpretation required when collating and interpreting data. Conclusions Reflection in physical therapy could be advanced by a thorough conceptualization of reflective practice, a broader and deeper pool of research to inform optimal implementation of reflection across the career span from learners to experts, and a clear definition and linkage of reflection to epistemologies of physical therapy practice.

Amongst adults with chronic pain, overweight and obesity are highly prevalent. The association between chronic pain and overweight is driven by several explanations, including increased biomechanical load, changes in the gut microbiome, and low-grade (neuro)inflammation. Moreover, the link between overweight, obesity and chronic pain can best be considered from a lifestyle perspective. Since conservative treatment for chronic pain is often limited to short-term and small effects, addressing important comorbidities within a lifestyle approach could be the next step towards precision medicine for these patients. Indeed, evidence shows that combining weight reduction with conservative pain management is more effective to reduce pain and disability, compared to either intervention alone. This perspective article aims to update the reader with the current understanding of the possible explanatory mechanisms behind the interaction between overweight/obesity and chronic pain in an adult population. Second, this paper applies this knowledge to clinical practice, including assessment and conservative treatment of overweight/obesity in adults with chronic pain. Henceforth, clinical recommendations and guidelines are provided based on available scientific evidence and the authors’ clinical expertise. Impact This paper will guide clinicians in the implementation of weight reduction programs within pain management.

While the American Physical Therapy Association has upheld a code of ethics since 1935, the philosophical underpinnings of physical therapist practice have yet to be robustly explicated. Theoretical work in the field of philosophy of medicine can be engaged to study physical therapist practice. Modifying the phenomenological and teleological framework of Edmund Pellegrino, a physician and prominent bioethicist, the purpose of this theoretical paper is to particularize Pellegrino’s philosophy of medicine to construct an internal morality of physical therapy. Acknowledging that the internal morality of health care professions is founded in the relationship between a patient and a health care professional, this paper analyzes the nature and telos, or end, of physical therapy through 3 phenomena of physical therapy—the fact of disability, the act of profession, and the act of physical therapy. This paper claims that, rather than medicine’s clinical truth of a good treatment decision, physical therapy’s clinical truth is a good process that capacitates patients. This relational approach to an internal morality robustly underpins a philosophy and ethics of physical therapy.

Shared decision making (SDM) is a collaborative approach between clinicians and patients, where the best available evidence is integrated with patients’ values and preferences for managing their health problems. Shared decision making may enhance patient-centered care and increase patients’ satisfaction, engagement, adherence, and ability to self-manage their conditions. Despite its potential benefits, SDM is underutilized by physical therapists, and frequent mismatches between patients’ and therapists’ rehabilitation goals have been reported. Physical therapists can use evidence-based strategies, tools, and techniques to address these problems. This paper presents a model for SDM and explains its association with improved patient outcomes and relevance to situations commonly encountered in physical therapy. It describes freely available resources, including health literacy universal precautions, teach-back, motivational interviewing, decision aids, and patient-reported outcome measures that can help physical therapists integrate SDM into their clinical practices. This paper also explains SDM facilitators and barriers, suggests a theoretical framework to address them, and highlights the need for SDM promotion within physical therapy practice, education, administration, and research.

There has been increasing interest in the secondary prevention of chronic pain and pain-associated disability over the past 3 decades. In 2011, psychologically informed practice (PiP) was suggested as a framework for managing persistent and recurrent pain, and, since then, it has underpinned the development of stratified care linking risk identification (screening). Although PiP research trials have demonstrated clinical and economic advantage over usual care, pragmatic studies have been less successful, and qualitative studies have identified implementation difficulties in both system delivery and individual clinical management. Effort has been put into the development of screening tools, the development of training, and the assessment of outcomes; however, the nature of the consultation has remained relatively unexplored. In this Perspective, a review of the nature of clinical consultations and the clinician-patient relationship is followed by reflections on the nature of communication and the outcome of training courses. Consideration is given to the optimization of communication, including the use of standardized patient-reported measures and the role of the therapist in facilitating adaptive behavior change. Several challenges in implementing a PiP approach in day-to-day practice are then considered. Following brief consideration of the impact of recent developments in health care, the Perspective concludes with a brief introduction to the PiP Consultation Roadmap (the subject of a companion paper), the use of which is suggested as a way of structuring the consultation with the flexibility required of the patient-centered approach to guided self-management of chronic pain conditions.

