Keeping it all in balance: a qualitative analysis of the role of balance outcome measurement in physical therapist decision-making and patient outcomes

PURPOSE

The use of outcome measures (OMs) is a hallmark of contemporary physical therapy in the USA. The effect of OM utilization on patient care decisions and the results of PT services remain poorly understood. The purpose of this study is to explore PTs perceptions about the relationship between balance OMs and decision-making and how that interaction impacts patient outcomes, particularly for patients with acquired brain injury.

MATERIALS AND METHODS

This qualitative study used semi-structured phone interviews with an interview guide. Maximum variation sampling was used. Thematic analysis was situated in a priori determined theory-based categories.

RESULTS

Twenty-three physical therapists (PTs) from diverse geographic areas and practice settings participated. Therapists expressed diverse views on the impact of OM use on patient outcomes, but the majority perceived that using OMs improved rehabilitation outcomes. The use of OMs was related to the selection of optimal intervention type and intensity and justified continued high-frequency rehabilitation services. OMs were important to therapists' decision-making.

CONCLUSIONS

In the present study, PTs reported that they believe the use of validated, clinically useful OMs may improve patient outcomes.Implications For RehabilitationBalance outcome measures are considered an important tool to the optimal management of the profound impact of balance impairments after brain injury.Most physical therapists in this study believe that using balance outcome measures results in better outcomes for patients with brain injury.In this study, physical therapists reported using outcome measures in wide-ranging ways to guide clinical decisions about balance in those with brain injury.

Occupational adaptation as a social process for dementia care teams

BACKGROUND

Few studies have examined a group's collective experience of occupation using occupational therapy theoretical models. Dementia caregiving requires a diverse team of caregivers who learn and work together to resolve shared challenges. An Occupational Adaptation (OA) theory-based training program for dementia care teams was developed to better understand the team's adaptive process inherent in cooperative caregiving.

AIM/OBJECTIVES

Describe how the team learned together and how the training impacted their teamwork.

MATERIALS/METHODS

Fourteen employees at one continuing care retirement community underwent OA-based training. During the program, the team analysed and resolved challenging dementia care cases. Participant observations, participant journals, open-ended surveys, and follow-up semi-structured interviews were analysed.

RESULTS

The thematic framework included five steps: unite around a shared challenge, tap the collective adaptive repertoire, collaborate on case-specific plans, implement with teamwork, and return for ongoing problem solving and integration. The program enhanced appreciation for teammates' knowledge, skills, and experiences, learning from each other, and integration of team-centered OA process.

CONCLUSION/SIGNIFICANCE

The OA-based program appears to have facilitated adaptation that was complex, social, and generalisable. OA theory is enriched with a social view of occupational adaptation opening new opportunities for therapists and researchers to understand and facilitate adaptation among teams.

Optimal timing and neural loci: a scoping review on the effect of non-invasive brain stimulation on post-stroke gait and balance recovery

BACKGROUND

Little is known about the optimal timing and neural loci for applying noninvasive brain stimulation (NIBS) to promote gait and balance recovery after stroke.

OBJECTIVE

To identify the optimal timing and neural loci of NIBS for gait and balance recovery after stroke.

METHODS

We performed a PubMed search using keywords of stroke, transcranial magnetic stimulation, transcranial direct current stimulation, NIBS, balance, and gait. Interventional trials with various designs published in English were selected. Both flowcharts and tables were used for the result presentation.

RESULTS

The majority of selected 31 studies included individuals with chronic stroke and primary motor cortex (M1) stimulation. Studies' quality ranged from 4 to 10 (max = 10) on the Pedro scale. NIBS led to improvements in gait and balance in individuals with chronic and subacute stroke, yet the evidence for the acute phase of stroke is limited. Further, stimulation over the ipsilesional M1 resulted in improvement in gait and balanced performance. Stimulation over non-motor regions such as the cerebellum has been limitedly explored.

CONCLUSION

Current evidence supports the use of NIBS to the M1 in conjunction with behavioral training to improve gait and balance performance in individuals with subacute and chronic stroke. Future research is recommended to evaluate the effect of NIBS during acute stroke and over neural loci other than M1, and to implement a more rigorous method.

