Becoming an anti-racist interprofessional healthcare organization: Our journey.

The COVID-19 pandemic amplified the egregious disproportionate burden of disease based on race, ethnicity, and failure of organizations to address structural racism. This paper describes a journey by members of the National Academies of Practice (NAP) who came together to address diversity, equity, and inclusion (DEI). Through collaborative efforts, a virtual, interactive workshop was designed and delivered at NAP's 2021 Virtual Forum to facilitate discussions about DEI priorities across professions and to initiate a sustainable action plan toward achieving inclusive excellence. Resulting discoveries and reflections led us to the essential question: can we truly become an anti-racist interprofessional healthcare organization?

Individuals With and Without Low Back Pain Use Different Motor Control Strategies to Achieve Spinal Stiffness During the Prone Instability Test.

BACKGROUND: The prone instability test is used to identify individuals with low back pain (LBP) who would benefit from trunk stabilization exercises. Although activity from muscles during the leg-raising portion of the prone instability test theoretically enhances spinal stiffness and reduces pain, evidence for this is lacking. OBJECTIVES: To compare and contrast (1) pain and stiffness changes between prone instability testing positions, and (2) muscle activation patterns during the prone instability test leg raise in individuals with and without LBP. METHODS: Participants with (n = 10) and without (n = 10) LBP participated in this laboratory case-control study. Spinal stiffness was measured using a beam-bending model and 3-D kinematic data. Stiffness changes were compared across the test positions and between groups. Surface electromyographic data were collected on trunk and limb musculature. Principal-component analysis was used to extract muscle synergies. RESULTS: Spinal stiffness increased across testing positions in all participants (P<.05). Participants with LBP experienced reduced pain during the test (P<.001). No between-group difference was found in spinal stiffness during leg raising during the test (P>.05). Participants without LBP used 3 muscle synergies during the leg raise and participants with LBP used 2 muscle synergies. CONCLUSION: Spinal stiffness increased in all participants; however, participants without LBP demonstrated a muscle synergy pattern where each synergy was associated with a distinct function of the prone instability test. Participants with LBP used a more global stabilization pattern, which may reflect a maladaptive method of enhancing spinal stability. J Orthop Sports Phys Ther 2019;49(12):899-907. Epub 3 Aug 2019. doi:10.2519/jospt.2019.8577.

Item Distribution in the Berg Balance Scale: A Problem for Use With Community-Living Older Adults.

BACKGROUND AND PURPOSE: The Berg Balance Scale (BBS) is a commonly used clinical test measure to determine balance performance and fall risk. However, a ceiling effect of the BBS has been reported in studies of older adults with relatively higher levels of physical performance. The underlying reason for this ceiling effect may be that the task items in the BBS are insufficiently challenging to discriminate individuals with less severe balance limitations. The purpose of this study was to investigate the unidimensional construct, item difficulty hierarchy, and item distribution of the BBS in order to determine its usefulness among community-living older adults (CLOAs). METHODS: CLOA volunteers (N = 112; 34 men, 78 women), mean age 82.4 years (SD = 7.9) (range, 65-99 years), were tested with the BBS by physical therapy faculty and students from Drexel University. Rasch principal component analysis (PCA) was used to investigate the dimensionality of the BBS, and the Rasch rating scale model was used to determine the item difficulty hierarchy and distribution. RESULTS: Rasch PCA confirmed the unidimensional construct of the BBS as a balance ability test. Two items failed to fit the Rasch model, "sitting unsupported" and "standing unsupported with eyes closed." Item difficulty hierarchy indicated that the most difficult test item was "stand on one leg" and the easiest was "sitting unsupported." Item and person measures ranged from -4.35 to 2.66 and -1.77 to 6.58 logits, respectively. Person and item separation indexes were 2.10 and 6.41 (reliabilities of 0.82 and 0.98, respectively). CONCLUSIONS: Comparing the item difficulty and person ability, the balance ability of the CLOAs exceeded the difficulty of the test items, rendering it less useful for detecting balance ability and fall risk in CLOAs. More challenging test items, or selection of a different balance test, are recommended for use with this population.

