The Case for Developing a Movement System Framework for Older Adults.

Leaders and scholars from multiple academies of the American Physical Therapy Association are developing and defining movement system diagnoses to guide practice. However, there is no consensus on the need for or content of such frameworks. This Perspective describes current thought about movement system diagnoses in physical therapy and summarizes the work of the Academy of Geriatrics (APTA Geriatrics) Movement System Diagnosis Task Force (GMS-TF) as it contributes to the movement system diagnosis discussion within the profession. Initially convened to define movement system diagnostic labels unique to older adults, the GMS-TF's developmental process identified the need for a clearer diagnostic framework onto which specific diagnoses will later be added. Although The World Health Organization International Classification of Functioning, Disability and Health model is a strong foundation for the patient-client management model, the GMS-TF proposes formal incorporation of the Geriatric 5Ms (mobility, medications, memory, multi-complexity, and "what matters most") into a movement system framework for older adults. The GMS-TF concurs with the APTA Academy of Neurology Movement System Task Force proposal that observation and analysis of key functional tasks are the foundation of any examination of older adults. The GMS-TF suggests adding several additional movement tasks that are important for older adults. The GMS-TF believes that this strategy highlights the health care needs of older adults and prioritizes physical therapist care for older adults with complex needs. This Perspective is the foundation for a future movement system diagnosis model for older adults that will complement and facilitate the development of models of care to be applied across the lifespan.

The Effects of a Divided-Attention Timed Stepping Accuracy Task on Balance, Strength, Endurance, and Functional Performance in Healthy Older Adults: A Pilot Study.

The aim of this study was to investigate whether a 6-week Divided-Attention Stepping Accuracy Task (DATSAT) intervention improved the primary outcome measure, maximal step length; other balance measures (Berg Balance scale and Timed Up and Go test); leg strength; endurance (6-min walk test); and functional tasks in 15 community-dwelling healthy older adults ( x¯ age: 71.5 years, female: 46.7%) compared with 15 community-dwelling healthy older adults in a Bike and Strength (B&S) program ( x¯ age: 73.8 years, female: 33.3%). Participants trained 3× per week, 30-60 min per session. Stepping-group differences were significant for all measures. B&S group improved in maximal step length (anterior and lateral), strength, and one functional task. Stepping group outperformed B&S group in Timed Up and Go and maximal step length posterior. B&S group outperformed stepping group in two strength measures. Exertion scores were lower for the stepping group. Overall, Divided-Attention Timed Stepping Accuracy Task training resulted in more within-group improvements and two between-group measures with less perceived effort and shorter intervention times.

Validation of the 2-Minute Walk Test with the 6-Minute Walk Test and Other Functional Measures in Persons with Multiple Sclerosis.

BACKGROUND: Persons with multiple sclerosis (MS) commonly have difficulty walking. The 6-Minute Walk Test (6MWT) assesses functional capacity but may be considered burdensome for persons with MS, especially those with higher disability levels. The 2-Minute Walk Test (2MWT) may be an alternative measure to the 6MWT. The purpose of this study was to investigate the validity of the 2MWT in persons with MS. METHODS: Twenty-eight ambulatory persons with MS aged 18 to 64 years participated in this cross-sectional study. Participants completed five measures of walking performance (2MWT, 6MWT, usual and fast gait speed, and Timed Up and Go test) and two functional measures (Berg Balance Scale and five-times sit-to-stand test) during a testing session. Participants were classified into two subgroups based on Disease Steps scale classification. RESULTS: The 2MWT was significantly correlated with the 6MWT (r = 0.947), usual gait speed (r = 0.920), fast gait speed (r = 0.942), the Timed Up and Go test (r = -0.911), and other functional measures. The 2MWT explained 89% of the variance seen during the 6MWT. The distances completed on the 2MWT and 6MWT accurately distinguished the subgroups. CONCLUSIONS: This study demonstrated good construct and discriminant validity of the 2MWT in persons with MS, providing an efficient and practical alternative to the 6MWT. Validation of the 2MWT with other functional measures further supports these findings.

Using a divided-attention stepping accuracy task to improve balance and functional outcomes in an individual with incomplete spinal cord injury: A case report.

