Tara Jo Manal

Practice guidelines for anterior cruciate ligament rehabilitation: a criterion-based rehabilitation progression

Abstract Knowledge related to the anterior cruciate ligament (ACL) and its role in the stabilization of the knee has increased exponentially since the 1980 s. More precise and more anatomic surgical techniques have developed based on a growing body of literature on the anatomy and biomechanics of the anterior cruciate ligament. The rehabilitation arena has also risen to the challenge to provide state-of-the-art rehabilitation to complement advances in surgical stabilization. The understanding and integration of the abundance of literature on surgical reconstruction, graft biology, and behavior guides the design and progress of the rehabilitation program. Effective rehabilitation after anterior cruciate ligament reconstruction must balance the loading of tissues necessary to stimulate the recovery of the knee while at the same time avoiding stresses that compromise graft integrity. Historically, rehabilitation programs have been temporally based. A performance-based decision-making approach may prove to be more universally applicable and less confining. Achieving the critical clinical milestones, the basis for rehabilitation progression, ensures that all patients are adequately challenged while at the same time assuring that none are progressed too quickly. Combining contemporary surgical and rehabilitation techniques will maximize the patients potential and ensure optimal patient function and satisfaction.

Psychometric Properties of Commonly Used Low Back Disability Questionnaires: Are They Useful for Older Adults with Low Back Pain?

OBJECTIVES To evaluate the psychometric properties of two commonly used low back pain (LBP) disability questionnaires in a sample solely comprising community-dwelling older adults. DESIGN Single-group repeated measures design. SETTING Four continuing care retirement communities in Maryland and in Virginia. Participants. Convenience sample of 107 community-dwelling men and women (71.9%) aged 62 years or older with current LBP. Outcome Measures. All participants completed modified Oswestry Disability (mOSW) and Quebec Back Pain Disability (QUE) questionnaires, as well as the Medical Outcomes Survey Short-Form 36 questionnaire at baseline. At follow-up, 56 participants completed the mOSW and the QUE for reliability assessment. RESULTS Test-retest reliability of the mOSW and QUE were excellent with intraclass correlation coefficients of 0.92 (95% confidence interval [CI]: 0.86, 0.95) and 0.94 (95% CI: 0.90, 0.97), respectively. Participants with high pain severity and high levels of functional limitation had higher scores on the mOSW (P < 0.0001) and QUE (P < 0.001) scales than other participants, which represents good construct validity for both scales. The threshold for minimum detectable change is 10.66 points for the mOSW and 11.04 points for the QUE. Both questionnaires had sufficient scale width to accurately measure changes in patient status. CONCLUSIONS It appears that both questionnaires have excellent test-retest reliability and good construct validity when used to evaluate LBP-related disability for older adults with varying degrees of LBP. Neither questionnaire appears to have superior psychometric properties; therefore, both the Oswestry and Quebec can be recommended for use among geriatric patients with LBP.

The American Physical Therapy Association's Top Five Choosing Wisely Recommendations

Improving health care in our country requires simultaneous pursuit of 3 aims: improving the effectiveness of care, improving the health of our population, and reducing the per capita costs of health care.1 As our nation focuses on ways to achieve this triple aim, the unwarranted overuse of health care resources is a significant concern. The continuing rise in health care costs, estimated at

Trunk Muscle Training Augmented With Neuromuscular Electrical Stimulation Appears to Improve Function in Older Adults With Chronic Low Back Pain: A Randomized Preliminary Trial.

2.8 trillion or 17.2% of gross domestic product in 2012, puts financial pressure on our national economy. Consequently, individuals are burdened by rising insurance premiums, deductibles, and copayments, often in addition to lost wage increases due to rising costs of premiums incurred by employers.2 Proponents of the triple aim have suggested there is ample capacity in our current health care system to achieve these goals by reducing unnecessary tests, treatments, and procedures.1 In fact, the Institute of Medicine estimates that in 2009 alone more than

Application of Educational Theory and Evidence in Support of an Integrated Model of Clinical Education

