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Feldman PH, McDonald MV, Onorato N, Stein J, Williams O. Feasibility of deploying peer coaches to mentor frontline home health aides and promote mobility among individuals recovering from a stroke: pilot test of a randomized controlled trial. Pilot Feasibility Stud 2022; 8:22. [PMID: 35101133 PMCID: PMC8801561 DOI: 10.1186/s40814-022-00979-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Accepted: 01/11/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Each year, approximately 100,000 individuals receive home health services after a stroke. Evidence has shown the benefits of home-based stroke rehabilitation, but little is known about resource-efficient ways to enhance its effectiveness, nor has anyone explored the value of leveraging low-cost home health aides (HHAs) to reinforce repetitive task training, a key component of home-based rehabilitation. We developed and piloted a Stroke Homehealth Aide Recovery Program (SHARP) that deployed specially trained HHAs as "peer coaches" to mentor frontline aides and help individuals recovering from stroke increase their mobility through greater adherence to repetitive exercise regimens. We assessed the feasibility of SHARP and its readiness for a full-scale randomized controlled trial (RCT). Specifically, we examined (1) the practicability of recruitment and randomization procedures, (2) program acceptability, (3) intervention fidelity, and (4) the performance of outcome measures. METHODS This was a feasibility study including a pilot RCT. Target enrollment was 60 individuals receiving post-stroke home health services, who were randomized to SHARP + usual home care or usual care only. The protocol specified a 30-day intervention with four planned in-home coach visits, including one joint coach/physical therapist visit. The primary participant outcome was 60-day change in mobility, using the performance-based Timed Up and Go and 4-Meter Walk Gait Speed tests. Interviews with participants, coaches, physical therapists, and frontline aides provided acceptability data. Enrollment figures, visit tracking reports, and audio recordings provided intervention fidelity data. Mixed methods included thematic analysis of qualitative data and quantitative analysis of structured data to examine the intervention feasibility and performance of outcome measures. RESULTS Achieving the 60-participant enrollment target required modifying participant eligibility criteria to accommodate a decline in the receipt of HHA services among individuals receiving home care after a stroke. This modification entailed intervention redesign. Acceptability was high among coaches and participants but lower among therapists and frontline aides. Intervention fidelity was mixed: 87% of intervention participants received all four planned coach visits; however, no joint coach/therapist visits occurred. Sixty-day follow-up retention was 78%. However, baseline and follow-up performance-based primary outcome mobility assessments could be completed for only 55% of participants. CONCLUSIONS The trial was not feasible in its current form. Before progressing to a definitive trial, significant program redesign would be required to address issues affecting enrollment, coach/HHA/therapist coordination, and implementation of performance-based outcome measures. TRIAL REGISTRATION ClinicalTrials.gov, NCT04840407 . Retrospectively registered on 9 April 2021.
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Affiliation(s)
- Penny H Feldman
- Center for Home Care Policy & Research, Visiting Nurse Service of New York, 220 East 42nd Street, New York, NY, 10017, USA
| | - Margaret V McDonald
- Center for Home Care Policy & Research, Visiting Nurse Service of New York, 220 East 42nd Street, New York, NY, 10017, USA.
