Physical Therapy最新文献

Importance: Hospitals can follow the steps outlined in this administrative case report to identify and address potential overutilization waste.

Objective: Acute care physical therapist evaluation and intervention can identify functional needs, safety needs, and develop treatment plans to optimize function, activity, safety, and the ability to discharge home safely. However, health care waste results when therapy referrals are utilized beyond these needs. This administrative case report aimed to define and categorize physical therapist overutilization to guide health care waste reduction.

Design: This administrative case report describes a 2-phase project to develop and implement a low-value referral (LVR) tracking system within a large health care system. During phase 1, the development phase, semi-structured group consensus meeting stakeholders identified 4 LVR categories and developed a data collection tool for a hospital-wide feasibility project. Phase 2 collected data on clinician-identified LVRs over a 2-year timeframe to identify LVR category, referring provider, and patient care unit from which the LVRs are located.

Setting: Baylor University Medical Center (BUMC) is a quaternary care academic medical center in Dallas, Texas, with 914 licensed acute care beds.

Participants: All physical therapists evaluating and treating patients at BUMC during the project.

Results: Out of 40,815 total physical therapist referrals, 2263 were identified as LVRs. The authors found that 5.54% of hospital referrals were LVRs, with more than 75% of LVRs associated with patients currently at their baseline functional state and/or independent with activity/mobility. Furthermore, 27% of all LVRs came from just 20 referral sources (mean = 30.55; SD = 9.76), and 43.9% were located on 3 patient care units, making targeted and customized education and collaboration initiatives feasible.

Conclusion and relevance: This case report demonstrates that acute care hospital physical therapist overutilization can be easily defined by category, source, and location. This meaningful data can be used to divert potential health care waste toward evidence-informed patient care designed to improve outcomes.

Importance: Rehabilitation supports independence for older adults with disability, but access is often unequal. One potential driver is insurance coverage limitations.

Objective: This study characterized trends and racial disparities in rehabilitation insurance benefit exhaustion among older adults from 2015 to 2022.

Design: Repeated cross-sectional analysis and survey-weighted logistic regression using data from the National Health and Aging Trends Study (NHATS). Models were clustered at the patient level to estimate changes in exhaustion from 2015 to 2022, and an overall estimate of racial disparities over this time period.

Setting: Population-based survey of patients in rehabilitation facilities and clinics in the United States.

Participants: The sample included 5653 rehabilitation user-years (weighted N = 38.3 million) contributed by 3386 community-dwelling Medicare beneficiaries aged 70+ who received rehabilitation services between 2015 and 2022.

Exposures: The primary exposure of interest was racial and ethnic identity, categorized as Non-Hispanic Black and Non-Hispanic White.

Main outcome and measures: The main outcome was patient-reported rehabilitation insurance benefit exhaustion, defined using NHATS survey responses.

Results: From 2015 to 2022, the overall rate of patient-reported rehabilitation insurance benefit exhaustion among older adults declined from 32.0% (95% CI = 28.1%-35.7%) to 27.9% (95% CI = 24.4%-31.3%). However, racial disparities persisted and widened over this period. In 2015, 39.2% (95% CI = 29.7%-48.8%) of Black older adults reported benefit exhaustion compared to 30.7% (95% CI = 26.3%-35.0%) of White older adults. By 2022, rates declined to 25.7% (95% CI = 21.6%-29.8%) among White adults and 38.5% (95% CI = 27.4%-49.5%) among Black adults. In adjusted analyses, the odds of patient-reported rehabilitation insurance benefit exhaustion were higher for Black versus White adults from 2015 to 2022 (OR = 1.50; 95% CI = 1.20-1.86).

Conclusions: Although overall rates of patient-reported rehabilitation insurance benefit exhaustion declined modestly from 2015 to 2022, 1 in 4 still reported terminating their rehabilitation episodes because of self-reported insurance benefit exhaustion in 2022 with growing racial disparities over time.

Relevance: These findings highlight the need for Medicare reforms that expand and equitably enforce coverage to ensure all older adults-particularly those from marginalized groups-can complete the rehabilitation necessary to maintain independence.

Importance: Impaired fundamental movement skills are prevalent among children with developmental coordination disorder (DCD) and mild cerebral palsy (CP). Although postural control is a prerequisite for gross motor skills, its role in fundamental movement skills is understudied.

Objective: This study aims to determine the extent to which postural control contributes to fundamental movement skill performance in children with DCD, mild CP, and with typical development (TD).

Design: This was a case-control study.

Participants: Participants were 127 children aged 5.0 to 10.9 years (DCD [N = 48], TD [N = 59)], mild spastic CP [N = 20]). Children with CP were classified as Gross Motor Function Classification System (GMFCS) I (N=11) or II (N=9), and as having either unilateral (N=11 or bilateral CP(N= 9).