Interrater and Test-Retest Reliability and Minimal Detectable Change of the Balance Evaluation Systems Test (BESTest) and Subsystems With Community-Dwelling Older Adults.

BACKGROUND AND PURPOSE: Falls are a common cause of injuries and hospital admissions in older adults. Balance limitation is a potentially modifiable factor contributing to falls. The Balance Evaluation Systems Test (BESTest), a clinical balance measure, categorizes balance into 6 underlying subsystems. Each of the subsystems is scored individually and summed to obtain a total score. The reliability of the BESTest and its individual subsystems has been reported in patients with various neurological disorders and cancer survivors. However, the reliability and minimal detectable change (MDC) of the BESTest with community-dwelling older adults have not been reported. The purposes of our study were to (1) determine the interrater and test-retest reliability of the BESTest total and subsystem scores; and (2) estimate the MDC of the BESTest and its individual subsystem scores with community-dwelling older adults. METHODS: We used a prospective cohort methodological design. Community-dwelling older adults (N = 70; aged 70-94 years; mean = 85.0 [5.5] years) were recruited from a senior independent living community. Trained testers (N = 3) administered the BESTest. All participants were tested with the BESTest by the same tester initially and then retested 7 to 14 days later. With 32 of the participants, a second tester concurrently scored the retest for interrater reliability. Testers were blinded to each other's scores. Intraclass correlation coefficients [ICC(2,1)] were used to determine the interrater and test-retest reliability. Test-retest reliability was also analyzed using method error and the associated coefficients of variation (CVME). MDC was calculated using standard error of measurement. RESULTS: Interrater reliability (N = 32) of the BESTest total score was ICC(2, 1) = 0.97 (95% confidence interval [CI], 0.94-0.99). The ICCs for the individual subsystem scores ranged from 0.85 to 0.94. Test-retest reliability (N = 70) of the BESTest total score was ICC(2,1) = 0.93 (95% CI, 0.89-0.96). ICCs for the individual subsystem scores ranged from 0.72 to 0.89. The CVME (N = 70) of the BESTest total score was 4.1%. The CVME for the subsystem scores ranged from 5.0% to 10.7%. MDC (N = 70) for the BESTest total score at the 95% CI was 7.6%, or 8.2 points. MDC at the 95% CI for subsystem scores ranged from 11.7% to 19.0% (2.1-3.4 points). DISCUSSION: Results demonstrated generally good to excellent interrater and test-retest reliability in both the BESTest total and subsystem scores with community-dwelling older adults. CONCLUSIONS: The BESTest total and individual subsystem scores demonstrate good to excellent interrater and test-retest reliability with community-dwelling older adults. A change of 7.6% (8.2 points) or more in the BESTest total and a percentage change ranged from 11.7% to 19.0% (2.1-3.4 points) in the subsystem scores are suggested for clinicians to be 95% confident of true change when evaluating change in this population.

Kinematic characterization of clinically observed aberrant movement patterns in patients with non-specific low back pain: a cross-sectional study.

BACKGROUND: Clinical observation of aberrant movement patterns during active forward bending is one criterion used to identify patients with non-specific low back pain suspected to have movement coordination impairment. The purpose of this study was to describe and quantify kinematic patterns of the pelvis and trunk using a dynamics systems approach, and determine agreement between clinical observation and kinematic classification. METHOD: Ninety-eight subjects performed repeated forward bending with clinical observation and kinematic data simultaneously collected. Kinematic data were plotted using angle-angle, coupling-angle, and phase-plane diagrams. Accuracy statistics in conjunction with receiver operating characteristic curves were used to determine agreement between clinical observation and kinematic patterns. RESULTS: Kinematic patterns were consistent with clinical observation and definitions of typical and aberrant movement patterns with moderate agreement (kappa = 0.46-0.50; PABAK = 0.49-0.73). Early pelvic motion dominance in lumbopelvic coupling-angle diagram ≥59° within the first 38% of the movement represent observed altered lumbopelvic rhythm. Frequent disruptions in lumbar spine velocity represented by phase-plane diagrams with local minimum occurrences ≥6 and sudden decoupling in lumbopelvic coupling-angle diagrams with sum of local minimum and maximum occurrences ≥15 represent observed judder. CONCLUSION: These findings further define observations of movement coordination between the pelvis and lumbar spine for the presence of altered lumbopelvic rhythm and judder. Movement quality of the lumbar spine segment is key to identifying judder. This information will help clinicians better understand and identify aberrant movement patterns in patients with non-specific low back pain.

