Advancing Rehabilitation Paradigms for Older Adults in Skilled Nursing Facilities: An Effectiveness-Implementation Hybrid Type 1 Clinical Trial Protocol.

OBJECTIVE: Skilled nursing facility rehabilitation is commonly required to address hospital-associated deconditioning among older adults with medical complexity. In skilled nursing facilities, standard-of-care rehabilitation focuses on low-intensity interventions, which are not designed to sufficiently challenge skeletal muscle and impart functional improvements. In contrast, a high-intensity resistance training approach (IntenSive Therapeutic Rehabilitation for Older NursinG homE Residents; i-STRONGER) in a single-site pilot study resulted in better physical function among patients in skilled nursing facilities. To extend this work, an effectiveness-implementation hybrid type 1 design, cluster-randomized trial will be conducted to compare patient outcomes between 16 skilled nursing facilities utilizing i-STRONGER principles and 16 Usual Care sites. METHODS: Clinicians at i-STRONGER sites will be trained to deliver i-STRONGER as a standard of care using an implementation package that includes a clinician training program. Clinicians at Usual Care sites will continue to provide usual care. Posttraining, changes in physical performance (eg, gait speed, Short Physical Performance Battery scores) from patients' admission to discharge will be collected over a period of 12 months. The Reach, Effectiveness, Adoption, Implementation, and Maintenance framework will be used to evaluate i-STRONGER effectiveness and factors underlying successful i-STRONGER implementation. Effectiveness will be evaluated by comparing changes in physical function between study arms. Reach (proportion of patients treated with i-STRONGER), adoption (proportion of clinicians utilizing i-STRONGER), implementation (i-STRONGER fidelity), and maintenance (i-STRONGER sustainment) will be concurrently quantified and informed by clinician surveys and focus groups. IMPACT: This effectiveness-implementation hybrid type 1 cluster-randomized trial has the potential to shift rehabilitation care paradigms in a nationwide network of skilled nursing facilities, resulting in improved patient outcomes and functional independence. Furthermore, evaluation of the facilitators of, and barriers to, implementation of i-STRONGER in real-world clinical settings will critically inform future work evaluating and implementing best rehabilitation practices in skilled nursing facilities.

"We're not broken. We're human." A qualitative meta-synthesis of health-care providers' experiences participating in well-being programs.

INTRODUCTION: Protecting health-care provider (HCP) well-being is imperative to preserve health-care workforce capital, performance, and patient care quality. Limited evidence exists for the long-term effectiveness of HCP well-being programs, with less known about physiotherapists specifically. PURPOSE: To review and synthesize qualitative research describing experiences of HCP, generate lessons learned from the greater population of HCP participating in workplace well-being programs, and then to inform programs and policies for optimizing psychological well-being in an understudied population of physiotherapists. METHODS: This qualitative meta-synthesis included a systematic literature search conducted in September 2020; critical appraisal of results; and data reduction, re-categorizing, and thematic extraction (reciprocal translation) with interpretive triangulation. RESULTS: Twenty-five papers met the inclusion criteria. Participants included physicians, nurses, and allied health providers. All programs targeted the individual provider and included psychoeducational offerings, supervision groups, coaching, and complementary therapies. Four themes were constructed: 1) beneficial outcomes across a range of programs; 2) facilitators of program success; 3) barriers to program success; and 4) unmet needs driving recommendations. CONCLUSIONS: The findings enhance our understanding of diverse individual-level programs to address HCP well-being. Beneficial outcomes were achieved across program types with system-level support proving critical; however, HCP described barriers to program success (HCP characteristics, off-site programs, institutional culture) and remaining needs (resources, ethical dissonance) left unaddressed. Organizations should offer individual-level programs to support physiotherapists in the short term while pursuing long-term, system-level change to address drivers of well-being.

Gait mechanics are influenced by quadriceps strength, age, and sex after total knee arthroplasty.

Although most patients are satisfied with outcomes after total knee arthroplasty (TKA), many retain preoperative altered gait mechanics. Identifying patient characteristics associated with gait mechanics will improve rehabilitation strategies and enhance our understanding of movement disorders. Therefore, the purpose of this study was to identify which patient characteristics are related to gait mechanics in the surgical limb during walking post-TKA. Patient characteristics included age, body mass, sex, quadriceps strength, self-reported function, and knee pain. General linear regression was used to compare patient characteristics associated with gait mechanics, after controlling for gait speed, functional capacity and time from surgery. We tested 191 patients cross-sectionally at 6-24 months after primary, unilateral TKA. Quadriceps weakness in the surgical limb was associated with less peak vertical ground reaction force (PvGRF) (ß = .245, p = .044), knee extension moment (ß = .283, p = .049), and knee extension excursion (ß = .298, p = .038). Older age (ß = .168, p = .050) was associated with less PvGRF. Quadriceps strength in the nonsurgical limb (ß = -.357, p = .021) was associated with greater knee extension excursion in the surgical limb. Females with TKA (ß = -.276, p = .007) had less knee flexion excursion compared to males. Faster gait speed was also associated with greater PvGRF (ß = .585, p < .001), knee extensor moment (ß = .481, p < .001), and knee flexion excursion (ß = .318, p < .001). Statement of Clinical Significance: This study showed quadriceps weakness, slower gait speed, older age and being female were related to altered gait mechanics post-TKA. These findings will help clinicians better educate patients and develop targeted interventions for improving care in patients post-TKA.

