Search

Objective: To compare single and multiple physiotherapy sessions to improve pain, function, and quality of life (QoL) in patients with musculoskeletal disorders (MSKDs)., Data Sources: AMED, Cinahl, SportsDiscus, Medline, Cochrane Register of Clinical Trials, Physiotherapy Evidence Database, and reference lists., Study Selection: Randomized controlled trials (RCTs) comparing single and multiple physiotherapy sessions for MSKDs., Data Extraction: Two reviewers extracted data and assessed risk of bias and certainty of evidence using Cochrane Risk of Bias tool 2.0 and Grading of Recommendation Assessment, Development, and Evaluation., Data Synthesis: Six RCTs (n=2090) were included (conditions studied: osteoporotic vertebral fracture, neck, knee, and shoulder pain). Meta-analyses with low-certainty evidence showed a significant pain improvement at 6 months in favor of multiple sessions compared with single session interventions (3 RCTs; n=1035; standardized mean difference [SMD]: 0.29; 95% CI: 0.05 to 0.53; P=.02) but this significant difference in pain improvement was not observed at 3 months (4 RCTs; n=1312; SMD: 0.39; 95% CI: -0.11 to 0.89; P=.13) and at 12 months (4 RCTs; n=1266; SMD: -0.05; 95% CI: -0.49 to 0.39; P=.82). Meta-analyses with low-certainty evidence showed no significant differences in function at 3 (4 RCTs; n=1583; SMD: 0.05; 95% CI: -0.11 to 0.21; P=.56), 6 (4 RCTs; n=1538; SMD: 0.06; 95% CI: -0.12 to 0.23; P=.53) and 12 months (4 RCTs; n=1528; SMD: 0.08; 95% CI: -0.08 to 0.25; P=.30) and QoL at 3 (4 RCTs; n=1779; SMD: 0.08; 95% CI: -0.02 to 0.17; P=.12), 6 (3 RCTs; n=1206; SMD: 0.03; 95% CI: -0.08 to 0.14; P=.59), and 12 months (4 RCTs; n=1729; SMD: -0.03; 95% CI: -0.12 to 0.07; P=.58)., Conclusions: Low certainty meta-analyses found no clinically significant differences in pain, function, and QoL between single and multiple physiotherapy sessions for MSKD management for the conditions studied. Future research should compare the cost-effectiveness of those different models of care., (Copyright © 2023 The Authors. Published by Elsevier Inc. All rights reserved.)

Objective: To determine the prospective association of pain coping strategies and symptoms of anxiety and depression with work absenteeism in people with upper limb musculoskeletal disorders., Data Sources: A systematic search of PubMed, Web of Science, Embase, Cochrane Library, and Scopus databases was conducted from inception to September 23, 2022., Study Selection: Prospective observational studies of adults with upper limb musculoskeletal disorders were included. Included studies had to provide data on the association of pain coping strategies (catastrophizing, kinesiophobia, self-efficacy or fear avoidance) or symptoms of anxiety and depression with work absenteeism., Data Extraction: Study selection, data extraction, and assessment of methodological quality (Newcastle Ottawa Scale) were performed by 2 independent authors. Random-effects models were used for quantitative synthesis., Data Synthesis: Eighteen studies (n=12,393 participants) were included. Most studies (77.8%) reported at least 1 significant association between 1 or more exposure factors (pain coping strategies or symptoms of anxiety and depression) and work absenteeism. Meta-analyses showed a statistically significant correlation between the exposure factors of catastrophizing (r=0.28, 95% confidence interval [CI]: 0.15 to 0.40; P<.0001) and symptoms of anxiety and depression (r=0.23, 95% CI: 0.10 to 0.34; P=.0003) with work absenteeism. The correlation between self-efficacy and work absenteeism was non-significant (r=0.24, 95% CI: -0.02 to 0.47; P=.0747)., Conclusions: Rehabilitation teams should consider assessing catastrophizing and symptoms of anxiety and depression to identify patients at risk for work absenteeism. Addressing these variables may also be considered in return-to-work programs for individuals with upper limb disorders., (Copyright © 2023 The Authors. Published by Elsevier Inc. All rights reserved.)

Objective: To compare the efficacy of region-specific exercises to general exercises approaches for adults with spinal or peripheral musculoskeletal disorders (MSKDs)., Data Sources: Electronic searches were conducted up to April 2020 in Medline, Embase, Cochrane Central Register of Controlled Trials, and Cumulative Index to Nursing and Allied Health., Study Selection: Randomized control trials (RCTs) on the efficacy of region-specific exercises compared to general exercises approaches for adults with various MSKDs., Data Extraction: Mean differences and standardized mean differences were calculated using random-effects inverse variance modeling. Eighteen RCTs (n=1719) were included. Cohorts were composed of participants with chronic neck (n=313) or low back disorders (n=1096) and knee osteoarthritis (OA) (n=310)., Data Synthesis: Based on low-quality evidence in the short-term and very low-quality in the mid- and long-term, there were no statistically significant differences between region-specific and general exercises in terms of pain and disability reductions for adults with spinal disorders or knee OA. Secondary analyses for pain reduction in the short-term for neck or low back disorders did not report any statistically significant differences according to very low- to low-quality of evidence., Conclusions: The difference in treatment effect remains uncertain between region-specific and general exercises approaches. Based on very low- to low-quality evidence, there appear to have no differences between both types of exercise approaches for pain reduction or disability for adults with spinal disorders. Future trials may change the current conclusions. More evidence is needed for region-specific exercises compared to general exercises for other peripheral MSKDs including knee OA., (Copyright © 2021. Published by Elsevier Inc.)

Objective: To calibrate the Lower Extremity Functional Scale (LEFS) items into a regional lower extremity physical function (LEPF) item bank and assess reliability, validity, and efficiency of computerized adaptive test (CAT) and short form (SF) administration modes., Design: Retrospective cohort., Setting: Data were collected from patients treated in outpatient rehabilitation clinics for musculoskeletal impairments of the hip, knee, foot, and ankle that responded to all 20 LEFS items at intake., Participants: Patients aged 14 years or older who started an episode of care during January 2016-October 2019 and identified the lower extremity region as the source of a primary musculoskeletal complaint. Total cohort included 78,186 patients (mean age, 53±19y, range, 14-89y)., Interventions: Not applicable., Main Outcome Measures: Item response theory (IRT) model assumptions of unidimensionality, local item independence, item fit, and presence of differential item functioning (DIF) were studied. LEPF-CAT- and LEPF-SF-generated scores were evaluated., Results: An 18-item solution was supported for its unidimensionality and fit to the IRT model, with reliability estimates >0.9 for all administration modes. No DIF impact on LEPF scores was identified. Scores discriminated between multiple patient groups in clinically logical ways and were highly responsive to change, with negligible floor or ceiling effects. CAT scores were generated using an average of 4.9 items (median, 4)., Conclusions: The LEPF scores were reliable, valid, and efficient for assessing perceived physical function of patients with musculoskeletal impairments of the hip, knee, foot, and ankle; thus, it was found suitable for research and routine clinical administration. These findings are limited to the type of patients included in this study, with further validation needed to assess their generalizability., (Copyright © 2021 The American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

Objective: To develop and evaluate a measure of clinician-observed and patient-performed self-care function for use during inpatient rehabilitation., Design: Retrospective analysis of self-care assessments collected by therapists using confirmatory factor analysis (CFA) followed by multidimensional item response theory (MIRT)., Setting: Freestanding inpatient rehabilitation hospital in the Midwestern United States., Participants: Inpatients (N=7719) with stroke, traumatic brain injury, spinal cord injury, neurologic disorders, and musculoskeletal conditions., Interventions: Not applicable MAIN OUTCOME MEASURES: A total of 19 clinician-selected self-care measures including the FIM and patient-performed, clinician-rated measures of balance, upper extremity function, strength, changing body position, and swallowing. Clinicians completed assessments on admission and at least 1 interim assessment., Results: CFA was completed for 3 patient groups defined by their highest level of balance (sitting, standing, walking). We reduced the number of items by 47.5% while maintaining acceptable internal consistency; unidimensionality within each item set required development of testlets. A recursive analysis defined a self-care measure with sensitivity (Cohen d max-min =1.13; Cohen d last-first .=0.91) greater than the FIM self-care items (d max-min .=0.94; d last-first .=0.83). The CFA models provided good to acceptable fit (root mean square error of approximations 0.03-0.06). Most patients with admission FIM self-care ratings of total assistance (88%, 297 of 338) made improvements on the MIRT self-care measure that were undetected by the FIM; the FIM detected no change for 26% of these patients (78 of 297). The remaining 74% (219 of 297) improved on the MIRT-based measure an average of 14 days earlier than was detected by the FIM., Conclusions: This MIRT self-care measure possesses measurement properties that are superior to the FIM, particularly for patients near its floor or ceiling. Methods assure accommodation for multidimensionality and high levels of sensitivity. This self-care measure has the potential to improve monitoring of self-care and manage therapy effectively during inpatient rehabilitation., (Copyright © 2020 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

