The Functional Gait Assessment in Older Adults: Validation Through Rasch Modeling.

BACKGROUND: The Functional Gait Assessment (FGA), a measure of walking balance ability, was developed to eliminate the ceiling effect observed in the Dynamic Gait Index (DGI). Three presumably more difficult tasks were added and 1 easier task was removed from the original 8 DGI tasks. The effects of these modifications on item hierarchy have not previously been analyzed. OBJECTIVE: The purpose of this study was to determine: (1) the ordering of the 10 FGA tasks and the extent to which they map along a clinically logical difficulty continuum, (2) whether the spread of tasks is sufficient to measure patients of varying functional ability levels without a ceiling effect, (3) where the 3 added tasks locate along the task difficulty continuum, and (4) the psychometric properties of the individual FGA tasks. DESIGN: A retrospective chart review was conducted. METHODS: Functional Gait Assessment scores from 179 older adults referred for physical therapy for balance retraining were analyzed by Rasch modeling. RESULTS: The FGA task hierarchy met clinical expectations, with the exception of the "walking on level" task, which locates in the middle of the difficulty continuum. There was no ceiling effect. Two of the 3 added tasks were the most difficult FGA tasks. Performance on the most difficult task ("gait with narrow base of support") demonstrated greater variability than predicted by the Rasch model. LIMITATIONS: The sample was limited to older adults who were community dwelling and independently ambulating. Findings cannot be generalized to other patient groups. CONCLUSIONS: The revised scoring criteria of the FGA may have affected item hierarchy. The results suggest that the FGA is a measure of walking balance ability in older adults that is clinically appropriate and has construct validity. Administration of the FGA may be modified further to improve administration efficiency.

Physical therapist practice in the emergency department observation unit: descriptive study.

BACKGROUND: An upward trend in the number of hospital emergency department (ED) visits frequently results in ED overcrowding. The concept of the emergency department observation unit (EDOU) was introduced to allow patients to transfer out of the ED and remain under observation for up to 24 hours before making a decision regarding the appropriate disposition. No study has yet been completed to describe physical therapist practice in the EDOU. OBJECTIVE: The objectives of this study were: (1) to describe patient demographics, physical therapist management and utilization, and discharge dispositions of patients receiving physical therapy in the EDOU and (2) to describe these variables according to the most frequently occurring diagnostic groups. DESIGN: This was a descriptive study of patients who received physical therapist services in the EDOU of Massachusetts General Hospital during the months of March, May, and August 2010. METHODS: Data from 151 medical records of patients who received physical therapist services in the EDOU were extracted. Variables consisted of patient characteristics, medical and physical therapist diagnoses, and physical therapist management and utilization derived from billing data. Descriptive statistics were used to analyze data. RESULTS: The leading EDOU medical diagnoses of individuals receiving physical therapist services included people with falls without fracture (n=30), back pain (n=27), falls with fracture (n=22), and dizziness (n=22). There were significant differences in discharge disposition, age, and total physical therapy time among groups. LIMITATIONS: This was a retrospective study, so there was no ability to control how data were recorded. CONCLUSIONS: This study provides information on common patient groups seen in the EDOU, physical therapist service utilization, and discharge disposition that may guide facilities in anticipated staffing needs associated with providing physical therapist services in the EDOU.

Minimal clinically important difference of the functional gait assessment in older adults.

BACKGROUND: The Functional Gait Assessment (FGA) is commonly used to measure walking balance. The minimal clinically important difference (MCID) has yet to be determined for the FGA. OBJECTIVE: The purposes of this study were to determine: (1) the MCID in the FGA for older community-dwelling adults relative to patients' and physical therapists' estimates of change and (2) the extent of agreement between patients' and physical therapists' estimates of change. DESIGN: This study was a prospective case series. METHODS: Patients and physical therapists rated the amount of change in balance while walking after an episode of physical therapy for balance retraining on a 15-point global rating of change (GROC) scale. Weighted kappa statistics were calculated to express agreement between patients' and physical therapists' GROC ratings. Functional Gait Assessment change scores were plotted on receiver operating characteristic curves. A cutoff of +3 on the GROC was the criterion used for important change. The optimal FGA change cutoff score for MCID was determined, and sensitivity (SN), specificity (SP), and likelihood ratios (LRs) were calculated. RESULTS: One hundred thirty-five community-dwelling older adults (average age=78.8 years) and 14 physical therapists participated. There was poor agreement between the patients' and therapists' ratings of change (weighted kappa=.163). The estimated MCID value for the FGA using physical therapists' ratings of change as an anchor was 4 points (SN=0.66, SP=0.84, LR+=4.07, LR-=0.40). No accurate value for the FGA MCID could be determined based on the patients' ratings of change. LIMITATIONS: The small sample size was a limitation. CONCLUSION: Poor agreement between therapists' and patients' ratings indicate the need for further communication relative to patient goals. The 4-point MCID value for the FGA can be used for goal setting, tracking patient progress, and program evaluation.

The Mobility Scale for Acute Stroke predicts discharge destination after acute hospitalization.

