Interventions to Improve Long-Term Adherence to Physical Rehabilitation: A Systematic Review.

OBJECTIVE: To evaluate the impact of physical rehabilitation interventions, supplemented with one or more adherence-enhancing components, on outcomes among adults with hip or knee osteoarthritis or chronic lower back pain. DESIGN: Primary literature search from inception of each database to July 27, 2021, guided by relevant search terms and keywords to search titles and abstracts. All articles meeting eligibility criteria were included for data abstraction. DATA SOURCES: MEDLINE, CINAHL Complete, and Embase. ELIGIBILITY CRITERIA FOR SELECTING STUDIES: Randomized and nonrandomized trials evaluating adherence-focused intervention components conducted in addition to an index usual care or usual care-like physical rehabilitation program among adults with hip or knee osteoarthritis or chronic low back pain. Eligible studies included a comparator group of the same index physical rehabilitation intervention without the adjunctive adherence components. Included studies measured outcomes at least 3 months after the rehabilitation course. RESULTS: Of the 10 studies meeting inclusion criteria, 6 interventions were delivered concurrent to an index rehabilitation program and 4 were delivered sequentially. Of the 3 studies that reported a positive effect on long-term adherence, only 1 was a low risk of bias study. There is very limited evidence of a beneficial treatment effect of adjunct adherence interventions on long-term physical function, self-efficacy, or adverse events. CONCLUSION: We found inadequate evidence evaluating adherence-enhancing interventions for the specific promotion of long-term adherence to home rehabilitation programs. Future studies should consider testing interventions specifically built to target behavioral maintenance of home rehabilitation programs.

Identifying Barriers and Facilitators to Veterans Affairs Whole Health Integration Using the Updated Consolidated Framework for Implementation Research.

BACKGROUND: Veterans Affairs (VA) implemented the Veteran-centered Whole Health System initiative across VA sites with approaches to implementation varying by site. PURPOSE: Using the Consolidated Framework for Implementation Research (CFIR), we aimed to synthesize systemic barriers and facilitators to Veteran use with the initiative. Relevance to healthcare quality, systematic comparison of implementation procedures across a national healthcare system provides a comprehensive portrait of strengths and opportunities for improvement. METHODS: Advanced fellows from 11 VA Quality Scholars sites performed the initial data collection, and the final report includes CFIR-organized results from six sites. RESULTS: Key innovation findings included cost, complexity, offerings, and accessibility. Inner setting barriers and facilitators included relational connections and communication, compatibility, structure and resources, learning centeredness, and information and knowledge access. Finally, results regarding individuals included innovation deliverers, implementation leaders and team, and individual capability, opportunity, and motivation to implement and deliver whole health care. DISCUSSION AND IMPLICATIONS: Examination of barriers and facilitators suggest that Whole Health coaches are key components of implementation and help to facilitate communication, relationship building, and knowledge access for Veterans and VA employees. Continuous evaluation and improvement of implementation procedures at each site is also recommended.

"We're not broken. We're human." A qualitative meta-synthesis of health-care providers' experiences participating in well-being programs.

INTRODUCTION: Protecting health-care provider (HCP) well-being is imperative to preserve health-care workforce capital, performance, and patient care quality. Limited evidence exists for the long-term effectiveness of HCP well-being programs, with less known about physiotherapists specifically. PURPOSE: To review and synthesize qualitative research describing experiences of HCP, generate lessons learned from the greater population of HCP participating in workplace well-being programs, and then to inform programs and policies for optimizing psychological well-being in an understudied population of physiotherapists. METHODS: This qualitative meta-synthesis included a systematic literature search conducted in September 2020; critical appraisal of results; and data reduction, re-categorizing, and thematic extraction (reciprocal translation) with interpretive triangulation. RESULTS: Twenty-five papers met the inclusion criteria. Participants included physicians, nurses, and allied health providers. All programs targeted the individual provider and included psychoeducational offerings, supervision groups, coaching, and complementary therapies. Four themes were constructed: 1) beneficial outcomes across a range of programs; 2) facilitators of program success; 3) barriers to program success; and 4) unmet needs driving recommendations. CONCLUSIONS: The findings enhance our understanding of diverse individual-level programs to address HCP well-being. Beneficial outcomes were achieved across program types with system-level support proving critical; however, HCP described barriers to program success (HCP characteristics, off-site programs, institutional culture) and remaining needs (resources, ethical dissonance) left unaddressed. Organizations should offer individual-level programs to support physiotherapists in the short term while pursuing long-term, system-level change to address drivers of well-being.