The impact of standardized balance measurement on physical therapist decision-making in acquired brain injury: a survey

BACKGROUND

The use of balance outcome measures (OM) is proposed to enhance physical therapy services and patient outcomes.

OBJECTIVE

Explore current practices of balance OM use and OM's role in United States physical therapists' decision-making with patient's acquired brain injury (ABI).

METHODS

Cross-sectional survey utilizing snowball sampling, n = 373. Survey items required ranking agreement with statements on Likert scale. Multinomial logistic regression used to determine the relationship between survey answers and participant characteristics.

RESULTS

Ninety-three percent of therapists reported using outcome measures with patients with ABI. Those who reported not using outcome measures with patients with ABI were significantly different on setting, primary patient population, APTA section membership, and ANPT membership. All respondents who primarily treated neurologic diagnoses used outcome measure with clients with ABI, compared to 87% of respondents who worked primarily with orthopedic clients. Comfort, equipment availability, and psychometric properties were the most frequent reasons for choosing a measure. Therapist decision-making was impacted by outcome measures; this frequency was dependent on practice setting, primary patient population, and specialty certifications.

CONCLUSIONS

Physical therapists use a low diversity of outcome measures to assess balance. Respondents rated psychometric properties as more important than past published research. This is the first study to demonstrate that outcome measures play a role for most United States PTs in decision-making in all stages of the patient management model including identification of problems, diagnosis, prognosis, intervention selection, termination of services, and discharge planning, as well justifying service delivery.

Outcomes of Team-Centered, Occupational Adaptation-Based Versus Traditional Dementia Workforce Training : Résultats comparés d'une formation axée sur l'équipe et l'adaptation occupationnelle et de l'approche de formation traditionnelle pour le personnel travaillant auprès des personnes atteintes de démence

Background. Dementia workforce training aligned with Occupational Adaptation (OA) theory may facilitate teams resolving challenges in the care environment more than traditional skills-based (SB) training, although comparisons are needed. Purpose. This pilot study compared effectiveness of an OA and SB program on relative mastery and team development for dementia care teams at a continuing care retirement community. Method. In a quasi-experimental study, employees underwent nine sessions in an OA or SB program. Relative Mastery Measurement Scale and Team Development Measure results were collected pre-, mid-, post-intervention. A 3 × 2 ANOVA determined differences in group score changes across time. Findings. Data from 28 employees (14/group) showed group-by-time interaction reached statistical significance for both relative mastery (F = 3.17, df = 2, p = .05) and team development (F = 8.38, df = 2, p = .001). Implications. OA-based training may improve dementia care teams' collaborative mastery over real-world challenges. While preliminary findings inform program developers, further research must explore clinical effectiveness.

Walking with and without a robotic exoskeleton in people with incomplete spinal cord injury compared to a typical gait pattern

BACKGROUND

Robotic exoskeleton (RE) enables individuals with lower extremity weakness or paralysis to stand and walk in a stereotypical pattern.

OBJECTIVE

Examine whether people with chronic incomplete spinal cord injury (SCI) demonstrate a more typical gait pattern when walking overground in a RE than when walking without.

METHODS

Motion analysis system synchronized with a surface electromyographic (EMG) was used to obtain temporospatial gait parameters, lower extremity kinematics, and muscle activity in ambulatory individuals with SCI and healthy adults.

RESULTS

Temporospatial parameters and kinematics for participants with SCI (n = 12; age 41.4±12.5 years) with and without RE were significantly different than a typical gait (healthy adults: n = 15; age 26.2±8.3 years). EMG amplitudes during the stance phase of a typical gait were similar to those with SCI with and without RE, except the right rectus femoris (p = 0.005) and left gluteus medius (p = 0.014) when participants with SCI walked with RE. EMG amplitudes of participants with SCI during the swing phase were significantly greater compared to those of a typical gait, except for left medial hamstring with (p = 0.025) and without (p = 0.196) RE.

CONCLUSIONS

First-time walking in a RE does not appear to produce a typical gait pattern in people with incomplete SCI.