Background. Mobility limitations are common following stroke and frequently lead to poor participation in physical activity (PA). Purpose. The purpose of this study was to describe PA across the various stages following stroke (acute, subacute, and chronic). Data Sources. Searches were conducted in 5 databases. Study Selection. Eligible studies included participants with stroke whose PA was quantitatively measured for at least 4 hours in a single session. Two reviewers independently reviewed titles and abstracts. Data Extraction. One reviewer extracted data and assessed quality using the Downs and Black checklist. Weighted means were calculated for PA outcomes. Data Synthesis. Searches yielded 103 eligible papers including 5306 participants aged 21 to 96 years. Devices (eg, activity monitors) were used in 73 papers, and behavioral mapping (observational monitoring) in 30. Devices show that people with stroke took on average 5535 steps per day (n = 406, 10 studies) in the subacute phase and 4078 steps (n = 1280, 32 studies) in the chronic phase. Average daily walking duration (% measured time) was higher in the chronic phase (9.0%, n = 100) than subacute (1.8%, n = 172), and sedentary time was >78% regardless of time post stroke. Acute data were lacking for these variables. Matched healthy individuals took an average of 8338 steps per day (n = 129). Behavioral mapping showed time in bed was higher in the acute than subacute phase (mean 45.1% versus 23.8%), with similar time spent sitting (mean 37.6% versus 32.6%). Limitations. Limitations of this review include not pooling data reported as medians. Conclusions. Physical activity levels do not meet guidelines following stroke. Time spent inactive and sedentary is high at all times. Increasing PA and developing standardized activity targets may be important across all stages of stroke recovery.

As collaborative efforts grow between rehabilitation scientists and those working in molecular/cellular technologies, physical therapists increasingly appreciate the relevance of regenerative rehabilitation and genomics in their research and practice. Traditionally, PTJ might not have been considered a natural home for papers focused on regenerative medicine and genomics, but the robust response to our call for papers suggests that the tide is turning. In fact, because of the number of submissions received, what started as a special issue has expanded into a special series . In this editorial introducing the first installment of the series, we provide a framework for the importance of this area to physical therapist practice and highlight the articles that inaugurate the series. The Alliance for Regenerative Rehabilitation Research and Training (AR3T) defines regenerative rehabilitation as “the integration of principles and approaches from the fields of rehabilitation science and regenerative medicine.”1 Regenerative medicine focuses on the enhancement of endogenous stem cell function or the transplantation of exogenous stem cells to repair or replace tissue function that has been lost due to injury, disease, or aging. As such, the efficacy of rehabilitation interventions to restore physical functioning may be enhanced through the use of cellular and other regenerative therapies. Of no surprise to those in the rehabilitation field, regenerative medicine technologies have been shown to benefit from the application of targeted and specific mechanical stimuli. Advances in the field of regenerative medicine offer exciting new opportunities to enhance tissue regenerative capacity where the endogenous response fails, thereby opening up the scope of physical therapist practice where physical therapists are experts in the prescription of physical activity and modalities to promote tissue healing and recovery. The potential to synergize rehabilitation practice and regenerative medicine technologies is elegantly …

BackgroundThe generation of research can be likened to the production of consumer goods, with a producer (the study authors and funders), a product (the study and publications arising from it), and consumers (those who read and cite the published study).ObjectiveThe aim of this study was to use bibliometric indexes to track changes in the producers, products, and consumers of the journal Physical Therapy from 1945 through 2010.DesignAn analysis of published manuscripts (excluding letters, editorials, corrections, commentaries, and book reviews) in Physical Therapy was performed using a reliable bibliometric audit tool. Articles were sampled every 3 months and at 5-year intervals over a 65-year period. Information relating to authorship, the research methods used, and citation patterns was collected. Data were analyzed descriptively.ResultsThere have been substantial shifts in the nature of research published over the last 65 years in Physical Therapy. In 1945, the typical paper was anecdotal and authored by 1.4 American authors (working in hospitals), and consisted of 4 pages and 4 references. In 2010, the typical paper used a cross-sectional survey or randomized controlled trial design, with 4.6 multinational authors (working in universities), and consisted of 12 pages and 49 references.LimitationsFindings are specific to the articles published in Physical Therapy that were sampled in this bibliometric analysis.ConclusionsThe changes seen in the research published in Physical Therapy mirror the shifts that have occurred in other industries: increasing quantification, standardization, collaboration, and internationalization. These trends are likely to continue in the future.