Objective: To assess the effectiveness of instrument-assisted soft tissue mobilization (IASTM) to other treatments or placebo in athletes or participants without extremity or spinal conditions and individuals with upper extremity, lower extremity, and spinal conditions., Data Sources: The MEDLINE, EMBASE, CINAHL, and PEDro electronic databases were searched from January 1998 to March 2018., Study Selection: Randomized controlled trials of participants without extremity or spinal conditions or athletes and people with upper extremity, lower extremity, or spinal conditions, who revived IASTM vs other active treatment, placebo, or control (no treatment), to improve outcome (function, pain, range of motion)., Data Extraction: Two independent review authors extracted data, assessed the trials for risk of bias using the Cochrane Risk of Bias tool in included studies, and performed the rating of quality of individual trials per outcome across trials was also performed using the Grading of Recommendations, Assessment, Development, and Evaluations guidelines., Data Synthesis: Nine trials with 43 reported outcomes (function, pain, range of motion, grip strength), compared the addition of IASTM over other treatments vs other treatments. Six trials with 36 outcomes reported no clinically important differences in outcomes between the 2 groups. Two trials with 2 outcomes displayed clinically important differences favoring the other treatment (without IASTM) group. Six trials with 15 reported outcomes (pressure sensitivity, pain, range of motion, muscle performance), compared IASTM vs control (no treatment). Three trials with 5 outcomes reported no clinically important differences in outcomes between the 2 groups. Furthermore, in 1 trial with 5 outcomes, IASTM demonstrated small effects (standard mean difference range 0.03-0.24) in terms of improvement muscle performance in physically active individuals when compared to a no treatment group., Conclusion: The current evidence does not support the use of IASTM to improve pain, function, or range of motion in individuals without extremity or spinal conditions or those with varied pathologies., (Copyright © 2019 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

Objectives: To determine if the Patient-Reported Outcome Measurement Information System (PROMIS) physical function, pain interference, self-efficacy, and global rating of normal function (GRNF) scales are able to accurately characterize a patient's acceptable symptom state (PASS)., Design: A cross-sectional analysis, using receiver operator curves and chi-square analysis to explore criteria to determine thresholds (80% and 95% sensitivity/specificity) for PASS that are applicable to PROMIS and GRNF scales., Setting: Phone survey after primary care., Participants: Patients (N=94) attending primary care for musculoskeletal problems., Interventions: Not applicable., Main Outcomes Measures: Accuracy and proportion of patients classified as PASS Yes or No., Results: Receiver operator curve analysis showed significant area under the curve (AUC) values for each PROMIS scale (AUC>.72) and the GRNF rating (AUC=.74). Identified PROMIS thresholds suggested PASS was achieved when scores were at or slightly worse than the US population average. A score of ≥7 and ≤4 characterized patients that were PASS Yes and No, respectively, on the GRNF rating. A moderate (80%) specificity/sensitivity criteria yielded 72.3%-73.5% accuracy for a majority of participants (>69.9%)., Conclusion: This analysis suggests the PROMIS and GRNF scales are able to characterize PASS status with moderate accuracy (∼70%) for a large portion of patients (∼70%). New to this study is the association of self-efficacy with PASS status. PROMIS scales at or slightly worse than the US population average characterized PASS status., (Copyright © 2018 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

Objectives: Work-related components are an essential part of rehabilitation programs to support return to work of patients with musculoskeletal disorders. In Germany, a guideline for work-related medical rehabilitation was developed to increase work-related treatment components. In addition, new departments were approved to implement work-related medical rehabilitation programs. The aim of our study was to explore the state of implementation of the guideline's recommendations by describing the change in the delivered dose of work-related treatments., Design: Nonrandomized controlled trial (cohort study)., Setting: Fifty-nine German rehabilitation centers., Participants: Patients (N=9046) with musculoskeletal disorders were treated in work-related medical rehabilitation or common medical rehabilitation. Patients were matched one-to-one by propensity scores., Interventions: Work-related medical rehabilitation in 2014 and medical rehabilitation in 2011., Main Outcome Measures: Treatment dose of work-related therapies., Results: The mean dose of work-related therapies increased from 2.2 hours (95% confidence interval [CI], 1.6-2.8) to 8.9 hours (95% CI, 7.7-10.1). The mean dose of social counseling increased from 51 to 84 minutes, the mean dose of psychosocial work-related groups from 39 to 216 minutes, and the mean dose of functional capacity training from 39 to 234 minutes. The intraclass correlation of 0.67 (95% CI, 0.58-0.75) for the total dose of work-related therapies indicated that the variance explained by centers was high., Conclusions: The delivered dose of work-related components was increased. However, there were discrepancies between the guideline's recommendations and the actual dose delivered in at least half of the centers. It is very likely that this will affect the effectiveness of work-related medical rehabilitation in practice., (Copyright © 2018 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

Objective: To examine the validity of the self-report Work-Disability Functional Assessment Battery (WD-FAB) physical function scales relative to clinician ratings of function and a performance-based functional capacity evaluation called the Physical Work Performance Evaluation (PWPE)., Design: Cross-sectional., Setting: Outpatient rehabilitation., Participants: Adults (N=50) participating in physical therapy for musculoskeletal conditions., Interventions: Not applicable., Main Outcome Measures: Patients completed the PWPE and the WD-FAB physical function scales including Changing and Maintaining Body Position, Whole Body Mobility, Upper Body Function, and Upper Extremity Fine Motor. The physical therapist also answered the WD-FAB questions on the patient's physical functioning. The WD-FAB computer-adaptive test version administered up to 10 items for each scale. The PWPE produces ratings from 0 to 5 indicating overall Level of Work ability: 0 (unable to work); 1 (sedentary); 2 (light); 3 (medium); 4 (heavy); 5 (very heavy). The PWPE also produces Level of Work ability ratings in the Dynamic Strength, Position Tolerance, and Mobility subsections., Results: Participating in the study were 50 patients with 1 or more conditions (shoulder, n=21; knee, n=16; low back, n=13; ankle/foot, n=10; neck, n=8; hip, n=7). The patient-based WD-FAB scores demonstrated moderate, statistically significant correlations with the provider proxy WD-FAB report (R=.49-.65). The WD-FAB Upper Body Function scale scores demonstrated moderate strength relationships with the PWPE overall ratings. The Whole Body Mobility and Changing and Maintaining Body Position scales did not demonstrate statistically significant relationships with the PWPE overall ratings., Conclusions: We found moderate evidence for validity for the WD-FAB Upper Body Function, Whole Body Mobility, and Changing and Maintaining Body Position scales relative to clinician report and varied evidence relative to the PWPE in this clinical sample., (Copyright © 2018 American Congress of Rehabilitation Medicine. All rights reserved.)

Objective: To investigate frequency, type, and characteristics of work anxieties in patients with somatic illness., Design: Cross-sectional observation study., Setting: Neurology, orthopedic, and cardiology rehabilitation clinics., Participants: Patients (N=1610; age, 18-65y) with work anxieties., Interventions: Not applicable., Main Outcome Measures: Patients who scored high on at least 2 of 9 items in the work-anxiety screening questionnaire and who reported impairment were investigated with a differential diagnostic interview on work anxieties and with the Mini-International Neuropsychiatric Interview on non-work-related common mental disorders. Patients also filled out a self-rating questionnaire on their subjective symptom load and sociodemographic data., Results: Approximately 20% to 27% of the investigated inpatients in somatic rehabilitation (altogether n=393) received a work-anxiety diagnosis. Patients with orthopedic illness report highest work anxiety and have previous longest sick leave (20.6wk in the past 12mo). Patients with orthopedic illness suffer from work-related adjustment disorder with anxiety, social anxieties, and workplace phobias, whereas patients with cardiac illness are more often affected by hypochondriac anxieties. Anxieties of insufficiency and worrying occur equally in all indications., Conclusions: About a quarter of patients in somatic rehabilitation are in need of additional diagnostic attention owing to work anxieties. Differential diagnostic of work anxiety is needed for initiating adequate therapeutic action. Somatic rehabilitation physicians should be aware of work anxieties in their patients, especially in patients with orthopedic illness with previous long-term sick leave., (Copyright © 2017 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

