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Objective. Physical function is associated with important outcomes, yet there is often a lack of continuity in routine assessment. The purpose of this study was to determine data elements and instruments for longitudinal measurement of physical function in routine care among patients transitioning from acute care hospital setting to home with home health care. Methods. A 4-round modified Delphi process was conducted with 13 participants with expertise in physical therapy, health care administration, health services research, physiatry/medicine, and health informatics. Three anonymous rounds identified important and feasible data elements. A fourth in-person round finalized the recommended list of individual data elements. Next, 2 focus groups independently provided additional perspectives from other stakeholders. Results. Response rates were 100% for online rounds 1, 3, and 4 and 92% for round 2. In round 1, 9 domains were identified: physical function, participation, adverse events, behavioral/emotional health, social support, cognition, complexity of illness/disease burden, health care utilization, and demographics. Following the fourth round, 27 individual data elements were recommended. Of these, 20 (74%) are "administrative" and available from most hospital electronic medical records. Additional focus groups confirmed these selections and provided input on standardizing collection methods. A website has been developed to share these results and invite other health care systems to participate in future data sharing of these identified data elements. Conclusion. A modified Delphi consensus process was used to identify critical data elements to track changes in patient physical function in routine care as they transition from acute hospital to home with home health. Impact. Expert consensus on comprehensive and feasible measurement of physical function in routine care provides health care professionals and institutions with guidance in establishing discrete medical records data that can improve patient care, discharge decisions, and future research. Keywords: Acute Care, Home Care Services, Measurement: Applied, Medical Informatics, Introduction Within the framework of the International Classification of Functioning, Disability and Health, physical function is the result of interaction between a person's body parts, their whole person, and their [...]

Objective. Poor knowledge of the relationships between physical function (PF) in the hospital and patient outcomes in an inpatient rehabilitation facility (IRF) limits the identification of patients most appropriate for discharge to an IRF. This study aimed to test for independent associations between PF measured via the AM-PAC '6-clicks' basic mobility short form in the hospital and outcomes in an IRF. Methods. This was a retrospective cohort study. Primary data were collected from an acute hospital and IRF at 1 academic medical center. Associations were tested between PF at hospital admission or discharge and PF improvement in the IRF, discharge from the IRF to the community, and 30-day hospital events by estimating adjusted relative risk (aRR) using modified Poisson regression and the relative difference in IRF length of stay (LOS) using Gamma regression. Results. A total of 1323 patients were included. Patients with moderately low, (aRR = 1.50; 95% CI = 1.15-1.93), moderately high (aRR = 1.52; 95% CI = 1.16-2.01), or high (aRR = 1.37; 95% CI = 1.02-1.85) PF at hospital discharge were more likely than those with very low PF to improve their PF while in the IRF. These same patients were more likely to discharge from IRF to the community and had significantly shorter IRF LOS. Hospital-measured PF did not differentiate risk for 30-day hospital events. Conclusion. Patients with moderate--but not very low or very high--PF measured near the time of acute hospital discharge were likely to achieve meaningful PF improvement in an IRF. They also had a shorter IRF LOS so may be ideal candidates for discharge to IRF. Prospective studies with larger samples are necessary to test this assertion. Impact. Providers in the hospital should identify patients with moderate PF near the time of hospital discharge as those who may benefit most from post-acute rehabilitation in an IRF., Medicare costs on post-acute care (PAC) utilization exceeded $59 billion in 2013, nearly tripling since 2001. (1) Therefore, new policies aim to improve the value of PAC utilization in the [...]

Keywords: Health Services Administration, Models, Organizational, Evidence-Based, Practice, Health services researchers and clinical operations leaders share similar goals to resolve inefficiencies and variability in health care delivery to improve outcomes, but have traditionally conducted their work using distinct [...]

Background. The impact of physical therapy on the outcomes of patients with acute low back pain (IBP) stratified by the STart Back Screening Tool (SBST) is unclear. Objective. The purpose [...]

