"Definitely a Dark Time:" professional and ethical issues in post-acute care physical therapy during the COVID-19 pandemic.

BACKGROUND: Disproportionate effects of the SARS-CoV-2 (COVID-19) pandemic on older adults in post-acute care settings created many professional and ethical challenges for patients and healthcare providers. OBJECTIVE: The purpose of this study was to examine the professional and ethical issues of physical therapists (PTs) and physical therapist assistants (PTAs) in providing facility-based post-acute care in residential settings (skilled nursing facilities, inpatient rehabilitation facilities, and long-term acute care hospitals) during the COVID-19 pandemic. METHODS: A qualitative descriptive research design was used to explore professional and ethical issues during the COVID-19 pandemic. PTs and PTAs described their experiences during semi-structured interviews conducted virtually. Interview data was analyzed with reflexive thematic analysis. RESULTS: Thematic analysis produced 4 themes: facility-wide battle against infection and death, doing the best you can to provide care amidst COVID-19 constraints, promoting ethical good and doing the right thing, and a dark intense time. CONCLUSIONS: Professional and ethical constraints on providing care faced by PTs and PTAs during the COVID-19 pandemic can inform current and future clinical practice. Although some of the challenges faced by PTs and PTAs were unique to COVID-19, many problems represent preexisting systemic and organizational issues that were exacerbated by the pandemic.

Strategies to Support Learning of Gross Motor Tasks in Children with Autism Spectrum Disorder: A Scoping Review.

AIMS: Children with autism spectrum disorder (ASD) display motor difficulties that may impact social and communication interactions and participation in everyday activities. These difficulties may be related to a difference in the way they learn new skills. Therefore, strategies to support motor learning to optimize skill acquisition and retention may be beneficial. This scoping review described current motor learning strategies used to optimize acquisition, retention, transfer, and generalizability of motor tasks in children with ASD. METHODS: Three databases were searched from inception through 2021. Studies were included if they involved participants with ASD ≤ 18 years old, evaluated learning of a novel gross motor task, manipulated a motor learning variable, and were written in English. RESULTS: Twenty-two articles met eligibility criteria. Most articles examined strategies that manipulated the instruction of task, with few articles examining feedback or practice. Skill acquisition was the most represented motor learning outcome, with fewer studies examining retention, transfer, or generalizability. CONCLUSIONS: Positive results in 95% of the articles suggest that the use of support strategies to optimize motor learning is feasible and beneficial for children with ASD, and that modifications to instruction, feedback, and practice schedules should be considered in motor interventions.

Doing things you never imagined: Professional and ethical issues in the U.S. outpatient physical therapy setting during the COVID-19 pandemic.

OBJECTIVE: Despite being the most prevalent physical therapy practice setting in the United States, no literature to date has examined the professional and ethical issues faced by outpatient physical therapists during the COVID-19 pandemic. The purpose of this study was to explore professional and ethical issues experienced by outpatient physical therapists in the United States during the COVID-19 pandemic. DESIGN: An explorative semi-structured interview study using reflexive thematic analysis METHODS: Virtual semi-structured interviews explored physical therapists' experiences during COVID-19 in the OP setting. Data was analyzed using reflexive thematic analysis as described by Braun and Clarke. RESULTS: Respondents worked predominantly with patients with orthopaedic impairments. Six primary themes and associated subthemes were identified: 1) Disruption of routine professional and personal life. 2) Negative impacts on health and wellbeing (physical, mental, and social). 3) Barriers to relationships, communication, and providing quality care. 4) Telehealth as a safe option to increase access with opportunities and challenges. 5) Discomfort practicing in an environment of misinformation, mistrust, and divisiveness. 6) New & pre-existing ethical issues in the COVID-19 context. CONCLUSIONS: Results of this study indicate that physical therapists in the outpatient setting wrestled with critical questions regarding outpatient physical therapy practice during the COVID-19 pandemic: the role of touch in professional identity, challenges to the therapeutic alliance, effect of productivity and fiscal expectations and whether outpatient physical therapy is essential during public emergencies.

Goal Attainment Scaling in Outpatient Physical Therapy for Chronic Low Back Pain: Protocol for a Mixed Methods Study.

