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.
Importance: Chronic plantar heel pain is common and often recalcitrant yet understanding of modifiable risk factors that influence its trajectory of recovery is limited.
Objective: The objective of this study was to describe associations of changes in physical and psychological measures and symptom descriptors over 12 months with changes in pain, function, and quality of life in people with chronic plantar heel pain.
Design: A prospective cohort with longitudinal follow-up was used.
Setting: A community setting in southern Tasmania was used.
Participants: The participants were 220 people with a clinical diagnosis of chronic plantar heel pain.
Exposures: The exposures were body mass index (kg/m2), waist circumference (centimeters), ankle plantarflexor strength (kilograms), ankle and first metatarsophalangeal joint dorsiflexion mobility (degrees), pain catastrophizing beliefs (Pain Catastrophizing Scale), depression (9-item Patient Health Questionnaire), multisite pain, morning stiffness, neuropathic symptoms (painDETECT), and physical activity (accelerometry).
Main outcomes and measures: The Foot Health Status Questionnaire pain and function domains and the 6-dimension Assessment of Quality of Life Scale were used. Outcomes and exposures were assessed at baseline and 12 months. Data were analyzed using linear mixed-effects models with exposure × time interactions.
Results: Increasing pain catastrophizing and neuropathic painDETECT scores over 12 months were associated with a poorer trajectory of pain recovery (pain catastrophizing interaction β = -.39 [95% CI = -0.01 to -0.77]; painDETECT interaction β = -.79 [95% CI = -0.10 to -1.48]). In full multivariable models, there were no other significant associations between any other variable and pain. The only associations with foot function and quality of life were weak negative associations of steps per day and sedentary time with function and quality of life, respectively.
Conclusions and relevance: Increasing pain catastrophizing and neuropathic symptoms were associated with poorer pain outcomes over 12 months in individuals with chronic plantar heel pain. These findings highlight the importance of pain beliefs and neurogenic factors in the prognosis of chronic plantar heel pain. Interventions targeting pain beliefs and neuropathic mechanisms may improve outcomes in subgroups with these characteristics.
Transgender, nonbinary, and gender-diverse (TNBGD) individuals experience significant inequities in health, access to health care, and participation in physical activity for a myriad of reasons, including gender dysphoria and the physical effects of gender-affirming practices like chest binding. Physical therapists have the requisite clinical skills to evaluate and treat these individuals, potentially enhancing overall health and wellness while reducing barriers to physical activity. Binding is a common practice for many TNBGD individuals, often performed to achieve improved congruence between an outward physical appearance and one's gender identity. Given the typical frequency and duration of binding, negative binding-related symptoms such as thoracic or rib pain, shortness of breath, and postural changes may occur. Physical therapists can be the provider of choice in minimizing the symptom burden and adverse effects of binding, but as a profession, we must improve inclusive care practices, deepen our understanding of the physiologic impacts of binding, and implement culturally responsive care plans tailored to the needs of TNBGD patients. Increased access to inclusive physical rehabilitation may improve lifelong health, promote physical activity, and mitigate health inequities in this population. Clinicians can purposefully advertise their preparedness and willingness to serve lesbian, gay, bisexual, transgender, queer, intersex, asexual, and 2-spirit patients and work to understand and address disparities in health care access and quality. As a profession, we must continue to evolve to meet the needs of society, especially those who face systemic barriers and marginalization.
Importance: Virtual reality (VR) has been introduced to stroke rehabilitation along with omnidirectional (360°) treadmills to promote improvements in walking and balance.
Objective: The primary objective was to develop a rehabilitation omni-VR game and estimate the feasibility and usability of the game according to individuals with chronic stroke and physical therapists. The secondary objective was to generate preliminary walking characteristics and postural sway data among survivors of stroke.
Design: This was a mixed-methods feasibility study.
Setting: This study took place at a stroke research lab in Halifax, Canada.
Participants: The participants were individuals with chronic stroke and stroke rehabilitation physical therapists.
Exposure: The research team developed a VR game involving 8 walking and balance tasks on an omnidirectional treadmill. Physical therapists and survivors of stroke tested the game in a single session and participated in a semi structured interview.
Main outcomes and measures: Main outcomes and measures were recruitment rate, user experiences, participant burden, technical issues, safety, and exercise dose. Descriptive statistics were calculated for feasibility outcomes and interview data were analyzed using reflexive thematic analysis.