| | - Nicole Onorato
- Center for Home Care Policy & Research, Visiting Nurse Service of New York, 220 East 42nd Street, New York, NY, 10017, USA
| | - Joel Stein
- Department of Rehabilitation and Regenerative Medicine, Columbia University Vagelos College of Physicians and Surgeons, Department of Rehabilitation Medicine, Weill Cornell Medicine, New York-Presbyterian Hospital, 180 Ft. Washington Ave., Harkness Pavilion Room 1-165, New York, NY, 10032, USA
| | - Olajide Williams
- Department of Neurology, Columbia University, 710 West 168th Street, New York, NY, 10032, USA
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Buie JNJ, Zhao Y, Burns S, Magwood G, Adams R, Sims-Robinson C, Lackland DT. Racial Disparities in Stroke Recovery Persistence in the Post-Acute Stroke Recovery Phase: Evidence from the Health and Retirement Study. Ethn Dis 2020; 30:339-348. [PMID: 32346280 PMCID: PMC7186057 DOI: 10.18865/ed.30.2.339] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Background and Purpose Blacks have a higher burden of post-stroke disability. Factors associated with racial differences in long-term post-stroke disability are not well-understood. Our aim was to assess the long-term racial differences in risk factors associated with stroke recovery. Methods We examined Health and Retirement Study (HRS) longitudinal interview data collected from adults living with stroke who were aged >50 years during 2000-2014. Analysis of 1,002 first-time, non-Hispanic, Black (210) or White (792) stroke survivors with data on activities of daily living (ADL), fine motor skills (FMS) and gross motor skills (GMS) was conducted. Ordinal regression analysis was used to assess the impact of sex, race, household residents, household income, comorbidities, and the time since having a stroke on functional outcomes. Results Black stroke survivors were younger compared with Whites (69 ± 10.4 vs 75 ± 11.9). The majority (~65%) of Black stroke survivors were female compared with about 54% White female stroke survivors (P=.007). Black stroke survivors had more household residents (P<.001) and comorbidities (P<.001). Aging, being female, being Black and a longer time since stroke were associated with a higher odds of having increased difficulty in ADL, FMS and/or GMS. Comorbidities were associated with increased difficulty with GMS. Black race increased the impact of comorbidities on ADL and FMS in comparison with Whites. Conclusion Our data suggest that the effects of aging, sex and unique factors associated with race should be taken into consideration for future studies of post-stroke recovery and therapy.
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Affiliation(s)
- Joy N. J. Buie
- WISSDOM Center, Medical University of South Carolina, Charleston, SC
| | - Yujing Zhao
- Division of Infectious Diseases, Medical University of South Carolina, Charleston, SC
| | - Suzanne Burns
- WISSDOM Center, Medical University of South Carolina, Charleston, SC
- School of Occupational Therapy, Texas Women’s University, Denton, TX
| | - Gayenell Magwood
- WISSDOM Center, Medical University of South Carolina, Charleston, SC
- College of Nursing Medical University of South Carolina, Charleston, SC
| | - Robert Adams
- WISSDOM Center, Medical University of South Carolina, Charleston, SC
| | | | | | - WISSDOM Research Center Study Group
- WISSDOM Center, Medical University of South Carolina, Charleston, SC
- Division of Infectious Diseases, Medical University of South Carolina, Charleston, SC
- School of Occupational Therapy, Texas Women’s University, Denton, TX
- College of Nursing Medical University of South Carolina, Charleston, SC
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Treatment Documentation in Practice-Based Evidence Research for Patients Receiving Physical Therapy Because of Lymphedema. Arch Phys Med Rehabil 2019; 100:1467-1474. [DOI: 10.1016/j.apmr.2019.01.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2018] [Revised: 12/15/2018] [Accepted: 01/01/2019] [Indexed: 11/19/2022]
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Lisabeth LD, Horn SD, Ifejika NL, Sais E, Fuentes M, Jiang X, Case E, Morgenstern LB. The difficulty of studying race-ethnic stroke rehabilitation disparities in a community. Top Stroke Rehabil 2018; 25:393-396. [PMID: 30187831 DOI: 10.1080/10749357.2018.1481606] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
OBJECTIVE Minority populations have worse stroke outcomes compared with non-Hispanic whites (NHWs). One possible explanation for this disparity is differential allocation of stroke rehabilitation. We utilized a population-based stroke study to determine the feasibility of studying Mexican American-NHW differences in stroke rehabilitation in a population-based design including identification of community partners, development of standardized data collection instruments, and collection of pilot data. METHODS As part of the Brain Attack Surveillance in Corpus Christi project, we followed 48 patients for the first 90 days after stroke, and attempted to work with community partners to garner information on rehabilitation modalities used. With input from local occupational and physical therapists and speech language pathologists, we created data collection forms to capture rehabilitation activities and time spent on these activities and conducted a 3-month data collection pilot. RESULTS Of the 79 rehabilitation venues in the community, 63 (80%) agreed to participate. During the pilot, 545 data forms from 20 stroke patients were collected corresponding to ~18% of stroke patients. Forms were used by 13 partners during the pilot including 3 of 4 inpatient rehabilitation facilities, 4 of 13 skilled nursing facilities, 4 of 26 home health agencies, and 2 of 36 outpatient rehabilitation providers. CONCLUSIONS Initial agreement from rehabilitation providers to participate in research was excellent, but completion of study related data collection forms was sub-optimal suggesting this approach is not feasible for a future population-based stroke rehabilitation study. Further methods to study post-stroke rehabilitation disparities in communities are needed.
