Acute Care Section - APTA, Inc. JACPT Journal of Acute Care Physical Therapy Fall 2010 ● Volume 1 ● Number 1 CASE REPORT Chronic Inflammatory Demyelinating Polyradiculoneuropathy from a Physical Therapist’s Perspective: A Case Report University of Rochester Acute Care Evaluation: Development of a New Functional Outcome Measure for the Acute Care Setting CLINICAL PRACTICE The Effects of a Physical Therapy Triage System on the Outcomes of ICU Patients with Respiratory Failure RESEARCH REPORT APTA 2010 Combined Sections Meeting Platform Presentation Abstracts Poster Abstracts 4 14 21 30 34
Transcript
Acute Care Section - APTA, Inc.
JACPTJournal of Acute Care Physical Therapy
Fall 2010 ● Volume 1 ● Number 1
CASE REPORTChronic Inflammatory Demyelinating Polyradiculoneuropathy from a Physical Therapist’s Perspective: A Case Report
University of Rochester Acute Care Evaluation: Development ofa New Functional Outcome Measure for the Acute Care Setting
CLINICAL PRACTICE
The Effects of a Physical Therapy Triage System on the Outcomes of ICU Patients with Respiratory Failure
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Fall 2010 • Volume 1 • Number 1
CASE REPORTChronic Inflammatory Demyelinating Polyradiculoneuropathy from a Physical Therapist’s Perspective: A Case ReportDoris Y. Chong, Leslie B. Glickman, Paz Susan Cabanero-Johnson
University of Rochester Acute Care Evaluation: Development of a New Functional Outcome Measure for the Acute Care SettingJulie DiCicco, Deborah Whalen
CLINICAL PRACTICE
The Effects of a Physical Therapy Triage System on the Outcomes of ICU Patients with Respiratory FailureJoni Rapp, Jaime C. Paz, Christine McCallum, Jeanne Cole, Lynn Steffey
RESEARCH REPORT
APTA 2010 Combined Sections Meeting, San Diego, CA
Platform Presentation AbstractsPoster Abstracts
Arnold, Stephen Carp, Lee Ann Eagler, Barbara Ehrmann, Karen Holtgrefe, Diane Madras, Stephen Morris, Barbara Smith, Beth Smith, Bonnie Swafford, and Patricia Ohtake have provided the kind of feedback necessary to elevate the scientific value of the manuscripts submitted thus far. This level of critique has been beneficial for the authors as well as preparing JACPT for consideration for indexing in MEDLINE®. Inclusion in MEDLINE is critical for the recognition of acute care physical therapy as a unique health care entity. We are required to submit an entire year’s worth of issues to be considered and our plan is to apply for inclusion as soon as we have this first year of issues completed.
Finally, the efforts of Lieve Monnens and Judy Oiler of our management company, APTANJ, have been critical in making this transformation into a full-fledged, standalone journal for acute care physical therapy. Lieve and Judy have been responsible for the physical design as well as keeping us all connected and on track.
Getting this first issue to press--and trying to make it perfect--has been a huge undertaking and I hope all reading this will both celebrate this accomplishment and seek ways to add to our journal. We are particularly in need of individuals who will find advertisers and promote our journal beyond the members of the Section. Please send comments or questions to [email protected].
Glenn L. Irion, PhD, PT, CWS Editor in Chief, Journal of Acute Care Physical Therapy
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Editorial Board
Glenn Irion, PT, PhD, CWS - Editor in ChiefAssociate Professor of Physical TherapyUniversity of South Alabama307 N. University BlvdHAHN 2011Mobile, AL 36688phone 251 445-9243fax 251 [email protected]
PRESIDENTJames M. Smith, PT, DPT Assistant Professor of Physical TherapyUtica College, 1600 Burrstone RoadUtica NY 13502-4857phone: (315) [email protected]
JACPTJournal of Acute Care Physical Therapy Welcome to the Journal of Acute Care Physical Therapy!
The first issue of JACPT has been in development since our strategic planning retreat at this time last year. At this retreat, we were challenged with ways of supporting our Section’s mission and vision. Among those aspects of the mission and vision, elevating the practice of acute care physical therapy and making ourselves more visible to the health care community were particularly instrumental in the decision to create a journal dedicated specifically to the science and practice of acute care physical therapy.
A successful Journal is only one avenue for promoting the mission and vision of the Acute Care Section. The Board of Directors and Editorial Board of JACPT will continue to work closely to achieve three basic missions for JACPT 1. Demonstrating a unique body of knowledge that distinguishes the acute care physical therapist from other physical therapists; 2. Defining the role of the acute care physical therapist within health care; 3. Demonstrating a growing evidence-base to the practice of acute care physical therapy.
To distinguish ourselves, we need a repository for the body of knowledge that defines our role in health care. This body of knowledge should be sufficiently different from other physical therapy practices that we become recognized as the experts in practice of physical therapy for those with acute care needs. It also needs to define our place in health care such that practitioners outside physical therapy seek out the acute care physical therapist. A third aspect is the continued growth of this area of practice. Thus, the emphasis of JACPT on the science and practice of acute care physical therapy.
I have been fortunate that the Editorial Advisory Board members for Acute Care Perspectives have taken on new roles as Associate Editors. Scott LaRaus, Kevin Brueilly, and Jane Wetzel have the important task of synthesizing the reports of peer reviewers with their own analysis of submitted manuscripts and reporting to me with recommendations. They also review resubmissions/revisions of submitted manuscripts to ensure required revisions meet the standards of publication in JACPT. The development of JACPT has added several tasks beyond those of Acute Care Perspectives. I am happy to announce the appointment of Beth Smith as Deputy Editor. She adds another perspective in addition to another pair of hands and eyes to make JACPT the publication that I had hoped it would be. Input from the Associate Editors and Deputy Editor have proved invaluable as we have put this first issue of JACPT into a physical form. We have been fortunate to have so many individuals volunteer to become peer reviewers. The efforts of Scott
EDITORIAL
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Chronic Inflammatory Demyelinating Polyradiculoneuropathy from a Physical Therapist’s Perspective: A Case Report
Doris Y. Chong, PT, MSc, DScPT, NCSNeurologic Clinical Specialist, inpatient acute care at Stanford University Medical Center in CaliforniaAdjunct Assistant Professor, Samuel Merritt UniversityAssistant Clinical Professor, San Francisco State [email protected]
Leslie B. Glickman, PT, PhDAssistant Professor and Director of Post-Professional Programs at the University of Maryland, School of Medicine, Department of Physical Therapy and Rehabilitation Science in Baltimore Maryland. [email protected]
Paz Susan Cabanero-Johnson, PT, DScPTEducation Program Specialist, Department of Veteran Affairs in MarylandAssistant Clinical Professor, University of Maryland at [email protected]
Doris Y. Chong, Leslie B. Glickman, Paz Susan Cabanero-Johnson
ABSTRACT
Purpose: Although the literature describes several medical interventions for chronic inflammatory demyelinating polyradiculoneuropathy (CIDP), no evidenced-based approaches to rehabilitation specific to CIDP can be found. This case report reviews key background information on CIDP, and describes an interdisciplinary approach to rehabilitation in an acute care setting. It illustrates the use of medical knowledge, clinical reasoning, and evidence in selecting outcome measures, formulating a plan of care, and guiding clinical decisions.
Methods: This case describes a 59-year-old man with multiple significant co-morbidities during a six-month period characterized by significant pain, sensory changes, and progressive weakness. He deteriorated dramatically from independent ambulation to requiring a wheelchair. Symptom progression attributed to end-stage liver disease led to further diagnostic tests and eventually, a definitive diagnosis of CIDP. Initial findings included significant major muscle group weakness and a Functional Independence Measure (FIM) score of 23 out of 126. Intervention was focused on therapeutic exercise, balance training, and functional training with progressive endurance activities. FIM score improved to 56, sufficient for discharge to an acute rehabilitation facility.
Conclusion: For this patient with CIDP, effective collaborative team communication and interdisciplinary management worked to optimize clinical decision making and recovery.
Journal of Acute Care Physical Therapy is the journal of the Acute Care Section-APTA. The goal of the publication is to provide timely information to Section members in matters that relate to acute care physical therapy practice. We accept articles that offer a professional opinion, clinical approaches and techniques, research, literature review, and continual quality improvement information. JACPT is published four times a year and is mailed to Section members and paid subscribers. JACPT is copyrighted and registered with the Library of Congress. It is indexed in EBSCO and Gale. Articles are submitted directly to the Editor-in-Chief. At least two reviewers and an Associate Editor will review submitted articles. The Editor-in-Chief is ultimately responsible for all decisions. Articles submitted to JACPT are expected to be original work that has not been previously published or under consideration by another publication. The Editor may consider republication of articles published elsewhere only with explicit permission of the other publication.
FormatArticles must be submitted electronically as documents that can be read by Microsoft Word 2007 for Windows or Word 2008 for OS X (.doc or .docx). Use an easily readable 12-point font such as Times New Roman or Arial. Type your article in double-spaced full-page format and we will convert it to the newsletter layout. Both pages and lines must be numbered. Microsoft Word has a line numbering function to generate line numbers for you. Please minimize the use of text formatting. We will set formatting for headings consistent with the style of the articles that appear in JACPT. Because manuscripts undergo a masked review process, you must submit a masked version with all author names, affiliations and any other potentially identifying information removed from the article. An unmasked copy must also be submitted and will be kept with the Editor-in-Chief only. Submit articles to the Editor-in-Chief at [email protected]. Each table and figure must be sent as a separate file. Although authors may be well-intentioned, please refrain from creating an article with embedded tables and figures. During layout, we must have the flexibility to place figures and tables where needed. If embedded, figures and tables will need to be extracted, which is time-consuming and may lead to problems with size and clarity of the figure or table.
Cover LetterA cover letter must be submitted as described in the full instructions on our website. Cover letters with signatures from all authors may be mailed or faxed to the Editor at 251-445-9238.
AbstractAn abstract of the article suitable for electronic indexing services such as EBSCO is to be included. It should be generally be less than 200 words and contain headings appropriate to the type of article. These headings generally include Purpose, Methods, Results, and Conclusions. Other types should include a minimum of Purpose, Methods, and Conclusions.
Protection of SubjectsThe name of the Institutional Review Board or Institutional Animal Care and Use Committee that approved the research protocol must be included in the Methods section of the manuscript. Remove the name of the IRB or IACUC in the masked version.
Biographical SketchInclude a 2-3 sentence biographical sketch for each author in a separate file to aid in masking the identity of authors during review. This information will not be distributed to reviewers or Associate Editors. Include the professional title, affiliation of each author, and an address (may be e-mail) where readers may contact an author for further information. All funding sources supporting the work should be acknowledged following the biographical sketch at the end of the article.
ReferencesJournal of Acute Care Physical Therapy follows the referencing style outlined in the Publication Manual of the American Medical Association (AMA). Examples of the use of AMA Style can be found in JACPT as well as a large number of medical and health-related journals.
Tables and IllustrationsCaptions for Illustrations as well as tables must be submitted in a separate document, i.e., list of tables and list of figures. Captions or titles may not be embedded in illustrations or tables. Placing labels within illustrations is discouraged. If text labels are included in a figure, they must be of sufficient size to be legible when the illustration is reduced to the width of one column of the publication. Authors must obtain and submit written permission to publish photographs in which patients are recognizable. Black and white photographs copy best. Electronic .jpg format is preferred and must have a minimum resolution of 150 dpi.
ReprintsWe provide all authors with single copies of the issue in which their articles appear. If an article has multiple authors, we prefer to send copies to the lead author to distribute. If this is geographically difficult, please supply our Editor with mailing addresses for those individuals who will require separate mailings. Complete instructions for authors may be obtained from the Acute Care Section’s website www.acutept.org
ADVERTISING
JACPT accepts advertising that conforms to the standards of the APTA. We offer advertising space inside the front and back covers, on the back cover and within other available space inside the journal. Sizes available include full-page, half-page, quarter-page, and business card. We prefer submissions in digital format. All advertising is subject to the approval of the Journal of Acute Care Physical Therapy Editor. The Editor reserves the right to decline an advertisement deemed inappropriate for publication.The acceptance of any advertisement does not constitute endorsement by the APTA or the Section. Please contact the Acute Care Section’s management office at [email protected] or 888-762-2427 for rates and other information.
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Patients improved significantly in their cardiovascular fitness, muscle strength, and quality of life. Despite the high intensity training, patients also reported a twenty per cent (20%) reduction in fatigue severity and impact of fatigue from pre- to post-intervention. Although impairments, activity limitations, and participation restrictions resulting from CIDP fall under the physical therapist’s scope of practice and the Guide to Physical Therapist Practice includes a practice pattern on GBS or CIDP (Pattern 5G: Impaired motor function and sensory integrity associated with acute or chronic polyneuropathies),43 evidence supporting PT as an integral part of the functional recovery of CIDP is anecdotal.
Based on available literature, the physical therapist’s roles include:
Facilitating medical referral and 1. need for further diagnostic tests when suspecting an unconfirmed case of CIDP. For example, patients with clinical presentations suggestive of CIDP but with an unknown etiology or diagnosis may trigger a referral to physicians and suggestions for a lumbar puncture or an NCS.
Using knowledge of atypical 2. symptoms, clinical variants, differential diagnoses, and varying responses related to medical therapies to assist in differentiating the condition from others, and formulating a more accurate
rehabilitation prognosis and plan of care. For example, the physical therapist needs to communicate with physicians if patients with preliminary diagnoses of CIDP do not show functional improvement with traditional medical therapies. Differential diagnoses or change in medical therapy may need to be considered. Rehabilitation prognosis and plan of care may need to be revised if a differential diagnosis results.
Applying knowledge of the side 3. effects of prednisone therapy to the choice of exercise options. For example, in the presence of osteoporosis where high-impact exercise may increase the risk for falls and fractures, the physical
Definite Probable Possible
Clinical Presentation
>2 months progressive onset of yysymptoms
Majority of motor dysfunctionyy
Symmetrical and proximal + distal yyweakness
Areflexia or hyporeflexiayy
All clinical presentation must be present
All clinical presentation must be present
All clinical presentation must be present
Laboratory Features
CSF protein level of >45 mg/dLyy
Nerve biopsy = demyelinationyy
All laboratory features must be present
CSF result must be positive or 2 positive results out of 3 (CSF, biopsy, NCS)
1 positive result out of 3 (CSF, biopsy, NCS)
Electrodiagnostic Features (NCS)
Reduction in CV in >2 motor yynerves
Abnormal CB/TD in >1 motor yynerves
Prolonged DL in >2 motor nervesyy
Absent FW or prolonged minimum yyFW latencies in >2 motor nerves
Chronic Inflammatory Demyelinating Polyradiculoneuropathy from a Physical Therapist’s PerspectiveChronic Inflammatory Demyelinating Polyradiculoneuropathy from a Physical Therapist’s Perspective
Chronic inflammatory demyelinating polyneuropathy or polyradiculoneuropathy (CIDP) is a relatively uncommon autoimmune disorder of peripheral nerves that leads to progressive and significant weakness, sensory loss, and areflexia.1 Due to its heterogeneous presentation, distinguishing this condition from other neurological diseases and treating it in the early stages can be difficult. Yet early medical and rehabilitation intervention is crucial to functional recovery in spite of the lack of a definitive diagnosis and functional progress.
Several medical interventions for CIDP are described in the literature, but no evidence-based approaches to rehabilitation specific to CIDP can be found. This case report reviews key background information on CIDP and describes an interdisciplinary approach between medical and physical therapy (PT) providers in an acute care setting. It illustrates the use of medical knowledge, clinical reasoning, and evidence in selecting outcome measures, formulating a plan of care, and assisting with clinical decisions.
The prevalence of CIDP ranges from 1.24 to 7.7 per 100,000 in many regions of the world including Australia, Japan, the United Kingdom, Norway, and Italy.2-7 It affects people of all ages but is most prevalent in those between 40 to 60 year old regardless of gender.8 In the US, incidence was reported to be 1.6 per 100,000 per year to a high of 8.9 per 100,000.9 As many as about 300,000 patients could have active CIDP at a given time10 and CIDP could represent 10-30% of previously undiagnosed neuropathies.8
The pathogenesis of CIDP begins with an autoimmune response to an unknown trigger. The trigger leads to lymphokine-induced damage to myelin sheaths and axons of peripheral nerves.11,12 Proposed triggers include influenza vaccination, tetanus toxoid immunization13,14 and hepatocellular carcinoma.15,16 Viral infection is more likely to trigger an autoimmune
response in individuals who have immune-compromised conditions.
