Marianne Beninato

Using the International Classification of Functioning, Disability and Health as a Framework to Examine the Association Between Falls and Clinical Assessment Tools in People With Stroke

Background: Falls in people with stroke are extremely common and present a significant health risk to this population. Development of fall screening tools is an essential component of a comprehensive fall reduction plan. Objective: The purpose of this study was to examine the accuracy of clinical measures representing various domains of the International Classification of Functioning, Disability and Health (ICF) relative to their ability to identify individuals with a history of multiple falls. Design: A case series study design was used. Setting: The study was conducted in a community setting. Participants: Twenty-seven people with stroke participated in the study. Measurements: Clinical assessment tools included the lower-extremity subscale of the Fugl-Meyer Assessment of Sensorimotor Impairment (FMLE) and Five-Times-Sit-to-Stand Test (STS) representing the body function domain, the Berg Balance Scale (BBS) representing the activity domain, the Activities-specific Balance Confidence (ABC) Scale as a measure of personal factors, and the physical function subscale of the Stroke Impact Scale (SIS-16) as a broad measure of physical function. We used receiver operating characteristic (ROC) curves to generate cutoff scores, sensitivities, specificities, and likelihood ratios (LRs) relative to a history of multiple falls. Results: The FMLE and the STS showed a weak association with fall history. The BBS demonstrated fair accuracy in identifying people with multiple falls, with a cutoff score of 49 and a positive LR of 2.80. The ABC Scale and the SIS-16 were most effective, with cutoff scores of 81.1 and 61.7, respectively, positive LRs of 3.60 and 7.00, respectively, and negative LRs of 0.00 and 0.25, respectively. Limitations: A limitation of the study was the small sample size. Conclusion: The findings suggest that the ICF is a useful framework for selecting clinical measures relative to fall history and support the need for prospective study of tools in more-complex domains of the ICF for their accuracy for fall prediction in people with stroke.

The accuracy of individual Berg Balance Scale items compared with the total Berg score for classifying people with chronic stroke according to fall history.

Background and Purpose: To determine whether individual Berg Balance Scale (BBS) items or a group of items would have greater accuracy than the total BBS in classifying community-dwelling people with stroke with a history of multiple falls. Methods: The subjects were 44 community-dwelling individuals with chronic stroke; 34 had one or no falls in the past six months, and 10 had multiple falls. Each BBS item was dichotomized at three points along the scoring scale of 0-4: between scores of 1 and 2, 2 and 3, and 3 and 4. Sensitivity (Sn), specificity (Sp), and positive (+LR) and negative (−LR) likelihood ratios were calculated for all items for each scoring dichotomy based on their accuracy in classifying subjects with a history of multiple falls. These findings were compared with the total BBS score where the cutoff score was derived from receiver operating characteristic curve analysis. Results: Dichotomized point 3-4 for items B11 (turning 360 degrees), B12 (alternate foot on stool), B13 (tandem stance), and B14 (standing on one leg) all revealed Sn greater than 60%. B14 had the best Sn and Sp (0.90 and 0.50). Combining B11, B12, or B13 with B14 did not improve Sn. Total BBS receiver operating characteristic curve revealed a cutoff score of 52 (Sn = 90% and Sp = 41%). Conclusion: Using selected items from the BBS may be more time efficient and accurate than the total BBS score for classifying people with chronic stroke living in the community with a history of multiple falls. Prospective study is needed to validate these findings relative to fall prediction.

Applying concepts of responsiveness to patient management in neurologic physical therapy.

Determining whether real change has taken place as a result of treatment and whether that change constitutes important change are challenges central to evidence-based physical therapist practice. Recently, the literature reporting these values for clinical measures has expanded considerably. In this article, we discuss some of the indices for identifying real change and important change, and how physical therapists can use these indices to enhance the interpretability of change scores derived from clinical measures. Specifically, we define and discuss the uses of the minimal detectable change and the minimal clinically important difference. We provide suggestions for how these indices can be used to make change scores more meaningful to therapists, patients, their caregivers, and third-party payers. Accurate interpretation and application of these indices are crucial to informed patient management and clinical decision making. We also present some of the limitations confronted as we try to apply these values across various patient diagnostic groups and across the spectrum of initial level of impairment. Finally, recommendations are made for directions for future research in this important area of outcomes research and how clinicians can contribute to these efforts.

Perspective: impact of the IIISTEP conference on clinical practice.

In July 2005, physical therapy clinicians, educators, and researchers gathered for the IIISTEP (Symposium on Translating Evidence to Practice) conference. The purpose of IIISTEP was to link research and clinical practice through the exchange of ideas and research findings between scientists and clinicians. This paper represents the personal perspective of a group of colleagues who attended IIISTEP as clinicians/educator teams. The purpose of this paper is to illustrate how information from IIISTEP has challenged our existing concepts regarding physical therapy practice and begun to alter our clinical practice. Some key concepts presented by scientists and clinicians at IIISTEP are reviewed including current perspectives on neuroplasticity and frameworks for considering function, health, and the disablement process. Considerations for clinical application are outlined. Patient cases are used to illustrate how integration of this information has altered our approach to patient management.