Objective: To examine whether motivational interviewing (MI) leads to more sustainable return-to-work outcomes for injured workers undergoing rehabilitation., Design: Cluster randomized controlled trial., Setting: Workers' compensation rehabilitation facility., Participants: Claimants (N=728) undergoing rehabilitation for musculoskeletal conditions, who were predominantly employed (529, 72.7%) men (460, 63.2%) with chronic conditions (mean duration, 234d)., Interventions: MI is a goal-oriented, client-centered counseling approach that facilitates behavioral change through identifying and resolving ambivalence. Treating clinicians at the facility were randomized into 2 groups. One group included 6 clinicians who were trained to conduct MI interventions during rehabilitation, while the control group included 6 clinicians who continued standard procedures., Main Outcome Measures: Outcomes included compensation outcomes over 1 year after discharge. This included reception of disability benefits and recurrence rates. Analysis was stratified by admission employment status and included chi-square test, t test, and multivariable regression., Results: Participants included 728 claimants, of whom 367 (50.4%) were treated with MI. Unemployed claimants in the MI group received significantly more partial temporary disability benefits (mean, 8.2d vs 0.2d; P=.02), indicating return to modified work duties. Employed claimants in the control group had a higher recurrence rate (9.1% vs 4.5%; P=.04). The adjusted odds ratio for benefit recurrence was 2.7 (95% confidence interval, 1.1-6.5) after controlling for age, sex, and number of previous claims., Conclusions: Use of MI appears to lead to more sustainable return to work after rehabilitation and facilitates transition to modified work duties., (Copyright © 2017 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

Objective: To examine the state of psychometric validation in the health-related work outcome literature., Data Sources: We searched PubMed, PubMed Central, CINAHL, Embase (plus Embase Classic), and PsycINFO from inception to January 2016 using the following search terms: stroke, multiple sclerosis, epilepsy, spinal cord injury, brain injury, musculoskeletal disease, work, absenteeism, presenteeism, occupation, employment, job, outcome measure, assessment, work capacity evaluation, scale, and questionnaire., Study Selection: From the 22,676 retrieved abstracts, 597 outcome measures were identified. Inclusion was based on content analysis. There were 95 health-related work outcome measures retained; of these, 2 were treated as outliers and therefore are discussed separately. All 6 authors individually organized the 93 remaining scales based on their content., Data Extraction: A follow-up search using the same sources, and time period, with the name of the outcome measures and the terms psychometric, reliability, validity, and responsiveness, identified 263 unique classical test theory psychometric property datasets for the 93 tools. An assessment criterion for psychometric properties was applied to each article, and where consensus was not achieved, the rating delivered by most of the assessors was reported., Data Synthesis: Of the articles reported, 18 reporting psychometric data were not accessible and therefore could not be assessed. There were 39 that scored <20% of the maximum achievable score, 106 scored between 20% and 40%, 82 scored between 40% and 60%, 15 scored between 60% and 80%, and only 1 scored >80%. The 3 outcome measures associated with the highest scoring datasets were the Sheehan Disability Scale, the Fear Avoidance Beliefs Questionnaire, and the assessment of the Subjective Handicap of Epilepsy. Finally, only 2 psychometric validation datasets reported the complete set of baseline psychometric properties., Conclusions: This systematic review highlights the current limitations of the health-related work outcome measure literature, including the limited number of robust tools available., (Copyright © 2016. Published by Elsevier Inc.)

Objective: To investigate the effectiveness of aquatic exercise in improving lower limb strength in people with musculoskeletal conditions., Data Sources: A systematic search used 5 databases, including MEDLINE, CINAHL, Embase, SPORTDiscus, and The Cochrane Library., Study Selection: Randomized controlled trials evaluating aquatic exercise with a resistance training component for adults with musculoskeletal conditions compared with no intervention or land-based exercise were identified. Fifteen studies from the initial yield of 1214 met these criteria., Data Extraction: Data related to participant demographics, study design, and methods, interventions, and outcomes, including numerical means and SDs, were extracted independently by 2 reviewers., Data Synthesis: Nine of the 15 studies were of high quality, scoring at least 6 on the Physiotherapy Evidence Database Scale. Limited consideration of the prescription of resistance in the aquatic exercise and application of resistance training principles existed. Low- or very low-quality evidence indicates there was no difference in average effect between aquatic exercise and no exercise in improving hip abductor strength (standardized mean difference [SMD], .28; 95% confidence interval [CI], -.04 to .59), knee extensor strength (SMD, .18; 95% CI, -.03 to .40), knee flexor strength (SMD, .13; 95% CI, -.20 to .45), or lower limb endurance (SMD, .35; 95% CI, -.06 to .77). Low-quality evidence indicates no difference in average effect between aquatic and land exercise for knee extensor (SMD, -.24; 95% CI, -.49 to .02) or flexor strength (SMD, -.15; 95% CI, -.53 to .22)., Conclusions: It is likely that the inadequate application of resistance in water is a significant contributor to the limited effectiveness of aquatic exercise interventions in improving hip and knee muscle strength in people with musculoskeletal conditions. Future research is needed to quantify resistance with aquatic exercises and to determine if using opportunities for greater resistance in aquatic rehabilitation and appropriate resistance training principles can be more effective in improving muscle strength., (Copyright © 2016 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

Objective: To explore factors that might be relevant when designing a triage tool., Design: A mixed-methods study using multivariable logistic regression analysis to identify significant factors associated with requiring different levels of care, and qualitative focus groups exploring views of patients and physiotherapy clinicians regarding case complexity., Setting: A community-based adult musculoskeletal service delivering tier 1 (standard physiotherapy) and tier 2 care (complex care beyond the scope of standard physiotherapy) and providing onward referral to orthopedic clinics (tier 3)., Participants: Quantitative data were extracted from a random sample of patients (N=484) who had received treatment for musculoskeletal conditions. Patients and physiotherapists who had received care or who worked in the service participated in focus groups., Interventions: Not applicable., Main Outcome Measures: Themes that emerged from focus groups were compared against predictors of requiring complex care found to be significant (P<.05) after quantitative data analysis., Results: A total of 184 patients (38.0%; 95% confidence interval, 33.8-42.4) received complex care. Peripheral joint problems, unclear diagnosis, and symptoms affecting sleep were significant independent predictors of requiring complex care. These data supported some of the main themes raised at focus groups., Conclusions: A substantial proportion of patients receive tier 2 complex care. Further studies are needed to evaluate whether the predictive factors found to be significant in our study might be useful for developing a tool for more effective triage to the most appropriate tier of musculoskeletal care., (Copyright © 2016 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

The Kinesio taping method was developed in Japan for use in humans in 1979. The use of complementary therapies is becoming common in equine athletes and the discovery of Kinesio taping potential brought it into the animal world. Kinesio taping can be used to treat a wide range of clinical conditions, from tendon injuries to neurologic disorders and from muscle contractures to postural insufficiencies. Its use in veterinary medicine is promising, but relies heavily on evidence-based clinical reports. Further scientific research is needed to fully understand the real effectiveness of application., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Hydrotherapy has become a key element within equine rehabilitation protocols and is used to address range of motion, proprioception, strength, neuromotor control, pain, and inflammation. Various forms of hydrotherapy can be tailored to the individual's injury and the expected return to athletic performance. This article describes the mechanisms of action of hydrotherapies and potential use in the clinical management of equine musculoskeletal injuries., (Published by Elsevier Inc.)

The central body axis or core is a key component in controlling body posture and providing a stable platform for limb movements and generation of locomotor forces. Persistent dysfunction of the deep stabilizing muscles seems to be common in horses indicating a need for core training exercises to restore normal function. Core training should be performed throughout the horse's athletic career to maintain a healthy back and used therapeutically when back pain is identified. This article reviews the structure and function of the equine thoracolumbar spine with special reference to function, dysfunction, conditioning, and rehabilitation of the core musculature., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Objective: To investigate the predictive ability of the Upper-Limb Work Instability Scale (UL-WIS) for transitioning out of work among injured workers with chronic, work-related upper extremity disorders (WRUEDs)., Design: Secondary analysis of a 12-month cohort study with data collection at baseline and 3-, 6-, and 12-month follow-up. Survey questionnaires were used to collect data on an array of sociodemographic, health-related, and work-related variables., Setting: Upper extremity specialty clinics., Participants: Injured workers (N=356) with WRUEDs who were working at the time of initial clinic attendance., Interventions: Not applicable., Main Outcome Measure: Transitioning out of work., Results: Multivariable logistic regression that considered 9 potential confounders revealed baseline UL-WIS (range, 0-17) to be a statistically significant predictor of a subsequent transition out of work (adjusted odds ratio, 1.18; 95% confidence interval [CI], 1.07-1.31; P=.001). An assessment of predictive values across the UL-WIS score range identified cut-scores of <6 (negative predictive value, .81; 95% CI, .62-.94) and >15 (positive predictive value, .80; 95% CI, .52-.96), differentiating the scale into 3 bands representing low, moderate, and high risk of exiting work., Conclusions: The UL-WIS was shown to be an independent predictor of poor work sustainability among injured workers with chronic WRUEDs; however, when applied as a standalone tool in clinical settings, some limits to its predictive accuracy should also be recognized., (Copyright © 2015 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