Clinical, laboratory, and electrodiagnostic features are used to diagnose CIDP. Based on these criteria, the diagnosis of CIDP may be categorized as possible, probable, or definite categories (See Table 1).17,18 Laboratory and electrodiagnostic criteria for a definitive diagnosis vary between institutions in level of sensitivity and specificity.19 A successful treatment trial in the absence of clinical, laboratory, and electrodiagnostic features may also help confirm a diagnosis of demyelinating neuropathy.10,17,20
Since CIDP is an extremely heterogeneous condition, the exact clinical manifestations differ from person to person. Diagnosis depends on which structures are involved such as cranial nerves or central nervous system21-25 and its clinical presentation such as distal versus proximal and symmetrical versus asymmetrical.26,27
Differential diagnosis may include polyneuropathy associated with monoclonal gammopathy of undetermined significance (MGUS), polyneuropathy-organomegaly-endocrinopathy M protein and skin changes (POEMS), and Charcot-Marie-Tooth disease (CMT). Yet, age of onset, clinical course, electrophysiological presentation, and response to medical therapy of these diagnoses differ from CIDP.28-30
Patients with CIDP follow one of three clinical courses: monophasic, relapsing, or progressive. The monophasic course consists of one single episode of clinical deterioration followed by sustained improvement. The relapsing course involves at least two separate deteriorations with at least one improvement between relapses. The progressive course presents with unremitting gradual deterioration. Factors determining clinical course are unknown.
The clinical course of CIDP is heterogeneous with variable prognosis. Sixty-one per cent (61%) of patients
with a relapsing or monophasic course experience minimal non-disabling symptoms.31 In contrast, only 8% of patients with a progressive course have minor symptoms. Patients with CIDP often present with decreased functional balance, diminished quality of life, and increased fatigue.32 In general, patients with a sub-acute onset, symmetrical symptoms, and distal nerve abnormalities in nerve conduction studies (NCS) have better prognostic outcomes compared with those with a chronic onset, asymmetrical presentation, and demyelination in the proximal nerve segments.31,33
Initiating intervention as early as possible until improvement reaches a plateau is the norm.34 The most common medical therapies include prednisone, plasmapheresis, and intravenous immunoglobulin (IVIg), with similar short-term efficacy among the three.35 First choice may depend on medical history and concurrent medical status, cost, side effects, and administration factors.
Prednisone dosage varies and treatment continues until strength returns to normal or the condition reaches a plateau over a three-to-six-month-timeframe.8,18,34,36,37 As early as two weeks after the initiation of prednisone, patients often show improved strength and disability scores.38 Treatment with IVIg has a high response rate and long-term efficacy.39 Plasmapheresis is less commonly used due to its invasive nature, the need for special equipment, and high cost.40 Physicians consider alternative therapies when patients do not respond readily to basic intervention or when they relapse.36,41
Very little evidence-based literature is available to assist therapists with the rehabilitation of patients with CIDP. One study examined the effects of a 12-week high-intensity bicycle exercise program on physical fitness, functional outcome, fatigue, and quality of life in patients with CIDP and Guillain-Barré Syndrome (GBS).42
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Impaired Motor Function and Sensory Integrity Associated with Acute or Chronic Polyneuropathies.43 The physical, occupational, and speech therapists recommended patient discharge to an inpatient rehabilitation setting after his acute care stay to optimize functional recovery. In addition, he would benefit from a social work or psychology consultation for emotional support during the process of rehabilitation.
PrognosisFor CIDP, prognosis depends on clinical course, clinical presentation, and initial response to medical therapy.31,33 Long-term poor outcomes, including severe disability and inability to walk, occur in thirteen per cent (13%) of patients with CIDP even without comorbidities.32,34 Since this patient’s path to a confirmed CIDP diagnosis was lengthy, with severe existing co-morbidities, clinical presentation and initial response to medical therapy would determine his prognosis. Strong indicators included a somewhat symmetrical clinical presentation, demyelination in the distal nerve with abnormalities in NCS,
and a fair response to initial steroid therapy. Due to a chronic onset of CIDP, expectations were for a slow and incomplete functional recovery with the patient requiring assistive devices and perhaps orthothes for future functional mobility. On a positive note, this patient was very motivated and had a supportive family.
Plan of Care and InterventionsPhysical therapy short-term goals (one week) included:
Decreased pain level at low back 1. and bilateral hips from 8-10/10 to 7/10 on NPRS to enable participation in bed mobility, transfer, and seated ADLs.
Improved static sitting balance 2. from dependent assistance to maximal assistance to enable participation in seated ADLs and prevent adverse effects from prolonged bed rest.
Improved bed mobility from 3. dependent assistance of two persons to maximal assistance of two persons to prevent pressure
ulcer development. Bed mobility activities include rolling, scooting, bridging, and supine to and from sitting.
Increased bed to wheelchair 4. transfer from unable (limited by pain) to dependent assistance of two persons. This would increase sitting tolerance for pneumonia prevention.
Decreased pain level at low back 1. and bilateral hips to 5/10 on NPRS to enable participation in transfer, seated ADLs, and wheelchair mobility.
Improved overall muscle strength 2. by one grade on MMT to facilitate use of extremities for functional mobility.
Improved static sitting balance 3. with dependent assistance to dynamic sitting balance with stand-by assistance to facilitate independence in seated ADLs using upper extremities.
Systems ResultsCardiovascular/Pulmonary Temperature: 37.1°C
Blood pressure: 115/73 mmHg in supine
Heart Rate: 95 beats per minute (bpm)
Respiration: 18 bpm
Oxygen saturation: 93% on two liters of oxygenMusculoskeletal Symmetrical weakness, lower extremities weaker than upper extremitiesNeuromuscular Alert & Oriented x 2
Abnormal tone and deep tendon reflexes (DTR)Integumentary Skin rash at buttock areaInternal Organ Negative liver and renal function tests
Incontinent bowel and bladder
Table 2. System Reviews
Chronic Inflammatory Demyelinating Polyradiculoneuropathy from a Physical Therapist’s Perspective
therapist needs to adjust activity accordingly.
Observing the patient for possible 4. side effects by closely monitoring vital signs and reporting these effects. For example, hypotension and cardiac arrhythmia may occur during IVIg and plasmapheresis therapies and mobility may be contraindicated.
Communicating observations in 5. a timely and objective manner to other health care providers to facilitate better plan of care. For example, alert them to important signs and symptoms as well as key patient responses to functional activities and therapeutic interventions.
CASE DESCRIPTIONHistoryThe patient was a 59-year-old man with a past medical history of non-Hodgkin’s lymphoma, papillary thyroid cancer, hepatitis C, and liver cirrhosis. His surgical history included thyroidectomy, nonmyeloablative allogeneic stem cell transplant, and transjugular intrahepatic portosystemic shunt (TIPS) placement. His general health was otherwise noncontributory. The patient worked as a civil engineer during the six months prior to his hospital admission, is married and lives with his wife in a single-story home.
Approximately six months prior to this hospital admission, the patient had worsening liver function and underwent TIPS placement with subsequent improvement. Two months later, he again experienced worsening of liver disease, developed low back pain, and lower extremity weakness. Symptoms progressed to include headaches, fatigue, and bouts of pneumonia. The patient’s functional ability decreased over a four-month period leading to wheelchair use for mobility. Multiple acute care hospital admissions followed and eventually he was admitted to a skilled nursing facility (SNF). Despite continued rehabilitation, his functional status continued to decline. This was initially
attributed to end-stage liver disease, leading to discharge to home hospice care. Eventually, during an acute care admission for respiratory distress, further diagnostic tests revealed demyelinating features in the upper and lower extremities, most prominent in the distal regions, compatible with CIDP. A definitive diagnosis of CIDP was made one week after this hospital admission.
Systems Review & ExaminationAt the initial PT examination, the patient reported a 50-pound weight loss over the last several months. Table 2 shows the results of the cardiovascular/pulmonary, integumentary, neuromuscular, musculoskeletal, and internal organs systems review. Both the patient and his wife’s goal was to obtain a definitive diagnosis of his condition with the ultimate hope that his condition was treatable. The patient also wanted to regain the ability to ambulate.
Physical examination included:
Pain: The patient reported 8-10/10 1. pain in the low back and bilateral hips on the numeric pain rating scale (NPRS), where zero = no pain and 10 = worst possible pain. NPRS is a responsive measure in patients with low back pain.44 His pain increased with touch or any gentle lower limb movements, and eased with rest and intravenous (IV) morphine.
Passive range of motion (PROM): 2. Bilateral upper extremity PROM was within functional limits (WFL). Therapists were unable to test PROM of the lower extremities secondary to pain. From observation during functional mobility, he showed bilateral passive hip and knee flexion to 90° in sitting, bilateral hips and knees reached full extension in supine, and ankle dorsiflexion to a neutral position.
Coordination: He demonstrated 3. diminished finger-nose-finger coordination and rapid alternating movements (RAM) tests of his
upper extremities. The tests did not reveal any gross dysmetria. Coordination and RAM of his lower extremities were not available due to severe weakness and pain.
Sensory systems: Proprioception, 4. vibration, and pinprick sensation were decreased on both lower limbs and bilateral C3-4 dermatome sensation.
Tone: Muscle tone in the upper 5. extremities was grade one (1) on the Modified Ashworth Scale but did not limit functional ROM. Pain on both lower extremities prevented the examination of muscle tone. Deep tendon reflexes (DTRs) were absent at the Achilles tendons and diminished (1+) at biceps, triceps, and patellar tendons bilaterally.
Muscle strength: Weakness 6. was more severe in both lower extremities than the upper extremities and in distal versus proximal regions (Table 3).
Functional abilities: Based on 7. the Functional Independence Measure (FIM),45 bed mobility, feeding, grooming, and orientation required total assistance; problem solving and attention to task required moderate assistance (Table 4).
While the Guide to Physical Therapist Practice43 also suggested other tests and measures, they were not included at the initial examination due to the patient’s low functional level, pain, and activity tolerance.
Evaluation and DiagnosisThis patient was totally dependent for all activities of daily living (ADLs) and functional mobility with the inability to continue his previous role as an engineer. He presented with significant pain, impaired sensation, impaired DTR, significant weakness in all extremities, impaired sphincter control, and impaired social cognition. His impairments, activity limitations, and participation restrictions were consistent with Practice Pattern 5G:
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medical unit rounds exists. In this case, the authors believed frequency and quality of interactions and communications served this patient well. These included:
Frequency: Daily reciprocal 1. communication exchanges with occupational/speech therapists and nurses, and as needed with physicians. Weekly patient-care rounds with all other disciplines such as social workers and case managers.
Type: Reading progress notes 2. of other team members, discussing changes in patient
condition, and providing input during patient rounds.
Key areas: Alerts for medical 3. concerns, issues, challenges, and obstacles that limit rehabilitation progress, patient frustration levels, and achievements towards functional goals, exercise tolerance, general motivation, and well-being.
Red flags: Communications 4. for any neurologic changes, significant decline in muscle strength and/or functional abilities (signs and symptoms may indicate medication
intolerance or adverse side-effects).
The strength of communication included focus on patient-centered goals and support for providers, patient, and family. A weak area for this particular case was that communications were not always totally clear and timely. Recommendations for future improvement include greater sharing of test results, medication changes, and possible side effects of and expected results from medications and rehabilitation.
Social cognitionSocial interaction15. 2 6Problem solving16. 2 4Memory17. 2 4
Total FIM Score 23 56FIM Levels. 7 = Complete independence (timely, safe, no helper). 6 = Modified independence (device, no helper). 5 = Supervision (subject = 100%). 4 = Minimal assist (subject = 75%+). 3 = Moderate assist (subject = 50%+). 2 = Maximal assist (subject = 25%+). 1 = Total assist (subject = less than 25%). 0 = Unable to test.
Table 4. Functional Independence Measure (FIM)44
Chronic Inflammatory Demyelinating Polyradiculoneuropathy from a Physical Therapist’s Perspective
I4. mproved bed mobility from dependent assistance of two persons to moderate assistance of one person to maintain skin integrity. Bed mobility activities include rolling, scooting, bridging, and supine to and from sitting.
Improved bed to wheelchair 5. transfer from unable (limited by pain) to maximal assistance of one person squat pivot transfer with a sliding board. This would increase time out of bed for seated ADLs and exercises.
Improved wheelchair mobility 6. from unable to able to propel wheelchair 150 feet with minimal assistance (required assistance less than 25% of time) to increase independence with locomotion.
Initial goals did not include ambulation secondary to significant lower extremities weakness on MMT, pain, limited activity tolerance, and risk of overstretch weakness. The physical therapist examined the patient’s condition weekly and used examination results to determine whether the patient was ready to initiate gait training.
Intervention sessions: Each session consisted of approximately thirty minutes of therapeutic exercise and functional mobility training for an average of five times per week. The actual duration of each visit and frequency of treatment depended primarily on the patient’s activity tolerance and fatigue level, as well as the operational nature in the acute care setting. The patient also performed ADLs (grooming, personal hygiene, and upper body dressing) to tolerance and strengthening exercises using exercise putty and elastic bands outside of PT sessions. In addition, nursing staff assisted the patient to get out of bed into a cardiac chair initially and a wheelchair using a mechanical lift as the patient progressed. Table 5 summarizes the interventions by week. The interventions were chosen based on the patient’s interests, goals, and priorities in this setting. This was an attempt to minimize the adverse effects of bed rest, balancing overuse and fatigue with the patient’s pain level, and perceived effort related to activities, and motivation.
OutcomesAbout one week after the beginning of prednisone therapy, the patient made substantial progress in his strength and functional mobility. He stayed in the acute care hospital for one month and progressed steadily in his body function, strength, and functional mobility (Tables 3, 4, 6). Upon discharge from acute care, the patient required minimal assistance for bed mobility, supervision for wheelchair mobility on level ground, and maximal assistance of two persons for bed to wheelchair transfer. He was able to maintain good sitting balance without support while performing ADLs. Improvement in overall ADLs performance, social cognition, and continence bowel management supported his admission to an acute rehabilitation setting.
The positive relationship between team members was a key to optimal patient management in addition to a fluid and dynamic approach to the plan of care. While the literature reported daily multidisciplinary rounds in intensive care units were associated with decreased mortality rate,46 no published frequency guidelines for
Table 3. Manual Muscle Testing of Major Muscle Groups
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demyelinating polyneuropathy in New South Wales, Australia. Ann Neurol. 1999;46(6):910-913.
Lunn MP, Manju H, Choudhary PP, et 3. al. Chronic inflammatory demyelinating polyradiculoneuropathy: A prevalence study in southeast England. J Neurol Neurosurg Psychiatry. 1999;66:677-680.
Mygland A, Monstad P. Chronic 4. polyneuropathies in Vest-Agder, Norway. Eur J Neurol. 2001;8:157-165.
Chio A, Cocito D, Bottacchi E, et 5. al. Idiopathic chronic inflammatory demyelinating polyneuropathy: an epidemiological study in Italy. J Neurol Neurosurg Psychiatry. 2007;78:1349-1353.
Lijima M, Koike H, Hattori N, et al. 6. Prevalence and incidence rates of chronic inflammatory demyelinating polyneuropathy in the Japanese population. J Neurol Neurosurg Psychiatry. 2008;79:1040-1043.
Rajabally YA, Simpson BS, Beri S, 7.
et al. Epidemiologic variability of chronic inflammatory demyelinating polyneuropathy with different diagnostic criteria: study of a UK population. Muscle Nerve. 2009;39:432-438.
Kissel JT. The treatment of chronic 8. inflammatory demyelinating polyradiculoneuropathy. Semin Neurol. 2003;23:169-179.
Laughlin RS, Dyck PJ, Melton LJ, et al. 9. Incidence and prevalence of CIDP and the association of diabetes mellitus. Neurology. 2009;73(1):39-45.
Latov N. Diagnosis of CIDP. 10. Neurology. 2002;59(suppl 6):S2-S6.
Independent yywheelchair mobility on level ground 500 feet
Abbreviation: NPRS, numeric pain rating scale.
Table 6. Summary of Weekly Physical Therapy Progress in Functional Mobility & Pain
Chronic Inflammatory Demyelinating Polyradiculoneuropathy from a Physical Therapist’s Perspective
DISCUSSIONThe purpose of this case report was to describe the collaborative medical and PT management of a patient with CIDP who had multiple significant co-morbidities and many complications over the course of his diagnostic and acute care period. The patient’s course of improvement relied on coordination of care between the medical and rehabilitation teams for optimal recovery. In the first two weeks of his acute care admission, the patient showed little progress in bodily function and mobility. His initial pain level, low functional status, poor endurance, and anxiety about mobility greatly limited physical therapy interventions. The physical therapist’s provision of supportive care, persistence, encouragement, and reinforcement of even small gains, likely slowed the onset of functional decline and immobility, and eventually laid the groundwork for a road to recovery. The physical therapist also used knowledge of specific factors about CIDP and evidence from the literature to remain vigilant for significant changes in the patient’s condition, communicate regularly with the team, and implement a flexible plan
of care. Medical interventions were key initially to reversing the inflammatory process, which allowed the patient to benefit from rehabilitation.
The patient in this case had slow functional gains despite improvement in strength and endurance. Complications related to his co-morbidities, which included an incidental finding of kidney stones, a urinary tract infection with methicillin-resistant staphylococcus aureus, and TIPS malfunctioning during his acute care stay, might have contributed to the slow improvement.