Comparing Occupational Adaptation-Based and Traditional Training Programs for Dementia Care Teams: An Embedded Mixed-Methods Study

BACKGROUND AND OBJECTIVES

With a growing demand for a dementia-capable workforce, attention shifts from disseminating knowledge of care strategies to facilitating teams translating knowledge into practice. Occupational Adaptation (OA) is a theoretical framework used to facilitate people resolving real-world challenges through active problem-solving, using relative mastery as its measure. This pilot study evaluated if and how OA-based training improves dementia care teams' relative mastery and team development more than a skills-based (SB) program.

RESEARCH DESIGN AND METHODS

We report results of an embedded mixed-methods study with 28 employees of a continuing care retirement community (2 groups randomly assigned to 9-week programs). Data collection entailed 2 surveys conducted pre-, mid-, and postintervention; observations; journals; and follow-up interviews. We extended beyond quantitative and qualitative analyses with cross-cutting analyses exploring exemplar and exceptional cases.

RESULTS

The OA group reported significantly greater improvements in relative mastery and team development (p < .05). Qualitative data supported the statistical findings and illuminated processes that led OA to outperform SB. OA participants, those who analyzed real cases and alternated collaborative planning with cooperative action, were more likely to indicate pre-post differences in relative mastery and team development.

DISCUSSION AND IMPLICATIONS

We identified features of the OA program that diverse participants deemed effective; features that suggest how OA could underpin clinically relevant learning for workers. Further research is required to develop evidence of clinical effectiveness; however, our findings have relevance for agencies wishing to promote knowledge translation and collaborative problem-solving in dementia workforce training.

Differences in predictors for gait speed and gait endurance in Parkinson's disease

INTRODUCTION

Both gait speed and gait endurance directly impact independence and community engagement for individuals with Parkinson's disease (PD). However, factors accounting for variability in gait speed and gait endurance performance are unclear. The purpose of this study was to investigate whether key factors associated with gait speed in individuals with PD also predicted gait endurance.

METHODS

Community dwelling ambulatory individuals with PD were recruited for a single session. Key measures included 10 Meter Walk Test (10MWT) and 6 Minute Walk Test (6MWT) and key factors: age, disease severity [Movement Disorders Society United Parkinson's Disease Rating Scale (motor scale only) (MDS-UPDRS motor)], plantar flexor strength [Calf Raise Senior (CRS)], fatigue [Fatigue Severity Scale (FSS)], cognition [Montreal Cognitive Assessment (MoCA)], and balance [Four Square Step Test (FSST)]. Multiple linear regression analyses were conducted to determine clinical relationships.

RESULTS

Seventy-two individuals with PD (mean (standard deviation) (age = 70.83 (7.91) years; 50 males; MDS-UPDRS motor = 30.67 (13.50)) completed all assessments. The model predicting gait speed was significant, F(6, 65) = 15.143, p <.001, accounting for 54 % of the variance. Of the predictor variables age, MDS-UPDRS motor, CRS, MoCA and FSST scores were significant predictors. The model predicting gait endurance was significant, F(6, 65) = 15.608, p <.001, accounting for 55 % of the variance. Of the predictor variables, age, MDS-UPDRS motor scale, and CRS scores were significant predictors.

DISCUSSION

Gait speed and gait endurance are similarly influenced by age, motor impairment, and plantarflexion strength. However, cognition and balance were predictors only of gait speed, which may suggest unique task differences exist between gait speed and gait endurance.

Ankle motor strategy use in older and younger adults as assessed by a two-dimensional kinematic analysis smart device application

Background/aims

Motor strategies change with age, resulting in balance deficits. Clinical options for objectively measuring motor strategies are limited. The use of two-dimensional kinematic analysis through smart devices and applications may provide a cost-effective portable solution for measuring differences in motor strategy use between older and younger adults. The aims of this study were to investigate the concurrent validity of a two-dimensional software and two-dimensional application and to determine whether the application could capture the difference in ankle motor strategy use by older and younger adults (construct validity).