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Affiliation(s)
- Lynda D Lisabeth
- a Department of Epidemiology , University of Michigan School of Public Health , Ann Arbor , MI , USA
| | - Susan D Horn
- b Departments of Biomedical Informatics and Population Health Sciences , University of Utah Medical School , Salt Lake City , UT , USA
| | - Nneka L Ifejika
- c Department of Neurology , McGovern Medical School at UTHealth , Houston , TX , USA
| | - Emma Sais
- d Stroke Program , University of Michigan Medical School , Ann Arbor , MI , USA
| | - Michael Fuentes
- e Corpus Christi Rehabilitation Hospital , Corpus Christi , TX , USA
| | - Xiaqing Jiang
- a Department of Epidemiology , University of Michigan School of Public Health , Ann Arbor , MI , USA
| | - Erin Case
- a Department of Epidemiology , University of Michigan School of Public Health , Ann Arbor , MI , USA
| | - Lewis B Morgenstern
- d Stroke Program , University of Michigan Medical School , Ann Arbor , MI , USA
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Burns SP, White BM, Magwood G, Ellis C, Logan A, Jones Buie JN, Adams RJ. Racial and ethnic disparities in stroke outcomes: a scoping review of post-stroke disability assessment tools. Disabil Rehabil 2018; 41:1835-1845. [PMID: 29569497 DOI: 10.1080/09638288.2018.1448467] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
Purpose: To identify how post-stroke disability outcomes are assessed in studies that examine racial/ethnic disparities and to map the identified assessment content to the International Classification of Functioning, Disability, and Health (ICF) across the time course of stroke recovery. Methods: We conducted a scoping review of the literature. Articles published between January 2001 and July 2017 were identified through Scopus, PubMed, CINAHL, and PsycINFO according to predefined inclusion and exclusion criteria. Results: We identified 1791 articles through database and hand-searching strategies. Of the articles, 194 met inclusion criteria for full-text review, and 41 met inclusion criteria for study inclusion. The included studies used a variety of outcome measures encompassing domains within the ICF: body functions, activities, participation, and contextual factors across the time course of stroke recovery. We discovered disproportionate representation among racial/ethnic groups in the post-stroke disability disparities literature. Conclusions: A wide variety of assessments are used to examine disparities in post-stroke disability across the time course of stroke recovery. Several studies have identified disparities through a variety of assessments; however, substantial problems abound from the assessments used including inconsistent use of assessments, lacking evidence on the validity of assessments among racial/ethnic groups, and inadequate representation among all racial/ethnic populations comprising the US. Implications for Rehabilitation An enhanced understanding of racial/ethnic disparities in post-stroke disability outcomes is inherently important among rehabilitation practitioners who frequently engage with racial/ethnic minority populations across the time course of stroke recovery. Clinicians should carefully consider the psychometric properties of assessment tools to counter potential racial bias. Clinicians should be aware that many assessments used in stroke rehabilitation lack cultural sensitivity and could result in inaccurate assessment findings.