Mixed-Methods Approach to Understanding Determinants of Practice Change in Skilled Nursing Facility Rehabilitation: Adapting to and Sustaining Value With Postacute Reform.

BACKGROUND AND PURPOSE: Postacute care reform is driving physical and occupational therapists in skilled nursing facilities (SNFs) to change how they deliver care to produce better outcomes in less time. However, gaps exist in understanding determinants of practice change, which limits translation of evidence into practice. This study explored what determinants impacted change in care delivery at 2 SNFs that implemented a high-intensity resistance training intervention. METHODS: We used a mixed-methods, sequential explanatory design to explain quantitative findings using qualitative methods with a multiple-case study approach. Quantitative data were collected on therapists' attitudes toward evidence-based practice and aspects of intervention implementation. We conducted focus groups with therapists (N = 15) at 2 SNFs, classified as either high- (SNF-H) or low-performing (SNF-L) based on implementation fidelity and sustainability. RESULTS AND DISCUSSION: Determinants of SNF rehabilitation practice change included the organizational system, team dynamics, patient and therapist self-efficacy, perceptions of intervention effectiveness, and ability to overcome preconceived notions. A patient-centered system, positive team dynamics, and ability to overcome preconceived notions fostered practice change at SNF-H. While self-efficacy and perception of effectiveness positively impacted change in practice at both SNFs, these determinants were not enough to overcome challenges at SNF-L. To adapt to changes and sustain rehabilitation value, further research must identify the combination of determinants that promote application of evidence-based practice. CONCLUSIONS: This study is the first step in understanding what drives change in SNF rehabilitation practice. As SNF rehabilitation continues to face changes in health care delivery and reimbursement, therapists will need to adapt, by changing practice patterns and adopting evidence-based approaches, to demonstrate value in postacute care.

The Impact of Home Health Physical Therapy on Medicare Beneficiaries With a Primary Diagnosis of Dementia.

BACKGROUND: Dementia is a leading cause of disability for adults older than 65 years. Exercise intervention slows functional decline and improves balance; however, the efficacy of physical therapy (PT) services for persons with dementia is unknown. The purpose of this study is to assess the effect of home health PT services on physical function for Medicare beneficiaries with a primary diagnosis of dementia. DESIGN: Observational cohort study using a combined Medicare data set of home health beneficiaries; we performed augmented inverse probability weighted regression with demographic, comorbidity, and symptom-level characteristics analyzed as covariates. SETTING: Home healthcare, United States, 2012. PARTICIPANTS: Medicare beneficiaries who had a primary diagnosis of dementia and home health function evaluations at discharge (n = 1477). INTERVENTION: PT treatment, examined by (1) any PT and (2) PT visit number. MEASUREMENT: Improvement in composite activity of daily living (ADL) scores from home health admit to discharge. RESULTS: Any PT increased the probability of improvement in ADLs by 15.2% (P < .001). Compared to 1 to 5 PT visits, 6 to 13 visits increased the probability of ADL improvement by 11.6% (P < .001). CONCLUSION: PT intervention is beneficial for ADL function improvement in Medicare home health beneficiaries with a primary diagnosis of dementia. J Am Geriatr Soc 68:867-871, 2020.