Methods

Video clips captured by Sony and iPad Air cameras were used to assess concurrent validity between the two-dimensional software and application. A total of 30 older (72.6 ± 4.0 years) and 30 younger (26.5±4.5 years) adults performed forward and backward stepping. A two-dimensional applicationmeasured the ankle position in degrees and time taken in seconds to initiate and complete a compensatory step.

Results

The two-dimensional software and app demonstrated excellent reliability (ICC2,1 ≥0.994). The ankle forward stop angle differed significantly between older and younger adults (P=0.012). No differences were observed in time taken to initiate and complete a compensatory step.

Conclusions

The two-dimensional application appears to be a valid alternative to two-dimensional software for measuring ankle motor strategies. Further investigation for clinical use is warranted.

Effects of two different types of ankle-foot orthoses on gait outcomes in patients with subacute stroke: a randomized crossover trial

OBJECTIVE

To identify whether patients in the subacute stage of stroke, with foot drop, would have better gait outcomes when using a double-adjustable AFO (DA AFO) or a posterior leaf spring AFO (PLS AFO) at baseline without practice and to determine whether one week of practice would significantly change gait outcomes with either of the AFOs.

DESIGN

Within-subject 2 × 2 repeated measures design.

SETTING

Postacute and outpatient rehabilitation center.

PARTICIPANTS

Twenty individuals with mean age of 57 years (SD: 12.0 years) with subacute stroke.

INTERVENTIONS

Participants were measured using DA AFO and PLS AFO at baseline. Follow-up measurements were taken after one week of practice with each type of AFO in randomly assigned order.

OUTCOME MEASURES

Gait endurance (6-Minute Walk Test (6MWT)), gait symmetry, and gait velocity at self-selected and fast-paced velocity measured using GAITRite gait analysis system and patient report of AFO preference.

RESULTS

At baseline, no significant differences were found between the 2 AFOs (P > 0.05). There was no significant interaction (P > 0.05) of AFO and practice for gait endurance, symmetry, and velocity. Main effect of practice was significant for gait endurance (P < 0.001), self-selected velocity (P = 0.001), and fast-paced velocity (P < 0.001). In all, 16 participants preferred using DA AFO for walking.

CONCLUSIONS

No difference between DA AFO and PLS AFO was found on measures of gait endurance, symmetry, and velocity at baseline or after practice. With practice over time, participants improved in gait endurance and velocity regardless of AFO type.

Responsiveness, minimal detectable change, and minimal clinically important difference of the sitting balance scale and function in sitting test in people with stroke

Background: Limited studies have examined the responsiveness of the Sitting Balance Scale (SBS) and Function in Sitting Test (FIST). No studies have investigated the psychometric properties of these tools in skilled nursing facilities.Objective: The purposes of the study were (1) to examine responsiveness of the SBS and FIST, in people with stroke, receiving rehabilitation in skilled nursing facilities; and (2) to estimate the MDC and MCID of these scales.Methods: Forty participants completed the FIST, SBS, and Barthel Index (BI) at admission and discharge. Internal responsiveness of the FIST and SBS was measured using Effect Size (ES) and Standardized Response Mean (SRM). Examining the association between the difference in scores on the SBS or FIST and the difference in scores on the BI determined external responsiveness. MDC and MCID were estimated for both measures.Results: The ES and the SRM for both scales were large (1.01-2.30) indicating excellent internal responsiveness. Both scales demonstrated satisfactory external responsiveness, showing good association with change in BI scores (p < .01). MDC₉₀ of the SBS and the FIST were 2.3 and 3.9, respectively. Anchor-based MCID estimates were 4.5 and 3.5, and distribution-based were 3.5 and 4.8 for the SBS and FIST, respectively.Conclusions: Both scales demonstrate sufficient responsiveness in the skilled nursing setting. Our findings suggest a change of 5 on the SBS and 4 on the FIST are clinically important, and clinicians may use these values to assess patient progress.