With funding from a cooperative agreement from the National Institute on Disability and Rehabilitation Research, we have worked for the past 5 years on the development of a rehabilitation treatment taxonomy, a system of classifying all treatments delivered by all rehabilitation disciplines for all diagnostic groups of patients, whatever the setting in which these services are delivered. To date, we have focused on developing a conceptual framework for such a taxonomy, specifying the scope of the taxonomy and the basis for classifying treatments. A recent supplement of the Archives of Physical Medicine and Rehabilitation contained a series of articles setting forth the background for the project, our approach to conceptual issues, and the need to classify treatments based on a theory of how active ingredients bring about change in a clinical target of treatment (some aspect of patient functioning) through a specific mechanism of action.1 It also contains papers on how therapists view classification and lessons learned during a previous effort at classifying learning interventions, as well as commentaries by various scholars who had an opportunity to review these papers. Here we summarize the key points. The field of rehabilitation has made substantial advances in defining and measuring the functional outcomes of the rehabilitation process and the patient characteristics that are associated with those outcomes. However, we lack a rigorous and shared approach to defining, classifying, and measuring the rehabilitation treatments that are hypothesized to moderate the relationships between patient factors and outcomes. At present, rehabilitation treatments may be described as number …

Objective Physical therapy is placing new emphasis on how the profession might contribute to improving population health. However, little is known about the nature of population-based practice (PBP) of physical therapists. Therefore, the purpose of this study was to develop a view of PBP from the perspective of physical therapists engaged in it. Methods Twenty-one physical therapists participating in PBP were interviewed. Qualitative descriptive analysis was used to summarize results. Results Most of the reported PBP was at the community and individual level, and the most common types of PBP were health teaching and coaching, collaboration and consultation, and screening and outreach. Three topic areas were identified (with respective themes): characteristics of PBP (meeting group or community needs, promotion and prevention, access, and movement), preparation for PBP (core vs elective, experiential learning, social determinants of health, and health behavior change), and rewards and challenges of PBP (intrinsic rewards, funding and resources, professional recognition, and complexity of behavior change). Conclusion PBP in physical therapy presents practitioners with rewards and challenges as they work to improve the health of populations. Impact Physical therapists who are currently engaged in PBP are, in effect, defining the role of the profession in improving health at a population level. The information in this paper will help the profession move from a theoretical view of the role of physical therapists in improving population health to understanding what this role looks like in practice.

To the editor: The authors are to be complimented for a strong paper describing a methodologically complex process in an understandable manner. Although others have applied computerized adaptive testing (CAT) applications in outpatient rehabilitation for several years,1 Jette et al2 are the first to publish results of a practical application of a CAT in a peer-reviewed journal. The strength of the work by Jette et al lies in the process used to develop the product. Item response theory (IRT) methods and CAT applications have the potential to be the foundation of outcomes measurement development in rehabilitation just as they were in educational measurement.3 We should not forget that IRT and CAT are not new; they are just new to rehabilitation and medicine. Jette et al discuss in the current paper and in earlier work how these methods can be used to develop a new outcomes scale, assess the strengths and weaknesses of the scale, and discuss how a scale can be improved when scale deficits are identified via practical application in busy clinics. These methods are sorely needed for many common paper-and-pencil instruments that are so popular in rehabilitation. The study is not without limitations, many of which are detailed nicely by Jette et al. One psychometric issue not discussed relates to differential item functioning (DIF).4 Differential item functioning occurs when patients from different groups—for example, patients with hip versus knee impairments—have different probabilities of endorsing item response categories. …

In the summer of 2018, The American Council of Academic Physical Therapy appointed 9 individuals versed in simulation education to form the Strategic Initiative Panel on Simulation to (1) investigate the use of simulation in physical therapist education, (2) explore the role of simulation in meeting accreditation standards and curriculum elements related to clinical education and interprofessional education, and (3) describe models and best practices for the use of simulation in physical therapist education. Over the 3 years of Strategic Initiative Panel on Simulation work, the panel identified several significant gaps in simulation education and research practice. This paper clarifies the essential elements required to optimize the delivery of simulation-based education in physical therapy following best practices, frames the existing challenges to move the profession forward, and recommends specific actions needed to address the many continued questions related to the effective use of simulation-based education in physical therapist education.