While the role of exercise prior to the beginning of medical therapy is unclear, an appropriate level of training may minimize complications related to immobility. Whether an exercise program with dedicated frequency and schedule would have furthered this patient’s functional gains in the acute stage is not known. Although the physical therapist managed the patient’s fatigue level closely during interventions, no objective measures of fatigue or participation restriction were used. Since fatigue is a major impairment in patients with GBS and CIDP,33,47 assessing how PT management affected this impairment,
regardless of disease stages and settings would have been beneficial. The Fatigue Severity Score and Fatigue Impact Scale are two examples of potential outcome measures that could be used to indicate a change in self-reported fatigue with exercise trainings.42 The development of standardized outcome measures and specific practice guidelines for CIDP could lead to best practice care for this condition.48
ACKNOWLEDGMENTSThe authors thank Jeffrey Teraoka, MD, Lisa Ikuma, MSPT, Debby Bolding, MS, OTR/L, and Diane Allen, PT, PhD for their valuable comments during the preparation of the manuscript.
REFERENCESHughes RA, Bouche P, Cornblath 1. DF, et al. European Federation of Neurological Societies/Peripheral Nerve Society guideline on management of chronic inflammatory demyelinating polyradiculoneuropathy: report of a joint task force of the European Federation of Neurological Societies and the Peripheral Nerve Society. Eur J Neurol. 2006;13(4):326-332.
McLeod JG, Pollard JD, Macaskill P, et 2. al. Prevalence of chronic inflammatory
Week 1 Week 2 Week 3 Week 4PROM and AAROM yyto upper and lower extremities, 5-10 repetitions each
Sitting balance and yyfunctional activities at edge of bed
PROM and AAROM yyto upper and lower extremities, 5-10 repetitions each
Sitting balance and yyfunctional activities at edge of bed
AAROM and AROM yyto upper and lower extremities, 5-10 repetitions each
Sitting balance and yyfunctional activities
Standing Frameyy
Transfer training yybetween bed and wheelchair
AAROM to lower yyextremities, 5-10 repetitions each
Hand strengthening yyusing exercise putty
Sitting balance and yyfunctional activities
Standing Frame or yyBody Weight Support Therapy
Transfer training yybetween bed and wheelchair
Wheelchair mobilityyyAbbreviation: PROM, passive range of motion; AAROM, active-assisted range of motion; AROM, active range of motion.
Table 5. Summary of Weekly Physical Therapy Intervention
Chronic Inflammatory Demyelinating Polyradiculoneuropathy from a Physical Therapist’s Perspective
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University of Rochester Acute Care Evaluation: Development of a New Functional Outcome Measure for the Acute Care Setting
Julie DiCicco, MPTPhysical Therapist, University of Rochester Medical [email protected]
Deborah Whalen, PT, DPT, MSSenior Physical Therapist, University of Rochester Medical [email protected]
Julie DiCicco, Deborah Whalen
ABSTRACT
The Physical Therapy Department at the University of Rochester determined a need for a functional outcome measure to be used in the acute care setting because current outcome measures in practice do not quantify the lower level function often found in this setting. After reviewing the literature, the John’s Hopkins Hospital Functional Acute Care Score (or JHH-FACS) was chosen to be trialed and did not adequately quantify the functional abilities of our patient population. The tool was modified after a trial use period and survey of staff members to create a new tool. We describe the steps taken to create the outcome measure, called the University of Rochester Acute Care Evaluation (or URACE), that objectively assesses an individual’s function while in the acute care setting.
Functional assessment is one of the crucial elements of the initial evaluation for acute care physical therapy practice.1 In the hospital setting, physical therapists employ interventions to address functional impairments related to strength, range of motion, flexibility, joint integrity, muscular endurance, and cardiopulmonary dysfunction. Accordingly, an individualized plan of care is formulated by acute care physical therapists to address functional skills such as gait, transfers, and bed mobility.1 Functional outcome measures are tools used to standardize assessment, analyze outcomes and improve quality of care for individuals undergoing physical therapy treatment. However, finding research in outcome measures for the
acute care setting has been difficult.
The recent focus on improving efficiency and reducing medical costs has led to a significant decrease in length of stay for acute care hospitalizations.2 This focus demands the acute care physical therapist prepare for discharge early in the rehabilitation process. Early discharge planning is frequently complicated as many individuals develop new or worsening functional impairments during hospitalization; therefore regaining mobility may occur at a much slower rate than the resolution of the acute illness.3 In addition, the aging population will continue to increase the demand for overall medical care and in turn physical therapy referrals.
Due to the nature of the illnesses or injuries that cause individuals to be admitted to acute care hospitals, declines in strength are common, which can impair tasks such as bed mobility, transfers, and ambulation. Significant functional decline has been observed within 48 hours of hospitalization.4 Although the average length of stay has decreased from 7.8 days in 1970 to 4.8 days in 2005, the time many individuals spend in the hospital can still contribute to debility and decrease in function.5 The potential for long-term loss of function has led to an emphasis on improving mobility as quickly as possible to enable the individual to be discharged either directly home or to a shorter term facility.
Neurol. 2008;28:168-184.
Magda P, Latov N, Brannagan III TH, 19. et al. Comparison of electrodiagnostic abnormalities and criteria in a cohort of patients with chronic inflammatory demyelinating polyneuropathy. Arch Neurol. 2003;60:1755-1759.
Rotta FT, Sussman AT, Bradley WG, et 20. al. The spectrum of chronic inflammatory demyelinating polyneuropathy. J Neurol Sci. 2000;173:129-139.
Alwan AA, Mejico LJ. Ophthalmoplegia, 21. proptosis, and lid retraction caused by cranial nerve hypertrophy in chronic inflammatory demyelinating polyradiculoneuropathy. J Neuroophthalmol. 2007;27:99-103.
Hemmi S, Kutoku Y, Inoue K, 22. et al. Tongue fasciculations in chronic inflammatory demyelinating polyradiculoneuropathy. Muscle Nerve. 2008;38(4):1341-1343.
Kokubun N, Hirata K. 23. Neurophysiological evaluation of trigeminal and facial nerves in patients with chronic inflammatory demyelinating polyneuropathy. Muscle Nerve. 2007;35:203-207.
Misra UK, Kalita J, Yadav RK. A 24. comparison of clinically atypical with typical chronic inflammatory demyelinating polyradiculoneuropathy. Eur Neurol. 2007;58:100-105.
Pineda AAM, Ogata K, Osoegawa 25. M, et al. A distinct subgroup of chronic inflammatory demyelinating polyneuropathy with CNS demyelination and a favorable response to immunotherapy. J Neurol Sci. 2007;255:1-6.
Lewis RA, Summer AJ, Brown MJ, et 27. al. Multifocal demyelinating neuropathy with persistent conduction block. Neurology. 1982;32:958-964.
Notermans NC, Franssen H, 28. Eurelings M, et al. Diagnostic criteria for demyelinating polyneuropathy associated with monoclonal gammopathy. Muscle Nerve. 2000;23:73-79.
Dispenzieri A. POEMS syndrome29. . Hematology Am Soc Hematol Educ Program. 2005:360-367.
Pareyson D. Differential diagnosis of 30. Charcot-Marie-Tooth disease and related neuropathies. J Neurol Sci. 2004;25:72-82.
Mygland A, Monstad P, Vedeler C. Onset 31. and course of chronic inflammatory demyelinating polyneuropathy. Muscle Nerve. 2005;31:589-593.
Kuwabara S, Misawa S, Mori M, 32. et al. Long term prognosis of chronic inflammatory demyelinating polyneuropathy: A five year follow up of 38 cases. J Neurol Neurosurg Psychiatry. 2006;77:66-70.
Westblad ME, Forsberg A, Press 33. P. Disability and health status in patients with chronic inflammatory demyelinating polyneuropathy. Disabil Rehabil. 2008;24:1-6.
van Schaik IN, Winer JB, de Hann R, 35. et al. Intravenous immunoglobulin for chronic inflammatory demyelinating polyradiculoneuropathy (Review). Cochrane Database Syst Rev. 2002;2:CD001797.
Gorson KC, Ropper AH. Chronic 36. inflammatory demyelinating polyradiculoneuropathy (CIDP): a review of clinical syndromes and treatment approaches in clinical practice. J Clin Neuromuscul Dis. 2003;4:174-189.
Said G. Chronic inflammatory 37. demyelinating polyneuropathy. Neuromuscul Disord. 2006;16:293-303.
Hughes R, Benas S, Willison H, et 38. al. Randomized controlled trial of intravenous immunoglobulin versus oral prednisolone in chronic inflammatory demyelinating polyradiculoneuropathy. Ann Neurol. 2001;50:195-201.
Hughes R. The role of IVIg in 39. autoimmune neuropathies: the latest evidence. J Neurol. 2008;225(Suppl 3):7-11.
Hahn AG, Bolton CF, Pillay N, 40. et al. Plasma-exchange therapy in chronic inflammatory demyelinating polyneuropathy: a double-blind, sham-controlled, cross-over study. Brain. 1996;119:1055-1066.
Kuitwaard K, van Doorn PA. 41.
Newer therapeutic options for chronic inflammatory demyelinating polyradiculoneuropathy. Drugs. 2009;69(8):987-1001.
Garssen MPJ, Bussman JBJ, Schmitz 42. PIM, et al. Physical training and fatigue, fitness, and quality of life in Guillain-Barré syndrome and CIDP. Neurology. 2004;63:2393-2395.
APTA. 43. Guide to Physical Therapist Practice. American Physical Therapy Association; 2001.
Childs JD, Piva SR, Fritz JM. 44. Responsiveness of the numeric pain rating scale in patients with low back pain. Spine. 2005;30(11):1331-1334.
Ottenbacher KJ, Hsu Y, Granger CV, 45. et al. The reliability of the Functional Independence Measure: a quantitative review. Arch Phys Med Rehabil. 1996;77(12):1226-1232.
Kim MM, Barnato AE, Angus DC, et 46. al. The effect of multidisciplinary care teams on intensive care unit mortality. Arch Intern Med.2010;170(4):369-376.
Boukhris S, Magy L, Gallouedec G, 47. et al. Fatigue as the main presenting symptom of chronic inflammatory demyelinating polyradiculoneuropathy: a study of 11 cases. J Peripher Nerv Syst. 2005;10(3):329-337.
Elings J, Erdmann PG, Menke E, et al. 48. Physiotherapy in patients with acute and chronic inflammatory polyneuropathies: a survey of clinical practice among physiotherapists associated with the Dutch Organization for Neuromuscular Diseases [abstract]. Ned Tijdschr Fysiotherapie. 2009;119(1):10-16.
Chronic Inflammatory Demyelinating Polyradiculoneuropathy from a Physical Therapist’s Perspective
CLINICAL PRACTICE
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using the chair-rise and the gait speed tests as they were quick, easy and objective. Unfortunately, these outcome measures were not inclusive enough for non-ambulatory individuals in the hospital setting. The next functional outcome measure trialed was the JHH-FACS. The committee introduced and in-serviced staff on the JHH-FACS tool, and precise methods of scoring as shown in Appendix 1. Thirteen staff therapists, ranging from less than 1 year to more than 20 years of acute care experience, were trained in the use and scoring of the instrument before using it on individuals in the hospital. The staff therapists had varying educational levels from bachelor’s to doctorate degrees in physical therapy. All thirteen staff members were asked to utilize the tool to score all adult individuals at evaluation and discharge and record all scores on the data sheets. After a 3-month trial period, the functional outcome committee surveyed the physical therapists on their opinion of the JHH-FACS and any suggested changes to the tool. The survey questions are included in Appendix 2. The survey answers were used to make changes to the tool to produce a more objective, sensitive outcome measure for the acute care physical therapists. (See Table 1) The new tool was again trialed for three months by all staff therapists. The survey was again given to the staff members for suggestions
and no further changes were deemed necessary.
RESULTSBased on the therapists’ survey responses, the Functional Outcome Committee made changes to the design of the JHH-FACS in order to make it more specific to the population in our medical center. When changing the JHH-FACS, the first area addressed was the issue of bed mobility not being scored independently of transfers and therefore neglecting possible progress being made by low functioning individuals. A considerable number of individuals referred to physical therapy at URMC have neurological disorders, severe deconditioning and other severe conditions that limit or prevent transfers and ambulation. The JHH-FACS was changed to allow assessment of lower level mobility in bed bound individuals without experiencing the floor effect present in the JHH-FACS. A subset system was also created for the height of the head of the bed and the use of bed rails due to the variety of conditions and contraindications seen in the hospital setting. (See Appendix 3) Higher scores were given for the ability to get out of bed with the head of the bed flat and no use of a bed rail as this is more difficult to perform. Subset categories helped to further standardize assessments as an individual’s ability to get out of bed can vary greatly depending on the position of the bed and utilization of a
rail. The subset categories were also able to identify measurable changes in functional mobility in patients who were primarily bed bound.
As suggested by many of the acute care therapists, revisions were made to improve sensitivity to ambulation distance as the previous JHH-FACS did not account for distances less than 5 feet.9 In the acute care setting, the measurement of subtle changes in distances ambulated were necessary as hospitalized individuals are typically only seen for an average of 5 days per week. Therefore, small changes in function need to be captured and measured as objectively as possible. A further modification was also made to the stair section. The category of stairs was broken into 4 subsets to better quantify the number of steps completed by an individual and to increase the overall sensitivity of the tool. (See Appendix 3) The new outcome tool was named the URACE. All staff was trained in how to score the tool before administering it to individuals in the hospital.
The scoring of the entire URACE tool was also uniformly changed to numeric values to allow for ease in statistical analysis and for a total score to be calculated. The original JHH-FACS tool was scored with both numbers and letters and was found to be confusing for the therapists scoring the tool. The URACE scoring form was also reformatted to
Evaluation: Development of a New Functional Outcome Measure for the Acute Care Setting
Ease of use Ease of scoring Scoring specificityAssesses patient’s abil-ity
Quick to administerConfusing with numbers and letters
No specific instructions for bed positioning or bed rail
Groups bed mobility and transfer abilities together
Includes only functional activities
Difficult to remember all scoring instructions
Ambulation distance does not include distances less than 5 feet
Able to assess ambulatory and non-ambulatory individuals
Includes activities that are already part of typical evaluation in acute care
Still somewhat subjective scoring
Stair distances given only 2 choices and not able to score for less than 6 steps
Able to assess with or without use of assistive devices for activities
Table 1. Feedback from staff survey following trial of the JHH-FACS
In the acute care setting, the physical therapists’ role includes clearly and objectively documenting the individual’s functional status as a means of developing a plan of care and making an appropriate discharge recommendation. The use of outcome measures allows physical therapists to standardize the assessment and documentation of an individual’s initial functional status. Outcome measures allow reassessment, so physical therapists can objectively document an individual’s improved level of function, determine the effectiveness of treatment, and finalize discharge planning. Discharge planning relies on the physical therapist to determine an individual’s previous level of function and then compare it to the current level of function as documented by the functional outcome measure.2 The individual’s home environment, equipment and any assistance at home are also taken into consideration.6 Discharge planning is therefore highly dependent on individuals’ functional mobility supporting the need for a standardized tool to ensure an objective assessment.
Due to the short length of stay and focus on early discharge planning the acute care setting is often fast paced. Individuals also may receive care from many different services during the course of only a few days, often reducing the time available for the physical therapist to effectively treat patients in a manner that will make substantial improvements in their functional status. Many therapists in acute care settings report feeling inadequate time to work with individuals due to the severity of individuals’ illnesses, and interruptions from other health care professionals and visiting families.1 Consequently, outcome measures for this setting should be designed so they can be completed in a timely manner due to limited individual contact time and potential interruptions.
One of many functional outcome tools used by physical therapists is the Functional Independence Measure (or
FIM™). FIM is an appropriate outcome tool for objectively assessing function in acute rehabilitation because of its validity in the general population and its reliability, However, FIM has not been shown to be effective in the acute care population.7 A floor effect can be seen in using the FIM for acute care due to the small functional improvement that is sometimes made in such short hospital stays and the low functional status of many individuals referred to physical therapy. Notably, the FIM does not account for the effects of medical complications and interruptions from other members of the medical team that often occur in the hospital setting. Complete FIM scoring requires input from other health care professionals as it is not designed solely for assessing mobility.
Less known is the Alpha FIM instrument, which was modified from the FIM, for the purpose of measuring an individual’s functional status during the first 72 hours of acute care hospitalization.8 The Alpha FIM was designed to triage individuals by determining the next appropriate care setting and pinpointing the earliest opportunity for transfer, but presents with the same interdisciplinary limitations as the FIM.8 Due to the limitations associated with the FIM and Alpha FIM, a tool that exclusively measures mobility that can be completed independently by a physical therapist is necessary for efficient assessment in busy acute care hospitals.