Health care worker perspectives on TB case finding and HIV services among pediatric TB patients in Tanzania

BACKGROUND: Tuberculosis (TB) and human immunodeficiency virus (HIV) infection in children are of concern due to the high morbidity and mortality they engender. Tanzania is working to improve TB and HIV case identification and treatment, as well as linkage of TB and HIV care in pediatric patients.METHODS: In-depth interviews were conducted in March 2016 at 10 high TB burden clinics in five districts of Tanzania to identify the barriers to pediatric TB diagnosis and HIV care. Health care workers (HCWs) at TB clinics who provided informed consent were administered interviews which were analyzed.RESULTS: Of 41 HCWs interviewed, 26 reported receiving pediatric TB training. Barriers to TB diagnosis included low community awareness, stigma and late presentation to the clinic. Barriers to HIV testing included children attending the TB clinic with someone who was not their parent/guardian and shortages of HIV rapid test kits. HCWs stressed the need for improved community education because it was perceived that some caregivers did not understand the importance of prompt TB and HIV treatment in children (although most were eager for a resolution of their child's illness).CONCLUSIONS: Efforts are needed to ensure effective TB and HIV diagnosis and treatment of children, provision of broader HCW and community education, enhanced TB-HIV contact tracing, and ensuring a continuous supply of HIV rapid test kits.

Concussion History, Career Status and Cumulative Years of Football Exposure Influence Concussion Assessment Performance in Elite Football Players

Objective

To explore relationship of concussion history, career status, and cumulative years of contact football exposure on total symptoms, symptom severity, neurocognitive function, and balance in elite football players.

Background

61% of retired football players report sustaining a concussion during their professional career. However, the influence of concussion history, career status and cumulative years played on total symptoms, symptom severity, neurocognitive function, and balance is largely unexplored.

Design/Methods

Elite football players (n = 102; age M = 27.75 ± 6.95 years) without a concussion (>30 days) underwent SCAT-3 assessments. Players were placed into a low (0–1) or multiple concussion (2+) history group and categorized by career status (draft prospects, active professional players and retired professional players). Data were analyzed using negative binomial regression and multiple linear regression analyses.

Results

58.8% of players reported symptoms. Most common symptoms were fatigue (33.3%), trouble falling asleep (31.4%), difficulty remembering (29.4%), and difficulty concentrating (20.6%). Multiple concussions group reported 3.07 times greater total symptoms (p < 0.001), 3.58 times higher symptom severity (p < 0.001), and lower SAC scores (1.42 points) (p = 0.033) compared to low concussion group. Professionals reported 1.88 times greater total symptoms (p = .038) and 2.35 times higher symptom severity compared to draft prospects (p = 0.001). Retired players reported 7.07 times greater total symptoms (p < 0.001), 8.97 times higher symptom severity (p < 0.001), lower SAC scores (1.98 points) (p = 0.025), and 3.67 more m-BESS errors (p = 0.002), compared to draft prospects. Players with 11–19 years football exposure reported 3.83 times higher symptom severity compared to players with <11 years football exposure (p = 0.001). Players with >19 years football exposure had 6.87 times higher symptom severity than players with <11 years football exposure (p < .001).

Conclusions

Retired players with multiple concussions and 19+ years of contact football exposure are likely to have more symptoms, higher symptom severity, and lower neurocognitive scores.

Putting patients at the center of kidney care transitions: PREPARE NOW, a cluster randomized controlled trial

Care for patients transitioning from chronic kidney disease to kidney failure often falls short of meeting patients' needs. The PREPARE NOW study is a cluster randomized controlled trial studying the effectiveness of a pragmatic health system intervention, 'Patient Centered Kidney Transition Care,' a multi-component health system intervention designed to improve patients' preparation for kidney failure treatment. Patient-Centered Kidney Transition Care provides a suite of new electronic health information tools (including a disease registry and risk prediction tools) to help providers recognize patients in need of Kidney Transitions Care and focus their attention on patients' values and treatment preferences. Patient-Centered Kidney Transition Care also adds a 'Kidney Transitions Specialist' to the nephrology health care team to facilitate patients' self-management empowerment, shared-decision making, psychosocial support, care navigation, and health care team communication. The PREPARE NOW study is conducted among eight [8] outpatient nephrology clinics at Geisinger, a large integrated health system in rural Pennsylvania. Four randomly selected nephrology clinics employ the Patient Centered Kidney Transitions Care intervention while four clinics employ usual nephrology care. To assess intervention effectiveness, patient reported, biomedical, and health system outcomes are collected annually over a period of 36 months via telephone questionnaires and electronic health records. The PREPARE NOW Study may provide needed evidence on the effectiveness of patient-centered health system interventions to improve nephrology patients' experiences, capabilities, and clinical outcomes, and it will guide the implementation of similar interventions elsewhere.