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Affiliation(s)
- Suzanne Perea Burns
- a WISSDOM Center , Medical University of South Carolina , Charleston , SC , USA
| | - Brandi M White
- b College of Health Sciences , University of Kentucky , Lexington , KY , USA
| | - Gayenell Magwood
- a WISSDOM Center , Medical University of South Carolina , Charleston , SC , USA.,c College of Nursing , Medical University of South Carolina , Charleston , SC , USA
| | - Charles Ellis
- d Department of Communication Sciences and Disorders , East Carolina University , Greenville , NC , USA
| | - Ayaba Logan
- e Department of Library Science and Informatics , Medical University of South Carolina , Charleston , SC , USA
| | - Joy N Jones Buie
- a WISSDOM Center , Medical University of South Carolina , Charleston , SC , USA
| | - Robert J Adams
- a WISSDOM Center , Medical University of South Carolina , Charleston , SC , USA.,f Department of Neurology , Medical University of South Carolina , Charleston , SC , USA
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Ellis C, Magwood G, White BM. Racial Differences in Patient-Reported Post-Stroke Disability in Older Adults. Geriatrics (Basel) 2017; 2:geriatrics2020016. [PMID: 31011026 PMCID: PMC6371106 DOI: 10.3390/geriatrics2020016] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2017] [Revised: 04/24/2017] [Accepted: 05/21/2017] [Indexed: 11/16/2022] Open
Abstract
Longstanding disparities have been reported in stroke-related outcomes with blacks experiencing more post-stroke disabilities. Little is known about long-term disability outcomes among older stroke survivors. This study was a retrospective analysis of data from the 2015 National Health Interview Survey (NHIS). A group of 655 stroke survivors (541 white and 114 black) age 65 and older were asked to rate their ability to complete 10 functional tasks without special equipment. Univariate comparisons were completed using t-tests and chi-square statistics for racial comparisons of disability reports. Multinomial logistic regression was used to determine odds of reporting disability after controlling for relevant covariates. The mean age of the sample was 76.6 years. After controlling for relevant covariates, white stroke survivors were less likely to report the following tasks being "very difficult/can't do at all" without using special equipment compared to blacks: reach overhead (OR = 0.39, 95% CI 0.23⁻0.65; p = 0.000) and grasp small objects (OR = 0.42, 95% CI 0.25⁻0.73; p = 0.002). Both black and white older stroke survivors experience significant post-stroke disability across a range of functional tasks. Slightly greater long term post-stroke disability appears to exist among older blacks.
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Affiliation(s)
- Charles Ellis
- Department of Communication Sciences & Disorders, College of Allied Health Sciences, East Carolina University, 3310H Health Sciences Building, MS 668, Greenville, NC 27834, USA.
| | - Gayenell Magwood
- College of Nursing, Medical University of South Carolina, 97 Jonathan Lucas Ave, Charleston, SC 29425, USA.
| | - Brandi M White
- Division of Healthcare Studies, College of Health Professions, Medical University of South Carolina, 151-B Rutledge Ave, Charleston, SC 29425, USA.
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Ramirez M, Teresi JA, Ogedegbe G, Williams O. Using Qualitative Methods to Assess the Conceptual Equivalence of the Spanish and English Stroke Action Test (STAT). QUALITATIVE HEALTH RESEARCH 2016; 26:1812-1822. [PMID: 27055498 DOI: 10.1177/1049732316636362] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
Members of racial/ethnic minorities, in contrast to majority groups, experience disparities in stroke risk factors, recognition, evaluation, and treatment. This article describes the use of qualitative methods to examine the cultural and lifestyle appropriateness, clarity of item-wording, comprehension of item intent, and conceptual equivalence of the developed Spanish and the revised English Stroke Action Test (which includes three additional atypical stroke symptoms more common in women). Thirty in-depth cognitive interviews were conducted (10 in Spanish) using concurrent structured probes. The desired ultimate outcome was to obtain conceptually equivalent measures in both languages. Four sources of variability in comprehension were identified: unfamiliar and/or idiosyncratic Spanish words used in translation; phrases in the original (English) and in the literal (Spanish) translation that were not understood; and unclear intended meaning of the original (English) items. Cognitive interviews helped identify problematic items, highlighted potential response errors, and provided insight regarding putative causes for inconsistent interpretation.