Background. Half of all patients with diabetes develop diabetic peripheral neuropathy (DPN), a complication leading to reduced mobility and quality of life. Although there are no proven pharmacologic approaches to reduce DPN risk or slow its progression, evidence suggests that physical activity may improve symptoms and enhance peripheral nerve regeneration. Objective. The aim of the study will be to determine the impact of an intense lifestyle intervention on neuropathy progression and quality of life in individuals with DPN. Design. The study will be a randomized controlled trial. Setting. The study will be conducted at 2 academic medical centers. Participants. The participants will be 140 individuals with type 2 diabetes and mild to moderate DPN. Intervention. The intervention group will receive 18 months of supervised exercise training, actigraphy-based counseling to reduce sedentary behavior, and individualized dietary counseling. Control group participants will receive diet and activity counseling at baseline and at 9 months. Measurements. The primary outcomes are neuropathy progression as measured by intraepidermal nerve fiber density in a distal thigh skin biopsy and the Norfolk Quality of Life-Diabetic Neuropathy score. Secondary outcomes include pain, gait, balance, and mobility measures. Limitations. Due to the combined intervention approach, this protocol will not be able to determine which intervention components influence outcomes. There also may be difficulty with participant attrition during the 18-month study intervention. Conclusions. The Activity for Diabetic Polyneuropathy (ADAPT) protocol resulted from a collaboration between physical therapists and neurologist researchers that includes as primary outcomes both a quality-of-life measure (NQOL-DN) and a physiologic biomarker (IENFD). It has the potential to demonstrate that an intensive lifestyle intervention may be a sustainable, clinically effective approach for people with DPN that improves patient outcomes and can have an immediate impact on patient care and future clinical trials., Approximately 30 million Americans have diabetes, half of whom will develop diabetic peripheral neuropathy (DPN). (1) Diabetic peripheral neuropathy causes reduced mobility and quality of life due to pain, sensory [...]

Diabetic peripheral neuropathy (DPN) occurs in more than 50% of people with diabetes and is an important risk factor for skin breakdown, amputation, and reduced physical mobility (ie, walking and stair climbing). Although many beneficial effects of exercise for people with diabetes have been well established, few studies have examined whether exercise provides comparable benefits to people with DPN. Until recently, DPN was considered to be a contraindication for walking or any weight-bearing exercise because of concerns about injuring a person's insensitive feet. These guidelines were recently adjusted, however, after research demonstrated that weight-bearing activities do not increase the risk of foot ulcers in people who have DPN but do not have severe foot deformity. Emerging research has revealed positive adaptations in response to overload stress in these people, including evidence for peripheral neuroplasticity in animal models and early clinical trials. This perspective article reviews the evidence for peripheral neuroplasticity in animal models and early clinical trials, as well as adaptations of the integumentary system and the musculoskeletal system in response to overload stress. These positive adaptations are proposed to promote improved function in people with DPN and to foster the paradigm shift to including weight-bearing exercise for people with DPN. This perspective article also provides specific assessment and treatment recommendations for this important, high-risk group., Peripheral neuropathy, one of the most common complications of diabetes mellitus, (1) typically is characterized as a symmetrical distal degeneration of peripheral nerves and impaired nerve regeneration. Diabetic peripheral neuropathy [...]

Background and Purpose. The authors previously reported that focused eccentric resistance training during the first 15 weeks following anterior cruciate ligament reconstruction (ACL-R) induced greater short-term increases in muscle volume, strength, and measures of function relative to standard rehabilitation. The purpose of this study was to evaluate the effects of early progressive eccentric exercise on muscle volume and function at 1 year after ACL-R. Participants and Methods. Forty patients who had undergone an ACL-R were randomly assigned to 1 of 2 groups: a group that received early progressive eccentric exercise (n=20) and a group that received standard rehabilitation (n= 20). Seventeen participants in the eccentric exercise group and 15 participants in the standard rehabilitation group completed a 1-year follow-up. Magnetic resonance images of the thighs were acquired 1 year after ACL-R and compared with images acquired 3 weeks after surgery. Likewise, routine knee examinations, self-report assessments, and strength and functional testing were completed 1 year after surgery and compared with previous evaluations. A 2-factor analysis of variance for repeated measures (group X time) was used to analyze the data. Results. Compared with the standard rehabilitation group, improvements in quadriceps femoris and gluteus maximus muscle volume in the involved lower extremity from 3 weeks to 1 year following ACL-R were significantly greater in the eccentric exercise group. Improvements in quadriceps femoris and gluteus maximus muscle volume were 23.3% (SD=14.1%) and 20.6% (SD=12.9%), respectively, in the eccentric exercise group and 13.4% (SD= 10.3%) and 11.6% (SD=10.4%), respectively, in the standard rehabilitation group. Improvements in quadriceps femoris muscle strength and hopping distance also were significantly greater in the eccentric exercise group 1 year postsurgery. Discussion and Conclusions. A 12-week focused eccentric resistance training program, implemented 3 weeks after ACL-R, resulted in greater increases in quadriceps femoris and gluteus maximus muscle volume and function compared with standard rehabilitation at 1 year following ACLoR., The restoration of muscle volume and strength (force-generating capacity) following anterior cruciate ligament reconstruction (ACL-R) continues to be a rehabilitation challenge. Interventions that can safely and effectively overload muscle early [...]