TRIAL REGISTRATION

NCT02722382.

The Effect of Visual Environmental Distraction on Gait Performance in Children

PURPOSE

Identify the effect of visual distraction on gait parameters in children and describe the role of walking experience (WE) in the management of visual distraction.

METHODS

Forty-two typically developing children, mean age 43.2 months (SD = 22.9) participated and were divided into three groups according to WE: early walkers (6-11 months of WE), preschool walkers (12-37 months of WE), and experienced walkers (38-79 months of WE). Gait parameters measured under two conditions (no visual distraction and with visual distraction) included: velocity, step length, step width, and double limb support percentage (DLS%) of gait cycle. Multivariate analysis of variance assessed differences in gait between groups (effect of WE) and within groups (effect of condition).

RESULTS

Significant main effects of WE group F(8,74) = 5.300, p ≤.001 and visual distraction condition F(4,36) = 2.586, p = 0.053 were found. Visual environmental distraction significantly affected gait performance in children regardless of walking experience. Velocity decreased from 110.04 to 97.73 cm/sec (p = 0.003) while DLS% of gait cycle increased from 18.29% to 20.39% (p = 0.025).

CONCLUSIONS

Results suggest physical therapists need to consider attentional requirements when assessing gait; even in children with more WE. If attention to task is a limiting factor for performance or learning of a motor task, it may need to be addressed directly as part of the treatment plan.

The effect of aerobic exercise on dual-task gait in individuals with Parkinson's disease

Background/Aims:

Dual tasking exacerbates gait deficits in people with Parkinson's disease. This pilot study aimed to examine the effect of aerobic exercise on dual-task gait in individuals with Parkinson's disease and begin to identify the impact of volitional pedal rate.

Methods:

Twenty people with Parkinson's disease were recruited and tested at baseline, post-intervention, and follow-up for motor (Unified Parkinson's Disease Rating Scale) and cognitive function (Repeatable Battery for the Assessment of Neuropsychological Status) and dual-task gait (Time Up and Go) conditions (manual and cognitive). A 12-week aerobic exercise intervention of cycle ergometry was carried out three times a week for 60 minutes each session. To assess our intervention, separate repeated measures of analysis of variance were conducted. As determined a priori, to assess the impact of volitional pedal rate, participants were divided after the intervention into a high-pedal rate group (>60 rpm) and a low-pedal rate group (≤60 rpm) based upon average maximal pedal rate throughout the intervention and analysed with the Mann Whitney U test and Related Samples Wilcoxon Signed Rank Test.

Findings:

Overall, motor function (P=0.580), cognitive function (P=0.077), and motor-cognitive interplay (P=0.168) did not improve after aerobic exercise. However, pedal rate groups were different for TUGmanual and TUGcognitive, but not on motor or cognitive function. Only low-pedal rate group improved over time (P=0.028 on TUGmanual) and demonstrated reduced dual task cost after the aerobic exercise (>Minimal Detectible Change of 18.1%).

Conclusions:

Though the low-pedal rate group experienced greater motor-cognitive interference, persons who pedalled at the slower rate demonstrated the most improvement in dual-task activities.

Aerobic exercise in people with multiple sclerosis: its feasibility and secondary benefits