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Affiliation(s)
- Mildred Ramirez
- 1 Hebrew Home at Riverdale, Research Division, Riverdale, New York, USA
- 2 Weill Cornell Medical College, New York City, New York, USA
| | - Jeanne A Teresi
- 1 Hebrew Home at Riverdale, Research Division, Riverdale, New York, USA
- 2 Weill Cornell Medical College, New York City, New York, USA
- 3 Columbia University Stroud Center, New York City, New York, USA
| | - Gbenga Ogedegbe
- 4 New York University School of Medicine, New York City, New York, USA
| | - Olajide Williams
- 5 Columbia University Medical Center, New York City, New York, USA
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Cary MP, Merwin EI, Oliver MN, Williams IC. Inpatient Rehabilitation Outcomes in a National Sample of Medicare Beneficiaries With Hip Fracture. J Appl Gerontol 2016; 35:62-83. [PMID: 25037153 PMCID: PMC4537688 DOI: 10.1177/0733464814541325] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2014] [Accepted: 06/01/2014] [Indexed: 12/30/2022] Open
Abstract
Effects of patient characteristics on rehabilitation outcomes (functional status at discharge, discharged home) were assessed in a retrospective study of Medicare beneficiaries admitted to Medicare-certified inpatient rehabilitation facilities (IRFs) following hospitalization for hip fracture in 2009 (N = 34,984). Hierarchical regression analysis showed significantly higher functional status at discharge (p < .0001) for patients with these characteristics: White or Asian, younger, female, lived alone, higher functional status at admission, fewer comorbidities, no tier comorbidities, and longer IRF length of stay (LOS). Likelihood of discharged home was higher for patients with these characteristics: Hispanic (1.49 [1.32, 1.68]), Asian (1.35 [1.04, 1.74]), or Black (1.28 [1.12, 1.47]); younger (0.96 [0.96, 0.96]); female (1.14 [1.08, 1.20]); lived with others (2.12 [2.01, 2.23]); higher functional status at admission (1.06 [1.06, 1.06]); fewer comorbidities, no tier comorbidities; and longer LOS (1.61 [1.56, 1.67]). Functional status at admission, tier comorbidities, and race/ethnicity contributed the most to variance in functional status at discharge. Living with others contributed the most to variance in discharged home.
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Jaffe KM, Jimenez N. Disparity in rehabilitation: another inconvenient truth. Arch Phys Med Rehabil 2015; 96:1371-4. [PMID: 25958194 PMCID: PMC4871110 DOI: 10.1016/j.apmr.2015.04.017] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2015] [Accepted: 04/23/2015] [Indexed: 11/25/2022]
Affiliation(s)
- Kenneth M Jaffe
- Department of Rehabilitation Medicine, University of Washington, Seattle, WA; Department of Pediatrics, University of Washington, Seattle, WA; Department of Neurological Surgery, University of Washington, Seattle, WA; Harborview Injury Prevention and Research Center, University of Washington, Seattle, WA
| | - Nathalia Jimenez
- Harborview Injury Prevention and Research Center, University of Washington, Seattle, WA; Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, WA
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Siebens HC, Sharkey P, Aronow HU, Deutscher D, Roberts P, Munin MC, Radnay CS, Horn SD. Variation in Rehabilitation Treatment Patterns for Hip Fracture Treated With Arthroplasty. PM R 2015; 8:191-207. [PMID: 26226210 DOI: 10.1016/j.pmrj.2015.07.005] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2015] [Revised: 07/08/2015] [Accepted: 07/13/2015] [Indexed: 10/23/2022]
Abstract
BACKGROUND Recommendations for health care redesign often advocate for comparative effectiveness research that is patient-centered. For patients who require rehabilitation services, a first step in this research process is to understand current practices for specific patient groups. OBJECTIVE To document in detail the physical and occupational therapy treatment activities for inpatient hip fracture rehabilitation among 3 patient subgroups distinguished by their early rate of functional recovery between time of surgery to rehabilitation admission. DESIGN Multicenter prospective observational cohort, practice-based evidence, study. SETTING Seven skilled nursing facilities and 11 inpatient rehabilitation facilities across the United States. PARTICIPANTS A total of 226 patients with hip fractures treated with hip arthroplasty. METHODS Comparisons of physical and occupational therapy treatment activities among 3 groups with different initial recovery trajectory (IRT) rates (slower, moderate, faster). MAIN OUTCOME MEASURE(S) Percent of patients in each IRT group exposed to each physical and occupational therapy activity (exposure), and mean minutes per week for each activity (intensity). RESULTS The number of patients exposed to different physical or occupational therapy activities varied within the entire sample. More specifically, among the 3 IRT groups, significant differences in exposure occurred for 44% of physical therapy activities and 39% of occupational therapy activities. More patients in the slower recovery group, IRT 1, received basic activities of daily living treatments and more patients in the faster recovery group, IRT 3, received advanced activities. The moderate recovery group, IRT 2, had some treatments similar to IRT 1 group and others similar to IRT 3 group. CONCLUSIONS Analyses of practice-based evidence on inpatient rehabilitation of hip fracture patients treated with arthroplasty identified differences in therapy activities among three patient groups classified by IRT rates. These results may enhance physiatrists', other physicians', and rehabilitation teams' understanding of inpatient rehabilitation for these patients and help design future comparative effectiveness research.