Physical Therapist Practice in the Emergency Department Observation Unit: Descriptive Study

Background An upward trend in the number of hospital emergency department (ED) visits frequently results in ED overcrowding. The concept of the emergency department observation unit (EDOU) was introduced to allow patients to transfer out of the ED and remain under observation for up to 24 hours before making a decision regarding the appropriate disposition. No study has yet been completed to describe physical therapist practice in the EDOU. Objective The objectives of this study were: (1) to describe patient demographics, physical therapist management and utilization, and discharge dispositions of patients receiving physical therapy in the EDOU and (2) to describe these variables according to the most frequently occurring diagnostic groups. Design This was a descriptive study of patients who received physical therapist services in the EDOU of Massachusetts General Hospital during the months of March, May, and August 2010. Methods Data from 151 medical records of patients who received physical therapist services in the EDOU were extracted. Variables consisted of patient characteristics, medical and physical therapist diagnoses, and physical therapist management and utilization derived from billing data. Descriptive statistics were used to analyze data. Results The leading EDOU medical diagnoses of individuals receiving physical therapist services included people with falls without fracture (n=30), back pain (n=27), falls with fracture (n=22), and dizziness (n=22). There were significant differences in discharge disposition, age, and total physical therapy time among groups. Limitations This was a retrospective study, so there was no ability to control how data were recorded. Conclusions This study provides information on common patient groups seen in the EDOU, physical therapist service utilization, and discharge disposition that may guide facilities in anticipated staffing needs associated with providing physical therapist services in the EDOU.

The Functional Gait Assessment in Older Adults: Validation Through Rasch Modeling

Background The Functional Gait Assessment (FGA), a measure of walking balance ability, was developed to eliminate the ceiling effect observed in the Dynamic Gait Index (DGI). Three presumably more difficult tasks were added and 1 easier task was removed from the original 8 DGI tasks. The effects of these modifications on item hierarchy have not previously been analyzed. Objective The purpose of this study was to determine: (1) the ordering of the 10 FGA tasks and the extent to which they map along a clinically logical difficulty continuum, (2) whether the spread of tasks is sufficient to measure patients of varying functional ability levels without a ceiling effect, (3) where the 3 added tasks locate along the task difficulty continuum, and (4) the psychometric properties of the individual FGA tasks. Design A retrospective chart review was conducted. Methods Functional Gait Assessment scores from 179 older adults referred for physical therapy for balance retraining were analyzed by Rasch modeling. Results The FGA task hierarchy met clinical expectations, with the exception of the “walking on level” task, which locates in the middle of the difficulty continuum. There was no ceiling effect. Two of the 3 added tasks were the most difficult FGA tasks. Performance on the most difficult task (“gait with narrow base of support”) demonstrated greater variability than predicted by the Rasch model. Limitations The sample was limited to older adults who were community dwelling and independently ambulating. Findings cannot be generalized to other patient groups. Conclusions The revised scoring criteria of the FGA may have affected item hierarchy. The results suggest that the FGA is a measure of walking balance ability in older adults that is clinically appropriate and has construct validity. Administration of the FGA may be modified further to improve administration efficiency.

Use of the International Classification of Functioning, Disability and Health as a framework for analyzing the Stroke Impact Scale-16 relative to falls.

Abstract Objective: To determine if subscores based on grouping Stroke Impact Scale 16 (SIS-16) items according to International Classification of Functioning, Health and Disability (ICF) components are more accurate in identifying individuals with a history of falls than the total SIS-16 score. Design: Case series. Subjects: 43 community-dwelling people with chronic stroke. Methods: Participants were grouped based on six month fall history (no fall versus one or more falls). The SIS-16 items were categorized as belonging to the Body Structure and Function (BSF), Activity (ACT) or Participation (PART) component of the ICF. SIS-16 total score and ICF component subscores were analyzed for their association with falls. Receiver Operating Characteristic Curves were (ROC) analyzed. Results: There were significant differences between groups on SIS-16 total (p = 0.006), BSF (p = 0.041) and ACT (p = 0.003) scores. The BSF and ACT component subscores had the highest specificity (0.91) and sensitivity (0.80), respectively, for categorizing participants according to fall history. The BSF + ACT component subscore demonstrated greater accuracy than the total SIS-16 for identifying people with falls (area under the curve = 0.78). Conclusion: The ICF may be a useful model for analysis of fall screening tools for people with chronic stroke. ICF component subscores are more accurate than the SIS-16 total score for this purpose.

Analysis of individual SIS-16 items relative to fall history in people with stroke

Fig. 2. AF = Any fall in prior six months compared with no fall (NF) in the same period. SIS-16 = the Physical Function subscore of the Stroke Impact Scale. Sum of significant items is summed scores of all individual SIS-16 items related to fall history. Arrow indicates optimal cut-off score considering both sensitivity and specificity. Reference diagonal line represents area of 0.50 (minimum to maximal area range = 0.0–1.00). Table 3