In 1996, the Johns Hopkins Hospital research committee piloted a modification to the motor FIM for use in the acute care inpatient setting, which they called the JHH-FACS. 9 The JHH-FACS was more specific than the FIM™ due to the ability to score each assistive device used as well as breaking down the increments of distance for locomotion. The principal objective was to improve the sensitivity of the motor portion of the FIM while taking into account the efficiency needed to be applicable to the busy environment of the acute care
Evaluation: Development of a New Functional Outcome Measure for the Acute Care Setting
setting. A small pilot study provided little detail regarding the methodology used to perform testing of inter-rater and intra-rater reliability. The findings indicated fair reliability with transfer ability and fair to good reliability with locomotion. The reliability of stair testing was incomplete due to lack of sufficient data.9
Many other functional outcome tools exist in the physical therapy literature including but not limited to the Timed-Up-and-Go Test (or TUG),10 the Berg Balance Scale,11 the gait speed test12 and chair rise test.13 These outcome tools were created to objectively measure an individual’s mobility. However, many of the tasks involved are too high functioning for a large number of individuals in an acute care setting and thus a floor effect might be seen. Tools such as those mentioned above may also fail to capture small changes in the function of the activity being measured. For example, a person not able to stand without assistance would receive a score of 0 on the TUG, gait speed and chair rise tests because the tools only take into account an individual’s ability to stand and walk, totally excluding any ability to sit up from bed.
After reviewing the current literature we were unable to find any standardized outcome measures relevant to patients in the acute care setting that met our needs of effectively analyzing the requisite functional mobility skills related to bed mobility, transfers, ambulation and stair negotiation. Therefore, the purpose of the functional outcome committee was to create an outcome measure that would objectively assess an individual’s function while in acute care.
METHODOLOGYThe Functional Outcome Committee of the URMC Physical Therapy Department trialed several different outcome measures in an effort to find a test that would be appropriate at both evaluation and discharge for our acute care hospital patients. The physical therapy department started
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Shumway-Cook A, Baldwin M, 11. Polissar NL, Gruber W. Predicting the probability for falls in community-dwelling older adults. Phys Ther. 1997; 77(8):812-819.
Studenski S, Perera S, Wallace D, et 12. al. Physical performance measures in
the clinical setting. J Am Geriatr Soc. 2003; 51(3):314-322.
Kigin C. A systems view of physical 14. therapy care: Shifting to a new paradigm for the profession. Physical Therapy. 2009; 89(11):1117-1119.
Evaluation: Development of a New Functional Outcome Measure for the Acute Care Setting
Appendix 1Appendix 1 {{144 The John Hopkins Hospital 1996; }}
Instr: Circle appropriate item in each column. * Please indicate below nature of interrupted score. *__________________________________________
__________________________________________ Patient name: __________________________ Therapist scoring I.E.: ___________________Date of I.E.: ______________________ Therapist scoring D.C.: _________________Date of D.C.: _______________________
Total #Rx’s at D.C.: __________________
Instr: Circle appropriate item in each column. * Please indicate below nature of interrupted score. *__________________________________________ ___________________________________________
Patcom #: __________________________ HX #: ______________________________ Date of I.E.: ___________________________
DC’d to (please circle one )Home Home PT Rehab NH Sub Acute Rehab OP Hospice
144 The John Hopkins Hospital 1996
Appendix 2
Questionnaire on the JHH-FACS
In your opinion is the JHH-FACS easy to administer?
Yes No
If no, please explain why.
In your opinion is the JHH-FACS easy to score?
Yes No
If no, please explain why.
Was the scoring specific enough? Yes No
If no, please explain why.
Do you feel this tool adequately enables you to score a patient’s ability?
Yes No
If no, please explain why.
What other changes would you recommend?
provide the therapist with a scoring key on the same document to avoid having to refer back separate scoring instructions for every individual seen. (See Appendix 3) Prior to using the URACE, all therapists were trained in the proper testing and scoring of the new tool. (See Appendix 4) The procedure of testing also needed to be consistent so that patients were assessed in the same way regardless of the clinician in an effort to improve interrater reliability. Therefore, the committee members decided, that the first time an individual performed a supine to sit maneuver with a physical therapist a URACE outcome measure was scored despite whether this occurred during the initial visit or on a subsequent visit. This ensured that all individuals being scored were off of bed rest and able to tolerate sitting upright.
DISCUSSIONThe goal of the functional outcome committee was to create an outcome measure that would objectively assess an individual’s function in the acute care setting as the trend in health care is on greater use of tools to objectify current evaluation techniques and assess outcomes to help determine treatment efficacy.14 With a focus on cost-saving measures and improved efficiency in health care today, physical therapists’ productivity has come under great scrutiny in the hospital setting. This requires an outcome measure that is both quick to administer and easy to score.2 Many physical therapists often choose to not administer an outcome measure on patients due to time constraints or the lack of availability of an appropriate measure. Many changes were made to the JHH-FACS to create more sensitivity for lower functioning individuals that are often seen in the acute care setting. The URACE is clearly able to assess a person’s function from bed mobility through stair negotiation. Accommodations were also made for different bed positions and equipment used during mobility in order to
ensure re-test scores were accurately measuring progress and helping to increase inter-rater reliability.
The URACE was designed with efficiency in mind. It is comprised of activities already included in a typical, general physical therapy evaluation so that no extra time is needed to administer the tool. The scoring of the tool can also be accomplished in an efficient manner simply by circling the correct score for each of the assessed activities. If a particular activity cannot be completed “not tested” is circled and the tester provides a brief written explanation. (See Appendix 3)
Similar to the FIM, the limitations to the URACE include not being able to account for individuals who are not yet stable enough for mobilization. The URACE tool allows physical therapists to assess the ability to go from supine to sitting at the edge of the bed, but does not account for lower level bed bound activities such as rolling or scooting up in bed. Another limitation, like the FIM, is that the scoring of the assistance level provided to the patient is still somewhat subjective. The amount of assistance is scored based on the percentage of the task completed by the patient and could be perceived differently by separate therapists. While this method of grading was found to be reliable in the FIM7, it is still a somewhat subjective grading system. The URACE has not thus far been tested for reliability and validity. Further study would need to be done to determine whether it has acceptable validity. Additionally, the URACE has no total score so therefore at this time it cannot be statistically correlated to the FIM or any other functional outcome tool. Further testing may also be useful to determine if the URACE can play a role in predicting appropriate setting for discharge.
Overall, the URACE outcome measure is appropriate to use in the acute care setting of a level I trauma center for a multitude of individuals. Clinicians in acute care or perhaps skilled nursing facilities could use this tool as it would
Evaluation: Development of a New Functional Outcome Measure for the Acute Care Setting
closely encompass their populations’ functional abilities.
REFERENCES
Curtis KA, Martin T. Perceptions 1. of acute care physical therapy practice: Issues for physical therapist preparation. Phys Ther. 1993; 73(9):581-594.
Jette DU, Brown R, Collette N, Friant 2. W, Graves L. Physical therapists’ management of patients in the acute care setting: An observational study. Phys Ther. 2009; 89(11):1158-1181.
Hirsch CH, Sommers L, Olsen A, 3. Mullen L, Winograd CH. The natural history of functional morbidity in hospitalized older patients. J Am Geriatr Soc. 1990; 38(12):1296-1303.
Cornette P, Swine C, Malhomme B, 4. Gillet JB, Meert P, D’Hoore W. Early evaluation of the risk of functional decline following hospitalization of older patients: Development of a predictive tool. Eur J Public Health. 2006; 16(2):203-208.
DeFrances CJ, Hall MJ. 2005 national 5. hospital discharge survey. Adv Data. 2007; (385):1-19.
Lopopolo RB, Keehn M. The effect of 6. hospital restructuring on the role of physical therapists in acute care. Phys Ther. 1997; 77(9):918-936.
van der Putten JJ, Hobart JC, Freeman 7. JA, Thompson AJ. Measuring change in disability after inpatient rehabilitation: Comparison of the responsiveness of the barthel index and the functional independence measure. Journal of Neurology, Neurosurgery & Psychiatry. 1999; 66(4):480-484.
Anonymous. Measurement and 8. Outcomes in the Acute Hospital. Proceedings of the Measurement and Outcomes in the Acute Hospital, February 2007.
The John Hopkins Hospital. 9. JHH Function Acute Care Score <http://www.acutept.org/resources.html>.1996.
Yeung TS, Wessel J, Stratford PW, 10. MacDermid JC. The timed up and go test for use on an inpatient orthopaedic rehabilitation ward. Journal of Orthopaedic & Sports Physical Therapy. 2008; 38(7):410-417.
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Evaluation: Development of a New Functional Outcome Measure for the Acute Care Setting
Appendix 4
Activities are scored taking into account the amount of assistance required by the patient and the percentage of patient effort put forth into the activity. The level of assistance is scored 1 to 7, again using the level of the patient effort along with the amount of assistance required. A score of N/T or not tested is given if the activity was not able to be completed for any reason including interruptions or safety reasons. Please identify reason for not tested for any activity not able to be scored.
Assistance Scoring:
1 = total assistance or <25% patient effort
2 = maximal assistance or 25-49% patient effort
3 = moderate assistance or 50-74% patient effort
4 = minimal assistance or >74% patient effort
5 = supervision or setup only
6 = modified independence by use of assistive device only
7 = independent
For all activities and all measures if a patient seems to be between two scores the lower of the two scores is given.
Scores are also identified for any assistive devices used or distances traveled.
For supine to sitting activity a bed score is given to objectively identify the position of the head of the bed as this can greatly effect a patient’s ability to complete the tested activity.
1 = > 45°
2 = < 45°
3 = head of bed is flat
For the supine to sitting activity a bedrail score is also given to objectively identify the use of a bedrail or not as this can also greatly effect a patient’s ability to complete the tested activity.
1 = use of bed rail
2 = no use of bed rail
For transfer scoring the amount of assistance is scored based on the above assistance scoring scale. Then the type of transfer is identified as outlined below:
1 = sit-pivot transfer
2 = sit-stand transfer
3 = stand pivot transfer
For transfer scoring a device must also be identified for the patient scored as below:
1 = walker
2 = crutches
3 = cane
4 = none/other
For locomotion scoring an activity must first be chosen and circled on the score sheet: ambulation or wheelchair mobility. The assistance level and device scoring is completed as above. Distance must be scored as below:
1 = 1-24ft.
2 = 25-49ft.
3 = 50-149ft.
4 = 150+ft.
For stairs scoring the assistance level is completed as outlined above. A score will then be given for device used on the stairs as below:
1 = handrail
2 = crutches
3 = cane
4 = none/other
Then a score must be given for distance as follows:
1 = 1-3 steps
2 = 4-6 steps
3 = 7-9 steps
4=≥10steps
In order to reflect a patient’s true ability it is important to allow and encourage a patient to give his/her best effort with all portions of the test.
URACE Testing and Scoring Instructions
1
Appendix 3
Appendix 3
Evaluation: Development of a New Functional Outcome Measure for the Acute Care Setting
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ABSTRACT
Background: In September 2003, the Summa Health System implemented an activity protocol and a triage system to prioritize the delivery of physical therapy services in the intensive care unit (ICU). The triage system first identified patients who required skilled physical therapy (PT) interventions to reach the expected continuum of care level (COC) at discharge and then allocated PT services accordingly.
Purpose: The purpose of this study is to answer the clinical question, “Does the triage system decrease length of stay (LOS), decrease the number of PT visits, and improve physical function while achieving the predicted COC level for patients with respiratory failure who were admitted to the ICU?”
Methods: A retrospective chart review utilized a sample of 117 patients, 60 patients from January to May of 2002 (Group 1) and 57 patients from January to March of 2007 (Group 2). Group 2 was further divided into 41 Level I patients (Group 2a), 12 Level II patients (Group 2b), and 4 Level III patients (Group 2c), based on the Triage system criteria. Non-parametric tests and central tendency comparisons were used to compare the hospital LOS, ICU LOS, number of PT visits, patient function at evaluation and discharge, discharge plan at evaluation, and continuum of care level for Group 1 and 2.
Results: Hospital LOS and ICU LOS were both decreased by two days and the number of PT visits per patient decreased by two sessions when comparing Groups 1 and 2. Significant changes in function from initial evaluation to discharge were shown in Group 1, Group 2a and Group 2b. Patients achieved the predicted COC level 72% of the time in Group 2.
Conclusion: A physical therapy triage system can decrease patient hospital and ICU LOS, decrease the number of PT visits and achieve the predicted continuum of care level.
The rising costs of health care, particularly in the intensive care unit (ICU)1 as well as the resultant reduction in reimbursement made by government and private insurance providers, has driven an increased need to decrease length of stay in acute care hospitals.2 Research has firmly established the increased benefits of earlier mobility after common medical events such as myocardial infarction (MI) and orthopedic surgeries, which include increased functional abilities, shorter length of stay (LOS), and decreased total cost of stay.3,4 In the past, critically ill (CI) patients were considered medically unstable and, therefore, placed on bed rest. However, recent research has begun to show how the early mobilization of patients in the ICU can produce similar beneficial results.3,5-9
Despite continued concern among health care providers that the CI patient may not be appropriate for early mobilization, a thorough medical and objective screening has been shown to provide safe mobilization without any major medical complications.10-12 A decision-making framework was described by Stiller et al,12 which included a thorough medical background review and monitoring of currently cardiovascular and respiratory status. In this study, patient functioning was improved without any significant changes in medical condition. Overall, extensive benefits can be achieved as a result of early mobilization of the CI patient if therapists are trained in proper screening and monitoring of these patients.10-12
As increased patient function has been linked to decreased length of stay, the Center for Medicare Services has encouraged hospitals to improve patient function through documented quality of care.13 Quality of care or change in level of functioning can be quantitatively measured through outcome tools such as the Functional Independence Measure and the Timed Get up and Go, which are commonly used in skilled nursing facilities, but are
not feasible for the acute care setting. As a result, the Kansas University Hospital Physical Therapy Acute Care Functional Outcomes Tool was developed. This tool helps to quantify improved function and mobility of ICU patients and was used at interdisciplinary quality improvement team meetings. The scale outlines change in function of several functional tasks including bed mobility, transfers, gait, and walking distances. The scale also considers the patient’s prior level of functioning and discharge status. Swafford et al13 found that in general those patients who returned home had higher score changes than those patients who made no improvement in function and were discharged to another level of patient care.13
In order to more easily determine the level of care needed at discharge, Scott and Petrosino14 developed the Physical Therapy Continuum of Care, a decision-making framework (Fig. 1). The framework outlines levels of the continuum of care from a physical therapy perspective and denotes the recommended treatment duration based on patient acuity in inpatient, outpatient and homebound practice settings. When determining the continuum of care level needed upon discharge from an inpatient acute care setting, the therapist should consider the patient’s current and premorbid functional abilities, the ability to participate in therapy sessions, the patient’s needs, and the prior living environment.
Patients with increasingly complex impairments are spending less time in intensive care units and acute care hospitals. The role of the physical therapist has begun to include prioritizing patients based upon their predicted response to interventions, length of stay, and expected level of health care required upon hospital discharge.16-18 Therefore Akron City Hospital, part of the Summa Health System (SHS) created a physical therapy triage system to help maintain quality of care by providing the appropriate number of PT visits needed to improve
patient function while still achieving the predicted continuum of care level at discharge. The triage system at SHS was developed in 2003 based upon the evidence that early mobilization helps to decrease LOS and after internal review of PT practices within the hospital. It was aimed at assisting therapists in prioritizing and expediting patient care while decreasing the number of physical therapy visits, based upon patient need. The internally developed triage system involves 3 components: 1) identifying patients who do or do not require skilled physical therapy interventions, 2) determining the frequency of visits necessary to reach the expected level of functioning and 3) determining the continuum of care level at discharge without compromising quality of care (Fig 2).19 The physical therapist uses the triage system for each CI patient evaluation in the ICU. During the plan of care development, the PT determines the continuum of care level expected upon discharge from the acute hospital based upon factors including living environment, prior level of functioning, and medical reimbursement available.
The triage system consists of 3 levels, each of which determines frequency of PT visits. A patient at Level 1 is able to follow commands and requires intensive skilled PT services to achieve the expected continuum of care level upon discharge. This patient receives 5 - 7 PT sessions per week. A patient at Level II is also appropriate for skilled PT services but is close to prior level of functioning and only requires 1 – 4 PT sessions per week to reduce deconditioning. A patient at Level III is not appropriate for skilled PT services and care is turned over to nursing. These patients are usually at their prior level of function and often include patients with long-term chronic conditions.
Prior to full implementation and acceptance of the triage system, a year-long quality assurance (QA) monitoring process was completed in 2004. This process involved evaluation
The Effects of a Physical Therapy Triage System on the Outcomes of ICU Patients with Respiratory Failure
The Effects of a Physical Therapy Triage System on the Outcomes of ICU Patients with Respiratory Failure
Joni Rapp, PT, DPTPhysical Therapist, Summa Hospital [email protected]
Jaime C. Paz PT, DPT, MSClinical Associate Professor, Walsh [email protected]
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The Effects of a Physical Therapy Triage System on the Outcomes of ICU Patients with Respiratory Failure
the final sample of 117 patients to collect the following data: diagnosis, number of PT visits, number of days from admission to PT examination, level of functioning at PT examination, level of functioning at discharge or at the last documented PT visit, the continuum of care level predicted at initial PT examination, and triage level designated by the evaluating physical therapist.
