Physical Therapy最新文献

Importance: Implementing evidence-based dosing of rehabilitation in skilled nursing facilities (SNFs) is essential to improve functional outcomes in a medically-complex population.

Objective: The objective was to evaluate an implementation program promoting high-intensity resistance rehabilitation (HIR) in SNFs by (1) measuring proximal (clinician knowledge, self-efficacy, and HIR perspective) and distal (HIR adoption and implementation) outcomes; (2) exploring how the program influenced distal outcomes (program processes); and (3) investigating clinician factors influencing HIR implementation.

Design: The design was a prospective convergent mixed-methods, theory-driven program evaluation.

Setting: This study was conducted across 8 rural Department of Veterans Affairs SNFs.

Participants: Rehabilitation clinicians (n = 38) and leaders (n = 16) were included.

Interventions or exposures: All sites received a multicomponent implementation program promoting HIR.

Main outcomes and measures: Validated questionnaires assessed HIR perspective (Perceived Characteristics of Intervention Scale) and adoption (Commitment to Change Scale). Study-specific questionnaires measured clinician HIR knowledge, self-efficacy, and implementation. Interviews and focus groups explored program processes and clinician factors.

Results: The program improved clinician HIR knowledge, self-efficacy, and perspective, leading to acceptable adoption rates. Implementation was marginally affected. Only clinician perspective correlated with adoption (ρ = 0.47). Qualitatively, the program supported distal outcomes by keeping HIR at the forefront of clinicians' mind, fostering positive outcome expectations, and enhancing team cohesion and accountability. Clinician creativity, adaptability, resilience, professional discipline, and previous experience influenced implementation.

Conclusion: The program influenced HIR adoption primarily by enhancing clinicians' positive perspectives of HIR. Future efforts could strengthen implementation by fostering team cohesion, accountability, and clinician creativity while also assessing environmental factors.

Relevance: Effective HIR implementation can optimize patient outcomes. Strategies that enhance clinician perspective and creativity, keep HIR at the forefront, and foster team cohesion and accountability may improve adoption. Additionally, assessing and addressing environmental factors may further support sustainable integration of HIR into clinical practice.

Importance: Total knee replacement (TKR) is common for advanced cartilage degeneration. Often, functional limitations persist, and late-stage exercise (2-4 months after TKR) may improve recovery.

Objective: The objective of this study was to identify predictors of late-stage functional recovery after TKR and their variations by exercise program.

Design: This study was a secondary analysis of a randomized controlled trial.

Setting: The settings were 1 physical therapy clinic and 4 community centers in Allegheny County, Pennsylvania.

Participants: The study included 199 individuals (mean age = 70 years; body mass index = 31 kg/m2; 60% women).

Interventions: Interventions were physical therapy exercises, community-based exercises, and usual care.

Main outcome and measures: The main outcome was functional recovery at 6 months after intervention. Functional recovery was defined as ≥50% improvement on the Western Ontario and McMaster Universities Osteoarthritis Index physical function subscale, at least somewhat better on the Global Rating of Change, and ≥ 20% improvement on ≥2 performance-based tests. Predictors were identified using logistic regression. Odds ratios (ORs) and 95% confidence intervals (CIs) were reported.

Results: In the entire cohort, 33% of participants achieved functional recovery, including 42% in the physical therapy group and 38% in the community group. Overall, better baseline health (odds ratio [OR] = 2.70 [95% CI = 1.34-5.47]), discharge to home (OR = 6.24 [95% CI = 1.94-20.09]), and higher Western Ontario and McMaster Universities Osteoarthritis Index pain subscale scores (OR = 1.22 [95% CI = 1.07-1.40]) predicted functional recovery. In the physical therapy group (n = 83), positive predictors were better health (OR = 4.40 [95% CI = 1.20-16.06]), discharge to home (OR = 11.67 [95% CI = 2.01-67.76]), regular use of nonsteroidal antiinflammatory drugs (OR = 3.76 [95% CI = 1.11-12.78]), and as-needed use of analgesics (OR = 10.53 [95% CI = 1.75-63.48]). Negative predictors, associated with a lower likelihood of recovery, were regular use of salicylates (OR = 0.22 [95% CI = 0.07-0.74]) and greater use of pain-coping strategies (OR = 0.51 [95% CI = 0.29-0.89]). No predictors were identified in the community group (n = 76).