Clinical observation of standing trunk movements: what do the aberrant movement patterns tell us?

STUDY DESIGN: Clinical measurement, cross-sectional study. OBJECTIVE: To investigate the reliability of observation of aberrant movement patterns (altered lumbopelvic rhythm, deviation from sagittal plane, instability catch or judder, and painful arc of motion) and to determine whether each pattern is associated with current low back pain (LBP). BACKGROUND: Identification of aberrant movement patterns during trunk motion is an important component of subclassifying patients with LBP and prescribing evidence-based interventions. However, reported reliability for observation of specific aberrant patterns is low, and observation of any aberrant pattern (clinical definition of positive test) has ranged from poor to moderate. In addition, the validity of the association of clinical observations of aberrant movements during forward bending with LBP or dysfunction has yet to be determined. METHODS: Experienced physical therapists simultaneously observed trunk movements of 102 subjects with no LBP, current LBP, or history of LBP. Kappa statistics were used to evaluate interrater agreement in identifying different types of aberrant patterns. Associations were used to determine the validity of the hypothesized relationship between aberrant patterns and LBP. RESULTS: Interrater reliability of identifying the different types of aberrant patterns in subjects with LBP ranged from fair (κ = 0.35; 95% confidence interval: 0.00, 0.71) to excellent (κ = 0.89; 95% confidence interval: 0.69, 1.00). Using the clinical definition of 1 observation of any aberrant motion, interrater agreement was substantial (κ = 0.65; 95% confidence interval: 0.00, 1.00). Significant association was found between judder, deviation, and LBP. The frequency of observed aberrant patterns was significantly associated with LBP. CONCLUSION: Simultaneous observation for specific aberrant movement patterns suggests that identification can be performed with at least fair interrater agreement, and observation of any pattern with substantial agreement. Aberrant patterns are more frequently observed in patients with current complaints of LBP; however, they also appear in individuals with a history of LBP and no LBP.

Comparative immunolocalisation of perlecan, heparan sulphate, fibroblast growth factor-18, and fibroblast growth factor receptor-3 and their prospective roles in chondrogenic and osteogenic development of the human foetal spine.

PURPOSE: A comparative immunolocalisation study of perlecan, HS, FGF-18 and FGFR-3 in the 12-20-week gestational age human foetal spine was undertaken to identify spatiotemporal associations between these components to provide insights into prospective roles in spinal development. METHODS: Comparative immunolocalisations of matrix and cell associated components in Histochoice-fixed paraffin-embedded human foetal spinal tissues. RESULTS: The 12-14-week-old human foetal spine was a predominantly cartilaginous structure with the discs displaying a relative paucity of proteoglycan compared to the adjacent cartilaginous vertebral rudiments, notochordal remnants were also observed. HS and perlecan had a widespread distribution throughout the spine at 12 weeks, however, FGF-18 was only localised to the outer AF margins and hypertrophic cell condensations in the vertebral bodies. This contrasted with HS distributions at 14-20 weeks, which were prominent in the developing intervertebral disc (IVD). Ossification centres were also evident centrally within the vertebral rudiments surrounded by small columns of hypertrophic chondrocytes which expressed FGFR-3 and FGF-18 and upregulated levels of perlecan. FGF-18 also had a prominent localisation pattern in the developing IVD and the cartilaginous endplate while FGFR-3 was expressed throughout the disc interspace. This suggested roles for perlecan, FGF-18 and FGFR-3 in chondrogenic and osteogenic events which drive discal development and ossification of the vertebral bodies. CONCLUSIONS: The above data supported a role for FGF-18 in discal development and in the terminal osteogenic differentiation of chondroprogenitor cell populations, which promote vertebral ossification during spinal development.