The chart review identified the level of function documented at initial PT
examination and at the last physical therapy treatment note prior to discharge from the hospital. For purposes of comparison, these data were collapsed and stratified into six levels of function (Table 1) similar to the classifications used in the Kansas University Hospital Physical Therapy Acute Care Functional Outcomes Tool.13 Several patients were seen only once by physical therapy and therefore, their data were eliminated from the comparisons of change in level of functioning.
The continuum of care (COC) level predicted by the evaluating therapist at the initial evaluation was divided into six categories based upon the following labels: long term acute care, skilled nursing facilities (SNF), rehabilitation, home with or without assistance, SNF versus home or uncertain. The category of “uncertain” was typically given when the patient was sedated or unconscious and a true prognosis could not yet be determined. The category of “SNF versus Home” was considered a correct prognosis if the patient had gone home or to a skilled nursing facility.
AnalysisData analysis was completed using SPSS 17.0 and Microsoft Excel 2007 software. Non-parametric tests were used and included the Mann-Whitney U and the Wilcoxon signed-ranks test. The Mann-Whitney U test was performed to compare Groups 1 and 2 regarding level of function, length of stay, and group characteristics. The Wilcoxon signed-ranks test was performed to compare change in function or change in COC level for an individual group over time. The level of significance was set at 0.05 for these analyses. Central tendencies, or averages, were used in addition to statistical significance to identify changes in the number of physical therapy visits and number of days of hospital and ICU length of stay for Groups 1 and 2.
RESULTSDemographicsThe characteristics for Groups 1 & 2 are outlined in Table 2. The characteristics of Group 2, which was further divided into Groups 2a, 2b and 2c, are outlined in Table 3. For the number of co-morbidities, which was calculated by counting the number of diagnostic codes, Group 1 was significantly higher (p < .001) than Group 2 (including subgroups) for reasons unknown to the authors. However, this may be attributed to changes in medical management over
Figure 2.
The Effects of a Physical Therapy Triage System on the Outcomes of ICU Patients with Respiratory Failure
of each ICU patient chart by a senior therapist to determine uniformity of the documentation of triage levels by the staff PTs. The result of the QA process determined few errors in the assignment of a triage level and follow up interventions by hospital PTs.
The purposes of this study were to evaluate the effectiveness of the triage system and to answer the clinical question: “Does the triage system decrease length of stay (LOS) (both hospital and ICU), improve physical function, and decrease the number of PT visits while achieving the predicted continuum of care level for patients with respiratory failure who were admitted to the ICU?”
METHODS
This is a non-experimental, descriptive
study in which a retrospective chart review of patients admitted to the ICU at SHS between January and March of 2002 and between January and March of 2007 was used for data collection.
SampleAn initial sample was collected by Summa Health Systems Quality Resource Management that included patients given a primary diagnosis of respiratory failure resulting in mechanical ventilation. Patients were excluded from the sample if they had expired while in the hospital, were discharged to hospice, were initially seen for cardiac or orthopedic procedures, or were found to have other life-limiting co-morbidities. The final sample included 2 Groups of patients. Group 1 consisted of sixty
patients who received PT services prior to initiation of the triage system. Group 2 consisted of 57 patients who received PT services after the triage system was put in place. Group 2 was further divided into three subgroups based on the triage system criteria (Fig. 2). Group 2a consisted of 41 patients triaged as Level I; Group 2b consisted of,12 patients triaged as Level II;, and Group 2c of 4 patients at Level III.
Data The administrative data provided by Summa Health Systems Quality Resource Management included age, sex, hospital length of stay, ICU length of stay, the number of co-morbidities, and discharge status from the hospital. A retrospective chart review was then completed by 3 physical therapists on
Figure 1. Physical Therapy Continuum of Care
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those patients who had the potential to improve more quickly or who required more intense therapy while decreasing the frequency of visits to patients with chronic conditions without compromising quality of care. As frequency of therapy visits increase, the patient should improve in function, which would allow for a more rapid transfer out of the ICU. Quality of care at Summa Health Systems indicates that the appropriate number of PT visits necessary to improve patient function and achieve the predicted continuum of care level at discharge has been provided.
Length of Stay A decrease in the number of physical therapy visits, the average hospital LOS, and the average intensive care unit LOS occurred from 2002 (Group 1) to 2007 (Group 2) (Fig 3). The decrease in the length of stay, for both hospital and ICU, may be in part due to changes in patient management in that 5-year time span as costs for acute care have risen and reimbursement has been reduced. However, the U.S. Department of Health and Human Services’ Healthcare Cost and Utilization Project20 indicated no change in average hospital LOS from 2002 to 2007. In comparison, the Summa Health System was able to decrease the hospital LOS in 2007, which may have been partially attributed to addition of the triage system. Further analysis of all the contributing variables to hospital LOS is necessary to fully determine the reasons for decrease in hospital LOS
at this facility.
Level of FunctionWe hypothesized that the triage system would increase physical function for the 2007 (Group 2) patients compared with the 2002 (Group 1) patients upon hospital discharge or at the last documented PT visit. Because Groups 1 and 2 were different at initial evaluation, statistical comparisons could not be made. Therefore, we
could not safely conclude that the triage system led to greater increase in physical function compared with physical therapy management prior to initiating the triage system. We were able to determine whether the patient categorization component of the triage system was effective. Group 2 was divided into Groups 2a (Triage Level I) and 2b (Triage Level II), and compared separately to identify
Group 2a(Triage level I)
Group 2b (Triage level II)
Groups 2c(Triage level III)
Number of patients 41 12 4Number of co-morbidities 6.4 7.5 7.75LOS 15.3 19.4 14ICU LOS 9.02 13.58 8Number of PT visits 3.42 5.08 1.25Days from admission to PT evaluation 5.3 4.83 3.5
Table 3. Characteristics of Group 2 Categorized by Triage Level
Figure 3.
The Effects of a Physical Therapy Triage System on the Outcomes of ICU Patients with Respiratory FailureThe Effects of a Physical Therapy Triage System on the Outcomes of ICU Patients with Respiratory Failure
a five-year span. The average number of physical therapy visits decreased by 2.5 visits in Group 2 compared with Group 1 (p=.001). The mean hospital length of stay and ICU length of stay decreased by approximately two days in Group 2 compared with Group 1, although statistical tests performed did not indicate a high probability of true differences between groups (Mann-Whitney U test for hospital LOS: p=.283, and ICU LOS: p=.876) (Fig 3).
Level of FunctionThe level of function at initial evaluation for Groups 1 and 2 appeared to be different based on the Mann-Whitney U test (p=.015). This suggests an initial difference between the groups, which prevented us from exploring any further between group comparisons regarding change in function from initial evaluation to discharge from hospital. Patients from both Group 1 and Group 2 who received only one PT visit were eliminated, as no comparison data was available at discharge. Additionally, all Group 2c patients were eliminated since these patients would not receive more than one PT visit.
For these reasons, a within group analysis was performed using the Wilcoxon signed ranks test to compare level of function from evaluation to discharge within Groups 1, 2a and 2b (Fig 4). The results indicated improvement from evaluation to discharge for Group 1 (p < .001), Group 2a (p < .001) and Group 2b (p=.009). When evaluating the
change in level of function within each group, Group 2a showed the greatest improvement with 85% of patients (27/32) advancing by at least one or more functional levels. Similarly, in Group 2b, 82% of patients (9/11) showed an improvement in physical functioning from initial evaluation to the last documented PT treatment. Group 1 also demonstrated an improvement with 77% of patients (42/55) improving in function.
Continuum of CareAnalysis of the continuum of care level predictions and outcomes was also completed only for Group 2 because achieving the predicted COC level was a goal of the triage system. Prior to the triage system, achieving the predicted COC was also a goal,
but it was not consistently monitored or documented and therefore could not be analyzed in this study. When considering the patients in Group 2, the evaluating physical therapist was able to correctly identify the COC level deemed necessary by the attending physician upon hospital discharge in 72% of the cases (Fig 5). Based on the Wilcoxon signed-ranks test (p=.064) the predicted COC level at evaluation was the same COC level achieved upon discharge. In other words the therapist’s COC prediction at the initial evaluation was correct.
DISCUSSIONThe purpose of this study was to determine the effectiveness of the physical therapy triage system in decreasing the number of physical therapy visits, decreasing the length of stay (hospital and ICU), increasing patient function, and achieving the predicted continuum of care level for patients with respiratory failure who were admitted to the ICU. The goal of the triage system was to improve patient function in order for the patient to advance from the ICU to the next level of care as quickly as possible while utilizing fewer PT visits. The intent was to provide physical therapy services with a higher frequency to
Group 1(pre-Triage)
Group 2(Triage)
P value (Mann-Whitney U test)2002 vs 2007
Number of patients 60 57Age 63 64 .764Ratio of Male to Female 27:33 26:31 .947Number of co-morbidities 20.75 6.74 .000LOS 18.4 16.1 .283ICU LOS 11.13 9.9 .876Number of PT visits 6.1 3.6 .001Days from admission to PT evaluation 4.68 5.03 .834
Table 2. Characteristics of Groups 1 & 2
Level of Function at initial examination and dischargeSedated, not tested, dependent for all transfers1. Bed mobility or bed exercises2. Pivot transfer or sit to stand transfer3. Ambulate 0-10 ft4. Ambulate 11-50 ft5. Ambulate 51-149 ft6. Ambulate 150 ft or more7.
Table 1. Data Collection Categories for Level of Function
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LimitationsThe limitations of this study include a relatively small sample size compared with a similar study9 and the possible role of changes in medical management over a five-year span. The samples analyzed for the study covered a small period and included patients with many different medical diagnoses, patients with a large age range, and patients with various medical histories including drug abuse and chronic non-life threatening conditions. Complexity in patient population may have further limited statistical significance; however, this variety of sampled patients may have increased the likelihood of outcome application to other mechanically ventilated patients. Additionally, the long time span between groups may have also affected the results. Over several years, length of stay and COC level may have been altered by not only the physical therapy protocols but also by changes in the health care system such as reimbursement restrictions and newer, more effective medical treatments.
Another possible limitation to this study was the data gathering points. For the data, the initial level of functioning was compared with the function documented at the last PT visit. However, the data collectors often noticed that higher levels of functional activity were achieved by patients during their stay than was recorded at the last PT visit. This was due partly to the common practice (at this facility) of allowing the patient to complete only bed exercises on the day of expected transfer to another facility to allow energy conservation. This practice may have negatively skewed the data and decreased significance; therefore a larger statistical significance may have been seen if the comparison had been made between level of functioning at initial evaluation and the highest level of activity achieved.
Further limitations of this study are due to the nature of a retrospective study and include a lack of standard
documentation and differing methods of patient care. This may have occurred as a result of staff with less triage protocol training, such as short-term contract employees and students. As described by Jette et al,15 clinicians with less acute care experience tend to be more conservative with their continuum of care level recommended upon discharge. This may also be true regarding the level of activity the therapist encourages their patients to achieve. Future research in this area will need to address these limitations to better understand the exact implications of this triage system or similar systems utilized at other facilities.
CONCLUSIONTriage systems similar to the one created by Summa Health System have been described in professional literature, however no current research studies have been identified to determine the efficacy of such a system.16,17 This research study demonstrates the effectiveness of a triage system in decreasing LOS (both hospital and ICU), and allocating the appropriate number of PT visits to CI patients. The data also demonstrate how physical therapy is able to increase the functional ability of the patient in the acute care setting regardless of a triage protocol. Lastly, physical therapists using the triage system were able to correctly identify the level of care required upon discharge. Results of this study confirm the vital role physical therapists play in the medical management of the acute care patient.
REFERENCESHopkins RO, Spuhler VJ, Thomsen 1. GE. Transforming ICU culture to facilitate early mobility. Crit Care Clin. 2007;23:81-96.
Reis E. Filling an acute need: PTs and 2. team collaboration in the hospital. PT Magazine. 2002;10(9):34-38,41,83.
Reis E. Filling an acute need: PTs and 3. team collaboration in the hospital. PT Magazine. 2002;10(9):34-38,41,83.
Allen C, Glasziou, Del Mar C. Bed 4.
rest: a potentially harmful treatment needing more careful evaluation. The Lancet. 1999;354(9186):1229-1233.
Chiang LL, Wang LY, Wu CP, Wu HD, 5. Wu YT. Effects of physical training on functional status in patients with prolonged mechanical ventilation. Physical Therapy. 2006;86(9):1271-1281.
Wong, WP. Physical Therapy for a 6. patient in acute respiratory failure. Physical Therapy. 2000;80(7):662-670.
Mundy LM, Leet TL, Darst K, 7. Schnitzler MA, Dunagan WC. Early mobilization of patients with community-acquired pneumonia. Chest. 2003; 124(3):883-889.
Morris PE, Herridge MS. Early 8. intensive care unit mobility: future directions. Crit Care Clin. 2007;23:97-110.
Morris PE, Goad A, Thompson C, 9. Taylor K, Harry B, Passmore L, Ross A, Anderson L, Baker S, Sanchez M, Penley L, Howard A, Dixon L, Leach S, Small R, Hite RD, Haponik E. Early intensive care unit mobility therapy in the treatment of acute respiratory failure. Crit Care Med. 2008; 36(8):2444-5.
Dean E. Mobilizing patients in the 10. ICU: evidence and principles of practice. Acute Care Perspectives. 2008;17(1):1,3-9.
Perme C, Chandrashekar RK. 11. Managing the patient on mechanical ventilation in ICU: Early mobility and walking program. Acute Care Perspectives. 2008;17(1):10-15.
Stiller K, Phillips AC, Lambert P. The 12. safety of mobilisation and its effect on haemodynamic and respiratory status of intensive care patients. Physiotherapy Theory and Practice. 2004;20:175-185.
Swafford, BB. Validity of Kansas 13. university hospital physical therapy acute care functional outcomes tool. Acute Care Perspectives. 2008;Fall:14-18.
Scott R, Petrosino C. Physical therapy 14. management. St. Louis, Missouri: Mosby Elsevier;2008:74-84.
Jette DU, Griver L, Keck C. A 15. qualitative study of clinical decision making in recommending discharge
The Effects of a Physical Therapy Triage System on the Outcomes of ICU Patients with Respiratory Failure
Figure 5. Continuum of Care Level at Discharge
The Effects of a Physical Therapy Triage System on the Outcomes of ICU Patients with Respiratory Failure
change in function from evaluation to discharge in each of those respective groups. Change in function within Group 1 was also analyzed to provide comparison to the triage subgroups. Improvement in function from initial evaluation to discharge within each group (Groups 1, 2a and 2b) was found to be statistically significant (Fig 4). Although the initial difference between Groups 1 and 2, did not allow us to test the full effectiveness of the triage system statistically, our results suggest that the triage system helps physical therapists in clinical decision making and their ability to allocate PT services appropriately to CI patients while still achieving improvement in functional levels. These results are consistent with previous literature documenting the ability of physical therapists to manage CI patients successfully in the ICU.1,8,9,12,13
Continuum of Care LevelThe Summa Health System triage classification includes a physical therapy evaluation of the patient, which identifies the expected discharge continuum of
care level. Each therapist considers many factors to determine the potential for each patient to reach a certain level
on the continuum of care by discharge from the ICU and acute care hospital including living environment, prior level of functioning, and available medical reimbursement. Upon the initial examination, physical therapists at Summa were correctly identifying the continuum of care level at discharge over 70% of the time (Fig 5). This may be a result of the ability of acute care therapists to predict and achieve goals since the COC level is strongly linked to physical level of functioning, or it may also be a result of the physical therapist’s role in discharge planning.15,21 At Summa Health System, the COC level prognosis is a vital communication tool between the evaluating physical therapist and other physical therapists, other health care providers, and social workers for discharge planning. Recent literature also documents a higher readmission rate for patients when a physical therapist’s discharge recommendations are not followed.21 Therefore, the results of this study help to substantiate the critical role that physical therapists have in patient care and discharge planning in the acute care setting.
Figure 4. Change in Level of Function
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APTA 2010Combined Sections Meeting San Diego, CA
Low Frequency Ultrasound Delivered at 35KHZ Decreases Methicillin Resistance in a Clinical Wound Isolate of MRSA.
1. Physical Therapy, Winston-Salem State University, Winston-Salem , NC, United States. 2. Microbiology, NC A&T University, Greensboro, NC, United States. 3. Pathology , Wake Forest University School of Medicine, Winston Salem, NC, United States.