BACKGROUND: Patient engagement in decisions regarding their health care may lead to improved outcomes and improved adherence to treatment plans. While there are several options for involving patients in their health care, goal setting is a readily accessible method for physical therapists to increase the involvement of patients in health care decisions. Physical therapy goals are often generated by health care providers based on subjective information or standardized, fixed-item, patient-reported outcome measures. However, these outcome measures may not fully reveal the activity and participation limitations of individual patients. Goal attainment scaling (GAS) is a patient-centered approach that allows patients to set meaningful goals. While GAS has been shown to be reliable, valid, and sensitive to change in various populations, there is limited evidence in the United States on utilizing GAS in physical therapy for patients with chronic low back pain (LBP). OBJECTIVE: The purpose of this paper is to describe the protocol for a study to (1) develop a way to apply GAS procedures for physical therapists treating patients with chronic LBP in the United States and (2) test the feasibility of applying GAS procedures for chronic LBP in an outpatient physical therapy setting. METHODS: This study used a mixed methods design with 2 phases: qualitative and quantitative. The qualitative phase of the study employed focus groups of patients with chronic LBP to identify an inventory of goals that were important and measurable. A series of prompts was developed from this inventory to assist physical therapists in collaboratively establishing goals with patients in a clinical setting. The quantitative phase of the study pilot-tested the inventory developed in the qualitative phase in patients with chronic LBP to determine feasibility, reliability, validity, and responsiveness. We also plan to compare how well GAS reveals change over time relative to traditional, fixed-item, patient-reported measures. RESULTS: Phase 1 data collection was completed in June 2020, while data collection for phase 2 was performed between March 2021 and December 2021. We anticipate that this study will demonstrate that GAS can be implemented successfully by outpatient physical therapists, and that it will demonstrate clinically important changes in patients with chronic LBP. CONCLUSIONS: GAS represents an opportunity for patient-centered care in the physical therapy management of chronic LBP. While GAS is not new, it has never been studied in real-world physical therapy for chronic LBP in a clinical setting. Due to unique time and productivity constraints, for GAS to be successfully implemented in this environment, we must demonstrate that clinicians can be trained efficiently and reliably, that GAS can be implemented in a clinical setting in under 15 minutes, and that GAS is able to detect clinically meaningful changes in patient outcomes. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/32457.

Goal attainment scaling for patients with low back pain in rehabilitation: A systematic review.

BACKGROUND AND AIMS: Goal attainment scaling (GAS) has been widely applied to chronic conditions; however, only recently has it been used for patients with low back pain (LBP). The objectives of this systematic review were to (a) examine the characteristics and rigor of published studies of GAS in the rehabilitation of patients with LBP, (b) describe how GAS has been applied in patients with LBP, and (c) evaluate the responsiveness and validity of GAS as an outcome measure in patients with LBP. METHODS: A systematic search of the CINAHL, PubMed, and MEDLINE databases was performed (1968 and 1 September 2020) in addition to hand searching. Studies including GAS procedures in patients with LBP during rehabilitation were included in the review. Two authors independently selected studies for inclusion and determined levels of evidence using the Oxford Levels of Evidence and rated each study for quality using the Newcastle-Ottawa scale and reporting transparency using the STROBE statement checklist. RESULTS: Six Level IV and one Level III/IV study were included in this review (search produced 248 studies for review). These studies assessed GAS feasibility, validity, sensitivity, and association with other outcome measures in patients with LBP. Findings suggest that patients with LBP are able to identify and set individualized goals during GAS, while GAS may be more sensitive to change and may measure different aspects of the patient experience as compared with fixed-item patient-reported measures. Additionally, GAS may have a therapeutic effect while improving patient outcomes and may be associated with patient satisfaction. CONCLUSION: Based on this review, GAS shows promise as a feasible patient-centered measure that may be more responsive to change than traditional outcome measures. However, GAS has been inadequately developed and validated for use during rehabilitation in patients with LBP.

Professional and Ethical Issues in United States Acute Care Physical Therapists Treating Patients With COVID-19: Stress, Walls, and Uncertainty.