Conclusions: Better baseline health, discharge to home after TKR, and higher pain levels predicted functional recovery. Physical therapy provided additional benefits for a subset of participants.

Relevance: This evidence helps clinicians set realistic functional recovery expectations and strategies to facilitate function late after TKR.

Importance: Reducing 30-day hospital readmission rates after ischemic stroke is a national priority, yet optimal rehabilitation service delivery strategies in acute care are unclear. Physical therapy and occupational therapy are essential for functional recovery, discharge planning, and readmission prevention, but the association between service delivery factors and readmission risk remains uncertain.

Objective: The objective was to evaluate the relationship between the timing and frequency of physical therapy and occupational therapy in acute care and 30-day readmission rates among patients with ischemic stroke.

Design: This was an observational cross-sectional study using electronic medical records from January 2018 to December 2021.

Setting: The study was conducted within a 13-hospital health system in Colorado.

Participants: Patients with a primary diagnosis of ischemic stroke (N = 1545) were included. Inclusion required receiving physical therapist or occupational therapist treatment, while exclusions included evaluation-only visits, discharge to hospice, leaving against medical advice, interhospital transfers, or death within 30 days. Final samples included 979 physical therapy and 713 occupational therapy patients, stratified by discharge destination (home vs postacute rehabilitation).

Exposures: Rehabilitation service delivery factors were: (1) time to evaluation: days from admission to first therapy evaluation; (2) time to treatment: days from evaluation to first therapy session; and (3) therapy frequency: total number of therapy sessions (1-2, 3-4, or ≥ 5). Separate analyses were conducted for physical therapist and occupational therapist services.

Main outcomes: The primary outcome was 30-day hospital readmission.

Results: Among patients discharged home, fewer days between physical therapist evaluation and treatment were associated with reduced odds of readmission (OR = 1.105, 95% CI = 1.003-1.217). Higher occupational therapy session frequency was linked to lower readmission odds (≥5 sessions: OR = 0.17, 95% CI = 0.029-0.994). After adjustment for length of stay, the association between occupational therapy frequency and readmission was attenuated, whereas the association between time to physical therapy evaluation and readmission remained significant. No significant associations were found in patients discharged to postacute rehabilitation facilities.

Conclusions and relevance: Early physical therapist treatment and frequent occupational therapy sessions were associated with reduced 30-day readmission risk for patients discharged home. Optimizing acute care rehabilitation service delivery is essential to improving postdischarge outcomes.

During the 2023 Carole B. Lewis Lecture, Michelle Lusardi, DPT, PhD, FAPTA, issued a call to action for the American Physical Therapy Association's Academy of Geriatric Physical Therapy (APTA Geriatrics): to embrace, enact, and evaluate the effectiveness of an annual mobility screen for aging adults. This call highlighted the need to quickly identify preclinical mobility limitations that indicate those at risk for functional decline, falls, and other adverse health outcomes. By moving to a true primary prevention model aimed at identifying preclinical issues, physical therapists can share findings, provide education about the importance of physical activity, and initiate referrals and/or interventions when needed. In response, APTA Geriatrics assembled an Annual Mobility Assessment Task Force to assess this issue and make recommendations. This Perspective Paper summarizes APTA Geriatrics' position on this issue, the Task Force findings, and actions to date. APTA Geriatrics believes that primary prevention efforts to identify risk for avoidable mobility limitations are essential for the physical therapy profession to embrace its mission to transform society by optimizing movement.

Importance: Amyotrophic lateral sclerosis (ALS) is a progressive neurodegenerative disease causing declines in muscular strength that affect respiratory function and functional independence. Although physical therapist interventions have been studied in ALS, their efficacy and evidence quality have not been systematically assessed across disease stages.

Objective: The objective of this study was to examine the efficacy of physical therapist interventions on clinical outcomes across ALS disease stages.

Design: This study was a systematic review using Joanna Briggs Institute methodology.

Setting: Multiple settings were used.

Participants: The participants were adults (>18 years old) with ALS or motor neuron disease.