Purpose/Hypothesis : The purpose of this study was to determine if low frequency ultrasound (LFU) delivered at 35 KHz reverses methicillin resistance in a clinical wound isolate of MRSA. Number of Subjects : A known clinical isolate of MRSA from a lower extremity wound with an established resistance to oxacillin and erythromycin was exposed to LFU treatment. Materials/Methods : The MRSA isolate was subcultured, plated and grown on sheep blood agar (SBA) using standard microbiological techniques. Serial dilutions of the organisms were prepared using sterile saline. Cultures received either no treatment or treatment with LFU for 30, 60 and 180 seconds. Inocula from each of the test groups were placed on SBA. Subsequently, an oxcillin test disk was placed on the SBA plates in the initial zone or first quadrant used for organism innoculation. The organisms were incubated at 37 degrees C and grown overnight. The zone of inhibition was determined
for each test group according to manufacturer’s guidelines. Three separate experiments were performed with 3 replications each. Inocula of the tested cultures that demonstrated conversion to a methicillin-susceptible organism were then plates and grown over night to determine persistence of methicillin susceptibility. This process was continued for 72 hours post-ultrasound treatment. Samples of MRSA from the control, nontreatment group and LFU treated groups were also examined using scanning electron microscopy to determine if ultrastructural changes had occurred as the result of treatment. Samples were also taken for flow cytometry. Results : Zones of inhibition congruent with oxicillin (oral form of methicillin) susceptibility were detected for the clinical isolate of MRSA at all tested treatment times. A dose-dependent increase in the zone of inhibition was detected with 35 KHz LFU treatment times as low as 30 seonds. The zone of inhibition increased by 14% with a treatment time of 60 seconds and by 30% with a treatment time of 180 seconds. These zones of inhibition were maintained for as long as 48 hours after LFU treatment. LFU was also effective in changing other colonial characteristics of MRSA as well as producing significant reduction in colony counts and changing membrane permeability. Conclusions : This is the first demonstration of the reversal of methicillin resistance with a biophysical energy. The data suggest that LFU reduces or reverses methicillin
resistance in a clinical isolate of MRSA for up to 48 hours after initial treatment.
Clinical Relevance : Delivery of LFU at 35 KHz may be an effective treatment for wounds heavily colonized or infected with MRSA.
KEYWORDS: MRSA, Low Frequency Ultrasound, Wounds
Survey on the Use of Aides to Support Physical Therapists’ Services
Smith, Jim M.; Crist, Molly H.; Probst, Suzanne. Utica College, Utica, NY, United States.
Purpose/Hypothesis : Use of staff to support the physical therapist (PT) is a strategy that may increase the PT’s efficiency. The profession has defined PTs and PT assistants (PTAs) as the only providers of interventions, and the aide as: “any support personnel who perform designated tasks related to the operation of the physical therapy service. Tasks are those activities that do not require the clinical decision making of the PT or the clinical problem solving of the PTA” (APTA HOD P06-00-17-28). The last investigation of the role of aides (1993) reported the use of aides for providing treatment was a common practice. The purpose of this investigation was to (1) determine the extent aides provide physical therapy services under the supervision of a PT; (2) identify PTs’ opinions about the utilization of aides; and (3) identify the resources PTs use to inform their decisions for aide utilization.
Platform Presentation Abstracts
placement from the acute care setting. Physical Therapy. 2003;83(3):224-236.
Reis E. Filling an acute need: PTs and 16. team collaboration in the hospital. PT Magazine. 2002;10(9):34-38,41,83.
Beattie PF, Nelson RM. Evaluating 18. research studies that address prognosis for patients receiving physical therapy care: a clinical update. Physical Therapy. 2007;87(11);1527-1535.
Summa Health System hospitals. 19. Inpatient physical therapy triaging process [memorandum]. Sept. 2003
U.S. Department of Health and 20. Human Services. Healthcare Cost and Utilization Project National Inpatient Sample. Available at: hppt://hcupnet.ahrq.gov. Accessed July 5, 2009.
Smith BA, Fields CJ, Fernandez 21. N. Physical Therapists make accurate and appropriate discharge recommendations for patients who are acutely ill. Phys Ther. 2010;90 (5)693-703.
The Effects of a Physical Therapy Triage System on the Outcomes of ICU Patients with Respiratory Failure
THE CRITICAL EDGEwww.acutept.org
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Number of Subjects : Twenty-two subjects s/p liver transplant [14 men, 8 women, mean age 53.9 years, mean time post-surgery 8.3 weeks ] (12 controls and 10 experimental) were recruited from a liver transplant clinic. Materials/Methods : A randomized study was conducted with a control group performing usual care ambulation and a treatment group performing a progressive HEP targeting the gastrocsoleus, quadricep, and gluteal muscle groups. The intervention progressed from gravity eliminated exercise to movement against gravity and elastic bands of increasing resistance. A physical therapist performed the initial exercise instruction and then provided telephone and clinic follow-up. Baseline, 8, and 12 week measurements were taken on strength measures: Heel-rise and Bridging; and activity limitation measures: 30 Second Chair Stand (CS), 6 Minute Walk Test (6MWT). Results : Repeated Measures ANOVA demonstrated significant differences in the change from baseline to follow up for Bridging (treatment increased from 23.5 to 56.5, control increased from 24.7 to 32.2 [p<.01]) and for CS (treatment increased from 9 to 14, control increased from 9 to 10 [p=.05]). Heel-rise approached significance (treatment increased from 10.4 to 21.4, control increased from 12 to 16.9 [p=.12]). Although the treatment group improved more than controls for 6MWT (treatment increased from 1294 to 1608, control increased from 1137 to 1371) the difference failed to reach statistical significance (p=.32). There were no adverse effects on liver enzymes or surgical incision dehiscence in either group. Conclusions : Both treatment and control groups improved from baseline; however, the treatment group that performed progressive resistance exercise improved more in strength and function compared to the control group that only performed aerobic walking activity.
Clinical Relevance : Post-transplant both treatment and control groups were expected to improve due to reversal of liver disease related protein-energy malnutrition. However, our findings demonstrated progressive resistance training increased muscle strength and function beyond that of usual post-operative care. A physical therapist directed HEP is ideal for this patient population due to the severity of their muscle wasting and the acuity of their post-operative medical status.
PT Staff Training Model for Optimizing Outcomes in Patients Status Post Ventricular Assist Device Placement
Fields, Christina J.; McKenney, Kate M. Division of Physical Therapy, University of Michigan, Ann Arbor, MI, United States.
Purpose/Hypothesis : The purpose of this platform presentation is to propose a model for PT staff training and aggressive physical therapy following ventricular assist device (VAD) placement. The average length of stay at the University of Michigan Healthy System (UMHS) is 21 days following VAD placement, while nationwide average is 30 days. We believe this shorter length of stay is partially due to an aggressive model of physical therapy management and coordination with VAD team. Our physical therapy model includes extensive staff training of safe, yet aggressive physical therapy involvement beginning post-operative day 1, well defined discharge goals and ongoing physical therapy throughout the acute hospital stay. Number of Subjects : Not Applicable Materials/Methods : We compared average inpatient length of stay data using information collected at UMHS and information published in the Journal of the American
Medical Association. Staff training for independent management of VAD patients includes: VAD specific perfusion training classes, hands-on practice with demo VAD, extensive VAD research notebook, mentoring by senior staff before and during direct patient care, and competency testing. Physical therapy goals for hospitalization and discharge include a standing order for physical therapy which is received post-operative day 0, standing activity orders which include up to chair three times per day and ambulation four times per day and physician expectations. Discharge goals include independence with mobility, independence with VAD alarms to allow for independent mobility, independence with strengthening program and independence with precautions to allow for safe mobility. Results : As noted above average inpatient length of stay following placement of a VAD is 21 days at UMHS. The most recently published data obtained from a November 2008 JAMA submission, indicates average length of stay is 30 days nationwide. We are also currently obtaining more up to date information from the national database. Conclusions : While there are multiple factors that affect length of stay, we feel that extensive PT staff training and aggressive physical therapy in the post-VAD placement patient contributes to our shorter length of stay and better patient outcomes. Clinical Relevance : As the number of facilities placing VADs increases, we hope to share a model of PT staff training and aggressive post-operative management designed to increase patient independence, shorten length of stay and avoid detrimental effects of bed rest such as loss of strength and function as well as medical complications including pneumonia, deep vein thrombosis, pulmonary embolism and pressure ulcers.
Number of Subjects : Subjects were PTs in Connecticut. 500 were randomly selected and mailed a survey. 120 surveys were returned for a response rate of 24% and 118 of the surveys were determined to be usable. Materials/Methods : A survey was designed to collect information from PTs on the tasks performed by aides. The survey also gathered demographic data and information on PTs’ opinions regarding support staff. The frequency distribution of responses was analyzed and Spearman’s rho analysis was performed to determine correlation between the responses and the demographic data. Results : The tasks identified as those most frequently performed by aides were thermotherapy (36%), aerobic/endurance activities (32%), active/resistive exercise with equipment (29%), whirlpool (16%) and data collection for height and weight (16%). Opinions on the use of aides included: 54.3% reported that the utilization of aides had presented them with an ethical dilemma during their career; 47.5% reported that they were comfortable with aide involvement in their practice; and 83.9% reported that they were legally responsible for actions of an aide. Resources that informed PTs’ decision on utilization of aides were familiarity with APTA’s position on the use of support staff (59%); instruction received during education (52%); familiarity with state statutes (52%); and recommendations from an administrator or manager (38%). Conclusions : A minority of PTs relied on aides to support them in the clinic. There was little, if any, correlation between aide utilization and demographic data. For some respondents the services provided by an aide did not appear to be consistent with positions of the APTA. The use of aides to perform services caused an ethical dilemma or discomfort for a sizable number of PTs. Clinical Relevance : PTs’ use of
aides to support clinical practice varied widely. PTs may benefit from education on the use or role of the aide in their practice, including information on statutory requirements and the positions of the APTA.
KEYWORDS: Aide, Direction and supervision
Total Femur Replacement: The Role of the Acute Care Phyiscal Therapist in Recovery and Outcomes
Lieberman, Allison1; Beecher, Gina1; Metoxen, Jason.2 I. PT/OT, New York University- Hospital for Joint Diseases, New York, NY, United States. 2. The Hospital for Special Surgery, NY, NY.
Purpose : The purpose of this presentation is to educate acute care physical therapists regarding existing indications, surgical techniques, post-operative management, and functional outcomes following a total femur replacement. This lecture will emphasize current literature, physician protocols, and physical therapy treatment options.
Description : This presentation will examine the history and surgical indications for the total femur replacement, describe the surgical techniques and prosthetic components available, and discuss post-operative patient complications and management. There will be a review of acute care protocols following the procedure, in addition to physical therapy and rehabilitation outcomes. A case study of a patient status-post total femur replacement will highlight the physical therapist’s role in treatment. Summary of Use : Physical therapists in the acute care environment will gain insight into the total femur replacement surgery, understand the restrictions following the procedure, be educated on physical therapy protocols, understand appropriate short and long-term physical therapy goals, and be capable
of educating patients and caregivers regarding rehabilitation outcomes. Importance to Members: As total femur replacement becomes increasingly common in the acute care setting, it is imperative that physical therapists in this environment have knowledge of current indications, surgical techniques, and post-surgical rehabilitation. This presentation will provide acute care physical therapists with current information about the total femur replacement and provide them with the tools to better educate their patients, colleagues, and other healthcare staff.
KEYWORDS: total femur replacement, tumor resection
Comparison of Targeted Lower Extremity Resistance Exercise with Usual Care Progressive Ambulation Post-Liver Transplantation
Mandel, David W.; Roach, Kathryn E. Physical Therapy, University of Miami Miller School of Medicine, Coral Gables, FL, United States.
Purpose/Hypothesis : Individuals with chronic liver disease develop significant muscle wasting (protein-energy malnutrition) resulting in impaired strength and activity limitations. Liver transplantation promotes survival and improves quality of life; however, muscular rehabilitation is not addressed by current post-operative care. Previous research using aerobic walking exercise post-liver transplantation demonstrated muscle strength remained impaired. Muscle requires progressive resistance to increase mass and strength. The purpose of this study was to compare the effect of a 12 week home exercise program (HEP) of targeted lower extremity resistance exercise on muscle strength to the usual care of progressive ambulation post-liver transplantation.
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Poster Abstracts
Gait and Balance Deficits in a Patient Hospitalized with Bipolar Schizoaffective Disorder: a Case Report.
Kranenburg, Megan; Cleary, Kimberly K. Eastern Washington University, Spokane, WA, United States.
Background & Purpose : In schizoaffective disorder, symptoms of schizophrenia and a mood disorder with psychotic features overlap. Up to one-third of patients diagnosed with schizophrenia may have schizoaffective disorder. Evidence indicates that affective disorders affect a person’s psychomotor skills and gait. Patients with schizophrenia show decreased ability to regulate stride length, and those with bipolar disorder exhibit significantly increased variability in swing time. Existing research is clear that the mental illness itself is likely the primary cause of altered gait patterns.
Case Description : The patient described in this report was a 56-year-old female admitted to an inpatient psychiatric hospital. In addition to her psychiatric illness, she had multiple systemic and musculoskeletal co-morbidities, including osteoarthritis, Type II diabetes, and asthma. In addition, an anoxic brain injury experienced during infancy left her with diminished cognitive function. Gait analysis revealed an unpredictable gait pattern. She dragged her right foot and used a step-to pattern that varied with speed, and she exhibited a Trendelenburg lurch bilaterally. Use of a front wheeled walker may have exacerbated poor gait habits. Her initial score on the Berg Balance measure
was 45/56, indicating falls risk of 80%. Her prognosis was fair to return to her goal of ambulating independently without an assistive device.
Outcomes : The plan of care for this patient included strengthening and gait retraining. Specific interventions included aquatic therapy (walking, side-stepping, bicycles, and wall squats), lower extremity ergometry, and wedge sitting. The patient’s difficulty maintaining focus during physical therapy sessions was the primary challenge to treatment. The patient was treated in the pool 3 times and in the clinic 7 times over her two and a half week episode of care. At re-examination prior to discharge, the patient’s Berg Balance score increased to 48/56, which reduced her falls risk to approximately 60%. Subjectively, the quality of her performance of these functional tasks also improved. No measurable, consistent improvement in gait was noted, but the patient did begin exercising independently by the end of the episode of care. The patient was discharged from the inpatient psychiatric hospital to a group home setting.
Discussion : The slight improvement in this patient’s balance may be attributed to aquatic therapy, which has been shown to decrease lateral postural sway in older women with lower extremity osteoarthritis. The ongoing gait deficits are most likely the result of her mental illness, however, future research should examine the effects of specific physical therapy interventions on gait dysfunction in patients with psychiatric illness. Information about these disease-specific dysfunctions
should also be formally incorporated into entry-level physical therapist education in order to fully prepare the acute care physical therapist for appropriate intervention planning in this patient population.
KEYWORDS: Gait, Schizoaffective, Balance
Efficacy of a 12 Week Progressive Resistance Training Protocol in a Patient Following Liver Transplantation
Mandel, David W.; Concepcion, Nicholas; Jiunta, Justin; Martis, Elissa; Ramos, Daniel. Physical Therapy, University of Miami Miller School of Medicine, Coral Gables, FL, United States.
Background & Purpose : Chronic liver disease affects more than 5 million Americans and results in severe loss of muscle mass, strength, and activity limitation. Liver transplantation serves as a modality to prolong survival and improve quality of life (QOL). However, research demonstrates muscle wasting continues, strength and QOL remains impaired, and many individuals do not return to employment. Current post-liver transplant care does not include rehabilitation of lost muscle strength. The purpose of this study was to assess the efficacy of a 12 week progressive resistance training (PRT) home exercise protocol, closely monitored by a physical therapist (PT), consisting of 14 exercises predominantly focusing on the lower extremities (LE). Research indicates that short-term PRT programs are effective at increasing strength and lean body mass
Device, Length of stay, Staff training.
The Challenges of Morbid Obesity and Multi-Organ Failure: A Case Study of Early Mobility in the Intensive Care Unit
Korupolu, Radha1; Zanni, Jennifer2; Butler, Martha2; Needham, Dale.1 1. Pulmonary & Critical Care Medicine, Johns Hopkins University, Baltimore, MD, United States. 2. Physical Medicine & Rehabiliation, Johns Hopkins Hospital, Baltimore, MD, United States.