Objective: To identify patient characteristics that influence physiotherapist's decisions on enrollment and attendance in a structured aerobic exercise program early after stroke., Design: Retrospective chart review., Setting: Rehabilitation hospital., Participants: Consecutive sample of people (N=345) admitted to inpatient stroke rehabilitation over a 2-year period., Interventions: Not applicable., Main Outcome Measures: Patient demographic characteristics, preexisting medical conditions, and poststroke outcome variables (neurological deficit, physical impairment, balance control, and functional mobility and independence) were compared between individuals enrolled and not enrolled in a structured aerobic exercise program. The rate of attendance was calculated for the enrolled group., Results: One hundred twenty-nine patients (38%) were enrolled in the structured aerobic exercise program. Patients who were older (P=.0093) and had cardiac disease (P=.012), cardioembolic sources (P=.0094), and arthritis (P=.031) were less likely to be enrolled in the structured aerobic exercise program. Poststroke outcome variables were not associated with enrollment. Among those enrolled, the rate of attendance was positively correlated with the FIM cognitive rating (r=.27; P=.0031)., Conclusions: Enrollment in structured aerobic exercise programs during inpatient stroke rehabilitation can be limited by safety concerns related to patients' cardiovascular and musculoskeletal status. Barriers associated with the perception of cardiovascular risk factors should be confronted because they do not preclude participation in cardiac rehabilitation. In addition, poststroke deficits do not limit participation in adapted aerobic exercise early after stroke. It is likely that the characteristics of the structured aerobic exercise program were integral to accommodate the breadth of poststroke deficits encountered in this study. Future research investigating physiotherapist and practice environment factors that influence the decision to prescribe and implement aerobic exercise is warranted., (Copyright © 2015 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

The use of brightness-mode ultrasound and Doppler ultrasound in physical medicine and rehabilitation has increased dramatically. The continuing evolution of ultrasound technology has also produced ultrasound elastography, a cutting-edge technology that can directly measure the mechanical properties of tissue, including muscle stiffness. Its real-time and direct measurements of muscle stiffness can aid the diagnosis and rehabilitation of acute musculoskeletal injuries and chronic myofascial pain. It can also help monitor outcomes of interventions affecting muscle in neuromuscular and musculoskeletal diseases, and it can better inform the functional prognosis. This technology has implications for even broader use of ultrasound in physical medicine and rehabilitation practice, but more knowledge about its uses and limitations is essential to its appropriate clinical implementation. In this review, we describe different ultrasound elastography techniques for studying muscle stiffness, including strain elastography, acoustic radiation force impulse imaging, and shear-wave elastography. We discuss the basic principles of these techniques, including the strengths and limitations of their measurement capabilities. We review the current muscle research, discuss physiatric clinical applications of these techniques, and note directions for future research., (Copyright © 2014 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

Objective: To investigate the effectiveness of aquatic exercise in the management of musculoskeletal conditions., Data Sources: A systematic review was conducted using Ovid MEDLINE, Cumulative Index to Nursing and Allied Health Literature, Embase, and The Cochrane Central Register of Controlled Trials from earliest record to May 2013., Study Selection: We searched for randomized controlled trials (RCTs) and quasi-RCTs evaluating aquatic exercise for adults with musculoskeletal conditions compared with no exercise or land-based exercise. Outcomes of interest were pain, physical function, and quality of life. The electronic search identified 1199 potential studies. Of these, 1136 studies were excluded based on title and abstract. A further 36 studies were excluded after full text review, and the remaining 26 studies were included in this review., Data Extraction: Two reviewers independently extracted demographic data and intervention characteristics from included trials. Outcome data, including mean scores and SDs, were also extracted., Data Synthesis: The Physiotherapy Evidence Database (PEDro) Scale identified 20 studies with high methodologic quality (PEDro score ≥6). Compared with no exercise, aquatic exercise achieved moderate improvements in pain (standardized mean difference [SMD]=-.37; 95% confidence interval [CI], -.56 to -.18), physical function (SMD=.32; 95% CI, .13-.51), and quality of life (SMD=.39; 95% CI, .06-.73). No significant differences were observed between the effects of aquatic and land-based exercise on pain (SMD=-.11; 95% CI, -.27 to .04), physical function (SMD=-.03; 95% CI, -.19 to .12), or quality of life (SMD=-.10; 95% CI, -.29 to .09)., Conclusions: The evidence suggests that aquatic exercise has moderate beneficial effects on pain, physical function, and quality of life in adults with musculoskeletal conditions. These benefits appear comparable across conditions and with those achieved with land-based exercise. Further research is needed to understand the characteristics of aquatic exercise programs that provide the most benefit., (Copyright © 2014 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

Objective: To examine whether use of functional capacity evaluation (FCE) leads to better outcomes for injured workers., Design: Cluster randomized controlled trial conducted with analysis at level of claimant., Setting: Rehabilitation facility., Participants: Participants included claimants (N=203); of these, 103 were tested with FCE. Data were collected on all claimants undergoing RTW assessment at the facility for musculoskeletal conditions. Participants were predominantly employed (59%) men (73%) with chronic musculoskeletal conditions (median duration, 496d)., Interventions: FCEs are commonly used to identify work abilities and inform return-to-work (RTW) decisions. Therefore, FCE results have important consequences. Clinicians who were trained and experienced in performing FCEs were randomized into 2 groups. One group included 14 clinicians who were trained to conduct a semistructured functional interview; the other group (control group) continued to use standard FCE procedures., Main Outcome Measures: Outcomes included RTW recommendations after assessment, functional work level at time of assessment and 1, 3, and 6 months after assessment, and compensation outcomes. Analysis included Mann-Whitney U, chi-square, and t tests., Results: All outcomes were similar between groups, and no statistically or clinically significant differences were observed. Mean differences between groups on functional work levels at assessment and follow-up ranged from 0.1 to 0.3 out of 4 (3%-8% difference, P>.05)., Conclusions: Performance-based FCEs did not appear to enhance RTW outcomes beyond information gained from semistructured functional interviewing. Use of functional interviewing has the potential to improve efficiency of RTW assessment without compromising clinical, RTW, or compensation outcomes., (Copyright © 2014 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

Objective: To investigate the feasibility of rehabilitation training with a new wearable robot., Design: Before-after clinical intervention., Setting: University hospital and private rehabilitation facilities., Participants: A convenience sample of patients (N=38) with limited mobility. The underlying diseases were stroke (n=12), spinal cord injuries (n=8), musculoskeletal diseases (n=4), and other diseases (n=14)., Interventions: The patients received 90-minute training with a wearable robot twice per week for 8 weeks (16 sessions)., Main Outcome Measures: Functional ambulation was assessed with the 10-m walk test (10MWT) and the Timed Up & Go (TUG) test, and balance ability was assessed with the Berg Balance Scale (BBS). Both assessments were performed at baseline and after rehabilitation., Results: Thirty-two patients completed 16 sessions of training with the wearable robot. The results of the 10MWT included significant improvements in gait speed, number of steps, and cadence. Although improvements were observed, as measured with the TUG test and BBS, the results were not statistically significant. No serious adverse events were observed during the training., Conclusions: Eight weeks of rehabilitative training with the wearable robot (16 sessions of 90min) could be performed safely and effectively, even many years after the subjects received their diagnosis., (Copyright © 2013 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

Objective: To investigate the impact of physiotherapy (PT) and occupational therapy (OT) services on long-stay home care patients with musculoskeletal disorders., Design: Observational study., Setting: Home care programs., Participants: All long-stay home care patients between 2003 and 2008 (N=99,764) with musculoskeletal disorders who received a baseline Resident Assessment Instrument for Home Care assessment, 1 follow-up assessment, and had discharge or death records., Interventions: PT and OT., Main Outcome Measures: The effects of PT and OT services on transitions in functional state, discharge from home care with service plans complete, institutionalization, and death were assessed via multistate Markov models., Results: Home care patients with deficiencies in instrumental activities of daily living and/or activities of daily living at baseline and who received home-based rehabilitation had significantly increased odds of showing functional improvements by their next assessment (for a state 3 to state 2 transition: odds ratio [OR]=1.17; 95% confidence interval [CI], 1.10-1.26; P<.0001; for a state 2 to state 1 transition: OR=1.36; 95% CI, 1.14-1.61; P=.0005). Receipt of PT/OT also significantly reduced the odds of mortality and institutionalization in this group., Conclusions: With increasing numbers of older adults with chronic conditions and limited funding for health care services, it is essential to provide the right services at the right time in a cost-effective manner. Long-stay home care patients who receive rehabilitation at home have improved outcomes and lower utilization of costly health services. Our findings suggest that investment in PT and OT services for relatively short periods may provide savings to the health care system over the longer term., (Copyright © 2013 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