Interventions: Physical therapist interventions within the professional scope of practice included therapeutic exercise, pulmonary training, manual therapy, and multimodal approaches.

Outcome measures: Outcome measures included effect sizes (ESs) and 95% CIs calculated for forced vital capacity (FVC) and the Amyotrophic Lateral Sclerosis Rating Scale (ALSFRS) or the ALSFRS revised (ALSFRS-R).

Results: Six databases were searched from inception to January 2025. Thirty-nine studies were included (25 experimental, 14 observational). Outcomes were heterogeneous, with 94 measures across studies: 23 included the ALSFRS or ALSFRS-R, and 16 included FVC. Most interventions targeted early-stage ALS (n = 27), limiting comparisons across stages. Multimodal training had moderate-quality evidence, with moderate effects on the ALSFRS-R (ES = 0.56 [95% CI = 0.09-1.03]), and low-quality evidence, with negligible effects on FVC (ES = -0.03 [95% CI = -1.47 to 1.41]). Pulmonary interventions had moderate-quality evidence, with small effects on FVC (ES = 0.40 [95% CI = -0.18 to 0.98]), and low-quality evidence, with negligible effects on the ALSFRS-R (ES = 0.04 [95% CI = -0.25 to 0.33]).

Conclusions: A range of physical therapist interventions for ALS were assessed, although most were early phase or low quality. Multimodal and pulmonary interventions showed modest benefits in the ALSFRS-R and FVC, respectively. However, variability in outcome measures and limited research beyond early-stage disease highlight the need for stage-specific trials using consistent functional outcomes.

Relevance: This review highlights the breadth of studies of physical therapy in ALS and underscores the need for more rigorous, targeted research.

Importance: In patients who are critically ill, functional dependence and muscle weakness may be influenced by side effects related to the timing of out-of-bed mobilization, but there is a knowledge gap regarding the impact of exercise prescriptions in specific intensive care unit (ICU) populations.

Objective: The objective of this study was to determine clinical reference values for the time to start out-of-bed mobilization of patients in the ICU to avoid functional dependence and muscle weakness at ICU discharge.

Design: This study was a secondary analysis of a prospective multicenter cohort.

Setting: The settings were the ICUs of 5 Brazilian hospitals.

Participants: The participants were adult patients with COVID-19, an ICU stay of ≥4 days, and prior functional independence.

Exposure: Time for out-of-bed mobilization was the first day the patient was mobilized to higher postures, provided there were no contraindications.

Main outcomes and measures: Functional status (Barthel Index [BI]) and muscle strength (Medical Research Council Scale [MRC]) were assessed within 2 days of ICU discharge. Receiver operating characteristic analysis identified clinical thresholds for days to initiate out-of-bed mobilization in association with 2 levels of functional dependence and muscle weakness. Optimal cutoffs were based on sensitivity, specificity, and area under the curve (AUC).

Results: A total of 339 patients (58 years old [SD = 46-66 years old]; Simplified Acute Physiology Score III = 51.3 [SD = 16.5]; 36% women; 53% on mechanical ventilation) were analyzed. Days to start out-of-bed mobilization for each outcome were as follows: 3 days for a BI of <85 points (sensitivity = 67%, specificity = 65%, AUC = 0.68 [95% CI = 0.63-0.74]); 4 days for a BI of <60 points (sensitivity = 60%, specificity = 65%, AUC = 0.66 [95% CI = 0.59-0.73]); 5 days for an MRC score of <48 points (sensitivity = 54%, specificity = 73%, AUC = 0.66 [95% CI = 0.59-0.73]); and 5 days for an MRC score of <36 points (sensitivity = 69%, specificity = 67%, AUC = 0.67 [95% CI = 0.49-0.85]).

Conclusions: Early out-of-bed mobilization, initiated within 3 to 5 days of physiological readiness, may differentiate patients who develop functional dependence or ICU-acquired weakness at ICU discharge from those who do not. However, since discrimination ranged from 66% to 68%, with a narrow margin for worse outcomes, this recommendation should be interpreted within context.

Relevance: Knowing clinical reference points for days to initiate out-of-bed exercises may help minimize poor physical outcomes at ICU discharge.