Objective. The prevalence of diabetes (type 2) in the general population has increased dramatically over the last decade, yet patients with diabetes are rarely referred for physical therapy management of their condition. The majority of patients referred for outpatient physical therapy have musculoskeletal-related conditions. Secondary conditions, such as diabetes, may be prevalent in this population, and physical therapists need to be aware of this to adjust interventions and treatment. The purpose of this article is to describe the prevalence of diabetes and the associated risk factors in adults referred for physical therapy in a primary care outpatient setting. Subjects and Methods. Patients aged 18 years or older referred for physical therapy were identified from the Centricity Electronic Medical Records database during the period of December 13, 1995, to June 30, 2007. Patients were evaluated on the basis of clinical (height, weight, blood pressure, laboratory values), treatment (prescriptions), and diagnostic (ICD-9 codes) criteria to identify the presence of diabetes or associated risk factors (eg, hypertension, elevated triglycerides, low high-density lipoprotein, body mass index, and prediabetes). Results. There were 52,667 patients referred for physical therapy, the majority of whom were referred for a musculoskeletal-related condition. Approximately 80% of the total study population had diabetes, prediabetes, or risk factors associated with diabetes. The prevalence of diabetes in the study population was 13.2%. Of the diabetes-associated risk factors evaluated, hypertension was the most prevalent (70.4%), and less than half (39.1%) of the study population had an elevated body mass index. Only 20% of the study population had values within normal limits for all clinical, treatment, and diagnostic criteria. Clinical and treatment measurements available to physical therapists identified the majority of associated risk factors. Conclusions. Although not the primary indications for referral, diabetes and associated risk factors were identified in a high proportion of the study population. The evaluation of associated conditions in the outpatient orthopedic setting needs to be considered for treatment planning adjustments and to optimize care., Diabetes mellitus is a chronic disease in which the body does not regulate blood glucose concentrations properly. (1) Diabetes is the sixth leading cause of death in the United States [...]

Background and Purpose. The purpose of this study was to compare the outcomes between a diabetes exercise training program using combined aerobic and high-force eccentric resistance exercise and a program of aerobic exercise only. Subjects and Methods. Fifteen participants with type 2 diabetes mellitus (T2DM) participated in a 16-week supervised exercise training program: 7 (mean age = 50.7 years, SD = 6.9) in a combined aerobic and eccentric resistance exercise program (AE/RE group) and 8 (mean age = 58.5 years, SD = 6.2) in a program of aerobic exercise only (AE group). Outcome measures included thigh lean tissue and intramuscular fat (IMF), glycosylated hemoglobin, body mass index (BMI), and 6-minute walk distance. Results. Both groups experienced decreases in mean glycosylated hemoglobin after training (AE/RE group: -0.59% [95% confidence interval (CI) = - 1.5 to 0.28]; AE group: -0.31% [95% CI = -0.60 to -0.03]), with no significant between-group differences. There was an interaction between group and time with respect to change in thigh lean tissue cross-sectional area, with the AE/RE group gaining more lean tissue (AE/RE group: 15.1 [cm.sup.2] [95% CI=7.6 to 22.5]; AE group: -5.6 [cm.sup.2] [95% CI = - 10.4 to 0.76]). Both groups experienced decreases in mean thigh IMF cross-sectional area (AE/RE group: -1.2 [cm.sup.2] [95% CI= -2.6 to 0.26]; AE group: -2.2 [cm.sup.2] [95% CI = -3.5 to -0.84]) and increases in 6-minute walk distance (AE/RE group: 45.5 m [95% CI = 7.5 to 83.6]; AE group: 29.9 m [95% CI = -7.7 to 67.5]) after training, with no between-group differences. There was an interaction between group and time with respect to change in BMI, with the AE/RE group experiencing a greater decrease in BMI. Discussion and Conclusion. Significant improvements in long-term glycemic control, thigh composition, and physical performance were demonstrated in both groups after participating in a 16-week exercise program. Subjects in the AE/RE group demonstrated additional improvements in thigh lean tissue and BMI. Improvements in thigh lean tissue may be important in this population as a means to increase resting metabolic rate, protein reserve, exercise tolerance, and functional mobility., Type 2 diabetes mellitus (T2DM) is a chronic illness marked by decreased insulin sensitivity and overall poor glucose control. A universally accepted component of the nonpharmacologic treatment for T2DM is [...]