The purpose of this study was to examine the interrater reliability of grades obtained by physical therapy and occupational therapy tutors in rating their students' term papers. This study was carried out in two phases. In phase 1, four student essay papers (two physical therapy students' papers and two occupational therapy students' papers) with grades that had been assigned from the previous year's course were randomly selected from a bank of papers. These papers were independently rated by three course planners (who were responsible for planning, coordinating, and tutoring in the course), and agreement as to the assignment of grades for each paper was established. In phase 2, the same students' essays were rated independently by eight course tutors. To test for differences among students' written essay papers and for differences among the raters in the subcategories of discipline (physical therapy versus occupational therapy) and level of expertise (novice versus experienced) in grading essays, a three-way analysis of variance was performed. An intraclass correlation coefficient (ICC) was calculated for interrater reliability. Although there were no statistically significant differences among the tutors with regard to their discipline and expertise, the reliability analysis produced an ICC of .79. Strategies to enhance the reliability of grading essays are discussed.

Objective Patients with neck pain commonly have altered activity of the neck muscles. The craniocervical flexion test (CCFT) is used to assess the function of the deep neck flexor muscles in patients with musculoskeletal neck disorders. Systematic reviews summarizing the measurement properties of the CCFT are outdated. The objective of this study was to systematically review the measurement properties of the CCFT for assessing the deep neck flexor muscles. Methods The data sources MEDLINE, EMBASE, Physiotherapy Evidence Database, Cochrane Central Register of Controlled Trials, Scopus, and Science Direct were searched in April 2019. Studies of any design that reported at least 1 measurement property of the CCFT for assessing the deep neck flexor muscles were selected. Two reviewers independently extracted data and rated the risk of bias of individual studies using the COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) risk-of-bias checklist. The overall rating for each measurement property was classified as “positive,” “indeterminate,” or “negative.” The overall rating was accompanied with a level of evidence. Results Fourteen studies were included in the data synthesis. The ratings were positive, and the level of evidence was moderate for interrater and intrarater reliability and convergent validity. There was conflicting rating and level of evidence for discriminative validity. Measurement error was indeterminate, with an unknown level of evidence. Responsiveness was negative, with a limited level of evidence. A limitation of this study was that only papers published in English were included. Conclusions The CCFT is a valid and reliable test that can be used in clinical practice as an assessment test. Because of the conflicting and low-quality evidence, caution is advised when using the CCFT as a discriminative test and as an outcome measure. Future better-designed studies are warranted.

Over the last decade, there has been a marked increase in attention to, and interest in, femoroacetabular impingement syndrome (FAIS). Despite continued efforts by researchers and clinicians, the development, progression, and appropriate treatment of FAIS remains unclear. While research across various disciplines has provided informative work in various areas related to FAIS, the underlying pathomechanics, time history, and interaction between known risk factors and symptoms remain poorly understood. The purpose of this perspective is to propose a theoretical framework that describes a potential pathway for the development and progression of FAIS. This paper aims to integrate relevant knowledge and understanding from the growing literature related to FAIS to provide a perspective that can inform future research and intervention efforts.