Results: Eight survivors of stroke (4 female, 4 male) and 4 female physical therapists participated in the study. Feasibility and usability targets were met, except for user experience scores and technical issues. For survivors of stroke, the mean steps taken during the VR game was 693.0 (standard deviation, SD = 223.6), they reached 66.4% SD = 10.7 of predicted maximum heart rate, and the mean game testing time was 25.5 minutes SD = 13.5. Five qualitative themes emerged: benefits of the omni-VR system, difficulties & challenges with omni-VR, suggestions for improvements, application to rehabilitation, and safety of the system.
Conclusions: There is preliminary evidence for the feasibility of omni-VR for stroke rehabilitation.
Relevance: The VR game appears to be of adequate intensity, provides a larger number of repetitions, and is of comparable duration to traditional rehabilitation sessions.
Importance: Corticobasal syndrome (CBS) is a rare tauopathy, with a complex pathophysiology that usually includes neuroinflammation. Parkinsonism, cognitive impairments, and sleep disturbances are common in CBS, although alterations in sleep architecture remain poorly characterized. Regular exercise has been recommended in CBS to manage gait dysfunction, balance issues, and cognitive decline. However, the effects of regular exercise on sleep quality, sleep architecture, and systemic inflammation in CBS remain unclear.
Objective: The purpose of this study was to describe the effects of regular exercise in CBS.
Design: The design of this study was a case report.
Settings: This study was conducted in an academic laboratory.
Participants: An individual with CBS participated in this case study.
Intervention: The participant completed a 12-week multimodal training program.
Main outcome(s) and measure(s): Cardiorespiratory fitness level was assessed with a symptom-limited cardiopulmonary exercise test and strength with a submaximal 1-repetition maximum test. Subjective and objective sleep quality were assessed using the Parkinson Disease (PD) Sleep Scale-2 and actigraphy, respectively. Sleep architecture was evaluated with polysomnography. Cognition and motor function were assessed with the Scale for Outcomes in PD-Cognition and Movement Disorder Society-Unified Parkinson's Disease Rating Scale part III (MDS-UPDRS-III), respectively, functional mobility with the Time Up and Go (TUG), and fatigue with the PD Fatigue Scale. Concentrations of inflammatory markers, including interleukin (IL)-1β, IL-6, IL-10, tumor necrosis factor, and C-reactive protein, were measured from serum collected after a 12-hour fasting period.
Results: Following the training program (34 sessions; 25.35 hours), improvements in fitness, objective sleep quality and architecture, cognition, TUG, and a reduction in systemic inflammation were observed. Conversely, MDS-UPDRS-III scores deteriorated, and the participant reported diminished subjective sleep quality and increased fatigue.
Conclusions: These results, which should be interpreted with caution, suggest that various clinical outcomes improved following multimodal training. Controlled studies are warranted to confirm these observations.
Relevance: This is the first case report describing the effects of a training program on sleep architecture and systemic inflammation in CBS.
Importance: Health professions education programs emphasize learning specialized knowledge that will be needed by the health care provider long after the initial exposure. Most laboratory investigations into memory have little applicability to the material learned in health professions education, and evidence is mixed on which material is retained and for how long.
Objective: The objective was to describe the retention levels of health professions education material among Doctor of Physical Therapy (DPT) learners over an extended interval and determine if retention varies by the level of knowledge assessed or the performance level of the learner.
Design: Learners completed 6 multiple-choice examinations as part of their standard curriculum. Each exam was integrated to include content covered across all instructional areas. Seventy-two items were selected from these 6 exams and re-administered in 2 retention tests occurring at approximately 5 and 15 months. The retention test items were dichotomized into high-level and low-level according to Bloom's taxonomy. We also compared the forgetting rates between learners in the top and bottom quartile, based on their initial exam performance.
Setting: Learners were enrolled in a residential DPT training program.
Participants: Ninety-four DPT learners participated.
Intervention(s) or exposure(s): This was a retrospective analysis of standard curriculum assessments administered without any interventions.
Main outcome(s) and measure(s): The main outcome was the learners' level of retention at the retention tests.
Results: Overall, retention decreased at the 5 and 15-month intervals. Initial performance was significantly lower on high-level Bloom's items, however, these items showed less forgetting over time compared to low-level items. Learners forgot 9% of the high-level Bloom's items compared to 17.5% of the low-level items. The forgetting rates overall and for each Bloom's level did not significantly differ across top and bottom quartile learners.
Conclusions: This study compared retention across levels of Bloom's taxonomy and compared high and low performing learners. An overall decrease in retention was found, that was attenuated by high-level Bloom's learning as compared to low-level learning.
Relevance: The attenuation of forgetting for high-level Bloom's questions and the stable rates of forgetting across high and low performers have implications for how programs might structure examinations to promote long-term retention. Future work should examine retention over extended intervals and investigate the effect of clinical experiences on the retention of material learned in the classroom.
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