Association Rule Mining to Examine Predictors for the Outcome of Gait Rehabilitation Programs in Stroke Survivors.

ABSTRACT: This study presents a novel application of association rule data mining to determine the predictors of the response to locomotor training and home exercise for improving gait after stroke. The study was a secondary data analysis on the Locomotor Experience Applied Post Stroke Trial dataset. The association rule analysis was applied to analyze three interventions: (1) early locomotor training, (2) late locomotor training, and (3) home exercise program. The outcome variable was whether participants poststroke had greater than median improvement in the self-selected comfortable gait speed. Three types of predictors were investigated: (1) demographics, (2) behavioral and medical history, and (3) clinical assessments at baseline. Association rules were generated when they meet two criteria determined based on the data: 10% of support and 70% of confidence. The identified rules showed that the predictors of the response were different across the three interventions, which was inconsistent with the previous report based on traditional logistic regression. However, the rules were identified with high confidence but low support, indicating that they were reliable but did not appear often in the Locomotor Experience Applied Post Stroke Trial dataset. Further investigation of these rules with a larger sample size is warranted before applying them to clinical settings.

Use of thrust joint manipulation by student physical therapists in the United States during clinical education experiences.

Introduction: Thrust joint manipulation (TJM) is used in physical therapy practice and taught in entry-level curricula in the United States (US); however, research regarding implementation by student physical therapists (SPT)s is scarce. Objectives: To explore the use of TJM in SPT clinical education and factors influencing implementation. Methods: In a cross-sectional exploratory study, accredited physical therapy (PT) programs in the US (n = 227) were invited to participate in an electronic survey. SPTs were queried about TJM use and their clinical instructor's (CI) credentials during their final musculoskeletal clinical experience. Results: Forty-five programs participated in the study, consisting of 2,147 SPTs. Of those, 414 (19.3%) responses were used for analysis and 69% reported using TJM. SPTs who utilized TJM were more likely to have a CI who used TJM (p < 0.001) and/or had advanced certification/training in manual therapy (p < .001). A majority of students agreed or strongly agreed that their academic preparation provided them with clinical reasoning tools (84%) and psychomotor skills (69%) necessary to perform TJM. SPT use of TJM was facilitated by CI clinical practice, SPT competence in psychomotor skill, confidence in clinical reasoning, and practice setting. A main barrier to student use of TJM was CI lack of TJM use. Conclusions: Clinical practice of the CI appears to be a key factor in determining student use of TJM. Level of evidence: 2b.

An examination of muscle force control in individuals with a functionally unstable ankle.

Previous studies suggest that functional ankle instability (FAI) may be associated with deficits in the ability to sense muscle forces. We tested individuals with FAI to determine if they have reduced ability to control ankle muscle forces, which is a function of force sense. Our test was performed isometrically to minimize the involvement of joint position sense and kinesthesia. A FAI group and a control group were recruited to perform an ankle force control task using a platform-based ankle robot. They were asked to move a cursor to hit 24 targets as accurately and as fast as possible in a virtual maze. The cursor movement was based on the direction and magnitude of the forces applied to the robot. Participants underwent three conditions: pre-test (baseline), practice (skill acquisition), and post-test (post skill acquisition). The force control ability was quantified based on the accuracy performance during the task. The accuracy performance was negatively associated with the collision count of the cursor with the maze wall. The FAI group showed reduced ability to control ankle muscle forces compared to the control group in the pre-test condition, but the difference became non-significant in the post-test condition after practice. The change in performance before and after practice may be due to different degrees of reliance on force sense.

A Novel Interprofessional Faculty Approach for Integrating Oral Health Promotion Competencies into a Physical Therapist Curriculum.