Objective The purpose of this review was to identify quality indicators described in the literature that may be used as quality measures in hospital physical therapy units. Methods The following sources were searched for quality indicators or articles: Web of Science, MEDLINE, IBECS, Latin American and Caribbean Health Sciences Literature, Cumulative Index of Nursing and Allied Health, Academic Search Complete, SportDiscus, SciELO, PsychINFO, Consejo Superior de Investigaciones Cientificas, and Scopus databases; the Agency for Healthcare Research and Quality, National Health System Indicator Portal, Joint Commission on Accreditation of Healthcare Organizations, and Organisation for Economic Co-operation and Development websites; and the National Quality Forum’s measures inventory tool. Search terms included “quality indicator,” “quality measure,” “physiotherapy,” and “physical therapy.” Inclusion criteria were articles written in English, Spanish, French, or Portuguese aimed at measuring the quality of care in hospital physical therapy units. Evidence-based indicators with an explicit formula were extracted by 2 independent reviewers and then classified using the structure-process-outcome model, quality domain, and categories defined by a consensus method. Results Of the 176 articles identified, only 19 met the criteria. From these articles and from the indicator repository searches, 178 clinical care indicators were included in the qualitative synthesis and presented in this paper. Process and outcome measures were prevalent, and 5 out of the 6 quality domains were represented. No efficiency measures were identified. Moreover, structure indicators, equity and accessibility indicators, and indicators in the cardiovascular and circulatory, mental health, pediatrics, and intensive care categories were underrepresented. Conclusions A broad selection of quality indicators was identified from international resources, which can be used to measure the quality of physical therapy care in hospital units. Impact This review identified 178 quality of care indicators that can be used in clinical practice monitoring and quality improvement of hospital physical therapy units. The results highlight a lack of accessibility, equity, and efficiency measures for physical therapy units.

Epigenetic processes enable environmental inputs such as diet, exercise, and health behaviors to reversibly tag DNA with chemical “marks” that increase or decrease the expression of an individual’s genetic template. Over time, epigenetic adaptations enable the effects of healthy or unhealthy stresses to become stably expressed in the tissue of an organism, with important consequences for health and disease. New research indicates that seemingly non-biological factors such as social stress, poverty, and childhood hardship initiate epigenetic adaptations in gene pathways that govern inflammation and immunity, two of the greatest contributors to chronic diseases such as diabetes and obesity. Epigenetic processes therefore provide a biological bridge between the genome—an individual’s genetic inheritance—and the Social Determinants of Health—the conditions in which they are born, grow, live, work, and age. This Perspective paper argues that physical therapy clinicians, researchers, and educators can use the theoretical framework provided by the International Classification of Functioning, Disability, and Health (ICF model) to harmonize new discoveries from both public health research and medically focused genomic research. The ICF model likewise captures the essential role played by physical activity and exercise, which initiate powerful and widespread epigenetic adaptations that promote health and functioning. In this proposed framework, epigenetic processes transduce the effects of the social determinants of health and behaviors such as exercise into stable biological adaptations that affect an individual’s daily activities and their participation in social roles. By harmonizing “nature” and “nurture,” physical therapists can approach patient care with a more integrated perspective, capitalizing on novel discoveries in precision medicine, rehabilitation science, and in population-level research. As the experts in physical activity and exercise, physical therapists are ideally positioned to drive progress in the new era of patient-centered population health care.

The COVID-19 pandemic has negatively impacted the health of people from communities of color and people of limited socioeconomic means in a disproportionate way due to social determinants of health (SDoH). The Centers for Disease Control defines SDoH as the “conditions in the places where people live, learn, work, and play that affect a wide range of health and quality-of life-risks and outcomes.” A related construct, social determinants of learning (SDoL), includes contextual conditions and variables that impact students’ ability to optimally participate in their education, including academic and clinical development. SDoL directly impact students’ ability to participate in the educational process. During the COVID-19 pandemic, students struggling with SDoH and, by extension SDoL, may be more likely to have sick family members, caregiving responsibilities, food and housing insecurity, and obligations to supplement lost family wages. SDoL are also influenced by individual experiences within and outside of the classroom. Beyond bringing this matter to the attention of our profession, especially clinical and academic educators, we must take action to reach and support students who are at higher academic risk due to the SDoL. The purpose of this paper is to: (1) define SDoL, (2) explain how SDoL are impacting DPT and physical therapist assistant students, and (3) discuss actions that physical therapists and physical therapist assistants can take to mitigate the effects of SDoL on current DPT and physical therapist assistant students., This Perspective is one of the first explorations of how SDoL affect physical therapy students during the pandemic and provides concrete suggestions on how educators in both academic and clinical settings can help students succeed when they are negatively affected by SDoL.