Background & Purpose : The prevalence of obesity has risen dramatically over recent decades, causing hospitals and rehabilitation facilities to develop new approaches to manage patients who are obese. Approximately 25% of patients in intensive care units (ICU) are obese and 7% are morbidly obese with these rates projected to increase. Critical illness in patients with morbid obesity presents unique challenges, including prolonged mechanical ventilation, thromboembolic disease, pressure ulcers, and markedly impaired physical function. For these patients, early physical therapy (PT) and mobilization may reduce complications, decrease length of stay and improve patient outcomes; however, interdisciplinary team work is key for success. Case Description : A 44-year old female with morbid obesity (BMI=69, 425 lbs, 5’ 6”) presented from home in septic shock with acute renal failure and hypoxemic respiratory failure. Her past medical history included hypoventilation syndrome requiring ventilatory support at night via tracheostomy, diabetes, hypertension and chronic venothromboembolic disease. Prior to admission, the patient could ambulate approximately 10 feet with a walker, but reported generally using a wheelchair for mobility. In the medical ICU (MICU), the patient received controlled mechanical ventilation via tracheostomy. Vasopressor support
and hemodialysis were required for the first 2 - 3 days. On MICU Day 2, PT was consulted and the patient sat at the edge of bed with assistance. Via the interdisciplinary efforts of PT, respiratory therapy and nursing to safely manage 2 central lines, mechanical ventilation and life support equipment, the patient received twice-daily graduated PT activities, including therapeutic exercise, sitting on the edge of bed, sit to stand, sitting in a chair, and ambulation. On MICU Day 7, the patient ambulated a total of 120 feet, with 3 rest breaks, using a walker. Outcomes : Rather than facing functional decline while in the MICU with septic shock and multi-organ failure, the patient left the MICU walking a much greater distance than her baseline as a result of intensive early PT and strong interdisciplinary teamwork. On Day 9, the patient was discharged from the MICU directly home (without a stay on the ward or in a rehabilitation facility) with continued PT via homecare. Discussion : Despite morbid obesity, markedly impaired baseline function, and septic shock with multi-organ failure, early mobility in the ICU was feasible and markedly improved physical function beyond baseline with discharge home directly from the MICU. In patients who are morbidly obese and critically ill, early and intensive PT with interdisciplinary teamwork may help prevent common hospital-acquired complications, improve functional status, and minimize length of stay. KEYWORDS: obesity, early mobility, critical illness
Identifying Components of Acute Care Physical Therapy Practice Through Analysis of Presentations at Combined Sections Meeting
Smith, Jim M. Utica College, Utica, NY, United States.
Purpose : Presentations at the Combined Sections Meetings (CSM) of the APTA reflect the topics being addressed by physical therapy clinicians and researchers. The identification of the topics being addressed in acute care will provide information about practices in acute care physical therapy. That information may be of interest to the Acute Care Section, as it is in the process of practice analysis as a component of developing specialist certification with the American Board of Physical Therapy Specialties. Description : There were 84 platform and poster presentations sponsored by the Acute Care Section at the CSM 2004 - 2009. The abstracts for the platform and poster presentations were reviewed. Presentations prior to 2004 were excluded to ensure analysis of current practice activities. Summary of Use : Eight categories evolved and the themes are identified in order of most frequent to least frequent:
Patient/client management for 1. multiple physical systems issues (26%)
Patient/client management for 2. integumentary issues (19%)
Patient/client management for 3. cardiopulmonary issues (17%)
Administration and practice 4. environment issues (15%
Education and professional 5. development issues (8%)
Patient/client management for 6. neuromuscular issues (5%)
Patient/client management for 7. musculoskeletal issues (5%)
Other/no specific category (5%)8.
Importance to Members: These
themes represent the topics and issues of scholarly interest to acute care PTs and PTAs. The common theme across the majority of the presentations was the management of complex or medically urgent patient/client issues. The most frequently encountered topics were issues and strategies for the physical therapist’s management of multiple-system pathology, followed by integumentary pathology. The domain of “administration and practice” issues revealed topics unique to the advancement of physical therapy practice in acute care environments. The relevance is that these categories identify the types and frequency of the topics of scholarly interest to acute care physical therapy that were addressed at CSM over the last 6 years. This should inform the current analysis of acute care physical therapy practice and it may inform the priorities for future research activity in acute care physical therapy.
KEYWORDS: practice analysis, practice area.
Medial sternotomies: A systematic review and evidence-based guidelines for postoperative sternal precautions
Tuttle, Karen; Mincer, Andi B.; Thompson, Anne W. Physical Therapy, Armstrong Atlantic State University, Savannah, GA, United States.
Purpose/Hypothesis : Current postoperative guidelines for patients who have had a medial sternotomy vary widely in activities allowed and timeframes for recovery. This study combined a systematic review of peer-reviewed literature, popular web sources for patient information, and biomechanical analysis of activities of daily living (ADL) that are commonly limited during recovery from a medial sternotomy. Number of Subjects : Three subjects were used for simple biomechanical analysis of sit to stand, push/pull, and lifting tasks.
Materials/Methods : Medline, PubMed, E-pub, and Galileo database searches were performed for peer-reviewed research articles, using “sternal precautions” and “sternal dehiscence” as keywords. Nursing and physical therapy texts and the American Association of Cardiovascular and Pulmonary Rehabilitation guidelines were reviewed. Additionally, dynamometry was used to establish the forces generated during various push, pull, and lift tasks. Results : While the type of surgical closure influences sternal stability,sternal dehiscence occurs in less than 3% of sternotomies. Biomechanical forces from typical ADLs should not have enough force to distract the typical closure more than 2 mm,which is the threshold for potential dehiscence. Coughing presented the greatest risk. Risk factors include obesity, postoperative infection (i.e. pneumonia and urinary tract infections), diabetes mellitus, re-operations, harvesting of bilateral internal mammary arteries, and age greater than 60 years old. Conclusions : Following medial sternotomy, all patients should be encouraged to (1) stabilize the chest by crossing their arms or hugging a pillow while coughing; (2) use lower extremities more than uppers when transferring from sit to stand; (3) use gentle, controlled motions when pushing, pulling, or lifting; (4) avoid resistance training and sports for three months with sternal stability testing prior to reengaging in these activities; and (5) immediately report any increased pain or feelings of instability in the sternum. Clinical Relevance : Postoperative guidelines should allow patients the maximum freedom to resume normal mobility, yet appropriately restrict activities which may be harmful. This report incorporates evidence from peer-reviewed literature and biomechanical analysis to provide comprehensive sternal precautions following medial sternotomy.
in adults with HIV and ESRD, both of which demonstrate similar degrees of muscle wasting.
Case Description : Patient was a 56 year old male diagnosed with Laennec’s Cirrhosis 3 years prior to transplantation. The patient’s past medical history reveals a 28 pack year smoking history, alcohol consumption, and family history of liver disease. The patient was evaluated 12 weeks post-transplantation for baseline measures of LE strength, function, and QOL. LE strength was assessed via Heel-Rise, Bridging, 30 Second Chair Stand, and the 6 Minute Walk Test (6MWT). QOL measures were recorded using a self-reported SF-36 and Chronic Liver Disease Questionnaire (CLDQ). The intervention, performed every other day, consisted of 14 LE exercises, targeting key muscle groups (gastroc-soleous, quadriceps, and gluteal), progressing from anti-gravity to resistance with elastic bands. The PT demonstrated proper performance of the intervention and reevaluated with weekly telephone monitoring. Post-intervention testing was conducted on weeks 8 and 12.
Outcomes : Exercise compliance was high. Post-intervention, the patient’s LE strength significantly improved from baseline: Heel-Rise increased by 23, Bridging increased by 47, Chair Stands increased by 4, and 6MWT improved by 676 feet. Our patient reported an increase in strength, energy level, and ability to lift heavy objects on the CLDQ. Improvements across all domains of the SF-36 were observed, with the most significant occurring in physical function, role physical, role emotional, and bodily pain.
Discussion : Current protocol post-transplantation consists of gradual return to normal activities without addressing musculoskeletal impairments associated with liver disease. This case report suggests that an emphasis on rehabilitation of LE muscle strength using targeted resistance exercise is effective in improving outcomes in this population. A PRT protocol should be considered as an adjunct to the current
usual care post-liver transplantation. A home based execise program was ideal for this patient population due to the acuity of thier post-operative medical status limiting frequent travel to outpatient clinics and potentially minimized healthcare costs.
The importance of adverse drug event (ADE) identification by the physical therapist (PT) in the acute rehabilitation setting: a case example.
Howard, Jennifer1; Nordon-Craft, Amy 1; Page, Robert 2; Struessel, Tami.1 1. Physical Therapy, University of Colorado-Denver, Aurora, CO, United States. 2. School of Pharmacy, University of Colorado-Denver, Denver, CO, United States.
Background & Purpose : Patients admitted to acute rehabilitation are expected to be medically stable and to participate in three hours of therapy per day. Earlier discharge from the acute inpatient setting has led to an increase in acuity and complexity of patients in this setting. Due to frequent patient contact and continuous assessment of function, a PT may be the first to identify subtle physiological changes and subsequent functional decline associated with medications. As PT education has evolved, there has been an increased focus on PT’s knowledge of pharmacotherapy. Even with this enhanced knowledge, PTs may not address ADE’s with members of the medical team due to lack of confidence, uncertainty of their role in pharmacological management, or failure to identify a link between rehabilitation decline and medication change. The purpose of this case report is to describe an example in which failure to identify an ADE contributed to a less than optimal patient outcome in the acute rehabilitation setting.
Case Description : LM is a 67 year old male who sustained an incomplete C6 ASIA B spinal cord injury following
a motor vehicle accident (MVA). Sixteen days post-MVA, LM was transferred to acute rehabilitation with multiple co-morbidities including type II diabetes mellitus, obesity, and hypertension, and poly-pharmacy. Due to acute respiratory and renal failure, he was transferred to acute care and required extensive medical management, including discontinuation of his ACE-inhibitor medication. Upon re-admission to the rehabilitation setting, LM remained in renal failure (creatinine level=3.9 mg/dL, BUN levels=84 mg/dL) but was tolerating progressive amounts of rehabilitation including sitting upright for one hour without orthostatic symptoms. Within 24 hours of reintroduction of the ACE-inhibitor, LM became severely orthostatic (52/36 at 45° of upright) despite use of an abdominal binder and lower extremity bandaging.
Outcomes : After the reintroduction of the ACE-inhibitor, LM was unable to fully participate in rehabilitation or progress in his functional goals. Lack of progress led to transfer to a long term acute care facility. His lack of progress was most likely primarily due to the ADE.
Discussion : ADEs occur across all health settings. Upon retrospective review the effect of the ACE-inhibitor on the patient’s physiological and functional status was identified. Risk factors for ACE-inhibitor intolerance include: serum sodium levels < 130 mEq/L, the addition of high dose loop diuretics, and baseline systolic BPs < 90 mmHg. Our patient met two of these criteria and ultimately demonstrated symptomatic orthostatic hypotension. PTs must be aware of the effects of medications on function and communicate observed changes in patient status to the rehabilitation team. Attention to the patient’s response to medications may help the PT develop an appropriate plan of care, explain changes in treatment effectiveness, and optimize rehabilitation outcomes in a medically complex patient.
KEYWORDS: adverse drug event, spinal cord injury, acute rehabilitation.
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Sartor-Glittenberg, Cecelia; Wong, Rebecca. Arizona School of Health Sciences, A.T. Still University, Mesa, AZ, United States.
Purpose/Hypothesis : Purpose: Determine if body-weight support treadmill training (BWSTT) improved the function of an individual with a chronic transtibial (TT) amputation and comorbidities, and who had already completed standard rehabilitation. Hypothesis: BWSTT would improve endurance, chosen gait velocity, self-reported locomotor ability and decrease fear of falling in an individual with a TT amputation and comorbidities.
Number of Subjects : Subject: A 41-year-old female with a left TT amputation due to musculoskeletal instability two and one half years prior to the study. She had comorbidities of obesity, weight 336 lbs or BMI of 54, and a recent right total knee replacement (TKR). Prior to the TKR she had a fear of falling, a history of falls and gait impairments.
Materials/Methods : Impairment measures included a measure of fear of falling using the Activities-Specific Balance Confidence Scale (ABC). Activity measures include distance walked during a 6-minute wat velocity using the 10-meter Walk Test, and a self-report of locomotor ability using the Locomotor Capabilities Index 5 (LCI5). Study protocol: 2 weeks of pre-testing (4 sessions total), 4 weeks of intervention, and 1 post-test 2 weeks after the intervention. The proposed intervention of BWSTT was to be carried out 3 times per week for 4 weeks. The outcome measures were to be collected during the pre-testing sessions and once per week prior to the third intervention session that week.
Results : Although the study was designed for 21 total sessions, only 8 sessions were completed: 4 testing sessions, 3 before intervention and 1 after 1 week of intervention, and 4 training sessions. The subject reported that she could not complete the study because she had to move to another
city. Of the testing sessions completed, the subject increased her chosen gait speed from 0.5 m/sec to 0.6 m/sec by the fourth testing session. Total distance walked during the 6-minute walk test increased by 88 feet. ABC scores changed from the fir to second testing session, from 51.9% to 60.6%. There was no significant change in the total LCI5 score through the four testing sessions; the scores ranged from 35 to 37 out of a possible 42.
Conclusions : Even though the subject did not complete the training sessions with the BWSTT, there were observable improvements in gait velocity and in total distance walked in 6 minutes. Based on the results of this study, BWSTT may be beneficial for individuals with TT amputations who ambulate with a prosthesis and have comorbidities, which may make traditional locomotor training impractical. Clinical Relevance : Although independent ambulation may be achieved following a lower extremity amputation, recent studies have shown that many individuals with amputation do not use their prosthesis at all, and if ambulation ichieved, approximately two-thirds of individuals remain ambulatory after two years. Although BWSTT is used in practice by prosthetists and physical therapists, there are not many research studies done on individuals with amputations.
KEYWORDS: prosthetics, body weight support treadmill training, amputee.
Developing and Implementing a Program using Functional Outcome Measures in Acute Care at Parkland Health & Hospital System (PHHS)
Belk, Beth; Cao, Keri. Parkland Health & Hospital System, Dallas, TX, United States.
Purpose : To display the development and implementation process of using functional outcome measures in acute care at PHHS. The steps described include functional outcome measure
selection, literature review, notebook compilation, PT staff education, and follow up with staff.
Description : The program development included outcome measure selection based on patient and diagnosis appropriateness, feasibility, high validity and reliability, and clinical relevance. A literature review for each outcome measure was performed to determine patient appropriateness and psychometric properties. 2 notebooks were compiled: notebook 1 included tables, instruction, and scoring interpretation, and notebook 2 included reference articles. An inservice was given to PT staff to explain the purpose of the program and instruction on the various outcome measures. The implementation process involved encourageing PT staff to use functional outcome measures during their acute care rotation. To ensure accountability, PT Staff was asked to record outcome measure usage on log forms. They were also asked to fill out a survey at the end of their acute care rotation describing benefits and limitations of using functional outcome measures in acute care. The authors collected the log forms and surveys to determine the need for change in the program. Summary of Use : This program provides physical therapists the tools for using functional outcome meausures in acute care. It specifically describes the development and implementation process of using functional outcome measures in acute care at Parkland Health & Hospital System. Importance to Members: The use of functional outcome measures in all areas of physical therapy is widespread. Most importantly outcome measures help determine effective and efficient treatment intervention, establish patient specific and functional goals, document change, and aid in reimbursement and benchmarking purposes. This program is an example of how to develop and implement the use of functional outcome measures in an acute care setting.
KEYWORDS: sternal precautions, sternotomy.
Impressions of Physical Therapy Students Towards Hospital Based Physical Therapy Care
Sanders, Babette1; Surufka, Megan 1; Tito, Nicole1; Smith, Jim M.2 1. Physical Therapy and Human Movement Sciences, Northwestern University, Chicago, IL, United States. 2. Department of Physical Therapy, Utica College, Utica, NY, United States.
Purpose/Hypothesis : Hospital-based physical therapy (HBPT) or acute care is one environment in which physical therapists (PTs) practice. PTs have many contributions during the course of a patient’s stay in the hospital and must possess a wide array of skills in order to provide competent services to the patient. However, despite the importance of HBPT, its popularity seems to be diminished in both the PT and student PT populations. There seems to be many negative connotations towards HBPT which are deterring the interest of a large amount of PTs or potential PTs. The purpose of this study was to gain information on student PTs reasons for the apparent decreasing interest in hospital based practice as a PT. Number of Subjects : 48 Materials/Methods : Materials/Methods : PT students from Northwestern University and Utica College completed a demographic sheet. After reviewing their responses, they were categorized into groups depending on the amount exposure or experience in the acute care setting for physical therapy. Exposure/Experience was determined based on the amount of hours completed in observation, volunteering, internship and employment in HBPT. The categories consisted of those with less than 20 hours exposure, those with more than 20 hours exposure, and those who had completed a formal full time clinical education experience. Small groups were formed with subjects from the same categories and
focus group discussions were held. During these discussions a series of 13 questions created by the researchers were asked and the group discussions lasted approximately 30 minutes. All focus group discussions were audio taped and the sessions transcribed and coded for common themes by the same researchers.
Results : Students with a formal clinical education experience expressed more specific insights regarding their impressions of HBPT. In general, their responses were more positive, with greater understanding of the inpatient setting as a whole and the value of physical therapy in the patients’ care; the responses from students with the least exposure to HBPT were more negative about HBPT.
Conclusions : Regardless of how much time was spent in HBPT for observation, volunteering, or even employment, students with specific full time clinical education experiences working in the clinician role demonstrated greater understanding and expressed more positive impressions of that setting. They suggested that acute care facilities do more to advertise the pace and complexity of HBPT as a positive work environment.
Clinical Relevance : Academic and clinical institutions should partner to provide more opportunities to expose students to HBPT so that they become more aware of the positive attributes this practice setting offers. This could potentially lead to more physical therapist students being attracted to HBPT as a career choice.
KEYWORDS: acute care, clinical education, career choices.
Patient readmission rates are lower when acute care physical therapists’ discharge recommendations are followed.