OBJECTIVE: To evaluate the predictive validity of the Mobility Scale for Acute Stroke (MSAS) in determining discharge destination (home or not home) after an acute stroke. DESIGN: Cohort study. SUBJECTS: Two-hundred and twenty-three patients with acute ischemic or intraparenchymal hemorrhagic, unilateral stroke METHODS: The MSAS was administered as part of the initial physical therapy examination. The Receiver Operating Characteristic determined the optimal MSAS cutoff score associated with discharge home. A multiple logistic regression equation with discharge destination as the criterion variable (home or not home) was conducted with age, length of stay and optimal MSAS cutoff score as covariates. RESULTS: Subjects were discharged home 35.9% (n = 80) and not home 64.1% (n = 143) of the time. Mean age was 68.5 years (standard deviation 1.8). The ROC determined 26 to be the optimal cutoff score for the MSAS. Results of the multiple logistic regression equation indicated that controlling for age and length of stay, only the MSAS cutoff score of 26 reliably predicted discharge to home with an adjusted odds ratio of 57.79 with a 95% confidence interval of 20.09-166.21. CONCLUSION: The MSAS may be useful for predicting discharge destination from the acute hospital after stroke.

Use of the International Classification of Functioning, Disability and Health as a framework for analyzing the Stroke Impact Scale-16 relative to falls.

OBJECTIVE: To determine if subscores based on grouping Stroke Impact Scale 16 (SIS-16) items according to International Classification of Functioning, Health and Disability (ICF) components are more accurate in identifying individuals with a history of falls than the total SIS-16 score. DESIGN: Case series. SUBJECTS: 43 community-dwelling people with chronic stroke. METHODS: Participants were grouped based on six month fall history (no fall versus one or more falls). The SIS-16 items were categorized as belonging to the Body Structure and Function (BSF), Activity (ACT) or Participation (PART) component of the ICF. SIS-16 total score and ICF component subscores were analyzed for their association with falls. Receiver Operating Characteristic Curves were (ROC) analyzed. RESULTS: There were significant differences between groups on SIS-16 total (p = 0.006), BSF (p = 0.041) and ACT (p = 0.003) scores. The BSF and ACT component subscores had the highest specificity (0.91) and sensitivity (0.80), respectively, for categorizing participants according to fall history. The BSF + ACT component subscore demonstrated greater accuracy than the total SIS-16 for identifying people with falls (area under the curve = 0.78). CONCLUSION: The ICF may be a useful model for analysis of fall screening tools for people with chronic stroke. ICF component subscores are more accurate than the SIS-16 total score for this purpose.

Applying concepts of responsiveness to patient management in neurologic physical therapy.

Determining whether real change has taken place as a result of treatment and whether that change constitutes important change are challenges central to evidence-based physical therapist practice. Recently, the literature reporting these values for clinical measures has expanded considerably. In this article, we discuss some of the indices for identifying real change and important change, and how physical therapists can use these indices to enhance the interpretability of change scores derived from clinical measures. Specifically, we define and discuss the uses of the minimal detectable change and the minimal clinically important difference. We provide suggestions for how these indices can be used to make change scores more meaningful to therapists, patients, their caregivers, and third-party payers. Accurate interpretation and application of these indices are crucial to informed patient management and clinical decision making. We also present some of the limitations confronted as we try to apply these values across various patient diagnostic groups and across the spectrum of initial level of impairment. Finally, recommendations are made for directions for future research in this important area of outcomes research and how clinicians can contribute to these efforts.

The accuracy of individual Berg Balance Scale items compared with the total Berg score for classifying people with chronic stroke according to fall history.

BACKGROUND AND PURPOSE: To determine whether individual Berg Balance Scale (BBS) items or a group of items would have greater accuracy than the total BBS in classifying community-dwelling people with stroke with a history of multiple falls. METHODS: The subjects were 44 community-dwelling individuals with chronic stroke; 34 had one or no falls in the past six months, and 10 had multiple falls. Each BBS item was dichotomized at three points along the scoring scale of 0-4: between scores of 1 and 2, 2 and 3, and 3 and 4. Sensitivity (Sn), specificity (Sp), and positive (+LR) and negative (-LR) likelihood ratios were calculated for all items for each scoring dichotomy based on their accuracy in classifying subjects with a history of multiple falls. These findings were compared with the total BBS score where the cutoff score was derived from receiver operating characteristic curve analysis. RESULTS: Dichotomized point 3-4 for items B11 (turning 360 degrees), B12 (alternate foot on stool), B13 (tandem stance), and B14 (standing on one leg) all revealed Sn greater than 60%. B14 had the best Sn and Sp (0.90 and 0.50). Combining B11, B12, or B13 with B14 did not improve Sn. Total BBS receiver operating characteristic curve revealed a cutoff score of 52 (Sn = 90% and Sp = 41%). CONCLUSION: Using selected items from the BBS may be more time efficient and accurate than the total BBS score for classifying people with chronic stroke living in the community with a history of multiple falls. Prospective study is needed to validate these findings relative to fall prediction.

Using the International Classification of Functioning, Disability and Health as a framework to examine the association between falls and clinical assessment tools in people with stroke.