Objective: To identify risk factors for work retention (a patients' ability to both obtain and retain employment) at 1 year after treatment for a chronic disabling occupational musculoskeletal disorder (CDOMD)., Design: Prospective cohort study., Setting: Consecutive patients undergoing interdisciplinary functional restoration treatment in a regional rehabilitation referral center., Participants: A sample of 1850 consecutive CDOMD patients, who were admitted to and completed a functional restoration program, were subsequently classified as work retention or nonwork retention at a 1-year posttreatment evaluation., Interventions: Not applicable., Main Outcome Measures: Measures, including medical evaluations, demographic and occupational data, psychosocial diagnostic evaluation, and validated measures of pain, disability, and depressive symptoms, were obtained at admission to, and discharge from, the program., Results: Using a multivariate logistic regression analysis, the following variables were found to be significant predictors of failure to retain work: older age (odds ratio [OR]=1.84; 95% confidence interval [CI], 1.33-2.54), female sex (OR=1.46; 95% CI, 1.09-1.94), nonworking status at discharge (OR=1.65; 95% CI, 1.11-2.45), extreme disability at admission (OR=1.46; 95% CI, 1.06-2.00), antisocial personality disorder (OR=2.11; 95% CI, 1.09-4.08), receipt of government disability benefits at admission (OR=2.28; 95% CI, 1.06-4.89), and dependence on opiate pain medications (OR=1.43; 95% CI, 1.02-2.00). The final model improved prediction by 75% over assigning all patients to the larger (work retention) group., Conclusions: This study identified demographic, psychosocial, and occupational factors that were predictive of failure to retain work. These risk factors may be used to individualize treatment plans for CDOMD patients in order to provide optimal functional restoration., (Copyright © 2012 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

Objective: To compare the responsiveness of 2 major systems developed for rehabilitation settings--the FIM and the interRAI Post Acute Care (PAC) assessment--in older patients., Design: Trained raters assessed patients with both tools at admission and discharge., Setting: Musculoskeletal (MSK) and geriatric rehabilitation units (GRUs) in 2 rehabilitation hospitals., Participants: Older adults receiving rehabilitation (N=208; mean age +/- SD, 78.5+/-9.3; 67% women)., Interventions: Not applicable., Main Outcome Measures: Responsiveness was evaluated using effect size (ES) and standardized response mean (SRM)., Results: ES and SRM were somewhat higher for the FIM motor (GRU ES=1.68, SRM=1.31; MSK ES=2.12, SRM=2.25) than the PAC (GRU ES=1.64, SRM=1.29; MSK ES=1.57, SRM=1.89) in both patient groups. Both tools were more responsive in MSKs than GRUs. This may reflect the greater frailty and clinical complexity of GRU patients., Conclusions: Both the FIM motor and the PAC were able to detect clinically relevant improvement in functional ability in older rehabilitation inpatients., (Copyright 2010 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

The application of manual techniques to pediatric athletic injuries has been considered alternative medicine. There are many injuries that are associated with loss of normal motion. Altered biomechanics can be readily identified and treated using manual methods. These include articular or thrust techniques, muscle energy, strain-counterstrain, and myofascial treatments, among others. Although there are few high-quality studies available, most available literature reports effectiveness of manual techniques in combination with therapeutic exercise for common pediatric motion restrictions.

Objectives: To evaluate the psychometric properties of the Manual Ability Measure-36 (MAM-36), a new hand function outcome measure, and to examine differences in manual abilities and item parameters in patients with neurologic and musculoskeletal conditions., Design: Convenience sample from 2 time periods, cross-sectional., Setting: Outpatient rehabilitation units and private hand clinics., Participants: Patients (N=337; mean age, 50.3+/-14.9y) with a variety of neurologic and musculoskeletal (orthopedic) diagnoses. Most of these individuals were community dwelling, and all had residual functional limitations in the hand(s)., Interventions: Not applicable., Main Outcome Measures: Rasch analysis was performed on MAM-36 data to evaluate both scale structure and psychometric properties, which include rating distribution, step measures, item fit, separation, and dimensionality. A t test was performed to examine the differences in manual abilities in patients with the 2 conditions. Uniform differential item functioning (DIF) between neurologic and musculoskeletal groups was examined. (DIF occurs when subgroup members within the sample with the same level of the underlying trait being measured respond differently to an individual item.) Manual ability estimates were recalibrated with step and common item anchoring; they were compared with those derived from the original analysis., Results: The 36 items measured a single construct with no misfitting items. The scale was used as intended. The items can reliably separate the participants into 5 ability strata. Neurologic patients had a significantly lower mean manual ability than musculoskeletal patients. Fourteen items exhibited DIF. However, DIF had no effect on either scale quality or calibration of manual ability. We decided that a single rating scale is appropriate for both groups., Conclusions: This study showed that the MAM-36 has more than adequate psychometric properties and can be used as a generic outcome measure for patients with a wide variety of clinical diagnoses., (Copyright 2010 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

Objective: To identify the risk factors for noncompletion of a functional restoration program for patients with chronic disabling occupational musculoskeletal disorders., Design: Prospective cohort study., Setting: Consecutive patients undergoing functional restoration treatment in a regional rehabilitation referral center., Participants: A sample of 3052 consecutive patients, classified as either completers (n=2367) or noncompleters (n=685), who entered a functional restoration program., Interventions: Not applicable., Main Outcome Measures: The measures used included medical evaluations, demographic data, Diagnostic and Statistical Manual of Mental Disorders psychiatric diagnoses, the Minnesota Multiphasic Personality Inventory, and validated questionnaires evaluating pain, depression, and occupational factors., Results: The findings revealed that patients who did not complete the program had a longer duration of total disability between injury and admission to treatment (completers=20mo vs noncompleters=13mo; P<.001). Furthermore, patients who were opioid-dependent were 1.5 times more likely to drop out of rehabilitation, and patients diagnosed with a socially problematic Cluster B Personality Disorder were 1.6 times more likely to drop out., Conclusions: Although some risk factors associated with program noncompletion may be addressed in treatment, socially maladaptive personality disorders, long-neglected disability, and chronic opioid dependence are the major barriers to successful treatment completion. The patients identified with personality disorders may display resistance to treatment and may be difficult for the treatment staff to deal with. Early recognition of these treatment-resistant personality characteristics in the functional restoration process may assist the treatment team in developing more effective strategies to help this dysfunctional group.

Objective: To evaluate the quality of Functional Capacity Evaluation (FCE) information in predicting return to work (RTW)., Design: Prospective cohort study., Setting: Inpatient rehabilitation clinic., Participants: Patients (N=220) with chronic musculoskeletal disorders (MSD) conducting a medical rehabilitation., Interventions: Not applicable., Main Outcome Measures: Patients filled in questionnaires at admission and 1-year follow-up. An FCE was performed on admission. RTW was defined as a combination of employment at 1-year follow-up with a maximum of 6 weeks sick leave because of MSD in the postrehabilitation year. As predictive FCE information, the physical capacity (Dictionary of Occupational Titles categories 1-5), the number of test results not meeting work demands (0-25), and the tester's recommendation of work ability in the actual job (> or =6h/d) were analyzed. Logistic regression models (crude and adjusted for the concurrent predictors employment, preadmission sick leave, and patient's prognosis of RTW) were created to predict RTW., Results: Complete data were obtained for 145 patients. The sample showed a non-RTW at 1-year follow-up for 37.9%. All FCE information showed significant relations to RTW (r=.28-.43; P<.05). In the crude as well as in the adjusted regression models, all FCE information predicted RTW, but the models' quality was low. The integration of FCE information led to an increase of 5%. The predictive efficiency was poor. The adjusted model for failed tests showed a substantial improvement compared with the reference model (concurrent predictors only)., Conclusions: There was a significant relation between FCE information and RTW with and without concurrent predictors, but the predictive efficiency is poor. Primarily, the number of failed tests seemed to be of significance for patients with ambiguous RTW prognosis. A first proposal for a prediction rule was discussed.