Fields, Christina J.1; Fernandez, Natalia M.1; Smith, Beth A.2
1. Division of Physical Therapy, University of Michigan Hospital, Ann Arbor, MI, United States.
2. School of Kinesiology, University of Michigan, Ann Arbor, MI, United States.
Purpose/Hypothesis : The purpose of our study was to determine the frequency with which the acute care PT’s recommendation of patient discharge location matched the patient’s actual discharge location, as well as the impact of mismatches. In addition, we explored factors associated with a mismatch. Number of Subjects : Our retrospective study included the discharge recommendations of 40 acute care PTs for 762 patients in a large academic medical center. Materials/Methods : We calculated the frequency of mismatch between physical therapist recommendation and patient discharge location. We assessed the relationship between mismatches and patient readmission rate. We also explored factors contributing to a mismatch: therapists acute care experience and treatment by one or multiple therapists from evaluation to discharge. Results : Overall, therapists’ discharge recommendations were followed 84% of the time. Patients were more likely to be readmitted when the PT recommendation was not followed. Conclusions : Our study supports the role of physical therapists in discharge planning in the acute care setting. Clinical Relevance : PTs demonstrated the ability to make appropriate discharge recommendations for complex, acutely ill patients with fluctuating functional and medical status.
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Wound margin maceration during the first three weeks of care resulted in a 15% increase in width and only a 2.6% decrease in length. Upon return to the traditional NPWT dressing, a 25% decrease in width and a 6% decrease in length occurred over the subsequent two weeks. Drainage decreased as customary with the NPWT usage. Necrotic and devitalized tissues were minimized via serial use of LFU. Negative wound cultures and the absence of local or systemic signs of infection negated the need for antibiotic management. Application of a skin graft or bioengineered skin substitute is currently being considered.
Discussion : While long-term outcomes are yet unknown, it did appear the wound derived benefit from the debriding and bacteriocidal effects offered via LFU. Further, no adverse effects to the orthopedic hardware or the operating ultrasound sound head were noted. Progress may have been slowed by initial difficulties with the alternate dressing component of the NPWT system. Analysis indicated the patient benefitted from concomitant use of LFU and NPWT to granulate over exposed hardware and prepare the wound for closure.
KEYWORDS: low frequency ultrasound, hardware exposure, wound healing.
A Comprehensive Physical Therapy Approach for a Premature Infant in the Neonatal Intensive Care Unit (NICU): Aligning with the Evidence
Tarr, Kelly M.2; Hakim, Ellen W.1
1. Physical Therapy and Rehabilitation Science, University of Maryland School of Medicine, Baltimore, MD, United States. 2. Physical Medicine and Rehabilitation, University of Maryland Medical Center, Baltimore, MD, United States.
Background & Purpose : Clinical research established that neurologic maturation of a neonate can be positively influenced by proper positioning, integration of massage techniques, implementation of calming
strategies and use of specific handling techniques. (Beachy, 2003; Ferrari et al., 2007; Hernandez-Reif, Diego, & Field, 2007; Hill, Engle, Jorgensen, Kralik, & Whitman, 2005; Short, Brooke-Brunn, Reeves, Yeager, & Thorpe, 1996; Campos, 1989). It is also reported that early intervention of the neonate improves long-term outcomes and quality of life. (Mahoney & Cohen, 2005). This case report assessed the impact of changes to infant development and organization in a neonatal intensive care unit (NICU) with implementation of select interventions by physical therapists, and reinforced by a multidisciplinary team.
Case Description : The subject of this report was an extremely low birth weight (1 pound, 2 ounces) infant born at 24 weeks gestational age. Significant medical complications included bronchopulmonary dysplasia, patent ductus arteriosus, hyperbilirubinemia, respiratory instability, and confinement to an incubator given inadequate thermoregulatory ability. Upon physical therapy examination at 31 weeks post-conceptional age, the infant presented with decreased maintenance of a flexed posture, hypotonia in the absence of purposeful movement, inability to self-calm, a right cervical rotation preference, and vital sign instability with position changes. Comprehensive, evidence-based interventions were implemented consisting of positioning techniques (swaddling and nesting), calming techniques (facilitated tuck and non-nutritive sucking) and massage. Determination of subject response to interventions, as well as neuromotor development and organization, occurred via the Morgan Neonatal Neurobehavioral Exam and vital sign monitoring.
Outcomes : Utilization of multimodal interventions revealed increased flexion and tone as evidenced by improved scores on the posture section of the Morgan Neonatal Neurobehavioral scale, improved ability to self-calm with facilitation, increased tolerance to changes in position as evidenced
by increased vital sign stability, slightly greater arousal, decreased touch aversion with handling as evidenced by decreased irritability, and reduced supplemental oxygen requirements. The subject’s right cervical rotation preference and limited respiratory endurance did not respond as anticipated despite intervention.
Discussion : Current findings demonstrate the benefits of early physical therapy intervention on a medically fragile infant in the NICU. Ongoing monitoring of the infant needs to occur to fully appreciate the degree to which developmental delay, as well as cognitive and behavioral disorders, were minimized or averted based upon the therapy offered. Additional investigation to identify more specific temporal guidelines for physical therapy involvement in the NICU would be of benefit.
KEYWORDS: premature infant and developmental disabilities, neuromotor development and physical therapy, Morgan Neonatal Neurobehavioral Examination.
Is a General Orthopedic Class Taught by Physical Therapists In A Community Hospital Effective in Providing Sustained Knowledge to Nurses?
Warner, Elizabeth M.; Montague, Diane C.; Zinko, Michael W. Physical Medicine, Bristol Hospital, Bristol, CT, United States.
Purpose/Hypothesis : The purpose of this project was to determine if the recently implemented class on general orthopedics given by physical therapists to graduate nurses new to our institution was effective. Feedback from new nurses revealed that the didactic portion of their training included less than 1 hour of lecture on the care of the patient with an orthopedic diagnosis. Our hypothesis was that an on-site training class specific to orthopedic care at our community hospital would result in improved nursing knowledge immediately after the class as well as one month later.
Self-Reported Measurements of Vital Signs by Physical Therapists
Harris, Katherine S.; Smith, Megan; Agnese, Kristen. Quinnipiac University, Hamden, CT, United States.
Purpose/Hypothesis : Vital signs are listed as part of a systems review that should be performed with all patients or clients at the start of physical therapy care. The purpose of this study was to survey physical therapists (PTs) who were members of the Connecticut Physical Therapy Association (CPTA) to determine the role in assessing vital signs and to determine if the assessment of vital signs has increased since past studies. The hypothesis stated that there would be an increase in the number of PTs who assess vital signs as compared to previous studies. It was also hypothesized that home health and acute care PTs would assess vital signs more frequently than PTs in other settings.
Number of Subjects : Members of the CPTA (Connecticut Physical Therapy Association),767, were invited to participate in an online survey.
Materials/Methods : The questionnaire consisted of demographic information and a 17-item survey about opinions regarding vital signs and assessment of vital signs. Data analysis included descriptive statistics consisting of frequency, return rate and response characteristics, measurement and use of vital signs, reasons given for not measuring vital signs and relationship between practice settings and the assessment of vital signs.
Results : One-hundred-four participants responded to the survey, for a response rate of fourteen percent. However, thirty-one surveys could not be used because the surveys were incomplete, therefore our sample size was 73. Usable survey questionnaires were received from 73 respondents (14% and of those 50.7% reported working in an outpatient facility. The
majority of respondents strongly agreed or agreed (71.2%) that measurement of HR, BP and RR should be included in physical therapy screening and 67.1% (strongly agree or agree) indicated that assessing vital signs on a routine basis in clinical practice was essential. The majority of respondents never assessed BP, HR or RR (37%, 31.5%, and 43.8%, respectively) as part of the examination of a new patient. Clinicians in home health, followed by acute care and nursing home (respectively), assessed vital signs the most while clinicians in the school system assessed vital signs the least.
Conclusions : Our data indicated that vital signs were infrequently measured in new patients and existing patients. However, the majority of participants generally agreed that vital signs should be assessed on a routine basis in clinical practice. Our data indicates that our hypotheses were correct and that more PTs are assessing vital signs than in previous studies and PTs in acute care, home health and nursing home settings are assessing vital signs the most. Clinical Relevance : Vital signs are a critical component to physical therapy evaluation and progression of treatment interventions. This small study indicated that vital signs are considered important though rarely obtained. Further research across care settings and geographic regions should be undertalen to assess barriers to vital sign monitoring.
KEYWORDS: vital signs.
Ascertaining the Effectiveness and Safety of Contact Low-Frequency Ultrasound (LFU) in an Acute, Post-Surgical Wound with Exposed Hardware
Hakim, Daniel2; Cooke, L. Ruth2; Myers, Barbara2; Horowitz, Jeffrey2; Hakim, Ellen W.1 1. Physical Therapy and Rehabilitation Science, University of Maryland School of Medicine, Baltimore, MD, United States. 2. Integrated Wound Healing Center, Franklin Square Hospital Center, MedStar Health, Baltimore, MD, United States.
Background & Purpose : It has been suggested that hardware exposure within a wound bed heralds a contaminated state and presents a deterrent to stable granulation tissue. With few existent guidelines predicting primary closure success atop exposed hardware, the safety and efficacy of second-generation healing technologies, namely LFU, under such circumstances have not been studied. This case report served to determine if LFU is a useful adjunct to negative pressure wound therapy (NPWT) in healing a wound with exposed hardware.
Case Description : The subject was a 54 year-old male referred to physical therapy (PT) status-post dehiscence of right tibiotalar calcaneal arthrodesis site. The patient’s past medical history included CAD, HTN, NIDDM and venous insufficiency. While best practice algorithms suggested favorable soft tissue reconstruction only upon hardware removal, maintenance of the implants was vital for bony fusion and joint stability. Consequently, irrigation and surgical debridement occurred to promote visualization of the wound bed, facilitate removal of necrosis and enable aggressive cleansing prior to use of NPWT. PT sessions included LFU and NPWT application 3 times per week. Operating parameters aligned with industry standards. Healing progress was ascertained via analysis of wound measurements, wound bed characteristics, wound drainage, and integrity of the periwound environment. Given wound location, need for compression, and use of a stabilizing orthosis, a new NPWT dressing component (for bridging) was initially attempted; however, difficulties with seal maintenance warranted resumption of traditional NPWT dressing approaches.
Outcomes : Within one week of post-operative debridement, the hardware was fully concealed by granulation tissue and wound depth decreased 19%. Emerging granulation tissue appeared stable and within four weeks wound depth decreased 53%.
Fall 2010 ● Volume I ● Number 1 JACPT41 Fall 2010 ● Volume I ● Number 1JACPT 42
Number of Subjects : All graduate nurses from 3/08 to 3/09 were included in this study. This was a total of 22 people. Materials/Methods : A written 10 question test (6 multiple choice and 4 true/false) was devised to be given pre- and then immediately post-class as well as again 1 month later. Students in the class were aware of the schedule for testing. Grades were recorded in an Excel Spreadsheet and statistics were compiled from this. Results : Scores show improvements in pre- to post-test scores as well as pre- to one month follow up scores. Pre-test mean was 57.7% with a range of 30%-90% and a standard deviation of ±13.43. Immediate post-test mean was 87.7% with a range of 80-100% and a standard deviation of ±6.85. One month follow up mean was 83.6% with a range of 70-100% and a standard deviation of ±8.39. Individual students averaged a postitive gain from pre- to post-test score of 28.6% and pre- to one month post-test scores of 25.9%. T test reveals statistical significance at the <0.05 level. Conclusions : A knowledge deficit has been reported by graduate nurses entering our facility regarding the care of the patient with an orthopedic diagnosis. Data collected shows improvements in test scores both immediately after and one month after the orthopedic class. These scores show knowledge gained is retained at least one month post-class. We recommend further study to assure that this knowledge will be retained for greater than a one month period as well as to determine if carryover to patient care is achieved. Clinical Relevance : True multi-disciplinary care is a model strived for by many practitioners. In order to achieve this, caregivers from across disciplines need to have an understanding of and respect for contributions made by all members of the healthcare team. By enhancing knowledge, teamwork and multidisciplinary care planning can be facilitated so that the goal of maximizing patient outcomes can be achieved.
KEYWORDS: orthopedics, post test, physical therapy.
Use of mobility protocol decreases the length of stay in the intensive care unit.
Berg, Beth2; McMahon, Peg2; Ronnebaum, Julie.1 1. Des Moines University, Des Moines, IA, United States. 2. Mercy Medical Center, Des Moines , IA, United States.
Purpose/Hypothesis : Background: Research has shown that immobilization for a critically ill patient leads to further complications and that physical therapy aids by improving function and may decrease the patients length of stay in the intensive care unit. Purpose: The purpose of this study is to assess the effectiveness of a prescribed mobility protocol for patients with respiratory failure in the intensive care unit. Additionally, we will assess the the implementation of the mobility protocol across different medical diagnosis. Hypothesis: We hypothesize that the mobility protocol will substantially decrease the length of stay in the intensive care unit as compared to those who received standard physical therapy treatments without the mobility protocol. Number of Subjects : Number of subjects: The study includes a stratified sampling of 100 patients that were admitted to the intensive care unit over the past year for the group with the implementation of the mobility protocol and the year prior to the implementation of the mobility protocol. The patients are divided into groups based on whether they received the mobility protocol or received standard physical therapy treatments without the mobility protocol. The groups include equal number of males and females. Materials/Methods : Materials/Methods: Patients admitted to the intensive care unit with respiratory distress were evaluated for specific criteria to be included in the mobiltiy protocol program. The mobility
protocol was administered by an acute care physical therapist. The mobility protocol includes transfer training, gait training abd therapeutic exercise along with specail settings on the ventilator. the physical therapy portion of the mobility protocol is administered 1 time per day after medical clearance. Some of the variables that are assessed include: the length of stay in the intensive care unit, time spent on the ventilator, lab reports, and vitals. Our study utilizes a single factor design for repeated measures, involving two groups of patients: those receiving the mobility protocol and those who did not. Results : Results: Preliminary results of the data, are indicative of improved gas exchange, decreased time on the ventialtor, and improved functional mobility. In addition, the length of stay appears to be minimized by 30% after the implementation of the mobiltiy protocol. Conclusions : Conclusion: There appears to be a positive correlation between the implementation of the mobility protocol and the reduced length of stay in the intensive care unit. This is an ongoing study to be completed by the end of the year and all of the results will be presented at the combined Sections Meeting. Clinical Relevance : Clinical Relevance: The use of the mobility protocol is beneficail in decreaseing the length of stay in the intensive care unit as well as decreasing further complications from immobility.
KEYWORDS: mobility protocol, intensive care, early mobility.
CSM10: Mobilizing Patients With Femoral Catheters in ICU: Clinical Considerations Christiane Perme, PT $45 Nonmember/$27 Member 0.15 CEUs (1.5 contact hours)
CSM10: Evidence-Based Medicine: Multiple Sclerosis Drugs and Exercise Implications Steven Kantor, DPT; Mary Jane Myslinski, EdD $98 Nonmember/$59 Member 0.325 CEUs (3.25 contact hours)
CSM10: Multidisciplinary Perspectives in the Management of Venous Thromboembolism Raegan Muller, MPT; Robyn Teply, PharmD, MBA $83 Nonmember/$50 Member 0.275 CEUs (2.75 contact hours)
Geriatrics Section: Clinical Management of Physical and Chemical Restraints Allison Lieberman, PT, MSPT, GCS; Hospital for Joint Diseases at NYU Langone Med Ctr, NY, NY $125 Nonmember/$75 Member/$67.50 Geriatric Section Member 0.5 CEUs (5.0 contact hours)
Progressive Multifocal Leukoencephalopathy in a Patient with AIDS Meredith E Drench, PT, PhD $49 Nonmember/$29 Member 0.2 CEUs (2 contact hours)
Promoting Early Mobility and Rehabilitation in the Intensive Care Unit - I Jennifer M. Zanni PT, MSPT, Department of Physical Medicine and Rehabilitation, Johns Hopkins Hospital, Baltimore, MD; Dale M. Needham MD, PhD, Department of Physical Medicine and Rehabilitation, Johns Hopkins Hospital, Baltimore, MD & Division of Pulmonary and Critical Care Medicine, Johns Hopkins University, Baltimore, MD $49 Nonmember/$29 Member 0.2 CEUs (2.0 contact hours)
Recognizing and Reporting Signs of Child Abuse Cynthia N Potter, PT, DPT, PCS $49 Nonmember/$29 Member 0.2 CEUs (2 contact hours)
Progressive Multifocal Leukoencephalopathy in a Patient with AIDS Meredith E Drench, PT, PhD $49 Nonmember/$29 Member 0.2 CEUs (2 contact hours)
Sciatica or Intermittent Vascular Claudication? John C Gray, PT, OCS, FAAOMPT $49 Nonmember/$29 Member 0.2 CEUs (2 contact hours)
The Integumentary System - Repair and Management: An Overview Joseph McCulloch, PT, PhD, FAPTA $49 Nonmember/$29 Member 0.2 CEUs (2 contact hours)
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