The aims of this study were to explore the feasibility of structured aerobic exercise followed by a period of unstructured physical activity and determine the impact of such exercise on cognition, mood, and quality of life in people with multiple sclerosis (MS). A convenience sample of 9 individuals with relapsing-remitting MS performed 30 minutes of aerobic exercise (upper- and lower-extremity ergometry and treadmill ambulation) twice weekly for 8 weeks, followed by 3 months of unstructured physical activity. Eight participants completed the intervention and posttest; 6 returned for the 3-month follow-up. Cardiovascular fitness, cognition, mood (measured with the Beck Depression Inventory-II; BDI-II), and quality of life (measured with the Multiple Sclerosis Quality of Life-54; MSQOL-54) were assessed. Participants completed 27.9 minutes of exercise per session, with an 85.1% attendance rate. Evaluation using the Wilcoxon signed rank test revealed no deleterious effects and improved results on the BDI-II and MSQOL-54 mental subscale. Analysis of change scores using the one-sample t test revealed that the BDI-II and MSQOL-54 were changed from zero after structured exercise, but only the BDI-II maintained improvement after unstructured physical activity. Further analysis of BDI-II subscales revealed that improvement occurred only in the Somato-Affective subscale. In this study, program feasibility was demonstrated in several ways. There were no declines in cognitive function over the 5-month period. Despite unchanged cognitive function, participants may value the improved mood enough to continue both the structured and unstructured physical activity. The role of unstructured physical activity in concert with periodic structured exercise programs merits further investigation.

Validity of the Sitting Balance Scale in older adults who are non-ambulatory or have limited functional mobility

OBJECTIVE

To determine whether the Sitting Balance Scale is an acceptable alternative to the Trunk Impairment Scale for measuring the construct of sitting balance, to examine relationships with other clinical outcomes and to establish discriminative validity.

DESIGN

Prospective descriptive methodological study.

SETTING

Acute care, inpatient rehabilitation, skilled nursing facility and home health.

PARTICIPANTS

Patients receiving physical therapy (N = 98; n = 20 acute care, n = 18 inpatient rehabilitation, n = 30 skilled nursing facility, n = 30 home setting) mean (SD) age, 80.5 (7.9) years. Nineteen were non-ambulatory and 79 had limited functional mobility with Timed Up and Go scores ≥20 seconds.

MAIN MEASURES

Sitting Balance Scale, Trunk Impairment Scale, Timed Up and Go, length of stay and setting specific clinical measures of sitting balance (OASIS-C M1850; MDS G-3b).

RESULTS

Moderate association between ambulatory status and sitting balance measures (Sitting Balance Scale r = 0.67, Trunk Impairment Scale r = 0.61; P = 0.0001). Moderate to strong relationships between Sitting Balance Scale, Trunk Impairment Scale and clinical outcomes varying by setting. MANOVA results revealed differences between ambulators and non-ambulators and among diagnostic categories for both instruments (P < 0.001).

CONCLUSIONS

The Sitting Balance Scale is comparable to the Trunk Impairment Scale for measuring sitting balance in older adults who are non-ambulatory or have limited mobility.

The effect of balance confidence and context on functional reach ability in healthy older adults

OBJECTIVE

To assess functional reach (FR) ability in 4 contexts in older adults (≥ 60 years) with high balance confidence (HBC) and low balance confidence (LBC).

DESIGN

A repeated-measures design was used to compare 2 groups in 4 reaching contexts.

SETTING

Community setting.

SUBJECTS

Twenty-four healthy older adults with HBC and 27 healthy older adults with LBC.

METHODS

FR distance was assessed in 4 contexts presented in random order: (1) traditional FR (TFR); (2) functional reach on foam (FRF); (3) object present functional reach (OPFR); and (4) object present functional reach on foam (OPFRF). For TFR and FRF, 3 trials were performed for each task, and the average reach distance across 3 trials was calculated. During the OPFR and OPFRF contexts, the object was moved toward or away from the participant in 1.3-cm increments until maximal reach distance to the object was obtained.

MAIN OUTCOME MEASURE

Maximal reach distance in each of the 4 FR contexts.

RESULTS

Participants in the HBC group scored significantly higher than did participants in the LBC group regardless of reaching contexts (P =.004). For both balance confidence groups, reaching distance increased significantly from FRF to TFR to OPFRF to OPFR (P < .001).

CONCLUSION

The results of this study highlight the beneficial effect of an external target on balance performance, even with the added challenge of an unstable surface. These findings suggest that although balance performance is greater for persons with HBC, the same pattern of reaching ability in differing FR contexts is found regardless of whether balance confidence is high or low. The clinical utility of these findings pertain to the importance of the use of task objects during FR balance assessment to determine an individual's balance capacity. Future research is needed to assess the effectiveness of context-oriented reaching tasks in balance training programs.