Examination of the Validity of a Clinical Prediction Rule to Identify Patients With Shoulder Pain Likely to Benefit From Cervicothoracic Manipulation.

Study Design Secondary analysis of a randomized controlled trial. Background Prognostic variables identifying patients with shoulder pain who are likely to respond to cervicothoracic manipulation have been reported; however, they have yet to be validated. Objective To examine the validity of previously reported prognostic variables in predicting which patients with shoulder pain will respond to cervicothoracic manipulation. Methods Participants (n = 140) with a report of shoulder pain were randomly assigned to receive either 2 sessions of range-of-motion exercises plus 6 sessions of stretching and strengthening exercises (exercise group), or 2 sessions of cervicothoracic manipulation and range-of-motion exercises followed by 6 sessions of stretching and strengthening exercise (manipulative-therapy-plus-exercise group). Outcomes of disability (Shoulder Pain and Disability Index, shortened version of the Disabilities of the Arm, Shoulder and Hand Questionnaire) and pain (numeric pain-rating scale) were collected at baseline, 1 week, 4 weeks, and 6 months. Time, treatment group, status of predictor variables, and 2-way and 3-way interactions were analyzed using linear mixed models with repeated measures. Results There were no significant 3-way interactions for either disability (P = .27) or pain scores (P = .70) for time, group, and predictor status for any of the predictor variables. Conclusion The results of the current study did not validate the previously identified prognostic variables; therefore, we cannot support using these in clinical practice. Further updating of the existing prediction rule may be warranted and could potentially result in new prognostic variables and improved generalizability. Limitations of the study were a mean duration of symptoms of greater than 2 years and a loss to follow-up of 19% at 6 months. Level of Evidence Prognosis, level 1b. Trial prospectively registered March 30, 2012 at www.clinicaltrials.gov (NCT01571674). J Orthop Sports Phys Ther 2017;47(4):252-260. Epub 3 Mar 2017. doi:10.2519/jospt.2017.7100.

Cervicothoracic Manual Therapy Plus Exercise Therapy Versus Exercise Therapy Alone in the Management of Individuals With Shoulder Pain: A Multicenter Randomized Controlled Trial.

Study Design Multicenter randomized controlled trial. Background Cervicothoracic manual therapy has been shown to improve pain and disability in individuals with shoulder pain, but the incremental effects of manual therapy in addition to exercise therapy have not been investigated in a randomized controlled trial. Objectives To compare the effects of cervicothoracic manual therapy and exercise therapy to those of exercise therapy alone in individuals with shoulder pain. Methods Individuals (n = 140) with shoulder pain were randomly assigned to receive 2 sessions of cervicothoracic range-of-motion exercises plus 6 sessions of exercise therapy, or 2 sessions of high-dose cervicothoracic manual therapy and range-of-motion exercises plus 6 sessions of exercise therapy (manual therapy plus exercise). Pain and disability were assessed at baseline, 1 week, 4 weeks, and 6 months. The primary aim (treatment group by time) was examined using linear mixed-model analyses and the repeated measure of time for the Shoulder Pain and Disability Index (SPADI), the numeric pain-rating scale, and the shortened version of the Disabilities of the Arm, Shoulder and Hand questionnaire (QuickDASH). Patient-perceived success was assessed and analyzed using the global rating of change (GROC) and the Patient Acceptable Symptom State (PASS), using chi-square tests of independence. Results There were no significant 2-way interactions of group by time or main effects by group for pain or disability. Both groups improved significantly on the SPADI, numeric pain-rating scale, and QuickDASH. Secondary outcomes of success on the GROC and PASS significantly favored the manual therapy-plus-exercise group at 4 weeks (P = .03 and P<.01, respectively) and on the GROC at 6 months (P = .04). Conclusion Adding 2 sessions of high-dose cervicothoracic manual therapy to an exercise program did not improve pain or disability in patients with shoulder pain, but did improve patient-perceived success at 4 weeks and 6 months and acceptability of symptoms at 4 weeks. More research is needed on the use of cervicothoracic manual therapy for treating shoulder pain. Level of Evidence Therapy, level 1b. Prospectively registered March 30, 2012 at www.ClinicalTrials.gov (NCT01571674). J Orthop Sports Phys Ther 2016;46(8):617-628. doi:10.2519/jospt.2016.6319.