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Affiliation(s)
- Hilary C Siebens
- Siebens Patient Care Communications, 13601 Del Monte Dr, Suite 47A, Seal Beach, CA 90740(∗).
| | - Phoebe Sharkey
- Department of Information Systems and Operations Management, Loyola University Maryland, Baltimore, MD(†)
| | | | | | | | - Michael C Munin
- Department of Physical Medicine and Rehabilitation, University of Pittsburgh School of Medicine, Pittsburgh, PA(#)
| | - Craig S Radnay
- Insall Scott Kelly Institute for Orthopaedics and Sports Medicine, New York, NY(∗∗)
| | - Susan D Horn
- Institute for Clinical Outcomes Research, Salt Lake City, UT(§)
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Ellis C, Boan AD, Turan TN, Ozark S, Bachman D, Lackland DT. Racial Differences in Poststroke Rehabilitation Utilization and Functional Outcomes. Arch Phys Med Rehabil 2015; 96:84-90. [DOI: 10.1016/j.apmr.2014.08.018] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2014] [Revised: 08/26/2014] [Accepted: 08/27/2014] [Indexed: 11/29/2022]
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Physical therapists' level of McKenzie education, functional outcomes, and utilization in patients with low back pain. J Orthop Sports Phys Ther 2014; 44:925-36. [PMID: 25353260 DOI: 10.2519/jospt.2014.5272] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
STUDY DESIGN Longitudinal, prospective, observational cohort. OBJECTIVE To examine associations between McKenzie training, functional status (FS) at discharge, and number of physical therapy visits (utilization) in patients receiving physical therapy for low back pain. BACKGROUND The McKenzie method is commonly used in treating patients with low back pain. METHODS A McKenzie postgraduate educational program was initiated in a large outpatient physical therapy service. Functional status data were collected at intake and at discharge. Separate hierarchical linear mixed models were used to examine associations between physical therapists' McKenzie training level (none; Parts A, B, C, and D; and credentialed), FS score at discharge, and utilization, controlling for patient risk factors. RESULTS The final data set included 20 882 patients (mean ± SD age, 51 ± 16 years; 57% women) who completed FS surveys at both admission and discharge. Patients treated by physical therapists with any McKenzie training had better outcomes (additional 0.7 to 1.3 FS points; P<.05 to <.001) and fewer visits (0.6 to 0.9, P<.001) compared to patients treated by physical therapists with no training. For patients treated by therapists with no versus some McKenzie education, 65% versus 70% achieved at least the minimal clinically important improvement, respectively. There were no significant differences in outcomes or utilization by level of McKenzie training. CONCLUSION There was a slightly greater improvement of 0.7 to 1.3 points in FS at discharge in patients receiving physical therapy for low back pain by physical therapists who underwent McKenzie training. This difference was clinically important for an additional 5% of patients who achieved the minimal clinically important improvement when treated by therapists with some McKenzie training. Reduction in physical therapy utilization was 0.6 to 0.9 visits, with the fewest visits utilized by patients of physical therapists at the McKenzie Part D and credentialed levels. Together, these findings suggest improved cost-effectiveness at advanced McKenzie training levels. Ways to improve ongoing education and patient outcomes were proposed.