OBJECTIVE: To the authors' knowledge, no peer-reviewed research has explored professional and ethical issues encountered by physical therapists in treating patients with COVID-19. The purpose of this study was to explore the experiences of physical therapists regarding the professional and ethical issues they encountered during the COVID-19 pandemic. METHODS: The current study used reflexive thematic analysis, a qualitative research design developed by Braun and Clarke, to analyze individual interviews. RESULTS: Analysis of the coded interviews produced 6 primary themes (uncertainty, physical therapist's role, ethical dilemmas and moral distress, emotions, providing care and working conditions, and management and leadership influence) and associated subthemes. CONCLUSION: Physical therapists reported numerous professional and ethical issues across the individual, organizational, and societal realms during the COVID-19 pandemic. This study highlights the need for education and resources to prepare physical therapists for professional and ethical issues encountered during pandemics. Specifically, there is a need to define the physical therapist's role in pandemics and prepare physical therapy personnel for dealing with ethical issues, stress, uncertainty, and organizational changes associated with pandemics. Ethical guidelines would support organizations in delineating fair processes for triage and allocation of scarce resources for acute care physical therapy during health care emergencies. IMPACT: The COVID-19 pandemic has produced significant changes in health care and physical therapist practice. This study reports results of the first, to our knowledge, research study focusing on professional and ethical issues experienced by physical therapists in acute care during the COVID-19 pandemic. As the United States faces an unprecedented spike in COVID-19 cases and deaths, results of this study may contribute to physical therapists' preparation for and response to professional and ethical issues encountered in acute care during the pandemic.

Comparison of the firefighter candidate physical ability test to weight lifting exercises using electromyography.

BACKGROUND: Muscular strength and endurance are important attributes for structural firefighting. Matching resistance exercises to firefighter job demands is not well-established. OBJECTIVE: This study compared the electromyographic (EMG) activity of major muscles during the Candidate Physical Ability Test (CPAT) and weight lifting exercises in firefighters. METHODS: A repeated measures study was conducted in 13 full-duty career firefighters (1 F, 12 M; age 18-44 years). Participants completed seven weight lifting exercises at a university laboratory. They separately completed the CPAT at a firefighting training grounds. During each activity, surface EMG (% maximum voluntary isometric contraction - MVIC) of major muscle groups was recorded and compared between exercises and CPAT. RESULTS: No difference in EMG activity was observed between exercises and CPAT for the deltoid, trapezius, lumbar multifidus, gluteal, and biceps femoris muscles. EMG activity was significantly greater during the CPAT for the abdominal obliques (32.3% ±27.7% vs. 12.1% ±8.3%, p <  0.001) and for the latissimus dorsi (21.8% ±25.1% vs. 11.4% ±7.7%, p <  0.001). CONCLUSIONS: Standard weight lifting and abdominal oblique exercises should be incorporated into resistance training programs for firefighters.

Factors associated with upper extremity contractures after cervical spinal cord injury: A pilot study.

OBJECTIVE: To examine the prevalence of joint contractures in the upper limb and association with voluntary strength, innervation status, functional status, and demographics in a convenience sample of individuals with cervical spinal cord injury to inform future prospective studies. DESIGN: Cross-sectional convenience sampled pilot study. SETTING: Department of Veterans Affairs Research Laboratory. PARTICIPANTS: Thirty-eight participants with cervical level spinal cord injury. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Contractures were measured with goniometric passive range of motion. Every joint in the upper extremity was evaluated bilaterally. Muscle strength was measured with manual muscle testing. Innervation status was determined clinically with surface electrical stimulation. Functional independence was measured with the Spinal Cord Independence Measure III (SCIM-III). RESULTS: Every participant tested had multiple joints with contractures and, on average, participants were unable to achieve the normative values of passive movement in 52% of the joints tested. Contractures were most common in the shoulder and hand. There was a weak negative relationship between percentage of contractures and time post-injury and a moderate positive relationship between percentage of contractures and age. There was a strong negative correlation between SCIM-III score and percentage of contractures. CONCLUSIONS: Joint contractures were noted in over half of the joints tested. These joint contractures were associated with decreased functional ability as measured by the SCIM-III. This highlights the need the need for detailed evaluation of the arm and hand early after injury as well as continued monitoring of joint characteristics throughout the life course of the individual with tetraplegia.

Scapular and humeral movement patterns of people with stroke during range-of-motion exercises.

BACKGROUND AND PURPOSE: In people with stroke, range-of-motion (ROM) exercises may contribute to hemiparetic shoulder pain, but the underlying mechanisms are unknown. This study examined scapular and humeral movement patterns in people with poststroke hemiparesis as they performed commonly prescribed ROM exercises. METHODS: Using kinematic techniques, we studied 13 people with hemiparesis, both with and without pain, as they performed 3 commonly prescribed ROM exercises: person-assisted ROM, self-assisted ROM, and cane-assisted ROM. Their data were compared with those of a group of 12 matched control subjects performing scapular plane shoulder elevation, using mixed-model ANOVAs. Correlation analyses were used to examine the relationship between participants' ratings of pain and kinematic data. RESULTS: The hemiparetic group had mild pain at rest that increased during the performance of the exercises. During shoulder elevation, humeral external rotation in the hemiparetic group was decreased in all 3 ROM exercises compared with that in the control group. Scapular upward rotation in the hemiparetic group was decreased for the person-assisted ROM exercise only. No differences in scapular tilt were found between groups. The extent of movement abnormalities was not related to pain severity. DISCUSSION AND CONCLUSIONS: People with hemiparesis had altered scapular and humeral movement patterns and increased shoulder pain when performing the ROM exercises. These data can assist clinicians in making decisions regarding which exercises to prescribe to preserve shoulder motion and prevent contractures in this population.