Objective: To assemble and synthesize the best evidence on the epidemiology, diagnosis, prognosis, treatment, and prevention of musculoskeletal injuries and pain in dancers., Data Sources: Medline, CINAHL, PsycINFO, Embase, and other electronic databases were searched from 1966 to 2004 using key words such as dance, dancer, dancing, athletic injuries, occupational injuries, sprains and strains, and musculoskeletal diseases. In addition, the reference lists of relevant studies were examined, specialized journals were hand-searched, and the websites of major dance associations were scanned for relevant information., Study Selection: Citations were screened for relevance using a priori criteria, and relevant studies were critically reviewed for scientific merit by the best evidence synthesis method. After 1865 abstracts were screened, 103 articles were reviewed, and 32 (31%) of these were accepted as scientifically admissible (representing 29 unique studies)., Data Extraction: Data from accepted studies were abstracted into evidence tables relating to the prevalence and associated factors, incidence and risk factors, diagnosis, treatment, economic costs, and prevention of musculoskeletal injuries and pain in dancers., Data Synthesis: The scientifically admissible studies consisted of 15 (52%) cohort studies, 13 (45%) cross-sectional studies, and 1 (3%) validation study of a diagnostic assessment tool. There is a high prevalence and incidence of lower extremity and back injuries, with soft tissue and overuse injuries predominating. For example, lifetime prevalence estimates for injury in professional ballet dancers ranged between 40% and 84%, while the point prevalence of minor injury in a diverse group of university and professional ballet and modern dancers was 74%. Several potential risk factors for injury are suggested by the literature, but conclusive evidence for any of these is lacking. There is preliminary evidence that comprehensive injury prevention and management strategies may help decrease the incidence of future injury., Conclusions: The dance medicine literature is young and heterogeneous, limiting our ability to draw consistent conclusions. Nonetheless, the best available evidence suggests that musculoskeletal injury is an important health issue for dancers at all skill levels. Better quality research is needed in this specialized area. Future research would benefit from clear and relevant research questions being addressed with appropriate study designs, use of conceptually valid and clinically meaningful case definitions of injury and pain, and better reporting of studies in line with current scientific standards.

Musculoskeletal conditions often manifest with the onset of pain and the resulting physical limitations. Musculoskeletal pain is almost inevitable in an individual's lifetime. It is one of the most common reasons for self-medication and entry into the health care system. Musculoskeletal pain affects 1 in 4 adults and is the most common source of serious long-term pain and physical disability. The monumental impact of musculoskeletal conditions is now recognized by the United Nations, the World Health Organization, World Bank, and numerous governments throughout the world through support of the Bone and Joint Decade 2000 to 2010 initiative. Individuals with musculoskeletal pain concerns are regularly ignored, their complaints often misunderstood by health care providers, and accordingly they do not receive timely or effective treatment. The standards of care in this document are designed to provide generic guidelines for appropriate care of people with acute or chronic musculoskeletal pain. This document was developed over a 4-year period using multiple international meetings and a Task Force of the Bone and Joint Decade for developing international standards for the care of acute and chronic musculoskeletal pain. The final document is a product of the World Health Organization Collaborating Centre for Evidence-Based Health Care in Musculoskeletal Disorders.

Objective: To examine the construct and predictive validity of the Patient-Specific Functional Scale (PSFS) in workers' compensation claimants., Design: Prospective cohort study with 1-year follow-up., Setting: A workers' compensation rehabilitation facility., Participants: Subjects included 294 claimants with a variety of musculoskeletal disorders. The sample was predominantly male (70%), with a mean age of 44 years. Subjects completed a battery of measures at baseline including the PSFS, the Pain Disability Index (PDI), and the Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36)., Interventions: Not applicable., Main Outcome Measures: Outcomes for determining predictive validity included administrative indicators of timely return to work and recovery during the 1-year follow-up. Analysis included Pearson correlation and multivariable Cox and logistic regression., Results: At baseline, the PSFS correlated moderately (r range, 0.3-0.5) with other indicators of functional limitation (PDI, SF-36 role-physical subscale) but negligibly with the SF-36 mental health and role-emotional subscales. The PSFS was associated with timely recovery (adjusted hazard ratio, 1.16; 95% confidence interval, 1.07-1.27) with increasing functional limitation related to delayed recovery., Conclusions: Results provide construct and predictive validity evidence for the PSFS as an indicator of functional limitation in workers' compensation claimants.

Objective: To examine trajectories of recovery and change in patterns of personal care and instrumental functional activity performance to determine whether different assessment interval designs within a 12-month period yield different estimates of improvement and decline after acute hospitalization and inpatient rehabilitation., Design: Secondary analysis of a 12-month prospective cohort study., Setting: Transition to the community., Participants: Adults (N=419) admitted to acute care and receiving inpatient rehabilitation for a neurologic, lower-extremity musculoskeletal, or medically complex condition., Interventions: Not applicable., Main Outcome Measures: Improvement, no change, and decline as measured by the personal care and instrumental scale of the Activity Measure for Post-Acute Care., Results: Assessment at the end of a single 12-month follow-up assessment interval showed that over 60% of the participants improved. In contrast, analysis of 2 fixed-length 6-month assessment intervals revealed an almost 40% decrease in the proportion who improved from 6 to 12 months. Fewer participants continued to improve in the time periods further from the acute hospitalization and the proportion of subjects who declined increased from 21.4% to 31.2% to 38.0% over the 3 consecutive assessment intervals (baseline to 1 mo, 1-6 mo, 6-12 mo). Only 58 (19.7%) participants continued on the same path of recovery from baseline to 12 months (9.8% improved over all 3 consecutive time periods, 3.1% made no change, 6.8% declined)., Conclusions: Examination of change over shorter compared with longer assessment intervals revealed considerable variability in the trajectories of recovery. Research is needed to determine the appropriate frequency and timing for measuring and monitoring function and recovery after an acute hospitalization.

Objective: To evaluate the literature on the effectiveness of aquatic exercise in relieving pain in adults with neurologic or musculoskeletal disease., Data Sources: A systematic literature search of 14 databases was examined for research on aquatic exercise over the period January 1980 to June 2006., Study Selection: Randomized controlled trials (RCTs) that included adults with neurologic or musculoskeletal disease, pain as an outcome measure, and exercise in water were included., Data Extraction: Information on the participants, interventions, and outcomes was extracted from the included studies. Quality appraisal was assessed using the Scottish Intercollegiate Guidelines Network criteria for RCTs., Data Synthesis: Nineteen studies met the inclusion criteria; 8 were of moderate to low risk of bias, and 5 of these had data suitable for meta-analyses. This showed that aquatic exercise has a small posttreatment effect in relieving pain compared with no treatment (P=.04; standardized mean difference [SMD], -.17; 95% confidence interval [CI], -.33 to -.01), but it is not possible to draw a firm conclusion because of the lack of consistency of evidence across studies. Comparable pain-relieving effects were found between aquatic and land-based exercise (P=.56; SMD=.11; 95% CI, -.27 to .50)., Conclusions: There is sound evidence that there are no differences in pain-relieving effects between aquatic and land exercise. Compared with no treatment, aquatic exercise has a small pain-relieving effect; however, the small number of good-quality studies and inconsistency of results means that insufficient evidence limits firm conclusions. Future studies should aim for focused research questions on specific aquatic exercise techniques, using robust methodologic designs and detailed reporting of temperature, depth, and care setting.

Objective: To evaluate the construct validity and the responsiveness of 3 measures of physical performance measures as outcome measures for frail older persons., Design: Pre-post design with measures at admission and discharge., Setting: Three inpatient geriatric rehabilitation programs., Participants: Fifty-two subjects (35 women, 17 men; age, 80+/-8y)., Interventions: Not applicable., Main Outcome Measures: Physical performance measures were Timed Up & Go (TUG) test, two-minute walk test (2MWT), and functional reach. Functional status was measured with the FIM instrument and the Modified Barthel Index., Results: The TUG and 2MWT scores differed significantly in groups of patients using different ambulatory aids (P=.006), whereas no such difference was observed for the functional reach (P=.40). The correlations between the TUG test and FIM and between the 2MWT and FIM were -.59 and .59 (P<.001), respectively, at admission, and -.42 and .47 (P< or =.04), respectively, at admission and discharge. The correlations between functional reach and the FIM were not significant (P> or =.09). Standardized response means were 1.1 for the TUG, 0.7 for the 2MWT, and 0.5 for functional reach., Conclusions: The TUG test and 2MWT are valid and responsive outcome measures in older persons participating in geriatric rehabilitation. Functional reach was a moderately responsive outcome measure but did not consistently reflect ambulatory or functional status.