Low to moderate relationships between gait and postural responses in Parkinson disease.

OBJECTIVE: To evaluate the relationship between spatiotemporal parameters of forward and backward gait and quality of compensatory stepping responses in forward and backward directions in people with Parkinson's disease with and without freezing of gait. DESIGN: Cross-sectional analysis. SUBJECTS: A total of 111 individuals with mild to moderate Parkinson's disease. METHODS: Forward and backward gait velocity and step length were evaluated using a GAITRite walkway. Forward and backward postural responses were evaluated using items from the Mini Balance Evaluation Systems Test and the Movement Disorders Society Unified Parkinson Disease Rating Scale motor subsection. Relationships between gait and postural responses were examined for the full sample and for sub-groups with and without freezing of gait. RESULTS: There were significant (p < 0.05) low to moderate correlations between postural responses and gait overall. Correlations were similar in the freezer and non-freezer sub-groups. Freezers performed worse than non-freezers on all gait parameters and backward postural response items (p < 0.05). CONCLUSION: Low to moderate relationships between gait and postural responses indicate the complexity of postural control and the potential involvement of different neural circuitry across these tasks. Better understanding of the relationships between gait and postural deficits in Parkinson's disease may inform the future development of targeted interventions to address these impairments.

Feasibility and preliminary efficacy of a telerehabilitation approach to group adapted tango instruction for people with Parkinson disease.

People with Parkinson disease (PD) demonstrate improvements in motor function following group tango classes, but report long commutes as a barrier to participation. To increase access, we investigated a telerehabilitation approach to group tango instruction. Twenty-six people with mild-to-moderate PD were assigned based on commute distance to either the telerehabilitation group (Telerehab) or an in-person instruction group (In-person). Both groups followed the same twice-weekly, 12-week curriculum with the same instructor. Feasibility metrics were participant retention, attendance and adverse events. Outcomes assessed were balance, PD motor sign severity and gait. Participant retention was 85% in both groups. Attendance was 87% in the Telerehab group and 84% in the In-person group. No adverse events occurred. Balance and motor sign severity improved significantly over time ( p < 0.001) in both groups, with no significant group × time effects. Gait did not significantly change. Since a priori feasibility criteria were met or exceeded, and there were no notable outcome differences between the two instruction approaches, this pilot study suggests a telerehabilitation approach to group tango class for people with PD is feasible and may have similar outcomes to in-person instruction.

Greater sexual reproduction contributes to differences in demography of invasive plants and their noninvasive relatives.

An understanding of the demographic processes contributing to invasions would improve our mechanistic understanding of the invasion process and improve the efficiency of prevention and control efforts. However, field comparisons of the demography of invasive and noninvasive species have not previously been conducted. We compared the in situ demography of 17 introduced plant species in St. Louis, Missouri, USA, to contrast the demographic patterns of invasive species with their less invasive relatives across a broad sample of angiosperms. Using herbarium records to estimate spread rates, we found higher maximum spread rates in the landscape for species classified a priori as invasive than for noninvasive introduced species, suggesting that expert classifications are an accurate reflection of invasion rate. Across 17 species, projected population growth was not significantly greater in invasive than in noninvasive introduced species. Among five taxonomic pairs of close relatives, however, four of the invasive species had higher projected population growth rates compared with their noninvasive relative. A Life Table Response Experiment suggested that the greater projected population growth rate of some invasive species relative to their noninvasive relatives was primarily a result of sexual reproduction. The greater sexual reproduction of invasive species is consistent with invaders having a life history strategy more reliant on fecundity than survival and is consistent with a large role of propagule pressure in invasion. Sexual reproduction is a key demographic correlate of invasiveness, suggesting that local processes influencing sexual reproduction, such as enemy escape, might be of general importance. However, the weak correlation of projected population growth with spread rates in the landscape suggests that regional processes, such as dispersal, may be equally important in determining invasion rate.