A spinal cord injury (SCI) frequently results in impaired balance, endurance, and strength with subsequent limitations in functional mobility and community participation. The purpose of this case report was to implement a training program for an individual with a chronic incomplete SCI using a novel divided-attention stepping accuracy task (DASAT) to determine if improvements could be made in impairments, activities, and participation. The client was a 51-year-old male with a motor incomplete C4 SCI sustained 4 years prior. He presented with decreased quality of life (QOL) and functional independence, and deficits in balance, endurance, and strength consistent with central cord syndrome. The client completed the DASAT intervention 3 times per week for 6 weeks. Each session incorporated 96 multi-directional steps to randomly-assigned targets in response to 3-step verbal commands. QOL, measured using the SF-36, was generally enhanced but fluctuated. Community mobility progressed from close supervision to independence. Significant improvement was achieved in all balance scores: Berg Balance Scale by 9 points [Minimal Detectable Change (MDC) = 4.9 in elderly]; Functional Reach Test by 7.62 cm (MDC = 5.16 in C5/C6 SCI); and Timed Up-and-Go by 0.53 s (MDC not established). Endurance increased on the 6-Minute Walk Test, with the client achieving an additional 47 m (MDC = 45.8 m). Lower extremity isokinetic peak torque strength measures were mostly unchanged. Six minutes of DASAT training per session provided an efficient, low-cost intervention utilizing multiple trials of variable practice, and resulted in better performance in activities, balance, and endurance in this client.

Receiving early mobility during an intensive care unit admission is a predictor of improved outcomes in acute respiratory failure.

INTRODUCTION: Hospitals are under pressure to provide care that not only shortens hospital length of stay but also reduces subsequent hospital admissions. Hospital readmissions have received increased attention in outcome reporting. The authors identified survivors of acute respiratory failure who then required subsequent hospitalization. A cohort of acute respiratory failure survivors, who participated in an early intensive care unit (ICU) mobility program, was assessed to determine if variables from the index hospitalization predict hospital readmission or death, within 12 months of hospital discharge. METHODS: Hospital database and responses to letters mailed to 280 acute respiratory failure survivors. Univariate predictor variables shown to be associated with hospital readmission or death (P < 0.1) were included in a multiple logistic regression. A stepwise selection procedure was used to identify significant variables (P < 0.05). RESULTS: Of the 280 survivors, 132 (47%) had at least 1 readmission or died within the first year, 126 (45%) were not readmitted and 22 (8%) were lost to follow-up. Tracheostomy [odds ratio (OR), 4.02 (95%CI, 1.72-9.40)], female gender [OR, 1.94 (95%CI, 1.13-3.32)], a higher Charlson Comorbidity Index assessed upon index hospitalization discharge [OR, 1.15 (95%CI, 1.01-1.31)] and lack of early ICU mobility therapy [OR, 1.77 (95%CI, 1.04-3.01)] predicted readmission or death in the first year postindex hospitalization. CONCLUSIONS: Tracheostomy, female gender, higher Charlson Comorbidity Index and lack of early ICU mobility were associated with readmissions or death during the first year. Although the mechanisms of increased hospital readmission are unclear, these findings may provide further support for early ICU mobility for patients with acute respiratory failure.

Early intensive care unit mobility therapy in the treatment of acute respiratory failure.

OBJECTIVE: Immobilization and subsequent weakness are consequences of critical illness. Despite the theoretical advantages of physical therapy to address this problem, it has not been shown that physical therapy initiated in the intensive care unit offers benefit. DESIGN AND SETTING: Prospective cohort study in a university medical intensive care unit that assessed whether a mobility protocol increased the proportion of intensive care unit patients receiving physical therapy vs. usual care. PATIENTS: Medical intensive care unit patients with acute respiratory failure requiring mechanical ventilation on admission: Protocol, n = 165; Usual Care, n = 165. INTERVENTIONS: An intensive care unit Mobility Team (critical care nurse, nursing assistant, physical therapist) initiated the protocol within 48 hrs of mechanical ventilation. MEASUREMENTS AND MAIN RESULTS: The primary outcome was the proportion of patients receiving physical therapy in patients surviving to hospital discharge. Baseline characteristics were similar between groups. Outcome data are reflective of survivors. More Protocol patients received at least one physical therapy session than did Usual Care (80% vs. 47%, p < or = .001). Protocol patients were out of bed earlier (5 vs. 11 days, p < or = .001), had therapy initiated more frequently in the intensive care unit (91% vs. 13%, p < or = .001), and had similar low complication rates compared with Usual Care. For Protocol patients, intensive care unit length of stay was 5.5 vs. 6.9 days for Usual Care (p = .025); hospital length of stay for Protocol patients was 11.2 vs. 14.5 days for Usual Care (p = .006) (intensive care unit/hospital length of stay adjusted for body mass index, Acute Physiology and Chronic Health Evaluation II, vasopressor). There were no untoward events during an intensive care unit Mobility session and no cost difference (survivors + nonsurvivors) between the two arms, including Mobility Team costs. CONCLUSIONS: A Mobility Team using a mobility protocol initiated earlier physical therapy that was feasible, safe, did not increase costs, and was associated with decreased intensive care unit and hospital length of stay in survivors who received physical therapy during intensive care unit treatment compared with patients who received usual care.