The American Physical Therapy Association’s Vision Statement of 2013 asserts that physical therapists optimize movement in order to improve the human experience. In accordance with this vision, physical therapists strive to be recognized as experts in movement analysis. However, there continues to be no accepted method to conduct movement analysis, nor an agreement of key terminology to describe movement observations. As a result, the Academy of Neurologic Physical Therapy organized a task force that was charged with advancing the state of practice with respect to these issues, including the development of a proposed method for movement analysis of tasks. This paper presents the work of the Task Force, which includes (1) development of a method for conducting movement analysis within the context of the movement continuum during 6 core tasks (sitting, sit to stand, standing, walking, step up/down, and reach/grasp/manipulate); (2) glossary of movement constructs that can provide a common language for movement analysis across a range of tasks: symmetry, speed, amplitude, alignment, verticality, stability, smoothness, sequencing, timing, accuracy, and symptom provocation; and (3) recommendations for task and environmental variations that can be systematically applied. The expectation is that this systematic framework and accompanying terminology will be easily adapted to additional patient or client-specific tasks, contribute to development of movement system diagnostic labels, and ultimately improve consistency across patient/client examination, evaluation, and intervention for the physical therapy profession. Next steps should include validation of this framework across patient/client groups and settings.

Last month I used the Editor's Note to debunk myths about the Journal and its peer-review process. My Editorial Board has reminded me about a few more rumors that need “busting.” “When your paper is rejected, it's all over.” Every author who submits to our Journal receives a “disposition” (decision) letter written by the Editor. The Editor explains the decision—which usually is based on a summary of the reviewers' comments and the comments of the Editorial Board member (EBM) or the Associate Editorial Board Member (AEBM)—and sometimes elaborates on these comments. Most important, the letter contains comments on whether the paper can be resubmitted. We want to see papers with potential resubmitted after authors make the revisions suggested by the reviewer team. We ask authors who need any clarification to contact the EBM, the AEBM, or the Editor, and we supply phone numbers and e-mail addresses in every disposition letter. Nothing saddens me or the review team more than to see a manuscript that could be resubmitted lost to our readers. Rejection feels lousy, and there is no getting around it. As I often write in disposition letters: As an author who has had my own papers rejected, I know that this decision is disappointing to you. Remember that all manuscripts submitted to the Journal are reviewed by content experts. The comments offered by the reviewer team are intended to guide you. The goal of this process is to ensure that credible information is presented as clearly as possible for the reader, and, in many ways, it assists authors in clearly and accurately communicating their ideas and data. When we say that we believe a manuscript can be successfully revised and resubmitted, we mean it! Resubmitted manuscripts often proceed swiftly through the …

Explaining the onset and maintenance of pain can be challenging in many clinical presentations. Allostasis encompasses the mechanisms through which humans adapt to stressors to maintain physiological stability. Due to related neuro-endocrine-immune system effects, allostasis and allostatic load (the cumulative effects on the brain and body that develop through the maintenance of physiological stability) offer the potential to explain the development and maintenance of musculoskeletal pain in certain cases. This paper outlines the concept of allostatic load, highlights the evidence for allostatic load in musculoskeletal pain conditions to date, and discusses mechanisms through which allostatic load influences pain, with particular focus on hypothalamic–pituitary–adrenal axis and sympathetic nervous system function and central, brain-driven governance of these systems. Finally, through case examples, consideration is given as to how allostatic load can be integrated into clinical reasoning and how it can be used to help explain pain to individuals and guide clinical decision-making. Impact Awareness of the concept of allostatic load, and subsequent assessment of physical and psychological stressors potentially contributing to allostatic load, may facilitate a broader understanding of the multidimensional presentations of many people with pain, both acute and persistent. This may facilitate discussion between clinicians and their patients regarding broader influences on their presentations and drive more targeted and inclusive pain management strategies.

Diet and nutrition are critical components of health, recovery from disease and illness, performance, and normal growth across the lifespan. Thus, it is important for physical therapists to be knowledgeable about nutrition and to have competency in providing information and guidance to patients/clients. Yet, there is an overwhelming amount of diet and nutrition information available from numerous sources, which makes it difficult to reach conclusions and determine the importance and relevance to patient care. The purpose of this perspective paper is to increase the knowledge and skills of physical therapists by providing guidelines for healthy eating and outlining diet and nutrition information most relevant for physical therapist practice and to clarify professional scope of practice related to diet and nutrition, including boundaries created by law, and the connection between healthy eating and health outcomes, muscle strength, bone health, and wound healing.