AIMS: Oral health is integral to overall health and wellness. All healthcare providers can contribute to improving health by including an oral health screening (OHS) in the physical examination. The aims of this study were to 1) develop and test a novel oral health curriculum and 2) compare the effectiveness of two distinct methods of instruction, a) simulation with physical therapists (PT) and dental professional co-debriefing and b) video observation with PT faculty- only instruction. METHODS: PT students (n=202) completed one of two educational experiences to learn how to perform an OHS, evaluate oral health findings, provide oral health education, and make an appropriate dental referral. Four distinct patient-specific cases were tested. RESULTS: Results indicated multiple teaching strategies, including a simulation with co-debriefing, improved PT student performance in OHS. Between-case analysis indicated that students performed better in making appropriate referrals for pathology-based cases than preventative care-based cases. Conversely students' patient education was better for preventative cases than pathology-based cases. Curricular revisions improved student performance in providing relevant patient education. A comparison of student performance using simulation with co-debriefing vs video observation with PT faculty-only instruction found no statistically significant difference. CONCLUSIONS: This novel oral health curriculum is a useful approach for teaching PT and other health professions students how to execute an OHS.

Hip-ankle coordination during gait in individuals with chronic ankle instability.

Individuals with chronic ankle instability (CAI) may have sensorimotor impairments that affect control at the hip in addition to the ankle. The purpose of this study was to compare hip-ankle coordination and coordination variability between individuals with CAI and healthy individuals during walking. Ten healthy subjects and 10 subjects with CAI were recruited to walk on a treadmill. Hip-ankle coordination was quantified using vector coding, and coordination variability was quantified using coefficient of correspondence. We found significant between-group differences in hip-ankle coordination in the frontal plane around loading response (Control: 165.9±18.4°; CAI: 127.6±48.6°, p=0.04) and in the sagittal plane around the first half of mid stance (Control: 307.2±9.8°; CAI: 291.8±11.4°, p<0.01), terminal stance (Control: 301.1±13°; CAI: 313.4±10.9°, p=0.04), and pre-swing (Control: 243.9±35.2°; CAI: 329.9±57.8°, p<0.01). We also found significant between-group differences in hip-ankle coordination variability in the frontal plane around the second half of mid stance (Control: 0.54±0.06; CAI: 0.45±0.07, P<0.01). CAI is associated with alteration of hip-ankle coordination and coordination variability in stance phase during walking. Gait training is important in CAI rehabilitation, and the training should address altered hip-ankle coordination to reduce the risk of recurrent injuries.

Feedback and Feedforward Control During Walking in Individuals With Chronic Ankle Instability.

Study Design Controlled laboratory study. Background Recurrent ankle sprains associated with chronic ankle instability (CAI) occur not only in challenging sports but also in daily walking. Understanding whether and how CAI alters feedback and feedforward controls during walking may be important for developing interventions for CAI prevention or treatment. Objective To understand whether CAI is associated with changes in feedback and feedforward control when individuals with CAI are subjected to experimental perturbation during walking. Methods Twelve subjects with CAI and 12 control subjects walked on a treadmill while adapting to external loading that generated inversion perturbation at the ankle joint. Ankle kinematics around heel contact during and after the adaptation were compared between the 2 groups. Results Both healthy and CAI groups showed an increase in eversion around heel contact in early adaptation to the external loading. However, the CAI group adapted back toward the baseline, while the healthy controls showed further increase in eversion in late adaptation. When the external loading was removed in the postadaptation period, healthy controls showed an aftereffect consisting of an increase in eversion around heel contact, but the CAI group showed no aftereffect. Conclusion The results provide preliminary evidence that CAI may alter individuals' feedback and feedforward control during walking. J Orthop Sports Phys Ther 2016;46(9):775-783. Epub 5 Aug 2016. doi:10.2519/jospt.2016.6403.

Risk Adjustment for Lumbar Dysfunction: Comparison of Linear Mixed Models With and Without Inclusion of Between-Clinic Variation as a Random Effect.

