Educational competencies for telehealth physical therapy: Results of a modified Delphi process.

BACKGROUND: Telehealth is becoming more prevalent in physical therapy, involving a whole host of clinical services. These services are often provided without structured training in telehealth, and no formal curricula currently exist for this purpose. OBJECTIVE: To develop a set of educational competencies (ECs) to guide instruction of telehealth-related skills in entry-level programs (i.e., Doctor of Physical Therapy), existing programs (i.e., residencies and fellowships), and potential future post-graduate programs specific to telehealth physical therapy. METHODS: Physical therapists and physical therapist assistants from diverse geographic locations and practice areas were invited to participate on an expert panel. A modified Delphi process was then used to evaluate the acceptability of draft ECs gathered from the extant literature by a steering group. Draft ECs were presented to the expert panel on a questionnaire, which asked expert participants to rate each draft EC according to applicability and clarity. Draft ECs were accepted if they met a priori established criteria for acceptability and clarity. Unendorsed ECs were revised by the steering group according to open-ended comments from respondents and presented during a subsequent round. Three rounds of surveys were undertaken. RESULTS: Thirty-eight participants formed the expert panel; 38 participants completed the Round 1 survey, 28 participants completed the Round 2 survey, and 24 participants completed the Round 3 survey. Delphi group members approved 48 ECs in the first round, 23 ECs in the second round, and 2 ECs in the third round. There were 4 ECs that remained unendorsed after the modified Delphi process. Endorsed ECs spanned 7 conceptual areas. Distinct sets of ECs characterized expected end points of first professional degree, existing residency and fellowship, and potential future telehealth physical therapy post-graduate program. CONCLUSIONS: Consensus-based ECs identified in this study may guide instruction in knowledge and skills relevant to physical therapy telehealth.

Accuracy of 2 activity monitors in detecting steps in people with stroke and traumatic brain injury.

BACKGROUND: Advances in sensor technologies and signal processing techniques provide a method to accurately measure walking activity in the home and community. Activity monitors geared toward consumer or patient use may be an alternative to more expensive monitors designed for research to measure stepping activity. OBJECTIVE: The objective of this study was to examine the accuracy of 2 consumer/patient activity monitors, the Fitbit Ultra and the Nike+ Fuelband, in identifying stepping activity in people with stroke and traumatic brain injury (TBI). Secondarily, the study sought to compare the accuracy of these 2 activity monitors with that of the StepWatch Activity Monitor (SAM) and a pedometer, the Yamax Digi-Walker SW-701 pedometer (YDWP). DESIGN: A cross-sectional design was used for this study. METHOD: People with chronic stroke and TBI wore the 4 activity monitors while they performed the Two-Minute Walk Test (2MWT), during which they were videotaped. Activity monitor estimated steps taken were compared with actual steps taken counted from videotape. Accuracy and agreement between activity monitor estimated steps and actual steps were examined using intraclass correlation coefficients (ICC [2,1]) and the Bland-Altman method. RESULTS: The SAM demonstrated the greatest accuracy (ICC [2,1]=.97, mean difference between actual steps and SAM estimated steps=4.7 steps) followed by the Fitbit Ultra (ICC [2,1]=.73, mean difference between actual steps and Fitbit Ultra estimated steps=-9.7 steps), the YDWP (ICC [2,1]=.42, mean difference between actual steps and YDWP estimated steps=-28.8 steps), and the Nike+ Fuelband (ICC [2,1]=.20, mean difference between actual steps and Nike+ Fuelband estimated steps=-66.2 steps). LIMITATIONS: Walking activity was measured over a short distance in a closed environment, and participants were high functioning ambulators, with a mean gait speed of 0.93 m/s. CONCLUSIONS: The Fitbit Ultra may be a low-cost alternative to measure the stepping activity in level, predictable environments of people with stroke and TBI who can walk at speeds ≥0.58 m/s.

Coordination of the non-paretic leg during hemiparetic gait: expected and novel compensatory patterns.

BACKGROUND: Post-stroke hemiparesis is usually considered a unilateral motor control deficit of the paretic leg, while the non-paretic leg is assumed to compensate for paretic leg impairments and have minimal to no deficits. While the non-paretic leg electromyography (EMG) patterns are clearly altered, how the non-paretic leg acts to compensate remains to be established. METHODS: Kinesiological data were recorded from sixty individuals with chronic hemiparesis (age: 60.9, SD=12.6 years, 21 females, 28 right hemiparetic, time since stroke: 4.5 years, SD 3.9 years), divided into three speed-based groups, and twenty similarly aged healthy individuals (age: 65.1, SD=10.4 years, 15 females). All walked on an instrumented split-belt treadmill at their self-selected speed and control subjects also walked at slower speeds matching those of the persons with hemiparesis. We determined the differences in magnitude and timing of non-paretic EMG activity relative to healthy control subjects in four pre-defined regions of stance phase of the gait cycle. FINDINGS: Integrated EMG activity and EMG timing in the non-paretic leg were different in many muscles. Multiple compensatory patterns identified included: increased EMG output when the muscle was typically active in controls and novel compensatory EMG patterns that appeared to provide greater propulsion or support with little evidence of impaired motor performance. INTERPRETATION: Most novel compensations were made possible by altered kinematics of the paretic and non-paretic leg (i.e., early stance plantarflexor activity provided propulsion due to the decreased advancement of the non-paretic foot) while others (late single limb stance knee extensor and late stance hamstring activity) appeared to be available mechanisms for increasing propulsion.

Quantifiable patterns of limb loading and unloading during hemiparetic gait: Relation to kinetic and kinematic parameters.

Persons with poststroke hemiparesis are characterized by asymmetry in limb loading (LL) and limb unloading (LU), which has been reported in static and quasi-static tasks but has not been quantified during walking. The purpose of this study was to determine the asymmetry in magnitude and duration of LL and LU in individuals with hemiparesis and its relationship with functional walking status and specific kinematic and kinetic variables during walking. Forty-four participants with chronic hemiparesis walked at their self-selected speeds and eighteen nondisabled control subjects of similar ages walked at predetermined matched speeds while three-dimensional ground reaction forces and body-segment kinematics were recorded. Magnitude of paretic LL was reduced, while duration was increased compared with the nonparetic leg and nondisabled controls walking at matched speeds. The paretic LL and LU was significantly correlated with average leg angle, while the nonparetic leg significantly correlated with average knee angle. Three different patterns of LL and LU were identified (concave, convex, and linear). Individuals with hemiparesis make several biomechanical adjustments that minimize LL of the paretic leg. LL deviations were more pronounced with increased lateral placement of the paretic foot and with decreased functional gait speed. Characterization of these deviations may inspire new strategies for rehabilitation.