Objective: To assess the validity of retrospective versus prospective criterions of change., Design: Single cohort pretest-posttest design., Setting: Physical or occupational therapy outpatient clinics., Participants: Volunteer sample of 211 patients with upper-extremity musculoskeletal problems., Interventions: Not applicable., Main Outcome Measures: Disabilities of the Arm, Shoulder, and Hand questionnaire, the Shoulder Pain and Disability Index, the Patient-Rated Wrist Evaluation, the Medical Outcomes Study 12-Item Short-Form Health Survey; global disability rating (GDR), retrospective global rating of change (GRC), and patient satisfaction., Results: Correlations were calculated among the baseline, 3-month follow-up, and change scores for each outcome measure with the change criterion instruments. Retrospective GRC and patient satisfaction ratings showed moderate correlations with the 3-month follow-up scores, but nonsignificant correlations with baseline scores. By contrast, the prospective GDR criterion showed significant correlations with both baseline and 3-month follow-up scores ranging between 0.3 and 0.4 (absolute value)., Conclusions: Retrospective self-report measures of change do not accurately reflect true change over time. The retrospective GRC and patient satisfaction were heavily influenced by current (posttreatment) status whereas the prospective global change measure reflected both baseline and posttreatment status equally and thus appeared to be a more valid measure of change over time. This study demonstrates the need for an alternative criterion for establishing true individual change.

Objective: To develop a hierarchical scale that measures activity limitations in walking in patients with lower-extremity disorders who live at home., Design: Cross-sectional study., Setting: Orthopedic workshops and outpatient clinics of secondary and tertiary care centers., Participants: Patients (N=981; mean age +/- standard deviation, 58.6+/-15.4 y; 46% men) living at home, with different lower-extremity disorders: stroke, poliomyelitis, osteoarthritis, amputation, complex regional pain syndrome type I, and diabetic and degenerative foot disorders., Interventions: Not applicable., Main Outcome Measures: (1) Fit of the monotone homogeneity model, indicating whether items can be used for measuring patients; (2) fit of the double monotonicity model, indicating invariant (hierarchical) item ordering; (3) intratest reliability, indicating repeatability of the sum score; (4) robustness, addressing the clinimetric properties within subgroups of patients; and (5) differential item functioning, addressing the validity of comparisons between subgroups of patients., Results: Thirty-five of 41 dichotomous items had (1) good fit of the monotone homogeneity model (coefficient H=.50), (2) good fit of the double monotonicity model (coefficient H(T)=.33), (3) good intratest reliability (coefficient rho=.95), (4) satisfactory robustness (within subgroups of patients defined by age, sex, and diagnosis), and (5) some differential item functioning (6 items in amputees compared with nonamputees)., Conclusions: A hierarchical scale, with excellent scaling characteristics, was developed to measure activity limitations in walking in patients with lower-extremity disorders who live at home. The measurements should be interpreted cautiously when making comparisons between amputees and nonamputees.

Objective: To evaluate the intra- and interrater reliability of tests from the Ergo-Kit (EK) functional capacity evaluation method in adults without musculoskeletal complaints., Design: Within-subjects design., Setting: Academic medical center in The Netherlands., Participants: Twenty-seven subjects without musculoskeletal complaints (15 men, 12 women)., Interventions: Not applicable., Main Outcome Measures: Seven EK tests (2 isometric, 3 dynamic lifting, 2 manipulation tests) were each assessed 3 times (over 4 days), twice by 1 rater (R1) and once by another rater (R2). Intrarater reliability was calculated using the EK test scores assessed by R1. Interrater reliability was calculated using the EK test scores assessed by both raters. Counterbalancing the rater order made possible the calculation of 2 interrater reliability levels (at time intervals of 4 and 8d). All reliability levels were expressed as intraclass correlation coefficients (ICCs)., Results: Intrarater and interrater reliability (8-d time interval) was high (ICC, >.80) for the isometric lifting tests, moderate (ICC range, .50-.80) for the dynamic lifting tests, and low (ICC, <.50) for the manipulation tests. The interrater reliability of the isometric and dynamic lifting tests (4-d time interval) was high (ICC, >.80), and it was moderate (ICC range, .50-.80) for both manipulation tests., Conclusions: The isometric and dynamic lifting tests of the EK have a moderate to high level of reliability; the manipulation tests have a low level of reliability.

Objective: To compare comprehensively the likelihood of various socioeconomically relevant outcomes between functional restoration completers and noncompleters, while simultaneously identifying risk factors for noncompletion., Design: A prospective cohort study of patients with chronic disabling occupational musculoskeletal disorders (CDOMD)., Setting: Chronic pain management facility., Participants: A total of 1440 patients with CDOMD were consecutively divided into 2 groups-one with 303 patients who did not complete the prescribed treatment program (noncompleters [NC]) and a second with 1137 patients who did (completers)., Intervention: The Interdisciplinary Functional Restoration: Rehabilitation program., Main Outcome Measures: Validated questionnaires about pain, disability, and depression were added to results of a structured 1-year posttreatment telephone interview on socioeconomic outcomes covering work status, health utilization, recurrent injury claims, and resolution of financial disputes., Results: The 1-year posttreatment socioeconomic outcomes were most striking. The NC group was 7 times more likely to have postrehabilitation surgery in the same area, and nearly 7 times more likely to have more than 30 visits to a new health provider in persistent health care-seeking efforts. The NC group also had only half the rates of work return and work retention, being 9.7 times less likely to have returned to any type of work, and 7 times less likely to have retained work at the end of the year. Regression analysis also revealed that work return, surgery in a compensable injured area, more health care utilization from a new provider, and more overall health care utilization (>30 visits) were most reliably predicted by whether the rehabilitation program was completed., Conclusions: This large prospective study determined that noncompleters of interdisciplinary tertiary rehabilitation for CDOMDs had comparatively poor socioeconomic outcomes in the year after discharge from treatment, especially on work status and health utilization outcomes. These outcomes are of great relevance to societal, medical, and indemnity costs and future worker productivity. Several risk factors of possible importance in identifying potential noncompleters early in the treatment program were identified that may yield more effective interventions tailored to maintain compliance and decrease the percentage of drop-outs.

Objectives: To describe the comorbidity of visual impairment and disability among patients hospitalized for systemic illness and to discuss rehabilitation., Design: Retrospective study., Setting: Hospital-based, academic tertiary medical center with referring neurology, ophthalmology, and rehabilitation units., Participants: Ninety-three hospitalized patients referred to the low vision rehabilitation clinic primarily by the physical medicine and rehabilitation and neurology units., Interventions: Measurements of best-corrected visual acuity and other visual function testing. Referrals were made for prescriptive glasses, assistive devices, rehabilitation, resources, and ophthalmologic evaluation., Main Outcome Measures: Specialized services, presence of comorbidities, and visual function measurements., Results: The mean admitting visual acuity revealed a moderate visual impairment. The primary diagnosis for admission (51%) was cerebrovascular accidents. There was a mean of 3.5 other comorbidities., Conclusions: The majority of patients admitted to the hospital for systemic diseases also had visual impairments. In many patients, this visual disability (either from the systemic and/or ocular disease) interfered with their activities of daily living.

Objective: To investigate the detection rate of psychiatric disorders in rehabilitation inpatients with musculoskeletal and cardiovascular diseases (CVDs)., Design: Cross-sectional survey; analysis of medical charts and discharge reports, combined with standardized diagnostic interviews., Setting: Four orthopedic and 6 cardiovascular rehabilitation hospitals in southwest Germany., Participants: More than 1700 inpatients with different musculoskeletal disorders and CVDs participated in the survey. On the basis of their General Health Questionnaire score, 205 patients with musculoskeletal diseases and 164 patients with CVDs were selected randomly for standardized interviews. Discharge reports of interviewed patients were analyzed., Interventions: Not applicable., Main Outcome Measures: Clinical interview (Composite International Diagnostic Interview [CIDI]) to obtain diagnoses of psychiatric disorders as defined by the Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV). Assessment of psychosocial burden and diagnoses of mental disorders, as well as admission to psychologic treatments, based on discharge reports of the attending physicians., Results: The detection rate (sensitivity) of mental disorders was 48% in the orthopedic rehabilitation patients and 32% in the cardiovascular patients. Specificity was 80% in musculoskeletal patients and 87% in cardiovascular patients. Differential diagnostic competencies were lacking, and only half of the physicians' diagnoses corresponded to the CIDI diagnoses., Conclusions: The results showed a need for current DSM-IV or International Classification of Diseases, 10th edition, psychodiagnostics in medical rehabilitation to detect mental disorders in patients in the rehabilitation process at an earlier stage and to refer patients with comorbid mental disorders to adequate treatment.