750 billion (or 1 in 3 dollars spent on health care) was spent on unnecessary medical tests, procedures, and missed prevention opportunities.3 Implementing strategies that reduce unnecessary tests and procedures becomes a challenge, particularly when considering that most of these tests and procedures are covered by insurance. The federal government and private payers have attempted to control health care expenditures and utilization by increasing the number and complexity of regulations and requirements that govern the provision of care. Although the intent may be to improve patient care, these frequently changing and increasingly intricate regulations have led to a burdensome practice environment, challenging the ability of clinicians and administrators to remain compliant. Additionally, attempts to control utilization and costs have led to a significant increase in audits and investigations.4 Because of the complexity of the regulatory environment, even the most diligent health care professionals may find themselves the subject of costly investigations or audits.5

Rehabilitation after revision anterior cruciate ligament reconstruction: Practice guidelines and procedure-modified, criterion-based progression

Objectives:To assess the feasibility of a trial to evaluate a trunk muscle training program augmented with neuromuscular electrical stimulation (TMT+NMES) for the rehabilitation of older adults with chronic low back pain (LBP) and to preliminarily investigate whether TMT+NMES could improve physical function and pain compared with a passive control intervention. Materials and Methods:We conducted a single-blind, randomized feasibility trial. Patients aged 60 to 85 years were allocated to TMT+NMES (n=31) or a passive control intervention (n=33), consisting of passive treatments, that is, heat, ultrasound, and massage. Outcomes assessed 3- and 6-month postrandomization included Timed Up and Go Test, gait speed, pain, and LBP-related functional limitation. Results:Feasibility was established by acceptable adherence (≥80%) and attrition (<20%) rates for both interventions. Both groups had similar, clinically important reductions in pain of >2 points on a numeric pain rating scale during the course of the trial. But, only the TMT+NMES group had clinically important improvements in both performance-based and self-reported measures of function. In terms of the participants’ global rating of functional improvement at 6 months, the TMT+NMES group improved by 73.9% and the passive control group improved by 56.7% compared with baseline. The between-group difference was 17.2% (95% confidence interval, 5.87-28.60) in favor of TMT+NMES. Discussion:It seems that a larger randomized trial investigating the efficacy of TMT+NMES for the purpose of improving physical function in older adults with chronic LBP is warranted.

Balance-confidence is associated with community participation, perceived physical mobility, and performance-based function among individuals with a unilateral amputation

Background and Purpose. The integrated model of clinical education has been incorporated into the educational curricula of various professions for decades. Currently, however, there is variability among physical therapist education programs in the use and design of such models. This position paper will not only highlight the pedagogy of early integrated clinical experiences, but also provide 2 examples of integrated clinical education models from successful physical therapist education programs. Position and Rationale. Evidence exists to demonstrate the utility of integrated and experiential learning models of clinical education in reinforcing the cognitive, psychomotor, and/or affective domains of learning. Early patient exposure in genuine clinical environments provides students with critical skills necessary for future professional practice. Further, integrated clinical education stimulates transfer, application, and reinforcement of classroom learning to authentic patient/client situations; provides exposure to varied service delivery models; and promotes self‐assessment and opportunities for skill development and professional growth. Discussion and Conclusion. Successful outcomes from integrated clinical experiences rely upon carefully constructed learning opportunities. Designing models wherein didactic and clinical faculty demonstrate consistent practice philosophies and hold students accountable for learning based upon the extent of didactic education completed provides for a seamless approach to student learning. The integrated model of clinical education allows faculty to control the type, sequence, and duration of clinical experiences, as well as the qualifications of the involved clinicians. To maximize student readiness for patient/client demands within the twenty‐first century and beyond, integrated clinical experiences should be viewed as an essential component of the core curriculum in physical therapist education.