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Racial/Ethnic differences in poststroke rehabilitation outcomes. Stroke Res Treat 2014; 2014:950746. [PMID: 25028619 PMCID: PMC4084586 DOI: 10.1155/2014/950746] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2013] [Accepted: 05/22/2014] [Indexed: 11/17/2022] Open
Abstract
Background. Significant racial and ethnic disparities in stroke incidence, severity, and morbidity have been consistently reported; however, less is known about potential differences in poststroke rehabilitation outcomes. Objective. To examine racial and ethnic differences in poststroke rehabilitation outcomes. Methods. We completed an in-depth search of Medline and several major journals dedicated to publishing research articles on stroke, rehabilitation, and racial-ethnic patterns of disease over a 10-year period (2003–2012). We identified studies that reported rehabilitation outcomes and the race or ethnicity of at least two groups. Results. 17 studies involving 429,108 stroke survivors met inclusion criteria for the review. The majority (94%) of studies examined outcomes between Blacks and Whites. Of those studies examining outcomes between Blacks and Whites, 59% showed that Blacks were generally less likely to achieve equivalent functional improvement following rehabilitation. Blacks were more likely to experience lower FIM gain or change scores (range: 1–60%) and more likely to have lower efficiency scores (range: 5–16%) than Whites. Conclusions. Black stroke survivors appear to generally achieve poorer functional outcomes than White stroke survivors. Future studies are warranted to evaluate the precise magnitude of these differences, whether they go beyond chance, and the underlying contributory mechanisms.
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Practice-Based Evidence Research in Rehabilitation: An Alternative to Randomized Controlled Trials and Traditional Observational Studies. Arch Phys Med Rehabil 2012; 93:S127-37. [DOI: 10.1016/j.apmr.2011.10.031] [Citation(s) in RCA: 88] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2011] [Revised: 10/19/2011] [Accepted: 10/19/2011] [Indexed: 11/19/2022]
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Physical therapy activities in stroke, knee arthroplasty, and traumatic brain injury rehabilitation: their variation, similarities, and association with functional outcomes. Phys Ther 2011; 91:1826-37. [PMID: 22003165 PMCID: PMC3229046 DOI: 10.2522/ptj.20100424] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND The mix of physical therapy services is thought to be different with different impairment groups. However, it is not clear how much variation there is across impairment groups. Furthermore, the extent to which the same physical therapy activities are associated with functional outcomes across different types of patients is unknown. OBJECTIVE The purposes of this study were: (1) to examine similarities and differences in the mix of physical therapy activities used in rehabilitation among patients from different impairment groups and (2) to examine whether the same physical therapy activities are associated with functional improvement across impairment groups. DESIGN This was a prospective observational cohort study. METHODS The study was conducted in inpatient rehabilitation facilities. The participants were 433 patients with stroke, 429 patients with total knee arthroplasty (TKA), and 207 patients with traumatic brain injury (TBI). Measures used in this study included: (1) the Comprehensive Severity Index to measure the severity of each patient's medical condition, (2) the Functional Independence Measure (FIM) to measure function, and (3) point-of-care instruments to measure time spent in specific physical therapy activities. RESULTS All 3 groups had similar admission motor FIM scores but varying cognitive FIM scores. Patients with TKA spent more time on exercise than the other 2 groups (average=31.7 versus 6.2 minutes per day). Patients with TKA received the most physical therapy (average=65.3 minutes per day), whereas the TBI group received the least physical therapy (average=38.3 minutes per day). Multivariate analysis showed that only 2 physical therapy activities (gait training and community mobility) were both positively associated with discharge motor FIM outcomes across all 3 groups. Three physical therapy activities (assessment time, bed mobility, and transfers) were negatively associated with discharge motor FIM outcome. LIMITATIONS The study focused primarily on physical therapy without concurrently considering other therapies such as occupational therapy, speech-language pathology, nursing care, and case management or the potential interaction of these inputs. This analysis did not consider the interventions that physical therapists used when patients participated in discrete physical therapy activities. CONCLUSIONS All 3 patient groups spent a considerable portion of their physical therapy time in gait training relative to other activities. Both gait training and community mobility are higher-level activities that were positively associated with outcomes, although all 3 groups spent little time in community mobility activities. Further research studies, such as randomized clinical trials and predictive validity studies, are needed to investigate whether higher-level or more-integrated therapy activities are associated with better patient outcomes.
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Invited commentary. Phys Ther 2011; 91:1084-5; author reply 1085-6. [PMID: 21724597 DOI: 10.2522/ptj.20100175.ic] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/09/2023]
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