Mechanical destabilization induced by controlled annular incision of the intervertebral disc dysregulates metalloproteinase expression and induces disc degeneration.

STUDY DESIGN: An investigation of mechanical destabilization of the lumbar ovine intervertebral disc (IVD) inducing IVD degeneration (IVDD) as determined by multiparameter outcome measures (magnetic resonance imaging [MRI], IVD composition, biomechanical testing, gene profiling, immunohistochemistry, and immunoblotting). OBJECTIVE: To assess the effect of IVD mechanical destabilization on matrix protein and metalloproteinase gene expression to investigate the pathophysiological mechanisms of lumbar IVDD. SUMMARY OF BACKGROUND DATA: Several earlier studies have used annular transection to induce IVDD in sheep, but none have optimized or validated the most appropriate lesion size. METHODS: The annulus fibrosus (AF) incision inducing maximal change in IVD biomechanics was applied to L1-L2, L3-L4, and L5-L6 discs in vivo to compare with a sham procedure at 3 months post operation. IVDs were evaluated by MRI, biomechanics, histopathology, proteoglycan and collagen content, gene expression, and aggrecan proteolysis by Western blotting. RESULTS: Significant changes were observed in lesion (6 × 20 mm(2)) compared with sham IVDs at 3 months post operation: reduced disc height on MRI; increased neutral zone in biomechanical testing; depleted proteoglycan and collagen content in the nucleus pulposus (NP) and lesion half of the AF but not in the contralateral AF; increased messenger RNA for collagen I and II, aggrecan, versican, perlecan, matrix metalloproteinase (MMP)-1 & 13, and ADAMTS-5, in the lesion-site AF and NP but not in the contralateral AF. ADAMTS-4 messenger RNA was increased in the lesion-site AF but decreased in the NP. Despite an upregulation in MMPs, there was no change in MMP- or ADAMTS-generated aggrecan neoepitopes in any region of the IVD in lesion or sham discs. CONCLUSION: Lumbar IVDD was reproducibly induced with a 6 × 20 mm(2) annular lesion, with focal dysregulation of MMP gene expression, cell cloning in the inner AF, loss of NP aggrecan, and disc height. Loss of aggrecan from the NP was not attributable to increased proteolysis in the interglobular domain by MMPs or ADAMTS.

Effect of stretch positions on hamstring muscle length, lumbar flexion range of motion, and lumbar curvature in healthy adults.

Hamstring stretching is a common practice in physical therapy to change not only hamstring muscle length (HML), but also lumbar flexion range of motion (LROM) or lumbar curvature (LC). Yet limited published research compares the effectiveness of two commonly used hamstring stretch positions, sitting and standing. The purposes of this study were to determine the effect of (1) stretch position on HML; and 2) HML on LROM and LC. Thirty-six participants (M=44.8 years, SD=17.1) with short HML (i.e., with shortness for men ≥45° and for women ≥ 24° of active knee flexion with 90° hip flexion) were measured for HML, LROM, and LC; randomly allocated to one of three groups: (1) hamstring stretching in sitting (SI); (2) standing (ST); or (3) no stretching (control); and remeasured after 4 weeks. Participants in the stretching groups performed two 30-second static stretches 4 days per week for 4 weeks. Multivariate analysis of covariance (MANCOVA) showed significance between the stretching groups and nonstretching group for HML only. Nonsignificance was shown for HML between the stretch positions (i.e., SI-active knee extension (AKE) and ST-AKE), indicating that both were equally effective for increasing HML. However, there was no change in LROM or in LC even though HML increased.

Altered trunk motor planning in patients with nonspecific low back pain.