Scapula and humeral movement patterns and their relationship with pain: A preliminary investigation.

PURPOSE: Altered movement patterns may contribute to this shoulder pain following stroke. The purpose of this study was to examine scapular and humeral movement patterns in people with hemiparetic shoulder pain (HSP), and to explore the relationships between pain and these movement patterns. METHODS: Kinematic data from nine participants with HSP and twelve matched controls were collected as they performed scapular plane shoulder elevation. Correlation analyses were used to examine relationships between participants' ratings of pain and kinematic data. RESULTS: The HSP group had decreased humeral external rotation compared to the control group. Despite a trend toward decreased scapular upward rotation, there was considerable variation in scapular upward rotation movement patterns across the participants with HSP. Scapular tilt was not different between groups. There was an inverse relationship between pain and scapular upward rotation, indicating that those with more pain had less scapular upward rotation. CONCLUSIONS: People with HSP demonstrated scapular and humeral movement patterns that differed from controls, where some of the altered movement patterns were related to reported pain levels. Rehabilitation management of people with HSP may be improved by careful assessment of scapulohumeral movement patterns and treatments aimed at normalizing these patterns.

Restricted active range of motion at the elbow, forearm, wrist, or fingers decreases hand function.

The purpose of this study was to investigate how restricting active range of motion (AROM) at various upper extremity segments influenced hand function in younger and older populations. Eighteen younger (27+/-4yr) and 15 older subjects (67+/-6yr) participated. A repeated-measures study design was used with six test conditions: one condition without AROM restrictions and five conditions with AROM restrictions (shoulder, elbow, forearm, wrist, fingers). AROM was restricted using customized braces. Hand function was measured using total time to complete the Jebsen-Taylor Test of Hand Function. We found that the older group took longer than the younger group to complete the Jebsen, and that restricting AROM at the elbow, forearm, wrist, or fingers resulted in decreased hand function for both groups. Because restricted AROM is a consequence of a variety of diseases and conditions, it is important to know how restricted AROM at multiple upper extremity segments affects hand function.

A comparison of serratus anterior muscle activation during a wall slide exercise and other traditional exercises.

STUDY DESIGN: Single-group repeated-measures design. OBJECTIVES: To investigate the ability of the wall slide exercise to activate the serratus anterior muscle (SA) at and above 90 degrees of humeral elevation. BACKGROUND: Strengthening of the SA is a critical component of rehabilitation for patients with shoulder impingement syndromes. Traditional SA exercises have included scapular protraction exercises such as the push-up plus. These exercises promote activation of the SA near 90 degrees of humeral elevation, but not in positions above 90 degrees where patients typically experience pain. METHODS AND MEASURES: Twenty healthy subjects were studied performing 3 exercises: (1) wall slide, (2) plus phase of a wall push-up plus, and (3) scapular plane shoulder elevation. Three-dimensional position of the thorax, scapula, and humerus and muscle activity from the SA, upper and lower trapezius, and latissimus dorsi were recorded. The magnitudes of activation for each muscle at 90 degrees, 120 degrees, and 140 degrees of humeral elevation were quantified from EMG records. Repeated-measures analyses of variance were used to determine the degree to which the different exercises activated the SA at the 3 humeral positions. RESULTS: The intensity of SA activity was not significantly different between the 3 exercises at 90 degrees of humeral elevation (P = .40). For the wall slide and scapular plane shoulder elevation exercises, SA activity increased with increasing humeral elevation angle (P = .001), with no significant differences between the 2 exercises (P = .36). CONCLUSION: The wall slide is an effective exercise to activate the SA muscle at and above 90 degrees of shoulder elevation. During this exercise, SA activation is not significantly different from SA activation during the push-up plus and scapular plane shoulder elevation, 2 exercises previously validated in the literature.