Main outcomes and measures: The Test of Gross Motor Development-3 (TGMD-3) evaluated fundamental movement skills, and the Kids-Balance Evaluation Systems Test-2 (Kids-BESTest-2) assessed postural control. The domain and total scores of both tests were used for analysis.

Results: Children with TD significantly outperformed those with DCD and mild CP, while DCD and mild CP performed similarly. Across groups the Kids-BESTest-2 and TGMD-3 correlated significantly (r = 0.42 - r = 0.77). The total Kids-BESTest-2 score and group (TD-DCD-mild CP) explained 69% of locomotor skill variance but did not significantly explain ball skill performance (R2 = 0.40). Among postural control domains, only anticipatory postural adjustments contributed to fundamental movement skills. Group effects were larger (ⴄp2 = 0.15-0.31) than the effects of Kids-BESTest-2 scores (ⴄp2 = 0.01-0.12).

Conclusions and relevance: The findings suggest that postural control plays a role in locomotor performance but that unique group-specific factors influence this relationship. Further research should investigate the impact of postural control task-oriented training on fundamental movement skills, and should examine the influence of additional factors, such as body functions and environmental influences on fundamental movement skill development.

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 with 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.

Importance: Patellofemoral pain (PFP) frequently affects military personnel, caused by the physical demands of duty-related training. Clinical practice guidelines (CPG) can guide PFP management, yet physical therapist practice patterns vary and often exclude CPG-recommended, evidence-based interventions.

Objective: The Evaluating the Effectiveness of Clinical practice guideline Adherence for Patellofemoral Pain (knEE-CAPP) trial assesses whether a CPG-adherent physical therapy approach more significantly reduces pain, disability, health care utilization, and analgesic medication prescription in Service members with PFP as compared to usual physical therapist care.

Design: This is a multisite, parallel arm randomized controlled trial.

Setting: The study will be conducted at 4 outpatient military physical therapist clinics.

Participants: Male and female active-duty Service members (n = 440) ages 18 years or older with PFP will be included.

Intervention: Participants will be randomized to receive CPG-adherent or usual physical therapist care. CPG-adherent care includes a standardized examination and treatment protocol based on the 2019 American Physical Therapy Association's PFP CPG Decision Tree Model. This model subcategorizes impairments to guide targeted interventions. Usual care encompasses care delivered by outpatient physical therapist providers without research team directives.

Main outcomes and measures: Anterior Knee Pain Scale (a patient-reported measure of knee-specific function) and Numeric Pain Rating Scale (a patient-reported measure of knee pain intensity).

Results: Changes in Anterior Knee Pain Scale and Numeric Pain Rating Scale scores at 3-month follow-up will be compared between arms. Secondary outcomes (perceived duty- and deployment-related confidence, knee-related health care utilization, and analgesic medication prescription) will be compared up to 12-months post-randomization.

Conclusions: This trial will determine the effectiveness of a standardized, CPG-adherent approach to PFP management for optimizing function, reducing long-term health care costs, and improving readiness for duty.

Relevance: A protocolized, CPG-adherent approach that can be implemented across health care settings is proposed.

Importance: Current rehabilitative approaches for the recovery of upper extremity (UE) and lower extremity (LE) function following stroke involve costly time- and personnel-intensive 1-on-1 motor learning-based training. Preliminary data in chronic stroke indicate facilitated aerobic exercise (FE), where volitional LE movements are mechanically supplemented, enhances UE motor recovery associated with task-based practice.

Objective: The goals of the Intensive Stroke Cycling for Optimal Recovery and Economic Value trial are to determine effects of FE in facilitating UE and LE motor recovery post-subacute stroke, to elucidate neural and biochemical substrates of FE-induced motor recovery, and to evaluate cost-effectiveness of a FE-centered intervention.

Design: A prospective, single-center, parallel group, rater-blind, pragmatic randomized clinical trial will be conducted.

Setting: The setting will be a large academic medical institution.

Participants: Individuals with hemiparesis due to subacute stroke (N = 66) will be enrolled.

Interventions: Participants will be randomized into FE followed by abbreviated sessions of physical and occupational therapy (FE + rehab) or usual care consisting of consecutive sessions of physical and occupational therapy (rehab). All participants will receive a comparable dose of contact time: 90 minutes, 2 times per week for 12 weeks.

Main outcomes: Motor outcomes will be collected at baseline, end of treatment (EOT) and EOT + 6 months. Electroencephalograms and blood biomarkers will be collected at baseline and EOT. Cost-effectiveness will be modeled over immediate and long-term horizons.

Relevance: The global effect of FE has the potential to enhance recovery in a growing population of stroke survivors in a cost-effective manner, thus accelerating its clinical acceptance. The mechanistic aim will explore the effects of each approach on substrates underlying neuroplasticity.