Differences in Physical Performance Measures Among Patients With Unilateral Lower-Limb Amputations Classified as Functional Level K3 Versus K4

Abstract Reconstructive surgery has become a more common solution for patients after rupture of the anterior cruciateligament (ACL) as a result of better surgical technique and more efficient and effective rehabilitation. As the incidence of ACL reconstruction surgery increases, the number of reconstructions that ultimately fail also increases. Failure of the primary reconstruction, whether caused by technical error during the surgery or an outside factor such as traumatic rerupture, often necessitates revision of the ACL reconstruction to restore joint integrity and optimize function. We have previously described criterion-based and procedure-modified rehabilitation after primary ACL reconstruction. The same principles that drive rehabilitation after primary reconstruction are factors after revision surgery; however, the progression must be modified. The major difference between the two surgeries lies in the ability of the surgeon to achieve adequate fixation of the new graft within the joint during a revision reconstruction. The second controlled trauma of revision surgery further compromises the bony structures that serve as the foundation for the new graft. Therefore, less rigid fixation after revision ACL reconstruction must be assumed. This necessitates a longer period of controlled weight bearing for every-day activities and slower progression of weight-bearing exercise during rehabilitation to ensure that biological healing can proceed without being compromised by the presence of forces that exceed the strength of the new graft fixation. Other factors such as staging of the revision surgery and concurrent bony procedures will also require modification of the rehabilitation. Understanding these factors and implementing the modifications that they necessitate into rehabilitation should lead to a more predictable return to high functional levels after revision ACL reconstruction.

Interrater Reliability of a Clinical Scale to Assess Knee Joint Effusion

ABSTRACT Objective To explore relationships between balance-confidence and: 1) community participation; 2) self-perceived mobility; and 3) performance-based physical function among individuals with a lower-limb amputation using a prosthetic. Design: Retrospective, cross-sectional study. Setting: Outpatient, multidisciplinary amputee clinic. Participants: Patients (n = 45) using a prosthesis, aged ≥ 18 years, with a unilateral transfemoral or transtibial amputation of ≥1 year, were included. Methods: Participants completed the following self-report measures: Activities-Specific Balance Confidence Scale (ABC); Community Integration Questionnaire (CIQ); Locomotor Capabilities Index (LCI); and two performance-based measures (i.e. Timed Up and Go and 6 Minute Walk Test). Linear regression modeling was used to explore relationships between balance-confidence (i.e. ABC) and self-report (i.e. CIQ and LCI) and performance-based measures (p ≤ 0.0125). Results: After controlling for potential covariates (i.e. age, sex, and body mass index), balance-confidence explained 47.4% of the variance in CIQ (p = 0.000), 53.0% of the variance in LCI (p = 0.000), 20.3% of the variance in Timed Up and Go (p = 0.001), and 18.2% of the variance in 6 Minute Walk Test (p = 0.001). Conclusion: Lower balance-confidence is associated with less community participation, lower self-perceived mobility, and poorer performance among patients with a unilateral lower-limb amputation.

Failure of Voluntary Activation of the Quadriceps Femoris Muscle After Patellar Contusion

OBJECTIVE To determine whether differences in physical function, assessed via self-report questionnaires and physical performance tests, exist between individuals with lower-limb loss using a prosthetic device classified as a K3 versus a K4 functional level. DESIGN Cross-sectional study. SETTING A university physical therapy amputee clinic. PARTICIPANTS Participants (N=55) were included if they (1) were aged ≥18 years with a unilateral transfemoral or transtibial amputation; (2) were classified as K3 or K4 functional level; (3) completed all relevant outcome measures; and (4) were currently using a prosthesis. INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES Locomotor Capabilities Index (LCI), Prosthetic Evaluation Questionnaire-Mobility Section (PEQ-MS), Timed Up and Go (TUG), 10-Meter Walk Test (10MWT), Amputee Mobility Predictor (AMPPRO), and 6-Minute Walk Test (6MWT). K level was determined by group consensus based on a standardized clinical evaluation. RESULTS After controlling for covariates, patients classified as K3 had slower TUG times (P=.002) and self-selected and fast gait speeds (P<.001), lower AMPPRO scores (P<.001), and walked shorter distances during the 6MWT (P=.003) when compared with patients classified as K4. No significant between-group differences for the LCI or PEQ-MS were found. CONCLUSIONS Clinicians involved in prosthetic prescription may consider including the TUG, 10MWT, AMPPRO, and 6MWT during their clinical evaluations to help differentiate between individuals of higher functional mobility. The LCI and PEQ-MS may be less useful in classifying individuals as K3 versus K4 because of a ceiling effect.