Objective: To develop a comprehensive set of short forms using item response theory (IRT) and item pooling procedures for the purpose of monitoring postacute care functional recovery., Design: Prospective study., Setting: Six postacute health care networks in the greater Boston area, including inpatient acute rehabilitation, transitional care units, home care, and outpatient services., Participants: A convenience sample of 485 adult volunteers who were currently receiving skilled rehabilitation services., Interventions: Not applicable., Main Outcome Measures: We developed a set of 6 short forms across 3 activity domains from new items and items from existing postacute care instruments., Results: Inpatient- and community-based short forms were developed for each of 3 activity domains: physical & movement, applied cognition, and personal care & instrumental. Items were selected for inclusion on the short forms to maximize content coverage and information value of items across the range of content and to minimize ceiling and floor effects. We were able to match the distribution of sample scores with very good item precision for 1 of the constructs (physical & movement); the other 2 domains (personal care & instrumental, applied cognition) were more challenging because of the variability in patient recovery and ceiling effects., Conclusions: ITR methods and item pooling procedures were valuable in developing paired sets of short-form instruments for inpatient and community rehabilitation that provided estimates of functioning along a common metric for use across postacute care settings.

Objective: To test the hypothesis that an algorithm-based questionnaire version of the Wheelchair Skills Test (WST) would provide a valid assessment of manual wheelchair skills., Design: Within-participant comparisons., Setting: Rehabilitation center in Nova Scotia, Canada., Participants: Twenty wheelchair users, 11 with musculoskeletal and 9 with neurologic disorders, with a wide range of wheelchair experience (1wk-20y)., Intervention: Each participant completed the questionnaire (WST-Q) and then the objective skills testing (WST, version 2.4)., Main Outcome Measure: The WST-Q consisted of 3 components, reported as separate versions: the knowledge version (WST-Q [K]) (structured oral questions only); the visual-aid version (WST-Q [VA]) (visual aids added for 6 of the skills); and the categorical perceived-ability version (WST-Q [PA])., Results: The mean total percentage scores for the WST-Q (K), WST-Q (VA), WST-Q (PA), and WST were 60.5%, 62.2%, 64.0%, and 59.8%, respectively. Only the WST-Q (PA) differed significantly from the WST (P<.05). Positive correlations existed between the objective WST and the WST-Q (K) (r=.91), WST-Q (VA) (r=.91), and WST-Q (PA) (r=.83). The percentage agreement on the individual skill scores ranged from 55% to 100%., Conclusions: The algorithm-based WST-Q has excellent concurrent validity in comparison with objective testing, when assessing the overall manual wheelchair skill levels of wheelchair users with a wide range of experience. It may be useful as a screening tool or when objective testing is impractical.

Objective: To demonstrate interrater reliability and predictive validity of the Pittsburgh Rehabilitation Participation Scale (PRPS), a clinician-rated 6-point Likert-type item measuring patient participation in inpatient rehabilitation sessions., Design: Prospective measurement of patient participation in physical and occupational therapy sessions during inpatient rehabilitation., Setting: University-based, freestanding acute rehabilitation hospital., Participants: Two hundred forty-two inpatients, primarily elderly, with a variety of impairment diagnoses (eg, stroke), who were admitted for inpatient rehabilitation., Interventions: Not applicable., Main Outcome Measures: Change in the 13 motor items from the FIM trade mark instrument, from admission to discharge., Results: The PRPS had high interrater reliability (intraclass correlation coefficient [ICC]=.91 for occupational therapists; ICC=.96 for physical therapists). The subjects had mean PRPS scores +/- standard deviation of 4.73+/-0.76. Mean PRPS scores predicted rehabilitation outcome (N=242, r=.32, P<.0001), as measured by change in motor FIM. The strength of this association did not change in a multivariate model that controlled for age, gender, race, impairment group, medical comorbidity count, length of stay, and admission FIM., Conclusions: Patient participation during acute inpatient rehabilitation can be easily and reliably measured, and PRPS scores predict functional outcome. The PRPS may have applicability in clinical and research outcome measurement.

Objective: To evaluate the outcomes of patients who require hemodialysis and are admitted to an inpatient rehabilitation unit., Design: Retrospective review of the data of all admissions to an inpatient rehabilitation unit in 2001., Setting: University medical center., Participants: All inpatient rehabilitation admissions in 2001 (N=531), including 497 patients who did not require hemodialysis and 34 who required hemodialysis., Intervention: A comprehensive rehabilitation program including physical therapy and occupational therapy. Speech and language therapy and rehabilitation psychology were provided when necessary., Main Outcome Measures: Length of stay (LOS), change in total score on the FIM instrument, FIM efficiency, and place of discharge., Results: Admission and discharge FIM scores of the patients requiring hemodialysis were virtually identical to those of the other patients admitted to the unit. The average LOS of the hemodialysis patients was 5.4 days longer than that of the other patients, and, therefore, efficiency scores of the dialysis group were less than those of the other patients. The rate of discharge to the community did not differ significantly for the dialysis group., Conclusions: Patients who require hemodialysis can benefit from rehabilitation services. Their improvement on the FIM instrument is comparable to that of other patients, but their LOS may be longer than that of other patients.

Objectives: To identify factors associated with orthopedic surgeons' and primary care physicians' referrals to physical therapy (PT) for musculoskeletal conditions., Design: Cross-sectional analysis of National Ambulatory Medical Care Survey data., Setting: US office-based physician practices., Participants: Visits to primary care physicians (N=4911) or orthopedic surgeons (N=4201) for musculoskeletal conditions., Interventions: Not applicable., Main Outcome Measures: Whether a PT referral was made., Results: After controlling for diagnosis, illness severity, and PT supply, insurance status and physician characteristics remained strong predictors of PT referral. Primary care visits covered by Medicaid or a managed care plan were less likely to result in PT referral than were visits covered by private insurance or a nonmanaged care plan. Orthopedic surgeon visits covered by workers' compensation or managed care were more likely to result in PT referral than were visits not covered by workers' compensation or not covered by managed care. Osteopathic primary care visits were more likely than allopathic primary care visits to result in PT referral. Given identical visit characteristics, orthopedic surgeon visits were more likely than primary care visits to result in PT referral., Conclusions: Significant differences exist in orthopedic surgeons' and primary care physicians' referrals to PT, both within and across specialties. Variation in PT referral may be indicative of problems with access and/or inappropriate referral.

Objective: To examine patient satisfaction after orthopedic impairment at 80 to 180 days after inpatient rehabilitation., Design: Retrospective design examining records from facilities subscribing to the Uniform Data System for Medical Rehabilitation (UDSmr)., Setting: Information submitted to UDSmr from 1997 to 1998 by 177 hospital and rehabilitation facilities from 40 states., Participants: The sample (N=7781) was 72.63% female and 88.60% non-Hispanic white, with a mean age +/- standard deviation of 73.07+/-11.81 years, and average length of stay (LOS) of 13.84+/-10.48 days., Intervention: Usual rehabilitation care. Main outcome measures Level of satisfaction 80 to 180 days after discharge as well as motor, cognitive, and subscale ratings for the FIM trade mark instrument. Predictor variables included gender, age, English language, marital status, discharge setting, LOS, rehospitalization, FIM gain, and primary payer., Results: A logistic regression model was used to predict patient satisfaction at follow-up. Five statistically significant (P<.05) variables were found and correctly classified 94.9% of the patients. Discharge motor FIM rating, rehospitalization, age, patient's primary language, and discharge setting were associated with increased satisfaction. Discharge motor FIM ratings were significantly associated with increased satisfaction in patients with joint replacements and lower-extremity fractures., Conclusion: unctional and demographic variables were identified as predictors of satisfaction in patients with orthopedic impairments.

Objective: To examine the discriminative validity of the Dutch Pediatric Evaluation of Disability Inventory (PEDI) to differentiate functional status between children with and without disabilities., Design: Cross-sectional study., Setting: A university children's hospital in the Netherlands., Participants: A clinical sample comprising 197 children with disabilities (infantile encephalopathy, n=40; juvenile idiopathic arthritis, n=20; neurometabolic conditions, n=36; neuromuscular disorders, n=9; skeletal disorders, n=28; spina bifida, n=41; traumatic injury, n=23), and 62 children without disabilities., Interventions: Not applicable., Main Outcome Measure: Functional status was measured by using a Dutch version of the PEDI., Results: Discriminant analysis established the sensitivity and specificity of the PEDI. Correct predictions of group membership (disabled vs nondisabled) were found in both children without disabilities (93.5% correctly predicted) and children with disabling conditions (91.6% correctly predicted)., Conclusion: The discriminative validity of the Dutch PEDI between children with and without disabilities was excellent., (Copyright 2002 by the American Congress of Rehabilitation Medicine and the American Academy of Physical Medicine and Rehabilitation)