Development, reliability, and validity of the Sitting Balance Scale

The Sitting Balance Scale (SBS) measures sitting balance for frail older adults who are primarily nonambulatory. Purposes were to generate items representing different functional abilities of sitting balance, reduce the number of items to make a clinically useful tool, refine the assessment, and establish reliability and validity. The study was conducted in multiple phases, with qualitative and quantitative methodologies. Content development used nominal group process, expert narratives, and literature review. After consensus was reached on content and scoring, item reduction began. Item retention and deletion decisions were based on a combination of practical considerations during field testing, expert and experienced clinician opinion of clinical relevance, and statistical information. Item retention or deletion decisions were based in part on the internal consistency analysis of the 19-item SBS based on 256 scores, which included participants who were apparently healthy and those with pathology. We applied a decision matrix to yield the final 11-item version. The 11-item SBS demonstrated good internal consistency (α = 0.762), intrarater rater reliability (ICC(3,1) = 0.96 to 0.99), and interrater reliability (ICC(2,1) = 0.87). On the basis of analysis of 156 scores, construct and concurrent validity were established. The SBS appears to meet the criteria required to make it a useful tool. The SBS can be used to assess sitting balance in frail individuals who are primarily nonambulatory who might exhibit floor effects for traditionally used balance measures. The SBS is the first attempt to assess lower balance abilities. Further assessment of the tool's validity with larger and varied samples is necessary.

Predicting the probability of falls in community dwelling persons with brain injury: A pilot study

PRIMARY OBJECTIVES

To determine the usefulness of select balance and functional mobility measures in predicting fall risk in community dwelling persons with brain injury (BI) and to develop a model to quantify fall risk.

RESEARCH DESIGN

An exploratory pilot study to predict fall risk in persons with BI. Non-manipulated independent variable was fall status with two levels, non-faller and faller. Dependent variables were scores on the Berg Balance Scale (BBS), the Dynamic Gait Index (DGI) and the Falls Efficacy Scale (FES); age, gender, supervision required and assistive device use.

METHODS AND PROCEDURES

Twenty-six participants recruited from support groups and community re-entry programmes were divided into two groups, fallers and non-fallers. The FES, BBS and DGI were administered.

MAIN OUTCOMES AND RESULTS

T-tests and chi-square tests revealed between group differences for age, FES, BBS, DGI and assistive device use. Spearman's rho statistic showed moderate relationships among the variables, FES, BBS, DGI and assistive device use. Logistic regression determined the DGI to best predict fall risk.

CONCLUSIONS

This study developed a predictive model that could be used by therapists to determine an individual's fall risk in the home or outpatient settings. Assessing risk allows therapists to identify individuals who would benefit from intervention designed to improve balance and gait ability, possibly preventing future falls and a second head injury.

The impact of HIV treatment on risk behaviour in developing countries: A systematic review

In developing countries, access to antiretroviral therapy (ART) is improving as HIV treatment becomes a greater priority in the global fight against AIDS. While ART has clearly beneficial clinical effects, increased access to treatment may also affect sexual behaviour. To examine the strength of evidence for the impact of medical treatment for HIV-positive individuals on behavioural outcomes in developing countries, we conducted a comprehensive search of the peer-reviewed literature. Studies were included if they provided clinical treatment to HIV-positive individuals in a developing country, compared behavioural, psychological, social, care, or biological outcomes related to HIV-prevention using a pre/post or multi-arm study design, and were published between January 1990 and January 2006. Only three studies were identified that met the inclusion criteria. All were conducted in Africa, utilized before/after or multi-arm study designs, and relied on self-reported behaviour. In all three studies, a majority of HIV-infected individuals reported being sexually abstinent, and access to ART was not associated with an increase in HIV-related risky sexual behaviours. However, one cross-sectional study found that ART patients were more likely to report STD treatment. The available evidence indicates a significant reduction in risk behaviour associated with ART in developing countries. However, there are few existing studies and the rigor of these studies is weak. More studies are needed to build an evidence base on which to make programmatic and policy decisions.