Physical therapy in the emergency department: A new opportunity for collaborative care.

Emergency department-initiated physical therapy (ED PT) is an emerging resource in the United States, with the number of ED PT programs in the United States growing rapidly over the last decade. In this collaborative model of care, physical therapists are consulted by the treating ED physician to assist in the evaluation and treatment of a number of movement and functional disorders, such as low back pain, peripheral vertigo, and various gait disturbances. Patients receiving ED PT benefit from the physical therapist's expertise in musculoskeletal and vestibular conditions and from the individualized attention provided in a typical bedside evaluation and treatment session, which includes education on expected symptom trajectory, recommendations for activity modulation, and facilitated outpatient follow-up. Early data suggest that both physicians and patients view ED PT services favorably, and that ED PT is associated with improvement of several important clinical and operational outcomes. Hospital systems interested in building their own ED PT program may benefit from the key steps outlined in this review, as well as a summary of the typical clinical volumes and practice patterns encountered at existing programs around the country.

The reliability of the modified reverse-6 taping procedure with elastic tape to alter the height and width of the medial longitudinal arch.

PURPOSE/BACKGROUND: Anti-pronation-taping utilizing both inelastic and elastic tape has been advocated to reduce pain and symptoms associated with excessive foot pronation. An important question regarding the use of taping is whether it can be applied consistently from one therapist to the next, from one session to the next or from one day to the next. Thus, the purpose of this study was to determine whether the "modified" Reverse-6 taping procedure using elastic tape could be applied to produce a consistent within-day and between-day change in the height and width of the medial longitudinal arch for a single clinician as well as between clinicians. A second purpose was to determine if the amount of general clinical experience influenced this consistency. METHODS: Fifteen asymptomatic individuals (10 female and 5 male) with a mean age of 28.7 years were recruited to participate in this study. The height and width of the midfoot at 50% of each subject's foot length was measured in standing using a digital gauge and caliper. These measurements were done twice on the same day, on two different days and again by two clinicians with different levels of experience before and after having their feet taped using the "modified" Reverse-6 taping technique using elastic tape. Both clinicians received a one-hour training session on how to apply the taping technique and were also given a DVD showing the technique that they could review. In addition to descriptive statistics, intra-class correlation coefficients (ICC) were used to assess each clinician's within-day and between-day reliability. Between-clinician reliability was also determined. RESULTS: The mean dorsal arch height and midfoot width before the application of tape was 62.7 and 78.9 mm. The mean dorsal arch height and width after the application of tape was 66.6 and 78.8 mm. The within-day reliability ICC(2,1) values for the two clinicians ranged from .865 to .991. The between-day reliability ICC(2,1) values for the two clinicians ranged from .874 to .985. The between-clinician reliability ICC(2,1) values ranged from .918 to .993. CONCLUSIONS: The results of this study indicate that the "modified" Reverse-6 foot taping technique using elastic tape can be used by more than one therapist for the same patient as well as from one session to the next with excellent reliability. LEVEL OF EVIDENCE: Level 2, Prospective Cohort Study.

Reliability, validity, and sensitivity to change of the lower extremity functional scale in individuals affected by stroke.