Once upon a time, the primary function of journals was to offer researchers and academics in search of status and tenure a place to publish, and to provide graduate students with an outlet for their efforts. Although few people would admit it, at that time there was more concern about how authors would be viewed by their peers (by “peers,” I mean their colleagues who also conducted and published research) and how readers would deal with new information. Those days have almost disappeared. Now as then, dynamic tension exists among authors, editors, and readers. The arrogance of the old days has diminished, and few authors today would state publicly that it is the “reader's problem” when the reader cannot understand a paper or apply its findings. But there still is some resentment on the part of authors when editors demand that they write readable papers. Similarly, journals still hear from readers who believe that articles are too complicated to be understood easily. Some readers seem to want everything pre-digested and do not care what is lost in the process. The Journal does care, however. The Journal Editors take no solace from the fact that two of their most important constituent groups may not be completely happy. The old line is that if you are getting criticism from both sides, you are probably doing something …

Articles that appear in Physical Therapy have passed through what is generally agreed upon to be a rather demanding peer-review process, a process that is designed to assist authors in refining and improving their manuscripts and to ensure that all published papers meet a minimal level of credibility. We do not publish research papers unless we believe that the paper is appropriate for our readers and contains a credible method used in an appropriate manner to answer a meaningful question. If the process is so rigorous, why do we often invite commentaries and conduct conferences in which people comment on articles? It's certainly not because we have second thoughts or hesitations about the articles! If we have concerns about a paper, either we will not publish it or we will continue to work with the authors to eliminate the source of our concerns.…

Objective The iWalk study showed significant increase in use of the 10-Meter Walk Test (10MWT) and 6-Minute Walk Test (6MWT) poststroke following provision of a toolkit. This paper examined the influence of contextual circumstances on use of the toolkit and implementation strategy across acute care and inpatient and outpatient rehabilitation settings. Methods A theory-based toolkit and implementation strategy was designed to support guideline recommendations to use standardized tools for evaluation of walking, education, and goal-setting poststroke. The toolkit comprised a mobile app, video, and educational guide outlining instructions for 3 learning sessions. After completing learning sessions, 33 physical therapists and 7 professional leaders participated in focus groups or interviews. As part of a realist evaluation, the study compared and synthesized site-specific context-mechanism-outcome descriptions across sites to refine an initial theory of how the toolkit would influence practice. Results Analysis revealed 3 context-mechanism-outcomes: (1) No onsite facilitator? No practice change in acute care: Without an onsite facilitator, participants lacked authority to facilitate and coordinate the implementation strategy; (2) Onsite facilitation fostered integration of select practices in acute care: When onsite facilitation occurred in acute care, walk test administration and use of reference values for patient education were adopted variably with high functioning patients; (3) Onsite facilitation fostered integration of most practices in rehabilitation settings: When onsite facilitation occurred, many participants incorporated 1 or both tests to evaluate and monitor walking capacity, and reference values were applied for inpatient and outpatient education and goal setting. Participants preferentially implemented the 10MWT over the 6MWT because set-up and administration were easier and a greater proportion of patients could walk 10 m. Conclusion Findings underscore contextual factors and activities essential to eliciting change in assessment practice in stroke rehabilitation across care settings. Impact This study shows that to foster recommended walking assessment practices, an onsite facilitator should be present to enable learning sessions and toolkit use.

To The Editor: I was very excited to read the professional perspective “How Should Treatments Be Critiqued for Scientific Merit?”1 by Susan R Harris in the February 1996 issue of Physical Therapy . This clear and powerful paper should be required reading for all therapists. I have assigned it to my scientific inquiry class to be analyzed and discussed. We need to remain open-minded about physical therapy treatment approaches while still maintaining some degree of skepticism for standard as well as nonstandard therapies. As Dr Harris has pointed out, we need to depend on previous research reported in peer-reviewed journals. In this way, we will build a solid base upon which we can expand our profession. I would like to use an example in Dr Harris' paper to elaborate on a problem that might occur when reading another's review of literature.… [ ARTICLE][1] [1]: /lookup/volpage/76/175?iss=2