BACKGROUND: Valid comparison of patient outcomes of physical therapy care requires risk adjustment for patient characteristics using statistical models. Because patients are clustered within clinics, results of risk adjustment models are likely to be biased by random, unobserved between-clinic differences. Such bias could lead to inaccurate prediction and interpretation of outcomes. PURPOSE: The purpose of this study was to determine if including between-clinic variation as a random effect would improve the performance of a risk adjustment model for patient outcomes following physical therapy for low back dysfunction. DESIGN: This was a secondary analysis of data from a longitudinal cohort of 147,623 patients with lumbar dysfunction receiving physical therapy in 1,470 clinics in 48 states of the United States. METHODS: Three linear mixed models predicting patients' functional status (FS) at discharge, controlling for FS at intake, age, sex, number of comorbidities, surgical history, and health care payer, were developed. Models were: (1) a fixed-effect model, (2) a random-intercept model that allowed clinics to have different intercepts, and (3) a random-slope model that allowed different intercepts and slopes for each clinic. Goodness of fit, residual error, and coefficient estimates were compared across the models. RESULTS: The random-effect model fit the data better and explained an additional 11% to 12% of the between-patient differences compared with the fixed-effect model. Effects of payer, acuity, and number of comorbidities were confounded by random clinic effects. LIMITATIONS: Models may not have included some variables associated with FS at discharge. The clinics studied may not be representative of all US physical therapy clinics. CONCLUSIONS: Risk adjustment models for functional outcome of patients with lumbar dysfunction that control for between-clinic variation performed better than a model that does not.

A survey of physical therapists' clinical practice patterns and adherence to clinical guidelines in the management of patients with whiplash associated disorders (WAD).

OBJECTIVES: To explore the clinical practice of physical therapists and examine adherence to clinical guidelines for treating patients with whiplash associated disorders (WAD). METHODS: A cross-sectional electronic survey was sent to 1484 licensed physical therapists from the Orthopedic Section of the American Physical Therapy Association and the American Academy of Orthopedic Manual Physical Therapists. The survey included demographic data and two clinical vignettes describing patients with acute and chronic WAD. The chi-square test was used to analyze responses. RESULTS: There were 291(19.6%) responses to the survey. Of those, 237 (81.4%) provided data for vignette 1 and 204 (70.1%) for vignette 2. One hundred and eighty (76.6%) respondents reported familiarity with evidence-based or clinical practice guidelines for treating patients with WAD. Of those, 71.5% (n = 128) indicated that they followed them more than 50% of the time. Therapists with an advanced certification were more likely to be familiar with clinical guidelines than those who were not certified (P<0.01). Responses indicated overall adherence to guidelines; however, there was a low utilization of quantitative sensory assessment, screening for psychological distress and some outcome measures. Significant differences in clinical practice (P<0.01) were found between therapists who were and were not familiar with guidelines and those with and without an advanced certification. DISCUSSION: Advanced certification and knowledge of guidelines appeared to play a role in the clinical practice of physical therapists treating patients with WAD. Further research is needed to explore factors affecting knowledge translation from research to clinical practice and to evaluate the outcomes of patients with WAD when clinical guidelines are applied in practice.

An exploratory examination of the association between altered lumbar motor control, joint mobility and low back pain in athletes.

BACKGROUND: Low back pain (LBP) is a common cause of lost playing time and can be a challenging clinical condition in competitive athletes. LBP in athletes may be associated with joint and ligamentous hypermobility and impairments in activation and coordination of the trunk musculature, however there is limited research in this area. OBJECTIVES: To determine if there is an association between altered lumbar motor control, joint mobility and low back pain (LBP) in a sample of athletes. MATERIALS AND METHODS: Fifteen athletes with LBP were matched by age, gender and body mass index (BMI) with controls without LBP. Athletes completed a questionnaire with questions pertaining to demographics, activity level, medical history, need to self-manipulate their spine, pain intensity and location. Flexibility and lumbar motor control were assessed using: active and passive straight leg raise, lumbar range of motion (ROM), hip internal rotation ROM (HIR), Beighton ligamentous laxity scale, prone instability test (PIT), observation of lumbar aberrant movements, double leg lowering and Trendelenburg tests. Descriptive statistics were compiled and the chi square test was used to analyze results. RESULTS: Descriptive statistics showed that 40% of athletes with LBP exhibited aberrant movements (AM), compared to 6% without LBP. 66% of athletes with LBP reported frequently self-manipulating their spine compared to 40% without LBP. No significant differences in motor control tests were found between groups. Athletes with LBP tended to have less lumbar flexion (63 ± 11°) compared to those without LBP (66 ± 13°). Chi-Square tests revealed that the AM were more likely to be present in athletes with LBP than those without (X2 = 4.66, P = 0.03). CONCLUSIONS: The presence of aberrant movement patterns is a significant clinical finding and associated with LBP in athletes.