The authors investigated differences in trunk muscle activation timing between patients with chronic nonspecific low back pain (NSLBP) and asymptomatic controls during a self-initiated postural challenge. The authors compared 30 participants with NSLBP to 30 controls. Surface electromyographic data were collected from bilateral trunk muscles. Dependent variables were trunk muscle onset and offset relative to extremity muscle activation and duration of the trunk muscle burst and abdominal-extensor cocontraction. Patients with NSLBP demonstrated significantly delayed trunk muscle onset latency (p < .01), and shorter burst (p = .02) and cocontraction durations (p < .01). Results suggest that patients with NSLBP may be inefficient in regulating trunk posture during voluntary extremity movements. These alterations could also represent a compensatory control pattern imposed by the CNS to avoid pain.

Reliability and responsiveness of the lower extremity functional scale and the anterior knee pain scale in patients with anterior knee pain.

STUDY DESIGN: Prospective methodological study of repeated measures using a sample of consecutive patients. OBJECTIVE: To determine the test-retest reliability and responsiveness of the Anterior Knee Pain Scale (AKPS) and the Lower Extremity Functional Scale (LEFS) in patients with anterior knee pain. BACKGROUND: Anterior knee pain is one of the most common orthopedic complaints affecting the knee. Yet there is currently no self-report outcome measure that has well-established reliability and responsiveness, specifically for this population. As a result, clinicians and researchers may be making inappropriate conclusions regarding patient outcomes by using questionnaires that are misleading. METHODS AND MEASURES: This multisite study involved 30 patients from 4 outpatient physical therapy clinics in Dallas, TX (24 women, 6 men; age range, 16-50 years; mean+/-SD age, 35.2+/-9.1 years). Patients receiving physical therapy for a chief complaint of anterior knee pain completed the AKPS and LEFS at their initial appointment and again 2 to 3 days later. Upon completion of physical therapy, the patients completed the AKPS, LEFS, and a global rating of change form. The treating therapist also completed a global rating of change form at the patient's final visit. The mean of the patient's and therapist's global rating of change was used as the criterion measure of change. RESULTS: Test-retest reliability was high for both questionnaires (ICC2,1 = 0.95 for the AKPS and 0.98 for the LEFS). A significant correlation was found between the criterion measure of change and both questionnaires. Receiver-operating characteristic curve analysis revealed that both questionnaires were moderately responsive with the area under the curve slightly higher for the LEFS (0.77) than the AKPS (0.69). CONCLUSION: The LEFS and the AKPS both demonstrated high test-retest reliability and appear to be moderately responsive to clinical change in patients with anterior knee pain. Reliability and responsiveness were slightly higher in the LEFS than the AKPS. Further research is needed to determine if these measures could be modified, or new measures created, to produce an even more sensitive tool for this population.

Effects of a late-phase exercise program after total hip arthroplasty: a randomized controlled trial.

OBJECTIVE: To investigate the effects of a late-phase exercise program for patients who underwent total hip arthroplasty (THA) 4 to 12 months earlier. DESIGN: A single-blind, randomized controlled trial. SETTING: Exercises were performed in subjects' homes. Exercise instruction and measurements taken before and after the trial were performed in an outpatient research and treatment center. PARTICIPANTS: Convenience sample of 34 adults 4 to 12 months post-THA randomly allocated to experimental or control groups. Twenty-eight subjects completed the study. INTERVENTION: An 8-week, hip-exercise intervention, during which the control group received basic isometric and active range of motion exercises; the experimental group received strength and postural stability exercises. MAIN OUTCOME MEASURES: Score on the 12-Item Hip Questionnaire; fear of falling; hip flexor, extensor, abductor, and knee extensor muscle torque; and postural stability in single stance. RESULTS: There was a statistically significant improvement in all measures of self-perceived function, muscle strength (hip flexors, 24.4%; hip extensors, 47.8%; hip abductors, 41.2%; knee extensors, 23.4%), and postural stability (36.8%) in the experimental group and no significant change in the control group. Neither group had statistically significant changes in fear of falling measures. CONCLUSIONS: An exercise program emphasizing weight bearing and postural stability significantly improved muscle strength, postural stability, and self-perceived function in patients 4 to 12 months after THA.