OBJECTIVE: To investigate reliability, validity, and sensitivity to change of the Lower Extremity Functional Scale (LEFS) in individuals affected by stroke. The secondary objective was to test the validity and sensitivity of a single-item linear analog scale (LAS) of function. DESIGN: Prospective cohort reliability and validation study. SETTING: A single rehabilitation department in an academic medical center. PATIENTS: Forty-three individuals receiving neurorehabilitation for lower extremity dysfunction after stroke were studied. Their ages ranged from 32 to 95 years, with a mean of 70 years; 77% were men. METHODS: Test-retest reliability was assessed by calculating the classical intraclass correlation coefficient, and the Bland-Altman limits of agreement. Validity was assessed by calculating the Pearson correlation coefficient between the instruments. Sensitivity to change was assessed by comparing baseline scores with end of treatment scores. Measurements were taken at baseline, after 1-3 days, and at 4 and 8 weeks. MAIN OUTCOME MEASUREMENTS: The LEFS, Short-Form-36 Physical Function Scale, Berg Balance Scale, Six-Minute Walk Test, Five-Meter Walk Test, Timed Up-and-Go test, and the LAS of function were used. RESULTS: The test-retest reliability of the LEFS was found to be excellent (ICC = 0.96). Correlated with the 6 other measures of function studied, the validity of the LEFS was found to be moderate to high (r = 0.40-0.71). Regarding the sensitivity to change, the mean LEFS scores from baseline to study end increased 1.2 SD and for LAS 1.1 SD. CONCLUSION: LEFS exhibits good reliability, validity, and sensitivity to change in patients with lower extremity impairments secondary to stroke. Therefore, the LEFS can be a clinically efficient outcome measure in the rehabilitation of patients with subacute stroke. The LAS is shown to be a time-saving and reasonable option to track changes in a patient's functional status.

The physical therapist as a musculoskeletal specialist in the emergency department.

Because patients with musculoskeletal injuries commonly seek intervention in the emergency department (ED), it has been proposed that practitioners with expertise in musculoskeletal practice can be of benefit in this setting. This clinical commentary describes the rationale for utilizing physical therapists as musculoskeletal specialists in the ED. Evidence indicates that physical therapists have the knowledge and skills to provide such expertise. Literature describing ED practice suggests that the management of patients with musculoskeletal conditions would be improved through the consistent integration of evaluation and treatment principles associated with physical therapy practice. Furthermore, early access to physical therapy, as can be provided in the ED setting, has the potential to positively influence patient recovery. Based on prior research and recent evolution of practice, further consideration of physical therapists as consultants in the ED is warranted, and, therefore, additional dialogue on the subject should be encouraged.

Reliability of the modified Foot Posture Index.

BACKGROUND: The Foot Posture Index (FPI) has been advocated as a simple and convenient tool to assess static foot posture in a clinical setting. Although published studies have indicated that the FPI has good intrarater reliability and moderate interrater reliability, these studies were conducted on a previous version of the tool that used eight criteria to score a patient's foot posture. The revised tool has only six criteria (FPI-6). The purpose, therefore, of this study was to investigate the intrarater and interrater reliability of the revised version of the FPI. METHODS: Three different raters used the FPI-6 to twice evaluate 92 feet from 46 individuals. RESULTS: Intrarater reliability was high but interrater reliability was only moderate. In addition, using the raw score generated by the FPI-6 to classify feet into one of five categories did not improve agreement between raters. CONCLUSIONS: The FPI-6 should be used with extreme caution and may actually have limited value, especially from a research perspective.

Differences in static scapular position between rock climbers and a non-rock climber population.

BACKGROUND: The increasingly popular sport of rock climbing is an activity which predisposes participants to overuse injuries. The unique physical demands associated with climbing, as well as a reported 33%-51% incidence of shoulder injuries in these athletes is suggestive of abnormalities in scapulohumeral biomechanics. OBJECTIVE: To examine the glenohumeral to scapulothoracic (GH:ST) ratio, as represented by end range static positions (ERSP) of the scapula and humerus, in a group of rock climbers and compare it to a group of non-climbers. METHODS: The GH:ST ratio of twenty-one experienced rock climbers was compared with 40 non-climbers using a bubble inclinometer to measure scapular upward rotation at the subjects' maximum glenohumeral elevation. RESULTS: As represented by ERSP, rock climbers had a significantly greater GH:ST ratio than non-climbers. The mean ratio of climbers was 3.7:1 compared with non-climbers at 2.8:1. Scapulothoracic motion appeared to be the source of this difference. DISCUSSION AND CONCLUSION: A possible explanation for this difference could be related to the extreme and prolonged positioning associated with rock climbing maneuvers that result in shoulder musculature imbalances in strength and flexibility.