BACKGROUND: Falls in people with stroke are extremely common and present a significant health risk to this population. Development of fall screening tools is an essential component of a comprehensive fall reduction plan. OBJECTIVE: The purpose of this study was to examine the accuracy of clinical measures representing various domains of the International Classification of Functioning, Disability and Health (ICF) relative to their ability to identify individuals with a history of multiple falls. DESIGN: A case series study design was used. SETTING: The study was conducted in a community setting. PARTICIPANTS: Twenty-seven people with stroke participated in the study. MEASUREMENTS: Clinical assessment tools included the lower-extremity subscale of the Fugl-Meyer Assessment of Sensorimotor Impairment (FMLE) and Five-Times-Sit-to-Stand Test (STS) representing the body function domain, the Berg Balance Scale (BBS) representing the activity domain, the Activities-specific Balance Confidence (ABC) Scale as a measure of personal factors, and the physical function subscale of the Stroke Impact Scale (SIS-16) as a broad measure of physical function. We used receiver operating characteristic (ROC) curves to generate cutoff scores, sensitivities, specificities, and likelihood ratios (LRs) relative to a history of multiple falls. RESULTS: The FMLE and the STS showed a weak association with fall history. The BBS demonstrated fair accuracy in identifying people with multiple falls, with a cutoff score of 49 and a positive LR of 2.80. The ABC Scale and the SIS-16 were most effective, with cutoff scores of 81.1 and 61.7, respectively, positive LRs of 3.60 and 7.00, respectively, and negative LRs of 0.00 and 0.25, respectively. LIMITATIONS: A limitation of the study was the small sample size. CONCLUSION: The findings suggest that the ICF is a useful framework for selecting clinical measures relative to fall history and support the need for prospective study of tools in more-complex domains of the ICF for their accuracy for fall prediction in people with stroke.

Perspective: impact of the IIISTEP conference on clinical practice.

In July 2005, physical therapy clinicians, educators, and researchers gathered for the IIISTEP (Symposium on Translating Evidence to Practice) conference. The purpose of IIISTEP was to link research and clinical practice through the exchange of ideas and research findings between scientists and clinicians. This paper represents the personal perspective of a group of colleagues who attended IIISTEP as clinicians/educator teams. The purpose of this paper is to illustrate how information from IIISTEP has challenged our existing concepts regarding physical therapy practice and begun to alter our clinical practice. Some key concepts presented by scientists and clinicians at IIISTEP are reviewed including current perspectives on neuroplasticity and frameworks for considering function, health, and the disablement process. Considerations for clinical application are outlined. Patient cases are used to illustrate how integration of this information has altered our approach to patient management.

The association of balance capacity and falls self-efficacy with history of falling in community-dwelling people with chronic stroke.

OBJECTIVES: To describe the frequency of falls; to relate capacity-based and self-efficacy measures to fall history; and to determine to what extent capacity-based and self-efficacy measures are explained by subject characteristics and stroke impairments. DESIGN: Cross-sectional. SETTING: Community. PARTICIPANTS: Convenience sample of 50 people with chronic stroke. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Fall history, Falls Efficacy Scale-Swedish Version, fear of falling, and the mood subscore of the Stroke Impact Scale. Balance, strength, and functional mobility were measured using the Berg Balance Scale, timed sit to stand, and Timed Up & Go, respectively. RESULTS: Falls were reported by 40% (n=20) of subjects; 22% (n=11) reported multiple falls. Subjects with fall history had more fear of falling (relative risk [RR], 2.4; 95% confidence interval [CI], 1.1-4.9), had less falls-related self-efficacy (P=.04), and more depressive symptoms (P=.02) than nonfallers. Subjects with multiple fall history had poorer balance (P=.02), more fear of falling (RR=5.6; 95% CI, 1.3-23), and used a greater number of medications (P=.04) than non- and 1-time fallers. Strength partially explained balance, mobility, and falls-related self-efficacy. CONCLUSIONS: Balance and falls-related self-efficacy are associated with fall history and should be addressed in people with chronic stroke.

Determination of the minimal clinically important difference in the FIM instrument in patients with stroke.

OBJECTIVE: To define the minimal clinically important difference (MCID) for the FIM instrument in patients poststroke. DESIGN: Prospective case series discharged over a 9-month period. SETTING: Long-term acute care hospital. PARTICIPANTS: Patients with stroke (N=113). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Admission, discharge, and change scores were calculated for the total FIM, motor FIM, and cognitive FIM. Assessments of clinical change were rated at discharge on a 15-point (-7 to +7) Likert scale by attending physicians, with MCID defined at a cutoff score of 3. The FIM change scores associated with MCID were identified from receiver operating characteristic curves. Bayesian analysis was used to determine the probability of individual patients achieving MCID. RESULTS: FIM change scores associated with MCID were 22, 17, and 3 for the total FIM, motor FIM, and cognitive FIM, respectively. The accuracy of the MCID was greater when subjects were categorized based on admission FIM scores than when considering the sample as a whole. Larger FIM change scores were related to MCID in subjects with lower admission FIM scores. CONCLUSIONS: These findings will assist in the interpretation of FIM change scores relative to physicians' assessments of important clinical change.